Double Standard of Government-Run Healthcare

With proper funding, Indian Health Services could be model for reform

August 7, 2009 -- There seems to be political consensus that our healthcare system won’t end up like those in Canada or England. OK, but what about the American version that exists today of a single-payer, government-run healthcare 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 healthcare network.

Health and Human Services Secretary Kathleen Sebelius recently told the Associated Press that the Indian Health Service has been a “historic failure,” and she promised to improve the agency.

The secretary would get a lot of support for that notion from Indian Country. Native Americans, who are the first to point out how the system hasn’t kept up with the need.

But this is a complicated issue. As National Congress of American Indians Vice President Jefferson Keel testified to Congress recently, “The truth is that the IHS system is not so much broken as it is ‘starved.’ 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.” It spends about one-third less per capita than Americans in general and half of what’s spent for the healthcare of a federal prisoner. Often that means a rationing of care, especially when it means contracting with doctors outside the IHS network.

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 Alaskan Native community with a sort of pre-paid insurance program (many treaties, executive orders and laws were specific in making American Indian healthcare a United States’ obligation).
But the federal management of its healthcare network is full of inconsistencies, including the way the government pays itself. Medicare only reimburses IHS or tribal health facilities for 80 percent of the costs; so an already underfunded IHS essentially subsidizes Medicare. According to the National Congress of American Indians fixing this one problem would add $40 million a year to the budget.
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 a rural healthcare network. So much so that many rural non-Indian communities are looking for ways to tap into the system for the general population.
And while the funding scarcity results in substandard care, it’s not the only story. There has been considerable improvement in American Indian and Alaskan Native health since the IHS was founded. One study reported: “In the first 25 years of the program, infant mortality dropped by 82 percent, the maternal death rate dropped by 89 percent, the mortality rate from tuberculosis diminished by 96 percent, and deaths from diarrhea and dehydration fell by 93 percent. The improvement in Indians’ health status outpaced the health gains of other U.S. disadvantaged populations.”
One reason for those improved health conditions was an early decision to invest in education, sanitation and preventative care. We know this about healthcare 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 healthcare 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 that patients see doctors and traditional healers on the same team. I know 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 and so my son’s umbilical 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.
Neither President Obama nor Congress needs a new study to improve the government’s management of Indian health programs. But it will require more money. The IHS could spend significantly more dollars on its patients – and still be a healthcare bargain for taxpayers. Congress also ought to remove the federal government’s double standard on Indian healthcare by reenacting the now expired Indian Health Care Improvement Act. This original law, signed by President Ford, was successful by any measure and one reason for the better statistics. Once again, improving the healthcare of American Indians and Alaskan Natives is a test: If the federal government can’t get this small segment of its own healthcare operations right, then it has no chance to reform an entire system. 
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’s a member of Idaho’s Shoshone-Bannock Tribes. 
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Mark, I agree in concept IHS could be a model or learning experience for a "public option"...far more meaningful than what is on the table in Washington, DC. However, your text is littered with troubling qualifications complaining of not being adequately funded as compared to what goes on in the rest of the marketplace. If half the care delivered in the broader world delivers little or no medical benefit, why shouldn't any follow on system, properly designed be able to flourish with just 80% of the revenues of that highly dysfunctional alternative? Otherwise why should I believe the model has obvious and compelling merit? Is it in our genetic code like farmers that we never have enough and we are always suffering the woes of inadequate dough? Give me a robust and positive plan than can flourish with 80% of par, and celebrate. Otherwise what is the point of going to all this effort?