The Rift

It's not necessarily apparent from reading this blog, but inside CAN -- on the member forums -- things are often rowdy, contentious, and argumentative. There's no flaming, thank God, but the discussion can get, well, passionate. There are lots of strong feelings going around, frequently in opposite directions. You could say that CAN is, among other things, a big, noisy mess.

I like it that way. I was bored to death with the acupuncture world before CAN came along. One of my favorite writers, Ursula K. Le Guin, describes a political entity in one of her novels as "not a nation but a family quarrel" -- and that has always sounded to me like an interesting place to live.

One reliable thing for us to argue over is whether or not CAN is creating, in one practitioner's words, "the next big rift in the acupuncture profession". Meaning, is CAN primarily just opening up more options for acupuncturists to make a living, or are we saying that doing community acupuncture is BETTER than doing conventional, one-on-one, high-priced acupuncture (sometimes pithily identified in CAN-land as Boutique Acupuncture)? Are we supporting "oneness in the profession", or are we picking a fight, CA vs BA? Are we being collegial or polarizing?

I get accused fairly regularly, in CAN and outside it, of being polarizing: of having an us-and-them attitude, of being negative and condescending toward acupuncturists in BA practices, of being -- in the words of one acutely disapproving colleague -- militant and incendiary. But being responsible for creating the next big rift in the profession -- wow, that's a whole new level of antagonism even for me. And as much as it gives me a revolutionary thrill to think that CAN and I are capable of wreaking that much havoc, I'm afraid that I need to politely and formally decline credit for this.

There's a rift, all right, but it isn't my doing.

Before CAN came along, I never saw any public discussion of the fact that acupuncture for years has only been consistently available to the very rich and the very poor. Economically speaking, the world of acupuncture patients has indeed been deeply polarized. On one pole -- shall we call it the North? -- we have those patients who can consistently afford to pay $75 to $100 per treatment out of pocket, or who have the rare (and expensive) health insurance that covers a therapeutically significant number of treatments. On the other pole, let's call it the South, we have patients receiving subsidized or donated acupuncture because they qualify for it by suffering from a life-threatening illness, a serious addiction, homelessness, or some other catastrophic event. The vast majority of Americans, however, don't live at either pole. And until CAN came along, the acupuncture profession apparently felt perfectly comfortable with the fact that if all of those folks wanted to get acupuncture, they merely needed to a) win the lottery, or b) have something really, really bad happen to them. Oops -- there I go again! -- except that, according to my student sources, it's STILL the official position in the majority of practice management classes that you need to "charge what you're worth" in your business, and if you happen to suffer from a social conscience, volunteer in a free clinic in your spare time -- otherwise you are devaluing the profession. In other words, students are still learning that for the greater good of the profession, they must gravitate toward one economic extreme or the other and ignore everyone in the middle. Come on, now -- wouldn't you have to call that "polarizing"?

In the workshop I taught two weeks ago in Maine, someone asked, rather apologetically, whether or not a sliding scale for acupuncture could really work, since, "human nature being what it is" wouldn't everyone just pay at the bottom? My answer in the workshop was that if you feel that way about it, you shouldn't have a sliding scale. The implication here is that basic human selfishness and venality would cause anyone, if they had a choice, to pay $15 rather than $35. Something about my answer didn't satisfy me, though, and I've been mulling it over ever since. I was standing in front of a blackboard with figures from the 2005 Census describing the income levels of American households, and here is what I wish I had said:

If you do the math, $15 divided by the monthly gross income of a household that takes home $20K per year is .0090. Similarly, $75 divided by the monthly gross income of a household that takes home $91K a year is .0099. I'd consider that a pretty comparable ratio. Thus, someone who is making $20K per year and pays me $15 per treatment is [u]proportionately[/u] paying pretty much the same as someone who makes $91K per year and pays their conventional acupuncturist $75 per treatment. And yet, it's OK to imply that someone who is paying me $15 is somehow selfish and irresponsible, that they are taking advantage of me. In the workshop we discussed why having judgments about who paid what on your sliding scale was an excellent way to kill your sliding-scale practice, but we didn't talk about what kind of a role classism played in the discussion itself. One aspect of classism is the assumption that people who don't have much money are more likely to be lazy, ignorant, irresponsible, impulsive, unstable and selfish than people who have a lot of money. And a fifth of American households took home $20K or less in 2005, while a fifth took home $90K or more. We're talking about comparable numbers of actual people at each end of the spectrum, and yet $75 paid for a treatment somehow represents something qualitatively superior to $15 paid for a treatment. Why don't boutique acupuncturists wonder if the patients who pay them $75 are taking advantage of them? Surely some of those folks could pay more, if acupuncture really mattered to them, if they really valued their health.

