I was a member I think for a few years when I started but mainly because they were the only one in business. I quickly changed when ABMP came into being.

In 2011 or so I went to my AMTA-WA Chapter to get help with the problem of insurance carriers reducing our allowable fees quite significantly. I asked for three years and finally got the answer — if there was something we could do, we would be doing it. So a group of us left AMTA and started the WA State Massage Therapy Association (www.mywsmta.org) to try to work on the issues that we had with the insurance carriers.

In about 2018 I left that group and had also worked with a few groups trying to start a medical massage therapy association that never came into being. The issues kept increasing. Covid Happened. The problem of illicit businesses got my attention and I bought the website www.lookbeforeyoubookamassage.com to work on the issues.

In 2023 I decided to give AMTA one more chance. I was attending the AMTA WA Convention where a new president was elected and at the luncheon she was asking for volunteers. For some crazy reason, I stepped up and worked on their website and then ran for a Board Position that I held for 2 years and then became the GR chair for the chapter. If you know how AMTA works, the chapters are the heart and sole of this organization, working for free to monitor and create legislation, give input to the Board of Massage and many other things.

I apparently asked too many questions — asked for help with ordinances, asked for what they stand for to give input to the Board of Massage on education'/CE, asked for them to track and preserve history more carefully, asked them to start a human trafficking committee or task force to study the problem and provide best practices in dealing with this problem.

I got the letter. You are doing something wrong, but we won’t tell you what so pleas stop or you will be removed. Huh? Yes indeed. It is very common. After a few of my friends got that letter before me, I actually requested a bylaws change to correct that and was told it was a legal thing and couldn’t be changed. Here is the story on all that.

When Asking Questions Becomes a Problem

For years, I have dedicated thousands of hours to researching the massage therapy profession. I’ve read legislation, compared state laws, analyzed organizational documents, followed regulatory meetings, interviewed people, and tried to make complicated issues understandable for massage therapists.

I don’t claim to know everything. I don’t claim to be right about everything.

What I do claim is this: I care deeply about getting the facts right.

Whenever I write, I work from publicly available documents whenever possible. I cite legislation. I compare original source materials. I distinguish between facts, interpretations, and my own opinions. And when I discover that I have made a factual mistake, I correct it.

Yesterday, however, I received a letter from an attorney representing AMTA accusing me of spreading “false statements,” “lies,” and “misinformation.” It was also cc’d to the other CEO and GR Chair for AMTA National. (Stegink, Flom, Specker)

What struck me most wasn’t the accusation itself.

It was what was missing.

The letter did not identify which specific statements were supposedly false.

As someone committed to accuracy, I welcome correction. If I have published an incorrect factual statement, I want to know exactly what it is. Tell me where I got it wrong. Show me the evidence. I’ll review it carefully and correct any verified error.

That’s how honest discussion works.

But disagreement is not the same as misinformation.

People can look at the same legislation, the same meeting minutes, the same public statements, and reach different conclusions. That is especially true when discussing public policy, organizational governance, legislative strategy, and the future of a profession.

Healthy professions should encourage those conversations—not discourage them.

Throughout my work, I have asked massage therapists to do something very simple:

Don’t believe me. Don’t believe AMTA. Don’t believe anyone without looking at the evidence.

Read the legislation.

Read the meeting minutes.

Read the position statements.

Read the original documents.

Then decide for yourself.

That has always been the purpose of Massage Therapy Nexus.

I have no interest in attacking individuals. My goal has never been to create division for the sake of division. My goal is to encourage transparency, accountability, and informed discussion about issues that affect every massage therapist.

The massage profession deserves organizations that welcome thoughtful questions, explain their decisions openly, and engage respectfully with members who hold different views.

We should never confuse criticism with disloyalty.

Nor should we confuse disagreement with misinformation.

Progress depends on our willingness to ask difficult questions, examine the evidence honestly, and continue learning—even when the answers make us uncomfortable.

That is the standard I intend to continue following. I will be continuing to ask the questions. I hope you will too.

Sincerely, Julie Onofrio, LMT

A Note About My Writing

The views expressed on this website and my social media platforms are my own. My commentary is intended to encourage discussion about issues affecting the massage therapy profession and is based on publicly available documents, legislative records, organizational publications, and other source materials.

When I express an opinion, it is my opinion. When I state factual information, I strive to ensure it is accurate and supported by reliable sources. If I become aware of a factual error, I will promptly review the evidence and make any appropriate corrections.

I welcome respectful dialogue and evidence-based discussion. If you believe I have made a factual error, please contact me with the specific information and supporting documentation so I can review it. Thanks for your continuing support! Julie Onofrio LMT

I graduated from massage school in 1987 with 250 hours of education. That was the requirement at the time. I opened a practice in a Seattle gym with a friend from school, and I had no idea what I was doing on the business side. Nobody did. There was nothing to read.

In 1996, Washington passed a law requiring health plans to cover massage therapy called the Every Category Law and overnight, a door opened that had been shut for the entire history of our profession.

Back then there were a few manuals on billing insurance. The way we learned was by helping each other. Back then there was no internet, email or anything so it was just information sharing the old fashioned way - talking to each other.

I wrote the first edition of my billing manual in 2005 specifically so nobody else would have to learn it that way. The manuals that were out there were not updated. I kept mine updated.

The door is open wider than it has ever been

Here’s what’s true in 2026, and what most massage therapists still don’t know:

The VA is the single biggest opportunity in our profession’s history. In 2017, the VA added massage under its Complementary & Integrative Health umbrella through VHA Directive 1137. Veterans can receive clinical massage as part of their treatment. You get an authorization before you treat, you bill the codes you were authorized for, and the VA pays the full cost. No co-pays. No chasing patients for money.

Over 250 Medicare Advantage plans now include massage therapy benefits. Original Medicare still doesn’t cover massage performed independently by an LMT — that hasn’t changed. But Medicare Advantage is a different animal, privately administered, and it has quietly become one of the fastest-growing sectors for our profession. Most of these plans target exactly what we’re good at: chronic musculoskeletal pain.

Workers’ compensation has been paying for decades. Musculoskeletal injuries are the number one workers’ comp claim in the country. That is not a niche. That is the center of the map.

Auto injury (PIP and MedPay) pays without co-pays. It’s documentation-heavy and attorneys are often involved, which scares people off. But the coverage is real.

Six sectors, actually. Add commercial insurance and employer self-funded ERISA plans, and you have six distinct systems that will pay a licensed massage therapist.

Six sectors. Six completely different sets of rules.

And that last sentence is the whole problem.

The barrier isn’t complexity. It’s not knowing where to begin.

Many claim it isn’t worth it. But there is another factor that does make it worth it. It is about being at the table and showing the carriers through charting how and why massage therapy works.

It is also about the dwindling pay rates of some health insurance carriers too. There is an answer to that too. In WA State we recently teamed up with 15 other professions and created a bill for fair pay. While it didn’t pass it was revealing. The insurance carrier lobbyists were caught lying for years saying that they would always negotiate a contract with massage therapists but it finally came out that indeed they don’t! After that some of the carriers started increasing their allowable fees.

So the problem is that no one has been advocating for us in the health insurance arena or health care integration. Learning to bill and just starting with a few cases will show you how it is all working and not working so we can also work to get to the table with insurance carriers and organizations like the VA and Workers comp.

Which brings me to the part that actually matters

I’ve spent nearly forty years in this profession. I’m was the AMTA-WA government relations chair. I helped found the Washington State Massage Therapy Association. I have spent an enormous amount of my life on advocacy. I have come to believe that the most powerful advocacy tool most therapists have isn’t a letter to a legislator.

It’s a clean claim.

Every properly billed, well-documented claim you submit is a data point. It says: massage therapy exists in a real clinical context, addressing a real health problem, with a measurable outcome. It builds the evidentiary record that policy is eventually written from.

Every therapist who gives up before starting is a data point too — an absence, a silence, a hole in the record where our profession should be.

Coverage and allowable fees do not expand because insurers wake up one morning persuaded of our value. It expands because therapists understand the rules well enough to insist on fair treatment inside them.

If you are not at the table, you are on the menu. That’s not a slogan. It’s a description of what happens when a profession declines to participate in the systems that determine its future. Allowable fees get set without our data. Rules get written about our scope without our input. And we find out afterward.

So here’s the guide

I put together a free Insurance Billing Field Guide — fourteen pages, no cost — because I got tired of watching people quit at step one. It is an introduction to the six sectors where massage therapists can bill and how each one actually works. Getting your NPI and CAQH set up. CPT and ICD-10 codes explained plainly, including the 8-minute rule and the pairings that trigger audits. Functional SOAP notes that get approved. The CMS-1500 form, box by box. HIPAA and the fraud statutes you need to know about. And the prescription rule, in detail, so you never take a phone rep’s word for it again.

It’s the overview I wish someone had handed me in 1996.

Download the free Field Guide →

If you want the complete version — the templates, the exact workflows, the appeal strategies, the legal detail — that’s my full manual, Modern Insurance Billing for the Massage Professional, now in its fourth edition. But start with the guide. Start with the NPI. Start this week.

When you have questions, bring them to the Massage Insurance Billing group. Insurance billing is isolating by design — carriers don’t publish what they pay, denials feel personal, and most of us are working alone. Comparing notes with other therapists is how we find out what’s actually true.

The door is open. It has never been open this wide.

Walk through it.

Julie Onofrio, LMT has been a massage therapist since 1987 and has billed insurance for most of that career — workers’ comp, motor vehicle collisions, and health insurance. She wrote the first edition of her insurance billing manual in 2005. See the full table of contents and details of the Massage Insurance Billing Manual.

This isn’t incompetence. It’s structural and until we understand the structure, we can’t fix it.

Let me explain the two legal systems that are supposed to be protecting the massage therapy profession — and why they keep failing us.

Two systems. Two completely different jobs.

Civil law — sometimes called administrative law — is where licensing lives. Your massage license is a civil instrument. Your state board is a civil agency. When the board fines someone, suspends a license, or denies an application, that’s civil law doing its job. Civil law is about regulation, compliance, and professional standards.

Criminal law is where trafficking, prostitution, and organized crime live. When law enforcement makes an arrest, charges someone with a crime, and sends a case to the district attorney, that’s criminal law doing its job. Criminal law is about punishing conduct that harms people and society.

Here’s the problem: these are two separate systems, with two separate agencies, two separate courts, two separate standards of proof, and almost no coordination between them. We keep trying to solve a criminal problem with civil tools.

What a licensing board can and cannot do

Your state board can inspect premises. It can review license applications. It can fine licensees, suspend licenses, and revoke them. It can deny renewal. In some states it can assess civil penalties.

What it cannot do: make an arrest. Kick down a door. Charge someone with a crime. Subpoena records from a criminal enterprise. Freeze assets. Compel testimony under oath in a criminal proceeding.

So when a board inspector walks into a business and finds unlicensed workers, they can write a civil fine. That fine goes to the owner of record — who may be a shell company, a fake name, or someone who has already moved on to open another location two miles away. The business keeps operating. The fine is a cost of doing business. The workers, many of whom are trafficking victims with no control over what happens to them, face the consequences.

You cannot regulate a criminal problem with an administrative solution. It has to go through the criminal justice system.

That is not a criticism of state boards. It is a description of reality. Boards were built to regulate professionals. They were not built to investigate criminal enterprises.

Four Things That Would Actually Change This — And How to Make Each One Happen

We have been having the same conversation for decades. How do we get rid of the sexually oriented businesses disguised as massage that are destroying our profession’s reputation, trapping women in exploitation, and making it impossible for licensed therapists to be taken seriously?

We keep getting the same answers: more ordinances, more establishment licensing, more paperwork, more compliance burdens on the people who already followed all the rules.

None of it is working. The number of these businesses has nearly doubled since 2018.

I want to talk about what would actually work. Not more laws layered on top of broken enforcement. Not more requirements for licensed therapists to prove they’re not criminals. What would actually change this.

There are four things and for each one I have some ideas on exactly how to push for it.

The Fix Is Simpler Than You Think

We keep making this complicated. It isn’t.

Four things would change this situation. Here they are, plain and direct.

1. Give law enforcement the authority to act.

Right now a police officer can walk into a massage business, find workers without licenses, and do almost nothing about it — because in most states, licensing violations go to the board, not to law enforcement. The board can write fines. It can’t make arrests.

We need law enforcement to be able to write a citation on the spot, the same way a cop writes a traffic ticket. No board referral. No complaint form. No waiting. An unlicensed worker in your business? The officer cites the owner. That day.

To make this happen, ask your state legislators one question: does a police officer in this state have the authority to cite a massage business owner for employing unlicensed workers? In most states, the answer is no. That is your opening.

2. Stop treating our profession as the problem.

Every law that piles new requirements specifically onto massage businesses — requirements that don’t apply to physical therapists, chiropractors, or acupuncturists — treats massage therapy as inherently suspect. We are not the problem. We are a healthcare profession that criminals are using as a cover. Those are not the same thing.

We regulate doctors. We prosecute drug dealers. We do not make every physician’s office prove it isn’t a pharmacy front. We should be demanding the same standard for ourselves.

When a new licensing bill comes up in your state, ask this: does this apply to physical therapy offices? If the answer is no, push back. Ask why massage is being treated differently. Put that question on the record every single time.

3. Make it a crime to OWN/ RUN an unlicensed operation — and aim at the owner.

A civil fine doesn’t stop an organized criminal operation. It’s a business expense. What stops it is a misdemeanor charge on the first offense and a felony on the second — aimed at the owner who is running the business, not the workers who may have no say in what happens inside it.

Add one more thing: a prohibition on reopening. An operator who has been convicted cannot open another massage business in this state (or any state - not sure how to make that happen). Period. That closes the revolving door where someone gets caught, closes the location, and reopens two blocks away under a different name three weeks later.

Talk to your state legislators about criminal penalties aimed at owners. Tell them the owner bears the responsibility, the owner faces the charge.

4. Stop trying to build the perfect case. Just make it uncomfortable to operate.

Human trafficking prosecutions are hard. They require enormous resources, terrified witnesses who may not be able to testify, and months or years of investigation. Most districts cannot build them. While everyone waits for the case that never comes, the business keeps running. Just make it harder to do business with stricter fines like felonies and high monetary penalties.

The Missouri Attorney General’s Hope Initiative produced a 45% statewide reduction in these businesses in nine months. Not through trafficking convictions. Through letters to landlords.

That is the model. Make it expensive. Make it visible. Make it a problem every single day. Ongoing unannounced inspections. License verification every time. Landlord letters. Business license denial for operators with a history of violations. Bad actor registries. None of these require a trafficking case. All of them make the business model harder to sustain.

The people running these operations are counting on us to stay confused, stay fragmented, and keep trying to solve a criminal problem through licensing paperwork while they operate in plain sight.

We can do better.

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That’s not an opinion. That’s the gap this work is trying to close.

Today I’m releasing a resource I’ve been building for the Massage Therapy Nexus HUB: a state-by-state analysis of every establishment licensing law currently on the books in the United States. Twenty-three states. Five questions answered for each one and a clear-eyed look at what we actually know — and what we urgently need to find out. ( I did this all myself - yes with the help of AI but I am checking everything so let me know of any errors or misinformation.)

Why this matters

The only published academic research on this question — a peer-reviewed study comparing Texas and Oklahoma1 during the period when Texas implemented licensing — found no evidence that massage therapist licensing reduced crime rates. That study had real limitations, and the authors acknowledged them. But its core finding was damning: we passed these laws, we told the profession it would help, and we never measured whether it did.

The FSMTB’s establishment licensing toolkit argues these laws are valuable tools. The profession’s two largest associations, ABMP and AMTA, have pushed back, arguing that establishment licensing treats massage therapy differently from every other healthcare profession and puts the burden of a criminal problem on civil licensing2. They’re both right about something. They’re both missing data.

The argument that has never been settled — because nobody has done the work to settle it — is this:

Does establishment licensing actually reduce the presence and operation of sexually oriented businesses disguised as massage, or does it simply create a compliance burden for licensed therapists while bad actors adapt and reopen somewhere else?

The scoping document in my research files puts it plainly: “Legislative whack-a-mole. Traffickers adapt and more and tougher establishment licensing laws are not the answer.” That might be true. But it also might not be. We don’t know.

The full guide — all 23 states, all five questions, every verify flag and research gap — is available as a downloadable PDF through the link. This is the foundation document for the research that needs to happen next.

The survey. No one has asked licensed massage therapists in establishment licensing states how the law has affected their practices. I built one.

Take the survey today.

Now I need more help.

I am asking for help in submitting public records requests to state boards for establishment license counts, denial rates, and enforcement actions. I am asking for your help first - ask your state board for the information. I have the full instructions here.

