Opinion Column

A Practical Reform: Indian Country As The 51st State

Health care reform will be high on the list of topics for President Barack Obama’s meeting next Thursday with representatives of the nation’s 564 federally recognized tribes. The president said he looks forward to talks with tribal leaders about ways to “improve their lives and the lives of their peoples.”

The president will be looking for political support from Indian Country for his broader reform proposals, while tribal leaders will be seeking improvements in the health care system for American Indians and Alaskan Natives.

The U.S. Indian Health Service is the closest thing this country has to a single-payer system, serving nearly two million American Indians and Alaskan Natives in 36 states. The agency represents the promise of health care for American Indians made through treaties and other laws and is a full health care delivery system. The IHS operates hospitals and clinics, funds tribal and urban facilities and manages programs ranging from sanitation to diabetes care.

But virtually everyone recognizes the IHS is seriously under-funded.

“Putting all the legal aspects aside, I think the trust responsibility can be summed up by saying that something is owed to American Indians for the lands that were both voluntarily given to the United States and forcefully taken, as well as the atrocities that were committed against their peoples,” said Democratic Rep. Frank Pallone Jr. of New Jersey at an Oct. 20 hearing about Indian health care. “But the federal government has consistently failed to live up to this responsibility in almost every respect.”

The Indian Health Service, in fact, doesn’t even count as an acceptable insurance plan under any reform bill. This is ironic because those same health proposals exempt American Indians from the individual mandate to purchase health insurance because of that IHS promise. But unless funding improves, health care reform will guarantee a permanent disparity in just about every Native American health statistic.

At a meeting of the National Congress of American Indians last month tribal leaders said they would ask the president for at least a “no harm” statement protecting the “already strained” Indian Health Service from future cuts.

Yet no one is asking the president for full IHS funding — at least directly.

One idea is to improve the IHS’ ability to tap Medicare, Medicaid and the Children’s Health Insurance Program. The Indian Health Service was left out of the original Medicare and Medicaid legislation and was not added until the Indian Health Care Improvement Act in 1976. It now receives about $650 million a year from Medicare and Medicaid, a figure still considerably less than it could be because entitlements promise money for every eligible person. However, the IHS is funded by annual appropriation.

These days Medicare is considered a nearly universal system forĀ America’s elders, There is a 20-fold difference in the actual number of Native elders 65 years of age and older not covered by Medicare than and the U.S. general population (or 15% versus 0.7%). Native elders do not have enough quarters of work to qualify for Medicare, but do qualify for Medicaid.

Enrolling more Native Americans in Medicaid is complicated by the partnership between federal and state governments. States write the rules, under broad guidelines, while the federal government pays for nearly all of the cost for Indian health programs. The Government Accountability Office found that the range of Medicaid reimbursements at IHS facilities ranged from 2 to 49 percent and not surprisingly, “the facilities with higher reimbursements had additional funds to hire staff and purchase equipment and supplies.”

The practical problem for Medicaid is its administration by state governments, which have uneven relationships with tribes and Indian organizations. Even if those states work well with tribes, imagine the complexity for tribes with members living on their home reservation, but in different states. For example the Navajo Nation program managers must help clients navigate the eligibility process under specific rules for Medicaid programs in Arizona, New Mexico and Utah.

This is a way to save money by cutting waste. Instead of sending federal dollars to state Medicaid (and Children’s Health Insurance Program) offices, there ought to be a way to transfer money directly to IHS. There could be a new set of flexible rules written for Native Americans with far less administrative overhead than the 36 different systems. The federal government could treat Indian Country, at least for health programs, as the 51st state. This seems to me a practical application of the nation-to-nation relationship.

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 is a member of Idaho’s Shoshone-Bannock Tribes.