Data & graphics

#NativeVote18 candidates for Congress, Governor, Lt. Governor, state legislatures



Interactive version of the graphic.


#NativeVote18 candidates for U.S. House, Senate

#NativeVote18 candidates for statewide offices

#NativeVote18 candidates for State legislatures

#SheRepresents — Native American women who are running for office in 2018

In general: It’s worth noting that I have started with state and federal offices, but plan on expanding to include legislatures, county commissions and city government offices.



Congress by the numbers — a data history.

Google has changed the way you can access pictures and it no longer is compatible with fusion tables. So I am looking for a solution or a new spreadsheet system. #Transparency

These are Google fusion tables with three tabs. The first is a spreadsheet; second is note cards for each candidate, and tab 3 is the interactive map.

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Chart: She Represents


The Native Media Universe

When Indian Country Today went dark, several of us thought it would be good to know what’s out there. This is a map of Native American radio stations, podcasts, news web sites, and more. Please ping me if you see something that’s missing.

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Fusion table 


History of federal spending in Indian Country (Spreadsheets)

Bureau of Indian Affairs

Thirty years: Agencies from 1977 – 2017


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Link: Interactive version of graphic.

Spreadsheet of Native Americans elected to state legislatures.








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Archive: Indian Country and Health Care Reform; my project as a Kaiser Media Fellow.



Forget Canada when there is an American version of a government-run health plan, the Indian Health Service

July 6, 2009

There seems to be political consensus that our health care system won’t end up like those in Canada or England. OK, but what about the American version of a single-payer, government-run health care agency?

The Bureau of Indian Affairs sent doctors to inoculate American Indians near military forts with smallpox vaccine in 1834. Perhaps that effort was more self-interest than preventative medicine, but by 1955 the newly created U.S. Indian Health Service became a full-fledged national, government-run health care network. It really is the only health care “system” in the United States that ranges with a range that goes from hospitals to health education.

“The Indian Health Service can and will be one of the leading prototypes for health care in America,” said Dr. Donald Berwick, one of the nation’s leading authorities on health care quality and improvement, at a conference this summer. “The Indian Health Service is trying to deliver the same or better care with half the funding of other systems in the United States.”

Berwick said he would be the first to say IHS needs more money – but at the same time the agency’s ability to execute is “stunning.” The very nature of the historical underfunding has resulted in a discipline that’s “an example for us all.”

That example would begin with a culture that funds projects designed to improve the health of its clients (instead of limiting expenditures to direct medical care). Beginning in the 1960s, IHS invested in reservation and rural water systems, sewage and solid-waste facilities and funds pays for technical assistance for those facilities. The result, according to the Congressional Research Service, is an 80 percent reduction in gastrointestinal disease among American Indians and Alaska Natives since 1973.

The same broad view of health care is the essence of a Special Diabetes Program for Indians that began in 1997. The $150-million-a-year project funds an extensive “best practices” network, incorporating the latest scientific findings into model and community-designed programs. This includes better training so patients can self-manage their treatment to with more access to physical fitness programs, diet education and early diabetes screening.

While diabetes remains at epidemic levels in Indian Country, there are hopeful signs of a turnaround. There has been a significant increase in the percentage of Indian diabetics that who are maintaining blood-sugar control and, more important, there has been a 40 percent reduction in complications from diabetes such as kidney disease and retinopathy.

This has implications for the rest of the country. Diabetes is already expensive, totaling $174 billion in 2007. And, unfortunately, the disease is growing at rates that are all too familiar in Indian Country. About one-quarter of all Americans have pre-diabetes and if the disease fully develops, the health care costs will top $13,200 per person compared to $2,560 per person for those for people without diabetes.

The Special Diabetes Program for Indians is inventing less expensive alternatives to treat and prevent the disease.

It’s a way of doing business that reflects the frugal nature of the IHS. The agency spends roughly $2,130 per-capita – about the same as the average for other industrial nations. But that compares to the $3,242 for federal prison inmates, $4,653 at the Veterans Administration and $7,784 for Medicare.

It’s both ironic and maddening that the richest nation in the world appropriates far less for American Indian health care than it does for any other similar program. But as tribal leaders have pointed out repeatedly, that has resulted in a health care system that’s “starved, not broken.” Increasing those resources is something that could be fixed in the appropriations process.

Indeed, Dr. Yvette Roubideaux, the agency’s new director, said during her confirmation hearing that the funding shortage is her top concern because IHS has not been able to keep up with its obligations. The General Accountability Office reported last year that because of shortages in budget, personnel and facilities, “the IHS rarely provides benefits comparable with complete insurance coverage for the eligible population.”

This may sound odd, but I think with sufficient resources, the Indian Health Service could be the model for reform. The agency already knows how to control costs and the successful operation of how to successfully operate a rural health care network. So much so that many rural non-Indian communities are looking for ways to tap into the system for the general population.

One reason for those improved health conditions was an early decision to invest in education, sanitation and preventative care. We know this about health care expenditures: Upfront spending saves money later. And the IHS provides an example of a government agency that did just that over its five decades.

Another way the IHS is different from other health care providers is because it’s an agency that listens to community-based clients. For example: The IHS often partners with traditional healers, medicine men and women – such as providing facilities, so patients see doctors and traditional healers on the same team. I know firsthand how valuable this is: firsthand: My oldest son was born on the Navajo Reservation at a hospital where nurse-midwives were both cognizant and supportive of traditional practices, so my son’s umbilical cord chord was saved and is planted on family land. My son has literal roots – but so does the federal agency because IHS listened to its constituents to define what’s important. This is what community care is about.

 Neither President Obama nor Congress needs a new study to improve the government’s management of Indian health programs. That system just needs more funding. But there ought to be a long exploration into what the rest of the health care system could learn from one the government already operates. 

Money at the clinic level


July 7, 2009

DENVER – Health care reform (or any major policy shift) is one thing in Washington, D.C. But it’s always something else at the field level. How can government get it right in both locations?

One way is to make certain that top government leaders have some experience working at the delivery end of the system.

Consider the new director of the Indian Health Service, Dr. Yvette Roubideaux. She spoke at the Indian Health Summit here on July 7.

Roubideaux, who is Rosebud Sioux, last worked for the IHS as director of the San Carlos clinic. She said she knows what it’s like working in an environment where there are too few resources – and long lines of patients waiting for care. This experience taught her to be “creative” with what you have. Yet at her Arizona clinic, Roubideaux took pride in the sense that the medical care was better than at a comparable private institution. But after four years, in large part due to the limited resources, she said, “I was burned out. It’s difficult work. I needed a way to refresh and renew.”

That renewal took her to the University of Arizona’s College of Medicine Medical School and what Roubideaux describes as “a great life.” Her schedule was her own. She could invest time on research that she cared about – and research is critical because in the health care field dollars follow the data. That’s why she spent the past 10 years working in academics, to help provide the data.

But that’s the question: What will it take for the government to appropriately fund its Indian health agency? Roubideaux says there are “hopeful signs, so far.” The Obama administration takes pride in saying that its some $500 million is included in the stimulus package and a 2010 fiscal year increase of 13 percent for IHS funding is the largest in 20 years. Perhaps that figure might be the most politically possible in this era of less.

In the context of national health care reform, the Indian Health Service is the paradox of government-managed care. If the agency can only muster only a slice of the resources needed, what would a larger system look like when you add into the equation the size of the baby boom generation? There is no way to pay for everything. Painful choices will have to be made about where and when to spend money.

These two health narratives are in conflict: One describes an agency that is “starved, not broken.” Yet at the same time the larger health care picture must figure out methods for delivering service for less – something the Indian Health Service excels at. The medical costs per IHS patient were $2,349 in 2008. Certainly less money per person than any other health system we know.

Indeed. One recent report found per-patient costs for private health care are $7,119. Medicare’s costs are pegged at $9,634.

I’m not arguing that the entire country should learn to live with a resource-starved health care system. That makes no sense. But I do wonder if the IHS were fully funding funded – still spending less fewer dollars spent than other private or other government models – then would our entire national health care system be sustainable?

And remember the difference between Washington and the field? In the capital, a trillion dollars evokes a so-so. But at a clinic on rural reservation, the notion of an extra couple of thousand dollars per patient is big money. And more: It’s effective spending.

Indian country & Health care reform: A beloved voice says look at IHS



An expert on quality calls the HIS a prototype for reform

July 8, 2009

DENVER – Dr. Donald Berwick is one of the nation’s leading authorities on health care quality and improvement. He’s president and CEO of the Institute for Healthcare Improvement. He’s also a clinical professor of pediatrics and health policy at the Harvard Medical School and a professor in the Department of Health Policy and Management at the Harvard School of Public Health. Berwick has been on boards ranging from the American Hospital Association to an elected member of the Institute of Medicine. ABC’s medical editor Dr. Timothy Johnson calls him a “beloved” voice.

Berwick uses that voice to say look at the Indian Health Service as a model for what the U.S. system could be. “The Indian Health Service can, and will be, one of the leading prototypes for health care in America,” he said at a National Indian Health Summit in Denver on July 8.

First, think about the money. Health care costs are double what the amount spent in other developed countries. And for that money, Berwick says, the “American health care is not the best in the world. It’s not even close.” Indeed, he calls the current health care system a “low-value” enterprise, one that strips money from both family and government budgets.

Then there is the IHS. “The Indian health system is trying to deliver the same or better care with half the funding of other systems in the United States,” he said. Spending by IHS is even less than that of other developed countries. Berwick said he didn’t want to underestimate the resource challenge – and he’d be the first to say IHS needs more money – but at the same time the IHS’ ability to execute is “stunning.” The very nature of the agency’s underfunding has resulted in a discipline that’s “an example for us all.”

There’s a paradox: The Indian Health Service isn’t broken, it’s significantly underfunded while the national health care system is both overbunded overburdened and broken.

“We cannot afford in the longer run universal coverage for the health care system we have today,” he said. The care system is “too broken, too fragmented, too wasteful … and it’s not up to the task.”

Real health care reform is “beyond almost anything this country has faced,” Berwick said. He defined reform as a triple aim: improving people’s health, improving the experience of care and controlling costs.

These three aims have different constituencies – and in many ways are competing ideas. How many drug companies want to sell fewer prescriptions? What incentives are there for hospitals to have fewer beds or be empty? And what will it cost to improve the population’s health over the near and long term? To address better health, money will need to be spent on the causes of illness rather than the symptoms.

But if you start over and design a health care system, it would look very much like the IHS, built around the need of the patients, or a community-focused population. Berwick calls this “population-based thinking.”

And that’s one of the strengths of the Indian Health Service is the constant collaboration between the agency, tribal governments, regional health boards, families, patients and on and on. Think about what this means: a regular, ongoing system for determining community, familial health priorities. This is a patient telling doctors what’s important, not the other way around. This is built into the very ethic of IHS.

Another strength of IHS is its culture of learning. “I’m stunned by the honesty of measurements,” Berwick said. “IHS data shows data that doesn’t work as well as what does. It raises the idea of a learning organization.”

At the very least, I think IHS has to be the model for a national rural delivery care system. There is nothing like it dollar for dollar anywhere in the world. But to bring up an old theme, if Congress fully funded the Indian Health Service, would redesigning the national health care system even require a debate?

First, do no harm


July 9, 2009

DENVER – The last national health care reform conversation was one-sided when it involved Indian Country. The topic was simply how would change impact the Indian health system.

That conversation remains critical.

Reno Keoni Franklin, chairman of the National Indian Health Board, said at the Denver Indian Health Summit that the current funding model has created a crisis for California tribes. Because of the state’s financial implosion, it’s an outright conflict of interest for the state to tell tribes what’s a reimbursable expense under Medicaid and Medicare.

This very notion is a preview of the impacts that could come from any larger health care reform. If nothing else, tribes are major employers and that promises to be the foundation for health insurance mandates.

But that’s just the beginning. For example: On Wednesday Vice President Joe Biden announced a deal where hospitals will contribute $155 billion in savings in government reimbursements. Perhaps it’s a helpful contribution to the federal deficit on the national level – but what kind of impact will this and other changes make on an already underfunded Indian health system? It’s one thing to suggest cost-cutting in a system that costs twice as much as those in other developed countries; yet that same “savings” could be devastating when applied to the part of the system that takes frugal to a new level.

What if reform means a future insurance program – federal or private – further strips the funding base from the Indian Health Service? It’s absolutely possible that a new program would cover uninsured American Indians and Alaska Natives – but without a full recovery for those costs to the IHS.

Of course, the best outcome would be a health care system that combined a variety of funding sources in a way that the Indian health system would get adequate support.

But, as Sally Smith, chairwoman of the Bristol Bay Health Corporation, said in Denver: “First, do no harm.”

The bottom line here is that the driving force in national health care reform is saving money because our current system is not sustainable. But it will be unfortunate – and with serious consequences for American Indian and Alaska Native people – if that broad notion is applied wholesale to the Indian Health Service.

That’s why I think that the very conversation about health care reform needs its own reform. We need to pull back and look at the bigger picture – and at least examine one system that doesn’t have profit built into its model. Lessons from Indian Country could help the entire country improve its health care systems.

That means changing the conversation. Big time. And that’s pretty hard to do when the legacy news media isn’t aren’t aware of what’s possible. Even the idea of saying, you know, the Indian Health Service model is worth considering in the health care reform debate is preposterous. It generates a blank stare. If that.

Thursday morning I read The Associated Press’ four-paragraph story about the Denver Summit. “Diabetes is one of the main topics. The Indian Health service says about 16.5 percent of American Indians and Alaska Natives ages 20 and older have diagnosed diabetes,” the AP reported.

It could be a story from last year – or a decade ago. Yet here we are at this extraordinary moment where the whole country is talking about health care reform – and the conversation from Indian Country is reduced to one that can be read on TV in 10 seconds. There’s no room for this story because the news media is are covering every twist and turn of the legislation in Washington, D.C.

The Denver Summit was planned a long time ago – long before any new anyone knew that health care reform was thought possible. Indeed, the official position of the IHS is no position on health care reform. And for good reason: The agency is consulting with tribes and its constituents about what reform means to them. IHS Director Yvette Roubideaux is urging Indian Country to weigh in, saying that she’s reading e-mails sent to

“Looking forward, there is no secret plan,” she said earlier this week. The idea to “really see how we can come together to improve the system.”

Serendipity and a correction

July 13, 2009

This is a story about how one thing leads to another – or the reason I am writing about health care reform for the next year or so.

A few months ago the Hearst Corporation announced that the Seattle Post-Intelligencer, my professional home for the past six years, was for sale. Unless a buyer was found – something unlikely – the print product would be closed. As bad as this sounds, I can’t complain. This came at a good time for me. I loved my job – and I have had a great ride in journalism. But I viewed this as an opportunity to push myself in a new direction.

That’s where serendipity played a role.

First, I applied for the Kaiser Media Fellowship. I thought it would be intellectually challenging to dive deep into a subject and to write about it consistently. Health care seemed a natural fit for several reasons. I’m grateful that Kaiser agreed – because now I have the gift of time.

Why health care reform? First, I believe that this country made a mistake with employer-based health care insurance. It worked fine when people went to work for one company – and stuck it out for a long stretch of time. But the world has changed. In Seattle, for example, there is an entire workforce of contractors who must buy their own, individual health insurance policies. Or what works for a major manufacturer doesn’t fit for a small construction company where employees are hired only after successful bids. Employer-based care doesn’t seem to work for a growing number of companies. Second, over the years I have been struck by how little discussion there has been about how existing federal health care agencies should be a part of the new structure, such as the Indian Health Service. Third, for a long time I have been fascinated by demographics. This country (indeed, the world) is going through an aging in a way that’s unprecedented. We have to come up with a health care plan that is sustainable for both ends of the system: Those who pay for it, the workers, as well as the ginormous Baby Boom baby boom who are mostly at the receiving end.

After the P-I ended its print product, I was offered a Maymester teaching post at the University of Colorado at Boulder. This was more serendipity because I taught (read this: learned a hell of a lot) a course on social media and democratic institutions. Now I want to design my health care reporting – and posting – on a social media model.

Here is how I plan to proceed:

I plan to write a column on a topic every Monday. This debate is moving fast – but I am relieved that Congress is going home without a resolution. I’ll also cover meetings from time to time with daily reports. I’ll also post video commentary.

I’ve already heard from readers – and will begin posting comments soon. I think interactivity is essential, the more ideas the better. Early in the fall I plan to add a wiki page with an outline of what health care should look like. We’ll see where that goes (the great thing about social media is that the experiment is as important as the answer).

My Twitter page for this project is TrahantReports. Because I’m traveling until early August, this is the best place – at least right now – for immediate feedback. E-mail works well, too.

Finally, this project is “open” architecture. Everything I write is free to be picked up, reposted, reprinted, retweeted, retransmitted or any other rebroadcast form that I haven’t thought of yet. The ideas are more important than a pride of authorship. It’s great if you give me credit – especially since this is a reflection of my opinion – but if you’d you don’t, I won’t squawk. Some of these posts I will respin (another “re”) as op-ed pieces for newspapers. Others I will pitch as TV news stories. I may, eventually, collect material for a book.

Open architecture also means being transparent. I have already already have made and will continue to make mistakes. But thanks to the speed of social media – and Web communication – I will correct mistakes immediately. Last week I posted a wrong e-mail address for those wanting to comment about health care reform. In case you missed it: the correct address (already fixed on the original post) is

Thanks. I look forward to hearing from you – and I’ll be back next week with another letter. My next step is to write about the delivery of Indian health care at the clinic level.

Talking and tinkering is standard fare

July 20, 2009

More than three decades ago another health care debate focused on Indian Country. At the time, there were too many dilapidated medical facilities, an inability to recruit and retain health professionals (especially American Indians), as well as a host of other structural deficits, Congress responded in 1976 by passing the $1.6 billion Indian Health Care Improvement Act.

The Office of Management and Budget recommended a veto. OMB’s deputy director Paul O’Neill said the Indian Health Service didn’t need the money because there was “no evidence that a vast infusion of funds … would achieve better or faster results than are being achieved under orderly program growth.” O’Neill argued that extra money would not be effective because Indian health statistics were “especially in connection with causes of death, e.g., alcoholism, accidents and suicide, associated with reservation social conditions, i.e., poverty, isolation and inadequate housing. Unfortunately, we have not been especially successful in combating alcoholism and suicides in non-reservation areas.”

Fortunately, President Ford had other advisers, including Dr. Ted Mars, who responded directly to O’Neill in a memo. “Admittedly, I am biased as a physician in favor of equity in length of life so you will have to excuse my considering the humanitarian aspect along with the budgetary, pragmatic and political,” Mars wrote. “Failure to adjust the present course is in my opinion a flagrant deprivation of human rights in a measurable as well as dramatic way.”

President Ford did the right thing: “I am signing this bill because of my own conviction that our First Americans should not be last in opportunity.”

Indeed, since that October 1976 signing, the evidence is that the Indian Health Care Improvement Act worked and helped significantly improve care for American Indians both on reservations and in urban areas. But, perhaps, more important was President Ford’s notion that First Americans should not be last in opportunity when it comes to health care.

That very phrase was rolling around in my mind as I listened to President Barack Obama talk about reform last week.

“This is what the debate in Congress is all about: whether we’ll keep talking and tinkering and letting this problem fester as more families and businesses go under and more Americans lose their coverage. Or whether we’ll seize this opportunity – one we might not have again for generations – and finally pass health insurance reform in 2009,” the president said in his urging for action.

Talking and tinkering has been the standard fare for congressional reauthorization of the Indian Health Care Improvement Act. This is not a new proposal, it’s not particularly complicated and it certainly ought to find a way to travel from the Capitol to the president’s desk in less time than a rewrite of the entire health insurance system in the United States.

But as the National Indian Health Board points out on its Web site: “For ten years, Tribal leaders, members and advocates have worked tirelessly with Congress to pass a modern IHCIA, but our efforts have not been successful. Reauthorization is long overdue – it is time to pass H.R. 2708 this year.”

While the president and Congress struggle over rewriting the broader health care reforms, it seems to me this one measure is a test of the system. If Congress cannot (after a decade) enact a health care measure that has a track record of success, then how is it possible to rewrite the entire health care insurance system in a few legislative moments?

The answer is it’s impossible.

The health care reform proposal in the House, for example, has provisions that mandate health insurance for both employers and individuals (with exceptions). But how will that work in Indian Country? What is the impact on an already underfunded Indian Health Service? Does this health care reform plan end or limit treaty obligations? Or, on a practical level, will a family that fishes seasonally be required to buy health insurance?

There are far too many questions for any bill that requires debate at a frenetic pace. But here is one answer: If Congress rushes through this process, it will be likely that the First Americans will continue to be last in opportunity.

Health insurance for the family selling pinions

July 27, 2009

GALLUP, New Mexico – My family and I walked around the flea market here Saturday. I’ve always thought this is the ideal representation of unabashed capitalism. It was hot, dusty and there were hundreds of booths and thousands of people buying and selling a remarkable range of goods, animals and services.

On one hand there are the types of items you’d find at any flea market: used car parts, clothes and carnival-quality toys. But add to that mix native foods such as Acoma bread, mutton stew or dried corn plus traditional products such as mountain tobacco, Navajo and Pueblo jewelry, live sheep and horses, and CD’s loaded with musical selections from traditional to Rez-style hip-hop.

Gallup may be a tourist town, but not many travelers venture from I-40 into the hot summer market. That’s too bad – they’d find great bargains, but it’s a lot easier to buy Indian jewelry from a modern air-conditioned trading post. No, this market is directed at primarily Navajo and Zuni customers, local people serving local people. That, to me, is the essence of small business.

Yet I don’t suspect the family selling pinion nuts is thought about as a small business in the context of health care reform. Small businesses are viewed as much bigger enterprises – for example, a construction company with a dozen or so employees.

“Small businesses play an important role in the U.S. economy,” says a new report released by the White House last week. “… the vast majority of firms in the United States are small, and these firms account for a substantial share of private-sector employment.”

Indeed, these are the very firms that cannot afford to pay health insurance premiums for their employees. As the White House report points out: “The current U.S. health care system is not working well for small businesses. Most obviously, small businesses pay substantially more to provide insurance for their workers. On average, small businesses pay up to 18 percent more than large firms for the same health insurance policy.”

Of course, this issue is even more complicated in Indian Country. Let’s use the construction company as an example. If most of your employees are Native American (and eligible for IHS services) or seasonal hires, it’s awfully difficult to justify paying private insurance premiums. Then there is the growing number of Native American families that ranch or farm (the Census reported a significant rise in this category in 2007).  Or the family business that gathers rice or pinions, operates a booth at the flea market, travels through the summer to powwow to sell fry bread and tacos. For these ventures, there is no incentive to buy health insurance. Consider the philosophical question: Should (or even can) a reservation-based entrepreneur subsidize a treaty right to health care?

While I was walking around the market, the president talked about the needs of small businesses. He’s right to focus on the health care needs of small businesses – but I think this conversation must also include the changing nature of work.

As more and more of us leave the corporate working world – complete with health care benefits – and venture into our own version of the flea market, we will . We will need a health care system that includes a viable self-insurance option, both in the larger community and for people in reservation-based economies. That’s why a public plan is essential to any reform.

But it must be a public option that recognizes the variety of work in this country. The definition of “affordable” needs to satisfy people who might earn a fabulous paycheck during fishing season and then coast for months after that. The public option will have to include people who might use the Indian Health Service for primary care, but who would be willing to pay extra for some services.

To say that the current system isn’t working well for small businesses is an understatement. But it’s much deeper than that: We’re looking at the very proof that this country made a mistake by linking health care to employment.

The Pink Adobe dictate: Judge the end of the delivery system

August 3, 2009

Last week I drove past the Pink Adobe in Santa Fe, New Mexico. The view evoked instant memories, starting with many wonderful meals. But it’s also where 20 twenty summers ago I interviewed John Ehrlichman. This was well after Watergate – make that, after his prison term – and Ehrlichman had moved to Santa Fe to re-establish himself.

Ehrlichman was officially President Richard Nixon’s assistant to the president for domestic affairs. But what I didn’t know then – and few know now – is that Ehrlichman was essentially Nixon’s deputy president. On many domestic matters – including Indian affairs – the deputy president made the decision and began implementation before bothering to tell the president. His influence on Indian issues was substantial, ranging from the return of Blue Lake to the Taos Pueblo to the Nixon message on self-determination.

Ehrlichman hinted at this when I asked him why Nixon was interested in Indian issues. He repeated the oft-told story about the influence of Nixon’s football coach, Wally Newman from Whittier College in California.

But Ehrlichman told me it was more than that: He said there was a White House meeting when a small group of aides figured that the American Indian population was small enough to demonstrate that government programs could be effective. Indeed, the federal government could not then (or now) solve all the problems in America. But what if the government could make a focused attempt to improve the lives of one group, American Indians?

After a year and a half in prison Ehrlichman moved to Santa Fe where he worked as a writer and an occasional consultant. One of his clients was a group of Indian parents working a problem at a school. Ehrlichman discovered that the bureaucracy of government was a “stone wall.”

In Washington, D.C., when a new program was launched, everyone would tell you how well it’s working, even when it wasn’t, Ehrlichman said. The great mistake of government was “that we bring these bright young people into the White House who have never experienced the end of the federal delivery system.”

I thought of these words in the context of the health care reform debate.

The legislation will be thousands of pages written by bright young people who’ve never experienced the end of the federal delivery system. Some of them are congressional staffers – others are paid lobbyists. As The New York Times pointed out Sunday: “The strategic course the White House has chosen may have had the unintended effect of increasing the breadth and complexity of the battle involving special interests.”

I have a utopian idea: Too bad there’s not an easy way to turn this notion around. What if the legislation was drafted at the clinic level and then sent up instead of down? Or, written from the patients’ point of view? Imagine a budget that fully funded clinics and then used the remaining funds to staff the regional and central offices? A memo might read: “We’d love to fund the important bureaucracy … if only we could afford it.”

The push for national health care reform is going in the opposite direction. Decisions are being made that will reshape the entire care system without considering how it will impact the government programs already in operation, such as the Indian Health Service. A recent letter by the National Indian Health Board and other Indian organizations supports the effort, but asks for consideration of an amendment to protect IHS. “While H.R. 3200 takes important steps to improving access to health insurance and preventative health care services for all Americans, the bill does not take into account the unique position of Indian health care providers,” the letter said. “Moreover, the bill does not respect the fact that Indian people have already paid for their health care by ceding millions of acres of land.”

House Natural Resources Committee Chairman Nick Rahall has proposed amendments that will ensure some preservation of the IHS delivery system – perhaps with even added money from new insurance sources.