Twenty-three states have some form of establishment licensing. Every single one of them passed that law without a benchmark, without a measurement plan, and without asking the people most affected — licensed massage therapists — whether it helped.

That’s not good enough. The profession deserves to know whether the laws being passed in its name are actually working. The victims in these businesses deserve better policy, not more paperwork. And the licensed therapists who carry the compliance burden every single day deserve someone asking whether it was worth it.

Here’s where I need your help.

I need people who are willing to help me request public records from state boards. Enforcement data, establishment license counts, denial rates — this information is public record. It just takes someone willing to submit the requests and wait for the responses. Sign up here to let me know you are working on your state.

Download the form letter to request public records. https://docs.google.com/document/d/1vEAdFykthdY9r6VJcqMNzz4OR_btf_OFtLC6OC_ihdU/edit?usp=sharing

I need LMTs in states that are currently debating establishment licensing to let me know what’s happening in your legislature. These debates are happening right now, with the same recycled arguments on both sides and no new data. We can change that.

For 128 years this profession has been fighting to separate itself from businesses that have nothing to do with massage therapy. We’ve tried associations, certifications, individual licensing, and now establishment licensing. Each tool has been adopted with confidence and evaluated with almost no rigor.

It’s time to actually look.

If you’re in state with establishment licensing, sign up to investigate your state! Let’s find out together what’s working, what isn’t, and what we should be asking for instead.

— Julie Onofrio, LMT
www.lookbeforeyoubookamassage.com
www.massagetherapynexus.com
Tired of waiting for our associations to do something. I am not even sure if this will work or provide us with the information we need to help create better laws. I won’t be stopping until we figure it out!

2

https://www.abmp.com/updates/news/abmp-and-amta-joint-response-fsmtb-human-trafficking-report

Some massage therapists think primarily in terms of anatomy, physiology, and biomechanics. Others focus on the nervous system. Some work from Traditional Chinese Medicine or Ayurvedic principles. Others incorporate Reiki, Healing Touch, Therapeutic Touch, or other forms of energy work into their practice.

The diversity of these approaches has helped the profession reach many different people. It has also created a problem that we rarely discuss openly.

We often use the same words to mean completely different things.

No word illustrates this better than energy.

What does “energy” actually mean?

If you ask a physicist what energy is, the answer is surprisingly straightforward.

Energy is the capacity to do work.

It exists in forms that can be measured, including heat, light, electricity, chemical energy, kinetic energy, and gravitational energy. Scientists can calculate it, measure it, and describe how it changes from one form to another.

Our bodies certainly contain energy in this scientific sense.

Our nerves conduct electrical signals.

Our muscles convert chemical energy into movement.

Our hearts and brains generate tiny electrical and magnetic fields.

Our cells constantly transform energy through metabolism.

None of this is controversial. It is basic biology and physics.

The other meaning of energy

Many traditional healing systems use the word energy very differently.

Traditional Chinese Medicine describes qi.

Ayurveda describes prana.

Reiki practitioners speak of universal life energy.

Healing Touch and Therapeutic Touch describe balancing or influencing the body’s energy field.

These ideas are meaningful to many practitioners and clients. They are part of long-standing healing traditions that deserve to be understood within their own historical and cultural contexts.

The difficulty arises when we begin using scientific language to describe concepts that science has not established.

When we say we are balancing electromagnetic fields, changing frequencies, or altering vibrations in a scientific sense, we are making claims that require scientific evidence.

At present, that evidence does not exist in the way many people assume it does.

Experience is not the same as explanation

This distinction is important because it is often misunderstood.

Suppose a client receives an energy-based treatment and leaves feeling calmer, sleeping better, and reporting less pain.

Those experiences are real.

The question is not whether the client improved.

The question is how we explain the improvement.

Many factors could contribute.

• The therapeutic relationship.

• Focused attention.

• Relaxation.

• Reduced stress.

• Changes in autonomic nervous system activity.

• Expectation.

• Meaning.

• Gentle touch.

• Time away from daily pressures.

• The body’s own capacity to recover.

These explanations are supported by growing scientific evidence.

None of them require an invisible life force to exist.

That does not prove traditional energy concepts are false.

It simply means we do not have scientific evidence demonstrating them as measurable physical phenomena.

There is an important difference between saying, “We do not know,” and saying, “Science has proven this.”

Why language matters

Some people will ask why this distinction is so important.

After all, if clients benefit, does the explanation really matter?

I believe it does.

Massage therapy increasingly presents itself as a healthcare profession.

We seek greater integration into hospitals, rehabilitation settings, multidisciplinary clinics, insurance systems, and public health.

Healthcare depends on clear communication.

When we use scientific words in ways that scientists do not recognize, we create confusion instead of clarity.

This has consequences.

It makes research more difficult.

It weakens our credibility with physicians and other healthcare professionals.

It gives critics an easy opportunity to dismiss legitimate benefits because our language appears to overstate what is known.

We don’t have to choose sides

This conversation is often framed as a battle.

Either you believe in energy work or you believe in science.

I do not think the profession benefits from that false choice.

Traditional healing systems deserve respect as historical and cultural models of understanding health.

Scientific medicine deserves respect for developing methods that allow ideas to be tested objectively.

Those two things can coexist. What we should avoid is presenting traditional beliefs as though they have already been confirmed by modern physics. Likewise, we should avoid dismissing every client experience simply because we cannot yet explain it.

Humility belongs on both sides.

A better way forward

Perhaps massage therapy should become more intentional about distinguishing among three different kinds of statements.

Traditional belief

“This healing system teaches that balancing qi supports health.”

Clinical observation

“Many clients report feeling calmer and more relaxed after this treatment.”

Scientific evidence

“Research has demonstrated measurable changes in these physiological processes.”

These are not competing ideas.

They simply answer different questions.

One describes a philosophy.

One describes experience.

One describes evidence.

Confusing them helps no one.

The future of massage therapy

As our profession continues to evolve, I believe our language will matter as much as our techniques.

We do not strengthen massage therapy by borrowing scientific terminology that has different meanings within science.

We strengthen it by being honest about what we know, careful about what we claim, and curious about what remains to be discovered.

Massage therapy has always lived at the intersection of art, tradition, and science.

We do not have to abandon any of those.

But if we hope to become a more respected healthcare profession, we should learn to recognize which one we are speaking from at any given moment.

That kind of clarity is not a weakness.

It is the foundation of credibility.

This article was created as a result of a discussion on Facebook about the ABMP article Energy Medicine in Bodywork Expand the Lens of Your Practice By Lynn Teachworth Summer 2026

Also read this article Science and Energy from Keith Grant, a physicist and massage instructor on his website Ramblemuse.

See also the video below: Does Reiki Work?

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**250 Years After America’s Declaration of Independence**

When, in the course of professional history, it becomes necessary for a profession to reclaim its purpose, restore its voice, and secure its future, respect for those we serve requires that we declare the principles upon which that future shall be built.

We hold these truths to be self-evident:

That every person deserves safe, ethical, competent massage care.

That therapeutic touch has value beyond relaxation alone, improving health, easing suffering, supporting recovery, and strengthening human connection.

That massage therapists are healthcare professionals, educators, business owners, researchers, and compassionate caregivers whose work deserves understanding and respect.

That a profession belongs to its practitioners, not to institutions or associations.

Whenever organizations lose sight of those they represent, whenever transparency gives way to secrecy, whenever politics replaces service, whenever division replaces collaboration, it is the right and the responsibility of professionals to seek a better path.

Therefore, we declare our independence from:

* confusion over who we are and what we do.

* outdated definitions that fail to describe modern massage practice.

* fear-based advocacy that defines us by what we are not.

* unnecessary division among therapists, schools, educators, researchers, businesses, and professional organizations.

* silence in the face of problems that affect both practitioners and the public.

* the belief that individual therapists have no voice in shaping their profession.

Instead, we declare our commitment to:

* evidence where evidence exists, and honest inquiry where it does not.

* ethical practice rooted in compassion and accountability.

* education that prepares therapists for the future, not merely for licensure.

* member-driven leadership that earns trust through openness and transparency.

* protecting the public while supporting ethical practitioners.

* confronting human trafficking and illicit businesses without allowing them to define massage therapy.

* advancing massage as an essential part of health and well-being.

* preserving the uniquely human value of therapeutic touch in an age increasingly shaped by machines and artificial intelligence.

We believe that disagreement need not become division.

We believe that progress requires conversation.

We believe that history should inform the future, not imprison it.

And we believe that the next generation of massage therapists deserves a profession stronger than the one we inherited.

Therefore, with respect for those who built this profession before us, and confidence in those who will carry it forward, we pledge ourselves to the work ahead.

Not for one association.

Not for one school.

Not for one philosophy.

But for the profession itself.

Because the future of massage therapy will not be written by a few.

**It will be written by all of us.

**The profession does not belong to any association, certifying body, regulator, or corporation. It belongs to every ethical massage therapist who serves with knowledge, skill, integrity, and compassion.**

The short answer: there was no massage therapist waiting to see you. That profession didn’t exist yet — not in America, not anywhere. But therapeutic touch was everywhere, tucked inside older, stranger systems of belief. Understanding it tells you a lot about the country that was just being born.

So no — there was no occupation called “massage” in Philadelphia or Boston in 1776. The word itself didn’t exist in English yet. The systematic techniques we now think of as “Swedish massage” were developed by a Swedish gymnast named Pehr Henrik Ling — who, in a small coincidence, was born in 1776, the same year as the Declaration. His movement cure wouldn’t take shape for another three decades, and it wouldn’t cross the ocean to America until the 1850s. The word “masseuse” didn’t enter common use until the 1880s. “Massage therapist” as a job title is practically modern — it dates to the mid-20th century.

So what actually happened when your body hurt?

Manual healing existed in 1776 America — just not as its own profession. It was folded into everything else: home remedies, midwifery, bonesetting, and the healing traditions that Native Americans and enslaved Africans carried and preserved, often against enormous pressure to abandon them.

The caregiver archetype is the root of all others in the history of massage therapy in North America. The domestic caregiver of colonial times tended to the needs of the sick and injured using simple medicines and herbal remedies, and provided comfort and healing for those under her care. She used basic manual techniques of friction and rubbing for various purposes in the execution of her duties. The caregiver accumulated practical knowledge and benefited from experience that was passed down from generation to generation in folk remedies and home care practices. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

At home, mostly by women. With trained physicians scarce outside the biggest cities, most healthcare in Revolutionary America happened in the kitchen, not the clinic. Families relied on household remedy books, inherited knowledge, and the hands of mothers, aunts, and neighbors. The era’s bestselling home medical guide, a Scottish physician’s manual called Domestic Medicine, sold tens of thousands of copies on both sides of the Atlantic and recommended rubbing, friction with oils or spirits, and warm compresses for everything from sprains to nervous complaints. This wasn’t considered a specialized skill — it was just what a capable household did.

When someone was sick or injured in the colonies, the first line of treatment was in the home, and was routinely provided by women.7 Folk healing, called “domestic medicine” by some anthropologists, was the primary line of care in the remote communities of the early colonies. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Midwives, who did far more than deliver babies. The best window we have into this world comes from the diary of Martha Ballard, a Maine midwife who delivered over 800 babies between 1785 and 1812 while also functioning as her town’s de facto doctor, nurse, and pharmacist. Her hands did the work that would later be split across a dozen professions — hers included the kind of manual, physical care we’d now recognize as bodywork, though nobody at the time would have called it that.

Bonesetters — the closest thing to a specialist. A handful of families made a name for manual manipulation specifically. The most famous were the Sweets of Rhode Island, whose bonesetting skill was passed down for generations. One of them, Job Sweet, was called on during the Revolution to treat wounded French officers, and after the war Aaron Burr reportedly summoned him to reset his own daughter’s dislocated hip. This was hands-on, technical, valued work — but it was about bones and joints, closer to what we’d now call orthopedics than to relaxation massage.

In colonial North America, when a disease or injury was beyond the expertise of those at home, folk healers or doctors were called upon for help. Among the most respected lay medical practitioners available at the time were the midwife and the bonesetter. The midwife and bonesetter archetypes are notable in the history of massage for a number of reasons. The midwife, who cared for the special needs of women, and the bonesetter, who treated musculoskeletal problems, demonstrate the importance of lay healers in colonial times. Especially in the early days, they would not have been considered alternatives to regular medicine – they often were the only health care providers in the area.

Midwives and bonesetters were highly skilled hands-on specialists sought out for their ability to heal – relying almost exclusively on their own experience and on traditions passed down from generation to generation without the benefit of schools and textbooks. Although their work was not defined entirely by soft tissue techniques, rubbing and friction were important tools in their skill sets. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Native healing traditions that predated the colonies entirely. Indigenous nations had their own long-standing systems combining herbal medicine, sweat lodges, prayer, and manual techniques like rubbing for pain and swelling. These traditions operated on their own terms, largely outside colonial society, and in some cases later influenced American manual medicine in ways history rarely credits properly.

In 1774, signer of the Declaration of Independence and prominent physician Benjamin Rush (1746-1813) presented a paper to an early medical society, the American Philosophical Society, titled An Inquiry into the Natural History of Medicine among the Indians. Among other things, Rush noted that the “Indians” around Philadelphia maintained good health by anointing their bodies with oil and by taking cold baths every day. He concluded, however, “We have no discoveries in the materia medica to hope for from the Indians of North America.” Apparently caregivers in the settlements thought otherwise. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Healing carried by enslaved Africans, often in secret. Enslaved communities maintained their own medical knowledge alongside — and often instead of — whatever care enslavers provided, including herbalism, spiritual healing, and hands-on treatment passed down from African traditions. This knowledge was so threatening to the social order that Virginia and South Carolina made it a capital crime for enslaved people to teach or practice herbal medicine. That a colony would criminalize healing knowledge tells you something about how much power was recognized in those hands, even as it was suppressed.
Article, "'I have been obliged to Send Nassaw': an enslaved healer's medical labour and skill in eighteenth-century Virginia," Medical History, 2021.

Why this matters on the 250th

There’s something worth sitting with here. The founding generation didn’t have massage therapists, chiropractors, or physical therapists. What they had was a patchwork — home remedies rooted in old European humoral theory, hereditary bonesetting families, midwives who were really community health workers, and Indigenous and African healing traditions that persisted despite everything working against them.

None of it looked like a spa. All of it was someone’s hands, doing their best, for another person’s body. Two hundred fifty years later, we’ve turned that instinct into a licensed profession with its own vocabulary and credentials — but the underlying impulse, that touch itself can heal, hasn’t really changed at all. It just used to run in the family, or live in the kitchen, or hide in plain sight.

So this Fourth of July, somewhere between the fireworks and the flag-waving, it’s worth remembering: the country’s founders had no massage therapists. But they had healers all the same — they just called them mothers, midwives, and neighbors.

Starting a state-focused massage therapy association has been both exciting and humbling. It began with the question: What does our profession need right here, in this state, at this time? For the Illinois Massage Therapy Professional Association, or IMTPA, the answer was clear.

Illinois massage therapists needed an organization focused specifically on Illinois law, Illinois advocacy, Illinois licensure issues, Illinois public safety concerns, and Illinois opportunities for healthcare integration. National organizations serve an important role, but they cannot always respond to every state and local issue with the speed or specificity those issues require. Massage therapy laws, local ordinances, regulatory decisions, legislative relationships, insurance coverage, healthcare integration, and public safety concerns often unfold in real time within each state. A state-focused association can help ensure therapists have a voice where those decisions are being made.

IMTPA is still in its early stages. We have not reached every milestone we hope to reach, and we are still learning as we build. Many of the ideas in this article are not presented as finished accomplishments, but as lessons, priorities, and goals that have guided the formation of IMTPA and may help others who are considering a similar effort in their own state.

Start With a Clear Purpose

Before forming an association, it is important to define why the organization needs to exist. For IMTPA, the purpose was not to duplicate what already existed. The goal was to create an Illinois-focused, profession-driven, member-centered organization that could respond to the specific needs of Illinois licensed massage therapists.

That meant asking:

• What are therapists in our state struggling with?]

• What laws or regulations affect daily practice?

• Are local ordinances treating legitimate massage therapy fairly?

• Are massage therapists included in healthcare conversations?

• Do therapists understand legislative changes that may affect their license?

A state association needs a clear mission from the beginning. Without that, it is easy to become reactive, scattered, or overly dependent on one issue. A strong mission helps guide decisions, explain the organization to others, and keep the work focused when things become busy.

For IMTPA, that mission continues to serve as a guide. We are still developing the organization, but having a clear purpose has helped us decide what issues deserve attention and what kind of association we want to become.

