Editorial: We Made Our Table, Now We Have to Lie On It

Prepare to navigate the intricacies of massage therapy education with Cal Cates and myself, Corey Rivera, in a conversation that's vital for the future of massage schools. We're treading into the uncharted territory of curriculum overhauls, necessitated by the Gainful Employment Act's momentum. July 2024 inches closer, and with it, the deadline for schools to meet the stringent 100% rule looms large. We'll be examining what these transformations mean for federal funding, the ongoing discourse around a standardized 625-hour training program, and the prospect of a two-tier licensure system that could redefine our profession.

The financial landscape for massage therapists can be as complex as the human body itself. We peel back the layers of IRS reporting, income misconceptions, and the stark realities of cash-based earnings in our field. Our candid discussion illuminates the struggles with underreported income and deciphers the myths that often cloud the true earning potential within our industry. We're not just talking about the dollars and cents; we're scrutinizing the impact of federal legislation on educational paths and how it shapes the aspirations and career sustainability for those who enter this trade with passion and purpose.

But passion alone doesn't pay the bills. The nobility of any profession is not measured by financial struggle, and we're dissecting the politics that shape our regulatory landscape. We're also addressing the burnout that threatens our ranks, pondering whether it's the physical toll or the relentless financial hustle that wears us down. And we're not stopping there. Our conversation extends an invitation to join us in reimagining healthcare through Healwell's mission and to lend your voice to this critical dialogue. Your insights are the heartbeat of our community, so tune in, engage, and be a part of the change we're striving to make.

Note: at about 15 minutes, Corey says "$40 an hour" when she really meant "40 hours a week." Oops!
US Bureau of Labor Statistics: Massage Therapy
Inside Higher Ed: Gainful Employment Proves Contentious, Again

Chapters

• 1:11 Gainful Employment Recap
• 3:00 Kudos to Massage Schools
• 5:35 Public Safety
• 10:19 The Earnings Premium
• 15:45 Trade Loans for Trade Schools?
• 18:09 Doing What You Love...
• 21:16 Lifting the Boats
• 25:17 People Aren't Healthy
• 27:27 Tell Us Your Feelings

Transcript

Corey Rivera: 0:44

Welcome to the Rub, a podcast about massage therapy. We say the quiet things loud have a hunger for change and a desire to connect the dots. I'm your host, corey Rivera, and in this episode, cal Cates, executive Director of Hewell, and I have a say the quiet things loud conversation about gainful employment In the description of the show. We promised we had opinions and here they are Okay. So to recap just a little bit, the Gainful Employment Act, which is a 700-page document so if you want to read it, man good on you has two provisions in it that are going to affect massage therapy schools. The first provision that we're most worried about is the 150% rule going down to 100%, which means if schools have a program that is longer than the minimum specified by their state, they will no longer get federal funding period dot for their program. An estimated 350 out of 1000 massage therapy schools will be affected by this, and it starts in July 2024. So, in order to comply, all of those schools that are affected will have to redo their entire curriculum, and that's a lot of work. It's a lot of work, so much work. So this is worrisome for all of us.

Corey Rivera: 2:08

The second part that you should know about are rules that come into effect a little bit later and they are that a school. So when you graduate from a school, all of your students or most of your students must meet two metrics. The first metric is an earnings premium, so a student must earn more money than they would if they only had a high school diploma specific to their state. The second one is called debt to earnings. It means that students can afford to pay back their student loans, and there's a whole equation for that. We're not going to go into the math, because nobody wants to listen to math, certainly not me. I have no idea how many schools will be affected by this. I don't think anybody knows as far as massage therapy schools go, but I can tell you it's not zero For sure. So starting from that wonderful point of view Calcates what you got for me.

Cal Cates: 3:00

Oh man, the first thing I want to do is sort of, on some really deep level, hats off to what we often call mom and pop even though that's a heteronormative way to describe it massage schools People who, as you were saying in the interview with Lance, who started a massage school because they love massage and they want to transmit that love to people who also think that they want to do massage therapy. I think so many people who enter into work inspired by a passion for something, you get into it and you go, oh gosh, okay, this is like a lot bigger than I realized and sort of there are regulations and requirements and competency and things that I think when you said about doing something like this, I'm sure that there are many people who were like, okay, so to start a massage school, here are all the steps. But I think a lot of people are just like I just wanna do this thing, I love and share it with other people and you know. So. I wanna start with that, because I do want to recognize the incredible lift that is being asked or that is asked of you when you engage in a secondary education endeavor as, like, the person who's gonna run that school, because the next thing I wanna say is like we have known about this for decades and now it's an emergency because we just kept thinking that we've kind of live in our own world as massage therapy and as massage therapy educators. And to you know, I see out on the discussion groups and stuff, massage therapists being like you know why are they targeting us? And I'm so glad that Lance addressed like this isn't about massage schools, it's about secondary education, like sort of trade schools, and so we fall under this umbrella. We're not the only type of education that is also now scrambling.

