Acupuncture Use in the United States: Who, Where, Why, and at What Price?

Abstract

Despite the increase in acupuncture uses and greater than ever before interest of funding agencies to fund biomedical research in acupuncture, little is known about the profile of acupuncture users. We examined who these individuals are, where they reside, why they use acupuncture, and what price they pay. The increased use and high costs associated with each acupuncture visit poses questions to health care insurers regarding its coverage. Profiling will help conventional providers identify the segment of the population who are more likely to use acupuncture and educate them on the possible risks and benefits of using it with conventional medicine.

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Acupuncture Use in the United States:
Who, Where, Why, and at What Price?
Shamly Austina, Zo Ramamonjiarivelob, Haiyan Quc & Gregory Ellis-
Griffithd
a Department of Critical Care Medicine, University of Pittsburgh,
Pittsburgh, Pennsylvania
b Department of Health Administration, Governors State University,
University Park, Illinois
c Department of Health Services Administration, University of
Alabama at Birmingham, Birmingham, Alabama
d Department of Public Health, Western Kentucky University,
Bowling Green, Kentucky
Published online: 15 Jun 2015.
To cite this article: Shamly Austin, Zo Ramamonjiarivelo, Haiyan Qu & Gregory Ellis-Griffith (2015)
Acupuncture Use in the United States: Who, Where, Why, and at What Price?, Health Marketing
Quarterly, 32:2, 113-128, DOI: 10.1080/07359683.2015.1033929
To link to this article: http://dx.doi.org/10.1080/07359683.2015.1033929
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Acupuncture Use in the United States: Who,
Where, Why, and at What Price?
SHAMLY AUSTIN
Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
ZO RAMAMONJIARIVELO
Department of Health Administration, Governors State University, University Park, Illinois
HAIYAN QU
Department of Health Services Administration, University of Alabama at Birmingham,
Birmingham, Alabama
GREGORY ELLIS-GRIFFITH
Department of Public Health, Western Kentucky University, Bowling Green, Kentucky
Despite the increase in acupuncture uses and greater than ever
before interest of funding agencies to fund biomedical research in
acupuncture, little is known about the profile of acupuncture users.
We examined who these individuals are, where they reside, why
they use acupuncture, and what price they pay. The increased use
and high costs associated with each acupuncture visit poses ques-
tions to health care insurers regarding its coverage. Profiling will
help conventional providers identify the segment of the population
who are more likely to use acupuncture and educate them on the
possible risks and benefits of using it with conventional medicine.
KEYWORDS alternative medicine, acupuncture, complementary
medicine, utilization, profiling
INTRODUCTION
Over the years, there has been a steady increase in the use of complementary
and alternative medicine (CAM) among the U.S. population (Coulter & Willis,
2004). CAM includes diverse and abundant practices such as acupuncture,
Address correspondence to Shamly Austin, PhD, MHA, Research & Development
Solutions, Quality Improvement Department, Gateway Health, 444 Liberty Avenue, Pittsburgh,
PA 15222. E-mail: saustin@gatewayhealthplan.com
Health Marketing Quarterly, 32:113–128, 2015
Copyright #Taylor & Francis Group, LLC
ISSN: 0735-9683 print=1545-0864 online
DOI: 10.1080/07359683.2015.1033929
113
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chiropractic care, naturopathy, ayurveda, and homeopathy. CAM therapies
are known as complementary medicine when used with conventional medi-
cine, and are known as alternative medicine when used alone (Floyd, 2006).
According to the 2007 National Health Interview Survey (NHIS), about 34%
of adults and 12%of children have used some form of CAM. An estimated
$33.9 billion out-of-pocket expenses per year are reported for CAM (U.S.
Department of Health and Human Services, 2008; National Certification
Commission for Acupuncture and Oriental Medicine, 2009).
