As more people gained access to insurance and primary care under the Affordable Care Act this year, naturopathic doctors hoped that their role in medicine might become more mainstream as well.

But that has generally not been the case, and services by these holistic practitioners are often not covered by health plans, particularly those purchased on Covered California, the state’s new insurance marketplace.

Naturopathic doctors, whose four-year graduate training focuses on primary care from a holistic perspective, feel that they are uniquely positioned to help meet the demands of the impending shortage of primary-care physicians in California. But physicians and regulators say they’re not sure the holistic doctors have the right training, despite the need for more providers.

Still, naturopathic doctors say they’re qualified to do some procedures and checkups, such as well-woman exams, and they want to be reimbursed by insurers for these services. There are a few naturopathic doctors that are listed as in-network providers with insurance plans known as preferred provider organizations, or PPOs, but most plans don’t include naturopathic benefits.

“In terms of annual exams, preventive care, chronic disease management, ND’s are filling a gap,” even if they’re not getting reimbursed by insurers for it, said Jacqui McGrath, a naturopathic doctor.

The California Association of Health Plans, which represents health insurers in the state, declined to comment for this story, instead referring questions back to the insurance companies. Anthem Blue Cross, Blue Shield, Health Net and Kaiser Permanente — the four largest insurers who participated in Covered California, the state’s insurance marketplace — also declined to explain why they generally don’t cover naturopathic services or did not return calls seeking comment. Blue Shield said it does include the alternative therapy of acupuncture as an out-of-network benefit in its Affordable Care Act plans, but naturopathic services aren’t covered.

Debate over qualifications

Under current regulations, naturopathic doctors are somewhat limited in what they can do under their license. The California Naturopathic Doctors Association is trying to expand the scope of what these practitioners are allowed to do.

But the California Medical Association said it’s concerned that naturopathic doctors don’t have enough education to do many primary-care exams and procedures.

“Naturopaths do not have equivalent training to physicians,” said Yvonne Choong, senior director for the Association’s Center for Medical and Regulatory Policy. 

She pointed out that the content of a physician and naturopathic do ctor’s four years of medical school is different. In addition, most physicians complete an additional three to seven years of residency training, whereas naturopathic doctors are not required to complete residency training, she said.

But many naturopathic doctors say their graduate training does provide them with enough training to perform at least some primary-care exams — something they’re already doing but often not getting insurance reimbursement for. According to Bastyr University, an accredited school of naturopathic medicine, naturopathy is a system of primary health care that emphasizes prevention and the body’s ability to heal itself using natural therapies, with a focus on the underlying cause of disease, rather than treating only the symptoms.

Trying to expand their scope

The National Institute of Health categorizes naturopathy under the heading of “complementary and alternative medicine,” a term that also includes meditation, chiropractic care and acupuncture. According to a 2007 survey conducted by the Institute, approximately 38 percent of adults and 12 percent of children have used some form of alternative medicine.

As part of their practice, naturopathic doctors can provide many of the same primary care services one might receive at a conventional doctor’s office — except that the services often aren’t covered by insurance.

“We do some things that are different, but we do the same: I order the same complete blood count, chem panel, lipid panel, blood sugar, thyroid testing, I can prescribe medicines,” said Aimée Gould Shunney, a naturopathic doctor practicing in Santa Cruz.  She added that her own practice focuses on women’s health and gynecology, so STD testing and prescribing birth control pills also fall under her scope.

However, naturopathic doctors can only prescribe medications under the supervision of a medical doctor, said Dhurga Reddy, a naturopathic doctor and chair of the state Naturopathic Association’s insurance committee. According to Reddy, naturopathic doctors originally opted to limit their scope of what they could do in order to gain licensure, more than 10 years ago. Reddy said they made certain concessions to their scope, with the hope they would be able to expand it down the road.

If a naturopathic physician does not have a supervisory relationship with a medical doctor, and the patient requires medication, the patient must then go to a conventional doctor for the prescription. “That creates a lot of redundancy,” Reddy said, which is one reason insurers might be reluctant to contract with naturopathic doctors.

Naturopathic doctors instead want to be allowed to prescribe certain drugs without supervision. It is one part of a four-part change they are hoping to bring to their scope of practice through state legislation.

They’re also seeking to be able to perform minor office procedures consistent with their training (such as the removal of a suspicious mole for biopsy), give orders to allied health professionals (such as order a nurse practitioner to start an IV on a patient) and perform joint manipulation consistent with naturopathic medical training.

Patients seek coverage

Many alternative providers had hoped that part of the Affordable Care Act, section 2706, would allow including practitioners like chiropractors and naturopathic doctors to be widely reimbursed by insurers. Sometimes called the “non-discrimination clause,” the section says that insurance companies “shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law.”

However, many insurance companies do not reimburse patients for services provided by alternative practitioners and they may not be legally required to after all. A 2013 guidance report issued by the U.S. Department of Health and Human Services that clarifies that the nondiscrimination clause “does not require plans or issuers to accept all types of providers into a network.”

Naturopathic doctors, meanwhile, are left to sort out exactly how federal health reform may apply to them and whether it will help their patients get insurance that covers their services.

Kirsten Smith, 43, is an accountant who has insurance offered through her employer, but the plan doesn’t cover naturopathic services. She’s worked with a naturopathic doctor in the past and said she would appreciate the services being covered in some capacity.

Smith said the naturopathic doctor she saw spent a significant amount of time talking with her about things like her eating and sleeping habits, and where she worked.

“I felt like it was a whole picture, rather than just a 15-minute ‘Go see the doctor,’” she said, adding that she takes supplements, and has regular visits for acupuncture and chiropractic care, the costs of which come out of her own pocket.

“I’m really big on empowering people to make choices for their own health care, rather than the insurance companies dictating who we can see and what’s going to be in our best interest,” she said. “Because nobody at the insurance company knows my health situation. It’s the doctors that I choose and that are in my area that do, and so, putting the empowerment back into the hands of the patient and the doctor.”