Indian health care

It’s amazing how fast a year goes by. Last May, when I met with the selection committee for the Kaiser Media Fellowship, I outlined my project. Several folks on the committee said I shouldn’t wait until fall to begin. The health care reform debate might be over by then – or so we thought.

Of course it didn’t work out that way. My year as a Kaiser Fellow has been amazing because it’s paralleled so much of the legislative debate. I started writing columns (or blog posts, depending on your point of view) on July 6, 2009.

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. And, now a different kind of debate begins. Federal agencies, primarily at the Department of Health and Human Services and Treasury are writing regulations to implement the new law. There will be fights over words like “quality” or how we define and measure success.

Heck, the government cannot even talk about the law without generating controversy. Republican Senate leader Mitch McConnell called a new Medicare brochure little more than propaganda. “The flyer purports to inform seniors about what the health care bill would mean for them. Much of it directly contradicts what the administration’s own experts have said about the law,” McConnell said. “So this is a complete outrage, and it’s precisely the kind of thing Americans are so angry about at the moment.”

This is simple math: Health care equals jobs. And the new health care reform law means even more jobs. In many communities across the United States, the health care industry is the region’s top employer. Indeed, if you put this in a global perspective, the National Health Service in the United Kingdom now employs 1 in every 23 workers in that country, some 1.3 million people. (The NHS is the third largest employer in the world, only ranking behind the Chinese army and India Rail.)

The numbers in Indian Country show that same kind of growth. Look at the figures before President Johnson’s Great Society (and the expansion of federal programs):  The Bureau of Indian Affairs employed 16,035 full time employees in 1969, while the Indian Health Service employed 5,740 people. That trend is now reversed. In 2009 the BIA employed 8,257 full time workers and the IHS had grown to 15,127 employees. These are just the number of federal employees, because tribes or organizations administer roughly half of the Indian health system.

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The demand for health care workers in Indian Country represents a public policy paradox: We need jobs in communities where the official unemployment rate is about 50 percent and yet the Indian Health Service reports shortages of health professionals.

The IHS describes its employment situation this way:

“The physician vacancy rate now stands at approximately 21%, and the average length of service of the approximately 800 federally employed physicians in Indian health is 10 years.

Congress passed the health care reform legislation – and President Barack Obama signed the bill into law. The Indian Health Care Improvement Act was included – and now we can put this debate to rest. Right?

Actually no. There are many more debates about health care reform to come – probably for years – and much work remains before this law can be implemented.

“Opponents will continue, and probably intensify,their opposition. They have promised legal challenges and arelikely to seek repeal of all or part of the legislation. Moreover,formidable implementation hurdles must be surmounted if healthcare reform is to achieve its goals,” Henry J. Aaron, Ph.D., and Robert D. Reischauer, Ph.D., recently wrote in the New England Journal of Medicine’s Health Care Reform Center blog. “On the political front, Republicans unanimously opposed thefinal bill in both the House and the Senate. They have expressedoutrage at the Democratic leadership’s decision to “ram through”reform using budget reconciliation to modify the Senate-passedbill sufficiently to make it acceptable to the House. The outrageis baseless, but the fury is real and will poison future debate.”

On top of that fury there are thousands of pages of federal regulations – words that will define complicated ideas like “quality” in the legislation – that still must be written and debated in draft form, before they can be implemented. And, as I’ve written before, this bill is only authorizing legislation. The appropriations process is on a different track that requires congressional action before some of the new ideas can be implemented.

Op-ed by Mark Trahant

President Barack Obama answered an important philosophical question last week: How will the federal government fully fund a starved Indian health system?

The answer is budget by budget: The administration boosted spending by 13 percent in fiscal year 2010 and is proposing another 9 percent increase for 2011. But this budget does not resolve the contradiction between “historic underfunding” and the larger reality about federal spending. The proposed budget calls for $5.4 billion in spending for Indian health care, ranging from clinical services to facility maintenance and construction. (The bulk of that money, $4.4 billion would be from appropriations, the rest comes from health insurance collections and special grants.)

