A dozen academic papers on the legislation history of acupuncture or traditional Chinese medicine (TCM) in the United States (U.S.) have been published, including the Nevada, California, New York, Massachusetts, Washington D.C. as well as surrounding states of Maryland,1–14 and Virginia.3 Virginia was once considered a state that was particularly resistant to acupuncture and its legislation, due to the historically strong conservative force in that state.3 Except for the practicing of acupuncture by Western-trained medical doctors, Virginia had been considered as one of three most unlikely states in the country to legalize the acupuncture practice by acupuncturists.3,15 However, some wanted to change that perception. Dr. Ralph Coan, a medical doctor from Maryland and a life-long supporter of acupuncture, was one of two founders of the American Association of Acupuncture and Oriental Medicine, which became the most important national association for TCM in the U.S.. He has served as president, vice president, and board member for a very long time. He testified in front of the Virginia State Assembly several times for the legislation of acupuncture.3 There were several others who were inspired by him, and made continuous efforts of their own.
Acupuncture legislation in Virginia was influenced by legislation of other states in the U.S. and other countries. No doubt that Chinese mainland was the first region in the world where the government had issued policies to support TCM, including acupuncture. China has treated TCM practitioners as physicians since the founding of the People’s Republic of China; but formal legislation for TCM was not passed until 2016.16 The first piece of legislation for acupuncture and TCM in the world was passed in Nevada, U.S., in 1973.17 Dr. Yee Kung Lok, the “Father of acupuncture in the United States,” was the first government-recognized doctor of Chinese medicine and acupuncture in Nevada state. His license number was no.1 and acupuncturists in the U.S. commemorate him because of his major contribution in that legislation. Mr. Arthur Steinberg and Mr. Jim Joyce also took the lead in passing acupuncture legislation in Nevada.9 Without their efforts, the development of TCM or acupuncture in the U.S. would be very different to start. On December 28, 1972, the Washington Acupuncture Center, the first government approved acupuncture clinic in the American history, opened its door.1–3,18 Fast forward today, there are a total of 48 independent jurisdictions, namely 47 out of 50 states in the U.S. plus Washington, D.C., that have laws regulating the practice of acupuncture or oriental medicine.19,20 This paper aims to review and discuss the history and the current situation of acupuncture legislation in Virginia, and provides some insights for the legislations in other states and at federal level.
2 Current basic situation in Virginia acupuncture legislation and personal experience as vice president of American TCM Association
At the beginning of 2018, there were approximately 38,000 active licensed acupuncturists in the U.S.; among them, Virginia had 502 (as of the end of August 2022, the number has become 58421), ranking 19th nationally.19,20 In recent years, I have been participating in legislative activities related to TCM or acupuncture. In Virginia, the administration of acupuncture or TCM has been handled by the Acupuncture Advisory Committee (AAC) under the Board of Medicine, instead of an independent acupuncture board like those in Nevada or California. The reason is cost-efficiency, as all AAC members work as volunteers and without salary. If an acupuncture board is established, the acupuncturists would be responsible for the salary of a specialized officer, which would cost an extra $30,000 to $50,000 per year; this means that the state licensing fee would increase significantly. In 2012, I made a proposal to the AAC, requesting that the Regulations Governing the Practice of Licensed Acupuncturists (hereafter referred as the Acupuncture Regulations) should clearly state that acupuncturists can legally use traditional Chinese herbal medicine(s), and that acupuncturists applying for a license should not only pass the national examination in acupuncture, but also pass the Chinese herbology and biomedical exams, since patients are increasingly using Chinese and Western herbal medicines. I also proposed that licensed acupuncturists with a background in TCM should be able to prescribe biochemical tests to monitor potential side effects or adverse effects during the period using the herbal medicine in patients. In a board meeting, the five members of the AAC expressed their oppositions after a collegial discussion. Their first consensus was that the Acupuncture Regulation (of Virginia) has clearly stated that acupuncturists can use “dietary supplements.” Chinese herbal medicine(s) should also be considered as food or dietary supplements; therefore, there is no need to add a term for “TCM” specifically. Second, regarding the proposal that “acupuncturists are required to pass the Chinese herbal medicine and biomedical examinations to apply for a license,” they felt that some acupuncturists would oppose to it because such professionals may only be interested in practicing acupuncture only. Third, adding the right to prescribe biochemical test is beyond the original scope of Acupuncture Regulations and it therefore could not be decided by the AAC. Instead, it should be decided by the Board of Medicine. AAC predicted that this proposal would be opposed by (western) medical doctors.
