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 nonprofit 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 & 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.
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. His new book is “The Last Great Battle of the Indian Wars,”
the story of Sen. Henry Jackson and Forrest Gerard. Comment at www.marktrahant.com
Additional resources:
A
letter from IHS director [PDF] Dr. Yvette Roubideaux to tribal leaders about activities
that the Indian Health Service is undertaking to deliver the benefits made
possible by the Indian Health Care Improvement
Act.
A Kaiser Family
Foundation brief [PDF] that explains the concept of the health care insurance
exchanges.
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