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NCCAM Strategic Plan: Positions of CRN (supplements), AMTA (massage) and CAHCIM (MD/IM academics) PDF Print E-mail
Written by John Weeks   

NCCAM Strategic Plan: Positions of CAHCIM (MD/IM academics), CRN (supplements) and AMTA (massage), plus

Summary:  This article continues an Integrator series on stakeholder perspectives on NCCAM's 2011-2015 strategic plan. Included are the positions of three significant organizations: the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) representing 44 medical schools, Council for Responsible Nutrition (CRN) representing large dietary supplement interests, and the American Massage Therapy Association (AMTA), the largest 501c6 professional association for that field of some 250,000 practitioners. These positions add to the set of 8 stakeholder responses previously published. One question posed: What would a "balanced" NCCAM portfolio include? Also noted are two other influential stakeholders: the NIH and the NCCAM's blogging detractors.
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This article continues the Integrator coverage of stakeholder input, solicited last fall by the NIH National Center for Complementary and Alternative Medicine (NCCAM), on the NCCAM 2011-2015 strategic plan. The plan will shape NCCAM allocation of some $600-million during those years, and beyond. Three organizations are included in this follow-up to the Integrator articles noted above: the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM), the Council for Responsible Nutrition (CRN) and the American Massage Therapy Association (AMTA).

Notably, the first two of these organizations are arguably the stakeholders
of most interest to NCCAM, other than the internal NCCAM culture and the critical scientific community. I briefly explore these at the end of the article.

Consortium of Academic Health Centers for Integrative Medicine: Powerful stakeholder
Consortium of Academic Health Centers for Integrative Medicine

The stakeholder that represents the leading institutional grant recipients and project partners for NCCAM is the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). CAHCIM's membership is 44 medical schools/academic health centers. CAHCIM's Research Working Group (RWG) first developed an internal list of priorities relative to the strategic plan. Subsequently, some of the RWG members and other CAHCIM leaders held a conference call with Josephine Briggs, MD, NCCAM's executive director to share their perspectives and discuss NCCAM's future. CAHCIM leaders provided the Integrator the following statement on the priorities they have identified.

"The primary focus of the recommendations of the Consortium of Academic Health Centers for Integrative Medicine’s regarding NCCAM’s strategic planning process has been on three issues

  • A recommendation that attention to a balance of basic science, clinical trials, and outcomes research inform the new strategic plan, as we feel that all three of these areas should continue to be represented in NCCAM’s portfolio. We are in support of Dr. Briggs’ stated plan to move towards more “real world” effectiveness trials rather than more large multi-site clinical efficacy trials over the coming years as we feel that outcomes research and effectiveness should be a major priority going forward.

       CAHCIM's 3 Priorities

    Balance in portfolio
    (more outcomes/effectiveness)

    Focus on areas
    with preliminary evidence

    Support training of researchers
    at CAM institutions

    We support the planned move at NCCAM toward more specific focus on particular research questions for which there is at least preliminary evidence to justify further study, such as effective treatment strategies for low back pain. We hope to continue in a dialogue regarding these areas of focus as the strategic plan develops.

  • We feel strongly that continued support for the training of researchers at CAM institutions should be a high priority for NCCAM, and that the current model of partnerships between academic medical centers and CAM schools to support this type of training and infrastructure development for the CAM schools is an excellent model.

"We are pleased at the level of openness of NCCAM leadership to input from CAHCIM regarding the strategic plan and look forward to continued discussion with Dr. Briggs as the plan develops."
Comment: First, it can not be understated what a profound shift in NCCAM's portfolio that "balance," noted in the initial priority, would mean. Outcomes/effectiveness research would jump from roughly 1% of the NCCAM budget in 2004-2006 and slightly more, recently, to 20%-40%. That's huge. (See Making Amends: Studies of Effectiveness and Cost-Effectiveness Represent <1% of NCCAM Budget, September 27, 2007.) The pain focus in CAHCIM's second priority dovetails nicely with this "real world" approach. Finally, and most remarkably, this MD-centric institutional stakeholder has directly urged that NCCAM make "a high priority" the continuance of programs to train CAM researchers at CAM institutions. This is not guild business as usual and is exceedingly timely. One hears rumblings that NCCAM may be protecting its flanks against conservative detractors (see below) by limiting its involvement with the licensed CAM fields and their institutions. That CAHCIM is making this one of just 3 priorities is heart-warming evidence of the emerging respect for symbiosis that will cundergird a healthy integrative future. Thanks to the CAHCIM leadership for preparing and sharing this statement for Integrator publication.   