One of the CAM therapies that have received particular attention during
the last decade is acupuncture. It is one of the fastest growing CAM therapies
in the United States (Burke, Upchurch, Claire, & Chyu, 2006) and has its
origin in traditional Chinese medicine (Kaptchuk, 2002; Vickers & Zollman,
1999). The National Certification Commission for Acupuncture and Oriental
Medicine reported a 32%increase in the number of visits to acupuncturists
between 2002 and 2007 (National Certification Commission for Acupuncture
and Oriental Medicine, 2009). The National Institutes of Health’s (NIH)
Research Portfolio Online Reporting Tools database lists about 73 federally
funded biomedical research studies in acupuncture (National Institutes of
Health, 2012). The NIH consensus panel has reported acupuncture as an
adjunct treatment or an acceptable alternative included in a comprehensive
management program for a variety of conditions (Burke et al., 2006; National
Institutes of Health, 1997). There is a growing body of literature on the
efficacy of acupuncture treatment for a variety of conditions, especially
musculoskeletal conditions, headaches, and asthma (Burke et al., 2006;
National Institutes of Health, 1997).
Despite the increase in acupuncture uses and greater than ever before
interest of funding agencies to fund biomedical research in acupuncture, little
is known about the profile of individuals who use acupuncture. Profiling,
defined as the ‘‘description of the salient characteristics of the best customers’’
(Ratner, 2011, p. 205), is a useful tool that can offer health care providers
information about the type of individuals they serve and consequently help
them focus on how to improve their services to better suit these types of
individuals. Given the pressure to provide integrative medicine and high
quality patient-centered care (Maizes, Rakel, & Niemiec, 2009), knowing the
profile of acupuncture users will guide acupuncturists to customize their skills
and services to meet the needs of users. Additionally, it will help allopathic
providers to identify the segment of the population that are more likely to
seek this kind of CAM therapy and educate them with the possible risks
and benefits of using acupuncture with conventional allopathic medicine.
Furthermore, getting a clear picture of acupuncture users might lead to better
and wider insurance coverage for acupuncture services.
Prior studies have profiled users of acupuncture in the United Kingdom
(McPheasron, Sinclair-Lian, & Thomas, 2006), minority and underserved
users of acupuncture in the United States (Highfield et al., 2012), U.S. women
114 S. Austin et al.
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who have used acupuncture (Upchurch et al., 2008), and users of acupunc-
ture in the United States during the past 12 months based on data collected
prior to 2002 (Burke et al., 2006). The studies that analyzed samples from the
United States are limited due to the fact that they either focused on specific
groups from the U.S. population (Highfield et al., 2012; Upchurch et al.,
2008), or they studied people who used acupuncture over a limited time-
frame (Burke et al., 2006). As a result, we do not have a true picture of
acupuncture users in the United States. The primary purpose of this study
is to address these limitations by profiling all adults who have ever used acu-
puncture in their lifetime based on the 2012 NHIS. Specifically, we examined
who these individuals are, where they reside, why they use acupuncture, and
what price they pay to get this treatment. In a secondary analysis, we ident-
ified the aforementioned characteristics from a sample of individuals who
reported that they had used acupuncture in the past 12 months (recent users)
to see if these results were any different.
THEORETICAL FRAMEWORK
We used the behavioral model of health care utilization to identify the factors
associated with acupuncture utilization. This model has previously been used
to examine the correlates of CAM utilization as well as acupuncture (Brown,
Barner, Bohman, & Richards, 2009; Upchurch et al., 2008). Upchurch and
colleagues used the behavioral model of health care utilization to examine
acupuncture use among U.S. women, while Brown and colleagues examined
the utilization of CAM among African Americans. According to the model,
individuals’ health care utilization behavior is a function of their predisposing,
enabling, and need-related factors (Andersen, 1995). Factors such as age,
gender, race=ethnicity, and education level, which predispose individuals’
decision to use acupuncture, are known as predisposing factors. Enabling
factors are those that have the potential to facilitate an individual’s ability to
utilize acupuncture services. Factors such as annual income, having any
health insurance, having a personal physician, place of birth, marital status,
and region of residence are enabling factors. Finally, factors that determine
the need for acupuncture treatment such as health status or medical
conditions are need-related factors (Andersen, 1995). Overall, health status,
arthritis conditions, cardiovascular conditions, stroke, and depression=
anxiety are some of the need-related factors included in our model.
