Research Article
Implications of ACA Repeal: Effects on Integrative Medicine
Robert P Kurtz and Luann Drolc Fortune*
College of Integrative Medicine and Health Sciences, Saybrook University, California, USA

ABSTRACT
With the installation of President Trump, patients, medical practitioners and insurance providers are all asking what developments might be expected for the Affordable Care Act (ACA), also known as Obamacare, and how repeal could affect the USA healthcare system. While most recent efforts for a full legislative appeal remain uncertain, the scope of the ACA’s effectiveness as a national policy is diminished by the continued state of uncertainty. Healthcare leaders and policy makers need to recognize the far-reaching implications for Integrative Medicine (IM) through repeal of the ACA. Since the enactment of the ACA, there has been a notable rise in engagement of integrative services throughout the US. In addition to expanded evidence and wider acceptance by conventional healthcare providers, specific ACA provisions allot for inclusion of integrative services. A repeal of the ACA may have an impact on IM’s access, growth and development through a change in reimbursement and coverage by depreciating reimbursement policies, limiting the number of services, reducing patients’ ability to access such modalities and sustaining practitioners able to cultivate the field. In addition, repeal of the ACA will only give cause to regenerate previously established challenges surrounding key IM agendas. What occurs in the USA in the months ahead could have global ramifications for the practice and proliferation of IM.
KEYWORDS
Affordable Healthcare Act (ACA); CAM; Healthcare policy; Healthcare reform; Integrative healthcare; Preventive medicine

Introduction
With the presidential election of Donald Trump, patients, medical practitioners and insurance providers are following developments toward a possible repeal of the Affordable Care Act (ACA), also known as Obamacare and the resulting impact on the US healthcare system [1]. Beyond political deal-making, the situation is exceedingly complex: a legislative repeal of the ACA is only the first step in reversing the present ACA driven system. Among myriad considerations is how a repeal of the ACA will impact Integrative Medicine (IM). Proponents claim that IM, defined by the National Center for Complementary and Integrative Health (NCCIH) as the coordination of conventional medicine with Complementary and Alternative Medicine (CAM) practices and approaches, offers potential solutions for the convoluted landscape of personal healthcare through its attention to preventative measures, lower associated costs and suitability to address pain, chronic conditions and side effects from conventional treatment [2]. Research sponsored by NCCIH is currently targeting IM applications for preventive health, oncology symptom relief and pain management, especially for military personnel and veterans [3]. Researchers have recommended IM as a possible solution to the escalating opioid epidemic [4].

Thirty percent of Americans - approximately 59 million adults and children over 4 yrs. from all demographics spent $30.2 billion for IM, with apparently greater usage among females and those with higher education and income [5]. With insurers trending toward partial payment of IM services. Consumers paid an estimated $14.7 billion out-of-pocket to IM providers [3]. While overall use and IM spending increased, the out-of-pocket expenditures were trending down over the past five years, possibly reflecting increased coverage from insurers for integrative services as prescribed under the ACA. Data further indicated that insurance coverage varied by service [6]. For example, 60% of chiropractic patients received some insurance coverage, but coverage rates were lower for acupuncture (25%) and massage (15%) [3]. Although conclusive data is limited, integrative therapies may be more cost-effective compared to usual care, particularly for severe illnesses and chronic conditions. Integrative medicine’s suitability to treat stress-related disorders accounts for the US military’s high use of IM services, which at 45% is higher than civilian use [7]. Integrative approaches have also been demonstrated to be cost effective: in one study, patients whose primary physician had additional CAM training had up to 30% lower healthcare costs and mortality rates [8]. The lower costs were attributed to fewer hospital stays and fewer prescription drugs, indicating that the nature of IM is not to simply add or substitute services but to reorient outcomes. Evidence supports IM for specific conditions, ranging from acupuncture for migraine to psychophysiology techniques for cardiac and stress related disorders [9]. In addition, IM services are often used for preventative purposes which cannot be easily measured in terms of cost savings [10]. Researchers have suggested IM practices would be more widely used under improved insurance coverage comparable to traditional medical reimbursement [4].

