presented in a US medical industry that, despite reform efforts, remains organized more as a production-oriented industry than as a national healthcare system.
3.1 Introduction: The US Context
Presenting the 50-year history of the evolution of the movement for integrative health and medicine in the United States for a largely European audience requires some translation. The form and course of the movement resulted in part from mainstream policy realities in the US. A central factor was the peculiar circumstance that the US is alone among wealthy nations to not have a national healthcare system. Medicine in the United States is fragmented. While the past two decades show some signs of change, US medicine has been best characterized as a medical industry, focused on volume rather than value (Miller 2009).
This peculiar circumstance created both opportunities and obstacles for the emergence of the integrative movement. Competitiveness between hospitals and insurers created opportunities. The nominally not-for-profit medical institutions battle fiercely for market share. When a survey published in the New England Journal of Medicine in 1993 (Eisenberg et al. 1993) showed that over a third of adults were using some form of “unconventional medicine” spending $ 13.7 billion per year, the competing interests woke up. The competition was used as leverage by integrative health activists. Who wanted to be left behind if a competing hospital was developing an Integrative Medicine center, or an insurer a benefit plan that covered acupuncture or naturopathic medicine or chiropractic or massage?
Yet at the same time, the fundamentally capitalist motivation proved also to be a major obstacle to integrative health’s advance. The volume-oriented industry prefers the margins from high cost specialist services and tertiary care than primary care and community clinics. Pitches that lower cost, high touch, time intensive integrative services delivered in an outpatient clinic might cut needs for services ran squarely against the dominant business model in the volume-oriented industry. These so-called “perverse incentives” in medicine have proved an enduring barrier to optimal use of complementary and integrative practices and practitioners (Weeks 2015). A report on medical harm from inside the dominant school of medicine in 2000 began to open the dialogue. The effort to shift “from volume to value” known as “value-based medicine” or as the “Quadruple Aim” created more interest in integrative contributions (Bodenheimer and Sinsky 2014).
The history shared in this chapter is one of a convergence of these two movements to transform the medical industry. The focus is on the one that began in the grassroots. The other grew from inside organized medicine. The reformers in both camps recognized that the now $ 3.4-trillion US medical industry has a deeply troubling resume. A third to fifty percent of what is done in regular medicine is estimated to be waste, and much of it harmful (Boat et al. 2008). Public resources are siphoned into tertiary care rather than invested preventively in community medicine and public health (IHI Leadership Alliance [n.y.]). Researchers at Johns Hopkins estimate that patient-safety issues alone are such that the regular practice of medicine kills 250,000 annually (Makary and Daniel 2016). As this chapter will show, the worlds of value-based medicine and integrative health and medicine are increasingly aligned in an effort to shift the incentives of the medical industry toward a system that focuses on creating health.
3.2 A Brief History of Integrative Health and Medicine in 5 Eras
3.2.1 Era 1: Affirming New Values
The evolution of the field may be traced back to the flourishing of new sets of ideas and values in the cultural revolution that was the Sixties. While classified as a counterculture by the dominant school, it can be viewed today not as a reaction but as an affirmative expression of new ideas. Some of these new values link directly to the ideas and practices carried in integrative health: awakening awareness of Eastern culture and practices such as meditation and acupuncture; back-to-the-land respect for natural cycles; rise of environmental awareness and of adverse effects of chemicals; the woman’s movement and the respect for more supportive approach; and, the use of marijuana and the attendant interest in the potential medicinal value of herbs of various kinds.
Other Sixties influences had a more indirect relationship with what would become the movement for integrative health and medicine. The rise in globalization and thus multicultural diversity fostered an opening to diverse medical traditions. The social justice movement, like that of feminism, challenged white, patriarchal Eurocentrism. While producing multiple advances, the dominant medicine of the time was marred by a long list of negatives: physician-centric; specialist and hospital focused; male-dominated; white and racist; known for minimal interprofessional respect and often abusive toward other practitioners; disrespectful to possible contributions from other cultures; reductive; and, finally, diminishing toward both the public health and the behavioral and social determinants of health. In these areas of the conventional medical culture, the values for a new kind of more holistic health care that emerged in the Sixties were potential antidotes.
3.2.2 Era 2: Advancing in Silos (1980–1995)
To take ideas and advance them required organization. In the short period of a half decade starting in the late 1970s, individuals interested in advancing many of the ideas birthed in the cultural amniotic stew of the 1960s produced a remarkable grouping of formally disconnected organizations and initiatives that had in common interlinking values: American Holistic Medical Association (1978); American Holistic Nurses Association (1979); first naturopathic medical schools in 25 years (1978); patient-centered care (1978); pioneering mind body research publications (1977–1978); National Wellness Institute (1977); and the American Association for Acupuncture and Oriental Medicine (1981). These and others began serving as platforms for change.
The founding of many of these organizations led to engagement with self-regulatory responsibilities and regulatory activity. These established the professions of naturopathic medicine, acupuncture and East Asian medicine; massage therapy, and direct-entry midwifery. (Chiropractic claimed its place earlier.) In the United States, licensing is the responsibility of state legislatures in each of the 50 plus states and territories. This legal structure allowed small groups of practitioners, backed often by influential and grateful patients, to make regulatory advances. Table 1 describes some of these advances in development and accreditation of schools, licensing, certification, and growth of each profession’s numbers. At the same time, the period was marked by little collaboration between members of different complementary and integrative professions. They were working hard in separate silos.
3.2.3 Era 3: Non-Integrated Integration (1995–2010)
A turning point for this activity was a New England Journal of Medicine article, noted in the introduction to this chapter. The January 28, 1993 publication of the results of a nationwide survey from a Harvard University team led by David Eisenberg, MD catapulted the grassroots movement into visibility and onto the pathway to recognition and respect. That 34% of adults were using “unconventional” methods outside the mainstream and spending $ 13.7 billion each year changed the behavior of multiple stakeholders. These data gave the field legitimacy and began to shift behavior in hospitals, among insurers, in reporting in the media, among researchers, and in the interests of elected officials.
Tab. 1 Development of Standards by the Licensed Integrative Healthcare Professions (Clugston et al. 2017; this table is from the Clinicians’ and Educators’ Desk Reference [CEDR] which was developed by the Academic Collaborative for Integrative Health [ACIH, formerly known as ‘ACCAHC’ – https://integrativehealth.org])