METHODS
Data
This is a retrospective cross-sectional study based on the 2012 NHIS, which
is a population-based random sample of noninstitutionalized population
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(The Centers for Disease Control and Prevention, 2012). Study respondents
are 18 years old or older. Data were collected using a computer-assisted per-
sonal interviewing method. The NHIS questionnaire has two parts: a core
section and a supplement section. The core section contains the household,
family, adult, and child components providing sociodemographic, health
care utilization, and behavior data. The questions in the supplement section
focus on topics such as CAM, and new and emerging health issues. The CAM
supplement collects information on acupuncture and other alternative treat-
ments. In 2012, the NHIS sample size for adults who responded to the CAM
supplement questionnaire consisted of approximately 34,525 noninstitu-
tionalized civilians residing in the United States (The Centers for Disease
Control and Prevention, 2012). We merged the adult CAM supplement
section with the person-level file from the NHIS family core questionnaire
to create a unique data set with information on adults’ acupuncture use
and their sociodemographic characteristics as well as their health conditions.
Our analysis included a final sample of 27,692 U.S. adults after we excluded
individuals with missing data related to the variables of interest.
Variables and Measures
The outcome variable acupuncture utilization was determined by assessing if
individuals ever utilized acupuncture services (yes=no). The explanatory vari-
ables were predisposing factors (i.e., age, race=ethnicity, gender, and education
level), enabling factors (i.e., income, health insurance, personal physician,
place of birth, marital status, and region of residence), and need-related factors
(i.e., overall health status and health conditions, including arthritis conditions,
cardiovascular conditions, stroke, hypertension, diabetes, cancer, breathing=
lung problems, depression=anxiety, and nervous system conditions).
Age groups were categorized as 18 to 44 years, 45 to 64 years, and 65
years or older. The variable race=ethnicity was categorized as White, African
American, Hispanic, Asian, and other (Native American, Alaskan, multiracial).
We included both genders (male and female) in our model. Education level
was categorized as those who had high school education or less, those who
had some college education, and those who had a bachelor’s degree or higher.
Income was categorized as individuals who made less than $55,000, those
who made $55,000 to $74,999, and those who made equal to or greater than
$75,000. About 45%of the sample had missing information on income. Hence,
we decided to include a fourth category as ‘‘undisclosed’’ for individuals who
did not disclose their annual income. Health insurance was categorized as the
presence of any type of health insurance and not having any health insurance.
Place of birth was categorized as U.S. born and non-U.S. born. Marital status
was categorized as married and others. The variable personal physician was
categorized as individuals who had one and those who did not have one.
Region of residence was categorized as Northeast, Midwest, South, and West.
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Overall health status was categorized as good and poor. The health
conditions included in the model were arthritis conditions, cardiovascular
conditions, hypertension, diabetes, cancer, breathing=lung conditions,
depression=anxiety, and nervous system conditions. Health conditions were
dichotomized, indicating whether the respondents had each one of these
conditions or did not have one.
Data Analyses
The Statistical Package for the Social Sciences (IBM SPSS Inc., Chicago, IL)
version 19.0 for Windows was used for all statistical analyses and the sample
was weighted based on 2010 U.S. census data. As NHIS has a complex sam-
ple design, the final calculated weights that we used in our analysis were the
product of design weight and poststratification weights. Univariate analyses
were performed to explore the characteristics of the population who have
ever used acupuncture in their life. The independent variables were tested
for any multicollinearity using Cramer’s V correlation. We used multivariate
logistic regression models to examine the correlates of acupuncture utiliza-
tion. Further, we reported the reasons for acupuncture use and the average
price incurred.
RESULTS
Table 1shows the descriptive characteristics of the sample. Of the 27,692
adults in the sample, about 6.7%(12.7 million) have used acupuncture in their
lifetime. With respect to predisposing factors, 21%of the sample was age 65
and older, 55%were female, 70%were White, and 30%had a bachelor’s
degree or higher education. With respect to enabling factors, about 39%of
the respondents had an annual household income of less than $55,000,
10%did not have any health insurance, 81%had a personal physician, 15%
were born outside the United States, and 56%were married. The majority
(36%) of the respondents resided in the southern United States. With respect
to need factors, 14%of the sample reported poor health status, 4%reported
arthritis conditions, less than 1%reported cardiovascular conditions or cancer,
and slightly more than 2%individuals reported hypertension, diabetes, or
depression=anxiety.