Proponents argue that IM offers a strategy to improve critical flaws in the US healthcare system. The US spends more than any other country on healthcare, at $10,345 per person and 16.9% of its GDP in 2016 [11,12]. Yet compared to other developed nations, the US ranked near the bottom in indicators of average life expectancy: 79 yrs ranked at 26th, and infant mortality ranked at 29th out of 35 nations [12]. Over 86% of $3.35 trillion in national expenditures treated chronic diseases, which accounted for 7 out of 10 deaths. Furthermore, the adult obesity ratio increased to over 30% in 2016 [12]. An estimated 38% of patients with mental illness went untreated, although the annual direct economic burden of serious mental illness was estimated at $317 billion, and drug-related deaths rose by 9% in a five - year period [12,13].

Although the US healthcare system is costly yet ineffective, this complex issue can be reduced to two factors: minimal and complicated price control as exemplified in the high cost of prescription drugs, as well as multiple layers of expenditures, many of which do not directly deliver healthcare services [14,15]. For example, employers hire third parties to negotiate drug discounts in a market where consumer prices are uncontrolled [16]. Another indirect cost is tied to the US legal system. A recent study found that physician fears of malpractice claims and legal reprisal were associated with up to 20% of higher patient costs [17].

Until the passage of the ACA a high proportion of Americans were uninsured. Under the ACA, the number of uninsured Americans dropped by 21.3 million, from over 16% in 2010 to 8.6% in 2016 [18]. The ACA also expanded minimum coverage, with mandated levels of specific services, including coverage for preexisting conditions, mental health and provisions that encouraged integrative care [19]. Thus, for those individuals interested in the future of this country’s provision of healthcare, President Trump’s ongoing efforts to repeal the ACA have likely been either extremely nerve-wracking or somewhat inspiring depending on which side of the political fence one happens to fall.

Over the past several years, there have been continuing fluctuations in the distribution of Americans who support or oppose the ACA. In 2010, there was an all time low favorability rating by citizens toward national health insurance in the US, dropping to just 35% [20]. Since December of 2016, however, Americans have demonstrated a notable shift toward support for the ACA: 48% favorable, 43% unfavorable, and 9% unsure/unanswered [20]. Perhaps these numbers reflect growing opinions on the reality that, with just a partial congressional repeal of the ACA, an estimated 85% of individuals reliant on federal and state exchanges for financially feasible health insurance would no longer benefit from associated tax credits [21].

As the President backed by a Republican controlled congress persistently pushes ahead to repeal and replace Obamacare, specific outcomes are still unclear. Under a proposed replacement plan, the American Health Care Act (AHCA), many Americans could lose access to care, and coverage requirements will be minimized or eliminated [19]. Popular ACA provisions that are jeopardized include removing individual spending caps, and an expansion of Medicaid eligibility. Proposed replacement programs would offer tax credits of $2,000 to $4,000 a year in place of government subsidized insurance policies, eliminate subsidies for low income families, and weaken protection for covering preexisting conditions [22]. Insurance coverage for many treatments are likely to be limited, severely impacting IM services, many of which target chronic conditions, preventative health measures, and adjunct remedies for mental health related diagnoses.