Build the Foundation Before You Build the Public Presence

It is tempting to launch quickly, especially when there is momentum or urgency around a legislative issue. But an association needs a solid foundation before it can effectively represent the profession.

Be sure to research your state’s laws and procedures for forming a professional association or nonprofit entity. Once the organization is properly established at the state level, consideration can then be given to the appropriate federal tax status. Understanding tax rules, reporting requirements, and financial responsibilities is extremely important. These details are what help keep the association legitimate, accountable, and able to serve the profession with credibility.

Some of the early steps aside from forming a legal entity include writing bylaws, creating basic policies, identifying board roles, setting membership categories, opening a bank account, and deciding how decisions will be made.

A professional association needs structure, transparency, and accountability. Members need to know who is leading the organization, how decisions are made, how money is handled, and how they can participate.

For IMTPA, governance documents, board policies, meeting procedures, membership structure, and internal systems have been important early priorities. Some of these pieces have been started, while others continue to be refined as the organization grows. Building this foundation has helped us better explain who we are, what we are working toward, and how therapists may eventually participate more fully.

Keep the Mission Bigger Than One Person

Many state-level efforts begin because a few people see a need and are willing to work. That is often how grassroots advocacy starts. Over time, the goal is to turn that early energy into a shared structure that others can participate in and help carry forward.

From the beginning, think about sustainability.

Create systems. Use shared documents. Keep meeting minutes. Track decisions. Write down processes. Create templates. Build committees when possible. Invite members to help with specific projects.

IMTPA is still working towards this. Like many new organizations, much of the early work has required a small group of people to carry several responsibilities at once. That is common in the beginning, but it should not be the long-term goal. A healthy association needs shared responsibility, clear roles, and room for others to step into the work. Not every volunteer needs to serve on the board. Some people may be willing to make phone calls, review local ordinances, write educational content, share social media posts, help with outreach, or attend a legislative meeting. A strong association creates many ways for people to participate.

Understand the State’s Legislative and Regulatory Landscape

A state-focused massage therapy association needs to understand how laws, rules, and regulations affect the profession. That does not mean every board member needs to be a legal expert or lobbyist. It does mean the association should learn how to track bills, read legislative language, understand committee assignments, monitor licensing board activity, and communicate clearly with members about what is happening.

For massage therapists, legislative updates can feel confusing or overwhelming. One of the most valuable services a state association can provide is translating complex policy activity into plain language.

For example:

• What does this bill do?

• Does it affect massage therapy?

• Is it moving forward or stalled?

• Who should therapists contact?

• What should they say?

• What happens next?

This is an area where IMTPA hopes to continue growing. Legislative tracking, compact discussions, licensing issues, and regulatory updates are all part of the work we believe a state association should be paying attention to. We are still developing our systems for communication and member updates, but the goal is to help Illinois therapists better understand what is happening before decisions are made without their input.

State associations can also help build relationships with legislators and regulators before there is a crisis. Advocacy is not only about opposing or supporting bills. It is also about education, trust, and being available as a professional resource.

Pay Attention to Local Ordinances

One of the biggest lessons from Illinois is that local ordinances matter. Massage therapists are often affected not only by state licensing law, but also by city and village rules. These ordinances may address zoning, business licensing, inspections, signage, hours of operation, room requirements, employee records, or anti-trafficking provisions.

Public safety is important. Communities have a legitimate interest in preventing illicit businesses and human trafficking. At the same time, ordinances should not unnecessarily burden licensed massage therapists who are practicing legally and professionally.

IMTPA has begun paying close attention to local ordinance activity because we believe licensed massage therapists should be included when local rules are being discussed. A state association can help by reviewing proposed ordinances, educating local officials about the impact on licensed therapists, encouraging stakeholder input, and referring municipalities to appropriate professional and public safety resources, such as FSMTB and The Network, when more specialized guidance is needed.

Focus on Member Value Early

When starting an association, people will ask: Why should I join?

That is a fair question.

Members need more than a mission statement. They need to see practical value. For a state massage therapy association, value may include legislative updates, compliance resources, local ordinance alerts, templates, professional guidance, networking, healthcare integration tools, employer resources, continuing education updates, and opportunities to participate in advocacy.

For IMTPA, these are goals we are working toward. Some resources may be created early, while others will take more time, more volunteers, more funding, and more member input. It is important not to promise more than a new association can realistically deliver right away.

Early member resources do not have to be perfect or expensive. They should be useful.

Examples of possible resources include:

• A state practice compliance guide

• A legislative update page

• A local ordinance checklist

• A provider outreach letter

• A documentation template

• A member survey

• A volunteer interest form

• A plain-language explanation of current bills

• A sample letter to local officials

• A guide to contacting legislators

As IMTPA grows, resources like these can help turn the mission into practical support for members.

Communicate Often and Clearly

Clear communication is one of the most important parts of building trust.

Massage therapists are busy. Many are solo practitioners. Many do not have time to follow legislative calendars, board meetings, municipal agendas, or policy changes. A state association can help by providing short, timely, accurate updates.

Communication should be professional, but it should also be understandable. Avoid unnecessary jargon. Explain what is known, what is not known, and what members can do. This is especially important for a new association. In the early stages, not everything will be fully developed. Not every question will have an immediate answer. Not every project will be finished. Being honest about that matters.

It is also important to be honest when something is still developing. Not every bill will pass. Not every local ordinance will change. Not every effort of advocacy will produce an immediate result. But members should be able to trust that the association is watching, communicating, and representing the profession in good faith.

Build Relationships, Not Just Campaigns

Advocacy works best when relationships are built over time.

State legislators, municipal officials, licensing board members, regulators, healthcare partners, schools, employers, and public safety organizations may all affect the future of massage therapy. A state association should think beyond one bill or one issue.

Relationship-building may include introducing the association, offering to be a resource, attending public meetings, requesting stakeholder input, thanking officials for their time, and following up respectfully.

For IMTPA, relationship-building is a long-term goal. The profession benefits when massage therapists are known as informed, professional, and constructive participants in state and local conversations.

Be Willing to Learn as You Go

No one starts an association knowing everything.

There will be questions about nonprofit structure, tax status, governance, insurance, banking, membership systems, websites, committees, volunteers, legislative tracking, public messaging, and board development. That is normal.

The key is to keep learning, ask good questions, document decisions, consult qualified professionals as needed, such as an attorney or CPA, and stay aligned with the mission. Starting a state association requires patience. It also requires humility. Some things will need to be revised. Some plans will change. Some volunteers will step back. New people will step forward. The work evolves.

Protect the Profession While Welcoming the Profession

A state massage therapy association should represent the profession with seriousness and care.

That includes supporting licensed practice, ethical standards, public safety, and professional accountability.

At the same time, the association should be inclusive. Therapists come from different work settings, educational backgrounds, career stages, and professional interests. Some are clinical. Some are spa-based. Some work with veterans. Some are employers. Some are sole proprietors. Some are new graduates. Some have been practicing for decades.

A strong state association does not require everyone to think exactly alike. It creates a place where therapists can work together on shared priorities. For IMTPA, this is a guiding principle. We are still building the structure to support broad participation, but the goal is to create an association where Illinois massage therapists can be informed, involved, and respected.

Practical Steps for Therapists Considering a State Association

For anyone considering starting a state-focused massage therapy association, I would suggest thinking about the process in stages.

Early Exploration

1. Identify the need in your state.

2. Learn your state’s massage therapy law and regulatory structure.

3. Understand the current legislative, regulatory, and local ordinance issues affecting massage therapists.

4. Gather a small group of committed professionals who are willing to explore whether a state association is needed.

5. Discuss whether existing organizations are meeting the specific needs of therapists in your state.

Formation and Foundation

6. Write a clear mission statement.

7. Research your state’s requirements for forming a professional association and nonprofit entity.

8. Create basic governance documents, including bylaws, board roles, decision-making procedures, and recordkeeping practices.

9. Decide on membership categories, dues, voting rights, and basic member expectations.

10. Consider the appropriate federal tax status and consult qualified professionals as needed, such as an attorney or CPA.

Building the Association

11. Build simple systems for communication, recordkeeping, member updates, and financial tracking.

12. Begin tracking legislation, regulatory activity, and local ordinance issues in a consistent way.

13. Create practical member resources gradually, based on the needs of therapists in your state.

14. Build relationships with legislators, regulators, local officials, schools, employers, public safety organizations, healthcare partners, and other professional resources.

15. Invite participation and stay transparent about what is established, what is still being developed, and where help is needed.

Final Thoughts

Starting a state-focused massage therapy association is a significant undertaking, but it is meaningful work when it is grounded in service, transparency, and a clear purpose. For IMTPA, the goal remains to support Illinois massage therapists, strengthen the profession, and help therapists become more informed and involved in the decisions that affect their work.

To anyone considering starting a state-focused massage therapy association in your own state, I hope you find success in the work ahead. Take your time, ask good questions, seek guidance when needed, and stay focused on serving your members and strengthening the profession.

About the Author: Colleen graduated from Illinois Valley Community College with an associate degree in massage therapy and later became an adjunct instructor there. She volunteered with AMTA-IL for 9 years — serving on the government relations committee, as membership chair, and as chapter president. She currently practices in her private practice in Ottawa and is a Community Care Partner with the VA.

Local governments are writing — or rewriting — ordinances that regulate massage businesses. Some of these ordinances are good. Some are well-intentioned but flawed. Some of them treat you, a licensed healthcare professional, like a suspect. It is clear that the leaders in our communities are not informed about what happens in a massage business which leads them to create ordinances that add burdens to massage therapists while ignoring the real problem in our communities - the fact that the men who frequent these places are doing so for various reasons.

The stakes are real. The wrong ordinance can require you to submit to a second criminal background check your state already required. It can let inspectors walk into your treatment room unannounced while a client is on your table. It can mandate unlocked doors putting you and your business at risk. It can force you to keep your hours to a schedule that makes no sense for your clients’ lives.

The right ordinance, on the other hand, can do something genuinely important: make it harder for sexually oriented businesses (SOBs) disguised as massage to operate in your community — and easier for clients to find you, a real massage therapist.

We need to understand the difference. Because if we’re not at the table when these rules get written, we become the target instead of the protected.

I will actually take it a step further and say if only our laws were able to make unlicensed massage a felony with stricter penalties and law enforcement would do their job of going after these ‘bad actors’, we would not need ordinances.

Why Ordinances Exist at All

Let’s be direct about what’s happening. SOBs disguised as massage businesses are operating in every state in the country. They use the cover of massage therapy — the signage, the terminology, the storefronts — to sell commercial sex. Many of the people working in these operations are trafficking victims, controlled through debt bondage, document confiscation, and physical coercion. The victims often don’t even understand that they are victims.

This is not a massage therapy problem. It is a crime problem that is using our profession as a disguise.

Because these operations look like massage businesses on the outside, local governments have tried to regulate them through massage ordinances. When the ordinance isn’t written carefully, the burden falls on licensed massage therapists rather than on the operators of illicit sex businesses.

We can fix that. But first we need to understand what’s actually in these ordinances and what the research says works.

What the Research Shows Actually Works

The Network Team, an anti-trafficking research organization, analyzed massage ordinances from cities across the country and interviewed law enforcement, city councils, and code enforcement officials in places that had measurably reduced the presence of SOBs disguised as massage. Successful Massage Ordinance Factors September 2021 provides insights into various ordinances and provides suggestions for successful ordinances.

The cities that succeeded didn’t just write a list of rules. They focused on two things simultaneously: preventing illicit businesses from opening in the first place, and having real teeth when violations occurred.

Aurora, Colorado implemented an ordinance in 2018 that required a thorough application process and gave the city authority to close businesses immediately for certain violations. Within a year, Aurora had closed 18 illicit businesses. By 2021, its closure rate was at least 93%.

Cedar Rapids, Iowa saw a nearly 60% drop in illicit businesses within a year of passing its ordinance in November 2018.

Johnston, Iowa implemented an ordinance requiring detailed credential verification for all employees — not just the owner of record — plus an in-person interview as part of the application process. The Network could find no illicit businesses listed on sex buyer review sites in Johnston since 2016.

What made the difference? Not unlocked doors or health certificates. The things that actually worked were:

• Unannounced inspection authority. Pre-scheduling inspections lets operators hide evidence and rotate workers. Unannounced inspections — the same standard we apply to restaurant health codes — don’t.

• Rigorous application processes that verify credentials for all employees and check criminal backgrounds, not just for the owner.

• Authority to close businesses immediately when unlicensed workers are caught giving massages, when sexual activity is found, or when evidence shows women are living on the premises.

• Prompt notification of personnel changes, because trafficking operations rotate victims frequently. Requiring a business to notify the city whenever a new worker starts — with that worker’s license information — closes a major loophole.

• Regional coordination. When Aurora drove illicit businesses out, they simply moved to Denver and neighboring suburbs. When those cities passed similar ordinances the following year, the regional net became much harder to escape.

What Burdens Legitimate Massage Therapists — And Doesn’t Work

Here’s where we have to be honest about the friction between two legitimate concerns: protecting trafficking victims and protecting licensed massage therapists.

Some ordinance provisions that get proposed — sometimes with good intentions — fall harder on licensed therapists than on the illicit businesses they’re trying to address.

Unlocked door requirements are a clear example. The idea is that inspectors can verify what’s happening inside a treatment room. But a client receiving a massage has a reasonable expectation that no one will walk in unannounced mid-session. The American Massage Therapy Association explicitly opposes this provision, and they’re right to. A legitimate massage therapist shouldn’t have to choose between client privacy and legal compliance. Alternatives — like door viewing panels or mandatory response to a knock — can serve the same purpose without stripping away professional standards.

Duplicate criminal background checks add cost and delay for licensed therapists when the state practice act already required one. If your state board ran a background check before issuing your license, a second local check provides no additional public protection.

Doctor’s examinations and health certificates have no parallel in any other healthcare profession. Requiring them implies that massage therapists are presumptively a public health risk. No other licensed health professional is treated this way.

Hour restrictions so narrow they don’t match other healthcare settings penalize the many legitimate therapists who see clients in the evenings and on weekends. Reasonable late-night restrictions — say, no operation after 10 p.m. — have real enforcement value, because that’s when illicit businesses do most of their business. Restrictions tighter than that hurt legitimate therapists without added benefit. (Most massage therapists have already limited their hours because of the high risk of getting those bad actors as clients at that hour. This is problematic for many workers like airline pilots/stewardesses, doctors, factory shift workers and others.)

Ordinance provisions that apply equally to solo practitioners miss the mark entirely. A solo massage therapist working out of a single room does not present the same risk profile as a multi-practitioner establishment with rotating staff. Exemptions for sole practitioners aren’t a loophole — they’re recognition of reality.

State Establishment Licensing vs. Local Ordinances: Which Is Better?

This is the question I get asked most. The honest answer: state establishment licensing is the stronger, more durable solution — but local ordinances fill critical gaps.

As of June 2026, 24 states have some form of state-level massage establishment regulation. If your state isn’t one of them, a local ordinance may be the only tool available.

But here’s why state-level licensing is generally superior:

It creates a uniform floor. A business can’t hop from city to city to escape stricter rules when the state standard applies everywhere. This is the Aurora problem made structural — when Aurora drove illicit businesses out, they moved. A state framework eliminates that game.

It puts oversight with people who understand massage. Your state massage board knows the difference between a legitimate therapeutic business and an illicit sex operation. Local code enforcement officials often don’t. The Federation of State Massage Therapy Boards (FSMTB) has developed a full model establishment licensing framework — complete with a model application, inspection checklist, and citation form — specifically designed to be adopted by states and adapted to local needs.

Fsmtbestablishmentlicensing

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It protects sole practitioners by design. The FSMTB model explicitly exempts sole practitioners, out-call therapists, and healthcare facilities from establishment licensing requirements. That’s not an oversight — it’s intentional recognition that a single therapist working independently is a different category than a multi-practitioner business.

It bars illicit businesses from the start. The FSMTB model includes explicit language prohibiting sexually oriented businesses from obtaining a massage establishment license. They can’t even apply.

It ties violations to the disciplinary system that licensed therapists already live within. An establishment that violates standards can lose its license through the same board that licenses individual therapists — with the same due process protections.

Local ordinances still matter, though, for one crucial reason: they can move faster than state legislation, and they have an enforcement tool state boards typically lack. A city inspector can post a “closed for violations” sign the same day a violation is found. State board disciplinary processes take months.

The ideal arrangement — and what the FSMTB model explicitly builds in — is state establishment licensing that sets the floor, with local authority to enforce and add location-specific requirements that don’t conflict with state law.

What a Good Ordinance Actually Looks Like

Based on everything the research shows, here’s what we should be pushing for — and what we should be pushing back on.