The correlation matrix in Table 2did not reveal any multicollinearity
problem. The minimum and maximum correlations observed among the
independent variables were 0 and 0.60, respectively.
Table 3shows the results from the weighted logistic regression identify-
ing the factors associated with acupuncture use. Adults in the 18 to 44 age
group were less likely (OR ¼0.53, p<.05) to use acupuncture compared to
older adults (65 years). Males were less likely to utilize acupuncture
Acupuncture Use in the United States 117
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TABLE 1 Sociodemographic Characteristics of Individuals From 2012 National Health
Interview Survey (N¼27,692)
Factors Variables Measures
Frequency
(%)
Predisposing Factors Age (in years) 18–44 43.0
45–64 36.5
65 20.5
Gender Male 45.5
Female 54.5
Race White 70.2
African American 11.6
Hispanic 12.4
Asian 5.0
Other 0.8
Education High school 38.2
Some college 31.4
Bachelor’s degree or higher 30.2
Enabling Factors Annual income <$55,000 38.6
$55,000–$74,999 7.0
$75,000 9.2
Undisclosed 45.2
Health insurance Yes 90.4
No 9.6
Personal physician Have one 81.4
None 18.6
Place of birth U.S. born 84.9
Non-U.S. born 15.1
Marital status Married 55.8
Others 44.2
Region Northeast 19.5
Midwest 23.2
South 35.5
West 21.8
Need-Related
Factors
Health status Good 86.4
Poor 13.6
Arthritis conditions Yes 4.2
No 95.2
Cardiovascular Conditions Yes 0.6
No 99.4
Stroke Yes 1.0
No 99.0
Hypertension Yes 2.4
No 97.6
Diabetes Yes 2.3
No 97.7
Cancer Yes 0.8
No 99.2
Breathing=lung problems Yes 1.7
No 98.3
Depression=anxiety Yes 2.4
No 97.6
Nervous system conditions Yes 1.8
No 98.2
Note. Percentages weighted to U.S. population estimates.
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TABLE 2 Correlation Matrix (Cramer’s V Correlation Coefficient) for Independent Variables
Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 Age 1
2 Race .15 1
3 Gender .04 .04 1
4 Education .13 .23 .03 1
5 Income .44 .11 .17 .34 1
6 Health insurance .19 .16 00.13 .15 1
7 Place of birth .05 .60 .01 .10 .02 .11 1
8 Marital status .10 .16 .10 .11 .12 .06 .08 1
9 Personal physician .16 .13 .05 .06 .07 .20 .08 .06 1
10 Region .03 .34 .02 .07 .07 .06 .16 .02 .06 1
11 Health status .18 .11 .01.21 .24 .01 .00.07 .04 .06 1
12 Arthritis conditions .19 .06 .05 .10 .19 .04 .03 .08 .05 .03 .28 1
13 Cardio-vascular conditions .06 .01 00.03 .07 .01 .00.03 .01 .00.13 .17 1
14 Stroke .09 .03 .01.05 .10 .02 .01 .01 .02 .02 116 .10 .08 1
15 Hypertension .13 .08 .01 .09 .15 .02 .00.06 .03 .05 .27 .36 .21 .18 1
16 Diabetes .12 .04 .00.08 .14 .02 .00.03 .03 .04 .28 .25 .17 .14 .42 1
17 Cancer .07 .02 .00.02 .07 .02 .01 .01 .02 .00.14 .09 .08 .06 .13 .10 1
18 Breathing and lung problem .08 .03 .00.06 .12 .02 .03 .04 .02 .01 .22 .22 .14 .08 .24 .18 .08 1
19 Depression .06 .03 .02 .07 .12 .00.02 .08 .02 .01 .21 .19 .13 .06 .23 .16 .06 .20 1
20 Nervous system disorders .04 .02 .01 .04 .09 .01 .03 .03 .02 .00.17 .12 .14 .05 .13 .11 .06 .11 .16 1
Correlations not significant at p>.05.
