A primer on health practitioner governance in the US.

In the US, health practitioner governance falls within state (rather than federal) jurisdiction. While laws governing health care workers today vary from state to state, all states have medical licensing regimes that legally constitute the practice of medicine “using such words as diagnosis, treatment, prevention, cure and prescribe” [7]. Across the US, the practice of medicine without a license is generally constituted as a crime; and US law entrenches conventional biomedicine as a normative reference point around which all therapeutic practices are governed. Several statutory modes of health practitioner governance have been implemented in the US, including: limited and unlimited licensure, mandatory licensure, title protection, statutory registration, certification, and licensing exemptions (negative licensing).

Biomedical physicians (MDs and DOs) are granted unlimited licensure across the country, granting them “broad leeway to diagnose and treat disease” [7]. Other health professionals, whether trained in biomedical and/or T&CM therapeutics—may also be subject to state licensing laws, but are generally granted limited licensure, authorizing “a narrower scope of practice” than biomedical physicians. Mandatory licensure, a construct entrenched in some health professional licensing statutes, explicitly stipulates that “an individual cannot practice without a state license”, often at peril of criminal prosecution [7]. Some states, conversely, use mechanisms of licensing exemptions, also referred to as negative licensing, to explicitly exclude certain practices that might otherwise be construed as falling under the scope of medical practice (e.g., bodily piercings, reflexology, massage therapy), leaving such practices in the public domain or carving out terrain for their governance by other means [7, 8]. Many health professional licensing laws also implement statutory title protection, whereby members of a particular licensed health profession have exclusive authority over particular the use of professional titles (e.g., Registered Nurse) and even the public use of particular language describing the work they do (e.g., nursing) [7]. Some states implement statutory registration, which in some states is a term synonymous with professional licensure; elsewhere, however, it may refer to a legal requirement for otherwise-unlicensed practitioners of a specified therapeutic approach to disclose, to a state agency, information about their qualifications to practice. Related, some states mandate that practitioners of specified therapeutic approaches document certification with a defined external agency but do not implement licensure for such practitioners. We endeavor to specify with clarity which of the aforementioned range of state governance approaches are being characterized in the study findings.

Professional entry into licensed health profession in the US is typically contingent on completion of uniform educational requirements stipulated in state statutes, rules and/or regulations. Such requirements (like statutory scopes of practice) may vary from state to state, even for a single occupation. In many cases, state regulators accredit or recognize particular educational institutions, or recognize the authority of educational accrediting bodies external to the state. State regulators may also sanction the authority of external (non-state) certification bodies to confirm practitioner qualifications for state licensure.

To better understand the statutory context of T&CM practitioner governance in the US, it is important to be aware of several T&CM-related contextual factors that may differentiate the US from other jurisdictions, in particular with respect to biomedical health professionals’ relationship to T&CM care. In particular, a group of laws exist in more than thirty US states that align with a principle dating back to the late 1800s, called ‘the Corporate Practice of Medicine (CPOM) Doctrine’. Such laws are designed to differentiate ‘regular’ biomedical physicians from so-called ‘irregulars’ (that is, T&CM practitioners), and include mechanisms that “prevent regular physicians from practicing with irregular practitioners” [9]. For example some states preclude medical doctors from being employed by chiropractors, or prevent chiropractors from “having direct ownership interests in medical practices” [9]. Although the full impact of CPOM Doctrine is beyond the present work’s scope, we provide an overview, in what follows, of a range of the degree of institutionalization of T&CM approaches within key conventional biomedical professions, and of other key elements of the T&CM regulatory and reimbursement landscape in the US today.

Biomedical doctors.

In the US, there exists a subset of conventional biomedical physicians—widely referred to as ‘integrative’ physicians—who variously include T&CM therapeutic approaches in their clinical work. It is important to note that in the US, the category of conventional biomedical physician includes, by definition, two distinct occupations: licensed ‘medical doctors’ (MDs) and ‘licensed osteopathic physicians’, that is, doctors of osteopathy (DOs). While the two groups were historically distinct, and continue to be educated at different institutions, their licensure is considered legally equivalent across the country [10, 11]. Although ‘osteopathic manual therapies’ (considered by the WHO to be a T&CM approach) continue to be taught in US medical schools that train DOs, these therapies are no longer widely-used by such physicians [12]. As such, the DO credential in the US should not be conflated with statutory recognition of osteopathic manual medicine practitioners, who are not otherwise subject to licensure in the US today; furthermore, licensed DOs should not be presumed to necessarily practice in an ‘integrative’ manner.

In 2014, the American Board of Physician Specialties—one of two major specialty-granting bodies for MDs and DOs across the US—recognized ‘integrative medicine’ as a new specialty, which continues to be governed under the auspices of the American Board of Integrative Medicine [13]. Eligible integrative medicine specialists must be licensed MDs or DOs who have additionally completed defined training in complementary and integrative medicine, as well as a standardized examination. However, the legal position of individual MD/DO’s who wish to incorporate unconventional therapies into clinical practice rests on interpretation of individual state medical practice acts, as well as related policies and practice standards.

We are unaware of any prior analysis of state policies or practice standards with respect to conventional doctors’ integration of T&CM therapies into clinical practice. However, in 2002, the US Federation of State Medical Boards published a policy document entitled, ‘Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice’ [13]. This policy, meant as a template for state medical boards, both “allow[s] a wide degree of latitude in physicians’ exercise of their professional judgment” and recognizes patients’ “right to seek any kind of care for their health problems”. The policy emphasizes that unconventional treatments offered by physicians should “have a favorable risk/benefit ratio compared to other treatments for the same condition; be based on a reasonable expectation . . .[of] a favorable patient outcome” and be expected to yield “greater benefit . . .than . . .no treatment” [14].

As detailed further on in the present work, there are some areas of T&CM practice (e.g., acupuncture, homeopathy) for which particular state regulators for MD/DOs have made explicit statutory stipulations.

Nurses.