In response, healthcare advisors and industry leaders from around the country have urged President Trump, his appointed Cabinet, and a Republican-led Congress to proceed with caution, suggesting that the current ACA structure be thoughtfully refined as opposed to altogether discarded [23]. Considering a potential abandonment of these cautionary counsels to healthcare policymakers, Americans might well see a significant undermining of national access to care and provisions of publically funded health insurance. Noting challenges already faced by the field of IM throughout Obama-led ACA policy developments, alterations to the ACA might significantly impact the delivery, access, and distribution of IM modalities.
Integrative Medicine and the ACA
A Definition
As a central tenet, IM focuses on maintenance and growth of the overall health and wellness of a person, instead of solely treating illness and disease. In an article by researchers at IM was described as an approach to medical practice that incorporates broad perspectives surrounding the whole individual, actively involving all relevant therapeutic models, healthcare providers and disciplines that might assist in realizing maximized health, healing and wellness [24]. Integrative medicine combines advancing technology and contemporary medicine with other carefully selected modalities that have successfully been demonstrated as safe and effective.

The NCCIH suggested that all definitions of IM generally involve coordinating each of the best and most applicable services offered by both conventional and complementary modalities for the benefit of each unique patient [3]. Duke Medicine stipulated that an underlying goal of IM is to bring together contemporary medical approaches and traditional health and wellness methods in a way that is meaningful to each patient and condition [24]. Additionally, IM has been described as a set of medical practices that emphasize the importance of patients’ total wellness needs, promoting the growth and maintenance of an optimum health status [25].
A Brief history
The United States is well known for its ability to effectively treat medically acute conditions; it has shown less efficacy in managing chronic diseases and measures of quality of life [26]. With an increased pattern of reliance on costly, invasive and risky treatment strategies, the US has been cited as maintaining the most expensive and least accessible healthcare system in the developed world [26]. The ACA was originally designed to address issues experienced by the conventional medical model [26]. In 2014, the Integrative Healthcare Policy Consortium (IHPC) responded by advocating that Congress promote regulations determining equal patient and provider rights for integrative healthcare services. Section 2706 is a provision of the ACA created to better incorporate mandated coverage policies supporting the broad range of licensed healthcare providers, including integrative medical modalities. The provision compels federal and state overseers to hold insurance companies accountable for reimbursement of IM practices [27]. However, as Pang et al., noted, many CAM approaches involve care and treatment practices that are often interpreted as nonconventional medicine and face resistance from conventional providers [28]. Affecting patients and practitioners alike, this has been one of the key barriers to effectively implementing IM programs.
Contemporary Relevance
Any repeal of the ACA might prompt the regeneration of prior challenges surrounding key IM agendas. Onlookers of these enduring issues might justly pose questions as to the relevance of such debates. In the realm of research, IM is being studied for potential benefits to multiple areas such as “pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors” [3]. It has been demonstrated that IM effectively addresses current problems in the healthcare system by providing additional safe, effective and financially superior treatments that can successfully manage, alleviate and even prevent common ailments and diseases, promoting improvements in national health and wellness [25]. Further, effective implementation of IM has shown promise for diminishing health burdens like chronic illnesses that significantly tax our local and national healthcare systems and for improvements in treatment of disease related outcomes, all with increased levels of monetary and health values [25,26]. Therefore, it might not be surprising that IM programs are becoming more common among highly reputable health and research facilities to provide integrative medical services, including the Mayo Clinic, Cleveland Clinic, Duke University Medical Center, Massachusetts General Hospital, Johns Hopkins, UCLA Medical Center, UCSF Medical Center, Vanderbilt University Medical Center, Oxford and Stanford Health Care.

On an individual level, Pang et al., proposed that patients frequently gravitate toward integrated CAM therapies because such services are often cheaper, less invasive and easier to access [28]. In addition to these factors, patients with chronic back pain, headaches and arthritis, as well as terminal illness such as cancer, incorporate integrative modalities to alleviate associated symptoms, where modern therapies do not always provide such relief and are often accompanied by unwanted side effects [28]. The most frequently engaged integrative CAM treatments have been identified as acupuncture, IM consultations and massage therapy [28].