But the important measure here is a practical application of the Pink Adobe dictate, the idea that policy and law ought to include the experiences from the end of the federal delivery system. Over the next few weeks there will be town halls across the country as members of Congress listen to their constituents about health care reform. This is an opportunity not to be missed because Indian people have much experience with the receiving end of the delivery system.

Control costs and expand access

August 10, 2009

One of the most difficult elements in the health care reform debate is the philosophical notion of “dualism.” In order to reach consensus we, as a nation, have to balance equally reasonable yet competing ideas about how to expand coverage and control costs.

Indian Country has experienced duality in many forms – often described as a “love-hate” relationship with the federal government and its programs. An example of this would be the way Native Americans are the first to point out what’s wrong with the Indian Health Service or the Bureau of Indian Affairs, but on the other hand, if you really want an argument, try taking those programs away.

The same could be said for the men and women who wear the uniform of the Commissioned Officers Corps of the Public Health Service. If you think about this country’s history – and the wars fought between American Indian tribes and the United States – it makes no sense at all for a military-like unit to provide health care services on reservations.

Yet this government agency may be the most effective (and the most quiet) provider of direct health care services. Indeed, while there’s debate in the Congress about the role of government in the health care arena, funding for the corps has already has been expanded in a big way.

The Commissioned Officers Corps and the National Health Service Corps (another agency) are both in expansion modes.

“Currently 4 million people, many of whom have no health insurance, rely on … clinicians to keep them healthy and treat their medical, dental and mental health ills,” according to the National Health Service Corps. The agency provides 3,800 primary health care workers in underserved communities across the country. And the agency says, “By the end of next year, those numbers are expected to grow to 8,108 clinicians serving almost 9 million people, as American Recovery and Reinvestment Act (ARRA) funding more than doubles the National Health Service Corps field strength.”

The Indian Health Service is a direct beneficiary, beginning with the agency’s transfer from the Interior Department in 1955. “Actually, the Public Health Service and the Commissioned Corps even predated the establishment of the Bureau of Indian Affairs,” said Forrest J. Gerard, a Blackfeet tribal member who wrote the Indian Health Care Improvement Act while working for Sen. Henry Jackson in the 1970s. “Their original mission was to check sailors on incoming ships to guard against them bringing in infectious diseases.”

The Reagan administration wanted to eliminate the corps in the 1980s. Gerard, then a lobbyist, was hired to lead the opposition.

“The Indians saved the Commissioned Corps,” Gerard said. “I pointed out that the whole Indian staffing for the IHS would be hit severely (if the plan went through).”

During the Vietnam War – and even later – many who served in the corps did so only because it counted as military service. But now the corps represents more people, especially those from Indian Country, who see the service as a career. The salaries for doctors, dentists and dietitians are not nearly as good as they would be in the private sector, but they are good wages back home on the reservation. And a career, like military service, requires twenty 20 years before being eligible for retirement. The service has some 7,000 openings for jobs now. And, even better, the scholarships will help fund the education of medical professionals in exchange for employment. This is win, win on many levels.

President Obama’s nominee for Surgeon General, Regina M. Benjamin, already understands the importance of the Public Health Service. She served in the corps for three years early in her career.

The Public Health Service is government-run health care at its best. Yet if you Google either the “Commissioned Corps” or “National Health Service Corps,” you’ll discover that it’s not even part of the current reform conversation. Medicare and Medicaid dominate the discourse as massive insurance pools (instead of direct-service programs).

The current rancor in the health care debate is limiting our reform options. It’s fine for government-run health care when it’s part of the military or for veterans. But when it’s civil service, whoa.

But the Commissioned Officers Corps of the Public Health Service is military. Sort of. And the Obama administration’s expansion is a smart if small step. But what if the corps were the given the mission of expanding services to the uninsured beyond the 9 million? What if the number matched those uninsured for at least primary care? Then the duality in debate would have to end because this government agency would be cost-effective while expanding access to the health care system.

Where do ideas come from? One bill’s history

August 17, 2009

Where do ideas come from?

When it comes to discussions about health care reform – strike that, this is now officially an “insurance reform” proposal – lobbyists, company bosses, experts, attorneys, bureaucrats and politicians dictate the sentences in the conversations. Across the country voices from town halls only serve only to add spice to the narrative. The deal will be struck based on the simple but absolute requirement in politics: What will earn enough support to pass Congress?

But Last week Montana Gov. Brian Schweitzer tossed out another idea. I don’t think he was talking about health care – but he should have been – when he said that the Obama administration should listen to the tribes to sort out the complicated issues facing the country.

“In the heartland, in a place like Montana, we have people who have lived sustainably on the land and they may well have the ideas of the future. All great ideas don’t start in Washington, D.C.,” Schweitzer said.

I wonder what the town halls would have had been like had the president heard and followed this advice. The discussions certainly would have been more about health care than insurance if the conversation included clients from one of the half-dozen Indian Health Service units in Montana. Indeed, there are only three segments of the U.S. population that now receive direct “government-run” health care: Native Americans, veterans and inmates in federal prisons.

Yet in the battle of ideas, the programs that the federal government already operates are not part of the discussion. Go figure. This was the way it was when Medicare was created, too.

New Mexico Sen. Clinton Anderson – when he wasn’t busy championing tribal termination – was the architect of the Senate’s Medicare legislation beginning in the late 1940s. Back then Republicans labeled the very idea of government insurance as “socialist.” Anderson wrote in his memoirs, “Outsider in the Senate,” that some members of the Republican minority “always seem to take pleasure in defeating social legislation, as if that’s how the country’s problems are solved.”

Anderson proposed a health care extension of Social Security in 1960 and the leader of the Senate opposition wasn’t a Republican, but Oklahoma Democrat Sen. Bob Kerr. “It’s never been quite clear to me why Bob – given his overall social philosophy – should have considered it almost a religious mission to defeat a medical-care program insured by the Social Security system. It was one thing to have reservations,” Anderson wrote. “It was quite another to become a crusader sworn to the program’s death.”

Then, like now, Kerr and his allies had an important weapon – money. Anderson said he once took Joseph Montoya to see Kerr when Montoya was running for a House seat. “Bob walked over to a locked safe, turned the combination and peeled off a number of bills, which I think was $1,000 and handed it over,” he wrote. This earned Kerr gratitude for later fights.

But Kerr died in 1963 – and it was another Democrat, Russell Long, who led the opposition. However, legislative action had to wait until after the 1964 election. (Anderson, for his part, told President Johnson that he had reserved “Senate 1” for a new Medicare bill.)

“On July 30, 1965,” Anderson wrote, “I joined President Johnson aboard the presidential jet, Air Force One, for a flight to Independence, Missouri, where the bill was to be signed. In the presence of Harry S. Truman, under whose leadership I had first begun to think of a national health insurance program almost two decades before the bill became law.”

Anderson wrote that it would have been easy to settle for less along the way, but was helped by the intensity of the opposition. “The long rear-guard action which the American Medical Association conducted enabled us, in effect, to enact not a skimpy law but one which went far toward meeting the real needs of both the elderly … and the poor (Medicaid). I was thrilled with the triumph and proud of our work.”

Think of the time-frame: Medicare started as a general welfare philosophy under President Franklin Roosevelt. Then the idea emerged stronger under President Truman – finally becoming a bill in 1960. That idea died. More than once. But it was only dead only until the legislation was signed into law in 1965.

Perhaps good ideas take time – a little perspective on the 2009 deadline for health care reform.

It’s a great job – except for the benefits

August 24, 2009

I am reading a job announcement for a great gig. It pays $15 an hour. Flexible hours, important work – and it’s classified as “long-term temporary.” That’s another way of saying: no benefits.

In a country that has opted for an “employer-based” health care system, this should be the smoking gun; primary evidence that it’s a mistake to tie health insurance to our work.

But under health care reform there would be an employer mandate and the company that put out the job announcement would be required to offer insurance or pay a fine. Right? Wrong. The letterhead on the job announcement says: U.S. Census Bureau. The same government that is demanding that employers offer health care tells its own workers simply, “no benefits.” This is not uncommon in either government or the private sector. Some 12 percent of the workforce is classified as part-time and employers design jobs keeping in mind a rigorous enforcement of that 30-hour week. A few employers do provide benefits to part-time employees, but there are also people who work two part-time jobs without benefits.

Here is the strange part: What would happen to this census worker with the health care bills that require individuals to purchase insurance? The United States would have to write a subsidy check for the individual it has hired on the cheap in order to save money on benefits.

The individual mandate has been called the common thread in all of the health care reform proposals before Congress.

The idea is to require the purchase of health insurance, similar to laws enforcing automobile liability insurance. Congress would then subsidize the cost of that insurance, based on income levels. This would be true for either the so-called “public option” or private insurance.

This is where it gets thorny for Indian Country. Would a treaty right to health care be considered “insurance” under the law? Or would individuals eligible for IHS services be required to purchase insurance under a mandate? And, if so, would the subsidy be automatic or based on income levels? The result could be some sort of means test.

A working paper by the staff of Senate Indian Affairs Committee Chairman Byron Dorgan, D-North Dakota, calls for a blanket exemption of individual Indians from this mandate. The paper says: “Exempt Indian tribes from any employer mandate penalties and individual Indians from individual mandate penalties. In recognition of the U.S. federal government’s trust responsibility to provide health care to AI/AN individuals, financial penalties should not be assessed against individual Indians failing to obtain health insurance coverage.”

On the House side, the pending bills do not spell out protections for the federal trust responsibility. House Natural Resource Committee Chairman Nick Rahall, D-West Virginia, has proposed a similar amendment to protect the Indian Health system from “inadvertent harm.”

The National Indian Health Board put it this way on Aug. 14: “Now is the time for Indian Country to reach out to Congressional members … it is extremely critical that Congress hears about the support for health care reform and the need for specific provisions to address the unique nature of the Indian health care delivery system.”

The fact is we don’t know if this language will be in the final bill. The health reform proposals in both chambers Houses are about as firm as a pool of water.

But even if there is an exemption for Indian Country, how will that provision be executed? Will it apply to individual Indians living on reservations and other areas considered Indian Country? What about people who move back and forth? Will they be subject to the mandate and penalties when working in the city – but free when they move back home?

There are also questions about an exemption for tribes under the employer mandate as well. Would this apply to the government operations only? What about tribal enterprises? Even casinos? On top of that, will the law be different for employees who are not tribal members? This is a big deal because in many rural communities tribes are the largest regional employer.

Robert J. Blendon, a professor of health policy and management at Harvard, said earlier this month that what is being debated now is not a restructuring of the American health care system but a proposed “law that says ‘everybody who works at Dunkin’ Donuts has to have insurance.’ It turns out millions of people work full time, but they get no [health] benefits. … People across the country can be heard crying, ‘I can’t afford to pay. Do whatever you want – just don’t ask me to pay.’”

That notion is especially complicated for Indian Country because of the fundamental declaration that a treaty right is the highest form of a government promise, pre-paid health care.

When a step aside was ‘a godsend’

August 31, 2009

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. At the Interior Committee, however, there was a growing bipartisan view that the bill was necessary.

Rick Lavis, who worked with Arizona Sen. Paul Fannin, said he had to sell his conservative boss on the cost of the legislation, $1.6 billion. “It’s costing how much?” Fannin asked. But the facts on the ground overwhelmingly supported the case. “The Indian Health Service was in total disarray – not as an organization – but in terms of facilities, its manpower, its ability to deliver health care,” Lavis said. Republicans also liked the idea that the health care improvement bill satisfied treaty obligations, rather than another big government anti-poverty effort.

Forrest Gerard, working for the Interior Committee and its chairman, Sen. Henry M. Jackson, arranged for a public forum with Kennedy and the National Indian Health Board. “Mel Sampson from Yakama agreed to ask, at the appropriate time, if Sen. Kennedy would forgo jurisdiction so that we might pass a bill,” Gerard said. “Amazingly, he agreed to do that at the meeting. I don’t think his staff was too happy.” Gerard, however, called it “a godsend.”

Gerard added this week that Kennedy’s experience as a legislative tactician recognized the importance of bipartisan support. “He also recognized that this move would help ensure insure that certain amendments he deemed critical, particularly on mental health, would be approved in the legislation.”

The result was the Indian Health Care Improvement Act was signed into law on Oct. 1, 1976.

I was thinking about this story during Ted Kennedy’s funeral. The list of his accomplishments is long and he is well deserving of the honors that came from every corner. But I also think Kennedy’s greatness ought to be measured by the act of stepping aside at a critical time. The passing the Indian Health Care Improvement Act (then and again now) was more important than any credit a senator could gain by occupying center stage.

This story also seems to be relevant to the current health care reform debate. The American Indian health system is different from that of the rest of the country and is a complicated structure. Health care reform will have unintended consequences ranging from new insurance requirements to a better (or worse) process for Medicare and Medicaid reimbursements. That’s why it’s so critical for tribes, Native health organizations and the congressional committees with a unique understanding of American Indian history and policy to have a say on any final health care reform bill.

Even better: Congress could reauthorize the Indian Health Care Improvement Act and adequately fund the health system that the U.S. government already operates. As Sen. Kennedy once put it: “We need no more buck passing; we know where the blame lies.”

Will ‘poor old grandma’ redefine this debate?

September 8, 2009

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 has 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 in partnership with the states and is 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 of why it was even necessary to amend the law to include American Indians and Alaska 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. It has not been a state responsibility.” The idea was that Medicare and Medicaid money would be a new source of financing money for Indian health programs.

Since the original Indian Health Care Improvement Act was signed into law there has been a steady increase in Medicare and Medicaid reimbursement to IHS. A 2008 study by the Government Accountability Office reported $677 million in reimbursement in fiscal year 2007. “However, facilities vary greatly in the total reimbursement obtained from these programs. For example, our prior work found that Medicaid reimbursements across 12 IHS-funded facilities ranged from 2 percent to 49 percent of the total direct medical care budgets.”

A 2007 study by the Upper Midwest Rural Health Research Center found a 20-fold difference in the uninsured rate for Native American elders 65 years of age and older compared to the U.S. population of the same age group, or 15 percent versus .07 percent. (Some 6 percent of Native American elderly are eligible for Medicaid rather than Medicare.)

There are several reasons for this high rate of uninsured elderly in Indian Country. At the top of GAO’s list: “Some officials we spoke with reported that some American Indians and Alaska Natives believe they should not have to apply for Medicare and Medicaid because the federal government has a duty to provide them with health care as a result of treaties.” Other barriers include transportation, language, identification, communication and even the complicated nature of the forms.

The GAO report said that Medicare still represents an “important means of expanding health care funding” for Indian Country. That remains true because as the American Indian and Alaska Native elderly population ages it can automatically tap these funds.

But in the larger health care reform there must be a way to better align the Medicare program with the existing Indian health care delivery system.

Medicare is an entitlement program. If you are eligible for services, the money is there. The IHS, on the other hand, is funded by appropriations. This is a good year because the Obama administration proposed a 13 percent increase.

But that very difference – entitlement versus appropriation – is what is driving the health care reform debate. Medicare, at least in theory, has unlimited funding. That theory is about to will be tested because in about a year and half when the first baby boomers turn 65 years old and are eligible for Medicare. Then over the next two decades some 77 million boomers will follow – about twice the number that is currently enrolled in Medicare.

One way or another we need to come up with a system-wide reform, one that makes the entire system sustainable. Either that or we will really need to worry about poor old grandma.

Back to the future: Public Health hospitals

September 14, 2009

Seattle-based, the world’s largest online retailer, will move into its new headquarters near Lake Union next year. Then Amazon will leave an old Art Deco building, once known as the U.S. Marine Hospital.

What if we took this empty building and turned it into a hospital? What if we staffed it with federal employees? What kind of health care would that look like?

The answers are in our history. Congress passed a law in 1789 that provided for health care for sick and injured merchant seamen. But the thinking, even then, was broader. Philadelphia faced an extraordinary yellow ever outbreak in 1783 that killed more than 4,000 people (out of a population of 37,000). And therefore Therefore, the primary mission of the new health service was to intercept diseases brought home by sailors returning from sea.

The Public Health Service and the marine hospital network eventually expanded across the country. This was the first “public option” because this government plan was funded by a monthly deduction from the seaman’s wages. The scope of medical activities grew as well, ranging from the treatment of epidemic diseases to industrial hygiene.

The PHS could have become the basis for a national health care delivery system. By the 1970s marine hospitals and clinics served American Indians, the urban poor, as well the agency’s traditional clients of merchant marines and some federal retirees.

“These hospitals have a record of service to this nation, and especially to its merchant seamen, which is long and distinguished,” President Richard Nixon wrote in a veto message to Congress over the funding of public health: “Nevertheless, it is clear that their inpatient facilities have now outlived their usefulness to the federal government. The number of individuals they serve is declining and many of the facilities have become old and outmoded.”

Nixon articulated many of the arguments that remain a part of our current discourse on health care reform; essentially the notion that direct medical services should not be a federal responsibility. In the budgets that followed, the Nixon and Ford administrations executed an incremental implementation of that idea.

Now it’s interesting to go back and read the congressional testimony about what would happen without these government-run hospitals.

“If we close down the Public Health Service hospital system, we are also dismantling a valuable laboratory of a different sort,” said John Murphy, chairman of the House Committee on Merchant Marine and Fisheries. “As our population increases, and as the cost of medical services rises, it is clear that we must experiment with new methods and techniques for the delivery of health care.”

This was June 11, 1976. And Even more prophetic, Murphy said that the Public Health Service hospitals could serve as a “yardstick” to measure both the cost and quality of health care in private institutions.

A coalition in Seattle attempted to save the hospital network. “Our PHS hospital has been in the forefront, caring for the poor and working poor who were previously left out of the medical system. Beginning with the Boeing layoffs in 1971, our hospital has served as the primary sources of assistance for 15 community clinics, established by residents of poor communities to serve their neighborhoods,” said Reynold Pilgrim, chairman of the Public Health Care Coalition in congressional testimony on June 14, 1976.

The government’s own numbers showed that the PHS system was more cost-effective than comparable private institutions. “The study demonstrates that three people can be cared for in PHS hospitals at the cost of caring for two in the private hospitals,” Pilgrim said. “The failure of the administration to realize the potential of the Public Health hospitals is a great tragedy. Our nation is in the midst of a deepening health care crisis. Medical costs are rising at twice the rate of wages, rising beyond the average family’s ability to pay.”

The health care crisis was tiny compared to today. It’s why we need to look again at those government programs that efficiently delivered health care.

President Barack Obama said just this past weekend that a public option insurance plan could work side by side with those from the private sector. “It’s the same way that public colleges and universities provide additional choice and competition to students.  That doesn’t inhibit private colleges and universities from thriving out there.  The same should be true on the health care front,” the president said.

I would take one more step. The Public Health Service hospitals provided additional choice and competition – at a two-thirds of the cost of private facilities.  We should consider going back to that future.

Shorttakes from Washington:

Exempting Native Americans from the mandate

September 16, 2009

WASHINGTON — There is growing consensus about a key element of health care reform: A requirement that you must buy health insurance. The idea is that the insurance pools would be less expensive if every American were included – especially younger, healthier workers who for a variety of reasons decide not to buy insurance. The reform proposals would require people to sign up for Medicaid, buy subsidized insurance, or purchase a policy at work or on their own.

This would be difficult in Indian Country, which already reflects the highest number of Americans who do not sign up for Medicare – the closest thing we have to universal coverage for the elderly (by my count almost a quarter of Native American elderly are not on the program). The story for Medicaid is similar. Moreover, in recent studies one of the reasons for the low participation is the notion expressed by many who did not believe they should have to sign up for any program because health care is a treaty obligation of the United States.

Speaking at the National Indian Health Board Consumer Conference in Washington, D.C., Health and Human Services Secretary Kathleen Sebelius said the president supports an exemption from that mandate for individual American Indians and Alaska Natives. “I’m going to make it very clear,” she said, “the administration strongly believes that the individual mandate and the subsequent penalties don’t apply to American Indians or Alaska Natives.”

There is consensus that the Senate Finance Committee’s bill when it surfaces will reflect this notion. The House bill does not address exemptions, but at the NIHB conference, Rep. Frank Pallone, D-New Jersey, said he would introduce amendments along those same lines.

The exemption is critical because of the already low participation by Native Americans in existing programs such as Medicaid. The enforcement of this mandate will be through the tax code. I don’t want to get ahead of the debate, but the definitions and regulations will be critical. Will the penalty exemption apply to those living within IHS service areas – “on or near” reservations? Or will it be wherever an AI/AN person lives, say Phoenix or Seattle?

The other mandate question is will tribes be required, as employers, to purchase insurance? The House bill does not address the issue, but does require states and local governments to buy insurance. The Senate might be more inclined to grant some sort of penalty exemption. And, again, the details are where the questions surface: Since the tax code is the enforcement mechanism, would tribes (or other governments) be required to file some sort of tax return to the IRS? Would tribal enterprises be treated differently than the governmental services?

Answers are hard to come by right now. Every item is subject to two pressure points: First, rounding up the votes to pass a bill. And, second, the “scoring,” or the estimated cost of the legislation, by the Congressional Budget Office.

Tribes in the larger health care debate: An endorsement

Most of the conversation in Indian Country is about how health care reform will impact the Indian health care system. But this week, the five tribes of North Dakota added their voice to the wider debate, backing President Barack Obama’s health care initiatives.

The United Tribes of North Dakota Board passed the resolution Sept. 10 urging significant health care reform during the current session of Congress. The United Tribes includes the Sisseton-Wahpeton Oyate, Spirit Lake Tribe, Standing Rock Tribe, Three Affiliated Tribes and the Turtle Mountain Band of Chippewa. Two of the tribes, Sisseton and Standing Rock, are located in both North and South Dakota.

The president’s proposals will assist Native Americans who do not have access to health care through IHS, said the resolution.

“Sixty percent of American Indians are now living off the reservation,” said David M. Gipp, United Tribes Technical College president. “Generally these people are not able to receive services from the IHS and are falling through the cracks when it comes to health care in America.”

The larger issue of health care reform should also include improvements in the Indian health care system.

“Our population is typically at greater health risk for most all diseases and especially diabetes, heart disease and cancer,” said Myra Pearson, Spirit Lake tribal chairwoman, Fort Totten, North Dakota. “Our need for a better health care system is among the greatest of any population in the country.”

The White House released a statement from Kimberly Teehee, senior policy advisor for Native American Affairs: “The president greatly appreciates the United Tribes of North Dakota for adopting a resolution supporting his health insurance reform plan, and for their call to Congress to take action. He looks forward to working with Indian Country as we act on this important moral issue.”

Taxing the logic of tribal health benefits

September 21, 2009

WASHINGTON – There is near universal agreement: The Indian Health Service needs more money. At the National Indian Health Board Consumer Conference last week, several members of the U.S. Senate and House were critical of the historic underfunding of IHS. These were Democrats, Republicans, some representing Indian Country constituents, others from districts with no reservations and few tribal members. Yet they communicated the same message: The United States made a health care promise to Native Americans and it’s wrong to fund a system with substantially less money than what is spent per person on federal prisoners.

The Indian health system’s funding is so low that many patients are counted as part of the uninsured population in government data.

The Senate Finance Committee’s health reform concept paper put it this way: “The IHS itself has stated that its funding does not allow it to provide all the needed care for eligible Indians.  As a result, some services are ‘rationed,’ with the most critical care given first. … The reality of this underfunding is that money for contract health services does not last the entire year, forcing IHS to limit services to circumstances involving a ‘loss of life or limb’ circumstance.  This predicament is so common in Indian Country that many tribal members fear that if they need care after June, they will be forced to go without.”

The Obama administration at least added 13 percent to its IHS funding request. But it’s a small step and neither the Executive Branch nor the Congress has made funding parity a priority or even a proposal.

So many tribes have stepped up and contributed their own money to improve health care in Indian Country. This ranges from paying extraordinary medical bills of tribal members to purchasing health insurance.

Hurrah. But this is where this story takes a strange twist: The government’s response to those innovative approaches is to treat this generosity as a taxable event. The IRS wants 1099 forms sent to individual members. (Perhaps a tax bill should be sent to the U.S. government instead.)

The Pechanga Tribe Band of Luiseno Indians in California studied its heath care needs for two years, and then enacted a mandatory group coverage policy for tribal members. “This has led to measurable improvement in the physical health of our tribe. Earlier this year, we opened a new exercise facility that both contributes to and facilitates the health and wellness of our tribal citizens,” testified Mark Macarro, the band’s chairman, before the Senate Indian Affairs Committee on Friday.

However, the IRS asked the tribe to demonstrate how the program was “need” based – or it would consider these taxable benefits.

“It appears to us that the IRS is interpreting ‘need’ as meaning only ‘financial’ need,” Macarro said. “From our perspective, this makes absolutely no sense. The Pechanga government has stepped in where the federal government has fallen short for our people. … Pechanga has decided not to wait on the federal government to fulfill its trust obligation to our people.”

The basic issue is how the IRS interprets its “general welfare” exclusion. Sarah Ingram, the IRS commissioner for Tax Exempt and Government Entities, said there is a difference in the law between those who work for tribes as employers and tribal members. “Where there is no employer involved, the (tax) Code contains no provision that would allow a tribal member who is not a tribal employee to exclude the value of tribally-provided health care coverage.”

There are two ways to fix this mess. Congress could clarify the law (the route the IRS would prefer). Or a “revenue ruling” could easily fix this problem administratively, testified Scott Taylor, a professor of law at the University of St. Thomas in Minneapolis. He cited other examples of such a governmental exclusion, including the Veterans Administration and Medicare. Taylor is an expert and was a professor-in-residence with the IRS.

For once, it seems, there ought to be enough consensus in Washington to force the easy route. This is common sense. The IRS ought to get a call from the White House and the Treasury Secretary and be told to resolve this issue quickly.

But there is another alternative: Those who decry the underfunding of Indian health could come up with real appropriations and make the system whole.




Spotlight on the Native American provisions

September 28, 2009

This week the Senate Finance Committee continues what’s called an “open executive session,” the process of weeding through 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 Alaska 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 Alaska 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’ and 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. This is the essence of the “pre-paid” health care notion.

Some of the other provisions in the Senate bill are even less in the spotlight. For example, the Indian Health Service could get more resources because the legislation would end some cost-sharing requirements for premiums and deductibles for American Indians and Alaska Natives at 300 percent below the federal poverty guideline. This is a large percentage of the IHS patients.