In the US, licensed nurses who incorporate T&CM approaches into their work are widely referred to as ‘holistic nurses’. Since 2006, the American Nurses Association—the nation’s primary professional nursing association—has recognized Holistic Nursing as a distinct nursing specialty. The specialty is accompanied by a specified scope and practice standards, which includes several T&CM health practices (e.g., meditation, yoga, energy therapies [14]). Another nursing specialty recognized by the American Nurses Association with some overlap with holistic nursing is known as ‘faith community nursing’ [15]. However, individual nurses must adhere to the scope of practice stipulations articulated in their state nursing practice acts. Stipulations related to the practice of holistic nursing vary by state. According to a 2021 analysis conducted by the American Holistic Nursing Association [16], seventeen US states including explicit reference to holistic nursing practices in their nursing practice legislation and/or related policy documents. While we will not elaborate further on these points here, we note further on in the present work that some state laws include acupuncture within the scope of advanced nursing professionals (‘nurse practitioners’), who receive additional graduate level training in nursing. In addition, as detailed further on, nurses with additional childbirth-related training may be licensed as nurse-midwives across all US states.

Dentists.

Although some US dentists incorporate T&CM therapeutic approaches into their clinical practices, and/or practice in ways otherwise distinct from their profession’s standard of practice, the US profession of dentistry does not currently recognize holistic or integrative dentistry as a specialty field. In 2011, the American Dental Association released a policy statement on complementary and alternative medicine in dentistry, which characterizes “interventions which are considered CAM” as “understudied interventions that require further scientific testing” [17]. In that same statement, the Association characterizes “the notion of CAM as a specific subset of interventions that belong to a specific discipline” as “questionable”.

Prior US-focused scholarship about T&CM practitioner governance.

Several scholars have previously reported on particular aspects of T&CM practitioner governance across the US, including studies addressing the overall regulatory contexts for such practitioners in the late 1990s and early 2000s [17]. Herman and Coulter have, more recently, provided an overview of the complex T&CM policy landscape in the US, pointing to tensions that arise as a result of differential licensure patterns across states and, in particular, whether T&CM practice is defined in policy as a ‘modality’ (e.g., acupuncture, massage therapy) or as part of the scope of a broader profession (e.g., acupuncturist, massage therapist) [18–20]. We discuss this issue again further on with respect to the context for T&CM reimbursement in the US.

In addition, a few recent studies specifically address the US context of acupuncture governance, including with respect to: statutory provisions governing licensed acupuncturists trained in East Asian medicine approaches, acupuncture-practising biomedical health care professionals [10], and providers of auricular (ear) acupuncture [21]; as well as studies characterizing the US acupuncturist workforce context, pointing both to significant growth within that occupational group over the last two decades [22], significant differences in practice acts by state, and to the current absence of rigorous related demographic and income data [23]. Other scholarly works address the historical and contemporary contexts of midwifery governance; a growing trend toward statutory governance and reimbursement of birth doulas [21]; chiropractic credentialing and scopes of practice [24]; licensed massage therapists’ vulnerability to sexual harassment and solicitation within a broader context wherein sex trafficking operations misrepresent themselves as massage therapy businesses [24] ; the potential for naturopathic doctors working as primary care providers to reduce health professional shortages [25]; legal issues surrounding medical doctors’ use of T&CM practices; and, ‘safe harbor’ state laws enabling the limited practice of T&CM therapies by unlicensed practitioners [26]. A few studies furthermore point to a broader context of unlicensed T&CM practitioners offering care across the US [27], whether as herbalists, yoga therapists, mindfulness educators, Ayurvedic practitioners or faith healers ; in the form of bodywork practices that fall outside of massage therapy’s legal boundaries [28]; or, with respect to the wide range of traditional/Indigenous therapeutic practitioners who offer care within ethno-specific communities [29]; at times in collaboration with biomedical professionals [30].

In addition to the aforementioned studies, grey-literature and other online reports by non-governmental organizations have addressed, in various formats, the legislative standing and/or reimbursement contexts of particular T&CM occupational groups, including acupuncturists [19, 31–40], birth workers (e.g., midwives and doulas ) [38, 41–49], chiropractors [50–61], homeopaths [62], massage therapists and bodyworkers [60, 63–75], naturopaths [56, 76–82], and psychedelic facilitators [83–86], as well as otherwise-unlicensed practitioners [e.g., 87]. To date, however, there has been no comprehensive account of the overall picture of statutory governance with respect to T&CM practitioners in the US, one of the gaps the present work aims to address.

The present study’s other major aim is to provide an overview of government reimbursement, and/or government-mandated reimbursement of T&CM services in the US, another area where prior scholarship remains patchy. Before turning to the study methods, we provide readers with an overview of the US health care reimbursement context, with reference to related scholarship addressing T&CM care.

Publicly-funded health care in the US.

There are five major programs in the US under which government funds subsidize health care costs: Medicare, Medicaid, Indian Health Service, Tricare, and the Veteran’s Health Administration. Each has its own associated set of reimbursable services, payment calculation approaches, and reimbursement mechanisms.

Medicare and Medicaid are health insurance programs meant to support access to health care by members of particular vulnerable populations. Medicare is a federal government health insurance program for persons aged 65 and older, and some persons with disabilities, offering coverage for hospital-based care, a defined set of outpatient medical services and supplies, and the cost of prescription drugs. Medicare beneficiaries pay monthly premiums to retain access to certain aspects of their coverage, also contributing ‘co-payments’ or ‘deductibles’ for some insured services. Medicare recipients may choose to access their benefits directly from the federal government (‘Original Medicare’) or through a Medicare-approved plan implemented by a private company (‘Medicare Advantage’) [88]. Medicaid, a health insurance program administered at the state (rather than federal) level, which subsidizes health care costs for some low-income people. Currently Medicaid programs are in place in all states. Medicaid benefits may be delivered directly by state governments or through ‘Managed Care’ programs in which, under ‘waiver’ agreements with the federal government, private insurance companies (who receive monthly premiums from state governments) deliver Medicaid benefits directly to eligible beneficiaries. While federal law mandates some health care services that must be covered by state Medicaid programs (e.g., hospital, physician and laboratory services), other benefits are optional (e.g., prescription drug coverage, dental and vision care). Medicaid benefits thus vary by state [89].

