1. For convenience and consistency, and except where reference to another term is required by the language of a particular statute, this study uses the word "alternative" to describe treatments that are not in conventional form. Selection of this term is also consistent with the fact of paradigmatic choice which is often inherent in the administration and use of many alternative treatments. Applicable state statutes are not uniform in the use of terminology to describe this field. See supra pp. 33-37. For a discussion of issues concerning terminology in this general subject area, see British Medical Association, Complementary Medicine - New Approaches to Good Practice 5-8 ( 1993).

2. Eisenberg et al., "Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use," 328 New Eng. J. Med. 246 (Jan. 28, 1993).

3. See infra pp. 38-39.

4. See Colgate, A Preliminary Inquiry into Insurance Coverage of Alternative Medicine (Dec. 1993) (unpublished study by the Office of Alternative Medicine, National Institutes of Health); N.Y. Times, July 28, 1993, at A1 and Cll; National Underwriter, July 26, 1993 (Life and Health/Financial Services ed.), at 11-12; forties, Dec. 20, 1993, at 25455; and Modern Healthcare, Aug. 9, 1993, at 96-98.

5. In 1991 the leadership of the American Massage Therapy Association, the Rolf Institute, Trager Institute, American Polarity Association, and the American Oriental Bodywork Therapy Association formed the Federation of Massage/Bodywork Organizations to foster greater communication and cooperation toward shared goals. Within the Federation, which collectively represents some 15,000 practitioners in the United States and is open to international participation, each organization retains its autonomous identity. E. Greene, "Five Member Federation Formed!, 30 Massage Therapy J. 18 (Summer 1991). The Federation's Joint Statement of purpose pledges its members, among other things, to establish a proactive legislative program. Id. The Federation was active in the legislative process leading to the establishment of the Committee on Massage/Bodywork Practitioners in Delaware and has formed a Joint Government Relations Committee consisting of representatives from each member organization. Telephone Interview with Elliot Greene, former President, American Massage Therapy Association (Nov. 1, 1993). Concerning the Delaware Committee on Massage/Bodywork Practitioners, see infra text accompanying note 71 (Part I).

The acupuncture community has also been active in promoting greater political unity among its providers, as evidenced by the formation of the National Acupuncture and Oriental Medicine Alliance in 1994. Among other objectives, the Alliance seeks to support state and regional legislative efforts concerning acupuncture and oriental medicine and to integrate these modalities into American health care. Letter from Vicky Radel, Dipl. Ac. (NCCA) and Casey White, L.Ac., Co-Chairs, National Acupuncture and Oriental Medicine Alliance to Colleague, Feb. 1994).

6. See Modern Healthcare, July 25, 1994, at 10; id. Aug. 9, 1993, at 98; id. Oct. 3, 1994, at 44; 5 Healing Healthcare Network Newsletter 3 (1994); and Wall Street Journal, Aug. 9, 1993, at B1 and B3.

7. See 5 healing Healthcare Network newsletter 4 (1994) and Newsweek, Mar. 8, 1993, at 61.

8. The American Chiropractic Association indicates that chiropractic is currently licensed in all fifty states and the District of Columbia and covered under most commercial health insurance policies and federal health care programs. Alternative medicine: Hearing Before the Subcommittee on Labor, Health, and Human Services, and Education and Related Agencies of the Senate Committee on Appropriations, 103d Cong., 1st. Sess. 153 (Statement of the American Chiropractic Association). The Association also indicates that chiropractic should be distinguished from the types of alternative modalities that will be studied by the NIH Office of Alternative Medicine:

We do not wish to belittle any other professions that will come under study at the OAM. While some have and others will doubtlessly make significant contributions to human health, as a group they have not yet reached the level of broad acceptance achieved by the chiropractic profession. Considering the fact that 19 million patients visit D.C.s yearly, that 85% of major employers cover chiropractic services under their employee health plans and that most major federal, state and commercial health care programs cover chiropractic services, it becomes clear that chiropractic does not belong in the same category as these other professions. Id. at 154.

