TrahantReports: Indian Country & health care reform

Local control and new money: Making a health care system ‘ours’

Mon, 26 Jul 2010 09:54:21 -0600

There’s an old joke: A Native American student comes home from a geography lesson, shows his grandfather a map, and then asks, “What did we call the United States before it was a country?” His grandfather answers, “Ours.”

I thought of this joke recently in the context of the U.S. Indian Health Service. Perhaps the agency’s history, its shortcomings and its chronic underfunding have all been acceptable to Indian Country because the system itself is “ours.” It’s been “ours” for most of our generation – a little more than five decades – where American Indian and Alaska Natives could receive health care in a system that was, and is, unique.

A quick look at the history: Since 1955 the Indian Health Service was transferred from an rickety network of hospitals and clinics run by the Bureau of Indian Affairs to a real health care system. In that same time frame the agency went from being a slice of the BIA to being larger than the BIA with a budget of $4.4 billion and some 15,000 employees. During that time there were substantial improvements in Indian health, including reducing overall mortality by 28 percent in the past thirty years, while still falling short in health parity for Native Americans.

That brings me back to the definition of “ours.”

Since 1955 that definition has meant government-run health care, mostly in the form of direct services operated by the Indian Health Service. But that definition has been changing slowly since the enactment of the Indian Self-Determination and Education Assistance Act of 1975. That law, of course, gives tribes as well as tribal and urban Indian organizations the right to contract for the management of these federal programs. Already more than half of IHS is run under contract – and that number should grow even more quickly because of changes under the Patient Protection and Affordable Care Act.

In a way I suspect the future of IHS is almost like its past, after its break from the BIA. The BIA was the largest agency that served American Indians and Alaska Natives, then it recent years it has become the IHS. This will probably remain true for the next few years. But look at the budgets for some of the clinics or hospitals run under contract and it’s clear there are new “big” players coming into the picture. IHS will remain a funder of last resort for patients from Indian Country, but more native patients are eligible for funding from the Centers for Medicaid and Medicare as well as the Health Resources and Service Administration funding rural health clinics and Federally Qualified Health Centers.

This is what a possible budget at a 638 facility – either managed directly by a tribe or a nonprofit foundation – might look like in coming years: 40 percent of its revenue from CMS reimbursements; 30 percent from HRSA programs; another 25 percent from IHS and 5 percent from everything else, including private insurance. These percentages could be managed up or down depending on nature of the clients, but my point is that Indian Health Service will be a significantly smaller player. (Its primary mission might focus more on oversight and as funding mechanism as well as data collection.)

Does this mean that these new government-wide health bureaucracies are overrunning the treaty and trust rights of American Indian and Alaska Natives for health care? Perhaps. You could certainly make that case.

But you could also make the case that the federal government is, finally, coming up with a formula for adequate funding for every patient. Even better there is a stronger case that this health care system will work better and more efficiently when it’s designed and controlled at the local level through self-determination.

This will be when the Indian health care system can truly be called “ours.”

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 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.

As we talk about health care: Substitute “either, or” for “if … then”

Mon, 19 Jul 2010 07:36:39 -0600

What’s the most important element missing from our national conversation about health care reform? I’ll boil it down to one word, governance.

Consider the story so far. We’ve known for decades that our health system is unsustainable; there is no question that it cannot continue on its present course. So Congress finally rounds up enough votes to pass the Patient Protection and Affordable Care Act and what happens? The debate starts over as if there’s a magic wand out there somewhere that will let us have everything we want in health care without any cost.

There is no magic wand. What’s more this whole discussion is a test of our ability to govern ourselves. How can we govern when we’re so divided over complex and philosophical questions? How can we govern ourselves when we don’t even agree on the basic facts?

Start with the general state of our health care system. The Center for Economic and Policy Research puts it this way: “The U.S. health care system is possibly the most inefficient in the world: We spend twice as much per person on health care as other advanced countries, but we have worse health outcomes, including a lower life expectancy. The government, through programs like Medicare and Medicaid, pays for approximately half of the country's health care, almost all of which is actually provided by the private sector. Thus, the bulk of our projected rising budget deficits are due to skyrocketing health care costs.”

The CEPR has a fascinating budget deficit calculator that shows if we get our health costs under control, “our budget deficits will not rise uncontrollably in the future. But if we fail to contain health care costs, then it will be almost impossible to prevent exploding future budget deficits.”

This is where democracy itself is tested. How do we, those who ultimately govern, control costs? It’s easy to say no. We dismiss redesigning the system, we fight benefit cuts, we oppose tax increases, and we continue the political fight over the very premise. This is not self-government, but a national self-delusion because the demographic imperative – the aging of our population – is absolute.

Yet in congressional districts across the country there are calls to repeal the health care reform bill. Last week Rep. Eric Cantor, R-Virginia, told CNBC: “ “We’ve got to repeal the bill and replace it, though, because no one’s accepting the status quo. OK? So repeal this bill.”