The US government additionally funds three distinct health programs—Indian Health Services, Tricare, and the Veterans Health Administration—each of which exclusively serves a particular US sub-population and has a defined set of ‘funded’ health services. Indian Health Services, administered as a division of the US Department of Health and Human Services, provides healthcare free of charge to Native American and Alaska Native people across the country, through a network of hospitals and outpatient centers. Eligible persons may receive inpatient and outpatient care for a defined set of services within a network of Indian Health Service and tribal medical facilities [90]. Tricare is a federal health care program, operated by the Department of Defense, which subsidizes specified civilian health and dental care and prescription drug costs for active-duty military service members, National Guard and National Reserve members, retirees, and their families [91]. With respect to care defined as medically-necessary, many beneficiaries are subject to an annual ‘deductible’, a co-pay portion for some services or prescriptions, and in some cases, an annual enrollment fee and/or monthly premium. The Veterans Health Administration is a national healthcare program that delivers outpatient care to US military veterans at a network of Veterans Affairs hospitals and outpatient clinics staffed by government employees. Eligible veterans may pay ‘co-payments’ (but no premiums or deductibles) for a portion of some kinds of eligible care costs.

A few previous studies address government reimbursement of T&CM care through the aforementioned programs. One study observes that chiropractors—who are constituted as physicians under Medicare laws—are the only licensed T&CM profession in the US to be eligible for direct reimbursement by Medicare; “an act of Congress” would be required to directly reimburse other T&CM professionals. Similarly, “some state Medicaid systems limit coverage to the provider types listed by Medicare”[9].

Other research addresses a recent trend toward coverage of non-pharmacological pain treatments (including various T&CM services) in the context of the ongoing opioid crisis [92–95]. Two recent studies provide detailed nationwide analyses of existing government reimbursement of non-pharmacological pain treatments; these works document a high degree of heterogeneity with respect to T&CM coverage across states and within federal programs [92, 96]. T&CM services covered by Medicaid in some but not all states and/or in some federal government programs include spinal manipulation, acupuncture, massage therapy, mindfulness and meditation, t’ai chi / qi gong, and yoga. Two other studies specifically report on the impacts of the state of Oregon’s inclusion of T&CM services for back pain within state Medicaid plans. As in prior studies documenting a connection between private insurance coverage for T&CM care and usage of such services [97, 98], Choo and colleagues observed [93, 95] an increase in T&CM service uptake among Oregonians following Medicaid inclusion [95]. However, uptake was not even across all demographics, with heightened increases observed among female, urban and older populations (and lesser uptake among “Black, American Indian / Alaska Native, and Hispanic [Medicaid] enrollees” [95].

It is important to note that the Veterans Health Affairs network include eighteen ‘Whole Health’ flagship sites across the country, along with thirty additional ‘Whole Health’ design sites, all “focused on . . .a personalized health plan that considers the physical, mental, emotional, spiritual and environmental needs of Veterans”. ‘Complementary and Integrative health’ is constituted as a central aspect of the Whole Health model, with some T&CM professionals being hired on a salaried basis at Veterans Health Affairs sites [9]. In addition, some Veterans Affairs sites include ‘healing lodges’, where Native American traditional healing ceremonies (e.g., sweat lodges, talking circles) take place for veterans; at least one such site was purpose-built using government funds [99, 100].

Statutory provisions for commercial health insurance.

Statutory provisions have been implemented both at the US state and federal levels that require private insurers, in particular cases, to reimburse T&CM practices and/or practitioners. These include two primary mechanisms: non-discrimination provisions, and essential health benefits.

As Herman and Coulter have observed, the reimbursement landscape for T&CM care in the US is rendered complex by the fact that third-party insurers may reimburse for particular ‘modalities’ (e.g., massage therapy, acupuncture) but not always recognize particular professional groups (licensed massage therapists, acupuncturists) as eligible providers of the services they are qualified to offer [9]. Non-discrimination provisions statutorily mandate commercial insurance companies to ‘not discriminate’ between licensed health care providers when reimbursing for particular insurable services. In 1996, for example, the state of Washington introduced a non-discrimination provision requiring private health insurance companies to cover services determined to be insurable, whether delivered by by biomedical professionals or by licensed T&CM professionals (e.g., chiropractors, acupuncturists, naturopathic doctors, massage therapists) [101–104]. Similarly, over forty states require that private insurers cover chiropractic care, at least eight have required reimbursement of licensed acupuncturists, and at least one additional state requires coverage of naturopathic care [103–105]. Further, in 2014, non-discrimination provisions were introduced under section 2706 of the federal Affordable Care Act [106]; these provisions aimed to prohibit private insurers from “discriminating against [T&CM] providers who are acting within the scope of their licenses” with respect to similar services otherwise reimbursed for conventional biomedical providers. However, implementation of the federal non-discrimination provision has been uneven across states [107], owing to the provision having been “written in such a way that may limit its impact on coverage decisions” [9]. Further, even where non-discrimination provisions have been implemented at the state level, many insurance companies continue to reimburse differentially between different types of providers (e.g., paying medical doctors more than chiropractors for the same service) [103, 107, 108].

Another type of statutory provision potentially impacting coverage of T&CM services involves ‘Essential Health Benefits’ (EHB), which refer to a “basic set of insurance benefits” included in private health insurance plans under a mandate under the Affordable Care Act [94]. In a state-by-state analysis of the inclusion of non-pharmacological treatments for low back pain within EHB benchmarks showed that spinal manipulation for low back pain (e.g., chiropractic or osteopathy) was included as an EHB in forty-six states. Hopes for increased T&CM coverage under EHB requirements were high when the Affordable Care Act (which has been since been modified in various ways) was first introduced [109]. However, despite a 2017 evidence-based guideline released by the American College of Physicians that recommended use of several T&CM approaches for low back pain (e.g., acupuncture, massage, yoga, tai chi), such have to date been included in “fewer than 10 states’ benchmarks plans”, often with “caps . . .placed on the number of treatments” [96].