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(OR ¼0.61, p<.05) than females. Compared to Whites, African Americans
were less likely (OR ¼0.58, p<.05) to use acupuncture. Individuals with
high school education or less (OR ¼0.33, p<.05) and with some college
(OR ¼0.61, p<.05) were less likely to use acupuncture than those who
had bachelors’ and higher degrees. Individuals who did not disclose their
income (OR ¼0.74, p<.05), those with an annual income of less than
$55,000 (OR ¼0.77, p<.05), and those with an annual income of $55,000
to $74,999 (OR ¼0.72, p<.05) were less likely to use acupuncture than indi-
viduals with annual income of $75,000 or higher. Compared to individuals
residing in the Western United States, individuals in other U.S. regions were
less likely to use acupuncture: Northeast (OR ¼0.61, p<.05), Midwest
(OR ¼0.49, p<.05), and South (OR ¼0.51, p<.05). Individuals with an over-
all poor health status (OR ¼0.76, p<.05) and diabetes (OR ¼0.50, p<.05)
were less likely to use acupuncture compared to individuals with an overall
TABLE 3 Results From the Weighted Logistic Regression for U.S. Individuals Who Ever Used
Acupuncture (N¼27,692)
Factors Variables (Reference category) Measures OR (95%CI)
Predisposing
Factors
Age (65 years) 18–44 0.53 (0.44–0.63)
45–64 0.96 (0.81–1.13)
Gender (Female) Male 0.61 (0.54–0.69)
Race (White) African American 0.58 (0.45–0.73)
Hispanic 0.84 (0.67–1.05)
Asian 1.17 (0.89–1.54)
Other 0.88 (0.45–1.73)
Education High school 0.33 (0.28–0.40)
(Bachelor’s degree or higher) Some college 0.61 (0.53–0.70)
Enabling
Factors
Annual income <$55,000 0.77 (0.63–0.95)
($75,000) $55,000-$74,999 0.72 (0.56–0.93)
Undisclosed 0.74 (0.59–0.92)
Health insurance (No) Yes 1.02 (0.78–1.32)
Personal physician (No) Have one 1.14 (0.93–1.40)
Place of birth (Non-U.S. born) US born 0.94 (0.78–1.32)
Marital status (Others) Married 0.92 (0.78–1.14)
Region (West) Northeast 0.47 (0.39–0.56)
Midwest 0.45 (0.37–0.54)
South 0.33 (0.27–0.40)
Need-Related
Factors
Health status (Good) Poor 0.76 (0.60–0.97)
Arthritis conditions (No) Yes 1.56 (1.14–2.14)
Cardiovascular conditions (No) Yes 0.71 (0.35–1.42)
Stroke (No) Yes 1.68 (0.90–3.11)
Hypertension (No) Yes 0.69 (0.43–1.11)
Diabetes (No) Yes 0.50 (0.32–0.80)
Cancer (No) Yes 1.11 (0.62–1.99)
Breathing =lung problems (No) Yes 1.30 (0.63–2.69)
Depression=anxiety (No) Yes 1.25 (0.85–1.81)
Nervous system conditions (No) Yes 2.47 (1.68–3.63)
Note. Sample weighted to U.S. population estimates. OR ¼odds ratio; 95%CI denotes confidence interval.
p<.05.
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good health status and those who did not have diabetes, respectively.
Individuals with arthritis conditions (OR ¼1.56, p<.05) and nervous system
conditions (OR ¼2.47, p<.05) were more likely to use acupuncture than
individuals who did not have these health conditions.
