Alaskan Natives

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.

By Mark Trahant

This week the Senate Finance Committee continues what's called an "open executive session," the process of weeding out hundreds of amendments to the America's Healthy Future Act of 2009. One by one amendments are considered, added or rejected until the bill takes a form ready for a vote by the full Senate.

There are a number of provisions for Indian Country that still need to survive this process. The first is the exemption for American Indians from the health insurance mandate (at least the penalties). The language of that provision is broad, a definition that includes American Indians and Alaskan Natives "irrespective of whether he or she lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside."

This definition makes the most sense because it will make the law fairly easy to administer. All it would take is to check a box on a Federal Income Tax Return and be identified as an eligible American Indian or Alaskan Native.

So far, at least, this exemption hasn't surfaced much in the larger public discourse. Jane Hamsher, one of the few bloggers who have written about the exemption, said it's not a surprise because "the three Democrats ... are part of the ‘gang of six' come from states (Montana, North Dakota, New Mexico) with disproportionately large Native American populations."

How this provision is viewed in the larger public discourse is important because it requires explanation: Most Americans know little about the Indian health care system or U.S. government's promises. A recent campaign by the Confederated Salish and Kootenai Tribes of Montana is a great example of jumping ahead of this issue: "The Rez We Live On" campaign makes the connection between land concessions and treaty health guarantees.