Sen. Kent Conrad, D-North Dakota, also successfully added language to the Senate bill that would eliminate the tax liability for individuals receiving tribal health insurance benefits. This became a problem after the IRS determined that tribal programs didn’t qualify for tax waivers unless they are either income-based or employment-based.

Another clause identifies tribes, tribal organizations and urban Indian organizations as an “Express Lane Agency.” The idea is to make it easier for individual Native Americans to apply for health care benefits across the spectrum, including Medicaid, CHIP (insurance for children) and other such programs that are state-administered.

However, Iowa Sen. Chuck Grassley, the ranking Republican on the committee, said last week he is troubled by this provision because of his immigration concerns. “As we have discussed in this committee in the past,” he said, “the role of Indian tribes in verifying citizenship has been questionable.”

The politics of that particular tangent is fascinating: So First Americans cannot identify immigrants (I guess the best evidence is the entire colonial history of the United States) when helping tribal people apply for benefits? Strange. Or how about this? Another senator warns that not everyone wants insurance benefits to include maternity care. All this stagecraft is designed to prevent the Democrats from reaching 60 votes in the Senate, the magic number that would make the Republican minority disappear.

The Senate process is the most transparent (at least right now) but there are other deeper currents. The House of Representatives is expected as soon as this week to merge together elements from three committee health care reform proposals. The House’s Indian Country provisions should surface at that point and provide more clarity about how the legislation will impact the Indian health care system.


Effortless health care? Not in a Medicaid plan

October 5, 2009

Members of Congress receive effortless health care. Like all government employees, there is a federal benefit plan with a basket of insurance options. But that’s Plan B.

The better deal is the full-service clinic staffed by Navy doctors. ABC News Medical Editor Tim Johnson reported last week about Capitol Hill clinics where “lawmakers receive top-notch, wait-free care, and money is largely no object. Members pay a flat annual fee of $503, and it covers all expenses – without submitting claim forms to their insurer.”

There is one fee, great medical service and not even the bother of filing for insurance. And the Capitol Hill clinic never runs out of money in June. Effortless.

Indian country Country has a different financing mechanism. Plan A is, of course, the Indian health system, the combination of federally run Indian Health Service facilities plus those health care programs managed by tribes or urban Indian organizations. Plan A is a system that’s regularly characterized as “starved” because it is funded with annual appropriations instead of based on patient need. Here is the rub: The Indian health system is so underfunded that it does not count as a qualified insurance plan (despite the treaty and statutory promises).

So Plan B is Medicaid. Medicaid is the country’s insurance plan for low-income families, pregnant women, people with severe disabilities and older people who do not qualify for Medicare (and for long-term care, but that’s another column). The funding for Medicaid is an entitlement. If someone is eligible, the money is there. Medicaid is a partnership between the federal government and state governments. States write the rules, under broad guidelines, and the federal government pays for part of or sometimes all of the cost.

Medicaid is a growing source of funding for the Indian health system (and under law is supposed to supplement, not replace, IHS revenue). The Government Accountability Office found that the range of Medicaid reimbursements at IHS facilities were from 2 percent to 49 percent “and the facilities with higher reimbursements had additional funds to hire staff and purchase equipment and supplies.”

“Medicaid is a key element of American Indian Alaska Native health care financing reform,” wrote Andy Schneider in the American Journal of Public Health in May 2005. Schneider went on to serve as the chief health counsel for the House Committee on Oversight and Government Reform.

But the practical problem of Medicaid is its administration by state governments, which have uneven relationships with tribes and Indian organizations. And even if those states do work well with tribes, there is an entirely different set of rules for every state. “The Medicaid program differs considerably from that in neighboring Minnesota and the Medicaid program in Arizona varies substantially from that in neighboring New Mexico,” Schneider wrote. Imagine the added complexity for tribes with citizens in different states, such as the Navajo Nation, when clients must go through the eligibility process.

These days Medicaid is under increased financial stress because states don’t have enough tax revenue to pay their share, ranging from about half to more than 75 percent. Last year Medicaid cost states $1,555 billion $1.55 trillion or about twice the amount spent on elementary and secondary education. Medicaid’s continued growth is certain as more people are eligible because they’ve lost their jobs – or under health care reform more will apply when it will be required by an insurance mandate.

A study by the Kaiser Commission on Medicaid and the Uninsured found that for every 1 percent increase in the national unemployment rate, a 3-4 3 percent to 4 percent decrease in state revenues, and a 1 percent increase in Medicaid (and a children’s health insurance program) plus another 1.1 percent increase in the uninsured.

It’s no surprise that states aren’t keen on any expansion of Medicaid eligibility, but the program (along with the companion program for children’s health) ought to be thought of as a way to provide more access to health care system generally.

The current health care reform proposals don’t change the funding mechanism for Medicaid in Indian Country. But it remains worth considering because it could save money: Consider a simple transfer from Medicaid to the Indian health system without going through 35 different state systems, each with its own transaction cost.

Schneider wrote in 2005 that such changes “are simply unachievable in the current political context.” Unfortunately, we are no closer to that ideal.

But why should the poorest Americans be the one that who must navigate through the complex grid of Medicaid? What if the system were turned around and federal guidelines made the states adjust their systems? It seems that American Indians and Alaska Natives ought to have health care options as easy to understand as a clinic on Capitol Hill. You know, effortless health care.

A spirited consensus about health care reform

October 12, 2009

Are we in the final days of the health care reform debate?

“The historic movement to bring real, meaningful health insurance reform to the American people gathered momentum this week as we approach the final days of this debate,” President Barack Obama said in his weekly radio address. “The Senate Finance Committee is finishing deliberations on their version of a health insurance reform bill that will soon be merged with other reform bills produced by other congressional committees.”

“What’s remarkable is not that we’ve had a spirited debate about health insurance reform, but the unprecedented consensus that has come together behind it,” the president said. “This consensus encompasses everyone from doctors and nurses to hospitals and drug manufacturers.” He listed a Republican governor and out-of-office politicians as part of that consensus.

But when Congress votes, it’s more likely we’ll see something other than consensus. We could call it a “spirited consensus.” There is clearly consensus to do something – but any agreement breaks down when the specifics are spelled out. It’s likely there will not be a single Republican vote in the House and at best only one or two Republican votes in the Senate. That division is both partisan and philosophical.

But it’s that divide that represents our biggest challenge as a nation, our ability to govern ourselves.

There is consensus that our health care structure is not sustainable. But that will remain true even if the health care reform proposals pass. Much of the hope for long-term cost control is pinned on an independent Medicare Commission. The idea from the Senate Finance Committee: “In years when Medicare costs are projected to be unsustainable, the Commission’s proposals will take effect unless Congress passes an alternative measure. Congress would be allowed to consider an alternative proposal on a fast-track basis.”

The Medicare system is unsustainable now. Medicare’s trustees – including Treasury Secretary Timothy Geithner, Labor Secretary Hilda L. Solis and Health and Human Services Secretary Kathleen Sebelius – in their annual report look at both the near- and long-term viability. Right now the “trust fund does not meet the short-range test of financial adequacy.” The fund is in worse shape because the payroll tax is shrinking with so many people either out of work or being paid less.

The bigger challenge is longer term. “The financial outlook for the Medicare program continues to raise serious concerns. Total Medicare expenditures were $468 billion in 2008 and are expected to increase in future years at a faster pace than either workers’ earnings or the economy overall,” the trustees reported. “As a percentage of GDP, expenditures are projected to increase from 3.2 percent in 2008 to 11.4 percent by 2083 (based on our intermediate set of assumptions). Growth of this magnitude, if realized, would substantially increase the strain on the nation’s workers, Medicare beneficiaries, and the Federal Budget.”

It’s important to understand the impact of these numbers on Indian Country. The Indian Health Service – and for that matter, every federal program in Indian Country – operates with annual appropriations from Congress. The growth of Medicare (plus other entitlement programs plus debt service) means that the rest of the federal budget will shrink in the decades to come. Every dollar will be harder to get because so much federal spending is on automatic pilot. That will make it even more difficult for the Indian health system to receive even adequate funding.

Driving this bleak outlook is the fact that the federal government made more promises than the country can afford.

So how is Congress, under the plan of health care reform, tackling this sustainability question? It’s telling citizens that to reach sustainability, Congress would let an independent, unelected body make the hard decisions.

But this is the screwy part: It would limit what the Medicare Commission could do. “The Commission would be prohibited from making proposals that ration care, raise taxes, or change Medicare benefit or eligibility standards,” according to the Senate Finance Committee’s proposal.

Are we in the final days of the health care reform debate? Sorry. This debate represents only the first baby step. Whether health care reform passes or not, we have a long way to go before we reach a real consensus.

Full funding for a right ‘guaranteed’ by treaty

October 19, 2009

The idea that American Indians should be exempted from any mandate to purchase health insurance has almost become almost a given in the debate about health care reform.

Last week Speaker of the House Nancy Pelosi wrote to the National Congress of American Indians and said:
“We cannot ask Indian people to be penalized for choosing to use the Indian health care system. The House bill will ensure that the exemption from the financial penalties is extended to federally recognized tribes and that tribally provided health care benefits are appropriately protected.”

The Senate Finance bill already contains such a provision.

I’ve wondered about this mandate from the beginning of the process. I know too many people who do not participate in the mainstream economy; many of these folks are either unable or unwilling to navigate such a complex system. Imagine someone who hunts, fishes or is involved in a subsistence enterprise, figuring out what part of their income should be used to purchase even subsidized health insurance.

But even if you agree with the exemption – as I do – there remains another issue to resolve, the money. Unless health care reform substantially improves the funding stream for the Indian health care delivery system, then the individual exemption is only a guarantee of permanent disparity. The reason for the exemption in the first place is that the Indian health care system does not qualify as an acceptable insurance plan. The funding gap is too great.

The speaker hints at this in her letter to NCAI when she said that the “health reform legislation must ensure that adequate funds are made available to tribes to stamp out preventable illness and conditions that are having a devastating impact in your communities, such as diabetes.”

Could health care reform open up new revenue streams for the Indian health system? In theory, yes. All of the current health care bills in Congress contain elements that could significantly boost the funding stream for the Indian Health Service.

One way that could happen is by expanding Medicaid. Already there are many Native Americans who are eligible for Medicaid who do not apply, so any improvement in the application process ought to improve funding.

Medicaid is primarily designed primarily for low-income families with children, pregnant women and people with disabilities. The income requirements vary by state (because states are partners in Medicaid). None of this is final, but the House and Senate bills add adults without children with incomes up to 133 percent of the federal poverty level: $14,404 per year for one person or $19,378 for two (the figure is higher in Alaska and Hawaii). (The Senate Health, Education, Labor and Pension Committee goes further, making those earning less than 150 percent of the federal poverty level eligible.)

While the Senate Finance Committee bill boosts federal funding to states between now and in 2019, it also proposes to exempt states from the Medicaid expansion if the state certifies that it is experiencing a budget deficit.

So the expansion could disappear into state budget woes. The Center for Budget and Policy Priorities says there is no sign that the financial situation at the state level is improving. “At least 48 states have addressed or still face shortfalls in their budgets for fiscal year 2010 totaling $168 billion or 24 percent of state budgets,” the center reported. “At least 27 states have implemented cuts that will restrict low-income children’s or families’ eligibility for health insurance or reduce their access to health care services.”

This is a great example of waste. (Remember everyone wants to cut fraud, waste and abuse.) Medicaid money for the Indian health system is often a 100 percent federal obligation, yet the guidelines, eligibility and paperwork flow through the states. It would seem that there is a simpler way to transfer money from one federal agency to another.

Pelosi wrote in her letter to NCAI that she is  “working closely with the committees and the Obama administration to ensure that the health delivery system that was guaranteed to American Indians and Alaska Natives through treaty rights is not inadvertently harmed.”

What about inadvertently funded?

The debate that drags on and on

October 26, 2009

How long will the health care reform debate drag on? The Hill newspaper says “deep into December and possibly beyond by a lengthy floor debate.”

If that seems like a long time, consider that the reauthorization of the Indian Health Care Improvement Act has been pending since 1999.

Last week hearings were held in the House to move that legislation forward. Again.

Rep. Frank Pallone, Jr., chairman of the House Energy and Commerce Subcommittee on Health, opened hearings on the Indian Health Care Improvement Act Amendments of 2009 by once again saying that, yes, there is a federal obligation to provide health care, and, no, the United States doesn’t deliver.

“Putting all the legal aspects aside, I think the trust responsibility can be summed up by saying that something is owned to American Indians for the lands that were both voluntarily given to the United States and forcefully taken, as well as the atrocities that were committed against their peoples,” Pallone said. “But the federal government has consistently failed to live up to this responsibility in almost every respect.”

The IHCIA would improve standards for cancer screening, authorize IHS to operate hospice, long-term care and assisted-living centers, upgrade epidemiology centers, create convenient-care demonstration projects and integrate mental health, social services, domestic child abuse, suicide prevention and substance-abuse suicide into the delivery system.

These days federal legislation of any kind is complicated (usually hundreds or thousands of pages) and it often has a built-in expiration date, so Congress must act again to reauthorize the law. The original Indian Health Care Improvement Act was signed into law by President Gerald Ford – and officially expired at the end of September 2000. The original funding mechanism for the Bureau of Indian Affairs and the Indian Health Service is the 1921 Synder Act. The law is only one page – and it does not expire.

The language of that act is instructive. It gives the BIA (and now the IHS) the authority to spend money “for the benefit, care, and assistance of the Indians throughout the United States.” That includes money for “relief of distress and conservation of health.”

I should add: A “permanent” authorization for the conservation of health because that’s what is needed again.

“It’s time to make the Indian Health Care Improvement Act a permanent federal law,” testified Rachel Joseph on Oct. 20 before the House subcommittee. Joseph was speaking on behalf of the National Tribal Steering Committee for the Reauthorization of the Indian Health Care Improvement Act and the National Indian Health Board.  “The theory that ‘sunset’ dates are needed to spur Congress to periodically review and update major laws has not worked in the IHCIA context.”

Joseph said the proof of the need is the decade-long legislative fight for that reauthorization “despite intense work and advocacy from throughout Indian Country.”

The Senate version of the IHCIA would make the law permanent.

However, a second track is to include the IHCIA as a part of the larger health reform legislation. New Mexico Rep. Martin Henrich said last week he was successful with that approach because health insurance reform “cannot leave Native Americans behind.”

If this process looks confusing, that’s because it is. The actual language of the House bill remains in draft form and subject to much revision and negotiation.

There is no longer debate about whether there will be a health care bill. The Associated Press put it this way:  “The questions are when, how — and who can compromise. Democratic leaders expect their members, looking ahead to next year’s elections, to vote for a health care bill despite any misgivings. But the vote-counters have no real way of knowing until each chamber produces a bill. That’s why negotiators have slogged through months of hearings, hundreds of amendments and meetings with members that require interminable listening, waiting, reassuring, cajoling and answering questions from the recalcitrant.”

The challenge for Indian Country is to become more than a footnote to the larger debate.

A Practical Reform: Indian Country as the 51st state

(Published by Kaiser Health News)

October 29, 2009

Health care reform will be high on the list of topics for President Barack Obama’s meeting next Thursday with representatives of the nation’s 564 federally recognized tribes. The president said he looks forward to talks with tribal leaders about ways to “improve their lives and the lives of their peoples.”

The president will be looking for political support from Indian Country for his broader reform proposals, while tribal leaders will be seeking improvements in the health care system for American Indians and Alaska Natives.

The U.S. Indian Health Service is the closest thing this country has to a single-payer system, serving nearly two million American Indians and Alaska Natives in 36 states. The agency represents the promise of health care for American Indians made through treaties and other laws and is a full health care delivery system. The IHS operates hospitals and clinics, funds tribal and urban facilities and manages programs ranging from sanitation to diabetes care.

But virtually everyone recognizes the IHS is seriously underfunded.

“Putting all the legal aspects aside, I think the trust responsibility can be summed up by saying that something is owed to American Indians for the lands that were both voluntarily given to the United States and forcefully taken, as well as the atrocities that were committed against their peoples,” said Democratic Rep. Frank Pallone Jr. of New Jersey at an Oct. 20 hearing about Indian health care. “But the federal government has consistently failed to live up to this responsibility in almost every respect.”

The Indian Health Service, in fact, doesn’t even count as an acceptable insurance plan under any reform bill. This is ironic because those same health proposals exempt American Indians from the individual mandate to purchase health insurance because of that IHS promise. But unless funding improves, health care reform will guarantee a permanent disparity in just about every Native American health statistic.

At a meeting of the National Congress of American Indians last month tribal leaders said they would ask the president for at least a “no harm” statement protecting the “already strained” Indian Health Service from future cuts.

Yet no one is asking the president for full IHS funding — at least directly.

One idea is to improve the IHS’ ability to tap Medicare, Medicaid and the Children’s Health Insurance Program. The Indian Health Service was left out of the original Medicare and Medicaid legislation and was not added until the Indian Health Care Improvement Act in 1976. It now receives about $650 million a year from Medicare and Medicaid, a figure still considerably less than it could be because entitlements promise money for every eligible person. However, the IHS is funded by annual appropriation.

These days Medicare is considered a nearly universal system for America’s elders. There is a 20-fold difference in the actual number of Native elders 65 years of age and older not covered by Medicare than and the U.S. general population (or 15% versus 0.7%). Native elders do not have enough quarters of work to qualify for Medicare, but do qualify for Medicaid.

Enrolling more Native Americans in Medicaid is complicated by the partnership between federal and state governments. States write the rules, under broad guidelines, while the federal government pays for nearly all of the cost for Indian health programs. The Government Accountability Office found that the range of Medicaid reimbursements at IHS facilities ranged from 2 to 49 percent and not surprisingly, “the facilities with higher reimbursements had additional funds to hire staff and purchase equipment and supplies.”

The practical problem for Medicaid is its administration by state governments, which have uneven relationships with tribes and Indian organizations. Even if those states work well with tribes, imagine the complexity for tribes with members living on their home reservation, but in different states. For example, the Navajo Nation program managers must help clients navigate the eligibility process under specific rules for Medicaid programs in Arizona, New Mexico and Utah.

This is a way to save money by cutting waste. Instead of sending federal dollars to state Medicaid (and Children’s Health Insurance Program) offices, there ought to be a way to transfer money directly to IHS. There could be a new set of flexible rules written for Native Americans with far less administrative overhead than the 36 different systems. The federal government could treat Indian Country, at least for health programs, as the 51st state. This seems to me a practical application of the nation-to-nation relationship.

“Unrealistic” high expectations for tribal consultation

November 9, 2009

More than 20 years ago, the BBC captured the essence of bureaucracy in a sitcom called, “Yes, Minister.” The basic plot was 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. Then again, I remember a longtime Washington bureaucrat who once told me, “I’ve seen ‘em come, I’ve seen ‘em go.”

Every president is challenged by the nature of bureaucracy, and the agency that best reflects that power is the Office of Management and Budget. OMB is where many good ideas all but disappear from public discourse. The agency is a budget traffic cop, saying “no” to any agency request that it thinks costs too much.

These days the Nixon administration gets much credit for the president’s July 1970 Indian affairs message that called for a sharp break with the past. “This policy of forced termination is wrong, in my judgment,” the president said. “We have turned from the question of whether the Federal government has a responsibility to Indians to the question of how that responsibility can best be furthered.”

But Nixon’s words were not all that different from President Johnson’s message to Congress in 1968. LBJ also said it was time to end “the old debate” about termination and he stressed self-determination. But the president’s words fell flat because there wasn’t support in Congress or the bureaucracy for such substantive change.

This is the context for President Barack Obama’s meeting with tribal leaders Nov. 5. “I know that you may be skeptical that this time will be any different,” the president said. “You have every right to be and nobody would have blamed you if you didn’t come today.  But you did.  And I know what an extraordinary leap of faith that is on your part.”

And that leap of faith was matched immediately with the sort of action that doesn’t draw headlines. The president picked the OMB as the key agency to implement the government’s new policy. “I hereby direct each agency head to submit to the Director of the Office of Management and Budget (OMB), within 90 days after the date of this memorandum, a detailed plan of actions the agency will take to implement the policies and directives of Executive Order 13175.”

OMG the OMB! (That’s “oh my god!” for those who aren’t receiving texts from a teenager with a cell phone.)

This is the same agency that urged President Ford to veto S. 522, the Indian Health Care Improvement Act, in 1976 because “substantial” funds had already been spent on Indian health. “We believe S. 522 is a particularly egregious example of unnecessary legislation that will result in high unrealistic expectations among the very group it is intended to help.”

I like the idea of unrealistic high expectations. Now that the order is published in the Federal Register we should expect a real consultation process with agencies ranging from the office of U.S. Trade Representative to the Internal Revenue Service. Consider this process mechanism: Because the OMB is responsible for this policy, the spending for tribal consultation by every government agency already has a green light.

On top of that, the task ahead will be easier because so many      Cabinet-level officers were at the meeting with tribes at the Interior Department. They already know, and get, why consultation is a big deal.

President Obama’s directive doesn’t guarantee success. But it is a significant step because it incorporates the bureaucracy itself into the way ahead. This may not make sitcom fodder, but it’s important because bureaucrats make much better partners than opponents.

The abortion debate overrides health care reform

November 16, 2009

I’d love to be wrong, but health care reform is dead.

I know, I know, the process is not over. In a week or so there will be a flurry of activity when Senate Majority Leader Harry Reid brings a compromise bill to the floor. There will be starts and stops and a pitch for 60 votes. There may even be enough to pass a bill of some kind.

But consider the process. I smile when I think of legislative “process” because I remember the cartoon from my youth, Schoolhouse Rock, where the bill itself explains the odds against it by saying, “I may die.” That phrase is the key to understanding the legislative maze: There are far more ways to kill a bill than to enact one. Every step through that labyrinth requires choices designed to attract enough votes to make one more step.

Such was the case in the House of Representatives when it voted to prohibit either a government-insurance program or a private one that accepts government subsidies from spending money to cover abortion services. This was considered critical to passing the bill because so many Democrats who were anti-abortion rights said it was either this or no bill. It worked: The House passed H.R. 3962 by five votes, 220 in favor, 215 against. Even then nearly 40 Democrats were on the “nay” side, including South Dakota’s Rep. Stephanie Herseth Sandlin. She told the Rapid City Journal: “I think they’ve had a sense, just as they did on other legislation, that my priorities for South Dakotans were not being adequately addressed.” But she should have qualified her statement to read: “some South Dakotans,” because her no vote also was a rejection of the Indian Health Care Improvement Act.

The thing about Congress is we don’t really know the real strength of the Democratic vote. Once the leadership had enough votes to ensure passage, they likely let members in swing or Republican districts vote the other way for show. The idea is it will help them preserve their jobs (and a Democratic majority).

But the real change in the debate was the abortion amendment. There had been a truce keeping abortion rights at status quo. The sponsors of health care reform picked this approach early. President Obama said in August: “You’ve heard this is all going to mean government funding of abortion. Not true.” The thought was the Hyde Amendment prohibiting the use of federal funds for abortions would stay firmly in place.

That was true until the congressional vote last week. Now the House bill is even more restrictive on abortion rights than any federal program or on current health insurance policies for federal employees. It’s particularly important in 17 states that permit the use of state Medicaid money for reproductive health, including abortions.

If the politics of this looks familiar it’s because the abortion debate is why the Indian Health Care Improvement Act failed last year. Sen. David Vitter, R-Louisiana, added an amendment to explicitly restrict abortion, ultimately dooming the bill. Leaders in the House wouldn’t even take up the bill after that amendment passed.

Vitter said he did this to block “legislative loopholes” that permitted some abortions in the Indian health care system. “It is time for that to change,” he said, “and it is time to finally close this loophole.”

But what Vitter really did was to demonstrate that he and his allies are willing to sacrifice anything – including health services for American Indians – in order to score points on the abortion issue. His amendment was called a poison pill. It’s still there – and is now why health care reform is over.

The good news, the hope, is that health care reform will surface again and again until it does pass. The combination of economics and demographics will continue to drive reform legislation forward. It might even be better next time because there will be many, many more reasons to go further.

I’d love to be wrong, but health care reform is dead.

Health care reform means a significant boost in resources for Indian Country

November 23, 2009

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 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 Alaska 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. The House approach is to expand Medicaid to individuals, couples and families with incomes up to 150 percent of the federal poverty level or about $33,000 a year for a family of four.

The expansion of Medicare, Medicaid and CHIP is important to the Indian health care delivery system because IHS and tribal or urban clinics can bill the federal government for every eligible patient without regard to federal budgets. If a person is eligible, the money is there. (Contrast that with the contract health care fund that is an appropriation and always short of funding.) This is also significant because single adults will be eligible for the first time based on income. The House legislation would also improve payments made to medical providers under Medicaid and CHIP. That, too, could add dollars to the Indian health system. On top of that there will be new money available to fund urban clinics, including those serving American Indians and Alaska Natives.

It’s unclear what the legislation would mean to American Indians and Alaska Natives who earn more than the federal poverty guidelines. The bills provide an exemption from the insurance mandate, so a lot would depend on what type of insurance is offered by their employer.

The House legislation requires employers with payrolls more than $500,000 a year – including tribal governments – to offer insurance or pay a penalty. The Senate bill does not require coverage, but does levy a fee for medium and larger businesses. This could be an issue for tribes with self-insurance programs, depending on the final language.

It’s also worth noting that the Senate bill includes a significant funding stream for education and workforce training. Even tribal colleges are on track to get a share in order to prepare more health professionals.

But beyond Indian Country and beyond the headline material – the public option, abortion coverage and insurance mandates – there are ideas in health reform that really ought to be front and center.

We know that the care of chronic diseases, including diabetes, is increasing faster than the capacity of the system and even now accounts for some three-quarters of spending. Nearly four in ten 10 Americans are dealing with at least one chronic illness such as diabetes, heart disease, cancer and arthritis. And if you look at the growth rates for diabetes (and the trend ahead from pre-diabetes), it’s clear there must be a systemic reform. Quickly. The richest opportunity for “bending the cost curve” comes from money spent on programs that prevent these chronic diseases (and their complications).

To say the process ahead is challenging is an understatement. Health care reform remains a difficult sale. But its passage, if it can be done, will signal to Americans, the insurance companies, and the medical community about the inevitability of dramatic change.

A political system where it’s easier to spend than save or easier to borrow than tax

November 30, 2009

The month of December promises to be full of drama: Will the Senate pass health care reform? Is there enough time to debate the hundreds of expected amendments before Christmas? And at the top of the wish list, are there really 60 votes to pass a bill?