Further, we examined the reasons for acupuncture use. Of the 1,999
individuals who reported acupuncture use, 351 individuals responded to
the item on the reasons for acupuncture utilization. The major reason
identified for acupuncture use was conventional allopathic medical treatment
was not effective for the individuals’ specific health issue (33%). About 30%
used acupuncture for general health=wellness as well as disease prevention;
27%used it because friends and family members suggested the therapy; and
21%used it as their health care provider recommended it. About 7%reported
conventional medical treatment as too expensive. The average price per visit
was $94 and 67%of the sample visited an acupuncturist between 2 and 10
TABLE 4 Results From Weighted Logistic Regression for Recent Users of Acupuncture
(N¼27,692)
Factors Variables (Reference category) Measures OR (95%CI)
Predisposing
Factors
Age (65 years) 18-44 0.73 (0.53–1.01)
45-64 0.82 (0.59–1.15)
Gender (Female) Male 0.48 (0.38–0.60)
Race (White) African American 0.62 (0.41–0.96)
Hispanic 0.77 (0.53–1.11)
Asian 1.33 (0.84–2.09)
Other 0.13 (0.01–1.09)
Education High school 0.31 (0.22–0.43)
(Bachelor’s degree or higher) Some college 0.58 (0.44–0.75)
Enabling
Factors
Annual income <$55,000 0.64 (0.44–0.95)
($75,000) $55,000–$74,999 0.74 (0.46–1.18)
Undisclosed 0.51 (0.34–0.78)
Health insurance (No) Yes 0.77 (0.49–1.21)
Personal physician (No) Have one 1.60 (1.13–2.27)
Place of birth (Non-U.S. born) U.S. born 0.85 (0.60–1.22)
Marital status (Others) Married 0.91 (0.74–1.11)
Region (West) Northeast 0.51 (0.37–0.72)
Midwest 0.37 (0.28–0.50)
South 0.30 (0.22–0.42)
Need-Related
Factors
Health status (Good) Poor 0.64 (0.44–0.94)
Arthritis conditions (No) Yes 1.24 (0.72–2.10)
Cardiovascular conditions (No) Yes 0.33 (0.07–1.58)
Stroke (No) Yes 1.31 (0.52–3.25)
Hypertension (No) Yes 0.43 (0.21–0.90)
Diabetes (No) Yes 1.07 (0.46–2.47)
Cancer (No) Yes 1.39 (0.47–4.07)
Breathing=lung problems (No) Yes 0.66 (0.25–1.72)
Depression=anxiety (No) Yes 0.99 (0.52–1.90)
Nervous system conditions (No) Yes 3.10 (1.68–5.71)
Note. Sample weighted to U.S. population estimates. OR ¼odds ratio; 95%CI ¼confidence interval.
p<.05.
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times. The majority obtained information about the therapy from the Internet
(17%); followed by 8%from scientific articles, magazines, and books; and
around 3%from television=radio or health food stores. Further, back pain
(23%) was reported as the major health condition for which individuals
sought acupuncture.
We conducted an additional logistic regression to investigate the deter-
minants of acupuncture use among individuals who used it during the past
12 months (recent users). The results of the analysis are summarized in
Table 4. About 3.1 million (1.6%) U.S. adults used acupuncture within the
12 months prior to the survey. The results with respect to age, having a per-
sonal physician and certain health conditions such as arthritis, hypertension,
and diabetes, were different from the sample of individuals who ever used
acupuncture. Our analysis indicated that those who had a personal physician
were more likely (OR ¼1.60, p<.05) to use acupuncture than individuals
who did not have one. The variables age, having arthritis, and having diabetes
were not significant predictors of acupuncture use.
DISCUSSION
We profiled acupuncture users in a sample of the U.S. adult population and
examined their reasons for using acupuncture. We found age, race, gender,
education, region of residence, overall health status, and having health con-
ditions such as arthritis, diabetes, and nervous system disorders to be predic-
tors of acupuncture use. The three major reasons for acupuncture use were:
first, conventional medical treatment was not effective for respondents’ specific
health problem; second, acupuncture was used for general health=wellness
and disease prevention; and finally, respondents used acupuncture based on
the recommendations from family and friends.