Every ordinance should require:

• Verification of valid state massage therapy licenses for all practitioners — employees and independent contractors, not just the owner on record

• Criminal background checks on owners and responsible managers (not individual therapists when the state already required one)

• Explicit prohibition on SOBs disguised as massage obtaining any establishment license or permit

• Public display of all licenses

• No living on premises

• No sexual conduct on premises

• Inspection authority

• Non-transferable permits — when ownership changes, the new owner must apply from scratch

Strong ordinances also include:

• In-person application interviews

• Pre-licensing inspections before a business can open

• Hours restrictions (no operation after 10 p.m.)

• Human trafficking awareness poster requirements in multiple languages

• License numbers required in all advertisements

• Landlord notification when illicit activity is found on the property

Ordinances should never include:

• Doctor’s examinations or health certificates

• Therapist dress or hygiene language beyond what state rules already require

• Unlocked door requirements (consider alternatives instead)

• Duplicate background checks when the state already requires them

• Requirements that apply equally to solo practitioners without exemption

What You Can Do Right Now

Your city council may be writing these rules right now. Your state legislature may be considering establishment licensing. You may not know about it until it’s already law.

Here’s how to get ahead of it.

Find out what’s already on the books in your city and state. Look up your local business ordinances and your state massage practice act. What do they say about establishment licensing? Inspections? Hours?

Get connected with your state massage therapy association. They track legislative activity and often need voices like yours when ordinances are being drafted. (AMTA has already said that they are not able to help with local ordinances so consider creating a coalition in your state that will work to address the problem locally)

Learn the FSMTB model. The Federation of State Massage Therapy Boards has published a full Massage Establishment Regulatory Toolkit — including model law, a model application, inspection checklist, and citation form. It’s publicly available at fsmtb.org. If your state or city is working on establishment regulation, this is the framework you want them to start from.

Show up. City council meetings are public. Public comment periods exist. When an ordinance is being drafted that affects your profession, you have a right to be in that room. Bring your perspective. Bring the research. Bring colleagues.

Correct the language. When your local news outlet calls an illicit sex business a “massage parlor,” write to the editor. When a council member talks about “cracking down on massages,” gently redirect: this is about sexually oriented businesses disguised as massage, not about massage therapy. Words matter, and the wrong language shapes the wrong policy.

The Bottom Line

The communities that have successfully reduced the presence of SOBs disguised as massage didn’t do it by treating massage therapists as suspects. They did it by making it very hard for illicit businesses to open, and by making it fast and decisive to close them down when they did.

That’s a framework we can support. That’s a framework that protects victims, protects our profession, and protects the public.

But we have to be in the room when it’s written.

A true continuing competence system — separate from professional development — would require every state to do four things differently (or our professional associations can do this together like they worked on the Entry Level Analysis Project together):

1. Research first, requirements second. Before any state mandates competency maintenance, it needs to identify: What specific knowledge gaps correlate with disciplinary actions or client harm in massage therapy? No state currently has this data. Building it is step one.

2. Assess competence, don’t just count hours. The current system counts seat time. A competency-based system would require practitioners to demonstrate knowledge — through pass/fail assessments with identity verification — in the specific areas tied to public safety.

3. Separate regulatory from developmental requirements. State boards handle public safety. Professional associations handle career growth. Never the same bucket.

4. Publish what works. Every state would be required to publish effectiveness data: Are disciplinary actions declining? Are client complaints decreasing? If the requirements aren’t producing measurable results, they get revised. (The main problem that most boards deal with are ethical issues and usually not injuries to clients.)

What the Competency Assessment Would Cover (All States, Core Module)

Every licensed massage therapist, in every state, would demonstrate current competency in:

Ethics & Professional Boundaries

• Scope of practice for their state

• Informed consent and draping standards

• Mandatory reporting requirements

• Recognizing and responding to boundary violations

Contraindications & Client Safety

• Current evidence on contraindications (updated, not based on 1990s textbooks)

• Red flags that require medical referral

• Communicating limitations and scope to clients

• Adapted techniques for special populations

Hygiene & Infection Control

• Current public health standards

• Bloodborne pathogen protocols

• Sanitation requirements specific to their state

Legal & Regulatory Updates

• Any changes to state law since last renewal

• Human trafficking awareness and reporting (now required in many states)

• Trauma-informed practice basics

Assessment format: Online, proctored, 50–75 questions, minimum passing score. Not a no-fail survey — an actual test. Multiple approved providers compete on quality and price.

Frequency: Every 2–4 years at license renewal (aligned with current renewal cycles). Cost cap: No more than the equivalent of 2–3 hours of work at the state’s median massage therapy hourly rate.

(After a certain number of years and with no violations, the CC requirement would most likely be reduced to zero. )

State-Level Variations (Flexibility Within the Framework)

While the core module is universal, states would be permitted to add one additional competency module based on documented local need:

These modules would be based on documented harm patterns in that state — not added arbitrarily.

What Would NOT Be Required (By Any State)

Under a true continuing competence model, the following would not count toward licensure renewal:

• Technique workshops (hot stone, Thai, bamboo, etc.) — these are professional development, not competency maintenance

• Modality certifications or specialty courses — same reason

• Business development courses — professional development

• Any course not directly tied to the entry-level safety competency framework

• Courses from providers who cannot demonstrate evidence-based content

These aren’t bad courses. They just belong in a different system — the voluntary professional development system run by professional associations.

What Professional Associations Would Build Instead

With regulatory CE requirements stripped down to what actually serves public safety, professional associations (AMTA, ABMP, specialty bodies) would build the professional development infrastructure the profession actually needs:

Specialty Certification Tracks (voluntary, recognized by employers and insurers)

• Clinical/Orthopedic Massage

• Oncology Massage

• Sports Massage

• Prenatal & Perinatal Massage

• Hospital-Based Massage

• Pediatric Massage

• Geriatric Massage

Formal Mentorship Programs

• New Graduate Mentorship (first 1–2 years of practice)

• Specialty Apprenticeships

• Business Mentorship for Solo Practitioners

• Master Practitioner / Mentor Designation

Research Literacy

• Science literacy courses

• Evidence-based practice integration

• Journal clubs and peer learning circles

Business & Career Development

• Solo practice development

• Employment navigation and workers’ rights

• Leadership and advocacy training

The Timeline: What Implementation Could Look Like

Year 1–2: Research Phase

• Commission research on what knowledge deficits correlate with harm in massage therapy

• Survey disciplinary records across all state boards

• Identify the specific competency gaps that regulations should address

Year 3–4: Pilot Phase

• 3–5 states pilot the competency assessment model at renewal

• Multiple providers compete to develop assessment tools

• Costs, pass rates, and practitioner feedback documented

Year 5+: Nationwide Rollout

• Remaining states adopt model based on pilot results

• Professional associations launch formal development frameworks

• Effectiveness data published annually and used to refine the system

Why This Hasn’t Happened Yet

The honest answer: MONEY and inertia.

The CE approval and delivery industry generates significant revenue. Organizations like NCBTMB and FSMTB have built infrastructure around the current system. Professional associations use CE as a membership benefit. State boards have invested in approval processes.

Changing the system means disrupting established revenue streams — even when the evidence (or lack of it) clearly supports change.

That’s why this conversation has to happen at the practitioner level first. When enough therapists understand what the system is supposed to do — and how far the current system falls short — the pressure for reform becomes impossible to ignore.

That’s what this series is about.

Understanding Continuing Competence in the Massage Therapy Profession An examination of the evolution, controversies, and future directions of professional development requirements for massage therapists

The Massage Profession’s $252 Million Mistake: Why We’ve Been Confusing Competence with Development for 30 Years

How fixing this one confusion could transform the entire profession.
A New Model for Maintenance of Competence Evidence-Based, Practitioner-Centered, and Focused on Actual Public Safety

I watched it happen again last week.

A city council, four hours into a the second meeting on this topic, voted to advance an ordinance that bans massage therapists from locking their front doors. The police chief said it would help him fight trafficking. The mayor said it would send a strong message. One massage therapist after another stood up and explained, calmly, that being forced to leave her door unlocked while alone with a client in a closed room doesn’t make her safer. It makes her a target. Dozens of emails were sent with the same supporting comments.

One of them had already been robbed when her door was unlocked. One was a survivor of assault inside her own practice. One described watching a stranger walk into a spa, grab something off the counter, and run — while the therapist was in the back, alone with a client, unaware.

The council passed it anyway. The last time they did add an amendment that said licensed massage therapists could ask for a voluntary inspection of their premises to get an exemption from the things in the ordinance that were asking us to break the law.

The ordinance also said that a massage business could not accept cash. Apparently the illicit businesses are mainly cash businesses and have tons of cash on hand and are part of larger money laundering schemes…so the council thinks by making all massage therapists stop taking cash that it would help them to investigate and prosecute.

They also want to regulate the hours a massage business can stay open. We all know that most licensed massage therapists don’t stay open that late because it often does attract that other crowd looking for happy endings. That also leaves a gap in care for people who work swing shifts and late hours. (Airline Pilots and attendants are a good example.)

They also wanted to ban warning systems and were not clear on the definition of what a warning system was or wasn’t.

So they were saying that they would use discretion and not go after licensed massage therapist but in essence they were saying we would be OK in breaking the law. This also would compromise our liability insurance plans and some code of ethics of the professional associations we belong to.

Who shows up.

One of the most interesting observations on the meetings were who is showing up to support massage therapists in these cases. It was clear that AMTA was NOT there even though they have a statement on their website with recommended language for ordinances. (I have asked the AMTA-WA Chapter to get involved and their hands are tied as AMTA National won’t help them with ordinances.)

I ran the ordinance and their statement through Claude.ai to provide this scorecard on the language.

Amta Standard Scorecard

109KB ∙ PDF file

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This is happening everywhere, and it’s going to keep happening, because the people writing these ordinances — police departments and city attorneys, usually with good intentions — don’t understand what massage actually is or how these businesses actually work. The people who do understand, the licensed therapists, mostly aren’t in the room.

I want to change that. So l am researching ordinances and establishment licensing to see what if anything helps the most to help create a best practices document or more specific guidelines for stopping these places.

The businesses they’re worried about are real

Let me be the first to say it: the illicit sex businesses operating under the cover of massage are a genuine problem. They’re in nearly every community. Many are tied to organized crime. The women working inside are frequently trafficking victims — coerced, controlled, sometimes living in the building, often unable to leave. They also don’t even know they are being trafficked as they willingly sign contracts with these bad actors thinking they are coming to work in the US to send money back to their families in China, Korea and other countries.

Those businesses should be shut down. The victims should be helped. No argument.

These are not massage businesses. They are illicit sex businesses that have stolen the name of my profession to operate. That distinction is the whole game — and it’s exactly the distinction these ordinances keep getting wrong.

Why the obvious approach backfires

When a council first confronts this, the instinct is to make operating as painful as possible. Ban locked doors so police can walk in. Ban cash to disrupt money laundering. Ban “warning systems” that tip off lookouts. Restrict hours.

It sounds tough. Here’s why it fails.

Traffickers adapt. Licensed therapists don’t. An organized criminal operation responds to a cash ban with prepaid cards and shell companies. It responds to a locked-door rule with lookouts. What it does not do is comply in good faith. Meanwhile the licensed therapist down the street — who follows the rules, because her license is her livelihood — loses her locked door, her cash-paying seniors, and her security alarm. The rule sorts people by their willingness to follow rules. Only the law-abiding get caught in it.

“They’re already operating illegally” is the tell. Practicing massage without a license is already a crime everywhere. If a city isn’t enforcing the laws it already has against businesses it has already identified, why would those same businesses suddenly comply with new rules about doors and payment methods? They won’t. The new rules only bind the people who were already following the law.

“We’ll just use discretion” isn’t a safeguard. Police reassure councils: don’t worry, we won’t enforce this against legitimate businesses. But that means writing a law and promising not to apply it as written — and leaving every therapist’s safety to depend on which officer shows up. A law that only works if it’s selectively unenforced is a law aimed at the wrong people.

This is why showing up matters

These ordinances are spreading fast, and right now they’re being written without us. That’s the whole problem. An informed therapist in the room — one who says “I want these businesses gone as much as you do, and here’s how to do it right” — changes the outcome. An empty chair changes nothing.

So I am building the tools to put you in that room.

For paid subscribers: the complete toolkit (Coming July 1, 2026 (hopefully)!

Below are the documents I’ve spent weeks building — everything a massage therapist needs to walk into a city council meeting and shape an ordinance instead of just reacting to one. They’re free to use, adapt, and bring to your own community.

• How to Use This With Your Council — read this first. A one-page strategy guide so you bring the right approach to your community, and don’t accidentally trigger a bad ordinance in a town that wasn’t even thinking about it yet.

• The Massage Ordinance Decision Guide (2 pages) — the pull-out summary to hand a council member who won’t read more than two pages.

• The Massage Ordinance Toolkit (full) — the complete reference. Plain-language sections for council members, technical sections for the staff and attorneys who draft, real-ordinance comparisons, a model-provision checklist, and the voluntary-inspection exemption written out as model language.

• How to Actually Stop Them — the prevention-and-closure plan: what actually shuts these businesses down, before they open and after.

• The rebuttal set — the side-by-side comparisons and point-by-point answers I built for a live ordinance fight, ready to adapt for yours.

Bring them. Share them. Put them in front of your council before the next ordinance is written about you instead of with you.

In the last piece I laid out the problem: forty-five states, forty-five different legal definitions of massage, agreeing at the core and contradicting each other at the edges. My argument was that the definition is the foundation everything else rests on, and that a profession which can’t define itself the same way twice is hard to take seriously.

It turns out the problem runs deeper than inconsistent statutes. Because before we can ask why the states can’t agree on a definition, we have to sit with an uncomfortable fact: the profession itself has never fully agreed on one either.

There’s research that says so directly and buried in that research is something more useful than another complaint — the beginning of a framework we could actually build on.

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“We don’t even know what massage is”

In 2010 the Massage Therapy Foundation gathered thirty-two experts — clinicians, educators, and researchers, collectively holding something like 900 years of experience — for a two-day symposium in Seattle. The original goal was to start building best-practice guidelines for stress and low back pain. But the conversation kept snagging on something more basic. The organizers later realized they couldn’t build the guidelines they came for, because the field hadn’t settled the question underneath them. The discussions were eventually analyzed and published by Ann Kennedy and colleagues in the International Journal of Therapeutic Massage & Bodywork under a telling title: “Clarifying Definitions for the Massage Therapy Profession.”

One participant put the whole problem in a single sentence: “...we don’t even know what massage is.” The researchers found that the struggle to define massage showed up in nearly half of the transcripts. Experts disagreed about which modalities counted — medical massage (and what is that?), energy work, use of tools, reflexology etc — and noted that the profession was hobbled by what they called “multiple taxonomies”: different people using different words for the same thing, and the same words for different things. They compared it to the parable of the blind men and the elephant. Everyone is touching the same animal. Everyone describes something different.

If the most experienced people in the field land there, the chaos in the statutes starts to make sense. The states didn’t create the confusion. They inherited it from a profession that handed them no clear answer to copy.

The distinction we keep missing: massage vs. massage therapy

Here’s the single most useful idea in the study, and it’s one most of us blur every day: “massage” and “massage therapy” are not the same thing.

The literature, and most state statutes, define massage as the manipulation of soft tissue. But the symposium experts were adamant that what we do is more than that. As one participant put it, the distinction “is not about what we do to the tissue... it’s the pattern, and the purpose, and the holistic nature of it. That’s what makes a massage a massage, not just soft-tissue manipulation.” Another asked the questions that should be on the wall of every massage school: Massage is a part of bodywork, but is all bodywork massage? Massage is manipulation of soft tissue, but is all soft-tissue manipulation massage?

Cross-fiber friction at the elbow is soft-tissue manipulation. It is not, by itself, massage. What makes it massage is that it’s patterned, purposeful, and delivered with therapeutic intent.

From that, the researchers proposed an actual definition of the construct massage — adapted from the Massage Therapy Body of Knowledge and sharpened with the experts’ insistence on pattern and purpose:

Massage is a patterned and purposeful soft-tissue manipulation accomplished by use of digits, hands, forearms, elbows, knees and/or feet, with or without the use of emollients, liniments, heat and cold, hand-held tools or other external apparatus, for the intent of therapeutic change.

Notice what that definition does that most statutes don’t. It builds intent and pattern into the meaning itself. It isn’t a list of strokes. It’s a description of purposeful work aimed at therapeutic change. That single shift — from “here are the techniques” to “here is the purpose” — is the difference between a definition that merely catalogs what hands do and one that says what the profession is for.