The notion of requiring a supermajority in the Senate may be one of our nation’s most anti-democratic traditions.  The Senate elects two members from each state. California’s 36 million citizens get two votes – exactly the same two votes as Wyoming’s 532,000 people. The supermajority makes matters worse because senators representing less than 40 percent of the population can block the legislation that most Americans favor.

The Senate has a unique history and in that favorite argument used by so many, “We have always done it that way.” The Senate has a unique history and culture and because of that it clings to the notion that “we have always done it that way.” But let’s be clear about this: The structure of the Senate does not represent democratic values. Why does this matter? Especially when it’s worked for more than two centuries? It matters because health care reform is a test of our continued ability to govern ourselves.

Politicians have been putting off difficult decisions for generations and we are moving toward a date of resolution. The requirement of fixing health care must be seen in the context of a political system where it’s easier to spend than to save, and easier to borrow than to tax.

The current scare over health care rationing makes this point exactly: No one has to give up anything. We can afford the very best, most expensive treatments, even when they don’t work.

But we really can’t. We can’t borrow enough money indefinitely. We have to reform the system so that we can make choices about what’s the best medical option for the most people. This is a concept that has been applied to Indian Country for a long time (often with tragic consequences). When Indian Health Service contract funds are depleted, many medical options disappear as well. It’s my hope that health care reform will improve, if not fix, this problem because there will be more funding sources open to IHS patients.

But despite the grand promises of the same doctor, the same insurance company, yada yada, for most Americans there will be a day when cost controls are an essential part of the equation. One way or another there needs to be a rational discussion about rationing care.

Before the end of the month Congress will once again have to increase the legal limit for the national debt that now exceeds $12 trillion. This is a number so big it doesn’t mean anything. But it’s not just a number; it’s a call to those of us who believe in self-government to figure out a strategy for us to say “no” to ourselves (and elect those who say “no” as well).

“The nation faces an unsustainable fiscal future unless the president and Congress change current policies,” according to updated projections from the Center on Budget and Policy Priorities. “The main driver of the long-term fiscal imbalance is the rising per-person cost of health care, which will increase spending and reduce revenues.”

Why is health care so expensive? It boils down to two things: More of us are growing older and we live longer. A study in the new issue of Diabetes Care is a good example. It says the cost of treating diabetes (the most expensive health care treatment regime) will double in the next 25 years to $336 billion a year. “These changes are driven more by the size of incoming age cohorts than by changes in obesity or overweight rates,” the study found.

We are growing older and more expensive. We can’t afford to borrow whatever amount we need to pay for any treatment we think might work. And, if we get this wrong, we risk either a generational civil war (“I’m not paying for you, old man”) or the United States collapses as quickly as the Soviet Union did. It’s the demographic imperative that ought to be at the heart of the Senate debate. Too bad it’s too much drama for politics.

Our system ties health care to our jobs (even when those jobs are gone)

December 7, 2009

There is much talk about the recession reaching bottom. The economy is at a turning point. Again. The proof, at least this time, was the drop in the national unemployment rate to 10 percent.

But that data point doesn’t really reflect the jobs picture in this country. Here are two better ones: State unemployment funds are running out of money and 9.24 million people are working part time (slightly down from a month ago) who would much rather work full time. A year ago the figure was 7.3 million.

Both of these numbers have huge implications for the health care reform debate. Too many people are working part time, without benefits, because it’s the only job they can find.

Mike Sherlock, an investment advisor, publishes a fascinating blog called MISH’S Global Economic Trend Analysis. He reports: “15 states have collectively borrowed more than $15 billion and another 9 states are in the red over unemployment benefits.” One One of the examples MISH cites is North Carolina North Carolina, where high unemployment has cost the state $1.4 billion in debt, growing as much as $20 million a day. The state is hoping the federal government at some point will forgive these loans because there’s no real plan to pay it back.

“Let’s do the math. The state budget is $19 billion. Potentially $4 billion will be borrowed to pay unemployment benefits. In other words, the state is borrowing an amount equal to 21% of its total budget just to pay unemployment benefits. Wow,” MISH reports.

That’s only one state of the 24 now in the red. Add to that the state projections for Medicaid and Children’s Health Insurance and the picture is more complete. And bleak.

Consider those who are working part time. If the economy is improving, folks should start getting more hours on the job (hopefully enough hours to quality for benefits). But that will happen not happen before new jobs are created. We have a long way to go.

Another element in this crisis is health insurance. Many of those who lost their jobs in the first wave are starting to run out of a federal subsidy for their health insurance under COBRA. Unless Congress acts (quickly) to extend that subsidy, health care costs for unemployed folks will be prohibitive. A family of four could see their health insurance costs go from roughly $500 a month to $1,500 a month. An increase that’s nearly impossible to cover without a job. A really, really great job at that.

The context for all of this is that we have tied our entire health care system to employment. Most people get their health care through work. If health care reform passes, this should improve through new subsidies and exchanges – in a couple of years. But the tradeoff is a requirement to buy health insurance.

Indian Country is a special case. American Indians and Alaska Natives will be exempted from the mandate. But there are employment-related questions that remain.

Would it make sense for an American Indian or Alaska Native entrepreneur to buy health insurance for her workers? There would be no requirement. The individual member would still be eligible for Indian Health Service. And, by the same measure, would any individual on the reservation buy into a health insurance exchange plan, even if it were subsidized? Tribal governments would probably buy plans for employees, but that would not close the gap.

I started with this project with the idea that the country nation has much to learn from Indian Country about health care reform. The relationship between health insurance and your job is a good example of that thinking. There is no employment-based system that can accommodate those outside of the regular workforce, those who fish, herd or bead. At the same time, fixing Indian Country’s structural unemployment – with rates that are unthinkable in any other context – must be a priority. This is a health care issue, too.

Want health care reform? Seek bliss … and work together

December 8, 2009

ORLANDO, Fla. – What do we want in a health care system?

It’s a question Dr. Donald Berwick asked an audience of 5,000-plus people at the Institute for Health Care Improvement’s National Forum on Tuesday.

Such an easy question. I can quickly rattle off answers: I want health care for my family. I want to be able to see a doctor when I’m ill. I want to be made healthy.

Stop. Berwick asks again. What do you really want? I want to be healthy.

This time think about it. Step back. Inhale. Think. Exhale. What do you really, really want?

Berwick explains how hard it is to skate ski and how he only hits perfection only a few times out of every hundred kicks. Yet it’s those moments he pursues. That’s what he really, really wants.

How does a cross-country kick fit into the health care reform debate? Berwick almost had surgery to replace his knee – something that would have prevented him from ever cross-country skiing again. But another doctor found an alternative to surgery. Perfect. Berwick wanted bliss, the richness of the human experience. One more moment on a mountain.

That notion is far removed from the politics of health care reform. The debate in Washington is about the role of government or insurance. It’s not about capturing bliss.

“Health care has no intrinsic value at all. None, Health does. Joy does. Peace does,” says Berwick. “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”

But our current system is not designed to empty hospital beds. Our reward system – dare I say, the very foundation of free enterprise – works best when hospital beds are full, CT scanners are humming and doctor visits are available on demand. That’s even true in government and the Indian Health Service because the appropriations process does not pay for those patients not requiring treatment. Yet that very idea, a paradox, is what could lower health care costs for all.

Berwick said it’s our version of the Tragedy of the Commons. The 1968 article in Science by Garrett Hardin described a pasture open to all that works reasonably well until “a day of reckoning, that is, the day when the long-desired goal of social stability becomes a reality. At this point, the inherent logic of the commons remorselessly generates tragedy.” The commons no longer works because each of us seeks the best deal for them.

“Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off,” Berwick said. “So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?”

Let’s make being a chump a good thing. The fact is the spirit of cooperation is already driving down medical costs in places as diverse as Anchorage with the Southcentral Foundation and Alaska Native Medical Center to Cedar Rapids, Iowa. Indeed, the great thing about the Indian health system is a head start in this regard. There is a long history of consultation – doctors and government officials working together with tribal leaders – for common solutions (and with little money). The Indian Health Service invented a prevention bundle – a series of tests – that look at many aspects of a patient’s life that helps identity and then treat problems ranging from spousal abuse to depression.

“I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong,” Berwick said. “It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.”

Forget health care reform. Let’s shoot for what we really, really want. But if we seek bliss, that means we must get folks working together.

Challenging the master narratives about government health care

December 15, 2009

ORLANDO, Fla. – There are two master narratives about the Indian Health Service. First, everyone knows the Indian health system needs more money. Everyone, it seems, except the collective members of Congress who, when they write budgets, can’t seem to appropriate at least as much money as they do for the U.S. Bureau of Prisons. And, second, critics say the Indian Health Service represents the failure of government-run care with complaints ranging from rationing to mismanagement of government funds. Just last week Sen. Tom Coburn, R-Oklahoma, repeated this narrative in his attack against the Senate’s health care reform bill. He again called the IHS “a failure.”

These two narratives stick because the truth is far more complicated. It’s hard to communicate a “yes, but” message in a political context. Yes, the IHS does ration care, but that’s because it has only so much money in its budget.  Yes, the IHS isn’t perfect with its spending (or insurance billing operations), but is that also a reflection of its limited budget? We really won’t know the answers unless the agency gets adequate funding.

There is another story that deserves at least the same attention as the first two themes: The really remarkable efforts underway to improve quality for American Indian and Alaska Native patients.

A partnership began three years ago with the IHS and the Institute for Healthcare Improvement focused on chronic diseases. The project is now called Improving Patient Care, or IPC, and is designed to show measurable improvements in preventive care, experience of care, managing chronic conditions, while maintaining financial viability.

In plain language, the goal of IPC is to make it easier for patients to see a doctor or nurse and then to spend less time in the waiting room (without spending too much money in the process). This is the ultimate initiative for doing more with less.

Dr. Charles “Ty” Reidhead, currently a fellow with the Institute for Healthcare Improvement in Boston as well as National Chief Clinical Consultant in Internal Medicine and chairman of the Chronic Care Initiative for the IHS, says the exciting thing about the IPC is that it is a tool to help “people who are already wanting to do better.”

“We learned pretty early on from the teams that it wasn’t just about chronic conditions,” Reidhead said. There was a solid track record of success from the IHS diabetes program, “so the idea was to do better at all the other conditions.”

The problem was if you pick any one condition, whether it’s cardiovascular or depression, a single focus might not be enough.

“We were worried that we wouldn’t change the system enough, we’d get better diabetes or depression care,” said Reidhead. “Instead what we tried to do to look at patient care to meet their needs, no matter what they came in with.”

One innovation to improve care was a standard bundle of patient tests, flagging early warning for alcohol misuse, depression, domestic violence, tobacco use, blood pressure and obesity.

Nearly 40 units in the Indian health system are part of the IPC pilot. A key element of the initiative is transparency. Results are measured and become learning tools that are shared across units in the program.

One of the reasons why the Indian health system is ahead of the rest or the country is the word “system.” If nothing else, this is what needs to be part of the larger discourse about health care. When a patient is discharged from a hospital, that system ends its service. There is no more. But that’s not true for health providers run by the IHS, tribes or urban organizations. They provide care for a “population.” The patient remains in the system even after being released from a hospital.

Why does a systemic approach matter? Because treating chronic diseases represents three out of four health care dollars. The goal of a low-cost, high-quality system is the only sustainable model going forward. And that is a story that must be told.


Are we there yet?

December 21, 2009

Early Monday morning the Senate moved health care insurance reform one step closer to becoming law. But the steps ahead, in political terms, must be perfect.

But I don’t want to bury the lead: The Indian Health Care Improvement Act is now in both the Senate and House version of health care reform. That means it’s off the table when the Senate and House iron out differences in Conference Committee (probably in early January). If health care reform becomes law, so does the Indian Health Care Improvement Act. That should open up new revenue stream for the Indian health system with new money for long-term care, more cancer screening and better mental health treatment options.

Other provisions in the health care bill itself should open up further resources, ranging from broader eligibility for Medicaid to higher reimbursement rates in rural areas.

Make no mistake: Indian Country benefits significantly from this health care reform legislation.

Now back to the politics. The Senate now has the 60 votes for passage. Monday’s test vote means the countdown has started. There will be more Senate votes, probably ending just hours before Christmas. Then the House and Senate versions will need to be reconciled, then two more votes, a majority in the House and a supermajority in the Senate of 60 votes. Then the bill goes to the White House for the president’s signature.

Exhausted? Think we’ve had enough of health care reform? Time to move on to the next issue, right? Sorry, but even if all that happens (I’ll explain the “if” shortly), the debate begins again on two separate tracks.

First, the Executive Branch will have to write regulations that define how the bill will be implemented. Take the word “quality” for example. What does that mean? What are the standards for quality care? Is it different in the Indian health system? The answers to many such questions will surface in thousands of pages of regulations issued by government agencies.

The second track would be the structure for an independent cost-cutting panel for Medicare. The House and Senate have different ideas about that, so the mission remains up in the air. But there will probably be a panel that will recommend where Medicare trims future costs (so much easier for an independent body to do that than Congress). This is where health reform could produce savings – something that is essential, given the nation’s demographics.

At this point it’s a bit like a long cross-country drive with young children: “Are we there yet? Are we?”

Well, it depends. A few weeks ago I pointed out that that the Indian Health Care Improvement Act failed in the last Congress because of abortion-related politics. Guess what’s hot on the agenda again? Abortion-related politics as it relates to the Indian health system. Those who are against abortion rights say the language in the Senate bill doesn’t go far enough to limit abortions (or more likely, abortion referrals) by the IHS. They want a specific prohibition along the lines of the Vitter amendment, language that doomed the Indian Health Care Improvement Act in the last Congress.

The test of all of this will be when the final bill reaches both houses of Congress; will the anti-abortion rights advocates (from both parties) have enough votes to stop health care insurance reform?

I’m more optimistic about this bill. When the president signs it into law it will be a signal sent to every patient, doctor, hospital, clinic, insurance company and taxpayer that the entire health care delivery system is being reshaped. The bill itself won’t make our health care better, but it launches a process that could do just that.

We’re not there yet. But we are moving.

Writing a check for Indian health

December 28, 2009

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 Alaska 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 halfway 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? Indeed, the history of federal appropriations – as well as the operation of a health care delivery system – ought to be applied to design of a larger health care system. That’s the ideal, anyway.

But there is another subject I want to write about during the next six months of my project: ideas for strengthening the Indian health system regardless of the larger reform. Yes, more money is needed. And, perhaps, health care reform will deliver on at least some part of the federal government’s promise.

But that’s not enough. The Indian health system must rapidly adapt to a new order of things. At the top of that list has to be a 21st century business model, one that recognizes the limitations of the federal government.

Sure, this will mean better third-party billing of private insurance plans, Medicaid and more. But even that will not be enough. There also ought to be a philanthropic component.

It’s time to invent a well-endowed national Indian health foundation, as well as regional and tribal foundations, to fund specific patient needs or programs that cannot secure government funding. The money could come from foundations, wealthy people, tribes, really, anyone who has compassion for people who need urgent health care they cannot afford. While the recession has taken its toll on the non-profit sector, Americans remain committed to giving.

This is the flip side of rationing; it’s an incredible opportunity to do something to improve the system without Congress. Some $350 billion is raised in this country for charities and as much as half goes to health care, notably hospitals. What if Indian Country had a non-profit fundraising goal of 1 percent of all health care giving? It’s a big number.

Actually the question is this: If the infrastructure were there, who wouldn’t want to give? Every story published about the failures of the system or Indian health disparity is just one more reason to write a check. An idea for the new year – Happy 2010.

Resolutions, experiments for a New Year

January 4, 2010

This New Year I am experimenting, instead of resoluting (I know, it’s not a real word, but it sounded right). I’m interested in how technology can play a role in behavior change: how to eat less, drink enough water, exercise more and sleep better.

This New Year I am experimenting, instead of resoluting. (I know it’s not a real word. But it just sounded right.) I’m interested in how technology can play a role in behavior change: how it might help us eat less, drink enough water, exercise more and sleep better.

The tool I’m playing with is called a Fitbit. I’ll write more about that later, but it’s already interesting because it measures steps, your sleep pattern (although I am quite ready to argue about falling asleep in the chair while watching TV). The device (and my family) says “yes,” but I know better.

I see how this technology could be helpful to wellness programs. Sunday I walked 11,289 steps (not quite three miles), consumed more than 2,000 calories and slept eight hours, waking up seven times during the night.

We change what we measure – and that includes our own behavior. Just by watching my personal data, I am inclined to walk more and eat less.

But that’s only part of what could make Fitbit important to a wellness routine. Part two will come when others I know are on the system and add their stats through social networks. Think of a community of folks who are rooting for your success, for your better health, as you urge them forward.

This is more experiment than resolution. But this is the season for resolutions – and for many that means it’s time to quit smoking.

A story in Indian Country Today reported about the Tulalip Tribe’s tobacco cessation effort. “Here at Tulalip and throughout Indian country we face an uphill battle in addressing use of tobacco. Some tobacco companies use Native American images and cultural symbols in their advertising, such as warriors, feathers and regalia. They also slip in words like ‘natural’ in the brand names to build image, credibility and sales within the Native American community,” Mel Sheldon, chairman of the Tulalip Tribes, told the newspaper.

I also like the innovative program run by the California Rural Indian Health Board– Keep Tobacco Sacred – because it reminds people about the traditional protocol for tobacco (instead of its recreational and commercial uses).

Smoking is a significant health concern for Indian Country. About a third of all American Indian and Alaska Natives are smokers, according to the National Tribal Tobacco Prevention Network. It represents the highest use rate for commercial tobacco in every age, ethnic and gender category in the U.S. We die in greater numbers because of tobacco use.

And it’s not just the act of smoking itself. Smoking complicates the management of chronic diseases, including diabetes.

But This is a complex problem for tribal leaders because some tribal enterprises depend on the sales or use of tobacco. Smoke shops are a source of reservation capital and jobs and tribal casinos market to smokers in states where other casinos, bars and just about any facility open to the public is smoke-free.

Unfortunately, it’s better for the casino business when there’s smoking. Even the casinos with separate non-smoking facilities find that people gamble significantly more per hour on the smoking side than in the non-smoking areas.

But what if the incentive framework was changed? What if the entire country – tribal casinos and their competitors alike – went non-smoking? That sounds far-fetched because the economics of a casino make this problem seem intractable.

But then again Indian Country has another history.

It turns out the Indian Health Service was one of the first hospital systems to go entirely non-smoking in 1985. “In late 1983, the PHS Indian Hospital on the Hopi Reservation at Kearns Canyon, Arizona, became the first to reach this goal,” the Centers for Disease Control said in a 1985 report. “Now, virtually all IHS facilities have become smoke-free. In addition, this initiative led to a smoke-free policy in the American Indian schools on the Navajo Reservation at Zuni, New Mexico.”

We don’t think of smoking at a clinic any longer. Could that be how we think of casinos one of these days? Some resoluting might be ahead.

The business model for an Indian health system

January 11, 2010

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 Alaska 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 Alaska 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. She said that means “to look at what we do well and also to look at what we don’t do well.” And then figure out where the tribes and the staff want to start with internal agency reform. She said the tribes are focused on big-picture issues: more funding, improvements in contract health program and better consultation networks.

“From the staff we received very few comments about improving health care services and most of the comments were about improving how we do business,” she said. “How we lead and manage people and how we do business as an organization.”

“That said a lot to me. You’d think in a health care system, your only focus is improving quality, but here, the staff said loud and clear, there are things about the Indian Health Service as a business that need to be improved.” She said this is particularly interesting and helpful because in order to “ultimately” improve the quality of care, “we have to improve the business.”

These two issues are not separate. Health organizations that improve patient quality are also improving their business operations (and vice versa).

One way to demonstrate both is to compete. American Indians and Alaska Natives often have choices in health care, especially those carrying employer-based insurance or Medicare. In that context the IHS is a competitor to those other health organizations and must demonstrate its expertise.

One of the biggest business challenges for the Indian Health Service is increasing revenue. The Obama administration boosted the IHS budget by 13 percent in 2010, but that is still less than what’s spent by other health organizations. Health care reform could help in this regard, too, as more American Indians and Alaska Natives are eligible or participate in insurance that opens up new billing options for IHS.

Consider the story of contract health services. This pool of appropriated money runs dry every year. “It’s a program that we know people aren’t satisfied with because in general American Indian and Alaska Native people believe that health care is owed to them. Unfortunately, with the contract health services program, we’re struggling to meet the needs with available resources,” Dr. Roubideaux said. “So the Indian Health Service has policies and regulations in place to help prioritize what referrals are paid for and that, unfortunately, results in some denials and deferments of services. We know the patients don’t like that. We know the tribes don’t like that, but it’s the reality of providing health care with a limited budget.”

The bottom line for contract health is the difference between appropriations – IHS must live within a budget – versus an entitlement program – Medicare pays for every eligible participant. That’s a decision that Congress, not the Indian Health Service, made.

Roubideaux said you could think of many ways to decide which referrals to pay for “but the only fair way is to look at the medical priorities.”

She said one thing IHS can do is to learn from best practices in contract health. That could mean better case management, patient education or billing alternative insurance resources.

Indeed, if health reform passes, that could open up more third-party billing options, again, reducing the stress on contract health funding.

Then new insurance dollars are part of the new business model for the Indian Health Service.

The world of if, then …

January 18, 2010

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 would 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 be 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 underfunding (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. 

Now what? Start over?

January 20, 2010

Did health care reform die at the ballot box? I’ve been reading on Twitter how pleased Republicans are with Scott Brown’s win for Ted Kennedy’s Senate seat. It’s a game changer.

The best way to catch the wave of that particular thought is to search Twitter using the hashtags #hcr or #tcot (health care reform and True Conservative on Twitter). The comments boil down to a push to “slow down” the government “takeover” of the health care system.

Unfortunately, “slow down” in this context means kill. Starting over is a process measured in years, not the months ahead before a new round of congressional elections.

Democrats say they’d still like to press ahead with a health bill, but it’s likely to be smaller. The House could, in theory, pass the current Senate bill without changes, sending it directly to the president. But that seems to be unlikely because those Democrats who weren’t all that excited about health care reform now have an easy exit. It’s scurry time in D.C.

The really tough thing about the chain of events is that it will be tricky to keep the Indian Health Care Improvement Act as part of any larger package; that likely means starting over as its own bill. Senate Indian Affairs Chairman Byron Dorgan told the Bismarck Tribune on Jan. 13 that the Indian Health Care Improvement Act remains a priority. Perhaps he can find a way to restart the bill on its own.

Washington moves from a game of “if  … then” construction to one of blame. The president should have done this, the Senate leadership that, or the House could have … .  You get the picture.

There were strategic choices made along the way that focused the debate in ways that didn’t pay off. Rolling the Indian Health Care Improvement Act is a good example. It would have been a smart move – if the bill passed. Now, not so.

One of the most interesting strategic choices was the framework of the debate itself. Health care reform, at least to me, is about solving two important problems: coverage for all Americans and controlling future costs before our system collapses. This debate was mostly about covering all Americans (or as many as could, given the politics). But the second issue, I think, is the one that must be dealt with soon. The system we have is not sustainable.

As the Congressional Budget Office noted recently: “ … if current laws do not change, federal spending on Medicare and Medicaid combined will grow from roughly 5 percent of GDP today to almost 10 percent by 2035. By 2080, the government would be spending almost as much, as a share of the economy, on just its two major health care programs as it has spent on all of its programs and services in recent years.”

Imagine the competition for federal dollars (or, conversely, the pressure to increase taxes) based on those numbers. It will be an even angrier debate than the one we’re having now.

Now that Republicans have 41 votes in the Senate, will they work together with Democrats to solve the problem? Good luck with that. We’re too close to the next election season.

This is a problem we can solve. Other countries have figured this out and reached consensus. Some have opted for single payer, others for a private-based system that still controls costs. But reading the anger on Twitter (or hearing from angry constituents in the town halls last summer) you have to wonder, how can we even have the right conversation?

We must find a way to work together – Democrats, Republicans and independents – with a clear purpose.  If we can’t do that (and soon) we’ll shift from the health care debates to a bigger philosophical question: Have we’ve lost our ability to govern ourselves?

The new currency: Transparency

January 25, 2010

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 supermajority 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 21st 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. “In addition to changing structures and processes within health care, we need to embrace new sorts of fresh thinking and fresh perspectives to get better, faster, more sustainable results,” wrote Helen Bevan, chief of service transformation at the National Health Service’s Institute for Innovation and Improvement in the report, The Power of One, The Power of Many.

What sort of fresh thinking?

Start by rethinking just who’s in charge. “Action and decision-making were really devolved rather than centralized,” the NHS said. “Where people could take action without reference back up the chain. Power was exercised by an empowered staff rather than just those with formal authority.”

This kind of empowerment only works only when it’s voluntary. Social media connects because people swarm around interesting people. It’s the same in a hospital staff when, the NHS found, “people did what they wanted to do, not what someone else wanted them to do.”

“At this point the reader may well be asking, ‘Why should I believe any of this? And anyway, are social movements not completely different from organizations?’ Both are reasonable questions,” the NHS said. And the answers must be “evidence-based.” The British health system says the pilots are still in early stages, but there are already many lessons surfacing.

Another example of fresh thinking is engaging – and seeking out feedback even when it’s critical. (Often there’s more to learn from a negative review, than a positive report.)

The independent site Patient Opinion asks patients to post: “If you’ve experienced health care recently, either as a patient yourself or as a carer or friend of someone else, please tell us how it was. What was good? What could have been better?”

The conservative opposition party in the United Kingdom is demanding more transparency and use of Social Media for the National Health Service. One proposal is a prize of 1 million pounds for a Website to “harness the wisdom of the crowds” for reviewing transformative proposals. One Tory Party leader, John Dehmam, told The Financial Timesto overhaul online “local spending reports” giving the public real-time information.

Critics dismiss this as an election gimmick. That could be. But it’s clear that transparency is a new currency in public discourse. Much of the anger about the health care reform bills could have been channeled into discourse had there been real-time, useful information online. Why not a wisdom-of-the-crowds approach to solving the two pressing problems in health care, namely expanding coverage to all Americans and reining reigning in the costs.

A few years ago, 300 million ideas would be unmanageable. Not so now. I can think of lots of ways that Congress could have made this reform process open and transparent. What about a chart in real time with all of the proposals, leading to a column that tells what’s in and what’s out? When it changes, just say so. No big deal. Or even more bold, could Congress handle a Wiki that collects ideas from every American? It’s worth an experiment or two.

