Cockroaches of Acupuncture, Part Two
beware the giant vacuum cleaner
Welcome to the Cockroaches of Acupuncture series: Part One, Part Two, and Part Three.
An alert POCA Tech student pointed out that on the same day I sent out Part One of this series, the New York Times published an article on How the Cockroach Took Over the World. What are the odds?! she wrote. Hmm. In case that coincidence gives anyone the creeps, let’s note that the main point of the NYT article was about cockroaches’ capacity for adaptation. “They have a very high number of genes, so they have a high, high potential for adaptation,” one researcher said. “To rapidly evolve into anything further.”
My goal is not to take over the world (that sounds stressful) but to ask a question about adaptation: can the acupuncture profession that came into being in the US in 1982 adapt itself to conditions in the present? Can it evolve in order to survive?
Lately I’ve been experiencing deja vu: writing and talking about the acupocalypse reminds me a lot of the early days of introducing people to the community acupuncture model. So I’m going to try to apply some of the lessons I learned from that time, and also try to avoid some of the mistakes I made back then.
After a few rounds of teaching community acupuncture workshops, sometime in 2007 or so I realized I needed to start out with facts rather than emotions. I decided to share household income data from the US Census before I tried to talk about anything else. That data is typically divided into quintiles (fifths), and if you look at the numbers you realize pretty quickly that three-fifths of the households in the US don’t have much disposable income.
The narrative of the acupuncture profession at that time was (and still is, in some places) that the community acupuncture model devalues acupuncture — because patients could pay $100 and up for a treatment if they really wanted to. See also: working class people spend all their money on beer, cigarettes and cable TV because they’re not educated enough to value their health. I was so angry about that narrative that I could spit nails. Those workshops were pretty well attended because people found it entertaining to watch me spit nails — but I discovered that nail-spitting and cursing and even crying in public about how awful it was, only went so far.
Instead I learned how to say more gently: I hate to break it to you, but if people have to choose between paying for acupuncture and paying for groceries, which one do you think they’ll pick? Look at the numbers, look at what most people are living on. The reality is that sometimes people just can’t afford things. Including healthcare.
And I’d look at my audience and see something shift, at least for some people: It’s not personal, it’s just math. And then those people were ready to think about adapting — to provide acupuncture in a way that more people could afford.
So let’s see if I can do that again, but for infrastructure. Without putting everyone to sleep. Remember the AHM Coalition, the new super group in the acupuncture profession? Here’s my cockroach-eye view on that.
The Coalition is composed of four organizations: ASA which is the professional membership organization for acupuncturists, CCAHM which is the professional membership organization for acupuncture schools, ACAHM which is the accrediting agency for acupuncture schools, and NCCAOM which is the credentialing body for acupuncturists. According to recent presentations, the Coalition’s purpose seems to be to reinforce the functions of the ASA — because that organization runs on a shoestring, with no paid staff, and has significantly fewer resources than the other three. According to Guidestar, in round numbers the ASA’s annual income is about $70K, CCAHM’s is about $500K, ACAHM’s is about $900K and the NCCAOM’s is about $3.5 million.1
Everybody with me so far?
I want to be clear that I’m not saying that the AHM Coalition is a bad idea (apologies for being snarky about it before). If the Coalition focused its efforts on adaptation, that would be great.
The problem is that so far nobody is talking about the thing that the acupuncture profession most needs to adapt to — and it’s a doozy. (Spoiler: it’s not dry needling!)
Three-quarters of the AHM Coalition is getting most or all of their money, directly or indirectly, from people entering the profession, i.e. students. Students pay tuition to their schools; the schools use that income to pay accreditation fees to ACAHM and membership dues to CCAHM. (CCAHM also earns money directly from students for administering the CNT exam.) The final step in entering the profession, once students have graduated, is to pay the NCCAOM to become certified, in order to eventually apply for state licensure. (The NCCAOM also receives revenue from acupuncturists re-certifying, but more than half of their income comes from applications for first time certifications and exam administration.)
There’s a general awareness that enrollment in acupuncture schools is declining; it’s down about 25% over the last decade, which has been enough of a loss to close some schools (about 25%). That’s not a precipitous decline, though, more like a gradual erosion.
However, since about 1990 — which was early days for acupuncture education in the US — students’ tuition money has mostly been borrowed. Almost all acupuncture schools depend on student loan funding (also known as Title IV) to make their operations possible, and access to that pipeline has resulted in longer degrees and more expensive programs, the kind that most students can’t pay for out of pocket. I don’t want us to get lost here by going too far down the rabbit hole of new federal student aid regulations — Gainful Employment and Defense to Repayment — so I’ll summarize: For the last three decades, acupuncture schools have relied on the federal government as a kind of third party payer, an invisible investor in acupuncture education. And the government is not happy with its return on investment.
