WASHINGTON,
D.C. – 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 7 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
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.
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.
Republish our articles for free, online or in print, under a Creative Commons license.