Transparency as a tool for reform

February 1, 2010

Paul Levy’s Running A Hospital “is a blog started by a CEO of a large Boston hospital to share thoughts about hospitals, medicine and health care issues.” The postings started as a lark. But when the president and CEO of Beth Israel Deaconess Medical Center writes openly, that it sends a message that filters down throughout the system. Other hospital professionals started blogs and more hospital data was posted in real time making transparency a core value.

People already use the Web to search out medical information of all kinds (several studies show it second only to porn for Internet searches). Health organizations have a natural, built-in audience of people wanting to know what’s going on.

So how do health professionals manage this interest? “Effective immediately, the Hospital is blocking access to social networking sites including Facebook, MySpace and Twitter from all Hospital computers,” says an internal memo from another system as blogged by Levy. “The Executive Team will be working in the coming months to ensure that we have written policies in place that articulate the appropriate use of social networking sites while on duty at the Hospital. Once these written policies are in place, we have educated all employees about expectations and disciplinary action associated with violating the policies.”

The message is clear. Information is scary. Adults cannot be trusted.

Levy’s response: “Any form of communication (even conversations in the elevator!) can violate important privacy rules, but limiting people’s access to social media in the workplace will mainly inhibit the growth of community and discourage useful information sharing. It also creates a generational gap, in that Facebook, in particular, is often the medium of choice for people of a certain age. I often get many useful suggestions from staff in their 20s and 30s who tend not to use e-mail. Finally, consider the cost of building and using tools that attempt to ‘track utilization and monitor content.’ Not worth the effort, I say.”

It’s not worth the effort – and it’s counterproductive. Transparency is an added value to any health care organization. Being open – even reporting your own mistakes or poor execution – is an essential strategy for building a stronger network.

Levy writes a key part of any leader’s job is  “to create an environment in which people are so comfortable with their role in the organization, and are given the right tools for doing their job, that they hold themselves accountable. After all, most people want to do well in their job and want to do good in fulfilling the values of the enterprise. Why not trust in their inherent desire to be successful personally and collectively?”

That also happens to be the policy of the Obama administration. A December 8 memo from the Office of Management and Budget called for the creation of “a culture of open government.” Agencies across government, including the Indian Health Service, are in the process of coming up with plans to make execute that idea.  But this is new for government. The idea of every agency staffing a Twitter or Facebook account is still a huge debate. Federal employees often have to leave the building and go to a coffee shop if they want to update even an official social media site. (If you want to see a government agency with a smart social media plan, check out

Dr. Yvette Roubideaux’s director’s blog has the potential to engage the American Indian public the way Levy does with his blog. But it requires a different way of thinking – something that’s rare in government. For example, when I talk to Indian Health Service employees for this project, they must get permission from either their area office or headquarters before engaging with the media (let alone social media).

Imagine what the Indian Health Service could bring to its patients by embracing openness. Real-time information, ranging from data to patient feedback, can help any organization improve results. Quickly.  What would happen if every clinic, hospital or any other facility in the Indian health system had its own social media page, complete with patient feedback? What if patients were encouraged to access a computer terminal in the waiting room and post comments on their way in and out of a facility?

Real-time information is not scary. It’s a tool for reform.

Growing the budget during tough times

February 8, 2010

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 health care 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 a per-person basis.

Indeed, last April a tribal task force recommended a $2.1 billion increase in the budget authority for IHS in fiscal year 2011. The tribal leaders called for a 10-year phase in of $21.2 billion to reach spending parity.

The National Indian Health Board describes the budget this way: “The Budget demonstrates the Administration’s continuing commitment to honoring the Federal government’s trust responsibilities and treaty obligations. Exempting IHS from the same ‘freeze’ that other programs and agencies are under is a significant sign. However, with IHS deeply and chronically underfunded, IHS services remain woefully short of need.”

Perhaps the area that most highlights that shortage of need comes in the area of contract health care, services that must be purchased for IHS patients. There is a $46 million boost, or more than 11 percent, from $398 million in FY 2010 to $444 million in FY 2011. That’s important because it’s increasing faster than medical inflation (about 5.7 percent) and the patient population growth of about 2 percent.

Contract care is often the primary narrative for the Indian Health Service in news accounts. This is the source of “don’t get sick after June.”

A few weeks ago, before the budget was announced, I talked to IHS Director Yvette Roubideaux about contract health. “It’s a program where we know people are not satisfied because in general American Indian and Alaska Native people believe health care is something owed to them. Unfortunately, with the contract health service program we’re struggling to meet the need with existing resources,” she said. “That, unfortunately, results in some denials and deferments of services.  We know that the patients don’t like this; we know the tribes don’t like that, but it’s the reality of providing health care with a limited budget.”

Dr. Roubideaux said the fair way is to stick with medically based decisions. She would also like increasing the alternative sources of funding, such as employee insurance, Medicaid or Medicare.

That’s the other side of the contract health story. When clients of the Indian health system bring their own insurance – employer-based, purchased directly or because of other public programs – adds resources. The FY 2011 revenue budget only shows a slight growth in this area, revenue from private and public health insurance is estimated at $829 million, up from $814 million.

The president’s budget is only a proposal, one that will be refined by the Congress. That might even mean more money. But it’s important to put this in perspective. Federal domestic spending is under pressure because it’s an easy symbol of excess. The federal spending that’s growing the fastest is off the table, namely Medicare, Medicaid and interest on the debt.

And that brings us back to the need for general health care reform: There won’t be spending parity in the Indian health system until that’s accomplished.

The Nuka model of health care starts with the notion that relationships matter in a health care regime and that Alaskan Natives are the owner-customers of the system. Douglas Eby, M.D., MPH, vice president for Medical Services at the Alaska Native Medical Center and Katherine Gottlieb, MBA, the president and chief executive officer of the Southcentral Foundation in Anchorage. Photo: Mark Trahant, free use, no credit necessary.

Customer/owners are key to the Nuka model of health care in Anchorage

February 15, 2010

ANCHORAGE, ALASKA — It takes about 30 seconds of walking around the campus of the Alaska Native Medical Center to appreciate that you are in a special place. There are values communicated in every hallway.

Colorful banners remind visitors that the entire campus is tobacco-free, there are many gathering places scattered about for family and community with the finest in traditional art showcased and in waiting areas, there are open computer terminals for people to research their own health information. Signs remind patients that if you’ve been waiting more than 15 minutes, talk to someone.

This is what the Indian health system should look like across the country. “No,” a friend corrected me, “this is what the U.S. health care system should look like.”

The Alaska Native Medical Center is two facilities in one. Essentially, there is an inpatient hospital and some statewide services managed by the Alaska Native Tribal Health Consortium. And outpatient services are administered by the Southcentral Foundation. The two management teams work closely together.

The Indian Self-Determination and Education Assistance Act of 1975 opened up contracting for tribal and native management of Indian Health Service programs. Southcentral (a non-profit affiliate of the Cook Inlet Region, Inc.) assumed some programs in 1987 and by 1999 ran the whole show. Today Southcentral serves some 55,000 people with 1,400 employees (including 10,000 in 55 remote villages).

“I believe that Alaska is the only state that has enacted Indian self-determination to the fullest extent of the law in assuming health care,” says Katherine Gottlieb, president and chief executive officer of the Southcentral Foundation. “We have taken what we had from the government and transformed it.”

Self-determination in Alaska means just that. It’s not just federal programs managed by a native organization; instead, the federal money is redesigned to build a system based on Alaska Native ownership.

So much so that Southcentral Foundation continually refers to its “customer/owners” as its foundation and inspiration.

Southcentral’s “Nuka” model of health care boils down to some basic ideas: that relationships are the key to health care; that patient care should be integrated, there should be same-day access to primary care; customer-owners are partners in their own health care and there they should be given ample opportunity to offer advice and feedback. And to make all of this happen, there should be a culture where training and retraining is valued.

Some two decades ago, the Indian Health Service asked Gottlieb to conduct a survey of its Anchorage hospital. “Are you sure you want to do that?” she asked. “I was, like, delighted because I knew what the answers were going to be. I was not surprised at all when the answers came back. Long waits. Everybody hated waiting.”

Most of the primary care back then was in the hospital’s emergency room where they were handling everything from “heart attacks, broken arms, strep throat, to you name it, and here we were coming in with our baby for just an appointment,” Gottlieb said. “I personally waited up to seven hours, waiting for an appointment, just to get in the door.”

After contracting from the IHS, Southcentral Foundation made surveys and listening to customer/owners a key ingredient in its culture. “I think transparency is a key to success,” said Gottlieb. “Transparency in yourself and in everybody.”

Most health care organizations take complaints and file them away. “We don’t file the complaints,” Gottlieb said. “We use them for improvement. Constant. Instant. Fast improvement.” Complaints are logged in and referred to a Customer Satisfaction Committee. Each department receives the complaints and asked for a response and a resolution. These complaints are reviewed quarterly at the vice presidential level.

“We are literally customer-owners, Alaska Natives. Our board of directors are all Alaska Natives,” she said. So when people are hired they are told this system is customer-owned. That’s part of the deal: Every patient is one of those owners.

And patient owners aren’t keen on waiting. That explains the 15-minute signs in the waiting room – and the philosophy behind the service. Patients can communicate by e-mail or fax – and expect answers on the same day.

The primary-care facility has four identical wings. Each entry area is smaller, more like a neighborhood clinic than a large facility’s overcrowded “waiting” room. But what is really striking is the attention to detail: The reception area is inviting; interview rooms are designed so patients and their medical team partners can have conversations sitting at the same level in rooms absent of examination tables (unless absolutely necessary). Customer-owners are treated with respect.

The medical team approach is different, too. The team sits together without hierarchy. Members include doctors, medical assistants, nurses, care coordinators and often a behaviorist. Customer-owners can choose their own team – and make changes if unhappy. The ideal is integrated, so patients don’t have to make as many return visits.

Consider how most health care dollars are spent: Expenses increase at the end of a person’s life. What if that was reversed? What if dollars instead were invested early on prevention? That means treating the root causes of diseases before they surface as heart diseases, diabetes, depression or domestic violence.

When root causes are treated, there will be a reduction in the health disparities that are so much a part of the Native American experience. Gottlieb describes this model as even more imperative because as the baby boom generation ages, those costs will be unaffordable.

The data backs up the Nuka model. There has been a 40 percent reduction in emergency room, urgent care. A 50 percent decrease in specialty care visits; a 20 percent decrease in primary care visits and a 35-plus percent decrease in admissions. “We have statistics that show a generational change,” Gottlieb said.

The Nuka model is not about money. “We still have a poorly funded IHS system. We are not fully funded,” says Gottlieb. In fact, she says, the government has not fulfilled its treaty-trust obligations to American Indians and Alaska Natives. “Not yet.”

Southcentral’s system is about 45 percent funded by the Indian Health Service, 50 percent from “aggressive” billing of third-party insurers or Medicaid and the remaining 5 percent from foundation or other government grants.

“You won’t find anything in Indian Country like this campus,” said Douglas Eby, the Alaska Native Medical Center’s vice president for medical services. There is less direct funding from IHS and this is by far the biggest, most sophisticated campus in the Indian health system that’s far better off than most for a variety of reasons ranging from leadership to the structure and resources of Alaska Native corporations.

“We were smart enough to say we need to optimize revenue, and we’ve done very well at doing that,” Eby said. But the growth in population, people moving in from the villages, flat funding from HIS IHS and health care being such a “wasteful” business drove a rethinking of business model. “Our real hope lies in controlling costs, doing things smarter, better and avoiding high care cost as much as possible.”

The same could be said about the entire U.S. health care system. And, it turns out, controlling costs also results in better health care outcomes.

Yes, this is exactly what America’s health care system should look like.

Finding consensus at Blair House on the Indian Health Care Improvement Act

February 22, 2010

President Barack Obama is hosting a health care summit Thursday at the Blair House. It will be televised live. We can all watch and judge the proposals for ourselves. That transparency is an ideal opportunity for the president, Democrats and Republicans to put their best ideas forward and debate different approaches to solving the health care crisis.

“I am inviting members of both parties to take part in a bipartisan health care meeting, and I hope they come in a spirit of good faith. I don’t want to see this meeting turn into political theater, with each side simply reciting talking points and trying to score political points,” the president said in his weekly radio address. “Instead, I ask members of both parties to seek common ground in an effort to solve a problem that’s been with us for generations.”

But after months of rancor about health care reform, is there any common ground left? Absolutely. And I hope our elected leaders think so, too.

First, there is common ground on the fundamental nature of the U.S. system, employer-based health care. Neither Democrats nor Republicans dare attack what should be at the heart of the debate.

I’ll throw out my wishful thought for the day: We made a mistake with employer-based health care and should be looking for a national exit strategy.

But Democrats are attached to the current system in part because labor unions, a key constituent group, have fought hard battles to win health care benefits for workers. This notion would be fine except the nature of work is changing (if you are lucky enough to have a job). If you work for yourself (or even want to work for yourself), the prospect of buying insurance on the open market these days is daunting. For example, I am relying on my former employer’s health care plan via COBRA. This plan is subsidized by a generous 66 percent subsidy from taxpayers (a back-door approach to health care reform?) but when that ends in a few months, I am not sure what I’ll do next.

On the other hand, the problem for Republicans is that once you say that employment-based health care is a mistake, the assumption is that the only alternative is a government-based single-player plan. There are, of course, other options but how do you make the practical transition away from employer-based plans? Yet a shift of the health care responsibility away from jobs to individuals actually represents conservative ideas about individual responsibility.

But that’s enough trashing of the employer-based system. At least for now. There is a political consensus that employer-based health care stays. (Again, for now.) So the debate will be a back and forth about what goofy mechanisms are required to keep in place an illogical, impossible-to-design health care insurance system.

There is another issue of common ground that probably won’t get the attention it deserves on Thursday: improving the Indian health system. This is clearly a government obligation and one where conservatives and liberals alike say the government has failed to live up to its promises. In an ideal world, that would mean full funding of the Indian Health Service.

But this week perhaps the best that can be done is an agreement to reauthorize the Indian Health Care Improvement Act. The president’s proposal includes this provision – as does do both the Senate and the House bills. It should be an easy sell.

Will Republicans agree? A generation ago, the original Indian Health Care Improvement Act had bipartisan support in Congress and was signed into law by President Gerald Ford.

Today one of the best cases for the conservative side of this debate comes from J.D. Hayworth. Hayworth is running against Arizona Sen. John McCain for the Republican nomination because, as Hayworth put it, McCain “campaigns like a conservative and … legislates like a liberal.” Hayworth’s credentials are solid in settings ranging from right-wing talk radio to any Tea Party assembly.

So what does Hayworth say about the Indian Health Care Improvement Act? As a member of the U.S. House of Representatives, he testified in support for the reauthorization in 2004. “Unfortunately, today’s health care delivery to Native American communities remains disproportionately less than what the general population receives here in the United States,” Hayworth said.

Part of the problem, Hayworth said, is the that “year-by-year appropriation is not the optimal way to fund Indian Health Services. The tribes do not like it. Fiscal conservatives do not like it.”

Nothing has changed. Tribes still don’t like year-by-year approach. Fiscal conservatives ought not either. There is a lot of common ground here that could help produce a Blair House agreement.

The best health care in the world (if you’re a Canadian premier)

March 1, 2010

I didn’t figure the Indian health system would be a huge agenda item at the Blair House bipartisan meeting last week. On paper, at least, the Indian Health Care Improvement Act is one of ten 10 titles in the president’s proposal. So ideally Title 10 would have rated a mention.

It would have been even better to hear a debate about the merits of reauthorizing the 1976 law at the summit with the Democratic and Republican leaders in Congress. Some of the Republicans at Blair House have complained many times that the Indian Health Service represents the worst of government-run care. So, we ought to ask, “Why not fully fund the IHS and give it the resources to be successful?”

No such question was asked. Then no tribal leaders were in the room and the only American Indian representative in Congress wasn’t there … so it was easy for the subject to never come up.

I watched the meeting on the Internet and updated short items on Twitter (a “live tweet” with my 140-word commentary about the meeting). I wrote: Can we agree US health care system finest in the world? No. Another point of diff. WHO ranks France first (we’re not top 10, 20 or 30) #hcr.

The context for this tweet was when Wyoming Sen. John Barrasso said: “I do believe we have the best health care system in the world. That’s why the premier of one of the Canadian provinces came here just last week to have his heart operated on. He said, ‘It’s my heart, it’s my life. I want to go where it’s the best.’ And he came to the United States. It’s where a member of parliament – a Canadian member of parliament with cancer came to the United States for her care. They all have coverage there, but what they want is care.”

If you believe the U.S. health care system is the best in the world, why change a thing?

As I wrote in my tweet, the World Health Organization has a different take on our “best” health care. We rank 37th overall. If you compare the United States to other industrial nations, we’re last. We’re 39th in infant mortality; 3rd third for adult female mortality; 42nd for adult male mortality; and 36th for life expectancy. But we do have a No. 1 spot: We spend more per person than any other country in the world.

The president responded to Dr. Barrasso by saying most Americans are “not premiers of any place. They’re not sultans from wherever. They don’t fly in to Mayo and suddenly, you know, decide they’re going to spend a couple million on the absolute best health care. They’re folks who are left out.”

And I thought the Indian health system wasn’t on the agenda?

We need more conversation about health care, wealth, poverty and how we define what makes the “best” health care system in the world.

No system is at its best when a Canadian premier can fly in for advanced surgery while a patient at a federally run Indian Health Service facility is told too bad that procedure will have to wait because there’s just not enough money in the pot called “contract health.” Or what does it say about the “best” when the government’s own auditors describe the Indian health system as too poorly funded to qualify as basic insurance?

But at least the Indian health system affords basic coverage for its patients. Across the country the situation for those without insurance is even bleaker. In Idaho, for example, the state next door to Barrasso’s Wyoming, the number of people on employer-based plans fell to 56 percent last year from 82 percent in 2002.

This is the moral divide. We can pretend our system is best in the world. Or we can try to make that ideal so. Every one of us should be able to say, “It’s my heart, it’s my life” too. Life, too”

Why the Indian Health Service should embrace Facebook

March 8, 2010

How does a health care agency listen to patient complaints in the era of social media? Well, the easiest thing to do is to ignore complaints or to explain them away. The best practice: Treat complaints as critical nuggets of information.

Let’s start with a bit of context. The U.S. Department of Health and Human Services and the Indian Health Service have an extensive process for tribal consultation. There is a formula for listening to tribal leaders about its operation, priorities and budgets. There’s also an open line for internal IHS reform. The IHS collects data about best practices, ranging from treatments for cardiovascular disease to partnerships with traditional healers. This is a simple but important way to share ideas about programs or treatments that work.

So the context is that the Indian Health Service has an extensive practice collecting information – complaints – from tribal and community leaders. In general, the Indian Health Service does a better job of listening to its constituents than most health care agencies. But that system was designed for another time.

So back to the question: How does a health agency listen to patient complaints in the era of social media? Each unit, clinic or hospital has a formal process, but most complaints aren’t filed; they are spoken between family members or said in the waiting room. How does a modern health care agency learn from that?

This is where the new world of social media kicks in. Patients are contributing thousands of bits of information on Facebook in a group called, “I just spent 6 hours at IHS just for them to give me Tylenol.”Angel White Eyes writes from Pine Ridge that she got the idea after getting sick a couple of months ago. “I was throwing up and coughing up blood. Plus had flu symptoms. I contemplated on going to IHS all weekend because I knew they’d only give me Tylenol.”

Her Facebook friends convinced persuaded her to go into the clinic anyway. “After sitting at IHS for 4 hours, I told them all my symptoms, and they said I had a virus and gave me some Tylenol and cough syrup and told me to stay home,” White Eyes said.

Then she posted a rant to her Facebook page. “At first I had joked about creating the group but one of my friends convinced me that it should actually be done. And I knew there were a lot of people who had their IHS stories too. I did expect to see their complaints and what had happened to them at IHS. I didn’t know what to categorize the group so I put it as just for fun because IHS is a joke in a way.”

More than 1,600 people have joined the group and are telling their own stories. Long waits and Tylenol are common themes. And not all of the information is critical. Some report good experiences with IHS.

This may sound odd but the Indian Health Service is lucky to have such a page already created on Facebook. The agency ought to embrace it, monitor it, react when it can and learn. It’s golden intelligence because it’s a real-time reaction from patients. (This is why federal agencies ought to have a social media policy that allows open access to Twitter, Facebook and other public communication tools.)

To me, the most damning complaints on Facebook and other comment boards is from the people who’ve completely given up on the Indian health system. Some say it’s better to make a co-payment at an off-reservation clinic because service is better. Or they suggest using insurance at IHS until their insurance deductible is met and then fly free from the system. That is a narrative thread that limits what can be done to improve Indian health for every patient. If you’ve already given up, why bother?

But those who complain openly want a health care system that works. Every time they write about what happened to them, it’s an open invitation for improvement. The IHS is lucky to have so many volunteers posting helpful information. In fact, I would put a terminal in every waiting room, perhaps with someone who could help patients who don’t use computers to get even more direct response. Embrace Facebook.

As a friend wrote on Facebook: “Angel White Eyes … Bless your Heart!! haha! This is too TRUE!!”

Health care reform vote should be a litmus test

March 15, 2010

Depending on where you live, you might be seeing TV commercials every few hours warning about the dangers of health care reform. The U.S. Chamber of Commerce is spending millions to stop this legislation. Most people live in districts where the members have already decided. If they’re Republicans, their vote is an automatic no. And, most Democrats are solid on the “aye” side, so the debate boils down to a few dozen Democrats who could vote either way.

South Dakota Rep. Stephanie Herseth Sandlin is a Democrat who’s on the fence. She said last month: “Since the outset of the health care reform debate last year, I’ve said that any health care proposal must meet the dual goals of increasing access to quality care while decreasing cost. I voted against the House version of the health care bill because it failed to meet these goals for South Dakota.”

She’s also said the Senate bill doesn’t meet this test. But is that a no? We don’t know. Yet. We’re waiting for her final answer this week.

There are political considerations. Herseth Sandlin represents a conservative-leaning state (John McCain carried South Dakota by 8 points over President Obama). A poll last month by Rasmussen Reports shows her ahead of the G.O.P. GOP challenger by 7 points, with 11 percent of those surveyed saying they were undecided. And these are not good numbers for her because she’s an incumbent who’s polling less than a 50 percent majority.

But these polls miss Indian Country. While South Dakotans vote about 3-to-2 Republican, counties where American Indians are in the majority vote almost 80 percent in favor of Democratic candidates. Herseth Sandlin did even better than that, winning Pine Ridge with nearly 97 percent of the vote. Even with a smaller turnout than the rest of the state this is critical because it helps a candidate make up ground quickly from the counties lost by a narrow margin. Make no mistake: a Democrat cannot win in South Dakota without the American Indian vote.

But this is where this story gets confusing. Herseth Sandlin is trying to be a conservative Democrat to most South Dakotans – her web Web page describes the fiscal requirements for a yes vote. Then, on another web Web page, she says separately how important the Indian Health Care Improvement Act is and why she supports its passage.

She wants both constituent groups to be happy. Sorry, it doesn’t work that way. The key here is that the health care reform legislation will boost resources for the Indian health system. In fact, the health care bill that comes before Congress is the only path for passage of the Indian Health Care Improvement Act in this Congress. A vote no on one is a nay on both.

Opponents of health care reform could have made this a non-issue by enacting the Indian Health Care Improvement Act when they had the chance – say, when it was a single bill, or in the last Congress or in Congresses before that. They didn’t, and so health care reform is the only viable route to improve the Indian health system. (Wouldn’t it be great if TV ads were on the airwaves saying this as often as the Chamber of Commerce ads attacking health care reform?)

This should not be a free vote for any member of Congress. Indian Country voters ought to make this a scorecard issue – yes, a litmus test – because it’s a life or death life-or-death situation for so many people who are officially categorized as uninsured because they rely on the Indian health system.

There are lots of reasons for Democrats to vote no on this bill: It’s messy, it leaves lots of loose ends and there will be a lot of hard work left uncompleted even after its passage.

But there are two huge reasons for going forward. First, it sends a signal that our system will (and must) change forever. This is step one. And, second, in the words of President Ford (when he signed the original Indian Health Care Improvement Act), “because of my own conviction that our first Americans should not be last in opportunity.”


Congress and President deliver on promises to improve Indian health system

March 22, 2010

The three most important things to know about what health care reform means to Indian Country are simple ideas. First, the United States, officially and permanently, recognizes its trust and treaty obligation for health care delivery to American Indians and Alaska Natives. Second, there will be more money (not enough, but more) pumped into the Indian health system. And, third, President Barack Obama has delivered on a major, long-sought promise to Indian Country.

Now let’s consider a few details.

When Medicare and Medicaid passed Congress in 1965 and were signed into law, there was no consideration – none – of how those bills impacted Indian Country. It was as if the Indian Health Service, then all federal employees, was off the books, a forgotten instrument. In fact there wasn’t even a plan that allowed IHS to tap into Medicare or Medicaid dollars. That had to wait for the Indian Health Care Improvement Act of 1976.

That is not the case with President Obama’s health care reform. Indian Country is included throughout the document in large and small measures designed to improve the health of Native people.

The Indian health system, for example, is designated as an “express lane” to help people enroll in Medicaid. That should make it easier for that funding stream to supplement IHS appropriations. There are many other important programs in the final bill, ranging from new education and training programs to improved regulations for tribally managed health facilities.

The most important provision is the reauthorization of the Indian Health Care Improvement Act (after 10 years of empty promises) as a title in the Senate health care package.

The president said early Monday morning: “Nor does this day represent the end of the work that faces our country. The work of revitalizing our economy goes on. The work of promoting private-sector job creation goes on. The work of putting American families’ dreams back within reach goes on. And we march on, with renewed confidence, energized by this victory on their behalf. In the end, what this day represents is another stone firmly laid in the foundation of the American Dream.”

It’s also a down payment on an American promise. The official goal remains lofty: The United States is supposed to provide the resources for American Indians and Alaska Natives to eradicate the health disparities between Indians and the general population. Much hard work will be required to even get close to such a goal. To make that happen there must be steady, increased appropriations even at a time when the rest of the federal budget is being trimmed. Remember that unlike Medicare or Medicaid, money for Indian health must be appropriated every year; it’s not an automatic entitlement. But this act at least puts Congress on record with a goal, one that should be matched by funding.

The measure itself “authorizes appropriations” for programs “to increase the Indian health care workforce, new programs for innovative care delivery models, behavioral health care services, new services for health promotion and disease prevention, efforts to improve access to health care services, construction of Indian health facilities, and an Indian youth suicide prevention grant program.”