CRN: Key dietary supplement stakeholder weighs in
2.  The Council for Responsible Nutrition

The Council for Responsible Nutrition (CRN) is the leading industry association representing dietary supplement manufacturers and ingredient suppliers. The CRN Board includes not only firms one might expect such as General Nutrition Corporation and Shaklee, but also the likes of Pfizer Consumer Healthcare, Archer Daniel Midland and GlaxoSmithKline not typically associated with the dietary supplement industry. CRN's 7-page position statement in response to the NCCAM white paper question is posted in its entirety on the CRN website in a PDF format.
CRN's vice president for scientific and regulatory affairs Douglas "Duffy" MacKay, ND contacted the Integrator with this CRN submission.
Paper 1: NCCAM Mandate and Mission
1. Major features of the current CAM research landscape that are important in considering future strategic directions for NCCAM and the field of CAM research in general.

CRN Comment:
Early CAM research involving botanical and other natural products has suffered from poor characterization of test material. CRN supports the current NCCAM emphasis on proper characterization of test material used in clinical trials, which assists with reproducibility of results. We applaud initial efforts that NCCAM and the Office of Dietary Supplements (ODS) have taken to address this problem, and endorse the continued allocation of resources to this area.

Particular needs and opportunities of importance to NCCAM's efforts in research capacity building

CRN Comment:
Clinical trials carried out using the development of chronic diseases as clinical endpoints are complex and costly. Therefore, CRN supports the allocation of NCCAM resources to assist in the development and validation of biomarkers as modifiable surrogate endpoints for both disease and “wellness”. CAM interventions, such as consumption of adequate omega‐3 fats, vitamin D, and lutein/zeaxanthin, have the potential to reduce the incidence of chronic diseases such as cardiovascular disease, cancer, and macular degeneration.

Implementation of clinical trials using surrogate endpoints, such as omega‐3 cell membrane levels, inflammatory cytokines profiles, and macular pigment density could increase CAM research capacity globally, by providing the foundation for shorter and more cost effective intervention studies.
The examples given above are used to demonstrate the concept of validated biomarkers as surrogate endpoints and do not reflect any particular CRN priorities.

Opportunities, obstacles, and NCCAM's future role in supporting research on approaches to improved states of general health and well‐being

  CRN recommends exploring the
definition of “wellness”, but
cautions NCCAM against allocation
of excess resources trying to
answer such a complex question.

CRN Comment: It is clearly a difficult task to define general health and well‐being. A state of “well being” may in fact be different for each individual. CRN recommends exploring the definition of “wellness”, but cautions NCCAM against allocation of excess resources trying to answer such a complex question. Achieving consensus among scientists, integrated practitioners, and researchers on a definition of wellness is analogous to a group a psychologists and councilors to agree on a definition for happiness.

NCCAM resources may be better allocated identifying and validating multiple objective measures that are known contributors to general health and wellness, while recognizing that these measures are only small, but measurable pieces to a larger puzzle. General health could be defined as a combination of physical measurements (BMI, percent body fat, basal body temperature, blood pressure, etc.) and biomarkers (inflammatory profile, omega‐3 index, serum 25‐hydroxyvitamin D levels, macular pigment density, bone density, etc.). NCCAM may also benefit by exploring emerging measurements of health status such as metabonomics, or the quantitative measurement of the dynamic multiparametric metabolic response of living systems. Other state of the art “omic” (genomic, proteomic, and metabolomic) measurements may also contribute to better understanding complex integrative modalities. NCCAM is well positioned to display leadership in these areas through collaboration with other NIH centers.

 Clinical trials that investigate
component CAM treatment
as opposed to single,
interventions, could
record all of the
objective measures
that reflect “wellness”.

Clinical trials that investigate multi component CAM treatment approaches, as opposed to single, isolated interventions, could record all of the objective measures that reflect “wellness”. If a CAM intervention improves several measurable indicators of “wellness”, it could be considered generally beneficial. For example, a study may demonstrate that a particular diet, food or dietary supplement may fail to confer a statistically significant reduction in blood pressure. The same intervention may have a modest impact on several other biomarkers of disease or “wellness”, which over time could significantly reduce the chance of a cardiovascular event or the development of chronic disease.

