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 Alaskan 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 Alaskan 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 under-funded.

“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.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.

This <a target="_blank" href="/news/102909trahant/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The federal government’s delivery of health care for American Indians and Alaskan Natives began more than two centuries ago, first in the War Department and then at the Bureau of Indian Affairs. Congress transferred those functions to the Indian Health Service in 1955. Today, the agency is a comprehensive health delivery system for nearly two million American Indians and Alaskan Natives, mostly living on Indian reservations and in rural communities in 36 states.

IHS critics correctly point out the disparities between American Indian health and the general population. The General Accountability Office reported in 2005 that because of shortages in budget, personnel and facilities “the IHS rarely provides benefits comparable with complete insurance coverage for the eligible population.” Often that means a rationing of care, especially when it means contracting with doctors and hospitals outside of the IHS network.

So how could IHS be any sort of model for health care reform? The answer: The Indian Health Service is sustainable; the patchwork we call a health care system is not.

“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 acknowledged that the IHS needs more money – but added that 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.”

For example, the IHS funds initiatives designed to improve the health of its clients rather than limiting expenditures to direct medical care. Beginning in the 1960s, it invested in reservation and rural water systems, sewage and solid waste facilities. It funds technical assistance for those facilities. The result, according to the Congressional Research Service, is an 80 percent reduction in gastrointestinal disease among American Indian and Alaskan 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 manage their treatment to get 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 are maintaining blood sugar control and, more important, there has been a 40 percent reduction in complications such as kidney disease and retinopathy.

This has implications for the rest of the country. Diabetes-related costs were $174 billion in 2007. And unfortunately, the disease is increasing at rates all too familiar in Indian Country. About one-quarter of all Americans have pre-diabetes and if the disease fully develops, in 2002 the health care costs topped $13,200 per diabetic patient compared to $2,560 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 for veterans and $7,784 for Medicare beneficiaries.

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 similar program. But that, as tribal leaders have pointed out repeatedly, 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.

If the Indian Health Service were reasonably funded the discussion about health care reform would be very different. The paradox is that we’d all see that “big” government health care has track record that is lean and efficient.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.

This <a target="_blank" href="/news/091709trahant/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

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 Alaskan 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 Alaskan 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 under-funded.

“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.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.

This <a target="_blank" href="/news/102909trahant/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The federal government’s delivery of health care for American Indians and Alaskan Natives began more than two centuries ago, first in the War Department and then at the Bureau of Indian Affairs. Congress transferred those functions to the Indian Health Service in 1955. Today, the agency is a comprehensive health delivery system for nearly two million American Indians and Alaskan Natives, mostly living on Indian reservations and in rural communities in 36 states.

IHS critics correctly point out the disparities between American Indian health and the general population. The General Accountability Office reported in 2005 that because of shortages in budget, personnel and facilities “the IHS rarely provides benefits comparable with complete insurance coverage for the eligible population.” Often that means a rationing of care, especially when it means contracting with doctors and hospitals outside of the IHS network.

So how could IHS be any sort of model for health care reform? The answer: The Indian Health Service is sustainable; the patchwork we call a health care system is not.

“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 acknowledged that the IHS needs more money – but added that 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.”

For example, the IHS funds initiatives designed to improve the health of its clients rather than limiting expenditures to direct medical care. Beginning in the 1960s, it invested in reservation and rural water systems, sewage and solid waste facilities. It funds technical assistance for those facilities. The result, according to the Congressional Research Service, is an 80 percent reduction in gastrointestinal disease among American Indian and Alaskan 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 manage their treatment to get 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 are maintaining blood sugar control and, more important, there has been a 40 percent reduction in complications such as kidney disease and retinopathy.

This has implications for the rest of the country. Diabetes-related costs were $174 billion in 2007. And unfortunately, the disease is increasing at rates all too familiar in Indian Country. About one-quarter of all Americans have pre-diabetes and if the disease fully develops, in 2002 the health care costs topped $13,200 per diabetic patient compared to $2,560 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 for veterans and $7,784 for Medicare beneficiaries.

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 similar program. But that, as tribal leaders have pointed out repeatedly, 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.

If the Indian Health Service were reasonably funded the discussion about health care reform would be very different. The paradox is that we’d all see that “big” government health care has track record that is lean and efficient.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.

This <a target="_blank" href="/news/091709trahant/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">