But that’s only step one, authorization. The Indian Health Care Improvement Act makes this process easier because the authorizing law itself is now permanent. It will not require “reauthorization,” a process that languished since the original act expired nearly a decade ago. A second step still needs to happen, though, so that Congress appropriates the funds for the authorized programs. That step will be much easier in the days ahead because the funding requests will match the law.

“Passage of the Indian Health Care Improvement Act is going to be especially important because of the symbolism of its passage itself,” IHS Director Yvette Roubideaux told me a couple of months ago. “It’s an act that will reaffirm the government’s responsibility for updating and modernizing the Indian Health Service.”

Over the years, many in Congress and in the White House have said the right words when it came to improving the health status of Native Americans. But this is a president and a Congress that’s delivering on those promises.

An exciting appointment to head federal Medicaid and Medicare agency

March 29, 2010

President Barack Obama is expected to nominate Dr. Donald M Berwick to head the Centers for Medicare and Medicaid. (Mark Trahant photo)

An exciting appointment to head the federal Medicaid & Medicare agency

Daniel Patrick Moynihan once said: “If you’ve been in government a long time, as I have been, then the most exciting thing you encounter in government is competence. Why is this exciting? Because it’s rare.” When I read the quote, even today, I can hear the late New York senator’s voice booming, his last word full with extra punctuation.

Today I’m excited for the government. Health care reform should bring nutrition to a starving Indian health system. And, if the next test for health care reform is execution, then the government might be on the right course. The New York Times reported Sunday that Dr. Donald Berwick is the president’s choice to head the Centers for Medicaid and Medicare Services.

This is a choice that exceeds Moynihan’s rareness of competency. Berwick represents the ideal, the one person you think could help the government, the people and the medical profession come together and a coalesce around the idea of excellent health care. Last December at the Institute for Healthcare Improvement conference, I watched hundreds of professionals cheer on Berwick as they would a rock star. This is a doctor who’s willing to talk about what’s really important to people. “Health care has no intrinsic value at all. None, Health does. Joy does. Peace does,” he said in December. “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”

Imagine that. Doctors we don’t need.

Berwick’s appointment is not official yet – and then the Senate would have to confirm him before he takes office. But I wanted to write about this now because Medicaid, Medicare and Children’s Health Insurance Program all play a key (and growing) role in funding the Indian health system.

The most important thing to know about CMS funding is that it’s an entitlement: If a person is eligible, the money is supposed to be there. That’s not true for Indian health because the system is based on annual appropriations. Every time IHS, a tribal program or an urban clinic can bill CMS for patient care, it adds money to the system.

This is also the way to improve the idea of “don’t get sick after June.” If a patient is eligible for Medicaid, the money is supposed to be there. It doesn’t require passing the life or limb life-or-limb test.

Berwick already has a working knowledge of the Indian health system. The Harvard professor wrote a book, “Escaping Fire: Designs for the Future of Health Care,” that cites the work of Southcentral Foundation and the Alaska Native Medical Center as a model of a quality, locally managed facility. Southcentral, the non-profit affiliate of Cook Inlet Region, Inc., operates the outpatient facility with self-determination funding from the IHS, other grants and money from Medicaid and Medicare.

Medicaid is especially complicated. The program is officially a partnership with between the federal and state governments. That means there are fifty 50 different regimes, policies and procedures. Eligibility varies state by state. There’s often a split in the state mechanism for behavioral health and other services.

And then there’s the money. According to the Kaiser Family Foundation: The funding shortfall for state budgets could top $350 billion by next year.

Indian Country isn’t supposed to be hit by these shortages; there’s a 100 percent federal reimbursement for eligible patients in the Indian health system (a process that’s supposed to be improved by the new health care reform law).

But nothing is simple when it comes to Medicaid and the Children’s Health Insurance Program. States aren’t keen to see these rolls expand even when there’s a federal guarantee. It’s even more complicated when you factor in those reservations that cross state lines. Utah would set the rules for Navajos living on that portion of the reservation, New Mexico another set, and Arizona with still another situation. I would love to see CMS rules that supersede state versions, treating Indian Country as a 51st state. Someday.

But there are other, more practical innovations that could happen at CMS immediately. There could be more experiments (requiring waivers) from providers about how health care is delivered. There could be less complicated paperwork to enroll in Medicaid as part of the implementation of health care reform.

Berwick is not a manager who will make the system we have work better. No, he’s the kind of leader who will help us invent something better – and the Indian health system will be a beneficiary.

A thorny question: Should American Indians and Alaska Natives buy their own health insurance?

April 5, 2010

The enactment of health care insurance reform raises a thorny (and complicated) question for Indian Country: Should American Indians and Alaska Natives eligible for services in the Indian health system buy their own insurance?

The first answer ought to be a resounding “no.” Clearly, the United States has an obligation for health care because of promises made through treaties and statutes. Indeed, the very enactment of the Indian Health Care Improvement Act is a legal restating of this principle. Health and Human Services Secretary Kathleen Sebelius said it this way on March 26: “This administration is intent on honoring the obligations of our government-to-government relationship with American Indian tribes, including the promise of adequate health care.”

But adequate health care is not an insurance plan, especially when that promise is so limited by money. And there is no possibility that Congress will fully fund the Indian health system anytime soon.

So where does that leave us? The Government Accountability Office said in a 2005 report: “There remain concerns about the extent to which health care services are available—that is, both offered and accessible—to Native Americans served by IHS.” One key issue here is the underfunding of Contract Health Services, money that is used to pay for health care providers outside of the Indian health system. Remember, unlike Medicare, Medicaid or the Children’s Health Insurance Program, IHS operates on an annual budget instead of an entitlement and it’s a limited source of funds. This budgeting notion will not change with health care reform.

But when private or government insurance money (or third-party billing in government-talk) is added into the Indian health system, that could improve services for all. The new law opens up all sorts of avenues for tribal and urban Indian clinics to bill insurance plans. Third-party billing is supposed to add new money; so current funding shouldn’t be limited by these dollars.

There’s been a lot of talk about a national mandate to buy health insurance under the new law. That’s true. But the issue is far more complicated for Indian Country because there also is a specific exemption from the penalties associated with the mandate. As IHS Director Dr. Yvette Roubideaux recently wrote on her blog: “Health reform just means that in general, American Indians and Alaska Natives can continue to be eligible for and use IHS, Tribal, or urban Indian health programs, but if they want to, they will be able to purchase health insurance through the exchanges, which should have more affordable options. If they don’t want to purchase health insurance, as long as they get their care through our I/T/U system, they won’t have to pay a penalty.”

So should individuals – despite U.S. promises – buy health insurance to pay for care in the Indian health system?

I see several “yes” answers developing.

First, it will be easier for individuals who are eligible for other government programs, such as Medicare and Medicaid to medical services for veterans. Medicaid, the program designed for people on low income, will enroll single adults for the first time. The glitch here is that states aren’t keen on Medicaid expansion even though there’s a 100 percent match for clients in the Indian health system.

Most tribal governments already offer health insurance for employees and the new law expands the potential for tribes to purchase insurance for tribal members as well (without tax consequences).

Other native people will buy insurance for their families because it unlocks choices. Bringing health insurance into the Indian health system could eliminate some of the delays or denials of care associated with Contract Health.

“We can bill for third-party reimbursements and help better fund our health services,” Dr. Roubideaux wrote. “However, they could also choose to leave us and get their health care somewhere else. Then we would lose our patients and potential reimbursements.”

Dr. Roubideaux says this is “all the more reason for us to change and improve the IHS, and emphasize customer service! We have to remain competitive and be the first and best choice for our patients.”

I’ve talked to many people who’ve given up on the Indian health system. They say it’s much better for their families to use their private insurance and go elsewhere. I understand that. It’s a choice for every family. But the only way the Indian health system will be better for our children and grandchildren is for us all to stick with it and to add whatever resources we can. Even if that means buying insurance.

The state of Navajo – sort of – and other health care experiments

April 12, 2010

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 are likely to seek repeal of all or part of the legislation. Moreover, formidable implementation hurdles must be surmounted if health care 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 the final bill in both the House and the Senate. They have expressed outrage at the Democratic leadership’s decision to “ram through” reform using budget reconciliation to modify the Senate-passed bill sufficiently to make it acceptable to the House. The outrage is 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.

The legislation also sets up many experiments, requiring either demonstration projects or feasibility studies.

One of the exciting studies will look at treating the Navajo Nation as a state for purposes for Medicaid, Medicare and Children’s Health Insurance. This could be a huge win-win-win. It’s a win for the states of Arizona, New Mexico and Utah because they would no longer have to process the paperwork for Navajos living on the reservation; the government should save money because the rules could be made simpler and easier to process with Navajo rules for eligibility instead of three different state standards, and the Navajo Nation should be able to better serve its citizens.

You’d think states would embrace Medicaid and Children’s Health Insurance for American Indians and Alaska Native served by the Indian Health System health system because the federal government picks up the cost. But there has always been a fear, I guess, that these constituents would somehow end up on the state’s expense. Treating Navajo as a 51st state would, at least, remove that worry from three states. And, if the process works, perhaps other tribes or tribal regional authorities could make it work, too.

Another change in the law allows more facilities in the Indian health system to provide services to non-Indians “so long as there is no diminution in services to eligible Indians.” This means that tribes can decide, as many have, to serve their neighbors (which could be employees or rural residents). On one hand, some Native American patients might feel that their clinic is already short on personnel and service. Then, on the other hand, by broadening the base of patients, smaller clinics could actually grow and have more resources to spend on every patient. Because the Indian health system is low-cost, many tribal and urban facilities often make money on Medicaid patients and are eager to accept new ones (which is really interesting because the larger narrative is that more and more clinics are refusing Medicaid patients because they are money losers).

One change that’s not experimental: The new law directs the Secretary of Health and Human Services to submit a plan to Congress creating a new Nevada IHS Area Office. No other state gets its own area office through the new law. Then again, no other state has the Senate majority leader as its champion.

Detroit’s geography of despair includes many seeds of hope

April 19, 2010

DETROIT – It’s hard to communicate the failure of public policy in this great American city (especially in a few hundred words). A drive around town highlights the consequences from decades of neglect: abandoned and burned-out homes, office buildings as ruins (and dangerous playgrounds), near-permanent unemployment and thousands of empty lots capped with mounds. These mounds are burial sites of sorts because when a building was destroyed the rubble was left in a pile until time and grass shaped each into a small hill.

Yet the geography of despair includes many seeds of hope.

One eastside neighborhood is transformed by inspiring folk art that brings humor and zest to several city blocks through The Heidelberg Project. Or there is the Community Health Awareness Group’s efforts to exchange needles so that drug users on the streets won’t as easily share disease. The program resulted in a drop of HIV infections from drug users from 33 percent to 17 percent. (And that, too, is the paradox because while an exchange is effective, it’s also difficult to fund.) Then there’s the Earthworks Urban Farm. Detroit is a city without large chain grocery stores – only discount stores and “party stores,” or neighborhood enterprises that sell more liquor than protein. Access to fresh fruit and vegetables is a regular barrier for a family trying to eat healthier. But at Earthworks more people – at least in this one neighborhood – are growing their own access to healthy foods.

The trip was a Kaiser Family Foundation site visit for media fellows. We looked at Detroit and its health system in depth. Before the trip, I expected the unfamiliar, an urban landscape that was different and bleak. But I quickly found there is a connection with the policy failures found here with those from Indian Country. At the end of that rope: deep, structural poverty and a health system where disparity is dismissed casually, as if it’s a fact that must be. To me that reflects a serious shortage of money from the state and federal governments – and just as important – a policy deficit where ideas, innovation and execution don’t get the support that’s needed.

Consider the tale of two clinics.

American Indian Health and Family Services helps the 57,000 Native Americans living in the greater Detroit area. Services are delivered at an old church and rectory donated by the Detroit Archdiocese in 1993. Jerilyn Church is the executive director of AIHFS. She’s Minnecoujou Lakota, born and raised on the Cheyenne River Sioux reservation in South Dakota. When she moved to Detroit she says she “wasn’t prepared” for the same type of unemployment as back home on the reservation.

“Yet despite our surroundings, we get a lot done with little resources,” Church says. “We could write a book about it.”

That book would detail the logistics of serving people who are mostly uninsured – and too often ineligible for safety-net programs like Medicaid. Among the AIHFS clients, only about a third have full-time employment. So when a patient requires health services beyond the basics of the clinic, the health provider – a doctor or a practical nurse – spends hours on the phone looking for a doctor or hospital that will provide “uncompensated care.” So instead Instead of treating people, these health professionals must act as brokers, looking for someone, anyone, in the health care system to help.

The paradox that is urban Indian health is that more than two-thirds of American Indians and Alaska Natives live in cities and yet receive only about one 1 percent of the Indian Health Service budget. There is hope, however, because of health reform and the Indian Health Care Improvement Act. The new law, Church says, should make it possible to hire at least one more health professional for the clinic. Another possibility down the road is to qualify American Indian Health and Family Services as a “Federally Qualified Health Center.” This is a designation that opens up the potential for additional federal funds, as well as better malpractice protections.

Indeed, the idea of a FQHC – as it’s known in fed speak – opens up other possibilities as demonstrated by the second clinic in this story. The Community Health and Social Services Center, or CHASS, started in 1970 to serve the Latino population in Detroit.

Today CHASS operates a comprehensive-care network, at clinics that serve Latino and African American neighborhoods, serving a population that that is 86 percent uninsured. Yet this FQHC has found a business model that works: CHASS has developed an unusual relationship with the Henry Ford Health System. The physicians are employees of Henry Ford and there is essentially a budget plan for uncompensated care. What’s in it for the Ford hospital network? Simple: It’s much cheaper to budget for a visit to a CHASS clinic than it is for that same patient to show up in an emergency room. So that’s where traffic is directed: Both CHASS and Henry Ford encourage people to make appoints appointments for chronic care, dental or routine office visits. This benefits both parties because the hospital system controls costs, and the patients stay healthier.

Across the country there are so many committed people who find new ways to make a difference. As health care reform goes from concept to program, there is much hope that seeds of excellence, like these planted in Detroit, will get the nutrition that’s needed to thrive.

Simple math: Health care reform = jobs

April 26, 2010

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 only 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.

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.

The dental vacancy rate of 24% is higher than it has been in many years. Pharmacy vacancy rates have increased to 11% from 8% in FY 2008 and nursing vacancies are up to 26% nationwide. Of particular concern is the shortage of registered nurses nationwide in both the inpatient and outpatient settings. These are the nurses most needed throughout Indian health. The agency expects the shortage of registered nurses will increase markedly over the coming years due to the increasing age of the U.S. nurse population (the average age of nurses in the U.S. is 47 years) and decreasing numbers of nursing schools, graduates and new students. Pharmacy is facing similar issues in that fewer people are entering pharmacy schools at a time when the need for pharmacists is projected to grow considerably over the next 8 – 10 years.”

The paradox represents a great challenge for American Indian and Alaska Native leaders. We know these jobs are there. Guaranteed. And this already rich opportunity is getting better because of the Patient Protection and Affordable Care Act (health care reform).

But the challenge is to get young people the kind of education needed to be successful. The way I look at it, there needs to be a significant investment in terms of strategy, time and money to meet this demand. Imagine what it means to guarantee a young person a job – better yet, a career.

The health care reform bill has several provisions designed to increase the pool of people entering medical-related fields. The big push is in the area of “primary care.” There should be training and scholarship money for at least the next five years for new models for programs such as team management of chronic diseases, a practice the IHS does well now.

The law also calls for: a Workforce Advisory Committee to develop a national strategy, a significant increase in scholarships and loans (including those with either repayment or retention incentives),

additional funding for training dollars for nurse practitioners. This is where the action is and a critical area because of the emphasis on nurse practitioners and physician assistants acting as a lead agent in primary care. The difference in the two jobs is interesting; both work under the direction of a medical doctor, and usually both fields require a Master’s Degree, master’s degree, but there are more hours of clinical training required for the PA and there are differences in the types of cases.

The Indian Health Care Improvement Act also opens up training and education dollars specifically for the Indian health system, specifically for paraprofessionals as Community Health Representatives and Community Health Practitioners.

There should be a wide range of jobs created by an expansion of the health system: dieticians to help people stay well by eating better, ethicists to help families talk through difficult decisions and administrators to move paperwork. The Center for American Progress estimates that between 2.5 million and 4 million jobs will be created during the next decade.

How big a number is 4 million new jobs? If even one-half of 1 one percent of those jobs ends up in the Indian health system, that’s an increase of 20,000 jobs or more people than work at IHS today. We’d better get ready for a great opportunity. Fast.

Measuring the progress in native health

May 3, 2010

Has the Indian Health Service been an effective, government-run delivery system?

Consider this from a White House memo: “While there has been improvements in health status of Indians in the past 15 years, a loss of momentum can further slow the already sluggish rate of approach to parity. Increased momentum in health delivery and sanitation as insured by this bill speed the rate of closing the existing gap in age at death.”

In other words, progress is slow. But Dr. Ted Marrs wrote the memo on April 26, 1976, and the subject was about the original Indian Health Care Improvement Act. “In 1974 the average age at death of Indians and Alaska Natives was 48.3. For white U.S. citizens the average age of death was 72.3. For others, the average age was 62.7.”

Dr. Marrs wrote that the “bottom line” was an unavoidable connection between “equity and morality” when there is a more than twenty 20-year differential in age at death between Indians and non-Indians.

So what do the numbers look like now?

The most recent Indian Health Service data on general mortality statistics is about a decade old now. But it showed that the twenty- 20-year differential has been reduced to a difference of less than five years. “The American Indian Alaska Native life expectancy at birth (both sexes) for the IHS service area population was 72.3 years,” according to the recent IHS report: “Regional Differences in Indian Health, 2002-2003 edition.” Compare that with the average life expectancy for all U.S. races, 76.9 years.

But even those numbers reflect grave regional disparities within the Indian health system. An American Indian in the Aberdeen area has a life expectancy of 66.8 years – or more than ten 10 years behind the U.S. average.

I’d love to go back through the raw data from 1976. It would be interesting to see what kind of progress that life expectancy number reflects even in Aberdeen. Clearly there were regional improvements, but how much? What worked?

To me this is the context that should be required in more of our data. We cannot look at what works – and what needs investment – in the Indian health care system unless we at least have a sense of the long view. This is not to say that the system is perfect or without serious problems that need fixing.

In March, for example, the Centers for Disease Control and Prevention released its report on the Health Characteristics of the American Indian or Alaska Native Adult Population: United States, 2004-2008. (Important note: The CDC’s definition of American Indian is broader than the IHS standard.) “In general, compared to other groups, non-Hispanic AI/AN adults are more likely to have poorer health, unmet medical needs due to cost, diabetes, trouble hearing, activity limitations and to have experienced feelings of psychological distress in the past 30 days,” the report said.

The bottom line: The native community “faces many health challenges as reflected in their higher rates of risky behaviors, poorer health status and health conditions and lower utilization of health services.”

That’s really not news. But there are other items in the CDC report worth more thought and exploration. For example: Unlike another recent government report, this one counts clients of IHS as insured. That data shows nearly 40 percent of AI/AN has private insurance; another 41 percent with public insurance (IHS, Medicare, Medicaid and the Children’s Health Insurance Program) and 19 percent are uninsured. That compares to the Hispanic population where the last two numbers are almost reversed, 40 percent unemployed and 14 percent with public insurance.

What does this mean? It means that American Indians and Alaska Natives have basic access to care. The CDC says 84 percent have a “usual place for health care.” That compares to 86 percent for white Americans, 85 percent for African Americans and 72 percent for Hispanics. The numbers show most of us have regular contact with our medical team.

And we are living longer. The CDC reports, “The AI/AN population has a life expectancy at birth that is 2.4 years less than that of all U.S. populations combined.”

There is not parity with the general population, not by a long shot, partly because of the chronic nature of so many diseases that afflict Indian Country. But one measure, “closing the existing gap in age at death,” has certainly been improving over the four decades.

The view from the inside: IHS employees

May 10, 2010

What do people who work (or who have worked) for the Indian Health Service think about the Indian Health Service?

This is an important question when looking at any organization. Do the health care professionals see themselves as working for a great team? Are they employed by a government agency that’s too stingy with the resources needed to do the job? Is there an internal perception about incompetence or mismanagement? Worse yet, does the daily grind reduce people’s effectiveness?

First: Context is critical. The Indian Health Service is a large system, employing more than 15,000 people with a budget exceeding $4.3 billion. (As a comparison, Kaiser Permanente, the nation’s largest non-profit, is more than ten 10 times bigger, employing 181,000 people with a budget of about $34 billion. I should also note the Kaiser Family Foundation is not affiliated with Kaiser Permanente.)

My point about these numbers is that even if 10 percent of the employees are unhappy, that represents a significant number of people. I have been hearing from many people through the year about what doesn’t work in IHS and often why. Some of the complaints involve specific employment issues – problems that, while serious, are not appropriate for a policy review. Others, however, point out specific concerns.

One example is a blunt note posted on Facebook: “I worked at the Aberdeen Area IHS for 2 years. The Property and Supply program for that area is in complete shambles. We definitely needed some HQ support to help create a meaningful accounting system. Every health system is underfunded, but what we do with our meager dollars is just good management to avoid loss, overages and shortages.”

Obviously, this person gave up – and left IHS. But that’s the challenge: How does a government agency tap into criticism in a productive way – so that people remain engaged, the organization learns from that criticism, and the results are real improvements.

Of course learning from criticism is easy with Social Media. It’s an open channel – good and bad. But that same conduit makes it easier for a dialogue. On the Facebook page, “I just spent 6 hours at IHS just for them to give me Tylenol,” this post does just that. “We are working really hard on projects such as ‘Improving Patient Care’ (IPC). I want our patients to talk with our patient advocate about their complaints so we can hold staff accountable. We have monthly meetings scheduled to meet with the community but hardly anyone comes. So this group is helping me to look for these types of problems in our hospital. Keep up the commentary. Thank you.”

IHS Director Yvette Roubideaux uses another method to listen with an internal reform bulletin board launched last summer. “Among the first steps is to look at what our system does well and do more of it,” she wrote. “Also, we must honestly look at what is not working well and take steps to find solutions.”

The top complaint from within: An ineffectual human resource mechanism and “calls to change/overhaul Human Resources – processes to employ people, develop, utilize, and compensate them.” Next on the list were complaints about the financial management and communication practices.

In response, Dr. Roubideaux said in March that the agency is working to “improve/streamline” the hiring process, including a more efficient outreach effort. Similar efforts are underway in financial management and communication.

Another way to look at employee satisfaction at IHS is to compare it with other government agencies. Best Places to Work in the Federal Government reflects a comprehensive survey from 212,000 civil servants in 279 agencies. (It’s produced by the Partnership for Public Service and American University’s Institute for the Study of Public Policy Implementation.) Scores are generated with categories ranging from leadership to matching employee skills with the agency’s mission. The three highest-rated places to work: The Nuclear Regulatory Commission, the Government Accountability Office and the National Aeronautics and Space Administration.

Best Places ranks the Indian Health Service at 151st out of 216 agencies surveyed. I compared the IHS with the Bureau of Indian Affairs and the Veterans Administration – where it’s firmly in the middle. The most interesting part of this index was that pay and benefits were seen as better at the BIA – and worse at the VA. The most promising signal in that data is the high correlation between employee skill sets matched with the IHS mission.

The perception of what it’s like to work at the IHS is critical because it’s Indian Country’s largest employer. This is also exactly why data collection is so important. How does IHS employment in terms of pay, skill sets and assessment compare to tribal or other health care agencies? Is there a difference before or after 638 contracts – funded by IHS, but either managed directly by a tribe or a nonprofit foundation?

The answers could help the agency – and the larger Indian health system – improve the way people are hired, trained and managed.

Indian health is not included in legislative or legal challenges to health care reform law

May 17, 2010

Passing health care reform was easy. Sure it was a legislative mess: It was too slow, too fast, too many pages and too short on specifics, too open to the influence of special interest lobbies – and too secretive, partly because the language was so complicated and difficult to translate into a simple narrative. Yet enacting health care reform was easy. Executing on real reform, now that’s a challenge.

It’s the same in Indian Country. The Indian Health Care Improvement Act is included as a section of the Patient Protection and Affordable Care Act. But this is only one item to check off on a long to-do list, not the goal itself. The next steps are just as important as the law itself: producing regulations that put the policy choices into action, funding by Congress to make the law work and execution of the law by the employees of the Indian Health Service, the federal government, as well as by tribes and provider organizations.

The irony of this is how the media cover covers this issue. The fight over the law was news. It was a big story by any measure. However, the equally important debate about health care regulations and the government’s execution of the law will probably get about one-tenth of the coverage. It’s harder to explain.

But one contest that is getting attention: the litigation by 20 states and other groups challenging the health care reform law. Washington Attorney General Rob McKenna recently posted this explanation about why he’s pressing the case: First, the “unprecedented requirement that individuals lacking health insurance must purchase private insurance or face a financial penalty” and, second, because reform represents a “massive expansion of the Medicaid program, requiring states to spend billions more on this program at a time when state budgets are already in crisis.”

That second point, it seems to me, is silly. No state is required to participate in Medicaid. And, if the burden is that great, then all a state would have to do would be to withdraw from the program. Indeed, the conservative Heritage Foundation said states could save $1 trillion by dropping Medicaid. But the states would have to do something else to provide its citizens with a health safety net – and that would added word be costly too. Nonetheless, this idea, if taken to its logical conclusion, would require substantial changes in the Indian health system (because state rules govern the Medicaid process, even though the federal government pays for American Indians and Alaska Natives).

But it’s also important to clarify what the states’ litigation is not about. As McKenna wrote: “This suit will not ‘overturn’ or ‘repeal’ the new health care reform legislation. In fact, this lawsuit will not affect most provisions in the 2,400-page bill, including several of the provisions of the federal health care legislation scheduled to take effect this year.”

In other words: Most of the bill is off limits. That includes the insurance provisions prohibiting denial of coverage over pre-existing conditions, expanding rebates for seniors’ drug coverage, and the inclusion of young adults on their parents’ plans. I would add that Indian Health Care Improvement Act to this off-limits list. It would be nearly impossible to challenge that provision legally because Congress has clear constitutional authority over Indian affairs.

If the litigation won’t overturn health care reform, could Congress do that? Last week the Web site Politico reported Republicans promising that course. “We’re going to do everything we can to make sure this law never, ever goes into effect,” Rep. John Boehner said at a news conference. “We’re going to rip out every possible mandate and increase, tax increase, that they’ve got contained in this bill. And yes, I understand that President Obama’s going to be in office.”