Governance, protected titles and scope.

Licensed acupuncturists. Acupuncture practitioners trained in East Asian traditional approaches are licensed almost universally across the US, in forty-seven states, DC and four territories. The most commonly-used statutory title for traditional acupuncturists in the US is Licensed Acupuncturist (LAc). However, a few jurisdictions use alternate or additional titles; for example, Registered Acupuncturist (RAc) in the state of Colorado, Acupuncture Physician (AP) in Florida, and Doctor of Acupuncture (DAc, DAcu) in Hawaii, Rhode Island and Florida. In thirty states, the practice of Chinese herbal medicine is included in the statutory scope of practice of Licensed Acupuncturists.

Auricular acu-technicians. Twenty-four states have introduced statutory provisions to permit persons otherwise not licensed in acupuncture to practice auricular (ear) acupuncture, also termed the ’5-needle protocol’ (5NP), to treat persons with mental health conditions, addictions, pain and trauma. Statutory provisions in fourteen of these states permit lay persons with defined training to perform the 5NP, usually under the supervision of a licensed acupuncturist or a medical doctor. Nine states permit auricular acupuncture provision by certain health care professionals (e.g., nurses, physician assistants, occupational therapists, emergency medical services professionals, correctional medical providers), mental health care professionals (e.g., psychologists, counsellors, therapists), and/or social service professionals (e.g., social workers). Some jurisdictions have implemented restricted titles for exclusive use by auricular acupuncture practitioners certified, registered or licensed by the state; these titles include Licensed Auricular Detoxification Specialist and Licensed Auricular Detoxification Technician.

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Table 1. Statutory governance and reimbursement profile of traditional and complementary medicine occupations in the United States.

https://doi.org/10.1371/journal.pgph.0001996.t001

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Table 2. Training requirements for major licensed T&CM professions in the US.

https://doi.org/10.1371/journal.pgph.0001996.t002

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Table 3. Demographic features of major licensed T&CM professions in the US.

https://doi.org/10.1371/journal.pgph.0001996.t003

Non-acupuncturist health care professionals. As shown in Table 4 and on Fig 4, several licensed health care occupations are permitted, in some states, to practice acupuncture (or similar techniques involving the bodily insertion of filiform needles, such as dry needling and ’meridian therapy’) more broadly within their scopes of practice. No additional protected titles are known to be implemented in these cases.

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Fig 4. Legal practice of acupuncture & related techniques (e.g., Dry needling) in the United States.

https://doi.org/10.1371/journal.pgph.0001996.g004

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Table 4. US jurisdictions legally sanctioning the use of acupuncture (or similar practices) in the scope of non-acupuncturist health care professionals.

https://doi.org/10.1371/journal.pgph.0001996.t004

Professional entry requirements.

Licensed acupuncturists. While training requirements vary somewhat by state, licensed acupuncturists across the US generally complete a minimum of 1900 hours of related training, along with a professional entry exam. Candidates for acupuncturist licensure in all jurisdictions except California are required to complete at least three of four national certification examinations delivered by National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). These examinations, which are available in the English, Chinese and Korean languages, address: a) East Asian medical theory; b) Biomedical sciences; c) Acupuncture and point location; and d) Chinese herbal medicine. Across the thirty states that include Chinese herbal medicine within the licensed acupuncture profession’s scope of practice, twelve require completion of the NCCAOM’s Chinese herbology exam in order to practice. The state of California’s Acupuncture Board administers an independent licensing examination—offered in English, Mandarin (Chinese) and Korean languages—to candidates in that jurisdiction; Chinese herbal medicine is included within that state’s acupuncturist scope.

Auricular detoxification practitioners. Training requirements for auricular detoxification practitioners vary by state, but generally require completion of trainings lasting at least three full days; some jurisdictions require certification with particular organizations (e.g., NADA), and some explicitly require additional completion of clean needle training.

Non-acupuncturist health care professionals. As shown in Table 4, statutory training requirements for non-acupuncturist, licensed health care professionals who are permitted to use acupuncture needles in their clinical scope vary considerably by profession and by jurisdiction.

Reimbursement. Medicare-eligible persons with chronic low back pain may be reimbursed for 12 acupuncture sessions over a 90-day period, which may be extended to a maximum of 20 treatments over twelve months if improvement is evident. However, it is important to note that licensed acupuncturists may not directly bill Medicare. As such, the care of licensed acupuncturists may only be reimbursed by Medicare if performed under the direct supervision of a billing provider (e.g., MD/DO, nurse practitioner); further, the reimbursement rates vary between different types of providers. Acupuncture services for pain and other conditions (by licensed acupuncturists, medical doctors and chiropractors) are widely available at Veterans Affairs Medical Centers and sometimes also reimbursed for veterans receiving care at other health care facilities. In addition, auricular acupuncture treatments (termed ‘battlefield acupuncture’ in this context) are made available at many Veterans Affairs facilities and, depending on local state laws, may be additionally delivered by health professionals other than those listed above. While Tricare does not generally cover acupuncture, some major Tricare facilities, such as the Integrative Health and Wellness service at the Walter Reed National Military Medical Center, and the Acupuncture and Integrative Medicine Center at Joint Base Andrews, do include acupuncture (for a variety of conditions) in their reimbursed offerings. In addition, ongoing acupuncture and auricular acupuncture training for medical professionals are offered at Walter Reed.

Governance, protected titles and scope.

Midwives. There are three distinct pathways to midwifery licensure in the US, each with its own protected titles, scope of practice and professional entry requirements. The first group of statutorily regulated midwives, who are universally licensed across all states and territories and DC, also hold a Registered Nurse license. They typically carry the protected title of Certified Nurse-Midwife / Certified Registered Nurse Midwife (CNM) or, in some jurisdictions, the titles of Licensed Nurse-Midwife (LNM) or Nurse Midwife. The second and third groups of midwives, together characterized as ‘direct-entry’ midwives, do not carry nursing credentials; and are often identified using the protected titles of Licensed Midwife (LM) Registered Midwife (RM) in the jurisdictions where they are regulated. One group of direct-entry midwives, who typically earn a ‘Certified Midwife’ credential, are licensed across nine states and DC; the other group, referred to as Certified Professional Midwives (CPM), are licensed in 35 states and DC.