The American Osteopathy Association (AOA) reports that osteopathy is currently authorized in all 50 states and the District of Columbia. American Osteopathy Association, "Osteopathic Licensing Summary" (July 1993) (copy on file with author). One of the significant legislative issues in the osteopathic field concerns the removal of barriers to membership by osteopaths on the medical staff of hospitals and other health care facilities and programs. See, e.g., Iowa Code Ann. § 135B.7 (Supp. 1994), which prohibits a hospital from denying clinical privileges to inter alia, an osteopath or an osteopathic surgeon solely by reason of the license held by the osteopath or the school or institution in which the practitioner received medical schooling or postgraduate training, if the medical schooling or postgraduate training is accredited by an organization recognized by the Council on Postsecondary Education or an accrediting group recognized by the U.S. Department of Education. See also Calif. Bus. & Prof. Code § 2453 (Supp. 1994); Colo. Rev. Stat. § 12-36-129(5) (1991); and Ohio Rev. Code Ann. § 3701.351(B) (1992);


I. Developments Concerning Specific Alternative Modalities

1. For a discussion of early acupuncture legislation in the United States, see McCrae, A Critical Overview of U.S. Acupuncture Regulation, 7 J. Of Health Poll, Pol'y, and L. 163 (1982). James Reston's account concerning the successful use of acupuncture to relieve his post-operative pain after an appendectomy in the People's Republic of China appears in the N.Y. Times, July 26, 1971, at A1. Concerning legislative developments in Iowa, Texas, North Carolina, and Maryland in 1993-1994, see infra pp. 3-4.

2. See generally National Acupuncture Foundation, State Acupuncture Laws 3-65 and 104-05 (1994 ea.) [hereinafter cited as State Acupuncture Laws]. See also infra text accompanying notes 18-19.

3. See Alaska Stat. § 08.06.190(1) (1991); Cal. Bus. and Prof. § 4937(b) (West 1990); D.C. Code Ann. § 2.3301.2(1) (1994); Me. Rev. Stat. Ann. tit. 32, Section12403(1) (1988); N.J. Stat. Ann. tit. 45, § 2C-2(a) (West 1991); Pa. Stat. Ann. tit. 63, § 1802 (Purdon Supp. 1993); Utah Code Ann. § 58-12-58(1) (Supp. 1993); and Va. Code Ann. § 54.1-2900 (1991).

4. See Hawaii Rev. Stat. § 436E-2 (1985); Md. Health Occ. Code Ann. § lA-101(e)(1) (Supp. 1994); Nev. Rev. Stat. § 634A.020(1) (1991); N.M. Stat. Ann. § 61-14A-3A (1993); and R.I. Gen. Laws § 5-37.2-2(1) (1987). See also Tex. Rev. Civ. Stat. Ann. art. 4495b, § 6.02(1)(B) (Vernon Supp. 1994), which recognizes "energy flow exercise" as within the definition of acupuncture.

5. See Alaska Stat. § 08.06.190(1) (1991) (traditional Chinese medical concepts); Colo. Rev. Stat. § 12-29.5-102(1) (1991) (traditional oriental concepts of evaluation and treatment); Fla. Stat. Ann. § 457.102(1) (1991) (traditional Chinese medical concepts); Iowa Code Ann. § 148E.1(1) (West Supp. 1994) (traditional oriental medical concepts); Me. Rev. Stat. Ann. tit. 32, § 12403(1) (1988) (traditional oriental theories); Mass. Gen. Laws Ann. ch. 112, § 148 (West Supp. 1993) (traditional oriental medical theories); N.C. Gen. Stat. Section 90-451(1) (1993) (traditional and modern Chinese medical concepts); Ore. Rev. Stat. § 677.757 (1993) (traditional and modern techniques of diagnosis and evaluation); Vt. Stat. Ann. tit. 26, § 3401(1) (Supp. 1994) (traditional and modern Oriental theories and diagnostic techniques); and Wis. Stat. Ann. § 451.01(1J (West Supp. 1993) (traditional oriental medical concepts).

6. See generally State Acupuncture Laws supra n. 2, at 71-75. "Lifestyle counseling" is an adjunctive therapy recognized under the acupuncture practice act of Vermont. See Vt. Stat. Ann. tit. 26, § 3401(1) (Supp. 1994).

7. See Hawaii Rev. Stat. §§ 436E-1 to 436E-14 (1985), (Supp. 1992), and (Comp. 1993); Me. Rev. Stat. Ann. tit. 32, §§ 12401-12413 (1988) and (Supp. 1994); Md. Health Occ. Code Ann. §§ 1A-101 to 1A-502 (Supp. 1994); Nev. Rev. Stat. §§ 634A.010-634A.240 (1991); N.M. Stat. Ann. §§ 61-14A-1 to 61-14A-22 (1993); and N.C. Gen. Stat. §§ 90-450 to 90-459 (1993).

