Build the Association Around the Problem

Editor’s note: This is part 3 of a three-part essay series, The Association Problem.

I think we have been thinking about association advocacy backward. In chiropractic, we tend to think political strength begins with participation. Get doctors to Legislative Day. Show up in large numbers so the presence itself becomes the message. Put enough chiropractors in front of enough elected officials that they understand there are real people and real practices behind whatever issue we are there to discuss. I have spent years asking doctors to do exactly those things, and I still believe they matter. A legislator who knows chiropractors in his or her district is different from one who only knows the profession through a lobbyist. But some of the interests with considerably more political influence are much less dependent on demonstrating their strength that way. Hospital associations and other large interests bring their people in when it matters, but their representation, relationships, lobbyists and government affairs people are already there. Member participation adds to an existing structure rather than creating one for the day.

The obvious difference is money. Hospitals are large economic enterprises; chiropractic practices generally are not. They have deeper pockets, larger PACs, more government affairs resources and the ability to hire people with more experience and better connections. We are never going to match that scale, but representation costs money, and when outside institutions can materially affect a business or profession, spending money to influence those institutions is part of the cost of doing business. That brings us back to the question that started this series: what problem are we actually solving for?

Professional associations grew up doing a lot of things because there were once a lot of problems that could not be solved easily anywhere else. They distributed information, created education, connected colleagues and built professional communities. Those functions mattered, and many still do. They just no longer require the association. Education, information, community, networking, coaching, professional conversation and mentorship all exist elsewhere now, often through organizations more specialized in doing one thing well.

Advocacy is different. Government affairs is the easiest place to see it, but the problem is broader than the legislature. The same imbalance exists anywhere an individual chiropractor is sitting across from an institution with far more resources, leverage and reach. One chiropractor has very little ability to change a statewide policy adopted by a large health insurer. One practice is unlikely to alter how a workers’ compensation carrier handles chiropractic claims. An individual doctor has limited influence when a corporation, health system, regulatory agency, employer group or another professional association takes a position that affects thousands of chiropractors. Being right and having enough leverage to move an institution are two different things.

A doctor can build a relationship with a legislator, challenge an insurer decision or rally colleagues around a particular issue. None of that creates durable statewide capacity to watch legislation, track regulations, maintain relationships across election cycles, engage large payers, work with agencies, build coalitions, respond to reimbursement threats, negotiate with other institutions and pursue changes that may take years to accomplish. That is the work that still requires the collective. If that is true, advocacy and collective representation should stop being treated as one important function of the association and become the organizing purpose of the association.

That is a much bigger change than putting another ten percent of the budget into lobbying. It means asking whether everything else the organization funds actually supports that work or simply reflects inherited expectations about what associations are supposed to do. Continuing education has value. Conventions can have value. Relationships among members matter. Leadership programs can develop future leaders. But valuable and necessary are not the same thing. If a convention generates enough money to help fund the work, run it. If an event strengthens relationships that make grassroots advocacy more effective, there is a reason to hold it. If a publication helps doctors understand an insurance issue or legislative fight and makes them easier to mobilize, that serves the work. What becomes harder to justify is subsidizing functions the market already provides while the same scarce dollars could be building capacity where individual doctors have little ability to protect or advance their interests alone.

For years, associations have tried to make membership more attractive by adding things: more benefits, more discounts, more education, more networking, more programs, more reasons to belong. That assumes the membership package needs more inside it. The market has already unbundled most of that package. If the remaining indispensable function is advocacy and collective representation, that should be the product—not in a vague “we protect the profession” sense, but as a deliberately capitalized operation a practicing chiropractor can understand. Proactive government affairs capacity. Effective lobbying talent. Relationships maintained year-round. Regulatory monitoring, coalition work, research when needed, political intelligence and a PAC large enough to matter.

It also means being able to sit across from a major health insurer without arriving as a collection of individual practices complaining about the same policy, to engage a workers’ compensation carrier with data and enough institutional standing to be heard, and to respond when a corporation or another organized healthcare interest adopts a position that harms the profession. Sometimes that requires a lobbyist. Other times it may require an attorney, economist, actuary, reimbursement expert or someone who understands the institution we are trying to move. The association does not have to employ every kind of expertise it might need. It does need enough capacity to put the right people at the table when the profession needs a voice there.

Grassroots engagement still matters, but it should be layered onto that capacity rather than asked to create it. When a close vote requires twelve chiropractors from a district to make calls, they should be ready. When a legislator needs to see chiropractic care in practice, that connection should be immediate. When an insurer or regulator needs to hear directly from doctors in the field, the right doctors should be in the room. The profession’s influence should not rise and fall according to whether enough individuals happen to be available and organized that week. The infrastructure should already exist.

That requires money, probably considerably more than we have been accustomed to paying. If fewer doctors are willing to pay several hundred dollars in dues, asking them to pay a thousand or fifteen hundred sounds almost absurd—unless price is not the real problem. I have spent my adult life running a business, and I pay a lot of money for things that make the business work. I do not ask whether my malpractice insurance creates a sense of belonging or whether my accountant provides networking opportunities. When I spend money on marketing, the size of the check matters less than what comes back on the other side.