In addition, for clinical trials that utilize herbs, nutrients and other CAM interventions, CRN recommends NCCAM emphasize clinical trials involving subjects who are considered “at risk”, but not yet clinically diagnosed with a particular disease or condition. This allows for more cost effective demonstration of risk reduction, e.g. utilize subjects who are at risk for osteoarthritis to demonstrate the OA risk reduction effect of glucosamine and chondroitin sulfate. While CRN supports risk reductions research done on “at risk” individuals we are also in support of condition‐based research that demonstrates the benefit of CAM therapies on individuals who already have a particular disease or condition.

The strength of individual CAM
therapies is often related to proper
application of the therapy as part
of a multi‐component intervention.
In large clinical trials where diverse groups of individuals (wide ranges of ages, ethnicities, baseline diet and health, and both genders) make up the study population a significant benefit for a subset of this group may be missed. It is important to encourage NCCAM funded researchers of large clinical trials to perform sub‐set analysis.

The strength of individual CAM therapies is often related to proper application of the therapy as part of a multi‐component intervention. It is valuable for NCCAM resources to support clinical sites that utilize a particular complementary and/or alternative modality as “demonstration projects”. For example, a study could be designed to compare the safety, efficacy, and costs of a Chinese Medicine approach to a common medical condition as compared to a Standard Allopathic approach. Results from such comparisons may help inform consumers trying to choose how to approach their own personal health issues. CRN is aware that other CAM stakeholders will comment in greater depth on the use of demonstration projects for comparative effectiveness research and we voice our support for the allocation of resources as such projects.

Paper #2
: NCCAM Priority Setting — Framework and Other Considerations

The need for greater shaping of the Center's research portfolio

CRN Comments:
CRN agrees it is important to focus investments of available resources on areas of research and development that offer the greatest potential of health benefit for the public or advancement of the general state of CAM research. It will also be important to continue directing some resources to a relatively broad, non‐targeted, investigator‐initiated, research project grant approach. The later approach casts a wide net, and continues to seed the research pipeline with new and emerging questions that can be built upon in the future.

NCCAM should be an integral part
of high level discussions and
investigations of whether it is
appropriate to apply a drug‐based
research paradigm to assess nutrient
and CAM‐related questions.

CRN also feels that resources should be allocated to exploring the questions of research study design. The CAM research community needs clear criteria and guidelines for how best to study effects of nutrients and other naturally occurring bioactive compounds in humans, and subsequently how to evaluate those findings. Exploring the nutrient‐chronic disease method using the same tools that were developed to explore the safety and efficacy of drugs has many inherent limitations.

NCCAM should be an integral part of high level discussions and investigations of whether it is appropriate to apply a drug‐based research paradigm to assess nutrient and CAM‐related questions. The former utilizes a reductionist approach and studies interventions in isolation. CAM, by definition combines multiple modalities using an integrative approach. Bringing together experts from both sides to explore this topic and possibly establishing alternatives to the drug paradigm is imperative to the future of CAM research.

The four factors (scientific promise, extent and nature of practice and use, amenability to rigorous scientific investigation, and potential to change health or health care practices) identified as key components of a framework for research priorities.

CRN Comments:
The four factors discussed in Paper #2 are rational guidelines for shaping priorities. CRN would like to emphasize that when considering option #3, “amenability to rigorous scientific investigation” the definition of rigorous scientific investigation should not be limited to reliance on the conventional randomized controlled trial (RCT) as the single gold standard. As mentioned in our previous comments, many experts opine that the misapplication of the drug‐based research paradigm to asses nutrient and CAM interventions, may lead to incorrect conclusions.
Drugs trials are designed to study a substance that has a single targeted effect, is not homeostatically controlled by the body, and can be easily contrasted with a true placebo group. Drugs also act quickly and have a large and easily measurable effect. In contrast many nutrients and other CAM therapies that have multiple target sites, may be homeostatically controlled, and are not amenable to a true placebo group. In addition, for nutrients and bioactive compounds the effects may be subtle and may take decades to manifest.

CRN would like to see NCCAM
display greater leadership in the
investigation of new research
methods designed to explore
the complexities of CAM therapies
and overcoming the methodological
challenges presented by the very
nature of these therapies.