As reflected in the NCCIH move to incorporate “integration” to its name, there has been a notable increase in coordination between conventional medicine and integrative treatments throughout the US over the last decade [3]. Over this period since the adoption of the ACA, integrative practitioners have also experienced an increase in developing professional standards of practice, supportive evidence and commensurate governmental regulation and oversight. Still, as demonstrated by limited and partial insurance coverage, integrative practices have yet to achieve full parity with their conventional medicine counterparts. Although it is difficult to quantify the potential significance of ACA repeal to the agenda of facilitating IM programs, it is possible that such repeal could hinder access for new patients to initiate and sustain integrative modalities, and thwart the forward progress of full integration.
A Repeal
As put forward by Manko et al., in order to dismantle or repeal the ACA, the Republican Party can proceed in one of two ways [1]. The first involves a possible scenario of a total repeal, which would eliminate current exchanges, insurance coverages, subsidies and all associated legal enforcements. A second possibility could involve the process of eliminating funding for the ACA’s underwritten laws as a means of federal budget reconciliation. Manko et al., stated that such a method would only require 51 votes in the Senate and would eliminate the chance of a Democratic filibuster [1]. Although this would not result in a full repeal, through a Section 1332 State Innovation Waiver, each state could independently amend their own insurance marketplaces in any number of creative ways, effectively eliminating mandates, exchanges and cost-sharing subsidies [1]. Said waivers would require demonstrable improvements to care access, quality and affordability by way of publically funded health insurance programs. However, this would not require any provisions to support further implementation of IM.

Even without repeal or revisions to the legislation, the mandates dictated by the ACA can be undermined by an intentional lack of enforcement. Under such a scenario, the Trump administration would likely provide leeway to states regarding enforcement of any adaptive, state level actions toward a more independently run healthcare system or, away from integrated services [1]. President Trump “would still have to answer to millions of lower and middle income Americans who now use federal subsidies to afford their premiums” [29]. However, it is likely to be months and even years before a clear resolution is reached and enacted.
Acknowledgment
The authors wish to acknowledge the support of Kristin Jamieson, Lauren McGregor, Michael Shapiro, Kristin M. Stagg, and Erin E. Kurtz for contributing their thoughts and perspectives to this manuscript.
Conclusion
Healthcare leaders and policymakers need to recognize the far reaching implications of decisions made throughout a repeal of the ACA. Abbott (2002) suggested any transformed ACA plan should require insurance providers to reimburse CAM treatments recognized as evidence-based, which would promote reduced overall healthcare spending and improved quality of life. Such endeavors would necessitate oversight by established government health regulatory agencies [26]. In any scenario, a significant shift in the national healthcare system is expected, requiring practitioners, hospitals, local and national health organizations to prepare for potentially unpredictable reforms [23]. Although patients and practitioners reliant on an enlightened approach to national health system might benefit from more empathy and engagement by current policymakers, perhaps the most effective process of change starts with the ultimate caretakers of the ACA - health practitioners and consumers. Whether a voting patient, practitioner, healthcare systems analyst, or politician, it is the duty of each to stay informed on and proactive with facilitating national healthcare improvements.

IM holds potential to improve and possibly reorient a troubled US healthcare system. Further investigations are needed to fully measure the cost benefits, but current indications validate IM as both cost efficient and better able to address chronic and mental health conditions unresponsive to conventional treatment. With growing academic evidence demonstrating efficacy and consumer preferences indicating acceptance, it appears healthcare systems and conventional medical providers are gradually accepting integration. Research and implementation measures indicate IM can fill gaps in conventional treatments, such as chronic cases, mental health conditions and pain management.

Conceivably, healthcare stakeholders should not rely on a governmental system more fragmented than the healthcare system, as the many potential advantages of IM offer rational alternatives. As preliminary indicators demonstrate cost effectiveness for IM, insurers and payers could independently act toward IM advancement. Much as optimal drug prices have been negotiated, payers could mediate IM services. For their part, IM practitioners could offset potential for silo-ism inherent in the diverse collection of practices and traditions taking steps toward interdisciplinary cooperation. But in the current state of confusion, the repeal or diminishment of the ACA could impact forward progress on all fronts. However, impeding the advancement of IM is only one of multiple complications; the impact of ACA repeal could reverberate throughout the US healthcare system for years. Perhaps all the stakeholders in this complex situation need to bear a portion of the responsibility.