Boehner’s statement is telling. The Republicans will focus on the mandates and tax increases – not the entire bill. The Indian Health Care Improvement Act is probably, even in that Republican scenario, off limits. But it’s also interesting to think about Boehner’s understanding about President Obama being in office – to repeal the law (or any part of that), Congress would have to sustain a veto. That not only means winning enough seats in November to become the majority party, but also enough for a two-thirds margin. The problem with that logic is math: There are not enough Senate seats up for election to produce that many Republican votes. This is an empty promise – at least as long as Obama is president.

The Obama administration is moving quickly to implement health care reform by writing regulation at lightning speed. And that includes implementation of the Indian Health Care Improvement Act.

Remember: Passing health care reform was easy. Now the real fun begins.

Tribes are employers – and there is a mandate

May 24, 2010

We’re still confused about the new health care insurance law. But there is this twist: More of us are starting to figure out what the Patient Protection and Affordable Care Act means to our families.

The Kaiser Family Foundation reports in a May poll: “Confusion over the new health reform law declined but remains widespread, with 44 percent of the public saying they were confused in May, compared to 55 percent in April. Moreover, more than a third of Americans (35%) (35 percent) say they do not understand what the impact of the law will be on themselves and their families, while 61 percent report feeling they do understand what that impact will be.”

It’s also interesting to see how we are learning about this new law.  “More than half report having gotten information from friends and family (68%), (68 percent), or from cable (63%) (63 percent) or broadcast news programs (55%). (55 percent). Further breaking down those getting health reform information from cable news, 25 percent of Americans indicated their main cable source on this topic was FOX News, 22 percent named CNN and 6 percent MSNBC.  In fact, cable news still tops the list of the public’s “most important” sources of news about the new law, with 30 percent saying they rely on that source more than any other.”

If cable news is teaching America about health care reform, well, let’s just say, there will be a lot more to learn later.

Of course, the story in Indian Country is not exactly a topic on cable. It’s also practically a non-story in daily newspapers, on TV and radio news programs or even Internet news sites. This is too bad because the Indian Health Care Improvement Act is a significant part of the entire reform process; it’s now a package deal.

What’s more, this lack of information means that Indian Country – tribes and individual citizens – will have a much more difficult time figuring out the impact of the law on our governments and our families. (My previous columns about effects ranging from job creation to Medicaid expansion are archived at Indeed, I suspect a poll of American Indians and Alaska Natives would find even more confusion than in the general society.

For example, the law immediately “fixes” the problem that occurred when tribal governments purchased blanket health insurance for members. The IRS had taken the position that such a deal was a taxable event. But, as a U.S. House timeline describes the next steps, the tax code “Excludes from gross income the value of specified Indian tribal health benefits.  The provision is effective for benefits and coverage provided after the date of enactment.”

In other words, tribes are free to supplement the Indian health system from their own resources.

But the big question – one that will need to wait for more specifics from the regulations – centers on how much health insurance will tribes be required to purchase for their full-time employees.

While individual American Indians are exempt from the insurance mandate, that provision does not apply to either tribal governments or reservation businesses. In general, employers with more than 50 workers must offer insurance. To make it even more complicated: The insurance plan must be affordable – costing the employee less than 9.5 percent of their household income.

There is an important loophole here. The law applies to full-time employers – so a company (or government) can reduce its health care costs by shifting its work force to part-time status. This is something to watch closely going forward.

The law says large employers, including tribal governments, must offer health insurance that meets a minimum standard of care. How will that mesh with services in the Indian health system? We won’t know yet but the rules to implement this part of the law are being rushed, using a process that skips some of the normal steps in agency rule-making. It’s likely that some tribal plans and self-insurance programs, at least those in place before March 23 (the day the president signed the bill into law), will have some leeway.

But the pesky details are yet to be written. No wonder some of us remain confused.

A big picture look as the health care debate accelerates

May 31, 2010

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 such as “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.”

That anger, however, depends on your point of view. In a few days, the health care reform law will become real to many seniors when they receive $250 rebate checks to fill-in the “donut hole” for the drug coverage gap in Medicare Part D. Imagine the conversation in even conservative states when seniors start calling their congressional offices after a member proposes repeal. (“You want to take away my coverage?”)

Then again, I understand the anger and the angst from many Americans about health care reform. When I started this project, my hope was to communicate some of the lessons about “government-run” health care to a larger audience. There is a lot to learn from what the government already manages in the health care arena. But the fact is the country is not ready for that conversation. Indeed, even a simple brochure, one similar to those produced by government agencies everyday, generates a new manufactured controversy when it involves health care reform.

Yet as we rebuild the health system – one that everyone understands is broken – we need to keep focused on the big picture. To me this boils down to two simple themes: the demographic imperative and the cost of health care.

First, let’s consider the demographic imperative. We human beings – in America, in Indian Country and around the world – are living longer. That one trend changes everything in our health care system yet it is outside our political discourse. No one is to blame for longevity – and, indeed, who would not want to celebrate this trend? But a longer life span is costly. For example, diabetes is the most expensive disease to treat and one of the key risk factors is age.

The second theme is financial. An aging population is more expensive. Medicare and Medicaid cannot continue without major shifts in thinking, resource allocation and even tax supports. This isn’t politics; it’s mathematics.

The law calls for an Independent Payment Advisory Board to recommend proposals to limit Medicare growth. (The Kaiser Family Foundation offers an excellent summary on the foundation’s Web site.) The panel’s mandate is tricky. On one hand, the recommendations are supposed to be implemented (unless Congress objects to the entire package) to achieve budgetary targets based on the Consumer Price Index. On the other hand, the board is not allowed to suggest rationing, a tax increase or a reduction of Medicare benefits.

It’s kind of funny. Other than making real cuts, the panel is free to explore any option. Yet this is exactly the kind of debate we need to have going forward.

But the independent panel, or any step in the health care law, is not the end but the beginning of a long march. We’ve taken a step. Soon we will take another.

I still believe that at some point the U.S. health care system will look more like the Indian health system than the other way around. But that idea is even more divisive than a Medicare brochure. This is a debate saved for another day.

So, for now, I’ll continue to explore the impact of health care reform on the Indian health system. There are many changes ahead, some intended, and others unplanned. Most of these changes will at least open up the prospect of a better delivery system. I have much more to write about along those lines – and so a little good news: My fellowship has been extended through the summer. I’m grateful for the opportunity – and thanks for all those who read, comment and who send me ideas to explore.

Do you need to see a doctor? Queue up.

June 7, 2010

“I need to see a doctor.” These six words have been written into our programming as modern humans. We wait in line at the clinic. We make an appointment. We know instinctively that this is the one person to see who can check out our health, fix us up when it can be done or design a treatment course when we are facing complicated health issues.

But that programming no longer works: There are not enough doctors, and, even if this goes against what we’ve been trained to think, seeing a physician is not always the best medical choice.

The shortage of primary care physicians is one of the larger trends that made health care reform necessary. Some 56 million Americans don’t have a regular doctor. And when you open up more health care access, that scarcity increases. When Massachusetts enacted universal coverage, it exacerbated the primary care shortage – something that is expected to occur nationally when some 30 million who have been uninsured seek regular care.

“By 2025, the wait to see a doctor could get a lot longer if the current number of students training to be primary care physicians doesn’t increase soon,” according to a new University of Missouri study. Jack Colwill, professor emeritus of family and community medicine in the MU School of Medicine, and his research team found that the U.S. could face a shortage of up to 44,000 family physicians and general internists in less than 20 years.

One of the factors complicating this issue is age. “Typically, older adults seek care from generalists nearly three times each year, double the rate of adults younger than 65,” Colwill found. That means the number of doctor visits will increase by 29 percent by 2025 while the number of family physicians will increase less than 5 percent.

Last month the New England Journal of Medicine published one practice’s “snapshot” of the work required for primary care. “Primary care practices typically measure productivity according to the number of visits, which also drives payment,” wrote Richard J. Baron, M.D. “Work that does not involve a visit from a patient is invisible to those who support and purchase primary care.”

Dr. Baron used electronic medical records to chart that invisible care. “At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it,” he wrote. “Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure.”

I think that radical change has to start within each of us – the patient – as we rethink what we need from a health care system. We should ask, and often, what do we expect? And, how do we pay for that?

I also think the education angle is interesting. Higher education is under incredible financial pressure – at the very moment we need more from those same institutions. Once again there is that same need for radical change in practice (medical and nursing schools) design and payment structure.

Just look at what’s happened to primary care training. A generation ago about half of all medical students picked general medicine over a specialty practice; today’s it’s only about 30 percent. In the larger health care system the main reason for that disparity is wealth. Specialists earn far more thangeneral practitioners; a gap of more than $100,000 per year.

The Patient Protection and Affordable Care Act addresses this shortage with several provisions. For example, bonuses will be paid for Medicare and Medicaid for primary care practices and repayment of student loans for underserved areas with the National Health Service Corps.

The Indian health system represents one of those underserved areas. The Congressional Research Service recently reported: “The IHS has a high vacancy rate in many of its health professions, 20 percent for physicians, dentists and nurses, for instance, as of December 2008.” The new law opens up a number of options for American Indians and Alaska Natives interested in health careers: scholarship and loan repayment programs; incentives designed to encourage health professionals to work at Indian health, funds for continuing education and new demonstration projects using students. There will be new grants for “teaching health centers” and for expanding or creating primary care residency programs. The law also allows for newly accredited or expanded primary care residency programs.

But even then will that be enough? How long will it take to fill those pipelines? The answers might not come from a doctor.

The medical practitioner will see you now

June 14, 2010

A family member and I visited a clinic over weekend. First, a nurse, then the doctor, then X-ray, back to the nurse and finally back to the doctor. The patient took lots of steps. The providers were earnest, carefully asking good questions then filling in the details on the patient’s chart.

But what if one or more steps are eliminated? Well, two things happen: Costs drop and patient care often improves.

How does less produce more? The answer is to shift the focus of the story – the programming – from the “doctor” to the patient.

For example, at the Alaska Native Medical Center in Anchorage, that relationship is described as working, “With the patient as the hub, the team includes the patient’s family, the primary care physician, a nurse case manager, certified medical assistants, case management support, a social worker and a behavioral health specialist. Additional ‘virtual’ team members include health educators, midwives, nutritionists and pharmacists. Many specialists (including chiropractors, massage, acupuncture and ‘usual’ medical specialists) are ‘layered’ in.”

In day-to-day terms that might mean a patient won’t see a doctor during an office visit – and be the better for it.

In addition to the team approach, there is a growing use of non-physician practitioners of all stripes. The Indian Health Service and affiliate facilities have a long history of using non-physician practitioners as a way to reach more people at less cost. Non-physician practitioners include: registered nurses, advance practice nurses, physician assistants and clinical pharmacists.

At least one major study – funded by the Robert Wood Johnson Foundation – found that the medical experience was about the same for patients that saw non-physician practitioners. The Web site Marketwatch reported earlier this month that nurse practitioners are one of the fastest growing categories for health care professionals. The article quoted Jeffrey C. Bauer, a medical economist with Chicago-based Affiliated Computer Services Inc., saying one reason is that nurse practitioners send spend twice as much time with patients. “That’s the No. 1 reason patients who have been to nurse practitioners like them as much or more than seeing physicians.”

Not surprising, the American Medical Association – the doctors – suggests a go-slow approach on this alternative for health care delivery.

The National Congress of American Indians recently published a paper on non-physician practitioners in the Indian Health Service. It reported that IHS has used non-physician practitioners for decades to “stretch limited resources.” However, one of the problems is that different area offices and facilities have different standards. And, an expansion of medical practitioners “would require changes at the local level.”

But even now – before the full implementation of the new health care reform law – the Indian health system has many innovative examples of medical practitioners. My family experienced this 18 years ago when nurse midwives delivered my son at Fort Defiance on the Navajo Nation. (We only realized how much quality time we received from midwives when our second son was born at a hospital where doctor visits were quick and frenetic.)

The range of work by nurse practitioners is extraordinary these days. “For example,” the NCAI paper said, “RNs can work in a hospital-based nursing practice, ambulatory care settings or in public health nursing. Public health nurses emphasize patient care (especially maternal and child care) and assessment of community needs. They target health education, health promotion/disease prevention, administer immunizations and make home visits to patients, among other public health services.”

Another area primary care alternative is the pharmacist, especially when patients return regularly for chronic care (such as diabetes, the most expensive disease in America).

“Many pharmacists in the IHS provide broad primary care clinical services, including assuring appropriateness of therapy, providing patient counseling, and disease management for both stable and unstable chronic diseases. These IHS pharmacists perform patient assessment, have various levels of prescriptive authority (initiate, adjust or discontinue treatment), formulate clinical assessments, develop therapeutic plans, manage chronic disease, and provide many other cognitive clinical services including health promotion, disease prevention, and appropriate coordination of care for follow-up,” the NCAI paper said.

A new primary care network is already under construction. But to make the system work better, the hope is that the new health care reform law will better coordinate all of this innovation. That means medical schools will be more strategic about professional training, insurance companies and federal providers will pay incentives for primary care by any professional – doctor or practitioner – and there will be better education so that patients understand their place in this framework.

And that means changing the story. We need to look forward to hearing something along the lines of “The medical practitioner will see you now.”


Expanding access to oral health through innovation

June 21, 2010

A philosophical question: How much medical training is needed to treat patients? Some say it’s the full course as proscribed by existing medical, nursing or dental schools. But when the shortages of doctors, nurses and dentists are ginormous, does the need require a different answer?

Consider oral health. “Shortages of dental practitioners and affordable dental care are hurting the health of millions of Americans, many of whom live with pain, miss school or work and, in extreme cases, face life-threatening medical emergencies that result from dental infections. The situation is particularly severe for poor children and families and in communities of color,” writes Burton L. Edelstein, DDS, MPH Columbia University and Children’s Dental Health Project in a Dec. 2009 report for the W.K. Kellogg Foundation.

And, like most health issues, the data shows that Indian Country is at the low end of the spectrum. One study described it this way: “The American Indian/Alaska Native population has the highest tooth decay rate of any population cohort in the United States: 5 times the US average for children 2–4 years of age. Seventy-nine percent of AI/AN children, aged 2–5 years, have tooth decay, with 60 percent of these children having severe early childhood caries (baby bottle tooth decay). Eighty-seven percent of these children, aged 6–14 years, have a history of decay—twice the rate of dental caries experienced by the general population.”

The study, by David A. Nash at the University of Kentucky and Ron J. Nagel with the Indian Health Service, found that “lack of access to professional dental care is a significant contributor to the disparities in oral health that exist in the AI/AN population. Two major factors contribute to inadequate access to care: the relative geographic isolation of tribal populations, particularly in Alaska, and the inability to attract dentists to practice in IHS or tribal health facilities in rural areas.”

So several years ago an experiment began in Alaska to change the training paradigm. The Alaska Native Tribal Health Consortium, working in partnership with the University of Washington, began training Dental Health Aide Therapists dental health aide therapists. These oral health agents work under the general supervision of a dentist (who is at another location). The dental therapists’ practice includes basic dental services, focusing on children’s needs, including tooth extractions, sending full reports to their supervising dentist.

The key to the program is that the therapists are trained right out of high school over a two-year program – and then work in the remote villages where it’s been nearly impossible to recruit full-time dentists.

“While dental therapy is still relatively new to the United States, past training demonstrations in various states have proven that the care they provide is safe, acceptable to patients, cost-effective and productive. Unlike earlier efforts, the two most recent dental therapy programs in the U.S. are not just training therapists but sanctioning their placement in underserved communities,” writes Edelstein in the Kellogg report.

The National Congress of American Indians Policy Research Center said expanding this program to American Indian communities outside of Alaska would “be a major health breakthrough for Native populations across the country.”

The American Dental Association and the Alaska Dental Society challenged the dental therapist program in court. But the case was dropped for a couple of reasons: Alaska Natives were exercising their own authority under the policy of self-determination and it’s hard to argue against limited oral health care when personnel shortages meant there was practically no care.

The federal Agency for Healthcare Research and Quality reports that the Alaska dental therapist model is absolutely successful expanding access to oral health:  “As of 2009, there are 13 dental therapists serving 42 villages in Alaska, providing year-round services to thousands of Alaskans who previously had access to services only a few weeks a year….” While the villages with “a dental therapist, these same communities have year-round access to basic safety-net services.”

Moreover, the report said, “a professor of dentistry from the University of Washington found that the first four dental therapists employed in Alaska met evaluators’ standards for record review, cavity preparation and restoration, patient management and patient safety. He recommended that the program not only continue but be expanded.”

Health care reform – not the law itself, but what it means in real-world practice – requires a new thinking about how to serve patients across the board. We need to write this generation’s definitions of who should do what – dentists, practitioner, hygienists and therapists. What are the education levels and licensing requirements? What’s the right balance for standards? The answers, in most cases, will be state by state, with some exceptions in the broader Indian health system.

The new health care reform bill and the Indian Health Care Improvement Act support more experiments with this model – including the possibility of training programs at tribal colleges. A philosophical question answered by meeting the needs of people.

The CHCs have arrived and represent the prospect of better funding for Indian health

June 28, 2010

This past weekend the Coeur d’Alene Tribe celebrated the 20th anniversary of the Benewah Medical Center in Plummer, Idaho. Z’In 1987,” the BMC Web site reports, “the Coeur d’Alene Tribe began to search for ways to improve the health care services at their small Indian Health Service satellite clinic. It was located at the Tribal Headquarters, several miles from the City of Plummer, Idaho. Many tribal members were dissatisfied with 15 years of fragmented care delivered in a semi-condemned building and with poor continuity of care.”

Indeed, the complaints about the IHS facility and its operation were similar to those heard across Indian Country. And, like many tribes, the Coeur d’Alene proceeded to create its own health care network. But this was a broader vision, one that went beyond just replacing and recreating IHS; there was also a sense of something new. Prevention was made a priority and a wellness center complimented patient care. There also was recognition of the gap in rural health care services. As Benewah Medical Center describes it: “None of the ambulatory care facilities in the four surrounding counties of the Northern Idaho town were providing services to the medically underserved on a sliding-fee basis.”

So a tribal community health center was created – launching two decades of innovation.

Fast forward to the Patient Protection and Affordable Care Act, the new health care reform law. Between now and 2015 the law significantly expands resources – funding – for community health centers (described in the law as Community Health Clinics, Federally Qualified Health Centers, or FQHCs in federal jargon, and Rural Health Clinics). There are technical differences in these definitions. Basically the details relate to how various medical services are paid for by the federal government.

But my view is that tribally managed health networks now have a significant financial advantage over IHS-run facilities. There are more pots of money to tap, ranging from the IHS contract under the Self-Determination Act to money from the Health Resources and Services Administration in the U.S. Department of Health and Human Services.

Funding for community health centers started growing under President George W. Bush, who doubled the spending in 2008 to $2.8 billion. Since then President Barack Obama has added money under the American Recovery and Reinvestment Act of 2009 for community health centers as well as an additional $12.5 billion for expansion of these efforts over the next five years as part of health care reform.

“With an eye toward meeting the primary care needs of an estimated 32 million newly insured Americans, the recently passed Patient Protection and Affordable Care Act underwrites the CHCs and enables them to serve nearly 20 million new patients while adding an estimated 15,000 providers to their staffs by 2015,” write Drs. Eli Y. Adashi, H. Jack Geiger and Michael D. Fine in the May 11 edition of The New England Journal of Medicine. “The new CHCs have arrived.”

The law identifies community health centers as a priority. There are new resources for the expansion, construction or renovation of clinics and to hire more medical providers. Nationwide, some 19 million people now use services at community clinics and the goal is to double that number (or about 10 percent of the U.S. population).

And, this time around, Indian Country is included, if tribes and urban organizations choose to participate.

Community health centers generally operate by charging patients on a sliding scale and have historically served the uninsured population. In Indian Country this takes on a different twist because for eligible American Indian and Alaska Native patients, the Indian Health Service still picks up the cost as the payer of last resort (non-eligible patients would still be billed based on what they can pay).

The significance of all this is that the community health center model represents an improved funding stream for the Indian health system. Currently a little more than half of the total Indian Health Service budget funds tribal or urban Indian facilities; a decade from now I could see that number at 90 percent or even higher. But IHS would only be only a portion of the funding story: Money would also come from insurance companies or the new insurance exchange; on top of that there would be Medicaid and Medicare; perhaps add in a foundation grant or two; and, finally, the funding would be completed by appropriations designated for community health centers. The total might not be full funding of the Indian health system, but it will be a lot closer to that goal.

There are those that who will argue that Indian Health Service should be fully funded, as is. But one can also make the case that this new opportunity – tapping money from a number of revenue sources – is recognition of tribal sovereignty, too. And a promise fulfilled.

Warning: Budget tsunamis are forecast

July 5, 2010

The health care reform law should significantly boost the amount of money pumped into the Indian health system. That’s the good news. Now brace for the bad: Really bleak budgets are coming soon.

The reasons are global: Governments all across the world are cutting spending and restricting eligibility for programs that people now take for granted. This trend is a wave gathering force like a tsunami. The first notice of this massive wave was when Greece could no longer support its debts with new borrowing. But that country is not alone because the trend is worldwide.

The new government in the United Kingdom is a stark example. The Liberal-Conservative coalition last week said some agencies could face budget cuts of up to 40 percent. According to The Guardian in London, “the only departments not included in the Treasury trawl will be health and international development, which have been ‘ringfenced’ for the current parliament.” Interesting word and concept: a ringfence is a transaction, or in this case a budget, walled off from the rest of the government’s budget. In other words: The National Health Service is supposed to be protected.

But this, too, is a reflection of the tsunami. The cuts to the National Health Service will be more targeted around the issue of efficiency. But there will be cuts.

Of course the United States is different. While we don’t have national health care, federal and state budgets propelled in part by rising Medicaid costs are crashing under the same financial tsunami. Medicaid is a state-federal partnership. Much of the political focus of Medicaid is its role providing health insurance to some 60 million low-income Americans. According to the Kaiser Commission on Medicaid and the Uninsured, health care reform could add another 16 million people to the program over the next five years. But while the focus on Medicaid is on the poor, the program spends two-thirds of its benefits for seniors and for people with disabilities. In theory, a state could end its partnership and save billions of dollars by not participating in Medicaid – but that’s not going to happen because so many of the people who benefit from Medicaid, especially seniors, vote. (One reason why cutting the program’s benefits for low-income people gets so much more attention.)

President Barack Obama has argued – I believe correctly – that this is exactly the wrong time to cut spending. People across the country need help from their government because of the recession. Yet Congress is starting to say “no” anyway, trimming spending that was once considered essential, such as extending unemployment benefits and assistance to buy COBRA health insurance (a subsidy I have relied on since my job went disappeared with the death of the Seattle Post-Intelligencer newspaper). The problem for the president is that with a supermajority required in the Senate – 60 votes – there will be far more “no’s” than “yea’s” when it comes to more spending.

“Democrats are leaving Washington for the July 4 recess without passing key parts of their health care agenda,” writes Andrew Villegas for Kaiser Health News. “…with states hit hard by the recession, an extension of extra Medicaid funds also seemed likely.” But because of a “contentious debate, with conservative Democrats and Republicans opposing programs that could add to the deficit.” The result, Villegas writes, is “the Medicaid and COBRA subsidies are still in limbo.”

Many American Indian and Alaska Native patients in the Indian health system are in a precarious spot because of this battle. Some of the increased spending for Indian Health Service depends on increasing Medicaid rolls. This is important because Medicaid, unlike the IHS budget, is an entitlement. Once a person is eligible, the money is supposed to be there (in contrast to a straight budget line that runs out of money once its it’s spent). This problem should be simple: States don’t have to pay for patients in the Indian health system because the federal government eventually picks up the cost. But the problem is each state will define eligibility and a tightening of state rules will mean that patients that who should be eligible for Medicaid Medicaid, won’t qualify.

It would be easy to dismiss states as uncaring. But the problem is there are fewer dollars available from tax collections during the recession.  State budgets are wrecked by too many promises, ranging from pension obligations to constitutional promises to always balance the budget.

The best course ahead is to be innovative, tap into as much new money now, and prepare for the worst. Indian Country can’t pretend that budgets will magically be dammed (or as the British say, ringfenced). The tsunami is on its way.

A call to action: Be the health care reform early adopters

A call to action: Be an early adopter

July 12, 2010

If the United States government were a corporation, the health insurance reform debate would have completely moved into its implementation phase. Essentially, the management and the board would have figured out the course of action, and then figured a way to execute that plan.

If that sounds easy, it’s not.

In my newspaper career I worked at large newspapers and small ones. In small ones we could execute lots of approaches, even trying ideas that flopped badly. (The great thing about a small newspaper is if an idea doesn’t work, try, try again.) But at large newspapers, well, change of any kind was difficult, slow and you had to sell the idea over and over.

Rogers demonstrated this problem in graphic form. He divided people in an organization into five groups: Innovators, early adopters, early majority, late majority and laggards.

So you convince innovators and early adopters until you build enough of a success story in order to convince the next group. Of course, some people will never be convinced and that has to be a part of the planning, too.

I’d like to think the Medicare and Medicaid debate followed the Rogers’ curve. On July 30, 1965, when the act was signed into law there was much opposition, a majority of Republicans in the Senate and just under half of the Republicans in the House voted “no.” There was no consensus – indeed, the bill was as labeled (as Obama’s is now) as “brazen socialism.”

But forty 40 years of the program – led by early adopters, and then, early and late majorities – changed the face of the debate. There are still laggards, but their ideas don’t stand up against popular support. We can, and should, continue the debate about how to pay for these programs and how to do that considering the impact with the context of the Baby Boom baby boom generation (because of its huge size) and the growing span of human life. But that’s a different debate than the premise itself of health care coverage for seniors and those eligible for Medicaid coverage.

Will President Obama’s health care reform follow the same trajectory? That question is hard to answer right now, but it does show why governing a country is far more complicated than running a corporation. Remember in the corporate world, once the managers and boards have made a decision, they sell their workers and customers on that change. But in American-style politics, the debate about the premise for the health insurance reform law continues. Resolution is probably years away.

The July issue of Health Affairs says: “There are already many indications that the real fate of health reform will unfold gradually and quietly. The U.S. Chamber of Commerce waged a fierce public campaign against the enactment of comprehensive health reform, but once the law passed, the chamber refused to join the overt conservative Republican drumbeat for repeal, declaring that it would work to influence congressional elections and press for favorable regulatory decisions.”