All three types of licensed midwives have similar scopes of practice with respect to supporting pregnancy, childbirth and postpartum care. However, CNMs and CMs additionally have hospital-attending privileges, as well as statutory authority to provide comprehensive health care across the lifespan, including diagnosis and treatment (e.g., medication prescribing). While CPMs do not generally have medication-prescribing authority, they may access and administer certain otherwise-restricted medications in some states; CPMs are also the only group of the three trained to attend births outside of hospital settings.

Across the US, there remain midwives—usually referred to as traditional midwives—who for reasons personal, religious or philosophical, may elect not to become formally credentialed or licensed. Such midwives risk criminal prosecution for practicing nursing or medicine without a license, as do CMs and CPMs in jurisdictions where direct-entry midwives are not licensed.

Naturopaths. In six of the 26 states with naturopathic medical licensure laws (elaborated further on), naturopathic doctors who have completed additional training in ‘naturopathic obstetrics’ may attend childbirths (much like midwives) within the scope of their naturopathic professional license.

Birth doulas. Birth doulas are not licensed anywhere in the US, but are increasingly recognized in statute, generally with the aim of providing Medicaid reimbursement for doula services. In nine states and DC, Medicaid programs are actively reimbursing doula care following related legislation. The regulatory landscape in this area is rapidly changing, with new developments emerging at the time of this work’s publication. Four states have for example passed legislation to reimburse doula care but implementation is not yet complete. As elaborated in the section on reimbursement below, additional related reimbursement programs (not formally entrenched in statute) are in place in other states as well.

Three states (Arizona, Louisiana, and Washington) have also introduced voluntary state registries for birth doulas with the aim of exploring Medicaid reimbursement in future; and Colorado has uniquely implemented a statutory provision that permit doulas (as non-medical personnel) to attend hospital births where only family members were previously permitted to be present.

Professional entry requirements.

Midwives. Educational pathways differ considerably for the three statutorily-recognized categories of midwives in the US. Certified Nurse-Midwives are uniquely required to hold a Registered Nurse license in addition to their midwifery credential. Aside from this requirement, however, pathways to licensure for Certified Nurse-Midwives and Certified Midwives are similar. Licensure candidates in both groups must complete a graduate-level degree program recognized by the Accreditation Commission for Midwifery Education (ACME) (lasting a minimum of 24 months), and a licensing examination administered by the American Midwifery Certification Board.

There are, by contrast, multiple routes to candidacy for the Certified Professional Midwife credential, which is widely-recognized by regulators in states where direct-entry midwives are licensed. Formal training options include completion of: a) a graduate-level degree program recognized by ACME (as above), along with documentation of at least ten non-hospital based birth experiences; or, b) a midwifery education program (usually lasting at least three years) recognized the Midwifery Education Accreditation Council. Another option, in particular for experienced, apprenticeship-trained and internationally-trained midwives, is to successfully complete a portfolio evaluation process through the North American Registry of Midwives (NARM). All certification candidates (both formally-trained and portfolio-validated) must subsequently complete a certification examination administered by NARM.

Naturopaths. Naturopathic Doctors licensed in the six states whose practice scope stipulations include naturopathic childbirth attendance as an optional certification are required to complete additional training, along with an examination administered by the American College of Naturopathic Obstetricians. Educational requirements stipulated (beyond standard naturopathic training) by individual states range from 100 (California, Montana, New Hampshire, Utah) to 200 (Oregon, Vermont). These didactic requirements are typically paired with a requirement to attend a minimum number of childbirths, which vary from 15 (Utah, California) to 50 (Montana, Oregon, Vermont).

Birth doulas. Most jurisdictions where birth doula services are eligible for Medicaid coverage have implemented voluntary state registries where birth doulas seeking reimbursement privileges may be listed. Inclusion on a state registry is generally contingent on a birth doula’s adherence to state-specified training standards; some states (e.g., in Maryland, Minnesota) require instead that Medicaid-eligible doulas be certified with external (i.e., non-governmental) organizations such as (e.g., DONA). Generally speaking, training requirements for Medicaid-eligible birth doulas are in the 16-hour range, while some states require more extended training (e.g., Oregon, 40 hours). Some states (e.g., California) also offer an ‘experience pathway’ to Medicaid-eligibility, contingent on prior documented work as a birth doula (rather than formal training).

Reimbursement.

Midwives. Third party reimbursement for midwifery varies considerably by licensure type, with care provided by Certified Nurse-Midwives being most extensively covered. Certified-Nurse Midwives are eligible for Medicare and Tricare reimbursement federally, a privilege not granted to licensed, direct-entry midwives. Medicaid programs in all US states similarly reimburse care delivered by Certified Nurse Midwives; however, Medicaid coverage extends to Certified Midwives and Certified Professional Midwives in just five and thirteen states, respectively. While most private insurance plans across the US reimburse care provided by Certified Nurse-Midwives and Certified Midwives, only six states mandate private coverage for Certified Professional Midwives.

Birth doulas. As noted earlier on, Medicaid coverage for the work of birth doulas is ongoing in nine states and DC, with implementation in process in four more states. In three more states (Kentucky, Missouri and Texas), Medicaid coverage for doula care is not entrenched in statute, but some managed care organizations nonetheless offer reimbursement to Medicaid recipients who receive doula services. In New York City, a municipal initiative is in place to reimburse doula services for Medicaid recipients, but no related legislation is in place in New York state as a whole. Seven states (Delaware, Georgia, Iowa, Massachusetts, Oklahoma, Tennessee, Texas), and the federal Tricare program, have pilot programs or research studies presently underway to explore reimbursement for doula care.