Cal Cates: 4:58

But I think that as I continue to think through you know one of ABMPs, I think well-founded points of resistance about this is the idea that there are people who go into massage as a hobby or as a side gig, and to me that screams two-tier licensure. To me that's the further encouragement for great. I don't wanna dissuade people from getting training to do massage as a hobby or as a side thing, and consumers don't know what they don't know and massage therapists for sure don't know what they don't know. So when we talk about this 150 hour rule and you know again, lance really smartly described that the law of licensure is about public safety. It is about I want you to be real, unlikely to hurt anybody. I don't care if you're good at this job, but I want you to not hurt anybody.

Cal Cates: 5:58

And for too long, I think, massage therapy has been willing to hold that as its bar. I mean even the. You know, the Veterans Administration created a federal job code for massage therapists a handful of years ago, and so, working with veterans who kind of by definition, if you're getting healthcare through the Veterans Administration, you are likely living with chronic and or serious illness, but the massage therapists who might be touching you through those VA sponsored programs is only required to have 500 hours of training, with nothing specific to serious illness or the common conditions and complications of veterans' healthcare. And so I feel like I hope this will be a wake up call for the profession and I've been in the profession almost 20 years and I it would it would be a major sea change for the profession to actually go oh, you're right, this is ours to fix and then actually set about fixing it.

Corey Rivera: 6:59

So I would like to point out that for over 10 years we've been talking about a 625 hour program standardization for over 10 years and we have not done it, we have not standardized it, we have not demanded it of anybody. We just checked that little box and said cool, and moved on and now we're in trouble. So Again, kind of did this to ourselves, people. So I would like to make the point very clear that this is not a massage school problem. This is a massage problem. We are all responsible. It's all of us. We are all responsible to fix it and talk about it and yell about it and make some actual changes where those schools are going to close.

Corey Rivera: 7:49

And we already have a deficit in our workforce here COVID, it was, I think, a 4% drop just from that and replacing those people is really difficult. That's a lot of knowledge that just left the field. Our burnout rate is relatively high. I'm not going to say it's statistic because I'm still tracking that down and when I have it, you listeners will be the first to know. But it's not good, it's not good. So people go into this profession and then they leave this profession and then they're just aren't enough for us to do this work.

Cal Cates: 8:25

So, yeah, I think this workforce piece is really huge and that you know. I mean I think at Heal Well we're talking about how a well trained massage therapy workforce and you know if you have spent five minutes with anyone from Heal Well, you know that that means probably actually more than 625 hours. But you know, again, we're talking about but in seat hours. We're not talking about like so what's in those hours, and I think there is still some pretty good variability there. But people massage therapists need to start behaving like and thinking of themselves as part of the healthcare workforce.

Cal Cates: 9:03

And you can't open a newspaper or open your computer, wherever you get your news, without seeing something about America's healthcare system being crunched by a workforce shortage nursing, doctors, pts, ots, et cetera across the board. There aren't enough people providing healthcare, and massage therapists, I think, generally say like oh well, that's not me, you know, I'm not going to replace a nurse. No, you were not. But there are things that you could be doing that could take some of the burden off nurses in the chain of healthcare. That could even take some of the burden off physicians and other providers If we could make good referrals, if we could spot early signs of disease.

Cal Cates: 9:39

If we could do things that we're simply not trained to do, we could be a part of taking some of the stress off the large workforce issue. But if we lose a third of our schools that already in many ways aren't meeting the standard I mean even the schools that will escape this ruling it doesn't mean that those schools are knocking it out of the park. And I think that comes back to your point, corey, that this isn't about. This is a massage profession issue. This is a broad massage issue. Certainly, schools are a big part of that, but as a profession we've got to get serious and we've never been good at that.

