Indian Health Care Improvement Act

Op-ed by Mark Trahant

What is the business model for the Indian health system?

On the surface this is a preposterous question because the U.S. government promised to fund the health care needs for American Indians and Alaskan Natives. It’s also supposed to be a simple business: Congress funds the system (the Indian Health Service, tribal contract facilities and urban programs), the agency spends that budget, and patients are treated.

But that’s why the question is not outlandish. The Indian health system has never had enough money – and therefore it’s essential to secure as many resources as possible in order to effectively treat the most patients.

“As we look at the Indian Health Service, we need to think of it as a business,” said Yvette Roubideaux, M.D., director of the Indian Health Service. “A lot of people think of the Indian Health Service as a service. It’s a service that provides health care to American Indians and Alaskan Natives. People who work in IHS think of their positions not just as jobs, but also as something important personally. Many people feel like they are on a mission working for the Indian Health Service – and I think that’s great. But I also think we have to recognize that we are a health care system – and that we’re a business. We have to look at how we run our organization, to improve the way we do business.”

Roubideaux calls this “Internal IHS Reform.” She began the business case by gathering data, listening to tribes and IHS employees.

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.

Op-Ed By Mark Trahant

More than twenty years ago the BBC captured the essence of bureaucracy in a sitcom called, “Yes, Minister.” The basic plot was that the Minister for Administrative Affairs, Jim Hacker, would come up with an idea – sometimes wonderful, sometimes odd – only to have its implementation sidetracked by civil servants.

Hacker’s nemesis, Sir Humphrey Appleby, once described his task as “the traditional allocation of executive responsibilities has always been so determined as to liberate the ministerial incumbent from the administrative minutiae by devolving the managerial functions to those whose experience and qualifications have better formed them for the performance of such humble offices, thereby releasing their political overlords for the more onerous duties and profound deliberations which are the inevitable concomitant of their exalted position.”

Of course bureaucracy in the United States is different. Our civil servants have far less power than they do in the United Kingdom.

By Mark Trahant
You hear a lot about grandma now that Congress is back to work on health care reform legislation.

"Poor old grandma" is a reason opponents say they will fight health care reform. Grandma will lose services, her Medicare will be less than it is, and some bureaucrat far away will decide when it's her time to die.

This is not the first time this debate has surfaced. In the 1960s opponents of Medicare used the phrase "poor old grandma" to warn that the legislation would rob elderly of their Social Security or provide insufficient care. They were wrong, of course. Medicare has probably become the most popular government program ever. These days it's common to speak as if Medicare is the universal coverage for American elderly. (Medicare is for the elderly and disabled, Medicaid is partnership with the states aimed at some people with low-income.)

And that's mostly true. Mostly. But Indian Country was largely left out of the original Medicare and Medicaid, plan, a problem that was fixed when President Ford signed the 1976 Indian Health Care Improvement Act into law.

Rick Lavis, a Republican, who was working for Arizona Sen. Paul Fannin, sent a memo to the Ford White House raising the question why it was even necessary to amend the law to include American Indians and Alaskan Natives. Then Lavis answered his own question by saying the act would "permit Indian Medicare and Medicaid beneficiaries to utilize their benefits in IHS facilities, which under present law is disallowed."

Lavis also argued that the IHS should be reimbursed at 100 percent rates in their facilities because "the federal government has obligations to provide services to Indians.

The following is by InvestigateWest advisory board member Mark Trahant:

Sen. Edward M. Kennedy jumped into American Indian issues with zeal after his brother, Bobby, was assassinated. Sen. Robert F. Kennedy had used the Indian Education Subcommittee as his platform during his extensive travels across Indian Country with the anti-poverty tour.

A young Ted Kennedy wrote in Look Magazine that RFK “saw, as I have seen, the resilience of the Indian way of life, a way of life that has for many generations resisted destruction despite government blunders that almost seem designed to stamp it out.”

In October 1969 Kennedy attended the National Congress of American Indians meeting in Albuquerque and called for the establishment of Select Committee on Human Needs of the American Indians in the U.S. Senate. The young senator blasted away at the Nixon administration. “We need no more presidential task forces. We need no more buck passing; we know where the blame lies,” the Albuquerque Journal quoted him telling the delegates. “We need no more empty promises; we know they are empty.”

A few months later Kennedy joined Bobby’s widow, Ethel, at an NCAI banquet. He promised to champion the native cause and to turn to American Indians because self-determination is the best solution.

But in the Senate there were competing ideas about how to make self-determination the policy of the land. One specific challenge was the Indian Health Care Improvement Act.

“The more serious threat (to the bill) came from Senator Edward Kennedy, a Massachusetts Democrat, or more accurately, from Senator Kennedy’s staff. As chair of the Health Subcommittee, Kennedy asked to share jurisdiction over the Indian health legislation,” wrote Dr. Abe Bergman and his co-authors in “A Political History of the Indian Health Service.”

Had the bill gone to Kennedy’s subcommittee there likely would have been little or no Republican support.