The artful design of the organizers was not to persist without complication. Cracks in the structure appeared in two distinct ways. The various organizations soon realized that the distribution of revenues was not even. Over time, the NCCAOM gathered more and more of the revenues while others fell behind. Interestingly enough, the greatest strains fell upon the organization that had the most difficult mission and which did not derive its revenue from the students. The AAAOM may have been the victim of an unintended consequence of the strategy of the organizers. They had sought to mimic the institutions of other healthcare professions. Strapped for revenue and struggling to find a way to attract a significant proportion of practitioners to membership, the AAAOM faced profound internal dissension. A strong minority of its leadership committed itself to emulating the other medical professions. At the same time, a vocal but bare majority sought to carve out a more inclusive and independent existence. In the end it was an encounter between the old counter-culturalists and an alliance of the Oriental practitioners and the new generation of practitioners, not connected to the counter-cultural roots, who just wanted to be like western doctors.

The organization split with vocal acrimony, leading to the formation of the American Association of Oriental Medicine (AAOM) and the AOMAlliance. The AAOM represented the alliance of Asian practitioners and the more professionally inclined western practitioners. Eventually, recognizing the reality of their demographics, this organization moved its operations to California. The AOMAlliance, populated by the variety of different kinds of practitioners, located itself first in Washington, DC and later, to follow a founder, in Washington State.

This fracture exaggerated other stresses within the profession. The disputes involved key leaders of all of the national organizations. Battle lines were drawn, but often obscured because the vast number of practitioners found the struggle distasteful. In short order, key leaders from the certification council (NCCAOM) moved to the leadership of the break-away AOMAlliance. At the same time, the NAF, always the weakest institution, merged its operations with that organization, where it remained until quite recently. The Accrediting Commission (ACAOM) tended to side with the AAOM, and the Council of Colleges, needing to recruit students to feed the economic engines of the colleges, tried to maintain strong relationships with all sides.

Other issues troubled the profession. Some states adopted practice legislation inconsistent with the protection of acupuncture's national organizations. California, home to half of the practitioners in the country, created its own certification program and its own accrediting mechanism for schools, bypassing both the NCCAOM and the ACAOM. The economic impact to both organizations cannot be overstated. Cut off from half of the potential student or college customers in the country, each organization has felt the economic loss keenly. At the same time, rival organizations occasionally spring up to challenge each of them. These organizations have failed, largely because of the strong mobilization of power within the profession by the threatened institutions. A recent challenge to ACAOM brought national leaders of every one of the institutions racing to assist in the defense of the original accrediting agency.

There remain two other important sources of money in the profession that have not been discussed. Both of these derive their revenue directly from practitioners who must purchase liability/malpractice insurance and the supplies and equipment to ply their trade.

Competition for the insurance business has been intense and brutal. Gradually this market has been dominated by a single player, an insurance company that had cut its teeth in similar disputes within the chiropractic profession. The persistent competition between acupuncture and Oriental medicine and the chiropractors makes this fact highly ironic. The success of this one company arose from two key strategies.

First, it allied itself with the AAOM, which had arranged to offer discounted insurance as a membership benefit. The company in question was not the first to make that deal with the AAOM, but was able to negotiate to obtain the relationship, at the expense of the competitor already in place. The terms under which the leadership of the AAOM switched its business to this company are not generally known, but rumors persist about an exchange of money to key decision makers for their support.

The second strategy involved repetition of another technique used earlier in capturing the chiropractic market. The insurance company established a monthly newspaper and distributed it free of charge to all practitioners. This venture paid for itself by extracting advertising revenue from companies offering supplies and other services to practitioners. It also provided a platform to advertise and advocate for both its own insurance and the programs of the AAOM, its partner in the discounted insurance business. The strategies were highly successful, despite the fact that other companies offered better and less expensive insurance products.

Practitioners ultimately paid for the growing wealth of this company in three ways: higher insurance premiums, higher prices on the products they purchased, and higher dues to their professional association. Both insurance company and association thrived under the arrangement. To cement the deal, the insurance pledged one million dollars over ten years to the association to augment its legislative work. Ironically, both association and insurance company remain located in California, home of half of America's acupuncturists. This is the state that directly excludes the NCCAOM and the ACAOM from participating in the revenue stream. It is, and always has been, about the money.

Here is where the money comes from and who pays it:

NCCAOM gets its money from students seeking to enter practice. Most of it comes from the NCCAOM Examination. A significant minority comes from practitioners by means of recertification and authentication of Continuing Education courses. It is generally regarded as the wealthiest of the organizations.

CCAOM gets its money directly from students and from the colleges who receive their support from students. It gets the money directly from students who must take the Clean Needle Technique Course in order to receive NCCAOM Certification, a tidy relationship between the two institutions. It receives the bulk of its money from the colleges.

ACAOM receives its revenues from students through the colleges as well. In this case, colleges must periodically have their accreditation reviewed and renewed. Colleges treat this as one of the ordinary expenses supported by their revenue stream.

The professional organizations, first the AAAOM, then the AAOM and the AOMAlliance, and now suddenly the AAAOM again with the recent merger, receive the bulk of their money directly from practitioners in the form of membership dues. It should be noted that the new merged organization still serves is insurance master, providing it access to an ever wider share of the market.

The NAF gets the lion's share of its meager resources from students who must buy the latest edition of the Clean Needle Technique Manual in order to take the required course. The book is produced by the NAF.

Quite a number of folks are making a lot of money, mainly from students and secondarily from practitioners. Students finance the colleges and the NCCAOM directly, often through increases in debt load that may never be recovered. Practitioners, many of whom struggle to make a living at all, finance a wealthy insurance company and professional organization. The money comes from you. The beneficiaries are the privileged few in this profession.