8. See Nev. Rev. Stat. § 634A.030 (1991) and N.M. Stat. Ann. § 61-14A7 (1993).

9. Practice acts in the following states provide for overall or direct regulation of acupuncture by the state medical board (parenthetical references indicate the collateral existence of an acupuncture board or committee): Calif. Bus. & Prof. Code §§ 4925 4979 (West 1990) and (West Supp. 1994) (Acupuncture Committee); D.C. Code Ann. §§ 2-3302.3(a)(2), (8)(a), and (b) (1994) (Advisory Committee on Acupuncture); Fla. Stat. Ann. §§ 457.101-457.118 (1991) and (Supp. 1994) (Board of Acupuncture); Iowa Stat. Ann. §§ 148E.1-148E.10 (West Supp. 1994); La. Rev. Stat. Ann. tit. 37, §§ 1356-1360 (West 1988) and (West Supp. 1994); Mass. Gen. Laws. Ann. ch. 112, §§ 148-162 (West Supp. 1994) (Committee on Acupuncture); Mont. Code Ann. §§ 37-13-101 to 37-13-316 (1993); N.J. Stat. Ann. §§ 45:2C-1 to 45:2C-18 (West 1991) (Acupuncture Examining Board); Ore. Rev. Stat. §§ 677.757-677.770 (1993); Pa. Stat. Ann. tit. 63, §§ 1801-1806 (Purdon Supp. 1994) (jurisdiction vested in State Board of Medicine and State Board of Osteopathic Medicine); S.C. Code Ann. §§ 40-47-70 and 40 47-75 (Law. Co-op. 1986); Tex. Rev. Civ. Stat. Ann. art. 4495b, §§ 6.01-6.14 (Vernon Supp. 1994) (Board of Acupuncture Examiners); and Va. Code Ann. §§ 54.1-2956.9 to 54.1-2956.11 (Supp. 1994) (Advisory Committee on Acupuncture).

10. In the following states, practice acts vest regulatory jurisdiction over acupuncture in a department or a departmental division, office, or official (parenthetical references indicate the concurrent existence of an acupuncture unit or body of advisors): Alaska Stat. §§ 08.06.010-08.06.190 (1991) and (Supp. 1993); Colo. Rev. Stat. §§ 12-29.5101 to 12-29.5-116 (1991) and (Supp. 1993); N.Y. Educ. Law §§ 8210-8216 (McKinney Supp. 1994) (State Board for Acupuncture); R.I. Gen. Laws §§ 537.2-1 to 5-37.2-23 (1987) and (Supp. 1993)("acupuncture consultants"); Utah Code Ann. §§ 58-12-57 to 58-12-69 (Supp. 1994) and 58-1-201 to 58-1-203 (1994) (Acupuncture Licensing Board); Vt. Stat. Ann. tit. 26, §§ 3401-3411 (Supp. 1994); ("acupuncturist advisors"); Wash. Rev. Code Ann. §§ 18.06.010-18.06.190 (1989) and (Supp. 1994) (Acupuncture Advisory Committee); and Wis. Stat. Ann. §§ 451.01-451.16 (West Supp. 1993).

11. See Alaska Stat. Ann. §§ 08.06.010-08.06.190 (1991) and (Supp. 1993); Cal. Bus. & Prof. Code §§ 4925-4979 (West 1990) and (West Supp. 1994); D.C. Code Ann. §§ 2-3301.2(1), 2-3305.4(a), 2-3302.3(a)(2), (8)(a), and (b) (1994); Hawaii Rev. Stat. §§ 436E-1 to 436E-14 (1985), (Supp. 1992), and (Comp. 1993); Me. Rev. Stat. Ann. tit. 32, §§ 12401-12413 (1988) and (Supp. 1994); Md. Health Occ. Code Ann. §§ 1A-101 to 1A-502 (Supp. 1994); Mont. Code Ann. §§ 37-13-101 to 37-13-316 (1993); Nev. Rev. Stat. §§ 634A.010-634A.240 (1991); N.M. Stat. Ann. §§ 61-14A-1 through 61-14A-22 (1993) and (Supp. 1994); N.Y. Educ. Law §§ 8210-B216 (McKinney Supp. 1994); N.C. Gen. Stat. §§ 90-450 to 90-459 (1993); Ore. Rev. Stat. §§ 677.757-677.770 (1993); R.I. Gen. Laws §§ 5-37.2-1 to 5-37.2-23 (1987) and (Supp. 1993); Tex. Rev. Civ. Stat. Ann. art. 4495b, §§ 6.01 through 6.14 (Vernon Supp. 1994); Utah Code Ann. §§ 58-12-57 to 58-12-69 (Supp. 1994); and Va. Code Ann. §§ 54.1-2900 and 54.1-2956.9 to 54.1-2956.11 (Supp. 1994).