Defense to Repayment means that if a student can prove that a school misled them with respect to their future career prospects, the government will cancel that student’s loans — and then order the school to reimburse the government for the loss. Gainful Employment means that the government is going to begin grading all institutions that receive Title IV on how well their students’ loan debt stacks up against future earnings. If the school is for-profit and gets a failing grade, the government can cut off its access to future student loans; if the school is a nonprofit, the government makes that information public. According to the most recent round of calculations, all acupuncture schools that take student loans (which I believe is all of them except POCA Tech and Middle Way) fail at Gainful Employment. And I think a lot of people are in denial about how many graduates of acupuncture schools have reason to apply for Defense to Repayment — and how many of them are, right now, in the process of doing so.
Not only are students increasingly unwilling to borrow money for higher education — which is reflected in declining acupuncture school enrollment — but the government is increasingly unwilling to lend it (and also looking for ways to claw it back). The new regulations might contribute to the slow erosion of people entering the acupuncture profession or they might represent imminent disaster for most acupuncture schools — it’s hard to tell which, but we’ll know within a few years. At which point it might be too late to do anything. Either way, the government is telegraphing that it wants to get out of the business of underwriting acupuncture education.
So from my cockroach perspective, it looks like most of the money will be sucked right out of the AHM Coalition’s member organizations — and out of the acupuncture profession’s infrastructure. Maybe quickly, maybe slowly, but inexorably. Picture the new student aid regulations as a giant vacuum cleaner. The irony is that the revenue that’s most secure (in the short term anyway) is actually the ASA’s, because hardly any of it comes from students.
As far as I can tell, nobody in the AHM Coalition or anywhere else in the acupuncture profession is planning for, or even willing to talk about, what happens when the giant vacuum cleaner starts to do its thing, the very thing it’s been warning everybody for years that it’s going to do. I’ve heard people in the acupuncture education business being indignant about the giant vacuum cleaner that’s looming over them, I know they’ve tried to argue with it and I hear they’ve even sued it, but it doesn’t care. It’s still there, looming. Getting ready to start sucking. Republican administrations have temporarily switched it off; Democratic administrations switch it back on; but nothing has made it go away.
And I hate to break it to you, but being indignant about the vacuum cleaner is not a plan. (Though acupuncturists are experts at indignation.) The reality is that the acupuncture profession won’t be able to afford its current infrastructure if the government stops investing via student loans. It’s not personal, it’s just math! The acupuncture profession built itself up through schools and credentialing, and both of those were possible at their current scale because 1) students didn’t have to pay for their education out of pocket and 2) they were willing to borrow.
It’s time — maybe past time — to imagine a system that doesn’t run on borrowed money. Nobody’s going to intervene and save the acupuncture profession from the forces sucking money out of it. Like a cockroach, it would need to move fast and save itself from the giant vacuum cleaner.
Adaptation and survival would require rapid evolution, which would be painful. If you ask me (a cockroach) what the AHM Coalition should be doing, it’s guiding the acupuncture profession through its own transformation (as opposed to worrying about dry needling). Facing inward, not outward against other professions. Which includes helping the acupuncture profession manage the pain of actually doing the math, the pain of facing economic reality, as a necessary step in adapting to a severely reduced income. Isn’t managing pain what acupuncturists do?
I’m very familiar with the creative prompt of: make a future for yourself or you won’t have one. This gets us back to the part about survival being a choice and a commitment.
Over the years I’ve learned that the biggest obstacle to WCA’s and POCA Tech’s survival — and to community acupuncture’s survival in general — isn’t denial alone. It isn’t the stubborn American conviction that everybody really can afford anything they want if only they “value” it enough, and suggesting otherwise means you’re just making excuses and losing at capitalism. Nope, the biggest obstacle to survival is the fear that what you can afford to do, with the resources you have, isn’t even worth doing.
For the past two decades, all kinds of people have told me in all kinds of ways: If that’s the best you can do, why bother?
What makes me a cockroach is that I don’t listen.
I shrug and keep going. (Okay, sometimes I cry for awhile, then I shrug and keep going.) I’ve learned that it’s possible to make solid, functional, valuable things out of very limited resources. The future of acupuncture in the US, on the other side of student loans, could be not only solid and functional but beautiful. It could be beloved and useful and rooted in communities that need it. It could be an uplifting force; a source of meaningful vocations; a diverse and economically sustainable field. And it could be all those things without depending on borrowed money. If acupuncturists are willing to adapt.
Up next in this series: what can you do about the acupocalypse? Part Three is here.
For purposes of comparison (same round numbers), WCA’s annual income is about $700K, POCA Tech’s is about $250K, and OCOM’s annual income was historically around $5 million. The POCA Cooperative’s annual income, like the ASA’s, is about $70K.