A celebration of the Indian Health Service in 1992.

[imgcontainer right] [img:IHS6496.jpg] [source]Indian Health Service[/source] A celebration of the Indian Health Service in 1992. [/imgcontainer]

A year goes by fast. Way too fast. Thirteen months ago I plunged into an exploration of the Indian health system. It’s been fascinating because there has been so much activity: Congress enacted the Patient Protection and Affordable Care Act and included with that bill the permanent authorization of the Indian Health Care Improvement Act.

I explored two basic questions. First, what lessons from the Indian Health Service ought to be part of the national health care reform debate? And, second, what is the impact of health care reform on the Indian Health system?

In some ways the first question is the more difficult because of its complexity. The “story” of the Indian Health Service told in Congress and by news organizations is primarily a recounting of how the government runs a health care delivery system.

Sometimes that story conveys a positive message.

“It may come as a shock to many that when I compare the private insurance industry to the Indian Health Service, VA, Medicare and Medicaid, it is the private insurance industry that is the worst,” writes Dr. Richard Anderson in the Cody Enterprise. “The reason for this is that when compared to government agencies, insurance companies are not in the business of providing health care benefits as much as the denial of such benefits to make a profit for shareholders. That’s why government agencies have much lower overhead and are more efficient in delivering services.” 

Far more often, however, the story is about how government fails as a provider. For example, a recent post on KevinMd.com: “So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.” 

What’s interesting to me about both these posts is that they were written after Congress enacted health care reform legislation. We’re still fighting over a law that already passed and will be impossible to repeal until at least 2012.

But these narratives – Indian Health as a single-payer success or failure – miss the complexity. It’s hard to find many news stories that describe the role of Indian Health Service as a partner and funder of tribal, non-profit and urban health care organizations, even though those costs take up more than half the IHS budget.

I would change the name of the Indian Health Service. It’s no longer a “service.” It’s a system. And in the coming decades I believe the IHS will provide even fewer direct health care services, while continuing to grow in areas associated with funding or the support of medical innovation and practices.

So what are some lessons from the Indian Health System that ought to be a part of the national health care reform debate? Three quick ones: 

 A demonstration of what it takes to support and operate a rural health network, even in remote locations, using practices such as telemedicine;

 Early implementation of an electronic record system for patients, experience and information that will be valuable as other providers move away from paper records;

 A search for a financial model that is frugal, yet fully funded. Neither the IHS (nor any private or government provider) has discovered the right balance. Not yet, anyway. 

Perhaps the most important lesson can be found in the Indian Health system’s experience with the care and management of chronic diseases, especially diabetes.

Diabetes is the most expensive disease in America. It’s the fifth leading cause of death, surpassing AIDS and breast cancer combined. It represents nearly a quarter of all hospital spending and as much as one out of every five health care dollars. [imgcontainer left] [img:IHS0002.jpg] [source]Indian Health Service[/source] The waiting room is the common experience for everyone seeking health care. Under the health reform law, however, patients will be able to choose between IHS clinics and those in the private sector, paid for by Medicaid. [/imgcontainer]

American Indians and Alaska Natives are three times more likely to have diabetes than are Whites  — and four times more likely to die as a result.

Because of these grim statistics, the Indian Health system has much practical experience in disease management. For example, the Special Diabetes Program for Indians supports community-directed programs, ranging from increased training to “best practices.” Over the decade the program reports a reduction in mean blood sugar levels of 13 percent in IHS patients as well as reduced LDL (or bad) cholesterol and significant reductions in protein in urine (a sign of kidney dysfunction). There are also promising statistics on fewer cases of end-stage kidney disease and other complications.

Indian Country’s experiences could be helpful in the nationwide effort to reduce diabetes, showing the importance of education and community-based efforts. 

Ten Years After

What will the Indian health system look like a decade from now?

That’s a tough one to answer. Potentially, a court ruling will strike down at least part of the Patient Protection and Affordable Care Act. And, there is always the possibility that Congress will rewrite the law — a remote possibility since a new law would require 60 votes in the Senate.

But in the meantime there is a new foundation already under construction. The building that will rest on that structure will not be the same as the one in place now.

Let’s start with the patient. Right now, nearly half of all American Indians and Alaska Natives are either uninsured or rely solely on the Indian Health Service.

Health care reform changes that. Beginning in four years, hundreds of thousands of people will become eligible for insurance through government programs, such as Medicaid, because of new income rules. This insurance can be used to pay for services at Indian health system facilities or at competing health care centers. People will have new choices

Another huge change is that states have more at stake than ever in the success of the Indian health system.

Let’s start with the premise that everyone who should be covered by these government insurance programs will be. (I know it’s a leap.) If a Native American patient goes into an IHS facility with that Medicaid card, then the state is reimbursed with a 100 percent match. Covering that patient does not cost the state.[imgcontainer right] [img:Navajo_hosp_Shiprock.jpg] [source]Indian Health Service[/source] The Navajo hospital in Shiprock, Arizona. [/imgcontainer]

If that same patient goes to, say, a for-profit clinic outside of the Indian health system, however, then the state must pay its share of the Medicaid costs, just as it would for any other citizen. The amount of state funding is relatively small between 2014 and 2019 – the state’s share is more than $21 billion out of the estimated $447 billion Medicaid pie – but the costs down the road are significant.

The point here is that state governments are now full partners in the Indian health system and have a financial interest in making the system work better. The more attractive the system is to Native patients, the less the state will be paying through Medicaid for private services.

There needs to be a full public education program, explaining to patients how they can be part of the Indian health system solution because, if all of this works as planned, the increases in Medicaid participation should add real money to the Indian health system.

What else will change over the next decade? 

Health care reforms will likely speed up the shift from IHS direct services to clinics and hospitals run by tribes, urban organizations and other non-profits. A few years ago the economic equation for contracting for IHS services was so-so. And that’s still true – if you only count IHS money. But there are other players ranging from Medicaid to funds designated for rural and community health clinics. These new sources of revenue tip the advantage – I think significantly – toward independent, tribally sponsored health enterprises.

This change, too, has profound implications for the Indian Health Service. The IHS is Indian Country’s largest single employer, with more than 15,000 employees. A generation from now that number is likely to shrink as funding is directed at tribal governments and other organizations. Yet the IHS role will remain critical – particularly in the sharing of medical information, best practices and standards.

What will the Indian health system look like a decade from now? I’m optimistic about the answer, but it really depends on the creativity and innovation that comes from Indian Country. The answer is up to all of us.

Mark Trahant has spent the past year as a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. His new book is “The Last Great Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest Gerard.

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