Governance, protected titles and scope.

Chiropractors are regulated across all 50 US states, the District of Columbia and five territories. Across these jurisdictions, chiropractors are authorized to use the protected title of Doctor of Chiropractic (DC). Chiropractic scopes of practice vary by jurisdiction, with spinal manipulation, physical examinations, and the use of diagnostic imaging (e.g., x-ray, CT, MRI, ultrasound), blood analysis, lifestyle counseling, nutrient supplementation being almost universally included. Many jurisdictions also include additional diagnostic procedures (urinalysis, fecal analysis, throat swab, pre-employment physicals, breast and genital exams) and treatment options (e.g., magnetic therapy, short wave therapy, massage, homeopathy, colonic irrigation) within the scope of chiropractic practice. Chiropractors are permitted to practice acupuncture (and/or related practices such as dry needling) is permitted in about two-thirds of jurisdictions. A wide range of additional diagnostic and treatment approaches are included in chiropractors’ scope in a minority of jurisdictions (e.g., hypnosis, electrolysis, minor surgery, limited drug prescribing, vitamin injection). In six states, chiropractors are recognized as primary care providers.

Chiropractic Assistants are recognized in statute in thirty jurisdictions. While the parameters of the Chiropractic Assistant role vary by state, commonly-delegated tasks include patient history taking and administration of low-risk therapeutic procedures. Three states license Chiropractic Assistants; Washington state, an outlier, licenses Chiropractic X-Ray Technicians as a standalone profession. Elsewhere, state ‘certification’ or ‘registration’ is granted to Chiropractic Assistants who meet professional entry requirements. The state of Louisiana uniquely uses a state certification mechanism to govern Chiropractic Assistants with an exclusive focus on the conduct of chiropractic x-rays.

Professional entry requirements.

Educational requirements for professional licensure of chiropractors are uniform across the US, consisting of: a) Four to five years (4200 hours) of formal training at one of twenty educational institutions accredited by the Council of Chiropractic Education; and, b) a professional entry examination delivered by the National Board of Chiropractic Examiners. Licensure and state certification/registration requirements for Chiropractic Assistant vary across the country. Many jurisdictions require that Chiropractic Assistants meet minimum, jurisdiction-specific training requirements (e.g., Mississippi, Oklahoma, Tennessee, South Dakota, North Carolina, Oregon). Other states (e.g., Idaho, Ohio) statutorily recognize Chiropractic Assistants but stipulate no minimum training requirements.

Reimbursement.

Some aspects of chiropractic care are eligible for reimbursement through the federal Medicare and VA insurance programs; and in 41 states, through Medicaid as well. While Chiropractors (who are considered physicians under Medicare) may bill Medicare directly for their services, chiropractic services eligible for Medicare coverage are limited to spinal manipulation. By contrast, veterans may access a range of chiropractic services—including spinal manipulation, manual therapies, acupuncture, and other non-pharmacologic approaches—at VA health facilities and VA-affiliated community care settings. While chiropractic care is not reimbursed by Tricare, active-duty service members and activated national guard/reserve members of the US military may access chiropractic care by referral at specific military hospitals or clinics. Across the 43 states where chiropractic care is eligible for Medicaid coverage, benefits vary: ranging from eight to fifty treatments per year, and/or at times limited to a specific dollar amount (e.g., Mississippi, $700). Chiropractic care is also widely reimbursed by private insurance across the United States.

Governance, protected titles and scope.

Homeopathy is not regulated as a standalone profession in any US jurisdiction. However, homeopathic practice is recognized in statute in several states. In jurisdictions where naturopathy is licensed, homeopathy is included within that profession’s scope; a few states also include homeopathy within the statutory scope of licensed acupuncturists, chiropractors and other regulated professionals. Furthermore, three states (Arizona, Connecticut and Nevada) license medical doctors (MDs and DOs) who wish to specialize in homeopathy using the protected title of ‘Homeopathic Physician’. Arizona and Nevada furthermore provide statutory certification/registration to non-physician ‘Homeopathic Assistants’ working under the supervision of a Homeopathic Physician.

Professional entry requirements.

Medical doctors (MDs/ DOs) seeking licensure as Homeopathic Physicians in their states must fulfill postgraduate training requirements in homeopathy in addition to being in good standing with their state medical boards. These requirements vary from state to state; and range from 120 hours (Connecticut) to 600 hours (Nevada), with some states additionally requiring a licensing examination. Homeopathic Assistants training requirements range from 200 to 400 hours.

Governance, protected titles and scope.

Massage therapy is statutorily regulated almost universally across the United States, in 47 states, DC, and two territories (Puerto Rico, US Virgin Islands). Regulation across these jurisdictions is primarily implemented via licensure regimes, except in the state of California, where massage therapists meeting defined entry requirement may voluntarily certify on a state registry. Currently, Kansas, Minnesota and Wyoming are the only US jurisdictions that do not statutorily govern massage therapy practitioners. Forty-four US jurisdictions protect the title of Licensed Massage Therapist (LMT) in statute for the profession’s exclusive use; other, less frequently used protected titles include CMT (Certified Massage Therapist), RMT (Registered Massage Therapist) and MMT (Master Massage Therapist). In addition to restricting these titles, some state regulations restrict use of the term ‘massage’ in the context of a paid service for exclusive use by licensed massage therapists.

Statutory definitions of massage therapy vary across jurisdictions. Many states constitute licensed massage therapy as a structured system of touch to the soft tissues; such touch is often characterized as having the purpose of relaxation, promotion of well-being, along with therapeutic effects. While many statutes characterize massage therapy as a health care service / treatment, licensed massage therapists do not have statutory authority to diagnose or treat disease. However, in several states, statutes indicate that licensed massage therapists may ’treat dysfunction’, ’provide pain relief’ or ’enhance tissue function’ based on an ’assessment’ of the client’s bodily condition. Many state regulations demarcate a set of specific practices as falling within the boundaries of licensed massage therapy; these commonly include manual therapy techniques (e.g., pressure, compression, kneading, stretching), the application of heat or cold, and topical applications.

