Public Health Cry, Sis

I remember reading the Little Red Book of Community Acupuncture, and later the Remedy and feeling really charged up about the revolutionary notion that we could change our health care system for the better. With a health care system as broken as ours, I suppose it’s not a tall order to make some positive change, especially on a personal level, but finally knowing that there were others out there wanting something more than a quasi-counseling/acu-guruhood was heartening. It was for me the first time I “got it,” that is that acupuncture wasn’t what I thought it was.

When we talk on the POCA blog and forums about “getting it,” that is getting what CA is about, there are a lot of different things that are indicators that people (punks, patients, communities) grasp the actual and potential benefits of community acupuncture. Early on a punk needs to get how broken and fucked up the acupuncture education system is; that they were led to believe, that acupuncture jobs existed that would off set their $80K acupuncture mortgage (lots of people have more student loan debt than that). A punk needs to get that CA might be the only way they get to actually have a job, a stable and ongoing job, a job that might allow them to get sick or take time off without having to close their business. A punk needs to get the realities of class values, and the household incomes for light to shine on the classist assumptions embedded in the acupuncture profession’s lame but ongoing cry for status and legitimacy or against patients who “just don’t value their health enough.”

It’s easier to get it if you, or anyone you know has ever dealt with chronic pain, medication that they can’t afford, treatments that are not effective, cause nasty side effects, or debt or bankruptcy connected to medical expenses. It’s also easier to get it if you or someone you know has gone without health care or health insurance because it wasn’t affordable.

The people that CA was designed to serve, especially working class or poor people, need to get that CA is something created for them. That it belongs to them, and they belong there. Punks, from a variety of different class backgrounds, need to get how class values, our own and others’, are reflected in the ways we make our clinics real- in every aspect from location, set-up, sliding scale, treatments, and how we talk about any of it. Every clinic that is successful (defined by people, and then lots of people, and then more people, getting acupuncture, as well as happy working punks and staff, and indicators of community building) is so because the different stakeholders getting it.

Another stakeholder is community. There is the immediate community of patients, punks, staff and all the people who come to the clinic or tell someone about the clinic or POCA, or POCA Tech. Our LOC maps with more pins and cards added each year makes it possible to see the links between the smaller and larger communities. There are other indicators; how many clinics can say that they’ve gotten referrals from doctors or counselors, or other providers that we don’t actually know? How is it that without even reaching out to these medical providers we are getting recommendations from them?

Over the past year many clinic have gotten more than just recommendations. We’re being pursued.
Here are a few examples: WCA has been working with Oregon’s medicare system for the past year, East Nashville had  satellite clinic in a corporate setting at the behest of eager and helpful patients, clinics on Cape Cod, in New Jersey are being consulted by hospitals starting CA programs,  Manchester was courted by Easter Seals to provide care onsite for people in recovery. During a 12 month period PCA launched a clinic inside a community health center with a $10K start-up incentive, the VA has started sending us (unsolicited) authorizations for vets to get treated at our clinic, and a local opiate treatment provider is working with us to figure out how they can get something set up for their patients.

It feels good to know we are not alone as providers searching for ways to create more care for patients. But I am cautious about the level of bureaucracy that ultimately can create obstacles to patient care in our setting, especially when these obstacles are imposed by the organizations or systems that want to partner with us.  But I still can’t help but wanting to try to figure out a way to work with them to get more people access to acupuncture. I have confidence in what we do since doing it has allowed our to provide almost 9x as many treatment in year 7 as in year 1. We are in a sense also bureaucratic and systematic, but we have been able to keep those things lean and simple. We have also been able to provide treatment that allows patients to figure out for themselves how acupuncture best works for them. The value of this cannot be underestimated, nor can our willingness, despite that all systems have some limits, to keep figuring things out.
[As a side note- ongoing and repeating themes of how to provide care to parents with children, people who can’t afford our sliding scales, people who have experienced trauma, etc. are a testament to this willingness to keep figuring things out.]

The willingness does not come without worry for me. I worry about having the resources to underwrite a second clinic or administer billing to the VA. I know how to do CA, I know how to do it well. I get it. I am trying to get what it would take to mesh with some other bigger delivery systems, and I don’t think that it is simply anxiety that gets in my way of finding a solution. Nor do I think that values between public health and CA are so skewed that solutions cannot be had. It’s more insidious than all of that. And it may also be just the reality that there are limits to all systems.

My anxiety comes at the place where we in following our mission, being willing to grow, change, and do things we didn’t necessarily expect to, like becoming employers, or starting a school, or a coop, meet up the existing health care systems that we want to see changed. Afloat on a sea of people in my community who need acupuncture our boat feels strong and directed. In the sea of managed care, reimbursement, billing, codes, claims, SS#s, etc. the wind seems to leave our sails.