In summary, CRN would like to see NCCAM display greater leadership in the investigation of new research methods designed to explore the complexities of CAM therapies and overcoming the methodological challenges presented by the very nature of these therapies.

The types and sources of information that must be included in an optimal priority‐setting process.

CRN Comments
: The NCCAM priority setting process should continue to rely heavily on stakeholder input. NCCAM should continue to seek expert input obtained through scientific workshops and forums; networking with investigators, practitioners, trade associations, consumers of CAM, and other stakeholders. The experience and viewpoints of top experts in the fields of nutrition, psychology, immunology, whole systems research, dietary supplements, Naturopathy, Chinese Medicine, Ayurvedic Medicine, Allopathic Medicine, Chiropractic Medicine , physical medicine, research design, and others are valuable assets the priority setting process.

In addition, when a proposed research project or program is related to a particular field, experts in the field should be consulted on the studies relevance and design. For example if a study is designed to investigate the safety and efficacy of a Traditional Chinese botanical, experts in the field of Chinese Medicine and botanical medicine should be consulted to see if the proposed project has plausibility.

Paper # 3:
Information and Communication About CAM Research and Decision making About CAM Use.

The major unmet needs of consumers and the general public in accessing, interpreting, and making use of research evidence about CAM

CRN Comments:
When a consumer who lacks medical and scientific knowledge is faced with a medical condition they are interested in fair and balanced information about ALL of their health care choices. Consumers desire the ability to compare the potential benefits, risk, costs, resulting quality of life, and personal commitment that accompanies each choice.

Health care consumers have a wide variety of personal preferences and have grown frustrated with physicians who feel that, “patient preference is least important” as indicated by Tilbert and colleagues findings published in 2009 and referenced in Paper #3. Even if a specific CAM therapy is considered less efficacious than its pharmaceutical counterpart, some consumers may confidently choose the CAM therapy. Factors that may contribute to this decision include quality of life, personal or religious beliefs, cost and availability. NCCAM should place a greater emphasis on the accurate communication of information about CAM, in context with other health care options available to consumers.

To assist the general public make an informed choice about health care decisions it is imperative the public is aware of the impact a particular therapy will have on their quality of life. NCCAM may consider recommending that validated “quality of life” questionnaires be used in both CAM and Drug trials. In some cases, a drug trial may show superior efficacy that may be offset by side effects that result in a quality of life. The quality of life may be unacceptable to the consumer and result in non‐compliance, which renders the CAM therapy superior in this context. When a consumer is choosing between using conventional drugs and/or CAM therapies, this information can be extremely valuable.

 The effectiveness of some CAM
therapies may require a significant
investment of time, money, and
self‐discipline by the patient.
Consumers should also be made
aware of the commitment required
to achieve the established benefits.

To be fair, the effectiveness of some CAM therapies may require a significant investment of time, money, and self‐discipline by the patient. Consumers should also be made aware of the commitment required to achieve the established benefits of a particular therapy. For example, there are many diet and lifestyle approaches to treating chronic heart disease. If properly educated on the personal commitment required to achieve these results, some consumers may choose a pharmaceutical management to their condition.

Finally it is important that consumers are aware of what type of practitioner is qualified to administer a particular CAM therapy. Educating the general public regarding the training, licensing, and scope of practice of different CAM practitioners should be part of the NCCAM’s outreach initiatives.

In summary, NCCAM communications should not be limited to the results of the latest clinical trials. This information should be placed in context with the real world and include information on the benefits, risks, costs, quality of life, and personal commitment that all of their choices (including allopathic and

CAM modalities) entail. In addition, when applicable, NCCAM communications should include the type of practitioner that is qualified to administer a particular therapy.

The major unmet needs of health care providers in accessing, interpreting, and making use of research evidence about CAM

CRN Comments
When interpreting and communicating research results to physicians, too often the message is black or white. The results of studies are communicated to health care providers in a fashion that suggests that a particular CAM therapy either works or does not work, when in reality it is much more complex.
Health care practitioners make treatment choices based on a wide variety of criteria. Often the inclusion or exclusion criteria for patients in a study make the results of that study not relevant to the patient sitting in their office. Health care practitioners would benefit from an evidentiary grading system that correlates different levels of evidence, with different levels of recommendation.