Advocacy will never produce that kind of clean arithmetic. A bill can take three sessions. Votes can disappear overnight. A relationship may take years to matter. Negotiations with a payer may produce incremental movement instead of an obvious victory. Some of the most valuable work is defensive, and defense is hard to value because success often means nothing happened. A simple return-on-investment calculation is impossible. Investment is not.

For much of the last decade in North Carolina, neutrality is roughly what it has felt like we purchased. I say that carefully because I know how much work sits behind that sentence. We have defended things. Relationships have been maintained. Problems have been handled that most doctors never knew existed. The preceptor bill was ours, and we moved it. But if a decade passes and the basic environment in which chiropractors practice is not materially stronger, it is reasonable to ask whether maintaining position has become the model rather than a temporary condition. Neutrality may not mean the people doing the work failed. It may be roughly what we funded them to produce.

We spread relatively limited resources across a broad organization, fund lobbying from that pool, ask for voluntary PAC money on top of it, depend heavily on volunteer leaders and mobilize doctors when something gets hot. Then we compare ourselves with institutions that maintain permanently funded legal, political, regulatory and corporate infrastructure and wonder why the relationship feels unequal. They may simply have bought more capacity.

We saw a version of this with a state health information exchange requirement, where chiropractic ultimately benefited from being removed from rules that would have imposed a real burden on practice. Much of the movement came through a for-profit entity within the profession and a set of long-cultivated relationships at key points in the legislative process. Assigning percentages of credit misses the point. An organization with an economic stake in the outcome had relationships, had a reason to use them and had enough institutional capacity to act when it mattered. Every chiropractor benefited whether they knew anything about the work or not.

A commercial organization does not wait for its customers to feel emotionally committed to advocacy before deciding that protecting its operating environment is part of the business. Associations should not have to either. The obvious objection is that concentrating more resources on advocacy makes the free-rider problem even more visible because nonmembers still benefit from the improved law, payer policy or regulatory protection. That is true. But layering more member benefits on top of advocacy has not solved it. We have been trying to force an inherently collective function into the logic of an individual purchase. Another discount does not change the underlying economics. A better investment might.

A chiropractor earning several hundred thousand dollars a year operates inside an environment shaped by laws, regulations, insurers, workers’ compensation systems, employers, corporations and other organized interests. Decisions made in any one of those places can affect the practice far more than an annual dues invoice. If the association can credibly connect the investment to stronger representation in those places, the conversation changes. So does the obligation on the association.

Asking doctors for materially more money should require materially more capability in return. Doubling dues so the same organization can do the same things with a little more breathing room is not the idea. The structure itself has to move. Some programs may disappear. Others may have to pay for themselves. Staffing priorities may change. The kind of CEO an organization needs may change. Success cannot primarily be measured by convention attendance, membership retention, newsletters opened, meetings held or bills monitored. Those measures say something about how the organization is functioning. They do not tell us whether the environment is different because the organization exists.

Many association leaders will argue that an association is broader than advocacy, that professional community matters, education matters, identity matters and narrowing the organization would hollow it out. Those things do matter. That does not answer the question: what problem requires us to solve it together? If education can be provided elsewhere, it will be. If another community better serves as the place where doctors gather, they will gather there. If a seminar company can deliver a better educational experience, there is no reason to pretend otherwise. The association does not need to be at the center of everything. It needs to be indispensable in the places where the individual chiropractor is not enough.

A doctor can purchase education alone, find community alone, choose a mentor, join a group, attend an event, read whatever information is useful and build professional relationships without asking thousands of colleagues to make the same choice. A doctor cannot create statewide legislative influence alone, negotiate from equal footing with a billion-dollar insurer alone, or build an enduring profession-wide relationship with every regulator, carrier, corporation, employer group or organized healthcare interest whose decisions may eventually reach the adjusting room. Those are the places where the collective still has work to do.

That requires going much further than declaring advocacy the number-one priority while continuing to run essentially the same organization underneath it. The budget, staffing and member proposition would be built around collective representation. Major expenses would have to justify how they contribute to that work. The PAC would be developed alongside it. Outside expertise would be available when needed. Individual doctors would be deployed strategically instead of being asked to compensate for institutional capacity that was never adequately funded. Then we would have to ask the profession to pay for what it says it wants. Maybe fewer people would. That is possible. But I am no longer convinced that a larger membership paying less for a broad collection of services necessarily creates a stronger association than a somewhat smaller membership willing to invest more deeply in an organization built to materially improve the environment in which everyone practices.

We have spent years asking how to get more chiropractors to value the association. Maybe the more honest question is what kind of association would be valuable enough that chiropractors would rationally choose to invest more in it. If the problems we still need the collective to solve are the ones where individual chiropractors do not have enough voice, leverage, access or capacity to solve them alone, then that is what we should build the collective to do.

Dr. Glenn Jaffe is a practicing chiropractor with more than twenty years in the profession. He served as president of the North Carolina Chiropractic Association and has worked at the national and legislative level on the profession’s governance priorities. He is the founder of BoldAzure, a leadership platform for chiropractors. He writes about where the profession is, how it got there, and what maturation actually requires.

Learn more at boldazure.com