Massage therapy is bigger than massage

The study’s second move is just as important. If massage is the patterned, purposeful soft-tissue work, then massage therapy is the larger practice that surrounds it — and the experts identified the dimensions that the usual definitions leave out entirely:

• Health promotion and education. The non-hands-on part — self-care, stretches, breath work, posture, the “homework” we send clients home with. The experts considered this essential to massage therapy, not an add-on, and noted that clients often follow a massage therapist’s self-care guidance more faithfully than other providers’.

• The therapeutic relationship and communication. Several experts argued that massage becomes therapy in the context of relationship and communication. One called it “the profound nature of the therapy.”

• Therapist experience, education, and skill. The point that a new graduate, at any hour requirement, is still entry-level until they’ve “touched a thousand people.”

• Setting and environment. A spa protocol that ignores who’s on the table is a different thing from individualized therapeutic care, even when the hands do similar work.

• Safety. Not just avoiding adverse events — the client’s emotional and psychological sense of safety, which one expert placed “at the core.” Without it, outcomes are limited.

Put together, the study draws a clear line: massage is the soft-tissue work; massage therapy is that work plus the education, the relationship, the skill, the setting, and the safety that turn manipulation into care. Most state definitions describe only the first thing and call it the whole profession.

Why we have to define this — and why it has to be ours

It would be easy to read all this as an academic exercise. It isn’t. The reason to nail down these definitions is that every other thing the profession wants depends on them.

Consider what stays broken as long as the definition does. Education can’t set the right number of hours or competencies if we can’t say what we’re training people to do. Research struggles, because — as the methodologists in the study point out — accurate measurement requires clear definitions; you cannot study a thing you can’t define. Insurance and physician referral stay limited, because other providers don’t know what they’re referring to. And regulation fragments into forty-five versions, because each state is left to answer “what is massage?” on its own.

The statutory chaos isn’t the root problem. It’s the symptom of a profession that never produced its own clear, shared answer for the statutes to adopt.

Which leads to the part that matters most. This definition has to come from us. Right now the legal meaning of massage is written by fifty separate legislatures, shaped by whichever schools, competing professions, and local politics happened to be in the room. If the profession doesn’t supply a clear, defensible, research-grounded definition, someone else will keep supplying it for us — and they’ll keep getting it wrong, because they’re not the ones with 900 years of experience in the room.

A profession defines itself. That’s almost what the word means. Medicine, nursing, physical therapy — each has a coherent professional definition of its scope that precedes and informs the laws, rather than being improvised state by state. We have the opposite: the laws came first, and they came inconsistent, because we never handed them a definition to work from.

Without an agreed definition of massage, massage therapy, and massage therapy practice, we cannot build the professional framework that every mature health-care field stands on — and we pay for that absence every single day. We pay for it at the billing desk, where the CPT codes we're forced to use (97124 "massage" and 97140 "manual therapy") were written for and by other professions and capture almost nothing of what we actually do; we have no codes that describe therapeutic massage on our own terms, so our work is billed as a generic procedure or not reimbursed at all.

We pay for it in the referral relationship, where physicians don't send patients to us because they can't be sure what "massage therapy" even means from one therapist or one state to the next.

We pay for it in research, because you cannot rigorously study — or prove the value of — a thing you have not defined.

We pay for it in the legislature, where 45 states wrote 45 different definitions precisely because we never handed them one and we pay for it in our own identity: as Sandy Fritz puts it in her article on Massage Magazine:

A strong professional identity is built on a unified vision, shaped by core values and ethical principles that guide practice standards and decision-making responsibilities in client care. A recognized professional identity influences how the massage therapy profession is perceived and how therapists see themselves within it. Establishing a professional identity enhances confidence and deepens the sense of belonging in the massage therapy field.

Professional identity is dependent on two factors:

• A definition of the profession

• A professional practice framework

One step further - where we are at. A State by State Scorecard.

To compare 46 different definitions fairly, I needed a consistent yardstick — and rather than invent one, I built it from the research. In 2010 the Massage Therapy Foundation gathered 32 experts for a two-day symposium to try to pin down what massage actually is. The resulting study (Kennedy et al., in the International Journal of Therapeutic Massage & Bodywork) didn’t just complain about the confusion; it proposed actual definitions and identified the elements a complete definition should contain.

I turned that work into six yes/no criteria and scored each state’s legal definition against them: (with the help of claude.ai)

• Soft-tissue core — does it define massage as manipulation of soft tissue? (Almost everyone passes.)

• Pattern & intent — does it capture purpose and intent, or just list strokes? The study’s biggest insight is that massage is “patterned and purposeful,” not a mechanical checklist.

• Health/well-being purpose — does it state a therapeutic aim?

• Massage vs. massage therapy — does it distinguish the act from the profession? The study argues these are two separate concepts we constantly blur.

• Self-care / education — does it include the non-hands-on part, like self-care guidance? The experts called this essential, and it’s the single rarest element in the country.

• Assessment / referral — does it recognize the therapist’s judgment about when massage is appropriate, contraindicated, or warrants a referral?

A quick, honest caveat: the study doesn’t hand you a six-item checklist — these are my interpretation of its findings, and someone else might slice them differently. The score measures how closely a state’s definition mirrors this research framework, not whether its law is “good.” A low score isn’t an insult; it’s a map of what’s missing.

Massage Definition Scorecard Visual (3)

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What do you think?

This is a problem worth naming plainly, because the definition is the foundation every other law rests on. It decides who needs a license, who is practicing illegally, which modalities are legitimate, and where massage ends and chiropractic, physical therapy, or esthetics begins. When the foundation varies this much, everything built on top of it varies too.

Here is what the state definitions actually say — where they agree, and where they don’t.

What the states agree on

The shared core is strong. Nearly every state defines massage the same way at the center:

• The work: systematic manipulation or structured touch of the body’s soft tissues — muscle, fascia, tendons, connective tissue. Not bone, not joints.

• The purpose: relaxation, relief of muscle tension and pain, stress reduction, improved circulation, general well-being.

• The methods: hands, forearms, elbows, knees, or feet, often plus devices that mimic the human hand. The standard techniques recur everywhere — effleurage, petrissage, tapotement, friction, vibration, compression, stretching.

• The adjuncts: hot and cold packs, hydrotherapy, topical oils, salts, and non-prescription creams.

• The boundary: every state agrees massage is not diagnosing illness, not prescribing drugs, not spinal adjustment or joint manipulation, and not anything requiring a separate license like medicine, PT, or acupuncture.

So there is a real, coherent profession at the center. The trouble is at the edges.

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Where the states diverge

Energy work — the deepest split. Maryland explicitly includes techniques meant to affect the body’s “electromagnetic energy or energetic field.” Massachusetts explicitly excludes them, naming Reiki, Shiatsu, Reflexology, and Feldenkrais as separate professions. Two states, opposite answers to whether energy work is even massage.

Which modalities count. Arkansas includes heliotherapy, electrotherapy (microcurrent, Russian stimulation), and cupping. Georgia includes taping and cupping but bans fluidotherapy, laser, and deep thermal modalities. Kentucky bans deep physical-agent modalities except pulsed electromagnetic field or microcurrent devices, and only with board-required training. Maryland names “instrument-assisted soft tissue manipulation” (muscle scraping) specifically.

Nebraska sorts massage into tiers — remedial (myofascial release), relaxation (Swedish), holistic (Ortho-Bionomy, Reiki) — and caps electrical stimulation equipment at 35 volts.

How clinical the work is. Arizona legally requires referral to a healthcare provider when a condition is beyond scope or contraindicated. Florida codifies “massage therapy assessment” as determining a course of treatment. New Hampshire includes “analysis of posture and movement.” Montana, New Hampshire, and Rhode Island include client education and self-care instruction. Other states define massage as technique alone.

Safety and conduct in the definition itself. Florida defines and prohibits sexual activity in detail, including drape removal without written consent. Oregon specifies exactly what draping must cover. Washington, West Virginia, and Maine write the prohibition on genital contact and sexual activity directly into their primary definitions.

Outright outliers. Connecticut excludes Thai yoga if the practitioner is Yoga Alliance–registered with 200 hours of training. Hawaii names lomilomi in its statute. Nevada exempts product demonstrations under two minutes. Texas protects the titles “masseur,” “masseuse,” and “body rubber.” Utah splits “bodywork” from “massage therapy,” reserving the latter for injury treatment, insurance-billed work, or work supervised by a physician or PT.

Why this happened

The variation is not random. It comes from a few clear causes:

1. No shared template. Most of these definitions were written during a wave of professionalization from the 1980s through the 2000s led mainly by AMTA, with no national model act to copy. Each state started from a blank page.

2. State authority, not federal. Licensing professions is constitutionally a state power. There is no national body that could issue one binding definition, so divergence was structurally guaranteed.

3. Local influence. Each definition was shaped by whichever schools, practitioners, and competing professions had sway in that state, and by what modalities were popular when the bill was written. A 1991 definition reads differently from a 2015 one.

4. An unsettled identity. The profession itself never agreed on what massage is — purely physical soft-tissue work, or a holistic practice that includes energy work and Eastern modalities. That unresolved debate is exactly what produced the Maryland-vs-Massachusetts split.

Why it matters, and what comes next

The definition is the most consequential sentence in the statute. When it varies state to state, so does everything downstream: who’s licensed, what’s legal, what’s billable, where the profession’s borders sit, and how clearly anyone — clients, insurers, physicians, legislators — can understand what a massage therapist actually does. A profession that can’t define itself the same way twice is harder to take seriously and harder to defend.

The definition is only the starting point. If the definitions vary this much, it’s worth asking how much the rest of the laws vary — education hours, exam requirements, continuing education, license reciprocity, permitted modalities, supervision rules. The definition is the visible tip of a much larger patchwork.

That’s the question I want to dig into next: why our states vary so widely across every part of massage law, and whether anything can actually be done about it. The likely answers — a model practice act more states adopt, an interstate compact for license portability, coordinated advocacy through the national organizations — each come with real obstacles, and each deserves a closer look.

For now, the takeaway is simple. The hands do the same work in every state. It’s the law around them that can’t agree — starting with the most basic question of all, what massage even is.

Resources on the HUB:

list of all state definitions: https://www.massagetherapynexus.com/massage-definitions/

Map with State Definitions and comparison option: https://www.massagetherapynexus.com/definitions-of-massage-therapy-by-state/

Create a comprehensive review where the definition... by Bodhi Haraldsson. https://drive.google.com/file/d/1L1gczKLe8rnzII9s1NAyfIeWcrPxcqKa/view?usp=sharing

I have been learning about and writing about Practice Frameworks and how other professions have used them to build the profession. The massage therapy profession has not had one, but we do have many of the pieces started like the Entry Level Analysis Project (www.elapmassage.org), the Body of Knowledge (preserved in my archive) both of which were created many years ago and the profession never did anything with them. The ELAP was a project of the coalition of massage associations and after it was completed, AMTA decided not to support it.

While AMTA continues to support the general content of the ELAP report, we have never endorsed or supported the 625-hour recommendation. ~AMTA OK

Do we need a Practice Framework? If so, who should be doing this and can they do it tomorrow?

Unions

The topic of Unions always comes up on Facebook and other places. If I had a dollar for every time someone said we need a union, I would be a multi-millionaire. I have written about them over the years and the conclusion is still the same. If you want one, create one.
See previous articles: Our hands give Massage, Hands That Labor: Do Massage Therapists Belong in the Labor Movement (On Substack)

On Unions (from my website www.massagepracticebuilder.com )

Who remembers the Massage Professionals Forum from ABMP -
Massage Union?? Posted by Julie Onofrio on November 8, 2009 at 11:38pm

I have created a Field Guide to Creating a Union for Paid members if you are interested in going that route. I do think there are other options and the top one I am now researching are Cooperatives.

A cooperative ("co-op") is a business that's owned and run by the people who actually use it or work in it — not outside investors. The rule is simple: one member, one vote. Doesn't matter who put in the most money. Everybody gets an equal say.

Some massage therapists have tried this but have not created a formal business structure to make sure everyone is on the same page. That is the important part of building one. More information coming soon.

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Licensing and Legislation

Over the years, I have been watching the Licensing and Legislation arena in the massage therapy profession. Our licensing laws are all over the place regarding the number of required hours of education and other things like scope of practice and CE requirements. I just created a page on the scope of practice of massage across the US and I have to say I am not surprised at how confused people are around what massage is or isn’t.

I also did a look into the number of hours of education that states were requiring and found some interesting trends. While the ELAP recommends 625 hours, many states are still at 500 although that is also down from a few years ago. Only 3 were at 1000 hours and when I look at the hours required, they are mostly class hours for filling the time not anything that is actually required for an entry level massage therapist to practice safely. Effectively is another thing though.

Whenever talk of licensing comes up, people seem to want a national license that will let people move around the country and work in any state without having to jump through all the hoops of licensing again. I don’t think that will ever happen because each state needs to remain in control of it and I don’t know of any other profession that has that sort of portability. Our best bet is the Interstate Massage Compact.

AI and Robot watch.

I have written about the Robots in the massage world and watching the technology change daily. The idea of robots is a touchy subject in the massage profession.

Robots will never replace human touch.

That statement may be emotionally satisfying, but it may also miss the real issue.

Robots do not need to replace massage therapists in order to reshape the profession.

On my Facebook page, I posted about Aescape and how they were claiming bankruptcy but also how they reinvented themselves as Aescape Recovery Inc.

There are also other robots in the field to be watched…stay tuned. Meanwhile did you see the robot dance on America’s Got Talent?

I will leave you with that for now!

Have a great weekend!

Julie Onofrio, LMT

Ask a massage therapist how they like their job (as an employee) going and you’ll often hear some version of he same story. The hands hurt. The schedule is unpredictable. The pay looks fine on paper until you realize you’re only getting paid for the minutes you’re physically in a room with a client — not the cleaning, not the notes, not the gaps between appointments, not the hours you sat waiting for a no-show. You trained for this, you’re licensed, you’re good at it, and somehow the math still doesn’t work.

There’s a deeper trap baked into the franchise model, too. As therapists point out, the most effective way to give yourself a raise often isn’t to ask for one — it’s to quit and jump to a new spa for the signing bonus. That cycle of studio-hopping serves no one. Clients lose the therapist they trust, therapists have to rebuild their following from scratch, and owners scramble to fill chairs in a tight hiring market. Everybody loses, and the model keeps turning.

For years the standard advice was to suck it up or go solo. But something has shifted. In October 2022, the therapists at an Elements Massage studio in Denver became the first unionized franchise-owned massage studio in the United States — and they voted 100% to do it. As one of the organizers, Lori Olcott, put it afterward: We did it. Now it’s your turn.

So let’s talk honestly about what’s possible. Because the answer is bigger and more interesting than just “form a union.”

Why now

Two big things changed to make this moment possible.

The first is who massage therapists actually are now. For most of the 20th century, this was a self-employed profession — and if you’re your own boss, you don’t need to negotiate a contract with yourself. Then franchising arrived. Massage Envy launched in 2002, Hand & Stone in 2004, Elements in 2006, and a wave of brands followed. By 2008, Massage Envy alone had over 8,000 therapists across 420 locations. A large and growing share of therapists now work as employees — people who can benefit from, and badly need, the protections employees in other industries take for granted.

The second is the broader mood. The pandemic exposed an ugly contradiction: the “essential workers” propping up the economy were often the lowest-paid and least-protected people at their companies. The massage industry rode the same wave. Prices for massage went up with inflation, but only about 16% of therapists reported getting a raise in 2022.

The conditions are ripe. The Denver studio just proved the rest of us right — and they haven’t been alone since. In 2023, therapists at a Hand & Stone in Gainesville, Florida voted 22–3 to unionize. In 2025, therapists at Dreamclinic in the Seattle area became the first in Washington State to do it. Three wins in three years. That’s a pattern, not a fluke.

A word about the number everyone gets wrong

Before we go further, we have to deal with a statistic — because it sits underneath almost every argument about whether massage therapists can organize, and it’s far shakier than anyone admits.

You’ll constantly read that “about 38%” or “40%” of massage therapists are self-employed, usually credited to the Bureau of Labor Statistics. Be skeptical of any single figure here, including that one. Depending on the source, the self-employed share has been reported at 35%, 38%, 43%, or 44% — all attributed to BLS — while AMTA’s 2026 Massage Profession Research Report puts it at roughly 75%. That’s not a rounding error. It’s a 40-point spread between two of the most-cited authorities in the field. The live BLS handbook has quietly stopped publishing a number at all; it now just says “many massage therapists are self-employed.”