The article by Theda Skocpol, a professor of government and sociology at Harvard, says much of the continued reform debate will be through challenges to “various administrative arrangements, taxes and subsidies to fund expansions of coverage. The redistributive aspects of health reform will be especially at risk, as business interests and groups of more-privileged citizens press for lower taxes, looser regulations and reduced subsidies for low-income people.”

So what does this big-picture debate mean for the small slice known as the Indian health system? It’s a call to action. This is an opportunity to become the innovators and the early adopters; demonstrating with stories and data how the health care system can be improved at the patient level. If we do this right, a generation from now, readers will look back at health care reform and wonder what the debate was all about.

As we talk about health care, remember to govern

July 19, 2010

What’s the most important element missing from our national conversation about health care reform? I’ll boil it down to one word: governance.

We’ve known for decades that our health system is unsustainable; there is no question that it cannot continue on its present course. So Congress finally rounds up enough votes to pass the Patient Protection and Affordable Care Act and what happens? The debate starts over as if there’s a magic wand out there somewhere that will let us have everything we want in health care without any cost.

There is no magic wand. But how can we govern when we’re so divided over complex and philosophical questions? How can we govern ourselves when we don’t agree on the facts?

Start with the general state of our health care system. The Center for Economic and Policy Research puts it this way: “The U.S. health care system is possibly the most inefficient in the world: We spend twice as much per person on health care as other advanced countries, but we have worse health outcomes, including a lower life expectancy. The government, through programs like Medicare and Medicaid, pays for approximately half of the country’s health care, almost all of which is actually provided by the private sector. Thus, the bulk of our projected rising budget deficits are due to skyrocketing health care costs.”

So how do we say no? We dismiss redesigning the system, we fight benefit cuts, we oppose tax increases and we continue the political fight over the very premise. This is not self-government, but a national self-delusion because the demographic imperative – the aging of our population – is absolute.

Yet in congressional districts across the country there are calls to repeal the health care bill. But let’s be clear about the mechanics. No matter what happens in the November election, there will not be the votes in Congress to repeal the law in 2010. President Obama will have more than enough to sustain a veto. In 2012, this question may surface as a theme in the presidential race – and let’s suppose the country votes in a Republican with a Republican Senate and House. Even then there may not be enough votes (thanks to the supermajority requirements in the Senate) for repeal.

Repeal, if it were to happen, will take years of debate. What then? Will there suddenly be a consensus of what should be done? Will we resolve the deep political divide about the role of government in our health care system?

Meanwhile, budget deficits will continue to grow. And we will be giving ourselves fewer alternatives about how to cut health care costs or how to tax and pay for those services. As we debate – and re-debate – health care reform, the fastest growing government “program” is interest on the debt. The Concord Coalition estimates that interest due from the federal deficit will reach $533 billion a year by 2015, or roughly, a third of federal income taxes.

Demographics (our country’s aging) and deficits both deal with hard numbers. We can cling to any ideology we want, but in the end the numbers are the numbers. We are a people growing older – and that’s a good thing. But it means our system must be adapted to account for that shift.

That brings me back to the challenge for a self-governing nation. We need to get away from the “either, or” discussion. Our framework is stuck. Either health care reform, or repeal. Either cut social welfare benefits, or tax. Either, or.

What we need now, instead, is a series of policy options. We need the language of “if, then.” If we do this, then here are the implications. If we spend energy on the repeal of health care reform, then we lose time really trimming our debt load. If we return to a smaller federal government, then what are the implications for each of us?

The health care reform bill is not perfect. There’s much that could be improved. But it’s now law and a tool that could bring health care costs down – along with the deficit. There ought to be consensus on that goal.

Local control and money: Making a health care system ‘ours’

July 26, 2010

There’s an old joke: A Native American student comes home from a geography lesson, shows his grandfather a map, and then asks, “What did we call the United States before it was a country?” His grandfather answers, “Ours.”

I thought of this joke recently in the context of the U.S. Indian Health Service. Perhaps the agency’s history, its shortcomings and its chronic underfunding have all been acceptable to Indian Country because the system itself is “ours.” It’s been “ours” for most of our generation – a little more than five decades – where American Indian and Alaska Natives could receive health care in a system that was, and is, unique.

A quick look at the history: Since 1955 the Indian Health Service was transferred from an rickety network of hospitals and clinics run by the Bureau of Indian Affairs to a real health care system. In that same time frame the agency went from being a slice of the BIA to being larger than the BIA with a budget of $4.4 billion and some 15,000 employees. During that time there were substantial improvements in Indian health, including reducing overall mortality by 28 percent in the past thirty 30 years, while still falling short in health parity for Native Americans.

That brings me back to the definition of “ours.”

Since 1955 that definition has meant government-run health care, mostly in the form of direct services operated by the Indian Health Service. But that definition has been changing slowly since the enactment of the Indian Self-Determination and Education Assistance Act of 1975. That law, of course, gives tribes as well as tribal and urban Indian organizations the right to contract for the management of these federal programs. Already more than half of IHS is run under contract – and that number should grow even more quickly because of changes under the Patient Protection and Affordable Care Act.

In a way I suspect the future of IHS is almost like its past, after its break from the BIA. The BIA was the largest agency that served American Indians and Alaska Natives, then it in recent years that biggest agency has become the IHS. This will probably remain true for the next few years. But look at the budgets for some of the clinics or hospitals run under contract and it’s clear there are new “big” players coming into the picture. IHS will remain a funder of last resort for patients from Indian Country, but more native patients are eligible for funding from the Centers for Medicaid and Medicare as well as the Health Resources and Service Administration funding rural health clinics and Federally Qualified Health Centers.

This is what a possible budget at a 638 facility – funded by IHS, but either managed directly by a tribe or a nonprofit foundation – might look like in coming years: 40 percent of its revenue from CMS reimbursements; 30 percent from HRSA programs; another 25 percent from IHS and 5 percent from everything else, including private insurance. These percentages could be managed up or down depending on nature of the clients, but my point is that Indian Health Service will be a significantly smaller player. (Its primary mission might focus more on oversight and as funding mechanism as well as data collection.)

Does this mean that these new government-wide health bureaucracies are overrunning the treaty and trust rights of American Indian and Alaska Natives for health care? Perhaps. You could certainly make that case.

But you could also make the case that the federal government is, finally, coming up with a formula for adequate funding for every patient. Even better, there is a stronger case that this health care system will work better and more efficiently when it’s designed and controlled at the local level through self-determination.

If we do this right, the Indian health care system will truly be called “ours.”

‘Docs or cops?’ Domestic violence is a public health issue in Indian Country

August 2, 2010

WASHINGTON  – It’s trite to say, “everything is connected.” It’s a phrase that comes up in the context of family, the environment or, perhaps, philosophy. When the subject is reservation violence, however, that same notion could be rewritten as a blunt question: Docs or cops?

Cops are getting most of the attention after the signing of the Tribal Law and Order Act.  At a White House ceremony on Thursday, Lisa Marie Iyotte introduced President Barack Obama. She is an enrolled member of the White Clay People, her father’s tribe, but grew up and lives as a Sicangu Lakota or Rosebud Sioux. She had the most difficult task: describing her own brutal assault and rape that was witnessed by her children. The attack was never prosecuted because of the jurisdictional maze that complicates criminal justice in Indian Country.

“All of you come at this from different angles, but you’re united in support of this bill because you believe, like I do, that it is unconscionable that crime rates in Indian Country are more than twice the national average and up to 20 times the national average on some reservations,” the president said. “And all of you believe, like I do, that when one in three Native American women will be raped in their lifetimes, that is an assault on our national conscience; it is an affront to our shared humanity; it is something that we cannot allow to continue.”

The president cited what will happen next: The hiring of more U.S. attorneys, more victim-witness specialists, a national training coordinator who will work with prosecutors and law enforcement throughout Indian Country, and more cops. Already the Interior Department reports a 500 percent jump in applications “the largest increase in history,” the president said, “and we’re working to deploy those officers to the field as quickly as possible.”

The bill boosts tribal authority, making it easier for local government to prosecute violent crimes and the Justice Department will collect and disclose data, including those crimes not prosecuted. The new law also will provide more resources for tribal courts, police departments as well as programs to combat drug and alcohol abuse or help at-risk youth. 

The new law is worth celebrating. But we should also remember that this law is just one step forward. This effort will not succeed unless Congress and tribes also recognize, support and fund the public health side of this equation. This is not a problem that can be solved by law enforcement alone.

Last month the Family Violence Prevention Fund and other health agencies (including the Indian Health Service) released a report that documents significant improvements in the public health approach. 
The new report: “
Building Domestic Violence Health Care Responses in Indian Country: A Promising Practices Report” represents the other element in this story. As Eileen Hudon, a domestic violence and sexual assault activist, says in the report: “The medical field is a good place to build a response to violence against Indian women because there is a high ethic to confidentiality, privacy and patient’s rights. The thinking embedded in the medical field closely aligns with an advocacy approach to addressing violence against women. So it has the potential to be a safe place to build an effective response to helping and protecting women.”

Some examples of model programs include: a Warm Springs initiative that focuses on coaching boys about healthy relationships, a Cherokee Indian Hospital group operating with the strategy of explaining to the community that violence is not just a women’s issue and a Utah Navajo outreach effort in the schools and in churches.

President Obama is right when he said this violence is “something that we cannot allow to continue.”

So what is it, docs or cops? Sorry, it’s the wrong question. If we are to remove the blight of domestic violence from Indian Country it has to be docs, cops, community people, public health, government and tribal leaders, basically, everybody. Then, this is as good a time as any to make it so.

The data story: How much? How many? And, by the way, who’s an Indian?

August 9, 2010

WASHINGTON – Every agency that serves American Indians and Alaska Natives must answer these questions in order to fuel the decision-making process: How much will it cost? How many people are served? And, by the way, who is an Indian?

None of the answers are easy. The demand for federal services is growing as resources shrink. And in the health care arena the key to sustainable funding is Medicare and Medicaid (including the Children’s Health Insurance Program) where definitions are complicated by multiple factors.

Consider eligibility: More than 560 tribal communities with members living on or near reservations or spread out in urban areas. Each tribe defines its membership but that data is rarely collected for use in health statistics because it’s often privately held. The U.S. Census allows each individual to define his or her own status by checking a box. (Some 5 million by this count.)

The Indian Health Service has another definition that adds descendants of enrolled members to the mix. And it collects data through its area offices, not states. Many IHS boundaries and reservations cross state lines, further confusing the data.

Medicaid collects some American Indian/Alaska Native statistics when it’s identified as a single race, excluding those who are multiracial or also consider themselves Hispanic. And, coming soon, there will be new rules from the Internal Revenue Service as part of the Patient Protection and Affordable Care Act because of the American Indian exemption from insurance mandates (as well as a new definition for urban Indians).

The Office of Management and Budget has yet another definition of American Indian and Alaska Native, one that is supposed to be the federal standard.

If you are still following this, on top of that grid, there are 36 states with different administrative structures (remember that Medicaid is a state-federal partnership providing medical insurance for the poor and for long-term care) each with its own process for collecting data. One result: Eleven of the 36 states collect little data about Native Americans and seven collect none at all.

As Matthew Snipp, a sociology professor at Stanford, recently said, “What a mess the data is….” But, he added, “it’s not unique to the American Indian population, the issues arise for any group when you try to measure race.” Snipp spoke at the recent American Indian Alaska Native Data Symposium held last month at the National Museum of the American Indians.

Few private health insurance plans, for example, collect the type of information that would be useful in this framework.

Of course data isn’t what’s really important here; instead, it’s how those numbers drive policy and funding and that’s where Medicaid and Medicare are the biggest players in that game.

Edward Fox, Squaxin Island Tribe, a consultant with Kauffman and Associates and author of the paper “Medicaid and Indian Health Programs,” said, “Medicaid expenditures exceed Indian Health Service expenditures in some areas.” He said in the Tucson area office, Medicaid is 156 percent of the IHS total; at Navajo, it’s 137 percent, Phoenix 94 percent and Alaska 91 percent.

Health care reform should boost financial support across the Indian health system because of the expansion of eligibility to include those to 133 percent of the federal poverty level and, for the first time, covering single adults.

The data has another purpose: To help understand – and to correct – the health disparity between American Indian and Alaska Native populations. What strategies, backed up by the data, work best to reduce diabetes? Or, better, are there clues to how to prevent the disease in the first place? And what do you compare those numbers against as a metric for success?

But it’s also why the data matters. It’s why the country and the American Indian/Alaska Native community have to get this right.

And, by the way, who is an Indian? That question soon takes on criminal proportions That question might generate a criminal inquiry when the IRS judges the Native American exemption to the health insurance mandate. But unlike the Census form, there will likely be a penalty for claiming a tribal affiliation when one doesn’t exist.

‘Government-run’ no longer defines the Indian health system

August 16, 2010

A single phrase is often used to define the Indian health system: “government-run.” Add those two words to any discussion about health care or reform and most people reach an immediate conclusion about the merits of the agency.

Now it is time for the phrase to disappear because it no longer accurately describes the Indian health system. After all, tribes or tribally authorized non-profit agencies administer more than half of the IHS budget, through the Self-Determination Act or Self-Governance compacts.

Certainly, the federal government plays a huge role in this health care delivery system – across the country. “As in all industrial nations, the U.S. government plays a large role in financing, organizing, overseeing and, in some instances, even delivering health care,” said a report last August by the Robert Wood Johnson Foundation. How big are the numbers? Federal direct spending – Medicaid, Medicare and such – accounted for 33.7 percent of all health care spending. If you add in tribal, local, state and other government funding to the mix, that figure reached $1.108 trillion – or about 46 percent of all health care dollars. The report said, “If tax subsidies that encourage provision of health coverage and health care are added in, the total public share comes close to three-fifths of all U.S. health spending.”

And all of these numbers are before the Patient Protection and Affordable Care Act was enacted into law and before any implementation.

But in the Indian health system something else is occurring: the growing role of private networks. This is not new. Dr. Everett R. Rhodes, a former director of the Indian Health Service, wrote in a 2002 article for the Western Journal of Medicine: “A shift of Indian health services to the private sector is now occurring, however, especially in western states where the majority of American Indian people live.”

Dr. Rhodes cited a variety of factors, including, “as the Indian population ages, however, the proportion of the IHS service population requiring care in the private sector will likely increase.”

The fact is individual American Indians and Alaska Natives with private insurance, Medicare and even Medicaid have a marketplace of medical choices. The Indian health system is just one option.

Last week, for example, the largest hospital system in the Dakotas announced a new initiative. Sanford Health hired Dr. Donald Warne, a member of the Oglala Lakota Tribe from Pine Ridge and former executive director of the Aberdeen Area Tribal Chairmen’s Health Board, to coordinate activities among the hospital system, the federal Indian Health Service and the 28 tribes within Sanford’s coverage region.

There will be more private interest in the Indian health system between now and 2014. One reason for that is even though Native Americans are not required to purchase health insurance, there are incentives under health care reform for individuals to do so.

The most important reason is that patients with private insurance don’t have to worry about contract health care running out of money. (This is also true for Medicaid, Medicare and other third-party insurance plans.) Another benefit: American Indians and Alaska Natives who purchase health insurance through the exchange do not have to pay co-pays or other cost-sharing if their income is under 300 percent of the federal poverty level (some $66,000 for a family of four, or nearly $83,000 in Alaska).

I think there is an opportunity here. I’d like to see a Native American enterprise selling such an insurance policy through the exchange that focuses on this unique segment of the population. It would be win-win-win. The individual would benefit with better coverage, the company could sell a policy at a profit, and the Indian health system could benefit from more third-party support.

When the Indian Health Service was created in 1955 its mission and operation was a government-run medical service. That simplicity is no more.

Indian Health Service’s lessons for us all

August 23 and 30, 2010

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 Healthhealth 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 says: “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 Service 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. Indian Health Service

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.

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, the state is reimbursed with a 100 percent match. Covering that patient does not cost the state.  Indian Health Service The Navajo hospital in Shiprock, Arizona.

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 only 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.


The White House Blog

Clearing Up a Few Myths on Health Insurance Reform and the Indian Health Service

By Kimberly Teehee on August 18, 2009

I wanted to record this new video for the “Reality Check” site and write this post to debunk the myth that the Indian Health Service (IHS) is a government health plan gone wrong.  It is truly unfortunate that recent press stories seek to scare Americans about health insurance reform by highlighting the IHS system.

download .mp4

First, the IHS system is not an insurance plan.  And comparing the two is like comparing apples to oranges.  IHS provides comprehensive health care services to approximately 1.9 million American Indians and Alaska Natives living on or near reservations in 35 states.  Some of these health services include doctor visits and check-ups, dental and vision care, diabetes prevention and treatment, mental health and substance abuse treatment, and home health care.  IHS also helps construct hospitals and clinics and provides safe drinking water and sanitation facilities to American Indians and Alaska Natives.  Health insurance, by contrast, provides individuals a guarantee to a defined set of benefits for a price.  While the IHS accepts insurance payments for care it provides, it is not an insurance plan.

Second, national health reform will not dismantle IHS.  American Indians and Alaska Natives will continue to have access to their Indian Health Service facilities. And third, while Indian health has been is historically underfunded, several tribes have developed innovative and award-winning approaches to provide health care to their communities. These sites serve as successful models for other rural and public health programs.  President Obama supports HIS, which is why he proposed a 13 percent increase in the FY 2010 budget, and invested $590 million in the American Recovery and Reinvestment Act of 2009.          

Kimberly Teehee is Senior Policy Advisor for Native American Affairs at the White House Domestic Policy Council.

The White House

Office of the Press Secretary

For Immediate Release

March 23, 2010

Statement by the President on the Reauthorization of the Indian Health Care Improvement Act

Earlier today, I signed into law the Patient Protection and Affordable Care Act, the health insurance reform bill passed by Congress.  In addition to reducing our deficit, making health care affordable for tens of millions of Americans, and enacting some of the toughest insurance reforms in history, this bill also permanently reauthorizes the Indian Health Care Improvement Act, which was first approved by Congress in 1976.   As a Senator, I co-sponsored this Act back in 2007 because I believe it is unacceptable that Native American communities still face gaping health care disparities.  Our responsibility to provide health services to American Indians and Alaska Natives derives from the nation-to-nation relationship between the federal and tribal governments.  And today, with this bill, we have taken a critical step in fulfilling that responsibility by modernizing the Indian health care system and improving access to health care for American Indians and Alaska Natives. 


Public Health Service

Indian Health Service

Rockville MD 20852

JUL 22 2010

Dear Tribal Leader:

I am writing to update you on activities that the Indian Health Service (IHS) is undertaking to deliver the benefits made possible by the Indian Health Care Improvement Reauthorization and Extension Act of 2009, which amended the Indian Health Care Improvement Act (IHCIA), and was included in the Affordable Care Act. The IHCIA provides authorities that assist the IHS and Tribes to advance our shared goal for improving the health of American Indian and Alaska Native (AI/AN) people.

Significant planning and coordination, consultation, and collaboration are necessary to implement many of the IHCIA provisions, especially those that provide new or expanded authorities for our health care programs.  Since the Affordable Care Act was passed by Congress

and signed by the President in March, we have identified milestones, timelines, and opportunities to coordinate with other agencies and partners.  We have also identified initial actions which may involve consultation with Tribes to fully implement over the next months and years.  During our initial implementation planning, we have identified some provisions that we believe are self-implementing and some provisions that require minimal actions to implement.  This is the first in a series of letters to notify you of these types of provisions.

This letter focuses on the Agency’s overall implementation of selected provisions to benefit all patients served by IHS, Tribal, and urban Indian health programs as specified in the law.  Please note that consideration of IHCIA authorities during negotiations with Tribes on fiscal year 2011 funding agreements is a much broader discussion than the content of this letter and may include additional provisions not mentioned in this letter.  IHS is committed to negotiating new IHCIA authorities with Tribes that would like to compact or contract for those authorities to the extent that we are able at the time of the negotiations.  Please do not infer that the provisions mentioned in this letter are the only authorities we are willing to negotiate.  In fact, we have already negotiated agreement on provisions that are not mentioned in this letter.  In the summaries that follow, the IHCIA section is cited and described briefly with the action the IHS is undertaking toward completing implementation.

The following section was added by Title I, Subtitle A, Indian Health Manpower:   

Sec. 113, Exemption from payment of certain fees, requires federal agencies to exempt Tribes

from paying licensing, registration, and other fees imposed by federal agencies.  Prior to the new

law, Tribes have paid a registration fee to the Drug Enforcement Agency (DEA) for each

primary care provider that prescribes controlled substances.  The DEA has notified their field

offices and the IHS that it will no longer charge Tribal providers for this fee.

The five sections that follow amended by Title I, Subtitle B, Health Services:



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Sec. 125, Reimbursement from certain third parties of costs of health services allows IHS,

Tribal programs and urban Indian organizations to be reimbursed from third parties for

reasonable charges billed for services provided to beneficiaries of these plans.  This provision

also permits Tribes and urban Indian organizations to recover the cost of care provided to

beneficiaries injured by a third party in accordance with the Federal Medical Care Recovery Act.

Because this provision now allows Tribal self-insurance plans to pay IHS for services to plan

beneficiaries, Tribes can volunteer to provide authorization for IHS to bill their self-insurance

plan in a Public Law 93-638 contract, the Annual Funding Agreement, or by written letter to the

respective IHS health facility that provided the services. 

Sec. 126, Crediting of reimbursements under various programs, including those under Titles XVIII, XIX, and XXI. This provision clarifies that reimbursements be returned to the service unit, the IHS, a Tribal program or an urban Indian health organization and that there be no offsets or limit on the amount obligated to the service unit.  IHS Area Offices and service units will be instructed to document compliance with this provision.

Sec. 127, Behavioral health training and community education, directs IHS to develop a plan to increase the staff providing behavioral health services by at least 500 positions within five years of enactment of the IHCIA.  I have approved an initial plan/strategy that will include consultation with Tribes and other stakeholders, to develop a final hiring plan for the positions, as specified, across the IHS/Tribal behavioral health care system within five years, of which at least 200 will be devoted to children, adolescents and families. The plan can then be implemented when resources for those positions become available. 

Sec. 129, Patient travel costs, continues to authorize funds to be used for travel costs of patients receiving health care services provided either directly by IHS, under contract health care, or through a contract or compact, and expands this authority to include reimbursement for costs for qualified escorts and transportation by private vehicle (where no other transportation is available), specially equipped vehicle, ambulance or by other means required when air or motor vehicle transport is not available.  The decision to pay for newly authorized patient travel expenses depends on local budget and priorities within the respective Contract Health Services (CHS) program.

Sec. 135, Liability for payment, clarifies that a provider has no further recourse against the patients for services authorized by the IHS under CHS.  The IHS has been and will continue to notify providers that CHS-referred patients cannot be billed for any deductibles or fees or co- pays for CHS-referred care.  The current notification letter from IHS-managed programs will be reviewed and updated, as necessary, to ensure that the standard language meets the statutory requirements of the IHCIA.  Tribes that have assumed control and operation of CHS programs through the Indian Self Determination and Education Assistance Act (ISDEAA) compacts and contracts are encouraged to note this new law and to modify their notifications to comply with the law. IHS encourages Tribal CHS programs that have not been issuing such notices to begin to issue such notices in accordance with the law. 


The three sections that follow are amended and added by Title I, Subtitle D, Access to Health Services:

Sec. 151, Treatment of payments under the Social Security Act (SSA) health benefits programs, reemphasizes that the IHS and Tribes update provider enrollment numbers and must provide the numbers to the HHS Secretary in order to receive reimbursements for payments from Medicaid, Medicare, Children’s Health Insurance Program, and other third-party payers for services.  IHS will work with Tribes to determine a strategy to ensure compliance with this provision.

Sec. 156, Nondiscrimination under federal health care programs in qualifications for reimbursement for services, prohibits discrimination against Tribal health programs under federal health care programs if they meet the generally applicable state or other requirements for participation. This provision eliminates the requirement for licensure if standards for licensure are otherwise met.  IHS may consider future implementation measures to ensure that this provision is consistently observed by all federal health care programs.   

Sec. 157, Access to Federal insurance, allows a Tribe or Tribal organization carrying out a program under the ISDEAA and an urban Indian organization carrying out a program under Title V of the IHCIA to purchase coverage for its employees from the Federal Employees Health

Benefits Program.  While the law creates this new authority, a mechanism needs to be developed to administer this option for Tribes and urban Indian organizations.  IHS recognizes that Tribes are very interested in this provision and we have been working with the Office of Personnel

Management to implement this provision and will consult with Tribes in the near future.   

Title I, Subtitle E, Health Services for Urban Indians.   

Sec. 162, Treatment of certain demonstration projects, made the Tulsa and Oklahoma City clinic demonstration projects permanent service units.  They are not subject to contracting or compacting under the ISDEAA.  The Oklahoma City Area IHS will communicate further with the two Program Directors and the Tribes in the Oklahoma City Area on how to formally incorporate these programs as service units in the Area.

Sec. 171, Establishment of the Indian Health Service as an Agency of the Public Health Service expands the authorities of the IHS Director to: (1) facilitate advocacy for the development of appropriate Indian health policy and; (2) promote consultation on matters related to Indian health. These provisions are a significant step in acknowledging the importance of the government-to-government relationship between the U.S. and Indian Tribes and give the IHS Director broader responsibilities for advising the Secretary on matters related to Indian health, and to collaborate and coordinate with other agencies and programs of the Department.  I recently discussed this provision with the Secretary and she supports my expanded role in advocating for Indian health issues and policy within the Department.  This was a goal of mine when I first was appointed the IHS Director, and I have already met with several agency heads 

and am at the table at all meetings with agency heads where decisions are made.  The Agency’s partnership and consultation activities with Tribes ensure that I can maximize the impact of this new and expanded role on improving health for American Indians and Alaska Natives across the entire Department of Health and Human Services.

I am committed to effective and meaningful consultation with Tribes to fully implement this important legislation as soon as possible.  In a letter to Tribal leaders on May 12, HHS and IHS initiated a formal consultation to ensure a strong partnership during implementation and requested your input on the consultation process and on priorities for implementation.  The letter is posted at If you have not provided input, I encourage you to do so in writing or by email to Although the July 1 deadline has passed, your input is still welcome.  Your input will support our consultation effort and move us toward timely and inclusive implementation of the IHCIA.

Finally, I want to underscore my commitment throughout this process to strengthen our partnership with Tribes by making the Agency’s work accountable and transparent.  I will continue to update you as progress is made on implementation of the IHCIA.  I will send you another letter detailing more provisions in the near future.

Sincerely yours,

/Yvette Roubideaux/

Yvette Roubideaux, M.D., M.P.H.

Indian Health Service Director