Several states also make explicit which ’styles’ or ’systems’ of bodywork (and at times, other practices) are or are not included within the profession’s statutory scope. Alaska, for example, delineates the massage therapist profession as exclusively governing the practice of ’traditional European or contemporary western massage therapy’, while explicitly excluding the bodywork practices of structural integration (’Rolfing’), reflexology, and the ’traditional practices of Native American traditional healers’. Hawaii uniquely includes Lomilomi (an Indigenous Hawaiian form of bodywork) within massage therapists’ statutory scope. In at least nine states, practitioners of several systems of Asian Bodywork Therapy may be licensed under state massage therapy boards along with practitioners of ‘Western’ styles massage therapy. In Washington DC, the state statute includes an extended list of bodywork styles that fall under massage therapy’s auspices (including but not limited to "Rolfing, Neuromuscular Therapy, Shiatsu or acupressure, Trigger Point massage, Trager, Tui na, Reflexology, Thai Massage, deep tissue massage, Myofascial Release, Lymphatic Drainage, Craniosacral, Polarity, Reiki, Swedish Massage, and Therapeutic Touch”). Arizona’s statute, by contrast, simply indicates that all forms of ’bodywork therapy’ are constituted to fall under the profession’s scope, though other practices (e.g., colonic irrigation) are explicitly excluded. The state of Florida, conversely, explicitly includes colonic irrigation within massage therapists’ scope, for practitioners with additional certification in that field. Other jurisdictions (e.g., Colorado, Massachusetts, Indiana, Kentucky) do not explicitly define European/western massage therapy as being their implied reference point, but explicitly exclude from the profession’s purview a defined group of bodywork practices that vary by state, but include such practices as reflexology, Rolfing, polarity therapy, Feldenkrais, Trager, shiatsu, and reiki.

Five states license reflexology practitioners separately from massage therapists; two of these states also license practitioners of structural integration. In some jurisdictions (e.g., Nevada, Washington) reflexologist and/or structural integration licensure are implemented under separate units within the state massage therapy regulating board. Tennessee and North Dakota, by contrast, have distinct reflexology licensing bodies; and New Hampshire uniquely licenses reflexologists and two other types of bodywork practitioners under a standalone Board of Reflexologists, Structural Integrators and Asian Bodywork Therapists. Protected titles for reflexologists vary across these jurisdictions, and include: Licensed Reflexologist (North Dakota, Nevada), Registered Certified Reflexologist (Tennessee), and Certified Reflexologist (Washington); protected titles for practitioners of structural integration include: Licensed Structural Integrator (New Hampshire) and Licensed Structural Integration Practitioner (North Dakota). In some jurisdictions (e.g., Nevada, New Hampshire), state laws not only restrict (for licensees) the use of the aforementioned titles, but also the terms ‘reflexology’ and ‘structural integration’, and, notably, the practice of these therapeutic modalities. Elsewhere (e.g., Washington), however, these practices remain in the public domain, with licensure limiting the use of protected titles alone.

Professional entry requirements.

While a national Federation of State Massage Therapy Boards supports state regulators “to ensure that the practice of massage therapy is provided to the public safely and competently,” professional entry requirements for licensed massage therapists are set by state regulators and vary across jurisdictions. All jurisdictions require at least 500 hours of training (usually in ‘Western’ massage therapy). Thirty-one jurisdictions have implemented minimum training requirements between 500 and 600 hours; nine require between 601 and 700 hours; three (list them) require 750 hours; and three (Nebraska, Puerto Rico, and New York state) require 1000 hours of massage therapy training. In addition, most jurisdictions require that candidates for massage therapy licensure complete one (of multiple) professional entry examinations, all of which require at least 500 hours of documented training but differ in key ways.

The MBLEx (Massage and Bodywork Licensing Examination), administered by the Federation of State Massage Therapy Boards, is an ‘entry level’ professional test accepted by regulators in 46 of the nation’s massage therapy-regulating jurisdictions; and is the only examination to be offered in both English and Spanish languages. A second examining agency, the National Certification Board for Therapeutic Massage and Bodywork, offers a ‘Board Certification’ examination which, like the MBLEx, is geared to candidates trained in ‘Western’ massage therapy, and is accepted interchangeably with the MBLEx by 40 jurisdictional regulators across the United States. Board certification by the NCBTMB is considered by some to be a more rigorous credential in Western massage therapy than MBLEx completion. In addition, nine state regulators accept (interchangeably with MBLEx and ‘Board Certification’) candidates trained in Asian Bodywork Therapy who successfully complete an examination which, until recently, was administered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) but has been discontinued. Two jurisdictions (New York and Hawaii) administer state-specific massage therapy licensing examinations; and the state of California uniquely requires no professional entry exam.

While there is no single system of educational validation for massage therapy in the United States, multiple organizations implement accreditation mechanisms for massage therapy programs. The American Massage Therapy Association (AMTA) for example, welcomes ’member schools’ from across the country that meet a 500-hour minimum educational threshold. Another, smaller organization, the Alliance for Massage Therapy Education (AFMTE), similarly offers School Memberships to massage training programs of 500+ hours. The Commission on Massage Therapy Accreditation (COMTA) offers two forms of higher-level, voluntary recognition for massage therapy schools; the first endorses schools’ curricular competencies, and the second other more rigorously accredits programs as a whole. While neither AMTA, AFMTE or COMTA recognition is directly linked to massage therapist licensing, some (but not all) state massage therapy boards (and other governing bodies) use guidance from these organizations to endorse or validate particular educational programs where prospective licensees may train.

Statutory training requirements for licensed reflexologists across the aforementioned jurisdictions are generally in the 200-hour range, with some states (e.g., Nevada, North Dakota, Washington) additionally requiring a reflexology-specific licensure exam. Training requirements for licensed structural integration practitioners are generally above 700 hours.

Reimbursement.