  Health care practitioners would
benefit from an evidentiary grading
system that correlates different
levels of evidence, with different
levels of recommendation.

For example, study results that suggest a particular CAM therapy is safe and may help some individuals may be an appropriate level of evidence to support individual consumer choice. When results suggest a therapy is safe and that efficacy is probable, this level of evidence may be appropriate for individual physician recommendations. When results suggest a treatment is safe and efficacious, this level of evidence may support inclusion into physician treatment guidelines as deemed appropriate by experts in that particular field. The highest level of evidence of safety and efficacy can be appropriate for public health recommendations.

Developing a communication system that translates research results into different levels or grades of evidence that support different levels of confidence for practitioner recommendations broadens consumer and physician choices. A communication system that informs practitioners in such a fashion could also discourage over‐reaching conclusions, such as “acupuncture does not work”, which sounds nonsensical to a fourth generation TCM practitioner whose experience suggests just the opposite or patient who has had their migraine headaches eliminated by an acupuncturist.

Research needed to better understand how both health care providers and the general public make decisions about CAM practice and use.

It is important for all health care providers to adopt a philosophy that seeks out therapies that are in the best interest of the individual patient, at a particular point in time. It would be helpful to better understand why health care practitioners tend to align with a particular philosophy and feel threatened by other modalities and philosophies.

Dogmatic opinions such as “herbs do not work” or “all pharmaceutical drugs are bad” are too dominant amongst all types of practitioners. It would be helpful to identify and gain a better understanding of unsubstantiated biases that are held by practitioners and how these biases may influence decision making about the use or avoidance of a particular modality. Understanding the source and influence of
biases may serve as valuable information that can assist in removing these biases, so that all stakeholders can make informed choices.
Comment: I found it intriguing to see how the CRN is not interested in mechanism, but rather underscore the use of herbs for wellness, as parts of multi-variable interventions and as parts of regimes which may engender useful qualitative outcomes. In short, the one significant stakeholder that might seem to be the most comfortable with a randomized controlled trial, drug-model of research is also directly distancing itself from that model. The focus on methodology and outcomes here indicates how profoundly important this is for NCCAM's future. The integrative intervention often involves one or more supplements, whether offered by an MD, DC, ND, AOM practitioner or holistic nurse. It will never fit into a square methodologic hole.

Massage association represents a profession with 250,000 practitioners
3. American Massage Therapy Association

Ron Precht, communications manager with the American Massage Therapy Association (AMTA), sent the following note shortly after the last Integrator publication of
stakeholder position papers:  "We noticed the piece you did in your blog about input given to NCCAM for their Strategic Plan. Judy Stahl [AMTA president] has asked me to forward on to you the separate response AMTA sent to NCCAM." Precht added that AMTA has "an ongoing relationship with NIH and they asked that we not use the online Q&A format, but rather submit a one-page letter with focused input." AMTA is the not-for-profit 501c6 membership association which represents the 250,000 practitioners massage therapy field nationally.
Dear Dr. Briggs and Strategic Planning Team,

In response to the call for stakeholder comment on the strategic plan for NCCAM, the American Massage Therapy Association (AMTA) wants to emphasize several areas which are germane to the purpose of NCCAM and would be beneficial to the American people.  These are specific to the benefits of massage therapy as both a stand alone therapy and as an adjunct to conventional medical treatments.

Our association encourages NCCAM
to expand clinical trials on ... the
application of massage therapy
as it is practiced.  

Our association encourages NCCAM to expand clinical trials on massage therapy that examine its efficacy in a variety of situations and involve the application of massage therapy as it is practiced.  Existing research has already demonstrated the value of massage, such as the Department of Veterans Affairs research, “Acute Post-Operative Pain Management Using Massage As Adjuvant Therapy” and the Mayo Clinic study on massage for breast cancer patients published August 2009 in the Clinical Journal of Oncology Nursing.  More trials are needed which examine how massage is effective and which protocols are demonstrated to be effective for specific health issues.

  More research is needed on
the efficacy of massage therapy
within an integrative setting
that involves both conventional
medical treatment and a holistic
approach with other
complementary therapies.
Likewise, more research is needed on the efficacy of massage therapy within an integrative setting that involves both conventional medical treatment and a holistic approach with other complementary therapies. Such research must examine the specific role massage can play in specific integrated care.