Another issue was the objection to physical therapists practicing acupuncture in the name of “dry needling” with a training of 11 to 54 hours through continued education since 2014. The author attended at least five board meetings of the Virginia Board of Physical Therapy along with other acupuncturists from Virginia and other states. We spoke at each meeting to express our explicit opposition and reasons for our opposition. As a Vice President of the American TCM Association (ATCMA) in academic and legislation affairs for the past 8 years, I worked closely with my ATCMA and other associations’ colleagues (Dr. Michelle Lau, Dr. Sarah Alemi, Dr. David Miller, Dr. Haihe Tian, Dr. Hui Wei, Dr. Hui Ouyang, Dr. Deguang He, Dr. Bolin Qin, and Dr. Jun Xu, etc.), launched two rounds of online public comments on the website of the Virginia Board of Physical Therapy, and encouraged 1,176 licensed acupuncturists, medical doctors, and patients to give comments on “dry needling” issue, to express our further opposition and the concerns.22 The major concern is that the so-called “dry needling” may pose a safety issue to the general public. The ATCMA and other concerned associations hoped that physical therapists could match the medical doctor’s acupuncture education requirement of 300 hours. However, as of now, this issue has been more than 6 years since the legislation passed, but it is still unresolved and ATCMA’s goal has not been achieved. The battle is still ongoing. The crucial issue is that the majority of acupuncturists are tired and have lost interest in protecting own professional privilege; it is worrisome.
3 History of Virginia acupuncture legislation
While attending some of the above-mentioned meetings, I got to know Mr. Floyd Herdrich, a pioneer in the Virginia acupuncture profession, and met him in person three times. I learned that he was the president of the Acupuncture Society of Virginia (ASVA) when acupuncture legislation was first passed in Virginia. I also received a hardcopy of an old newsletter from him. Virginia acupuncture legislation began in 1988 and was passed in 1994. Virginia is the 27th state in the U.S. to have acupuncture practicing laws,23 and it has been 28 years since then.
I would like to thank Dr. Ralph Coan, who made special contributions to the legislation of acupuncture in the U.S. as well as Mr. Bob Duggan. Both are fighters and famous figures in the field of acupuncture. Unfortunately, they passed away a few years ago. I mention them specifically, and want to use this article as a kind of special memorial to them. Duggan was a Catholic priest in his early years. He quit the religious work and married a woman named Diane. Then he and Diane went to the United Kingdom to study Five Element Acupuncture with Professor J.R. Worsley. Bob later became a representative of Five Element Acupuncture, the Dean of the Tai Sophia Institute in Maryland that he and Diane established. He was also a major promoter and advocate of three major organizations in acupuncture and Chinese medicine or Oriental medicine, that is, the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM, now CCAHM, Council of Colleges of Acupuncture and Herbal Medicine), Accreditation Commission for Colleges of Oriental Medicine (Note 1), and the National Certification Commission for Acupuncture and Oriental Medicine. He probably was the first person in the West to clearly and openly express dissent to “TCM” style acupuncture which was formed in 1950s by some acupuncture scholars converted from Chinese herbalists. This kind of acupuncture uses pattern identification (a clinical thinking mainly used by TCM internal medicine practitioners) to direct acupuncture practice. He personally named this kind of acupuncture as “herb” style acupuncture. He believes acupuncture should be based on the Huangdi Neijing (《黄帝内经》 The Yellow Emperor’s Inner Classic), and return to meridian theory to direct its practice. I strongly agree with him, and I have discussed this point of view in various situations and especially with some leaders of China Association for Acupuncture and Moxibustion. I am glad to know that currently more and more acupuncture professionals agree with this viewpoint.
