What will the Indian health system look like?
What will the Indian health system look like a decade from now?
That’s an impossible question to answer. There is the potential of a court ruling striking down at least part of the Patient Protection and Affordable Care Act. And, there is always the possibility of Congress will rewrite the law (I view this as remote because there would have to be a Super Majority to enact something else.)
But in the meantime there is a new foundation already under construction. The building that will rest on that structure will not be the same as the one in place now.
Let’s start with the patient. Right now, according to the Kaiser Family Foundation, [pdf] nearly half of all American Indians and Alaska Natives are either uninsured or rely solely on the Indian Health Service. But health care reform changes that. Big time. Beginning in four years, hundreds of thousands of people will become eligible for insurance through government programs (such as Medicaid) because of new income rules. This insurance can be used to pay for services at Indian health system facilities – or at competing health care centers. (Think about how many private walk-in clinics promise no waiting.)
Another huge change is that states have more at stake than ever in the success of the Indian health system. Let’s start with the premise that everyone who should be covered by these government insurance programs will be. (I know it’s a leap.)
If a Native American patient goes into an IHS facility with that Medicaid card, then the state is reimbursed with a 100 percent match. Covering that patient does not cost the state (at a time when budgets are stretched to the max). However if that same patient goes to, say, a for-profit clinic outside of the Indian health system, then eventually the state must pay its share of the Medicaid costs (the same as it would for any other citizen). The amount of state funding is relatively small between 2014 and 2019 – the states share is more than $21 billion out of the estimated $447 billion Medicaid pie – but the costs down the road are significant.
The point here is that state governments are now a full partner in the Indian health system and have a financial interest in making the system work better. This means there will need to be great scenario planning, exploring what happens when individuals make their choices. And there needs to be more discussion about the demand side of that equation in terms of hiring and retaining more doctors, nurses, pharmacists, midwives, nutritionists and administrators.
I also think there ought to be a full public education program, explaining to patients how they can be part of the Indian health system solution because, if all of this works as planned, the increases in Medicaid participation should add real money to the Indian health system.
What else will change?
Health care reforms will likely speed up the shift from IHS direct services to clinics and hospitals run by tribes, urban organizations and other non-profits. A few years ago the economic equation for contracting for IHS services was so-so. And that’s still true – if you only count IHS money. But there are other players ranging from Medicaid to funds designated for rural and community health clinics. These new sources of revenue tip the advantage – I think significantly – toward independent, tribally sponsored health enterprises.
This, too, has profound implications for the Indian Health Service. The IHS is Indian Country’s largest single employer with more than 15,000 employees. A generation from now that number is likely to shrink as funding is directed at tribal governments and other organizations. Yet the IHS role will remain critical – particularly in the sharing of medical information, best practices and standards – as well as acting as one funding conduit.
Now forget everything I’ve written. This is just my view after looking at the system for a year. I could be wrong.
What will the Indian health system look like a decade from now? I’m optimistic about the answer, but it really depends on the creativity and innovation that comes from Indian Country. The answer is up to all of us.
Mark Trahant has spent the past year as 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.