Corey Rivera: 10:19

So I want to dive into this earnings premium rule that students must earn more money than they would if they only had a high school diploma. Because we're not going to pass that and there's a bunch of reasons we're not going to pass that. So I know, I just said that I wasn't going to do audio math, but we're going to do. We're going to do just a little bit of numbers, I'm sorry. So gross income, according to AMTA 2023 profession report, is $32,000 a year on average. That's gross. It's not net, right. So that's it is gross. In many definitions it is indeed gross. So if you break that down hourly, it is $16 an hour for a 40 hour work week. And you and I know and everybody in massage knows, but apparently nobody outside of massage knows that you cannot work a 40 hour work week as a massage therapist. You will die, your hands will break, your legs will break, your soul will break, you will be crushed. You can't do it. But not only is the physical toll on your body far too high, but the mental toll of concentrating on one person for 60 minutes and I don't know for all of you who are not massage therapists, please do an experiment and concentrate on a single human for 60 minutes in your life. Just set that timer and focus on them and please notice how absolutely exhausted you are after about 10 minutes. It's hard. So a standard massage therapy work week is 20 hours of hands on time. That falls out to about $32 an hour. I would also like to note that it's so gross.

Corey Rivera: 11:57

Additionally, most massage therapists do not get paid for the work they do. That is not hands on. That includes cleaning your room. That includes changing your sheets, if you own your own business, trust me. That does not include doing the laundry, which is a lot of your time. It doesn't include any of the notes that you do. It doesn't include any of the phone calls you make. None of it. It is only your hands on time. I promise you work more than 20 hours altogether. The reporting for this earnings premium is going to come specifically and preferably from the IRS, so this bill will take into account IRS reporting and Cal. What would you say is the problem with IRS reporting and massage therapists?

Cal Cates: 12:44

Yeah Well, and I think I mean. The simple problem, of course, is that many massage therapists don't report a good chunk of their income because it is cash income and or tips which they don't make enough money in the first place, so of course they don't report.

Cal Cates: 12:57

This leads me to the second point, which is this issue of it not being a sustainable career. And so they are sort of backed into a corner, which one of the things that many of the advocates for this rule say that it will result in better informed students who enter educational programs with an understanding of what they will earn post graduation and how they will pay off student loans. And I will say that in talking with I mean, I went to massage school almost 20 years ago. I don't remember anyone that I remember them saying, like, can you pay this tuition? But no one throughout my schooling said you know, you're not actually going to make like, let's say, the going rate, because I think this is what people do.

Cal Cates: 13:35

They go to massage school and they say, okay, my aunt gets massages and she pays $90 for a massage.

Cal Cates: 13:41

If I do 40 massages a week for $90, I'm going to be rich, right? No one said to me throughout my whole massage, even in the business class where they told me how to do my taxes, they didn't say like, oh, I don't know what kind of calculus you're using, but just FYI, you're probably not going to, you're not going to do $40, $90 per massages and, to be safe, you're going to do like 40% of that is going to, you're just going to pay it in taxes just to like cover yourself. And here's how you do those taxes. Like I think that massage therapy and this may be true in cosmetology and other sort of trade schools which are getting discussed in the articles about this legislation people go into these professions trades with unrealistic expectations about their income potential and no one in the know disabuses them of those assumptions, and I would like to add that some people in the know don't disabuse them of this notion, specifically the Bureau of Labor Statistics.

Corey Rivera: 14:44

Yes, so reporting for this particular gainful employment thing will not come from the Bureau of Labor Statistics, but I do think that people, when they look up massage careers, go or end up at that website and they're like how much money does a massage therapist make? And there are codes and there are listings and there's data collected and the data collected says that massage therapists make $23.97 an hour, which I think is probably fair to say that that's it's not far off. However, the Bureau of Labor Statistics, in order to get you an annual number, just multiplies that by $40 an hour, so it tells you that you're going to make $49,000 as a massage therapist year. Because they also don't know that that's not possible. You can't do that.

Cal Cates: 15:34

Well, and let's also be honest about how far you get in this country on $49,000. I mean, even if that's post tax, that's a rough life, yeah Well, and another thing I want to make sure that we don't miss is that in some of the reading that I've done about this, robert Scheierman, who has been instrumental in changing the landscape of like predatory, for-profit secondary education and how those loans and how that payment goes, like really protecting students Are you hearing this cat? Just like cat or walling? Oh, no.