12. See Iowa Code Ann. §§ 148E.1-148E.10 (West Supp. 1994); Pa. Stat. Ann. §§ 1801-1806 (Purdon Supp. 1994); and Colo. Rev. Stat. §§ 12-29.5-101 to 12-29.5-116 (1991) and (Supp. 1993).

13. Fla. Stat. Ann. §§ 457.101-457.118 (1991) and (Supp. 1994); La. Rev. Stat. Ann. tit. 37, §§ 1356-1360 (West 1988); N.J. Stat. Ann. §§ 45:2C-1 to 45:2C-18 (West 1991) and (West Supp. 1994); Wash. Rev. Code Ann. §§ 18.06.010-18.06.190 (1989) and (Supp. 1994); and Wis. Stat. Ann. §§ 451.01-451.16 (West Supp. 1993).

14. See Mass. Gen. Laws Ann. ch. 112, §§ 148-162 (West Supp. 1994) (both licensure and registration required), and Vt. Stat. Ann. tit. 26, §§ 3401-3411 (Supp. 1994) (either registration or certification required). See also N.Y. Educ. Law § 8216(3) (McKinney Supp. 1994), which permits certain previously certified acupuncturists to retain this designation under the state licensure law.

15. See S.C. Code Ann. §§ 40-47-70 and 40-47-75 (Law. Co-op. 1986).

16. See D.C. Code Ann. § 2-3301.2(1) (1994) (general collaboration with physician or osteopath required); Iowa Code Ann. § 148E.10 (West Supp. 1994) (prior evaluation and referral by medical doctor, osteopath, chiropractor, podiatrist, or dentist required); La. Rev. Stat. tit. 37, § 1358 (West 1988) (nonphysician "acupuncturist assistant" must be employed by and work under supervision of a physician or physician acupuncturist); Mass. Gen. Laws Ann. § 161 (West Supp. 1994) (prior written letter of referral or written diagnosis from physician, osteopath, or dentist required); N.J. Stat. Ann. § 45:2C-5(a)(1) (West 1991) (prior referral or diagnosis from physician required); N.Y. Educ. Law § 8211(1)(b) (McKinney Supp. 1994) (acupuncturist must advise patient of importance of consulting with a physician concerning the patient's condition); Pa. Stat. Ann. § 1803(c) (Purdon Supp. 1994) (general supervision by a physician required); S.C. Code Ann. § 40-47-70 (Law. Co.-op. 1986) (supervision and referral by physician or dentist required); Texas Rev. Civ. Stat. Ann. art. 4495b, § 6.11(b) and (c) (Vernon Supp. 1994) (prior evaluation by physician or dentist required unless patient is referred by chiropractor); and Va. Code Ann. § 54.1-2956.9 (Supp. 1994) (prior diagnostic examination and referral by physician required).

17. See Texas Rev. Civ. Stat. Ann. art. 4495b, § 6.11(9) (Vernon Supp. 1994) (no prior referral from physician, dentist, or chiropractor is required if acupuncture treatment is for smoking addiction, weight loss, or as permitted by administrative rule, substance abuse); and Wash. Rev. Code Ann. § 18.06.140 (Supp. 1994) (in absence of consultation with or recent written diagnosis from a physician, continuation of acupuncture treatment is precluded if patient has potentially serious disorder, such as cardiac condition, acute abdominal symptoms, and other such conditions).