CA doesn’t exist in a vaccum and was not meant to. But how do we build community with the public health sector? Is public health  a sub-sector of an exploitative, extractive health care system? Will public health needs be better addressed by mandatory insurance coverage and will the private insurance sector find a way to extract the government underwriting for those who would not otherwise be able to afford insurance? Could our clinics, or collectively our coop work with say billing the VA to treat vets without changing the pattern of the fractal too much? What then?

We already “community style” acupuncture where people cherry pick parts of “the business model” to suit their own needs. I’m all for sustainable jobs, but the heart of CA is patient care. What would community acupuncture look like cherry picked by a big organization?

We’re forging new relationships with other communities of scale that are much larger than our own. And this scale reminds me of the vision of the full blossoming of the seeds of change planted in all of us way back when all of this was first being conceived, or emerging as it were. What would it take to make community acupuncture so accessible that it was delivered in or by public health agencies? They would need to “get it” too. Some of the providers at the VA, or a federally funded community health center, or medicare, or a county medical agency that isn’t allowed by law to dispense narcotics to their chronic pain patients are starting to get it. They’re reaching out to us, on an individual level they get it, but I worry that they can’t get it on an institutional level because the only game they know how to play is a version of the for profit care system, perhaps with cheaper lobbyists and less powerful politicians behind them.

From my small experience in partnering with public health as a CA clinic there have been a lot of challenges that have been manageable to navigate: the evidence based mind-set, very different patient culture- poorer and sicker would be one way to describe the people we serve at our 2nd clinic. The administration and providers have been mostly very helpful and supportive in our experience, less so in other instances, but there have been limits to what we can sustainably provide.

New relationships are often rosy at the outset, and eventually we begin to see where the challenges lie. In our case we’ve been able to get a clinic open and running [link to clinic tour video] that can be packed up into a 50’sq. closet, in a relatively short amount of time. We’ve been able to reach more people and provide more relief. We’ve had a lot of social capital supporting us, and the initial funding allowed us to navigate the first 6 months without going into the red. But here we are now, underwriting our own clinic; something that if we weren’t hobbled by limited access to the days and times that we can use the space that houses the clinic, would be fine. But we can’t quite do what we know how to do under these confines. During the beginning of the relationship there was talk of a dedicated space and now we know that will never be so. Hindsight on this is frustrating. I know that they have their own limitations, they’re looking for more clinical space for their own providers at this location, We’ve just been told that they want us there enough to not completely kick us out of the room. We’re clearly in the next phase of our relationship now, and their measurement of whether it is “working” will be evidence based. Our measure would be to see the kind of growth we’d expect, especially with an additional sliding scale that was designed to further remove barriers to care.

In this instance I think they get that we aren’t in this to try to extract from their coffers beyond what it takes to keep things running. But cynically I wonder if maybe they’ve been competing with private insurance and providers for government funding for so long that there’s no way they could trust some weirdo-scruffy-commie acu-punks. But wait- how is it that they are pursuing us at the same time? Phermones?

Meanwhile back in the belly of the much fucked-up, is-it-defunct-yet?-FPD-pushing-acupuncture-profession, articles, workshops, and of course higher, more expensive, degrees are being touted as the solution to slow practices, and lack of respect from main-stream medicine. And a way to reach across the gap. I picked up Acupuncture Today the other day and I am not surprised, but still sorry, to find articles called “Don’t’ Trust What a Patient Says.” There’s drivel about the importance of knowing mainstream lingo: “I sometimes hear from a certain segment of the TCM profession how there is a kind of conspiracy against our acceptance and inclusion…By far, the biggest obstacle to inclusion within the main-stream is this communication chasm.” Reading this crap makes me realize that our relationship issues with public health are still better than having anything to do with the rest of the profession.

We know our health care system needs to change, things are bad enough for enough people that change has got to come some way. In a few years time the CA movement has figured out more than the rest of the profession has in 3 decades about providing care and creating livelihoods. We’re getting unsolicited attention from places that the rest of the profession keeps thinking it has to jump through bigger and bigger hoops to garner. And it’s a problem for us.

We’ve managed to be invited in without having to master medical lingo, or put on white coats. Quite the contrary. We’ve been welcomed in because what we do works. We get it, our patients get it, and people standing inside and aside these organizations that are beginning to either actively pursue us or patch together some kind of version of CA, are evidence that we’re doing something right. Collectively we can figure out how to fit these things together better, or to create on our end what is needed to provide ever more care without sinking our own vessels. The vessel, the container, that our clinics are manifestations of, the entity that creates the fractal if you will, is essential to our success. It’s very pared down, very simple, intentionally and it needs to maintain that if it will succeed in other environments, or it just simply needs to maintain in its own environments and to continue to welcome more and more people to those.

Stay tuned for the next decade or so and we’ll have this figured out, we meaning us,  and you too.

Author: crismonteiro

I've always thought that I would live to be 100 years old and now that I have an actual idea of what it might be like to inhabit this body for a century I want to be damn sure that Community Acupuncture is around to help me through my days and in the end, on my way. In the meantime, I am passionate about getting shit done, and also having fun.