But let’s be clear about the mechanics of repeal. No matter what happens in the November election there will not be the votes in Congress to repeal the law in 2010. President Obama will have more than enough to sustain a veto. In 2012, this question may surface as a theme in the presidential race – and let’s suppose the country votes in a Republican with a Republican Senate and House. Even then there may not be enough votes (thanks to the supermajority requirements in the Senate) for repeal.

Repeal, if it were to happen, will take years of debate. But what then? Will there suddenly be a consensus of what should be done? Will we resolve the deep political divide about the role of government in our health care system?

Meanwhile budget deficits will continue to grow. And we will be giving ourselves fewer alternatives about how to cut health care costs or how to tax and pay for those services. As we debate – and re-debate – health care reform the fastest growing government “program” is interest on the debt. The Concord Coalition estimates that interest due from the federal deficit will reach $533 billion a year by 2015, or roughly, a third of federal income taxes.

Demographics (our country’s aging) and deficits both deal with hard numbers. We can cling to any ideology we want, but in the end the numbers are the numbers. We are a people growing older – and that’s a good thing. But it means our system must be adapted to account for that shift. It’s the same with interest on the debt. We can shrink the size of any government program, but the growing debt service is a bill that must be paid.

That brings me back to the challenge for a self-governing nation. We need to get away from the “either, or” discussion. Our framework is stuck. Either health care reform, or repeal. Either cut social welfare benefits, or tax. Either, or.

What we need now, instead, is a series of policy options. We need the language of “if … then.” If we do this, then here are the implications. If we spend energy on the repeal of health care reform, we lose time really trimming our debt load. If we return to a smaller federal government, then what are the implications for each of us?

The health care reform bill is not perfect. There’s much that could be improved. But it’s now law and a tool that could bring health care costs down – along with the deficit. There ought to be consensus on that goal.

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 and writes from Fort Hall, Idaho. Comment at www.marktrahant.com

A call to action: Be the health care reform early adopters

Mon, 12 Jul 2010 08:04:57 -0600

If the United States government were a corporation, then the health insurance reform debate would have completely moved into its implementation phase. Essentially, the management and the board would have figured out the course of action, and then figured a way to execute that plan.

If that sounds easy, it’s not.

In the corporate world there’s a lot of thought given about how to take an idea and then make it so. Everett Rogers and his 1962 classic book, The Diffusion of Innovations, shows how “innovation is communicated through certain channels over time among members of a social system.” When you have a good idea (or a bad one) the execution runs up against deeply ingrained obstacles. So really smart people spend a lot of time on the implementation of ideas.

In my newspaper career I worked at large newspapers and small ones. In small ones we could execute lots of approaches, even trying ideas that flopped badly. (The great thing about a small newspaper is if an idea doesn’t work, try, try again.) But at large newspapers, well, change of any kind was difficult, slow and you had to sell the idea over and over.

Rogers demonstrated this problem in graphic form. He divided people in an organization into five groups: Innovators, early adopters, early majority, late majority and laggards.

So you convince innovators and early adopters until you build enough of a success story in order to convince the next group. Of course, some people will never be convinced and that has to be a part of the planning, too.

I’d like to think the Medicare and Medicaid debate followed the Rogers’ curve. On July 30, 1965, when the act was signed into law there was much opposition, a majority of Republicans in the Senate and just under half of the Republicans in the House voted “no.” There was no consensus – indeed the bill was as labeled (as Obama’s is now) as “brazen socialism.”

But forty years of the program – led by early adopters, and then, early and late majorities – changed the face of the debate. There are still laggards, but their ideas don’t stand up against popular support. We can, and should, continue the debate about how to pay for these programs and how to do that with the context of the Baby Boom generation (because of its huge size) and the growing span of human life. But that’s a different debate than the premise itself of health care coverage for seniors and those eligible for Medicaid coverage.

Will President Obama’s health care reform follow the same trajectory? That question is hard to answer right now, but it does show why governing a country is far more complicated than running a corporation. Remember in the corporate world, once the managers and boards have made a decision, they sell their workers and customers on that change. But in American-style politics, the debate about the premise for the health insurance reform law continues. Resolution is probably years away.

The July issue of Health Affairs says: “There are already many indications that the real fate of health reform will unfold gradually and quietly. The U.S. Chamber of Commerce waged a fierce public campaign against the enactment of comprehensive health reform, but once the law passed, the chamber refused to join the overt conservative Republican drumbeat for repeal, declaring that it would work to influence congressional elections and press for favorable regulatory decisions.”

The article by Theda Skocpol, a professor of government and sociology at Harvard, says much of the continued reform debate will be through challenges to “various administrative arrangements, taxes, and subsidies to fund expansions of coverage. The redistributive aspects of health reform will be especially at risk, as business interests and groups of more-privileged citizens press for lower taxes, looser regulations, and reduced subsidies for low-income people.”