18. See generally State Acupuncture Laws supra n. 2, at 3-65.

19. See id.

20. Iowa Code Ann. §§ 148E.1-148E.10 (West Supp. 1994).

21. Tex. Rev. Civ. Stat. Ann. art. 4495b, §§ 6.01-6.14 (Vernon Supp. 1994)

22. N.C. Gen. Stat. §§ 90-450 to 90-459 (1993).

23. Md. Health Occ. Code Ann. §§ 1A-101 to 1A-502 (Supp. 1994).

24. J. Tauber, Drug Courts: A Judicial Manual 3 (June 15, 1994).

25. Id. at 10.

26. Id. at 33-42.

27. Violent Crime Control and Law Enforcement Act of 1994, Pub. L. No. §§ 50001 and 50002, 108 Stat. 1796, 1956-1959 (1994).

28. N.Y. Educ. Law § 8216(4) (McKinney Supp. 1994).

29. 1993 Conn. Legis. Serv. P.A. No. 93-295 (West).

30. Ore. Rev. Stat. § 430.560 (1993).

31. Minn. Stat. Ann. §§ 244.17-244.173 (West Supp. 1994).

32. Va. Code Ann. §§ 53.1-32, 53.1-145, and 53.1-185(4) (Supp. 1994)

38 Fed. Reg. 6,419 (Mar. 9, 1973).

33. Id.

34. Food and Drug Administration, Compliance Policy Guide § 7124.11 1987) [hereinafter cited as FDA Compliance Policy Guide].

35. The current classification of medical devices originates in amendments to the federal Food, Drug, and Cosmetics Act in 1976. See Pub. L. No. 94-295, 90 Stat. 539, currently codified at 21 U.S.C.A § 360c through 36. 01 (Supp. 1994). For background information concerning the petition to the FDA to reclassify acupuncture needles, see 3 Diplomate News 6-7 (Aug. 1994) (National Commission for the Certification of Acupuncture).

37. 54 Fed. Reg. 34,559 (Aug. 21, 1989). The Social Security Act prohibits payment under the Medicare program for service expenses which are not "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Social Security Act, 42 U.S.C.A. § 1395y(a)(1)(A) (Supp. 1994).

38. See Ariz. Rev. Stat. Ann. §§ 32-2901 to 32-2951 (1992); Nev. Rev. Stat. §§ 630A.010-630A.600 (1991); and Conn. Gen. Stat. Ann. §§ 20-8, 2010, 20-11, and 20-13 (Supp. 1994).

39. See infra text accompanying notes 48-50.

40. Ariz. Rev. Stat. Ann. § 32-2901A(4) (1992).

41. Id.

42. Nev. Rev. Stat. § 630A.040 (1991).

43. Department of Public Health and Addiction Services, Division of Medical Quality Assurance, Physicians Application for homeopathic Licensure Instructions 3 (Aug. 1993).

44. See Ariz. Rev. Stat. Ann. §§ 32-2902 and 32-2904 (1992) and Nev. Rev. Stat. § 630A.200 (1991).

45. Conn. Gen. Stat. Ann. § 20-8 (Supp. 1994). See also, id. §§ 19a, 14(a) and (b)(7) and 19a-17 (Supp. 1994).

46. See Ariz. Rev. Stat. Ann. §§ 32-2904, 32-2912, 32-2913, 32-2931, 32-2933, 32-2934, and 32-2938 (1992), and Nev. Rev. Stat. §§ 630A.200, 630A.230, 630A.240, 630A.340 to 630A.380, and 630A.560 to 630A.600 (1991).

47. See Conn. Gen. Stat. Ann. §§ 20-8, 20-10, 20-11, and 20-13 (Supp. 1994). Concerning the authority of the Department of Public Health and Addiction Services over the Homeopathic Medical Examining Board, see id. §§ 19a-14(a) and (b)(7) (Supp. 1994).

48. See Ariz. Rev. Stat. § 32-2907 (1992).

49. Concerning the right of a naturopath to use homeopathy, see Alaska Stat. § 08.45.200(3) (1991); Hawaii Rev. Stat. § 455-1 (Supp. 1992); Mont. Code Ann. §§ 37-26-103(4), 37-26-301(1)(a), and 37-26-302(2J(a) (1993); N.H. Rev. Stat. Ann. § 328-E:4I (Supp. 1994); and Wash. Rev. Code Ann. § 18.36A.040 (Supp. 1994). By administrative rule, Oregon also permits naturopaths in that state to use homeopathic remedies, although statutory authorization for this use is not entirely clear under Ore. Rev. Stat.