Lessons from the Indian Health System
A year goes by fast. Way too fast. Thirteen months ago I
plunged into my “year-long” exploration of the Indian health system. It’s been
fascinating because there has 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.
My idea was to explore two basic questions. First, what
lessons from the Indian Health Service ought to be a part of the national
health care reform debate? And, second, what is the impact of health care
reform on the Indian Health system? (I’ll write about that next week.)
In some ways the first question is the most difficult
because of its complexity. The “story” of the Indian Health Service told in
Congress and by news organizations is primarily the story of how the government
runs a health care delivery system.
Sometimes that even reflects 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. A
recent post on KevinMd.com is an example of that narrative: “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, as I have written before, one
that will be impossible to repeal until at least 2012).
But this narrative – Indian Health as a single-payer
(success or failure) – misses the complexity. It’s hard to find many news
stories at all that describe the role of Indian Health Service as a partner and
funder of tribal, non-profit and urban health care organizations. Even though
that activity represents more than half the IHS budget.
That’s why 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;
Experiences with an early implementation of an electronic
record system for patients, information that will be valuable as other
providers move away from paper records;
Searching 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. But the topic should be a part of the
discussion.
But perhaps the most important lesson is the Indian Health
system’s history 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
five health care dollars are spent on caring for someone with diabetes.
Unfortunately this epidemic is not news in Indian Country.
American Indian and Alaska Natives are three times more likely
to have diabetes than the white population (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.
The diabetes crisis is not over – but Indian Country’s
experiences could be helpful to the larger debate showing the importance of education
and community-based efforts.
Mark Trahant is a Kaiser Media Fellow examining the Indian
Health Service and its relevance to the national health care reform debate. He
is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall,
Idaho. Comment at www.marktrahant.com
His new book is “The Last Great
Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest
Gerard.
Additional resources:
New England Journal of Medicine article by Surgeon General Regina Benjamin on “Finding My Way to Electronic Health Records.
Financial Times: New report shows diabetes costs $83 billion a year in hospital
bills.
Republish our articles for free, online or in print, under a Creative Commons license.