Individuals Who Used Acupuncture
We found that older adults use acupuncture more than their younger counter-
parts. This suggests that as individuals age, they tend to pay more attention
to issues related to their health care and place more value on their health
(Zanjani, Schaie, & Willis, 2006). In addition, elderly people have multiple
morbidities that require the use of several health services. Hence, they may
be more likely to utilize acupuncture services. On the contrary, among the
individuals who have used acupuncture within the last 12 months prior to
the survey, age is not a significant predictor of acupuncture use. An increase
in out-of-pocket expenses for conventional health care may have encouraged
individuals, irrespective of their age, to use acupuncture. Moreover, the
number of underinsured adults in the United States dramatically increased
to 25 million in 2007 (Schoen, Collins, Kriss, & Doty, 2008). As the number
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of underinsured adults increases, individuals in this group may be more
willing to use acupuncture or other alternative treatments as it may be
perceived as a more affordable option relative to conventional medicine.
In addition, prior studies have indicated that acupuncture utilization
varies by race=ethnicity (Barnes, Bloom, & Nahin, 2008; Burke et al., 2006).
However, we found that being Asian is not a significant predictor of acupunc-
ture use. This suggests that as immigrants gradually acculturate, they relinquish
cultural practices of their native countries and adopt the cultural practices of
their host countries. In a study by Lee and colleagues, Mexican- and Asian-
American individuals are less likely to use ethnic-specific CAM providers after
spending more time living in the United States (Lee, Goldstein, Brown, &
Ballard-Barbash, 2010). Further, we found that females were more likely to
utilize acupuncture services than males. Previous studies have reported that
women are increasingly incorporating CAM therapies into their health
and well-being practices (Eisenberg et al., 1998; Tindle, Davis, Phillips, &
Eisenberg, 2005). It is reported that more than 1.2 million U.S. women have
used acupuncture (Upchurch et al., 2008).
Our findings also suggest that the use of acupuncture is more prevalent
among individuals with a bachelor’s or higher degree. Higher educational
attainment may lead to the opportunity to enhance individual’s social,
psychological, and economic skills (Winkleby, Jatulis, Frank, & Fortmann,
1992). Acupuncture utilization is not a mainstream medical treatment in the
United States. As a result, one may have heightened awareness of possible
alternative treatments available; awareness is closely correlated with an
individual’s education level and income. Therefore, individuals with a higher
education level and annual income may be more likely to utilize acupuncture
therapy. In addition, our findings also indicate that having a personal phys-
ician is associated with acupuncture use during the last 12 months before
the survey. This suggests that physicians have become more comfortable
advising their patients to use acupuncture, or that higher out-of-pocket
expenses for their physician’s office visit motivated individuals to seek
alternative therapies such as acupuncture.
Where and Why Do They Use Acupuncture?
Our study suggests that individuals residing in the Western United States are
more likely to use acupuncture. The United States is a vast country with a
heterogeneous population and where one lives has a potential influence on
health care utilization (Wood, 1995). The Western region of the country has
a larger Asian immigrant population and immigrants bring with them
ethnic-specific cultural experiences (Burke et al., 2006). Our investigation also
identifies those individuals who report overall good health status to be more
likely to utilize acupuncture to maintain their health status. The Grossman
theory, which focuses on health as a consumption good, may help to explain
Acupuncture Use in the United States 123
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this occurrence. The theory indicates that health is similar to a capital good and
it needs proper attention and maintenance (Grossman, 1972). Acupuncture is
considered as a preventative wellness type of treatment. Thus, healthy indivi-
duals may be more willing to seek out unconventional therapies to maintain
their good health status. Further, our results show that individuals with
arthritis conditions and nervous system disorders are more likely to use the
services of acupuncturists. Acupuncture is considered effective in treating
conditions such as osteoarthritis, lower back, neck, shoulder, knee, and other
chronic pains (Berman et al., 2004; National Institutes of Health, 1997).
Reasons for Acupuncture Use and Cost Incurred
The major reason reported for acupuncture use is the ineffectiveness of
conventional medical treatment. Our findings support previous studies
conducted in the field of health care utilization. Individuals tend to look for
alternative types of treatment when they do not find relief from conventional
treatment (Astin, 1998; Burke et al., 2006). The second major reason for acu-
puncture use is overall health and disease prevention. As our results indicate
the educated individuals, high-income earners ($75,000) and those with
good health status are more likely to use acupuncture. These individuals have
the monetary resources to indulge in nonconventional therapies that target
overall health maintenance and disease prevention. The third major reason
reported for acupuncture use is recommendations from family and friends.
