January 19, 2010

Uncertainty ahead for Indian health care, starting with Massachusetts election

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Op-ed by Mark Trahant

The Indian health system is stuck in a world of conditional sentences. That’s a sentence with the phrase, “if … then.” If Congress passes health care reform, then …

There are many variables based on a complex grid of “ifs.”

The most important conditional sentences involve the Indian Health Care Improvement Act. There are slightly different versions in both the House and Senate bills. If the House language is the one to prevail, “then” means one thing. But that meaning changes if it’s the Senate version, or even if it’s a merged bill.

One huge “if” is what happens if voters in Massachusetts say no to health care reform in general by electing the Republican candidate for Senate. “If Scott Brown wins,” Rep. Barney Frank, D-Mass., told the Associated Press, then “it’ll kill the health bill.” In that case, the “if … then,” is the 41st “no” vote when Senate rules require 60 votes for passage of the larger health care reform bill.

But even that is no sure thing. Senate leaders could try to move the bill before the new senator is sworn into office or the House could pass the Senate version without changes. There are many more “if … then” variations to ponder.

For example ABC News says there is the problem of time: “After a final health care deal is struck … it goes to the Congressional Budget Office (CBO) for a cost estimate, a process expected to take 10 days. After that, it will take at least seven days to pass the bill in the House and the Senate.” Or ABC News says there is also the possibility of “relying on the rules of reconciliation – which only require 50 votes for Senate passage – to move the measure to passage.”

The Indian Health Care Improvement Act would probably not survive reconciliation because the bill would have to be narrowed in its scope.

But one thing is certain: Health care reform will not end with passage or even the defeat of the bills in Congress.

That said: The Indian Health Care Improvement Act remains the key step for reform within IHS.

“I think passage of the Indian Health Care Improvement Act is going to especially important because of the symbolism of its passage,” said Yvette Roubideaux, M.D., M.P.H., director of the Indian Health Service in an interview earlier this month. “It’s an act that will reaffirm the government’s responsibility updating and modernizing the Indian Health Service.

Dr. Roubideaux says the Indian Health Care Improvement Act represents a collection of proposed changes for modernization. Some can be implemented quickly with existing dollars, while others will require more resources or new regulations.

“The good thing about passing the Indian Health Care Improvement Act is that it gets passed, and reauthorized, and sets the foundation for what we do over the next several years,” she said. “The challenge is that it’s just an authorization. A lot of the things that are in there may need additional resources and we’re not clear where and when those resources will come.”

Congress essentially works on two tracks. First, legislation authorizes spending, followed by a separate appropriations process to actually spend the money.

Dr. Roubideaux said there would be lots of “conversations” about additional resources. For example the original Indian Health Care Improvement Act authorized funds for scholarships, but the money wasn’t appropriated until two or three years later.

These days the competition for federal dollars within government, both in Congress and with other Executive Branch agencies, will be intense because of the general state of the federal budget and growing deficits. That said the IHS should get a fair share because of its historic under-funding (the president’s 2010 fiscal year budget increased IHS spending by 13 percent). The hope is the next budget, fiscal year 2011, will again increase more dollars for the Indian health system.

But the competition for increased resources will be made a lot easier if the Indian Health Care Improvement Act is passed and signed into law in the next few days or weeks.

Lots of ifs ahead.

Mark Trahant is an advisory board member of InvestigateWest and 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.

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