Chiropractic 2025:

Chiropractic 2025: Divergent Futures
Scenario Narrative
The Great Recession of 2008-2009 had already hit chiropractors harder than it had most health care providers. Then
in 2015, another recession had the economy on the ropes again. The economic downturns caused many people to
lose their jobs, homes, and hopes. Psychological and behavioral health got worse as depression and substance abuse
became ever more entangled, feeding off each other. Stressed families struggled to support their health. Instead of
wellness and prevention, many patients skipped visits and opted for over-the-counter pain relievers, online services,
minute clinics, and phony pain cures. Heart disease, cancers, diabetes, and low back pain all became more prevalent,
with incidence rates increasing for youth as well as for elders.
Although the economy slowly turned back to a period of economic growth in the years leading up to 2021, the
Federal Government’s ongoing debt and deficit reduction repeatedly forced sacrifices in long-term health. The
cumulative effect of spending cuts made during the recession in federal programs, particularly defense, Medicare
and Medicaid, lowered the demand for chiropractic in many settings. As the gap between the “haves” and the “havenots”
grew ever wider, spending for chiropractic services declined and more chiropractic practices found themselves
on the brink of bankruptcy.
Leaders in chiropractic care had claimed in 2015 that the public’s interest in conservative, natural modalities
was growing stronger, especially given the high cost of drugs and surgery. Moreover, they claimed private health
insurance companies were bound by Section 2706 of the Patient Protection and Affordable Care Act (PPACA)
to provide equal access and payment to all those licensed to provide physical medicine services. This required
insurance plans that covered services of a medical doctor to cover the same services when offered by another
licensed provider, such as a chiropractor. It seemed a promising time for chiropractic.
But the promise proved false. The PPACA failed to provide good coverage for the 32 million uninsured people
forecast to gain health insurance coverage by 2020. The most popular offerings in the health insurance exchanges
were high-deductible catastrophic care plans, which left millions of Americans paying out of pocket anyway. By
2020, 75 million Americans were uninsured, while the great majority of Americans were underinsured. Everybody
was trying to pay as little as necessary, while fees and the cost of care continued to grow outside the integrated
systems used by the well-insured.
Although the economy improved in the years leading up to 2021, the market for chiropractors did not rebound.
Given the economic and health care challenges, there had been little improvement in coverage or payment for
chiropractic care over the years. The two largest government insurance plans were exempt from Section 2706 of
PPACA. Medicare continued to pay chiropractors only for subluxation adjustments—and with periodic fee cuts—
but not for other clinical services like nutrition and tobacco counseling. As for Medicaid, states were chipping away
at benefits for most services and by 2025, few chiropractors saw Medicaid patients.
Most chiropractors during this period tried to join Accountable Care Organizations (ACOs) and Patient-Centered
Medical Homes (PCMH), which became the norm for quality primary care among those who could afford insurance.
Chiropractic leaders worked to position DCs as spine and musculoskeletal health providers on the PCMH team. This
was successful in many places, where DCs could establish relationships with medical directors in medical groups
and ACOs that would house the PCMH teams. More frequently, however, PCMH teams used the physical therapists
already employed by the ACO to address spinal health. By 2025, PCMH teams included 4,000 DCs (9% of the field)
and 8,000 physical therapists.
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