Individuals usually ask their relatives and friends for help and opinions on
health choices and, to a large extent, families and friends influence indivi-
duals’ choice of medical treatment (Boon & Kachan, 2008; Diefenbach et al.,
2002; Griffiths, 1995). The fourth major reason is nonaffordability of conven-
tional medical care. Conventional medical care has become less affordable
with the rise in health insurance premiums and out-of-pocket expenses. If
health care costs continue to increase faster than personal income, the
number of uninsured and underinsured will continue to grow and individuals
will seek comparatively less expensive alternative therapies of health care
(Pagan & Pauly, 2005).
The estimated average cost incurred among acupuncture users in our
study was $94 per visit and 67%individuals in this group visited acupunctur-
ists between 2 and 10 times. Even $94 per visit is a huge amount, especially
when multiple visits to the acupuncturists are taken into account. Currently,
Medicare does not cover acupuncture (Centers for Medicare and Medicaid Ser-
vices, 2012). However, some private health insurances such as Blue Cross and
Blue Shield and some health maintenance organizations such as Kaiser Perma-
nente cover acupuncture services (American Association of Acupuncture and
Oriental Medicine, 2012b). In addition, some states, such as Florida, Maine,
Montana, Nevada, Texas, Virginia, and Washington State among others,
mandate acupuncture coverage (California Health Benefits Review Program,
124 S. Austin et al.
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2011). California has been looking for scientific evidence on the effectiveness
of acupuncture before mandating its coverage (California Health Benefits
Review Program, 2011). Further, the Patient Protection and Affordable Care
Act (PPACA) does not specifically mandate acupuncture coverage. However,
the PPACA requires that plans should provide coverage of health services
included in the essential health benefits package (EHB). The EHB contains
a list of 10 categories of health services, including preventative services,
wellness services, and chronic disease managements. The American Associ-
ation of Acupuncture and Oriental Medicine is campaigning to convince the
Department of Health and Human Services that acupuncture meets the
inclusion criteria for EHB; hence, it deserves insurance coverage (American
Association of Acupuncture and Oriental Medicine, 2012a). The current trend
in increased acupuncture use and the high costs associated with each visit
to an acupuncturist poses questions to health care insurers regarding its
coverage.
Limitations and Future Research
The results of our study should be considered in the light of certain limita-
tions. Because of the cross sectional nature of our design, we could not
capture an individual’s transition from conventional medicine to acupuncture
and vice-versa. However, this is the first study that examined the correlates of
acupuncture use among individuals who have ever used acupuncture. The
data did not have information on whether the individual used acupuncture
as an alternative therapy or complementary therapy. This study could only
analyze those reasons that were included in the 2012 NHIS questionnaire.
Additional reasons, such as cultural values and beliefs that we believe were
important to acupuncture utilization, were not included. In addition, the data
collected were based on self-reports; the use of self-reported data increases
the possibility of having internal validity threats such as response bias and
patient recall bias. The response rate for ‘‘Reasons for utilization’’ in the survey
was only 18%(n¼351) of the total 1,999 individuals who reported utilization.
Hence, the generalization of our results regarding reasons for utilization
may be limited. However, the NHIS is a highly reliable and valid data set,
which has a wide degree of generalizability to the broader U.S. population
(Boslaugh, 2007).
Over the years, acupuncture has matriculated from cultural curiosity to
one of the leading CAM therapies in the United States (Kaptchuk, 2002). The
rising cost of conventional medical care and its nonaffordability may have
resulted in an increasing number of people seeking CAM therapies such as
acupuncture. Future research should focus on longitudinal designs, which
would allow the opportunity to account for an individual’s transition from
conventional medicine to complementary or alternative therapies such as
acupuncture, and health insurance provision for acupuncture users.
Acupuncture Use in the United States 125
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