But that question doesn't get asked, and maybe that's because $75, as the approximate market rate for an acupuncture treatment, represents the "normal" price for acupuncture. But the question is, normal for whom?

In 2005, a fifth of American households took home $20K or less, and .0090 of their monthly gross income is $15. The next fifth took home $20-36K, and .0090 of their monthly gross income is $15 to $27. The next fifth took home $36-57K, and .0090 of their monthly gross income is $27 to $43. The next fifth took home $57-91K, and .0090 of their monthly gross income is $43 to $68. The last fifth of American households took home $91K and above, and for the top fifth of that top fifth it was $150K or more. When I crunched those numbers, I noticed a distinct resemblance between the sliding scale that CAN encourages of $15 to $40 per treatment and .0090 of the monthly gross income of three-fifths of American households. ( Given that we are talking about households, not individuals, and that we want people to come in at least once a week for treatment, I think even .0090 can be a little steep, but that is another story.) The point is, a sliding scale makes things proportionate. $75 can be considered a reasonable sum only for folks securely lodged in the top economic fifth.

Boutique acupuncture is only for the top fifth of the American population. There's no way around that. The conventional style of practicing acupuncture excludes everyone else. When my colleagues suggest to me that it would be better if I could "honor each person in how they choose to practice", I understand what they mean in terms of individual interactions (even I don't normally spit at people I disagree with), but I flat-out don't get it in terms of the profession as a whole. The implication, to me, is that market rates are reasonable, the playing field is level, and mostly it's just a matter of personal choice and priorities, which are all pretty much equal in the end. The problem here is that I think those implications are delusional.

In the past few days I have encountered Michael Moore's "firefighting" argument for socialized healthcare in several different places. ( Nope, I haven't seen Sicko yet, but it's on my list, I swear.) It makes a lot of sense, and it goes like this: it would never occur to us to privatize firefighting in America, to make it a for-profit enterprise subject to the free market; it's a public service because we know that potentially everybody needs it, and it benefits everyone that it is free. You don't want your neighbor's house burning down and throwing sparks into your yard just because he can't pay the firefighters, and in the era of drug-resistant infectious diseases, the analogy is uncomfortably apt. So if we "socialize" firefighting (and police and libraries and public schools, for heaven's sake) why can't we socialize healthcare?

I'm thinking about a different angle on the same analogy. Say you're a firefighter, and you decide that, for reasons of your own, you really only want to put out fires in upper-middle class homes. Something about the way an upper-middle class home burns to the ground is just really intriguing to you, and a working class house in flames just doesn't give you the same satisfaction. Or maybe you grew up in an upper middle class neighborhood, and that's where you're comfortable; you don't really want to be anywhere else when you're fighting fires. Or maybe because upper middle class homes tend to be larger, you feel like you can spend more TIME, ONE ON ONE, fighting that fire, and you just do a better quality of work than you would on some little 600 square foot house that just goes up poof! in no time flat. Okay. I'm one of those kids who, growing up, never wanted to be anything but a firefighter (even though I wanted to be an allopathic firefighter for awhile), I've never been anything but a firefighter, I'm really serious about what I think my job is in the world, and I'm sorry, I'm having a little trouble honoring how you choose to practice firefighting. And in terms of the entire firefighting profession in America making a similar set of choices -- I'm having some trouble with that too.

What would you call that big gulf that divides the upper-middle class homes where our profession is happy to fight fires from the 80% plus percent of non-upper-middle class homes that we won't touch with a ten-foot hook and ladder? I'd call it a rift, actually. And I didn't put it there. I just don't want to pretend I don't see it.