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From its origins as an unconventional therapy in the late 19th century through decades of marginalization during the 20th century, chiropractic has acquired legitimacy and prominence (Meeker and Haldeman 2002). Signs of its success abound. They include a broadening of the laws and regulations affecting its licensure, scope of practice, and reimbursement; greater acceptance by both physicians and health plans; and a sustained demand for its services. Chiropractic's political base is strong, and it enjoys a high degree of patient satisfaction. Moreover, it is at the vanguard of complementary and alternative medicine (CAM), which receives ever greater proportions of health expenditures (Eisenberg et al. 1993, 1998) and which is being increasingly integrated into conventional medicine (Macy Foundation 2001).

Even so, chiropractic's future seems uncertain. Recent expansions of chiropractic colleges are swelling the ranks of practitioners while managed care is restricting payment for what chiropractors do and evidence-based medicine is demanding that what they do must have demonstrable value.

Chiropractic is the best established of the alternative health care professions. Although marginalized for much of the 20th century, it has entered the mainstream of health care, gaining both legitimacy and access to third-party payers. However, the profession's efforts to validate the effectiveness of spinal manipulative therapy, its principal modality, have yielded only modest and often contrary results. At the same time, reimbursement is shrinking, the number of practitioners is growing, and competition from other healing professions is increasing. The profession's efforts to establish a role in primary care are meeting resistance, and its attempts to broaden its activities in alternative medicine have inherent limitations. Although patients express a high level of satisfaction with chiropractic treatment and politicians are sympathetic to it, this may not be enough as our nation grapples to define the health care system that it can afford.