At a Billings hearing in May, Sen. Jon Tester expressed frustration about the management of the Indian Health Service.
The Montana Democrat said:
“We need to live up to our trust responsibility and offer tribes the
health care they deserve. Ongoing issues around service delivery,
transportation for critical care, billing and reimbursement issues
abound. We need to prioritize these issues and solve them.”
Tester, of course, is
chairman of the Senate Indian Affairs Committee. So his call for
improving the agency is worth considering.
Then again, when former Sen. Byron Dorgan (D-ND) was chairman of the same committee, he also held hearings and published a report
about the poor management record at IHS. “The investigation identified
mismanagement, lack of employee accountability and financial integrity,
as well as insufficient oversight of IHS' Aberdeen Area facilities.
These issues impact overall access and quality of health care services
provided to Native American patients in the Aberdeen Area. Many of these
issues may stem from a greater lack of oversight by the area office and
IHS headquarters fostering an environment where employees and
management are not held accountable for poor performance.” The year was
So what kind of progress has the Indian Health Service made during those four years? Unfortunately that’s the wrong question.
In the blink of an eye, the
very structure of health care has changed and is continuing to change
dramatically in the United States. Yet the structure of the Indian
Health Service is the same.
Take the name: Indian
Health Service. On the agency’s web page it adds the descriptive line,
“The Federal Health Program for American Indians and Alaska Natives.”
Yet some 40 percent of the
agency funds go directly to tribes, independent medical nonprofits or
urban health programs. The federal health program is a mechanism for
funding, not a federal health program. And that percentage is likely to
grow because the system is no longer equal. The IHS has less access to a
variety of funding pots that are available to tribal and urban health clinics.
A second problem with the IHS structure is that the United States for many policy reasons picked an insurance framework under the Affordable Care Act. And much of that insurance is built on an expansion of “entitlement” programs.
But the IHS is a health care delivery system, not an insurance regime.
And, unlike the entitlement programs of Medicare, Medicaid, and
Children’s Health Insurance, the IHS is funded through congressional
appropriations. So the agency’s primary source of funding is subject to
the whims of a Congress that is deeply divided about priorities and the
role of government.
This funding mechanism was
made worse by the Affordable Care Act when the Supreme Court said states
could choose to expand Medicaid (an insurance partnership for people on
low incomes) or not. State-based “optional” insurance is creating a
divide within the Indian health system. Under current law, IHS rewards
facilities for bringing in third-party payers from either private
insurance or Medicaid dollars. It’s money that’s added to a local clinic
or hospital budget. But most of that money is from Medicaid and if a
state rejects the expansion, that becomes, in effect, a structural
deficit. Almost half of the states, many with large American Indian or Alaska Native populations, have not expanded Medicaid.
So what should the Indian
Health Service look like in the age of Obamacare? That is the
conversation that should be occurring, but is not. It’s so much easier
to blame underfunding or management instead of rethinking the entire IHS
What would IHS look like if
it’s primary role was to act as a funding agent with the goal of
sending maximum resources — you know, money — directly to tribally-run
and other health care delivery agencies? Or what if Medicaid was
administered directly for tribes, leaving states out of the equation?
One thing I would change is
The Story. As I have written before, it’s important that Congress know
that past efforts worked. The creation of the Indian Health Service in
1955 and the Indian Health Care Improvement Act of 1976 both improved
the health of American Indians and Alaska Natives. Yes, there remain
health care disparities when compared to the general population but the
gap is far less than it was. And IHS did this by spending less money
than just about any other health care delivery system in the United
Sure, there are management
challenges at the Indian Health Service as noted by Senators Tester and
before that Dorgan. But as we near the 50th anniversary of the Indian
Health Care Improvement Act, it’s time to rethink the agency’s structure
and demand reform. It’s time to imagine what success looks like.
Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.