References
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Figures


Figure 1: (a) Chemical structures of PAMPS48-PEG227-PAMPS48 (AEA) and PEG47-PMAPTACm (EMm, m = 27,53, and 106).
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 2: Time-conversion (?) and the first-order kinetic plots (?) for the polymerization of AMPS in the presence of CPD-PEG-CPD in water at 70oC.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 3: GPC elution curves for a sample of HO-PEG-OH (Mn = 9.40 ? 103; Mw/Mn = 1.06) (----) and triblock copolymer of PAMPS48-PEG227-PAMPS48 (AEA, Mn = 2.32 × 104; Mw/Mn = 1.42) (--).
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 4: 1H NMR spectra for (a) EM53, (b) AEA, and (c) AEA/EM53 micelle in D2O containing 0.1 M NaCl at 20°C. Assignments are indicated for the resonance peaks.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 5: (a) Light scattering intensities and (b) Rh for PIC micelles of AEA/EM106 (?), AEA/EM53 (?), and AEA/M27 (?) as a function of fAMPS (= [AMPS]/([AMPS] + [MAPTAC])) in 0.1 M NaCl aqueous solutions. [AMPS] and [MAPTAC] represent the concentrations of the AMPS and MAPTAC units, respectively. The total polymer concentration was kept constant at 1 g/L.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 6: (a) Distributions of Rh for the PIC micelles of AEA/EM106 (?), AEA/EM53 (?), and AEA/EM27 (?) in 0.1 M NaCl aqueous solutions. (b) Relationship between relaxation rate (G) and square of the magnitude of the scattering vector (q2). (c) Plots of Rh as a function of Cp.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 7: A typical example of Zimm plots for AEA/EM106 micelle in 0.1 M NaCl aqueous solution.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.



Figure 8: TEM images for (a) AEA/EM27, (b) AEA/EM53, and (c) AEA/EM106 micelles.
[M]0 and [M] represent the concentrations of the monomer at polymerization time = 0 and the corresponding time, respectively.

Tables
SamplesMn(theo)a × 10-4Mn(NMR)b ×10-4Mn(GPC)c ×10-4Mw/MncRhd (nm)?-potential (mV)
EM270.780.830.821.034.518.2
EM531.361.411.111.024.324.2
EM1062.522.581.511.026.125.4
AEA3.213.262.321.426.1-14.4
Table 1: Number-average Molecular weight (Mn), Molecular weight distribution (Mw/Mn), hydrodynamic radius (Rh), and ?-potential for the polymers.
aCalculated from Equation (2), bEstimated from 1H NMR, cEstimated from GPC, dEstimated from DLS.

PIC micelles Mwa × 10-5 Rga Rhb Rg/Rh Naggc dPICd

?-potential

(mV)
(nm) (nm)
AEA/EM27 8.48 15.1 15.2 0.99 50 0.096 -0.88
AEA/EM53 189 36.6 41.0 0.89 735 0.109 -0.53
AEA/EM106 111 28.6 32.4 0.88 302 0.129 -0.20
Table 2: Dynamic and static light scattering data for PIC micelles in 0.1 M NaCl.
aEstimated by SLS in 0.1 M NaCl, bEstimated by DLS in 0.1 M NaCl, cAggregation number of PIC micelles calculated from Mw(SLS) of PIC micelles determined by SLS and Mw of the corresponding unimers determined by 1H NR and GPC, dDensity calculated from Equation (3).

Citation: Kurtz RP, Fortune LD (2017) Implications of ACA Repeal: Effects on Integrative Medicine. J Altern Complement Integr Med 3: 029.