Trahant: The double standard of government-run health care: the Indian Health Service

By Mark Trahant
Special to News From Indian Country 7-09

There seems to be political consensus that our health care system won’t end up like those in Canada or England. OK, but what about the American version of a single-payer, government-run health care 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 health care 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 are the first to point out how the system hasn’t kept up with the need – issues that will be explored at a National Indian Health Summit and in Denver July 7-9.

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 health care 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 health care a United States’ obligation).

But the federal management of its health care 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 health care 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 health care 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 health care 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 health care bargain for taxpayers. Congress also ought to remove the federal government’s double standard on Indian health care 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 health care of American Indians and Alaskan Natives is a test: If the federal government can’t get this small segment of its own health care 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 and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes.

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