Why the wild disagreement? Because “self-employed” isn’t one clean thing, and nobody counts it the same way. BLS builds its data from employer payroll surveys that, by design, don’t even capture self-employed workers — so its lens is structurally tilted toward people who are on someone’s payroll. AMTA surveys working therapists directly and counts anyone operating as a sole practitioner, which sweeps in the huge number of people who run their own practice and pick up part-time franchise or spa shifts to pay the bills. One method undercounts the independent side; the other captures the messy truth that most therapists don’t fit in a single box at all.

Hold onto that, because it changes everything about the next part.

“But massage therapists can’t unionize” — the real story

Here’s the objection you’ll hear the moment you bring up organizing: most massage therapists are independent contractors, and contractors can’t form a union.

It’s true that federal labor law only protects employees. Genuine independent contractors are excluded from the National Labor Relations Act — they can’t form a union under it, full stop. A lot of this profession gets handed 1099 forms and told they’re contractors.

But look back at that statistics mess. The reason nobody can agree on how many therapists are “self-employed” is that the line between employee, contractor, and self-employed in this field is blurry, inconsistently drawn, and — crucially — often drawn wrong. A 1099 form does not make you a contractor. The law looks at the actual relationship, not the paperwork. Many states now use what’s called the “ABC test,” and one of its prongs asks whether you do work outside the usual course of the hiring business. If you’re doing massage for a business whose entire purpose is selling massage, you almost certainly fail that prong — which means you may be a misclassified employee: someone being denied overtime, workers’ comp, unemployment, and the right to organize, all on the strength of a tax form that doesn’t reflect reality.

So the honest version of “massage therapists can’t unionize” is this: a real independent contractor can’t, but a large and uncountable share of the people labeled that way aren’t actually contractors at all. The fragmentation that makes the profession impossible to measure cleanly is the same fragmentation that lets employers blur a worker’s status — and that blur is frequently misclassification. The Denver therapists were employees who organized. Plenty of therapists currently filed under “self-employed” or “contractor” might discover, if they tested it, that they’re employees too.

This matters even if you never want a union. Misclassification is one of the most common — and most quietly expensive — things happening to massage therapists right now, and most people have no idea whether it’s happening to them. If you want to know where you stand, your state labor agency can evaluate a misclassification claim, and that’s a low-cost first move.

What a union can actually get you

The headline benefit is pay. Unionized workers earn, on average, about $200 a week more than their non-union counterparts — and because union contracts push for transparent, objective pay policies, they tend to shrink the wage gaps that hit women and workers of color hardest.

But money is only the start. A well-negotiated contract can lock in things franchise therapists rarely get to count on:

• Retirement plans and better insurance

• More paid vacation, sick leave, and PTO

• Reliable schedules and humane hours

• A real process for flagging safety hazards — and the leverage to make management fix them

• Equitable promotions and paid education

• Job security, even in “at-will” states

And here’s a point that often gets lost: unions can be good for owners, too. A large Norwegian study found unionized workplaces were more productive, likely because lower turnover means less money burned constantly training new hires, and better conditions attract more skilled people. Some of us are lucky enough to work for a great manager right now — but that security is always one ownership change away from evaporating. A contract is what makes the culture you built survive the sale of the studio.

How it’s done

Olcott describes two organizing strategies, and they’re worth understanding.

“Quiet as mice” means building support among your coworkers before management catches wind of it. Even the friendliest manager rarely welcomes union talk, so keeping things under wraps until you’re ready to petition lets you gather buy-in without tipping off anyone who might try to discourage it.

“Big and loud” is the opposite: you make it impossible for management to claim they didn’t know. That matters legally, because even in at-will states it is illegal to fire someone for organizing. If you’re a spotless employee who suddenly gets terminated right after talking union, that’s a bad look for the company if a complaint lands at the National Labor Relations Board.

The actual mechanics break down like this. First, talk to your teammates about whether a union makes sense and whether they’re willing to fight for one. Then decide what you actually want — wages, benefits, schedule control, better uniforms, whatever would make you better at your job. List everything, then sort the deal-breakers from the things you can compromise on; those become your demands at the table. Finally, petition the NLRB: you need at least 30% of your unit to sign a petition to trigger an election, and then a simple majority — 50% plus one of votes cast — to win it. After that, management is required to come to the table and bargain.

One liberating detail: you don’t have to organize the whole company or the whole city. A “micro-union” of just two or more people who share a workplace and a similar job can form its own bargaining unit. Other studios can follow with their own. You only have to start with your own room.

The risks are real — don’t pretend otherwise

This is where honesty matters. Organizers have been fired. Companies have retaliated against stores that tried to organize. These actions violate NLRB rules and can be reported — but getting reinstated after a wrongful termination can take a long time.

Expect the playbook. Employees at organizing spas are often required to sit through mandatory meetings run by “labor-management consultants” whose entire job is to talk you out of it. Managers may suddenly suspend reviews, raises, or bonuses and blame the union drive for “disrupting administration.” These tactics also break the rules — but companies usually have to be reported before they’ll stop.

This is exactly why most teams don’t go it alone. You can form an independent union and run it however you like, but you’ll shoulder all the paperwork and all the risk yourself. Going through an established union — UFCW, SEIU, CWA, and others all represent service and health-sector workers — means dues, yes, but also a team of lawyers for your NLRB filings, experienced negotiators sitting across from the corporate attorneys, and a strike fund that keeps a walkout from threatening your rent. One practical tip from the Denver campaign: if you know you want to join an established union, sign your union card early — that’s what gives you access to their legal team the moment retaliation starts, instead of scrambling to hire a labor attorney on your own.

What you can do this week

You don’t need to launch a union drive to start improving your situation.

Document everything. Your pay structure, scheduled hours versus paid hours, your downtime, your unpaid duties. The Denver organizers credited their detailed timelines for the win — when they could show clear, objective numbers, their concerns became impossible to wave away. This is the evidence base for everything else.

Check your classification. If you’re a 1099 worker at a massage business, run yourself through the ABC test. Given how unreliable the “who’s actually self-employed” numbers are, you genuinely may not be the contractor your employer says you are — and that single fact can change every option available to you.

Talk to your coworkers. This is the most underused right in the whole conversation. Discussing pay and working conditions, filing a report with a government agency, and organizing are all federally protected — protected whether or not a union ever exists. Keep early conversations off company systems and off the clock, but have them.

The bigger point

The massage industry has spent a long time treating burnout, bad pay, and turnover as personal failings — as if the problem were therapists who couldn’t hack it, rather than a business model that pays people for a fraction of the time they actually work and then wonders why they leave. The fact that we can’t even agree on how many therapists are employees versus self-employed is part of the same problem: a workforce this fragmented and this poorly counted is a workforce that’s easy to keep divided.

The Denver therapists named the real thing they were fighting for, and it wasn’t abstract. It was the teammates they didn’t want to leave, the clients they didn’t want to abandon, the studio with good parking and great restaurants nearby — the garden they’d nurtured and refused to let a new boss rip out. So they stood their ground and demanded to be treated like what they are: valuable, skilled, hard to replace.

You are not a replaceable cog in a massage machine. The healing touch is worth more than the industry currently pays for it — and the therapists figuring that out together are the ones who’ll fix it.

They did it. Now it’s your turn.

A union isn’t the only path — and for a lot of you, it isn’t even the right one. If you’re truly independent, or your shop is too small to organize, or you simply want out of the franchise model entirely, there’s a whole menu of alternatives that almost nobody talks about: worker-owned co-ops that share the profits, sector-wide wage boards, and the real economics of going independent (including exactly how many sessions a week it takes to come out ahead on booth rental).

This piece draws on “Massage Therapists and Labor Unions” by Lori Olcott, LMT, CMLDT, published by USOLMT (Now only on archive.org), along with AMTA’s 2026 Massage Profession Research Report, BLS data, and reporting on more recent organizing efforts. None of it is legal advice; for your specific situation, talk to an employment attorney or your state labor office.

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• The demand for massage is growing

• Dwindling numbers of massage therapists and massage schools

• Lack of leadership organizations transparency and working together to create a plan for the future

• Increasing numbers of illicit businesses and a lack of action by our associations to address the problem head on.

• Licensing laws that vary greatly by state in the number of hours of education required, CE required and scope of practice.

Now after studying history for many years, the message is clear.

The Future of the Massage Therapy Profession

Demand is growing. Public understanding of massage as a legitimate healthcare intervention — for pain, stress, injury recovery, anxiety, and a range of clinical conditions — has never been higher. Insurance coverage is expanding. Research supporting what massage therapists do is accumulating. In an era of increasingly impersonal, technology-mediated healthcare, the healing power of skilled human touch is not becoming less relevant. It is becoming more valuable.

The profession is failing to reach its potential. Not because of lack of skill or passion, but because of something more fundamental — something structural. The profession was built without a blueprint and until that blueprint gets built, the same problems will keep recurring, the same opportunities will keep getting missed, and the same arguments will keep happening without resolution. We have most of the pieces in place. Our organizations just need to put it all together so that we have a platform to stand on.

This is the article I have been building toward since I started this platform over a year ago. It is about where the profession is going — or where it could go — and what stands between here and there.

The ten things the profession needs to address

Over the past year of research, writing, and conversations with practitioners, educators, and policymakers, I have come to see the profession’s challenges as clustering around ten interconnected domains. They are not a random list. They are a system. Each one affects the others. Progress in one area accelerates progress elsewhere. Neglect in one area undermines everything else.

The first and most foundational is the missing professional framework — the absence of a shared document that defines what massage therapy is, what practitioners do, what competencies are required, and what standards govern practice. The profession built licensing laws, schools, certifications, and associations without this foundation. The result is fifty different licensing regimes, hundreds of schools producing graduates with wildly different levels of preparation, and a continuing education mandate that measures hours rather than competence. Every other problem on this list has roots here. The term “medical massage” has been commercially colonized because the profession never defined it. Licensing laws vary wildly because there was never a framework to align them. The same arguments recur decade after decade because without a shared foundation, they cannot be resolved.

The second is certification and credentialing. Board certification barely differs from basic licensing. The 750-hour advanced education requirement was quietly dropped. Private companies have flooded the medical massage space with proprietary certificate programs marketed as certifications, because the profession left a vacuum and commerce filled it. Therapists and consumers cannot tell the difference between a legitimate advanced credential and a profitable weekend course.

The third is healthcare integration — or rather, the failure of it. Insurance coverage is expanding, but massage therapists are not at the table where the terms of that coverage are being decided. Carriers are setting fees and defining scope without professional input. Washington State’s Every Category Law has been a working model since 1993. No other state has adopted it. The opioid crisis has created a policy window for massage as an alternative pain management intervention. The profession has not organized to walk through it. If we are not at the table, we are on the menu.

The fourth is illicit businesses and professional safety. Businesses hiding behind massage businesses are venues for commercial sexual services in virtually every metropolitan area in the country. This deters new students, exposes working therapists to harassment, and distorts public understanding of what massage therapy is. The profession has been avoiding this problem at the scale it demands for decades. The enforcement gap is structural and it will not close without organized, sustained attention.

The fifth is science literacy and research literacy. Most massage therapists do not engage with the research that supports their work. This is not an attitude problem. It is a literacy problem. Students were never taught what science is, how evidence is evaluated, or how to read a study. A profession whose members cannot evaluate evidence cannot build a credible research base, cannot challenge unsupported claims from certification programs and product marketers, and cannot make the evidence-based arguments that insurance carriers and policymakers require before they take massage therapy seriously. This could be remedied using AI to create a database of research that evaluates each study and connects it to practice creating tools for evidence based practice.

The sixth is professional literacy, history, and the future of the profession. Most massage therapists do not know how their profession is governed, how licensing laws are made, what their associations actually do, or what the history of the decisions that shaped their careers looks like. The profession’s history has never been comprehensively documented. The implications of AI, automation, and emerging technology for practice, education, and professional identity have barely been discussed — even as those changes are already arriving.

The seventh is mentorship and reflective practice. New graduates enter practice completely on their own. No mentorship programs. No clinical supervision. No structured peer support. Every other licensed health profession has addressed this. Massage therapy has not. The consequences are real: inconsistent practice quality, professional isolation, burnout, and a profession that loses experienced practitioners faster than it can develop them.

The eighth is employment issues. Massage therapists are routinely misclassified as independent contractors when their working conditions clearly meet the legal definition of employment. Piece-work pay shifts financial risk onto therapists for scheduling failures that are the employer’s responsibility. Physical sustainability — the real possibility of a long career in a physically demanding field — is rarely addressed systematically. The desire to unionize is real and legitimate, but the structure of the industry makes location-by-location organizing a slow path. Technology platforms are needed to connect therapists with flexible, legitimate, fairly-compensated fill-in work — the equivalent of nursing staffing apps like ShiftMed and CareRev — could help.

The ninth is an untapped opportunity: massage therapists as touch educators. Massage therapists are among the most skilled practitioners of intentional human touch in any professional field. That expertise has documented applications far beyond the treatment room — in infant massage education, caregiver training, healthcare provider education, trauma-informed touch, and community programs addressing touch deprivation. The profession has barely begun to explore this role. It is one of the most compelling arguments for the profession’s irreplaceable value in an era of automation.

The tenth is advocacy — or rather, the absence of it. Most massage therapists were never taught that they could shape the laws and standards that govern their practice. They were not taught how licensing laws are passed, how state boards work, or how to engage with the systems that determine their careers. This is not apathy. It is the predictable result of a professional education that never included civic or professional literacy. Advocacy is a skill. It is teachable. And a profession whose members don’t know how to advocate for themselves will always be governed by those who do.

What is coming whether the profession is ready or not

Here is what makes the next ten years different from the last forty: the external pressures are accelerating.

AI and automation are changing what is possible in massage therapy in ways the profession has barely begun to discuss seriously. Automated massage devices and robotic systems are improving rapidly and are already deployed in clinical and consumer settings. They will not replace skilled therapeutic massage — the therapeutic relationship, the clinical judgment, the capacity to adjust in real time to a client’s verbal and nonverbal communication, and the psychological and relational dimensions of healing touch are not replicable by a machine. But that case has to be made clearly, convincingly, and grounded in research. A profession that cannot articulate what it uniquely offers will find that articulation made for it — probably not to its advantage.

The healthcare system is moving with or without massage therapy at the table. The VA is developing standards. Insurance carriers are expanding coverage and simultaneously defining what they will and won’t pay for. Medicaid programs in two states already cover massage for certain conditions. Every month the profession is absent from these conversations, the terms get set without it.

Workforce pressures are mounting. Enrollment in massage schools has been declining for fifteen years. The number of accredited schools has shrunk. The physical demands of the work, combined with poor pay, misclassification, and professional isolation, are driving experienced therapists out of the field faster than new ones are entering. The profession is losing people it cannot afford to lose, to structural problems it has the tools to address but has not.

What the future could look like

Here is the version of the future that is possible — not utopian, not requiring everything to go right at once, but achievable within a decade if the profession makes different choices.

A unified professional framework exists and has been adopted across states. Licensing laws are becoming more consistent. An interstate compact allows therapists to practice across state lines. Board certification means something again. Medical massage has been formally defined. Multi-profession coalitions are operating in multiple states, advocating for fair reimbursement. The illicit business problem is being addressed at scale with a national awareness campaign and state-level establishment licensing. New graduates enter a mentorship infrastructure. A technology platform connects therapists with flexible, legitimate fill-in work. Massage therapists are teaching touch in recognized, reimbursed community and healthcare roles. And the profession’s members understand how it all works — its history, its governance, its research base — and participate in shaping it.

None of this requires a miracle. It requires information, organized and made accessible, and enough people in enough positions who understand the structural problems clearly enough to make different choices than their predecessors made.

What stands between here and there

Mostly organizational will and information.

The resources exist. The ELAP, the Body of Knowledge, the FSMTB Model Practice Act, the research base, the technology — all of it exists or is within reach. What the profession has consistently lacked is the shared information infrastructure that would allow its organizations, practitioners, and policymakers to see the full picture clearly enough to act together.

That is the problem Massage Therapy Nexus exists to address. Not by replacing organizational action — no independent platform can do what organized professional associations can do when they decide to do it — but by providing the research, history, and honest independent analysis that makes the cost of inaction visible and the path toward action clear. Ten domains. Ten areas where the profession’s future is being shaped right now — in legislative chambers, in association boardrooms, in insurance carrier offices, and in the daily experience of every massage therapist trying to build a sustainable career.

The future of the massage therapy profession is not guaranteed. It is not inevitable. It depends on enough people in enough positions understanding the structural problems clearly enough to make different choices.

This platform exists to make that understanding possible. I have a plan for the next year to fill you in on the history of our profession, provide the latest news of the profession and gather other writers to share what is happening in their neighborhoods.

The profession has everything it needs to build something worthy of the people who practice in it — and the clients who depend on them. The question is whether it will.

