Should health-care reform require insurers to cover chiropractors? Acupuncturists? Yoga? Spiritual healers? These are the questions raised by a recently noticed health-care amendment requiring insurers to consider covering "religious and spiritual health care."
The amendment, covered in this article, comes with backing from Senate heavyweights like Orrin Hatch, John Kerry, and the late Ted Kennedy. And while it does not mention Christian Science by name, it's been widely interpreted as a protection of the church's prayer treatments, which it encourages as an alternative to medical help. Others have understood the provision as even more far-reaching as to include any health provider acting within the scope of their license.The Freedom From Religion Foundation has criticized the amendment as an unconstitutional violation of church and state.
Even with its powerful supporters, the amendment seems unlikely to make the final bill; Pelosi already dropped it from the House version. But just the suggestion of covering religious health care highlights a difficult question for reformers: how, exactly, does prayer fit into the president's support for evidence-based medicine? Or, more broadly, is there a place for any sort of unproven, alternative medicine, religious or otherwise, in health-care reform?
Requiring insurers to cover therapies with unknown outcomes runs counter to the White House's push for medicine with a proven track record. The basic idea behind evidence-based medicine is that doctors ought to use treatments that have the best possible evidence that they work. What counts as the best possible evidence? Randomized clinical trials. "The random clinical trial is the gold standard for any kind of medical knowledge," explains Stefan Timmermans, a sociologist at UCLA who has written extensively on evidence-based medicine. "They show whether treatment works and allow doctors to make decisions based on evidence."
Clinical trials work fine for drugs, where trials can quantify and compare outcomes. But for alternative treatments, things like prayer or even yoga, the evidence gets much less clear; randomized trials are more difficult to conduct. "For drugs you have placebos and double-blinded studies," says Timmermans. "But you cannot have a placebo for testing behavioral interventions." So alternative treatments are essentially on an uneven playing field when it comes to evidence-based medicine. Timmermans admits that "it's not an equal-opportunity methodology."
Religious organizations have attempted to run their own trials, to prove the efficacy of their methods, but none so far have panned out. "There's a big body of research trying to show that religion improves health, but there isn't much empirical evidence coming out of it," says Wendy Cadge, a sociologist at Brandeis who studies the relationship between religion and health care. "So that raises questions about how we as a society think about what should be paid for."
Requiring insurers to cover prayer treatment may be a bit too extreme for health-care reform. More interesting to explore though, are other forms of nontraditional medicine, floated in reform bills, that have a stronger claim to an evidence base. Take, for example, complementary and alternative medicine, a field often criticized for unproven therapies. Some 38 percent of Americans use some form of it. Moreover, the field has increasingly embraced traditional research methods. Just a decade ago, the government established a National Center for Complementary and Alternative Medicine. The center studies "alternative healing practices"—anything from the use of echinacea to treat colds, to acupuncture for irritable bowel syndrome—"in the context of rigorous science." They use that gold standard Timmermans mentioned: randomized, clinical trials.
So is complementary and alternative medicine deserving of a place in health-care reform? Depends whom you ask: the bill Sen. Tom Harkin introduced includes "licensed complementary and alternative medicine providers" in the definition of the "health-care workforce," but the consolidated House and Sen. Max Baucus bills do not. More so than the prayer provision, it will interesting to see how—or whether—alternative medicine fits into the final reform bill.