Cal Cates: 16:11

So Robert Scheierman, who has been, since the early 2000s, instrumental in ending predatory, for-profit secondary education practices and really protecting students and looking at tuition structures and things like that, he is kind of the main architect of this, the original version of this that came out with the Obama administration. But he says that he doesn't feel like it makes sense for students to use federal loans at places like cosmetology schools, and I think that this is I think we would be lumped into that and I think I think so An interesting point that I mean now. So Robert Scheierman has never had a trade job. He has a bachelor's degree in economics from UC Berkeley, a master's in education from Harvard and a master's in public administration from UC San Francisco, so he's never, even maybe, been at a trade school. But what does that do to the labor sector and to the quality of what people are receiving from these service providers if we say this education no longer really qualifies for federal loan support?

Corey Rivera: 17:21

So that's saying that it isn't deserving of federal loan support.

Cal Cates: 17:25

Correct. He thinks that they would be better funded through job training programs. And that again takes us back to this place of like. Maybe, but this is where massage has allowed itself to exist in this liminal space of like. Are we rubbers, or are we healthcare providers with a complex set of knowledge practicing a discipline? Back to this question. I think we continue to come back. Our associations and our education standards continue to put the check squarely in the box of we are rubbers, we are people who have hands that rub muscles and people feel better after we do that. And if we're not going to advocate for our own advanced training standards, nobody outside is going to do it.

Corey Rivera: 18:10

No no, they're not so in that sort of vein of not being worth federal funding, which I'm still kind of trying to have rent my head around, actually. Yeah, there is another argument that I have read, mostly from Cosmetology. Who, by the way, is the trade that is going to get hit the hardest by this?

Corey Rivera: 18:31

Yeah yeah, Like hard, hard hits. But there was a sort of conversation that was like you can't prevent people from doing things that they love, and I think this is a really good place to talk about the phrase doing the thing that you love and how many problems I have with that phrase. So as a millennial, I was raised to believe that you must do the thing that you love and that you are a failure if you do not Literally like, if you don't love your job and find passion in your job and do the thing that just makes you so happy inside and makes you feel like you're changing the world and you have failed in your career period.

Cal Cates: 19:17

As a human.

Corey Rivera: 19:19

As a human. You have failed.

Cal Cates: 19:21

Correct.

Corey Rivera: 19:22

So that was something that was fed to me from essentially day one, like kindergarten. That that was the message, and that message has allowed a lot of capitalist capitalists, capitalists, constructions shall we say yes To extort a lot of people, because if you are doing it, because you love it, it's a really great reason for me not to pay you for it, regardless of how good you are at it, regardless of how much money you make me, regardless of the effect you might be having, regardless of anything. If you love it, why would you bring money into the equation?

Cal Cates: 20:01

Well, and if you really love it, you will pay me. Whatever I ask you to pay me to teach you how to do it.

Corey Rivera: 20:06

Absolutely, absolutely.

Cal Cates: 20:09

Yeah Well, I think this is that one of the things that makes me unpopular sometimes is that you know this points directly to this idea we have in massage therapy. There's almost sort of martyrdom, that like because we're suffering because we live on the edges in this underpaid sub world we are. You know it's a sacred, it's sacred work that we're doing and that you know we conjure images of Mother Teresa and you know destitution and that if we made a real living as massage therapists somehow we would be just as craven as the rest, and that you know this is, this is the mark of how I know that I'm doing. Something I love is that I can't always pay my bills and hope that the IRS is too busy to audit me.

Corey Rivera: 20:51

And need to ban food stamps and perhaps have two other jobs and can't feed my family and can't pay back my student loans and like have to deal with things like creditors, like Sally May who are pretty vicious, like all of those things roll together to make what I'm doing so special that I can't have a life because I'm doing it.

Cal Cates: 21:17

Well, and this is where I think it's also interesting that you know Lance was talking about Congress and Smucker and how he is trying to fight this change from the 150 to 100 percent rule and that probably his fight will be futile because of the current divisive nature of politics in our country.

Cal Cates: 21:33

And you know, I think we do a decent job of well, I don't know, we don't get into politics, we just say the things.

Cal Cates: 21:41

But if you think that voting doesn't matter, as a massage therapist like this is, this is what we are watching right now is actually, I mean, you know, I think you and Lance explored a little bit the what the Biden administration has done to try to really like lessen the burden of secondary education debt and to really look at consumer protections, and you know, things that were rolled back by the previous administration and that tend to get rolled back by Republican administrations that like to lift regulations.