HHS Secretary Kathleen Sebelius said: “Our budget also contains a significant increase in funds for the Indian Health Service as we continue to work to eliminate health disparities. It is the principle that we are trying to establish in our healthcare system – that regardless of race, ethnicity, gender or geography every American deserves high quality and affordable care.”

But while spending on Indian health is increasing – is it growing fast enough to catch up? There remains a significant gap between what is spent on an American Indian/Alaska Native patient than a federal prisoner, $2,130 per person versus $3,985. One measure used by the federal government is a benchmark based on spending for federal employees. The Indian Health Service is currently appropriated about 55 percent of that standard on per person basis.

Indeed, last April a tribal task force recommended a $2.1 billion increase in the budget authority for IHS in fy 2011. The tribal leaders called for a ten-year phase in of $21.2 billion to reach spending parity.

Op-ed by Mark Trahant

Perhaps one reason why the massive health care reform legislation is in so much trouble is that few people understand the details. The bill is massive, complicated, packed with official government jargon and so many specifics were kicked forward to regulators at some future point (such as figuring out the real Medicare cost reductions or definitions of basic terms such as “quality”). On top of that, there was confusion about the nuts and bolts of what program was in, and what was out. Essentially it was a secret process, except when there were leaks over specific proposals.

The bill followed the time-honored way of legislating. A senator says, “yes” after the bill is sweetened. Then another senator is wooed. And another until a super majority is found and the bill itself is hardly identifiable. Political horse-trading is one of the reasons people are angry about health care reform (as well – and this is important – a genuine debate about the role of government). It looks unfair and unseemly.

But does it have to be that way in the 21^st century? Can legislation or policy be forged in an open and transparent manner? This won’t resolve the debate about philosophy, but at least it allows people to have a say all through the process.

I think this is the way forward – and I’d like to see Congress, the Executive Branch and the Indian Health Service all have clear social media strategies that harness the power of an individual to help shape a larger mission.

This is not a new concept. The United Kingdom’s National Health Service is trying to harness social movement ideals.

Op-ed by Mark Trahant

I started my exploration of health care reform in July.

“The federal government accepts a double standard: Any discussion about rationing – or government care – is off the table unless you’re a member of an American Indian tribe or Alaskan Native community with a sort of pre-paid insurance program (many treaties, executive orders and laws were specific in making American Indian health care a United States’ obligation),” I wrote back then.

Six months later – or half way into this project – I am struck by how Indian Country is both a part of the health care debate and yet absent from its larger discussion.

We’re part of the conversation every time critics blast the Indian Health Service as a failure of government. We’re also included in the larger reform measure – the Indian Health Care Improvement Act – was added to the larger bill. That’s a good thing because this bill (unlike the original) has been awfully difficult to move through the Congress.

But we’re absent from the conversation because neither the Congress nor the Executive Branch has articulated what lessons can be learned from the history and experience of the Indian health system as it applies to the larger issue of health reform. It’s particularly frustrating to watch the politicians who are quick to point out the weaknesses of that system even though they have never proposed adequate funding or the dreaded idea of rationing.

Consider how the money question goes beyond Indian Country: If the federal government can’t deliver on this one, relatively small promise, how is it going to make good on remaking one-sixth of the economy in a few thousand pages of legislation?

Op-ed by Mark Trahant

A generation ago Indian Country wasn’t included in the conversation about health care reform. When Congress enacted Medicaid and Medicare it pretended that the Indian Health Service didn’t exist. It was as if it had never occurred to the government, that it, too, ran a major health care delivery system.

Say what you like about health care reform, the fact is that Indian Country is included in a big way this time around. If either the House or the Senate bill becomes law, there will be a significant boost in resources for the Indian Health system.

The largest single line item is the reauthorization of the Indian Health Care Improvement Act, included in H.R. 3962, the Affordable Health Care for America Act. The Congressional Budget Office “scores” the cost at $100 million through 2014 and $200 million over a decade. Most of that cost is attributed to the “expansion of payments under Medicare.” This is important because American Indians and Alaskan Natives have the highest percentage of any population over 65 not currently enrolled in Medicare programs.

But the bigger ticket is the expansion of eligibility for Medicaid and the Children’s Health Insurance Program.