— Julie Onofrio, LMT Massage Therapy Nexus massagetherapynexus.com

Let me tell you what I’ve been watching.

I’ve been watching our professional associations respond — or not respond — to events happening in the profession every single day. I wanted to understand where the breakdown in communication was happening, so I volunteered for three years with my local AMTA-WA chapter to see it from the inside. I’ve done deep dives into the history of our professional associations and documented the lack of transparency within them. I’ve watched school enrollments decline while demand for massage keeps rising. I’ve watched massage robots enter the market. I’ve watched the number of illicit businesses increase year after year while the profession produces mostly silence in response. And I’ve watched the profession continue without any overall plan for where it’s going.

All of that has finally come together for me — into something I can name clearly.

Why “Nexus”

I named this project Massage Therapy Nexus after reading Yuval Noah Harari’s book Nexus, which explores how information networks shape civilizations. His central argument is that the health of any society depends on the quality of its information systems — how information flows, who controls it, whether it reflects reality or distorts it.

That hit close to home.

In the body, the nervous system is our nexus — it connects everything, coordinates everything, makes coherent action possible. The massage therapy profession has never had that. We have associations, schools, certifying bodies, licensing boards, publications, and Facebook groups — but no nervous system connecting them. No shared information network that helps the profession understand itself, respond to threats, and move in a coordinated direction.

That’s what I want Massage Therapy Nexus to be.

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What This Publication Is

Massage Therapy Nexus is the national hub for professional news, history, advocacy resources, and community for the massage therapy profession — independently published, unaffiliated with any association, and funded entirely by readers like you.

Here’s what that means in practice:

The newsletter publishes every week. Free subscribers get current events coverage and access to the full resource library. Paid subscribers get the deeper editorial analysis — the historical context, the hard questions, the documented record of how the profession got where it is and what it would take to change course.

Through my years of gathering history and watching the profession I have narrowed it down to 10 domains where the profession needs structural change. I chose that word carefully — a domain isn't a problem waiting to be fixed, it's a territory that requires sustained attention, coordinated response, and institutional knowledge. The profession has been reacting to events within these domains for decades. The goal is to start acting with intention instead.

The HUB - the Central Information Resource explaining the 10 Domains:

• Practice Framework - We lack a Practice Framework to guide Licensing and legislation.

• Healthcare Integration - It is happening without a clear definition of the profession.

• Illicit Businesses - Hiding in plain sight in our communities for decades

• Professional Literacy - The History and Structure of the Massage Profession

• Science and Research Literacy - Tradition

• Mentoring/Reflective Practice - Support for therapists in every stage of their career.

• Employment - Understanding Pay Structures and Creating/Finding Sustainable Jobs in the massage profession.

• Touch Education - Brining Touch/Massage to schools and the general public.

• Advocacy 101 - Organizing in our local communities for support and advocacy.

• The Future of the Massage Therapy Profession - AI, Robots and what it means to be a human being.

The archive contains original publications from the profession’s history — documents that have been largely forgotten and that tell the story of decisions made decades ago that we are still living with today. Timelines and histories of AMTA, NCBTMB, national certification, the medical massage controversy, healthcare integration, state licensing, and more — built from primary sources, including scanned documents from collections that almost didn’t survive.

What’s Coming

Next week — June 1 — I’m publishing a whitepaper I’ve been working on for some time: A Vision for the Future of the Massage Therapy Profession.

It identifies ten interconnected areas where the profession needs structural change. Not a wish list — a documented analysis of what’s broken, why it keeps breaking, and what a coherent response would actually look like. It’s the most complete statement of what Massage Therapy Nexus stands for and why this work matters.

It will be free. I want every massage therapist who cares about this profession to read it.

After that, the newsletter will dig into each of those ten areas — one by one, with the historical record behind them and the current events that make them urgent right now.

What I’m Looking For

I will also be looking for contributors. If you are a massage therapist with something to say — about your state’s licensing situation, about what’s happening in your community with illicit businesses, about your experience with CE requirements or certification programs or insurance billing — I want to hear from you. The profession needs more voices willing to say the honest thing in public. This publication is a platform for that.

Nearly four decades into this profession, I still believe it matters. I believe the work massage therapists do is significant and undervalued. I believe the profession is capable of more coherence, more coordination, and more honest self-examination than it’s managed so far.

That’s what this is for.

If it’s what you’ve been looking for too — share this with one massage therapist who needs it.

— Julie Onofrio, LMT (See the About me page)

To distinguish between a profession and an industry, it’s important to understand the characteristics and criteria that define each. Let’s break down these concepts:

Profession

Education and Training: Professions typically require extensive and specialized education, often at a college or university level. This education is not just about practical skills but also theoretical knowledge.

Certification and Licensing: Professionals are usually required to be certified or licensed by a professional body or government agency. This ensures that practitioners meet certain standards of competence and ethics.

Autonomy and Responsibility: Professionals generally have a high degree of autonomy in their work and are responsible for their own actions. They are also accountable to their professional body for maintaining standards.

Ethical Standards: Professions are governed by codes of ethics, which set out the standards of conduct expected of practitioners. These codes are enforced by professional bodies.

Commitment to Public Interest: There is often an expectation that professionals will work in the best interest of the public or their clients, sometimes even above their own interests.

Continued Professional Development: Professionals are expected to engage in lifelong learning and keep up to date with advancements in their field.

Industry

Economic Activity: An industry refers to a group of companies or businesses that produce a particular type of goods or services. It’s a broader term that encompasses both trades and professions within a particular sector.

Variety of Roles: An industry can include a variety of roles, from manual labor to management, and doesn’t necessarily imply a specific level of training or education.

Market and Consumer Focus: Industries are primarily focused on the production and market dynamics, responding to consumer demand and economic trends.

Is Massage a Profession or Industry?

The massage therapy profession/industry has already undergone much of this transition and some states are ahead of others in becoming a profession. The field has working to create educational standards (AMTA, ABMP, AFMTE), certification processes (NCBTMB), and professional bodies (AMTA, ABMP) to oversee practice and ethics. This distinguishes it from an industry but we are not quite there yet.

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In the 2008, the White Paper On Becoming a Profession: The Challenges and Choices that will Determine Our Future by Rick Rosen, MA, LMBT wrote: “

“We need to move forward together if we want to become a full-fledged profession. Here are the action steps that will get us there:

• Establish a Body of Knowledge – (2010) We did that, but it has not been used or updated. The website is no longer functioning but the Society of Massage Archives has preserved it here.

• Improve the quality of massage therapy education – Entry Level Analysis Project was completed in 2012. ABMP has the Cornerstone Instructor Development Program and the Schools Forum. AMTA has the Schools Center. The Alliance for Massage Education (AFMTE) National Teacher Education Standards Project (NTESP) is on hold while they work to sort things out and rebuild their organization.

• Reorganize the credentialing process by putting licensure before certification – Board Certification (Board Certification in Therapeutic Massage and Bodywork (BCTMB®)is in place through the National Certification Board for Massage and Bodywork (NCBTMB) yet it does not show that a massage therapist has training beyond basic licensing requirements. Licensing laws vary greatly state to state. We do not have Specialty Certifications which could help show excellence in massage therapy. Here are the years that Licensing was implemented.

• Create parity among our state massage laws to increase portability – 2015 AMTA position paper calls for work on License Portability. “Portability, quite simply, means that the education and training credentials of a licensed massage practitioner could be more easily accepted when a practitioner moves to or opens a location in another state.”
  2023 The Federation of Massage State Boards in conjunction with the Department of Defense and the Council of State Governments creates the Interstate Massage Compact which is supported by ABMP but not AMTA.

• Develop and promote a unified professional identity – What would that look like?

• Use lessons learned from other professions – Other professions have a professional framework which they base their model practice act on to create a more unified profession.
  
  Learning from Our Peers: Physical and Occupational Therapy. Occupational therapists (OTs) and physical therapists (PTs) have well-developed infrastructures that massage therapy could learn from:
  
  Unified Professional Associations: The American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) function as powerful advocates, representing their professions in legislation, research, and education policy.
  
  Practice Frameworks: OTs and PTs have clearly articulated scope of practice documents and theoretical frameworks that define what they do, how they do it, and why it matters. These are referenced in legislation, taught in education programs, and used in public advocacy.
  
  Educational Standards and Accreditation: Accreditation bodies for OT and PT programs maintain rigorous and consistent educational requirements, updated regularly through collaboration with professional associations.
  
  Continuing Competence: PTs and OTs often operate under systems of continuing competence—not just CE hour accumulation. This ensures ongoing relevance and effectiveness in practice.

Structure of a Profession

Back in 2009, Rick Rosen wrote an article The Structure of a Profession: Where Does Massage Therapy Stand Today? on what it takes to become a profession. He stated:

While each mature profession has its own developmental history, culture, and methods of operation, there are six basic components that are common to all. These are:

1) Membership Association – We have two main associations – American Massage Therapy Association (AMTA, not for profit) and Associated Bodywork and Massage Professionals (ABMP). Having two main associations may have split up the profession too much making it more difficult to progress as a profession.

2) Independent Organization of Colleges or Schools – Alliance of Massage Education (AFMTE)

3) Accrediting Commission – Commission on Massage Therapy Accreditation (COMTA)

4)Federation of State Licensing Boards – Federation of State Massage Therapy Boards (FSMTB)

5) Specialty Certification Boards – National Certification Board for Therapeutic Massage and Bodywork (NCBTMB)

6) Research Center – Massage Therapy Foundation (MTF)

Coalition of Massage Associations

The Seven associations meet once a year usually in the spring to share visions and work together yet we are far from being a profession. The inability of our associations to work together on a shared vision is evident.

Conclusion

Some call massage a profession and some call it an industry, but structurally and functionally, massage therapy operates more like a fragmented occupation. The foundational infrastructure — consistent education standards, unified governance, recognized specialties, effective CE, and coordinated associations — is incomplete or dysfunctional.

Until these gaps are addressed, we can’t claim full professional status. The work ahead involves:

Key Priorities to Advance to Full Profession

1. Unify representation – Merge or create coalition between AMTA and ABMP (or a new joint body) for single national advocacy voice.

2. Adopt a national practice framework – Define and enforce scope, standards, and ethics.

3. Update the Model Practice Act using the Practice Framework

4. Mandate and update ELAP – Every school adopts and aligns with current, evidence-based competencies.

5. Updating and enforcing the Body of Knowledge

6. Create accredited specialty certifications – Clinical Massage, Oncology, Sports, Pediatric massage, etc.

7. Implement a National CE Registry – Consolidate NCBTMB/FSMTB systems, raise instructional quality. Move to Continuing Competence.

8. Strengthen research – Increase Massage Therapy Foundation funding and practitioner research literacy.

It’s the summer of 1894. London.

The British Medical Journal just dropped an exposé calling out so-called “massage shops” as fronts for prostitution. The article is titled — and I’m not making this up — *”Astounding Revelations Concerning Supposed Massage Houses or Pandemoniums of Vice.”*

Sound familiar?

A legitimate profession. Criminal operators hiding behind the name of massage. A confused public and licensed practitioners left holding the bag.

Four nurse-midwives in London read that BMJ article and made a decision. They were done being lumped in with sex businesses. Done having their profession defined by people who had nothing to do with legitimate massage. They founded the Society of Trained Masseuses within six months of that exposé — and they built it specifically to draw a line between real massage and what was happening in those backrooms.

That Society eventually became the Chartered Society of Physiotherapy — one of the largest and most respected healthcare professions in the world.

They got out.

Which means the question we have to sit with right now, in 2024, is this: **Can we do it again?**

We Have Been Here Before. Many Times.

Let’s be honest about the history, because it matters.

This is not a new problem. It’s not a post-pandemic problem. It’s not something the internet created. The massage profession has been confused with sexually oriented businesses for well over a century — and we have been fighting it the entire time.

In 1979, the president of AMTA was quoted in the *New York Times* saying that “massage parlors” are “usually a front for prostitution or other illicit sexual activity.” That was 45 years ago. The profession was already exhausted by the association then.

In 1987, AMTA made the news again pushing back on the word “masseuse” because of what it had come to mean.

We have tried licensing. We have tried national certification. We have tried professional associations and codes of ethics and continuing education requirements. And yet here we are. The problem hasn’t gone away — it’s gotten bigger, more organized, and more deeply embedded in the public imagination of what massage is.

Over 350,000 licensed massage therapists in the United States are still waking up every day and explaining to clients, to legislators, to their own families, that they are not *that kind of place*.

That has to stop. And to understand how to stop it, we need to understand what actually worked in 1894 — and why we’re in a harder position today.

What the 1894 Founders Did Right

Those four Victorian women didn’t just complain about the problem. They executed a strategy. And it was remarkably sophisticated.

**First, they separated identity through credentials.** They created rigorous examinations, a formal curriculum, and a code of conduct. The message was simple and aggressive: *we are not them, and here is the documentation to prove it.* Licensing became a visible, verifiable line in the sand — not a burden, but a badge.

**Second, they reframed what massage meant.** This is the move that changed everything. They aligned with the medical model. They positioned massage as a clinical intervention — something done to a spine, a joint, a nervous system. Not to a person as a sensual being. They didn’t just change their practices. They changed the *mental picture* the public had when they heard the word massage. Clinical rooms. Plain dress. Daytime-only practice. Medical referrals. Every detail said: *this is healthcare, not entertainment.*

**Third, they controlled the language from day one.** They named themselves deliberately. They refused to let anyone else define what their profession was. The word “trained” in “Society of Trained Masseuses” did enormous work. It said: there is a difference. We are it.

**Fourth, they found powerful allies.** They didn’t go it alone. Within the first years, 79 physicians publicly endorsed the Society. That medical patronage gave them credibility they could not have manufactured on their own.

**Fifth, they built institutional infrastructure.** The Society became the gatekeeper — vetting referrals, setting rates, policing its own members, establishing a monopoly on what legitimate massage looked like. They created the machinery that enforced the separation.

The result was a complete transformation of how the public understood massage. Not overnight. But durably.

Why It’s Harder Today — Let’s Be Honest

We are more entangled than the 1894 founders were. Here’s why.

**The scale is incomparable.** In 1894, the problem was a handful of London establishments. Today, sexually oriented businesses (SOBs) disguised as massage are operating in strip malls in every American city. We are talking about tens of thousands of locations, organized crime networks, and an industry generating hundreds of millions of dollars in criminal revenue. This is not a local scandal. This is a national crisis.

**The internet collapsed the distinction.** In 1894, you couldn’t Google “massage near me” and end up on an escort review site. Today the same search terms, the same storefronts, the same generic signage serve completely different markets. The confusion isn’t just social anymore. It’s algorithmic. It’s structural.

We lost the language battle in 2017

This is the one that haunts me. When the Polaris Project published their report on human trafficking and coined the term “illicit massage business,” they handed every reporter, every legislator, and every law enforcement officer in America a phrase that permanently embeds the word *massage* in the vocabulary of trafficking. Every headline that uses that term is an advertisement for the idea that massage and sex work are the same thing.

The 1894 founders never let that happen. They refused to be defined by the scandal. They named the problem themselves, in their own terms. We did not do that. And we are paying for it.

Establishment licensing is making things worse, not better.

It is almost like it is a last ditch effort to get the problem under control because it has gone on for so long. More than 20 states now have establishment licensing laws requiring licensed massage therapists to obtain additional permits, submit to inspections, and prove they are law-abiding. Here’s the problem: the 1894 founders used licensing to create distance from sex work.

Today’s establishment licensing does the opposite.

It treats every licensed massage therapist as a potential suspect. It embeds the massage profession inside the regulatory framework designed for SOBs, rather than separating us from it. There is no research — none — showing it reduces trafficking or closes these businesses.

If licensing a physical therapist’s office doesn’t require them to prove they’re not running a sex business, why does ours?

**We are fragmented.** AMTA, ABMP, the Federation of State Massage Boards — they are not pulling in the same direction. There is no unified strategy. No “Reclaim Our Name” campaign with muscle behind it. No coordinated legislative response. The 1894 founders acted together, fast, and with a shared vision. We are still debating terminology in committee meetings while legislators write laws that define us by our worst impersonators.

So. Can We Do It Again?

Yes. I believe we can. But not by doing more of what hasn’t worked.

Not by more licensing that treats us as the problem.

Not by staying quiet and hoping it goes away.

Not by letting Polaris or law enforcement or the nightly news define who we are.

The 1894 playbook still works. The principles haven’t changed. What changed is the scale, the technology, and the urgency. We need to execute that same strategy — a separation of identity, a reclaiming of language, a medical alignment, powerful allies, and institutional infrastructure — at a scale those four Victorian women couldn’t have imagined.

That is what this series is about.