Tai Sophia Institute (Note 2) was the first TCM college in the U.S. that was accredited by the Accreditation Commission for Colleges of Oriental Medicine to grant a master’s degree in acupuncture in 1985. Dugan was a very creative educator. His assignment for the masters’ students as part of their graduation requirement was to “complete a project that would have an impact on the world.” For this goal, some students choose to go to their own states or nearby states to promote acupuncture legislation.15
Claire Wistoff, a former TAI student who lived in Virginia at that time, planned to open an acupuncture center in Virginia after she completed her acupuncture studies. She wanted to help promote acupuncture legislation in Virginia. Considering the difficulty of passing acupuncture legislation in Virginia, she called together two other junior TAI students from Virginia, Mr. Floyd Herdrich and Ms. Ann Strozier Adams. While learning about the legislative process and the process for passing acupuncture legislation, they met a woman who told them that she had the privilege of having a meeting with Richard Morrison, the Virginia Health Secretary (the head of Virginia Health Department) at that time. Because she was a fan of acupuncture, she asked the Health Secretary, “How can I legally receive acupuncture in Virginia?” To which, Mr. Morrison said, “Ah, ah, now there is an opportunity, someone submitted a bill to make alternative medicine (acupuncture) legal” and encouraged her to do some lobbying work. They were treating this woman to breakfast at the time, so it was at this breakfast meeting that the three students formed ASVA and went to the state to lobby. This kind of society is used to be branded as “academic,” but it is inaccurate. In fact, it should be called “professional association” because such state associations serve the interests of the entire acupuncture industry. They do sometimes carry out academic activities; however, the purpose of such academic activities is mainly as a means to subtly raise fund for the organization. ASVA’s first board consisted of three people: Claire Wistoff as President, Ann Adams as Vice President, and Floyd Herdrich as Treasurer.
Since then, the three students drove every week to the state capital Richmond. It took 7 hours to drive back and forth; sometimes they went together, sometimes only one person. They visited and lobbied state legislators, including state representative Marianne Van Landingham. Marianne enthusiastically suggested that they should mobilize Virginia residents to write supporting letters, so that the legislators could hear the voices from the residents of their constituents. This was not an easy task. However, they were fortunate as several reports on the efficacy of acupuncture appeared in newspapers and on televisions at that time. The enthusiasm of the public for acupuncture was mobilized, so these students collected a lot of supporting letters from the public. Later, during the acupuncture legislation process, some residents even went with the three students to meet their representatives. Floyd made a bigger contribution to Virginia’s acupuncture legislation, persuading Senator Clive Duvall to submit an acupuncture bill to the state legislature. This bill was very brief, as it did not explicitly propose detailed content of acupuncture legislation, but just let the state medical administration install acupuncture (“…by the Board of Medicine to look at acupuncture in the state”). This was a good strategy, as it avoided a debate by members of Congress and left the executive branch to think about how to install and operate.
In the following years, although they had graduated, the three students still received full support and help from TAI’s administration, including legislative strategy seminars and financial supports. TAI’s alumni also initiated multiple donations to support them. They still went to the state health administrative department every week to “grin.” Sometimes people in these administrative departments were not enthusiastic about them, and they would just smile. I once asked Floyd, “You didn’t have an acupuncture license at the time, how could you practice acupuncture or solve your survival issue?” He told me that he had a clinic in Maryland and a clinic in Virginia; he was practicing legally in Maryland but illegally in Virginia. I asked him, “You’re not afraid of being caught and jailed by the Virginia State Police?” He smiled and told me that Virginia is a state in which “small government” has been advocated for. Unlike other states, there were not many police officers, and they would not spend a lot of money to arrest people for “small mistakes like illegal medical practice” as long as the health administrative department turns a blind eye. As the Health Secretary and the Board of Medicine had been discussing with the three students on how to install acupuncture into the Virginia’s health system, the administration did not care about Floyd and others practicing acupuncture without a license in the “northern border area” (northern Virginia). During this period, Floyd spent the most time and efforts on legislation, and finally, in 1994, Virginia’s Acupuncture Regulations was approved and signed into the law by Governor Douglas Wilder (Fig. 1), who is an African-American and a member of the Democratic Party. The law required acupuncturists to practice under the “supervision of a physician.” This requirement was removed in 1996,24 after lobbying by ASVA members, and replaced by a requirement that the patient must sign a document stating that they should go to a physician (a licensed practitioner of medicine, osteopathy, chiropractic, or podiatry) or get a prescription of a physician with a definitive diagnosis in order for the acupuncturist to treat them.