While massage therapy is not officially reimbursed by Medicare, up to 270 ‘Medicare Advantage’ plans—corporate programs contracted by the federal government to implement Medicare across the US—have been reported to reimburse pain-related massage therapy care. It is important to note that licensed massage therapists are not permitted to bill Medicare directly; and that other health care professionals (e.g., physical therapists) may also provide massage therapy services within their scope. Massage therapy is also available to veterans for various health conditions at the VA’s eighteen ‘Whole Health Flagship sites. With the exception of a few state Medicaid waiver plans, the services of licensed massage therapists are not generally reimbursed by Medicaid. However, some Medicaid ‘managed care’ plans, corporate programs contracted by state governments to implement Medicaid benefits, do include massage therapy in their coverage. Most Personal Injury Protection and Workers’ Compensation insurance payors reimburse for care delivered by licensed massage therapists. However, a minority of private health insurance payers reimburse licensed massage therapy care.

Governance, protected titles and scope.

Naturopathic medicine is currently regulated across about half of US jurisdictions (23 states, DC and two territories). Across most of these jurisdictions (n = 24), licensed naturopaths are authorized the single protected title of Naturopathic Doctor (ND); in Arizona, both the ND and NMD (Naturopathic Medical Doctor) titles are statutorily protected; and in Idaho, only the NMD title is reserved for the licensed naturopaths’ usage. Nine states permit use of the term ‘physician’ by licensed naturopaths, a practice strictly prohibited in eight other jurisdictions.

Licensed naturopaths’ statutory scope varies by jurisdiction, with most permitting them to diagnose, prevent and treat disease via dietary and lifestyle counseling, the recommendation of nutritional supplementation and botanical medicines, use of physical medicine modalities including hydrotherapy, as well as homeopathy. In a limited number of states, licensed naturopaths are furthermore authorized to order laboratory testing (n = 23), blood draws (n = 18) and diagnostic imaging (n = 20), offer gynecological care (n = 17), provide intravenous therapies (n = 13), perform minor surgeries (n = 14), prescribe/administer a limited subset of pharmaceutical medications (n = 12) or other controlled substances (n = 9), attend childbirths (n = 6) and perform acupuncture (n = 3). Licensed naturopaths are recognized as primary care providers in twelve states.

In three states (Florida, South Carolina, Tennessee) the practice of naturopathy is illegal except by a medical doctor. In other states where naturopathic doctors are not currently licensed, it is often possible for naturopaths (including ‘traditional naturopaths’ trained outside of institutions accredited by the Council on Naturopathic Medical Education, described below) to practice in a more limited way as unlicensed health care practitioners.

Two states recognize additional categories of naturopathic personnel to support the work of naturopathic doctors. The state of California recognizes (but does not license) Naturopathic Assistants in statute, who may (under a licensed naturopath’s supervision): support patient intake and diagnostic screen (e.g., taking blood pressure and pulse readings, drawing blood and collecting other specimens for testing); administer medication through various means including via injection; and, bandage wounds. Washington state has a statutory certification mechanism for Colon Hydrotherapists working in a direct affiliation relationship with a state-licensed naturopath. No protected titles exist for either of these occupational groups.

Professional entry requirements.

In co-ordination with the Federation of Naturopathic Medicine Regulatory Authorities, all jurisdictions that license naturopathic doctors across the US share uniform professional entry requirements, consisting of: a) four-years (at least 4100 hours) of training at one of four educational institutions accredited by the Council on Naturopathic Medical Education (CNME); and, b) the Naturopathic Physicians Licensing Examination, delivered by the North American Board of Naturopathic Examiners. All CNME-accredited naturopathic educational programs in the US are (along with their Canadian counterparts) members of the Association of Accredited Naturopathic Medical Colleges.

In California, Naturopathic Assistants must complete—under a licensed naturopath’s supervision—a minimum of 30 clock hours of specified training, as well as a specified number of injections and venipuncture/skin punctures in order to practice legally. Colon Hydrotherapists working under naturopathic supervision in the state of Washington must present credentialing in colon hydrotherapy with one of three external organizations (to a standard of approximately 265 hours), or complete equivalent direct training under the supervision of a licensed Washington naturopath, paired with a state board examination.

Reimbursement.

While the care of licensed naturopathic doctors is not currently eligible for reimbursement by federal government health insurance programs, six state Medicaid programs do cover some aspects of naturopathic care. In Arizona, only pediatric naturopathic care is eligible for coverage. Furthermore, some degree of private insurance reimbursement is available for naturopathic care in twelve states.

Religious exemptions.

There are currently three distinct religious exemptions to US federal prohibitions on psychedelic possession and usage, all meant to enable the use of particular psychedelic medicines within Indigenous spiritual contexts, including in a group setting led by community leaders. The 1978 federal American Indian Religious Freedom Act provides an exemption for members of a religious group known as the Native American Church to use peyote in spiritual ceremonial contexts, on Native reservations across the US. In 2006, a Supreme Court ruling affirmed the right of members of another religious group, Uniao do Vegetal, to use ayahuasca within the context of religious ceremony anywhere in the US. In 2009, an Oregon court ruling similarly ruled that members of the Church of Santo Daime in Oregon, may engage in ayahuasca ceremony, a ruling only applicable in the state of Oregon.

Psychedelic facilitator licensing.

In 2022, the state of Oregon (where possession of psychedelic substances has been decriminalized) became the first US jurisdiction to legalize the therapeutic application of psilocybin (‘magic mushrooms’ and related products) for mental health purposes for persons aged 21 and older. To this end, the state has begun four-fold process of licensing: a) practitioners of psychedelic facilitation, along with b) related manufacturers, c) laboratories, and d) legal facilitation sites. Persons eligible to become Licensed Psychedelic Facilitators in Oregon must: be at least 21 years of age; be resident in Oregon; have completed a secondary school diploma; undergo a criminal background check; complete a state- approved program of psychedelic facilitation training lasting at least 120 hours and meeting defined core requirements; and pass a related examination administered by the state.

Two other states–Texas and Utah–have recently passed laws (in 2021 and 2022 respectively) to enact studies related to possible future implementation of similar programs.