Over the next several articles, we are going to map the problem honestly. We are going to look at what’s working and what isn’t. We are going to look at language, legislation, law enforcement, landlords, and the media — all the places where the entanglement lives and where the separation has to happen.

And we are going to end with a concrete plan.

Not a wish list. A plan.

Because we have been fighting this fight for 130 years and we deserve a strategy that actually works. The Victorian women who built physiotherapy from the wreckage of a scandal proved it can be done.

Now it’s our turn.

*This is Article 1 of the Hands Off Our Name Series— an ongoing exploration of the entanglement between the massage therapy profession and sexually oriented businesses (SOBs), leading to a concrete action plan for separation. New articles drop regularly at lookbeforeyoubookamassage.com.*

Julie Onofrio, LMT, has been a licensed massage therapist for 39 and is the creator of lookbeforeyoubookamassage.com, a resource for clients, therapists, and communities working to understand and address this issue.

**Coming in Article 2:** The Language War — How the words we use (and allow others to use) either protect our profession or bury it. And what we can do about it right now.

The whole point of updating the book was to really start creating a movement toward Health Care Integration for all of the massage profession. This is not to separate out the spas/relaxation focused businesses as stress reduction is also a big part of healthcare. (It will take longer for carriers to pay for massage for stress reduction as currently they only pay for medically necessary massage for physical symptoms).

From my over 38 years of billing all sorts of insurance and watching our profession not get the support it needs to be a part of Health Care, I am working on creating a plan to make it so.

How to Get Massage Therapy Covered by Health Insurance in Every State

A Comprehensive Plan Built on Washington State’s Every Category of Provider Law

Massage therapy did not enter Washington State’s insurance system because insurers suddenly recognized its value. It entered because lawmakers intervened, patients demanded access, and providers learned how to work inside a system that was never designed for them. Every other state can do the same — and the legal groundwork is already laid.

This is a plan for making that happen, state by state, across the entire country.

Download the Free Field Guide to Billing Insurance

THE LEGAL FOUNDATION ALREADY EXISTS

Three legal pillars give every state the authority it needs to mandate insurance coverage for massage therapy. What has been lacking is not permission — it is coordinated action.

Washington State’s Every Category of Provider Law (1995)

Washington enacted one of the strongest and earliest provider nondiscrimination statutes in the U.S.: RCW 48.43.045. The Every Category Law. The intent was simple but radical for its time. If a health plan covers a service, it cannot discriminate against a licensed provider who is legally allowed to perform that service. Insurers could no longer say “we cover this treatment, but only if a doctor or physical therapist does it.”

The law requires insurers to reimburse any licensed health care provider for covered services when the service is within the provider’s scope of practice, when the service is medically necessary, and when the service would otherwise be covered if performed by another provider type.

Washington also explicitly defines massage therapy as a health care service under RCW 18.108. That statutory definition is crucial. Without it, insurers default to treating massage as a personal service and deny claims on definitional grounds before the clinical argument even starts.

That law did not magically make insurance companies friendly to massage. What it did was create legal footing. It gave massage therapists something far more powerful than approval: standing.

The Supreme Court Breakthrough: Kentucky Association of Health Plans v. Miller (2003)

For years, insurers argued that state provider nondiscrimination laws were preempted by ERISA, the federal law governing employer-sponsored health plans. This argument effectively froze other states from acting. The legal uncertainty was real enough to stall legislative progress for a decade.

In 2003, the U.S. Supreme Court ended that uncertainty. The Court ruled in Kentucky Assn. of Health Plans v. Miller that state any-willing-provider and nondiscrimination laws are not preempted by ERISA, provided they meet a two-part test: the law must be specifically directed toward insurers, and it must substantially affect the risk-pooling arrangement between insurer and insured.

Both conditions are easily met by well-drafted Every Category legislation. Washington’s law was retroactively validated by this decision. Every state now has clear constitutional authority to act. The barrier was never the law — it was the absence of coordinated political will.

See the complete history of the Every Category Law in WA and how Deborah Senn, the insurance commissioner at the time, fought the insurance companies and won!

The ACA Reinforces the Principle (2010)

ACA Section 2706(a) added a federal floor: group health plans shall not discriminate against any health care provider who is acting within the scope of their license. Federal enforcement has been inconsistent, but the statute gives advocates additional language to cite and creates a baseline that state laws can build upon. Importantly, the ACA did not override Washington’s law — it supplemented it.

The bottom line: the constitutional groundwork is already laid. ERISA is no longer the barrier insurers claim it is. Washington provides a working, defensible model. Other states can replicate it now.

THE ERISA GAP — BE HONEST ABOUT IT

State Every Category laws do not reach self-insured employer plans operating under ERISA, which cover roughly 60 percent of workers with employer-sponsored insurance. This is a structural limitation that advocates need to acknowledge honestly rather than paper over.

However, fully-insured plans — which state laws do govern — cover a substantial portion of the market and self-insured plans often adopt state coverage standards voluntarily for administrative uniformity. The strategy is to establish the state mandate first, then pursue employer-side advocacy, union contract negotiations, and longer-term federal legislative action to close the ERISA gap.

Acupuncture’s success in Medicare shows how this works in practice. Acupuncture advocates won Medicare coverage by starting narrow — targeting chronic low back pain only, at a moment when Medicare was under intense pressure to address the opioid crisis. They accepted physician oversight and visit caps as initial conditions. Coverage was granted. Now the expansion work begins from a position of inclusion rather than exclusion. Massage therapy can follow the same path.

STATE-BY-STATE READINESS

Not every state starts from the same position. Effective advocacy means understanding where each state stands and choosing the right approach for that context.

Are massage therapists considered to be healthcare providers in your state?

Does your state have an Every Category law or any-willing-provider language that would make it so massage therapists were allowed to become contracted providers, bill and get paid by healthcare insurance?

Does your state have opioid reduction legislation or pain management statutes that name massage therapy as a possible provider of services for this?

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THE FIVE-PHASE PLAN

Phase 1 — Define the Profession in Law (Years 1 to 2)

This is the non-negotiable prerequisite. Insurers rely on vague or absent statutory definitions to treat massage as a personal service and deny claims on definitional grounds. Without clear health care language in statute, every subsequent strategy is weakened.

Audit every state’s existing massage therapy licensing statutes for health care language. Draft model statutory language defining massage therapists as health care providers — adaptable to each state’s regulatory structure, but consistent in its core meaning. Ensure scope of practice language explicitly authorizes assessment, documentation, and functional goal-setting. In unregulated states, pursue state-level licensure as the first legislative priority.

Most critically, the profession needs to agree on one unified definition of clinical massage therapy. Today massage therapy is defined 40 different ways across 40 states that have licensing laws. This fragmentation is the profession’s biggest self-inflicted vulnerability. Insurers have stepped into that definitional vacuum and used it to restrict coverage. When the profession does not present a clear, unified definition rooted in clinical purpose, insurers default to their own restrictive interpretations. That stops when we define ourselves.

Phase 2 — Build the Coalition (Years 1 to 3)

Massage therapy alone cannot win insurance reform through lobbying power. But massage therapy positioned within a broader pain management, opioid reduction, and integrative care coalition can.

Clinical partners to recruit include chronic pain physicians, physical therapy associations, chiropractic associations, hospital integrative medicine departments, and VA healthcare advocates. Patient advocates to bring in include the American Chronic Pain Association, opioid recovery organizations, cancer patient support groups, and veteran service organizations. On the employer and insurance side, state chambers of commerce respond to cost-savings arguments, labor unions can negotiate massage coverage into collective bargaining agreements, and workers’ compensation system stakeholders are natural allies.

One practical tactic worth emphasizing: have licensed therapists provide chair massage to state legislators and their staff before committee hearings. This sounds simple. It is surprisingly effective. Policy debates about massage therapy are often conducted by people who have never experienced clinical massage. Humanizing the profession in person changes the conversation.

Phase 3 — Introduce and Pass Every Category Legislation (Years 2 to 4)

The model legislation needs four core elements. First, a definitions section that explicitly includes licensed massage therapists in the definition of health care provider. Second, a provider nondiscrimination section that prohibits coverage denial based on provider category when the service is within scope, medically necessary, and would be covered if performed by another provider type. Third, carrier obligation language requiring insurers to develop and publish credentialing criteria for all licensed provider categories, with written reasons required for any denial. Fourth, an enforcement section giving the insurance commissioner authority to receive and investigate complaints, with civil penalties for willful violations and a private right of action for affected providers.

The drafting must satisfy the Miller two-part test: the law must be specifically directed toward insurers, not employers, and must substantially affect the risk-pooling arrangement between insurer and insured. Get that right and ERISA preemption arguments fail.

For legislative strategy, identify a champion legislator in each target state — preferably someone on the health committee with personal or constituent experience with massage therapy. Brief the state insurance commissioner before the bill is introduced. Commissioners who become administrative allies can be as powerful as legislative sponsors.

Phase 4 — Build the Billing and Compliance Infrastructure (Years 3 to 6)

Washington’s history contains a critical lesson: passing legislation without a ready profession produces denials, billing errors, and insurer pushback that undermines the law’s intent. The law opens the door, but therapists still have to walk through it correctly. Infrastructure must be built in parallel with legislative campaigns.

When the law was passed here, one insurance company in particular required training in charting. Our AMTA-WA chapter also provided training on HIPAA and other legal requirements around billing and being a healthcare provider.

This means developing a national clinical documentation standard — a model SOAP note format, functional outcomes language, and medical necessity framework that meets insurer audit standards. It means creating state-by-state credentialing guides and building CAQH ProView profiles for LMTs pursuing insurance work. It means advocating for insurance billing fundamentals as a required competency in massage therapy school curricula. And it means establishing a voluntary national outcomes database where therapists can submit clinical outcome data — pain scores, functional status, cost comparisons. That data becomes the profession’s most powerful legislative asset in the years that follow.

Phase 5 — Federal Strategy: Medicare, Medicaid, and ERISA Reform (Years 5 to 10)

Three parallel federal tracks run simultaneously.

On Medicare, follow the acupuncture model. Introduce a narrowly scoped coverage bill targeting chronic low back pain, cancer-related pain, and post-surgical recovery. Accept physician oversight and visit caps as initial conditions. Once covered for those conditions, expand indications through outcomes data. The key is getting inside the system first.

On Medicaid, pursue State Plan Amendments in states where massage is already considered to be healthcare providers. (WA State is in the process of doing just that.) In parallel, push for managed care plan inclusion — many Medicaid managed care plans can cover massage as a value-added benefit without a full SPA. Build the cost-savings evidence base around reduced emergency room utilization, reduced opioid prescribing, and functional improvement in chronic pain populations. This is the argument that moves Medicaid administrators.

On ERISA, work with congressional allies to introduce an amendment either exempting provider nondiscrimination laws from ERISA preemption or extending ACA Section 2706 enforcement to self-insured plans. This is a long-game play. Build the coalition and the evidence base first. Establish a national Political Action Committee focused exclusively on massage therapy policy — paid, professional federal advocacy is not optional at this level.

On VA coverage, expand the VA Community Care pathway, which currently offers the most consistent independent coverage pathway for LMTs. Document outcomes rigorously. VA outcomes data becomes congressional testimony. Learning to bill the VA will also get you connected with the representatives for the VA and could be the start of being able to give input into the VA policies and procedures. (AMTA National has been working on that, but I think it could also come from the local massage therapists doing the billing and working with this population.)

THE CLINICAL FRAMING IMPERATIVE

Legislative strategy alone is insufficient. The profession must collectively shift how it presents itself — not to abandon holistic values, but to speak fluently in the language insurers, regulators, and legislators actually use.

Insurance does not pay for experiences. It pays for conditions.

Washington insurers did not start paying because therapists changed their hands-on work. They started paying because therapists changed how they documented and presented that work.

Words and phrases that need to retire: relaxation, stress relief, maintenance massage, wellness session, balancing energy, general wellbeing, holistic healing.

Words and phrases that get claims paid: functional limitation secondary to diagnosis, pain interference with activities of daily living, post-injury soft tissue mobilization, neuromuscular reeducation, documented musculoskeletal condition, medical necessity per referring physician.

Documentation must include ICD-10 coded diagnoses — the M54 series for spinal pain, M25 for joint pain, M79 for soft tissue disorders, M62 for muscle conditions, S-codes for injuries, G89 for chronic pain. Every claim must tie treatment to a diagnosable condition with functional goals and measurable progress. A physician referral or prescription must be on file. SOAP notes must support every billed unit.

This is not selling out. It is translation. The hands-on work does not change. The professional language around it does.

We need to get the CPT code for massage (97124) updated to reflect clinical massage and update the code for manual therapy (97140) to include massage therapists.

ANTICIPATING INSURER OBJECTIONS

Insurers will resist. They always have. Their resistance follows predictable patterns, and every advocate and therapist should have prepared responses.

When insurers say massage is not medically necessary, the response is that medical necessity is determined by the condition and the physician’s referral — not by the profession delivering treatment. Present the ICD-10 coded diagnosis, the physician prescription, the documented functional limitations, and the clinical guidelines naming massage therapy as a recommended intervention. The CDC opioid prescribing guidelines, the American College of Physicians low back pain guidelines, and the National Center for Complementary and Integrative Health evidence summaries all name massage therapy as evidence-supported.

When insurers claim insufficient evidence, cite the Cochrane reviews, NIH-funded research, and clinical practice guidelines that specifically recommend massage for low back pain, fibromyalgia, cancer-related pain, and post-surgical recovery. The evidence base is substantial. It has simply not been organized into a well-packaged advocacy document. That is a solvable problem.

When insurers raise ERISA preemption, acknowledge the limitation for self-insured plans honestly — then pivot to the plans the law does reach, and document every denial from ERISA plans for future federal advocacy.

When insurers argue that coverage will increase costs, present Washington State data showing that massage coverage with appropriate medical necessity requirements and visit limits did not produce runaway costs. The opioid cost-offset argument is particularly powerful: one avoided opioid prescription, one avoided emergency room visit, one avoided surgery pays for many massage therapy sessions. Coverage is risk reduction, not new expense. (See the AMTA report: American Massage Therapy Association. The Value and Efficacy of Massage Therapy in Integrated Health Care Available from: https://www.amtamassage.org/uploads/cms/documents/aca_book_final.pdf )

When insurers say they cannot credential massage therapists, present the existing infrastructure: state licensure requirements, NCBTMB board certification (although our Board Certification could use an update), the MBLEx national examination, CAQH ProView profiles, and professional liability insurance requirements. The infrastructure exists. What has been missing is organized presentation to insurer credentialing departments.

WHAT EVERY INDIVIDUAL THERAPIST CAN DO NOW

Structural reform is built from individual acts of professional engagement.

Start with your state law. Look up your state’s massage therapy licensing statute. Does it use health care provider language? Does your state have any provider nondiscrimination law? Visit your state insurance commissioner’s website. This is not optional — it is your professional foundation. Most massage therapists skip this step entirely, which is exactly why insurers get away with policies they legally should not.

Get credentialed even before you need it. Create a CAQH ProView profile. Apply to provider networks. Each application, even if denied, generates data about exclusion patterns that advocacy organizations can use.

Track functional outcomes with your clinical patients. Use validated outcome measures. Submit that data to the AMTA research database. The profession’s evidence base can only be built by practicing therapists.

Join your state AMTA chapter or better yet, start your own State Association as you will be able to do more. Attend state legislature health committee hearings. When your association issues a legislative action alert, respond to it. Political engagement at scale is how Washington’s law was won — not by associations alone, but by constituents showing up.

KEY LEGAL REFERENCES

Washington Every Category Law: RCW 48.43.045 https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.045

Washington Massage Therapy Health Care Definition: RCW 18.108 https://app.leg.wa.gov/rcw/default.aspx?cite=18.108

Regulatory Implementation: WAC 284-170-270 https://app.leg.wa.gov/wac/default.aspx?cite=284-170-270

Supreme Court ERISA Decision: Kentucky Assn. of Health Plans v. Miller (2003) https://www.law.cornell.edu/supct/html/00-1471.ZS.html

ACA Section 2706: 42 U.S.C. § 300gg-5

State Coverage Status Chart and Resources: https://www.massagepracticebuilder.com/massage-insurance-billing-resources/

History of Massage Therapy in Health Care: https://www.massagetherapynexus.com/history-of-massage-therapy-in-healthcare-2000-2024/

Insurance coverage for massage therapy is not a favor insurers will grant because they are persuaded. It is a legal right the profession must claim — methodically, state by state, with documented practice, strategic pressure, and professional maturity.

Washington opened the door in 1995. The Supreme Court cleared the legal path in 2003. The ACA added federal language in 2010. Every tool needed is already in place.

What happens next depends on whether the profession shows up for itself.