Cal Cates: 22:11

But we are, we are hustling to make a living, we need someone looking out for us, and so you know, some of the people who are pushing back against this rule is sort of broadly are saying, well, this just came out of nowhere and it's like, but it didn't, it was actually rolling and then the Trump administration said we're not going to do this, people have to take care of themselves. And Biden was like, wow, this is going to mess up, like you know. I think you really laid it out when you talk to Lance about this is bad for all of us If we let this continue. It is bad for all of us. And what will? Will massage therapy be able to get its eye on the ball and use this to tighten the ship and to lift all the boats?

Corey Rivera: 22:56

I have a boat. I would like it lifted.

Cal Cates: 22:58

Yes, my boat could use some lifting as well. Well, and I do feel like you can do massage as a hobby without going to massage school and that if we're talking about a 625 hour, I would argue that 625 hours is the baseline. If you want to do massage as a semi-organized hobby, you need that much training. If you want to go out and massage Americans who are living with chronic and serious illness and who are really needing you to know more than you're gonna learn in 500 hours or even maybe 625 hours, you need maybe a thousand hours, 1500 hours. You need to have some clinical rotations.

Cal Cates: 23:39

Like you know, physicians, people go to medical school and they say, oh, I'm gonna be an obstetrician. They still have to do a hospice rotation, they still have to do a gastro rotation. They learn about all these different things and in massage we just don't. We don't have any of that kind of exposure, so we just do what we can do to hustle to pay these loans. And then what? What's the latest five years is what people is how people last in the massage profession.

Corey Rivera: 24:04

Quote-unquote still still looking it up, still trying to get that number pinned down. But yes, five is what everybody at least reports and everybody says, oh, people blow their thumbs out.

Cal Cates: 24:14

Yes, that part of it. I mean sometimes wear and tear, but it's I would. I would imagine that it is just as much about wow, this is too much of a hustle for me. I could work much less hard and make at least this much money, possibly more, and that's what people decide to do, because they do have to pay their bills.

Cal Cates: 24:34

The other thing that I think is interesting in this is that our profession thinks it's ready, right, massage thinks it's ready for what. Ready for what? And and maybe this is the crux of the problem right, you can do countless different things and countless different settings as a massage therapist. As Lance said, if you, if you only want to do it as a hobby, you need to know XYZ. But honestly, the illusion we hold that the setting where you do massage determines what you need to know and be able to do continues to cloud our conversations about what's necessary from an education standpoint. People say, oh well, I only plan to work in a spa with healthy people. Mm-hmm, I, you are all probably tired of hearing me say it. I get tired of hearing myself say it.

Corey Rivera: 25:20

People aren't healthy and you can't tell by looking at them if they are healthy so and they're probably not gonna tell you if they think you're not gonna give them a massage exactly and if they think that you don't know what to do with that information.

Cal Cates: 25:34

You know, I mean if, if we this is like you know you don't massage people in the first trimester so you don't get sued. We have no data that shows that actually, massage in the first trimester results in miscarriages. That's just when miscarriages happen. You don't want to be the last guy in the room, but if I understand that, then I can explain to someone who has maybe heard that wives tale. This is, this is why this is in place, and it actually doesn't scientifically hold water.

Cal Cates: 26:00

Someone comes in says oh you know, I recently learned that I have diabetes. Okay, as a massage therapist, here are some additional questions I might ask you. But most massage therapists, I think we go oh, my uncle has diabetes, cool, get on the table. And not that you don't want them to get on the table, they can still have a massage. But we have not put ourselves out there as trusted providers who can integrate medical information in a useful way. That allows us to be another resource and I think this is this is the thing that we keep saying is that well, if I'm only gonna quote work with this population, I don't need to know about the human body that much, and I don't, I can't get behind that on a personal note saying that I don't want to know about anything just doesn't make sense to me as a information magpie who would like to know everything all of the time.

Corey Rivera: 26:57

I mean just yeah, struggle. But I understand that, like school, is a daunting prospect for a lot of people. I think particularly people who are drawn to massage therapy have had real terrible experiences. Yes, informalized education situations, and I can understand why. Looking at a 750-hour program you'd be like, but why?

Corey Rivera: 27:17

yeah yeah, but that's kind of how it is. So, yeah, if this episode gave you all kinds of feelings, awesome, you can tell us about them by emailing us at podcast at hewellorg, or joining us in the Heelwell online community at communityheelwellorg, or by leaving us a review on Apple podcasts. We look forward to sharing this conversation with you. Thank you for listening. Heelwell is a 501c3 nonprofit organization, and so you could support our work and support the revolution and change healthcare for everybody by donating to Heelwell.