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markt | Mar 22, 2010 10:50 AM

The three most important things to know about what health care reform means to Indian Country are simple ideas. First, the United States, officially and permanently, recognizes its trust and treaty obligation for health care delivery to American Indians and Alaska Natives. Second, there will be more money (not enough, but more) pumped into the Indian health system. And, third, President Barack Obama has delivered on a major, long-sought promise to Indian Country.

Now let’s consider a few details.

When Medicare and Medicaid passed Congress in 1965 and were signed into law there was no consideration – none – of how those bills impacted Indian Country. It was as if the Indian Health Service, then all federal employees, was off the books, a forgotten instrument. In fact there wasn’t even a plan that allowed IHS to tap into Medicare or Medicaid dollars. That had to wait for the Indian Health Care Improvement Act of 1976.

That is not the case with President Obama’s health care reform. Indian Country is included throughout the document in large and small measures designed to improve the health of Native people.

The Indian health system, for example, is designated as an “express lane” to help people enroll in Medicaid. That should make it easier for that funding stream to supplement IHS appropriations. There are many other important programs in the final bill, ranging from new education and training programs to improved regulations for tribally managed health facilities.

The most important provision is the reauthorization of the Indian Health Care Improvement Act (after ten years of empty promises) as a title in the Senate health care package.

The president said early Monday morning: “Nor does this day represent the end of the work that faces our country. The work of revitalizing our economy goes on. The work of promoting private sector job creation goes on. The work of putting American families’ dreams back within reach goes on. And we march on, with renewed confidence, energized by this victory on their behalf. In the end, what this day represents is another stone firmly laid in the foundation of the American Dream.”

It’s also a down payment on an American promise. The official goal remains lofty: The United States is supposed to provide the resources for American Indians and Alaska Natives to eradicate the health disparities between Indians and the general population. Much hard work will be required to even get close to such a goal. To make that happen there must be steady, increased appropriations even at a time when the rest of the federal budget is being trimmed. Remember that unlike Medicare or Medicaid, money for Indian health must be appropriated every year; it’s not an automatic entitlement. But this act at least puts Congress on record with a goal, one that should be matched by funding.

The measure itself “authorizes appropriations” for programs “to increase the Indian health care workforce, new programs for innovative care delivery models, behavioral health care services, new services for health promotion and disease prevention, efforts to improve access to health care services, construction of Indian health facilities, and an Indian youth suicide prevention grant program."

But that’s only step one, authorization. The Indian Health Care Improvement Act makes this process easier because the authorizing law itself is now permanent. It will not require “reauthorization” a process that languished since the original act expired nearly a decade ago. A second step still needs to happen, though, so that Congress appropriates the funds for the authorized programs. That step will be much easier in the days ahead because the funding requests will match the law.

“Passage of the Indian Health Care Improvement Act is going to be especially important because of the symbolism of its passage itself,” IHS Director Yvette Roubideaux told me a couple of months ago. “It’s an act that will reaffirm the government’s responsibility for updating and modernizing the Indian Health Service.”

Over the years many in Congress and in the White House have said the right words when it came to improving the health status of Native Americans. But this is a president and a Congress that’s delivering on those promises.


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. Contact him at

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