Why Advocacy Is So Hard to Fund

Editor’s note: This is part 2 of a three-part essay series, The Association Problem.

The dues invoice arrives the same way every year. Maybe it comes by email now instead of through the mail, but the decision behind it hasn’t changed much. Do I renew? Somewhere behind that invoice, the association is paying staff, a lobbyist, legal bills and the other expenses that come with representing a profession while most doctors are busy seeing patients and running their practices. The chiropractor opening the email sees a number, maybe a few hundred dollars or more, and has to decide whether paying it makes sense.

Most things we buy in practice are easier to evaluate. If I pay for continuing education, I take the course. If I buy software, I use it in my office. If I hire a consultant, that person works with me on my business. A laser or a new table sits in the office after I buy it, and I can decide over time whether it was worth what I paid. There is still plenty of judgment involved, but the exchange itself is easy to understand. I spent the money and got something in return.

Advocacy is different. A member pays dues and some of that money goes toward monitoring legislation, meeting with lawmakers, responding to regulators, working with insurers, paying lobbyists and dealing with issues that can affect every chiropractor in the state. Maybe a bill gets stopped, language in a proposed rule gets changed, reimbursement improves or a scope issue gets resolved. Whatever happens, the chiropractor across town who never joined the association gets the same result. He practices under the same law and the same regulations. His claims are paid according to the same reimbursement rules. There isn’t a member version of the law for the people who helped pay for it and another version for everybody else.

So the person paying for the work receives the benefit, but his payment isn’t what gives him access to it. In most cases, he would have received the result even if he had never joined.

That can be frustrating when you are involved in an association. You look at the membership list, compare it with the number of licensed doctors in the state, and it is hard not to notice how many people benefit from work they don’t help finance. It is tempting to call those doctors apathetic or selfish, or assume they simply don’t understand what the association does. There are certainly people for whom some of that is true. I just don’t think it explains the problem very well.

For the individual doctor, not joining can be a perfectly understandable financial decision. If I spend $15,000 on a piece of equipment, the chiropractor across town doesn’t get to use it. If I pay to attend a seminar, someone who didn’t register doesn’t get a seat. Most things we buy keep the benefit reasonably close to the person who paid for them. An association can’t do that with a favorable law, a regulatory decision or a reimbursement policy. Once that decision is made, every chiropractor in the state practices under it.

Yet we generally finance that work through the same membership arrangement we use to pay for everything else the association offers. You pay dues and receive some combination of meetings, education, discounts, publications, resources, networking and advocacy. Then you decide whether the whole package is worth the price. Most of those benefits can be limited to members. An association can charge a nonmember more for a convention or keep certain resources behind a membership login. It cannot keep a nonmember from benefiting when a bad provision gets removed from a bill.

That makes advocacy difficult enough to finance through voluntary dues, and then there is another problem. Some of the work is hardest to see when it goes well.

A bill gets filed with language that could cause trouble for chiropractic. The association catches it, talks with the sponsor, works through the issue and the language changes. Maybe the bill never gets a hearing. Maybe the provision disappears before it gets that far. Most chiropractors never read the original bill and never hear about the conversations. They open the office the next morning, see patients, deal with staff, finish their notes and go home. Their day looks exactly the way it did before.

The same thing happens with regulation. An agency proposes a rule that creates a problem. The association submits comments, talks with the agency and gets the language changed before the final rule comes out. The doctor in practice may never see the original proposal. There is no moment when everybody celebrates the reversal because, from the doctor’s perspective, there was never anything there to reverse.

Sometimes that is what success looks like. Nothing changed in the office.

There are advocacy wins that are much easier to see. A significant bill passes, scope changes or a reimbursement policy has an obvious effect on practice. You can point to what existed before and what exists now. But a lot of legislative work, especially defensive work, isn’t like that. It happens through conversations, meetings and changes in language made before the issue ever becomes something most doctors would know to worry about.

Try putting a value on that from inside a practice. What was the regulation that never took effect worth? How much was saved when a proposed reimbursement cut was reduced before anyone saw it? What was a conversation worth if it stopped a bad idea from becoming a bill? A relationship with a legislator can go years without producing anything a member can point to, and then suddenly matter on an issue that affects every doctor in the state. There may be substantial value in all of it, but none of it shows up neatly on the practice’s profit-and-loss statement.

The dues payment does. It shows up alongside malpractice insurance, software, payroll, rent, licensing fees, marketing, CE, taxes and everything else it costs to run the office. Some of those expenses are required. Others make money, save time or provide something the doctor can use and evaluate. Association dues ask for a different kind of judgment because some of what the doctor is paying for benefits people who didn’t pay, and some of it may be valuable precisely because a problem never reached the practice.

If that doctor decides not to renew, the law doesn’t stop applying to him. A regulatory decision doesn’t disappear from his office. The reimbursement rule doesn’t change because his membership expired. He can stop paying dues and continue practicing under whatever results the association is able to produce.

Associations can do a better job telling members about that work, and I think they should. They can explain which bills they worked on, what proposed rules changed, where the lobbyist spent time and what was happening before an issue became visible to everyone else. Members deserve to know what their money supports. But communication can only address the part of the problem that comes from not knowing. It can’t change the fact that the nonmember gets the legislative result too, and it won’t make every successful defensive effort visible to the people who never had to deal with what was prevented.

That is why I have a hard time accepting that the membership problem comes down to chiropractors not understanding the value of associations. Some don’t understand it. Others may understand it quite well and still decide not to join. A doctor can believe the legislative work matters and appreciate the people doing it while also looking at his own dues invoice and figuring that the work will probably continue without his check. As long as enough other doctors pay, the lobbyist will still be there, the legislation will still be monitored and someone will still respond when a problem comes up. He gets whatever result they produce.

For quite a while, he may be right. One doctor drops membership and nothing changes. Ten doctors leave and the association is still functioning. More leave and the work continues, because the people inside the organization adjust to what they have. Maybe there is less staff time. Maybe the association can’t work on as many issues at once, or spends more of its time responding to immediate problems because there isn’t enough money to do much beyond that. None of this has to produce a moment when everyone can see what was lost. The organization can simply become less capable while continuing to look, from the outside, like it is still doing the job.

There is an irony in chiropractic that I can’t completely ignore. We have spent generations arguing for maintenance and for dealing with problems before they become harder to correct, but we aren’t any better than anyone else at valuing prevention when the problem never shows up. If the legislative or regulatory work succeeds, the fact that nothing bad happened can become part of the reason the expense is questioned.

I don’t think scolding doctors about that gets us very far, and another membership campaign doesn’t change the basic problem. We are asking individual chiropractors to voluntarily pay for work whose results cannot be limited to the people paying for it, while some of that work is most successful when those same people never have to experience the problem it addressed.

The chiropractor who writes the dues check is helping pay for an outcome that will apply just as much to the chiropractor who doesn’t. When the next invoice comes around, both are still practicing under whatever the association was able to accomplish during the previous year.

One of them paid for it. The other did not, and nothing about the result requires that he ever does.

That may be a more useful place to start when we ask why more doctors don’t.

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