Of course, the requirements in Virginia’s acupuncture practicing law were stricter than those in other states. For example, when I applied for an acupuncture license in Virginia in 2001, I encountered difficulty. At that time, Virginia required acupuncture license applicants to obtain a degree from a domestic American school; if the applicant had a foreign degree, they must acquire an acupuncture license in another U.S. state in advance and had practiced acupuncture for more than 5 years. I was educated in China in a college of Chinese medicine for 5 years and had practiced in China for 16 years, and I strongly questioned this unreasonable requirement. In the following year, the regulation was changed; therefore, I could also be considered to have made a little “contribution” to the legislation of acupuncture in Virginia, and I am probably the first licensed acupuncturist in Virginia who has an education background in Chinese mainland and successfully applied for a license directly.
4 Some insights
My insight is that both “academic societies” and “professional associations” in the U.S. should be the organizations that serve the interests of their industry. TCM organizations should actively support the legislation and promote the development of Chinese medicine profession. On the other hand, TCM practitioners should dedicate more of their time to the advancement of their professions. Thinking of the reasons that Floyd and others were able to successfully legalize acupuncture in this “difficult” state, the first important factor is their dedications as they made efforts persistently for so many years. The second is the strategy. If they adopted the ordinary legislation process through the House like acupuncture legislation in some other states,3,9–11 it would be more difficult to be successful. They adopted legislation through the executive or administrative system. Looking at the acceptance of acupuncture by the Veteran Health Administration, and how TriCare medical insurance for civilian and military employees began to include auricular acupuncture in recent years, we will understand that legislation through the administrative system will cost much less and have a higher success rate than the formal legislative process through the legislative system. Now Medicare has started to cover acupuncture for chronic lower back pain for senior citizens in the U.S. since January 2021; however, acupuncturists are not eligible to treat Medicare patients because they are not listed as the Medicare providers. We should look for a resolution through the administrative system similar to that of the Virginia acupuncture legislation, although formal action of the legislation in the Congress has been conducted. As long as our acupuncture community and the public continue to keep their voices loud, it is estimated that in the next few years, this goal will eventually be reached. This is a personal prediction. Due to the limitation of the author’s personal background and experiences, this article may have some omissions, limitations and errors; comments or corrections are welcomed and appreciated.
Note 1: Since inauguration, it was named as National Accreditation Commission for Schools & Colleges of Acupuncture and Oriental Medicine (NACSCAOM), now known as the Accreditation Commission for Acupuncture & Herbal Medicine (ACAHM).
Note 2: It was established in 1974 as “The College of Chinese Acupuncture,” then renamed as “the Traditional Acupuncture Institute” in 1978, which was the origin of the term “TAI.” Now it is called “Maryland University of Integrative Health.”
The author expresses thanks to Mr. Floyd Herdrich for providing the ASVA Newsletter hardcopy (1994, including the photo), Dr. Sarah Faggert Alemi for the English editing, and all colleagues and friends who have made various contributions to the acupuncture legislation in Virginia (some were mentioned in current paper, some were not).
This study does not contain any studies with human or animal subjects performed by the author.
Arthur Yin Fan wrote and revised the manuscript.
Conflicts of interest
The author declares no financial or other conflicts of interest.
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