Beyond the basic research needs for examining the efficacy of massage therapy, AMTA calls on NCCAM to broaden communications to the medical community and the public to educate them on the results of massage therapy clinical research.  The anecdotal experiences of physicians, nurses and patients must be supplemented with education about research results.  This dynamic can enhance outcomes, use and further clinical examination.

Thank you for the opportunity to provide input on NCCAM’s strategic plan to meet its mandated mission.


Judy Stahl, President
Comment: AMTA's request for examination of the value of massage in integrative settings is directly in line with the Congressional mandate to explore integration into "the delivery system." To underscore a theme: While the AMTA letter includes language on "basic research" and looking at "how massage is effective," the association's focus is clearly on pragmatic research involving real world settings.

The NIH culture as stakeholder
4.  Regarding NIH's own culture and priorities as an NCCAM stakeholder

Comment:  NCCAM has two significant but hard to quantify, powerful stakeholders. They were briefly noted at the top of this article. One is the NIH itself. Whatever the recommendations of Congress or consensus among all other stakeholders, NCCAM still lives in a room in the larger NIH house and must get along. The homeowners are disposed toward basic research and RCTs, over the real world and effectiveness trials that one after another stakeholder is urging. NCCAM's insecurity in its first years particularly laid it open to going along to get along, despite what Congress told it to do. There is no doubt that today there is significant receptivity in NCCAM to embrace some of this "real world" direction. I have gathered from various sources that NCCAM, in the era of comparative effectiveness research (CER), faces less NIH resistance than one might imagine to this direction. Yet my guess is that prevailing biases will shape the "balance" CAHCIM urges toward the lower end of investment in effectiveness research.

A second question mark regards NCCAM's relationship with the historic NIH outsiders, known as CAM professions, who have almost no role or stature as advisers or as grantees anywhere else in the NIH.
Always not-for-attribution, I have heard from MD researchers and academics and CAM researchers that NCCAM may be re-evaluating its commitment to these fields. Is this so? What we know for sure is that NCCAM deservedly highlighted the evolution of MD-centric "integrative medicine" with a laudatory 300 words under "Research Capacity" in White Paper #1.  NCCAM did not, however, mention a word about another significant evolution, and that is the emergence of the research community in the licensed CAM fields and institutions. Had NCCAM wanted to, they could have shown a light on NCCAM's significant role in bringing these institutions into the government-funded, evidence-informed research world. This accomplishment could have been positioned as a platform for ongoing activity, much as "integrative medicine" was noted.

NCCAM's choices are interesting.  I have no idea whether we are seeing a conscious re-evaluation, or a merely a happiness that more of their own kind are in the field. The silence on the licensed CAM fields makes the CAHCIM advocacy of their licensed CAM colleagues and institutions (see #1 above) all the more commendable, and necessary. 

5.  NCCAM's detractors as stakeholders

Comment: The other key stakeholder likes to literally position itself above what it believes is NCCAM's worthless body of work, stake in hand, ready to put it out of its misery. NCCAM operates under a sort of terrorist threat from these antagonists.  A typical run-down from an NCCAM detractor, relative to NCCAM's strategic planning White Paper #1, is here at ScienceBasedMedicine.
Many of these medical doctors, like Yale's Steven Novella, MD, have academic medical credentials. Another is here at ScienceStage, where the author states:
"I have previously made my own opinions clear, as have fellow bloggers Gorski, Novella, Lipson, and Sampson: the best strategic plan for the NCCAM would be to extinguish itself.
Can NCCAM could be bombed and gutted at any moment? So far, these antagonists, going back in a direct line to the AMA's anti-chiropractic campaign in the 1960s through the so-called National Council Against Health Fraud in the 1980s to this current generation of bloggers, have failed miserably in their suppressive intent. The integrative practice movement and recognition has only gotten stronger. In addition, U.S. Senator Tom Harkin, angel and protector both, has only become more powerful. Is NCCAM really at risk?

All we know for sure is that we the people of these United States, and the NCCAM by extension, are quite agreeable to fear-based thinking, planning and prioritizing of our budgets. If NCCAM empowers the threat, rather than the popular movement, this stakeholder's influence will be to have NCCAM walk gingerly and not step far out of the box, even if the good of the people, the will of Congress and health care itself might be served from a more aggressive course correction, toward the real world, for NCCAM.

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