So what does this big picture debate mean for the small slice known as the Indian health system? It’s a call to action. This is an opportunity to become the innovators and the early adopters; demonstrating with stories and data how the health care system can be improved at the patient level. If we do this right, a generation from now, readers will look back at health care reform and wonder what the debate was all about.

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 and writes from Fort Hall, Idaho. Comment at www.marktrahant.com

Warning: Budget tsunamis are forecast

Mon, 5 Jul 2010 10:30:48 -0600

The health care reform law should significantly boost the amount of money pumped into the Indian health system. That’s the good news. Now brace for the bad: Really bleak budgets are coming soon.

The reasons are global: Governments all across the world are cutting spending and restricting eligibility for programs that people now take for granted. This trend is a wave gathering force like a tsunami. The first notice of this massive wave was when Greece could no longer support its debts with new borrowing. But that country is not alone because the trend is worldwide.

The new government in the United Kingdom is a stark example. The Liberal-Conservative coalition last week said some agencies could face budget cuts of up to 40 percent. According to The Guardian in London, “the only departments not included in the Treasury trawl will be health and international development, which have been ‘ringfenced’ for the current parliament.” Interesting word and concept: a ringfence is a transaction, or in this case a budget, walled off from the rest of the government’s budget. In other words: The National Health Service is supposed to be protected.

But this, too, is a reflection of the tsunami. The cuts to the National Health Service will be more targeted around the issue of efficiency. But there will be cuts.

Of course the United States is different. While we don’t have national health care, federal and state budgets propelled in part by rising Medicaid costs are crashing under the same financial tsunami. Medicaid is a state-federal partnership. Much of the political focus of Medicaid is its role providing health insurance to some 60 million low-income Americans. According to the Kaiser Commission on Medicaid and the Uninsured health care reform could add another 16 million people to the program over the next five years. But while the focus on Medicaid is on the poor, the program spends two-thirds of its benefits for seniors and for people with disabilities. In theory, a state could end its partnership and save billions of dollars by not participating in Medicaid – but that’s not going to happen because so many of the people who benefit from Medicaid, especially seniors, vote. (One reason why cutting the program’s benefits for low-income people gets so much more attention.)

President Barack Obama has argued – I believe correctly – that this is exactly the wrong time to cut spending. People across the country need help from their government because of the recession. Yet Congress is starting to say “no” anyway trimming spending that was once considered essential, such as extending unemployment benefits and assistance to buy COBRA health insurance (a subsidy I have relied on since my job went disappeared with the death of the Seattle Post-Intelligencer newspaper). The problem for the president is that with a super-majority required in the Senate – 60 votes – there will be far more “no’s” than “yea’s” when it comes to more spending.

“Democrats are leaving Washington for the July 4 recess without passing key parts of their health care agenda,” writes Andrew Villegas for Kaiser Health News. “…with states hit hard by the recession, an extension of extra Medicaid funds also seemed likely.” But because of a “contentious debate, with conservative Democrats and Republicans opposing programs that could add to the deficit.” The result, Villegas writes, is “the Medicaid and COBRA subsidies are still in limbo.”

Many American Indian and Alaska Native patients in the Indian health system are in a precarious spot because of this battle. Some of the increased spending for Indian Health Service depends on increasing Medicaid rolls. This is important because Medicaid, unlike the IHS budget, is an entitlement. Once a person is eligible, the money is supposed to be there (in contrast to a straight budget line that runs out of money once its spent). This problem should be simple: States don’t have to pay for patients in the Indian health system because the federal government eventually picks up the cost. But the problem is each state will define eligibility and a tightening of state rules will mean that patients that should be eligible for Medicaid, won’t qualify.

It would be easy to dismiss states as uncaring. But the problem is there are fewer dollars available from tax collections during the recession. State budgets are wrecked by too many promises, ranging from pension obligations to constitutional promises to always balance the budget.

The best course ahead is to be innovative, tap into as much new money now, and prepare for the worst. Indian Country can’t pretend that budgets will magically be dammed (or as the British say, ringfenced). The tsunami is on its way.

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 and writes from Fort Hall, Idaho. Comment at www.marktrahant.com

The CHCs have arrived & represent the prospect of better funding for Indian health

Mon, 28 Jun 2010 09:01:34 -0600

This past weekend the Coeur d’Alene Tribe celebrated the 20th anniversary of the Benewah Medical Center in Plummer, Idaho. “In 1987, the BMC Web site reports, “the Coeur d’Alene Tribe began to search for ways to improve the health care services at their small Indian Health Service satellite clinic. It was located at the Tribal Headquarters, several miles from the City of Plummer, Idaho. Many tribal members were dissatisfied with 15 years of fragmented care delivered in a semi-condemned building and with poor continuity of care.”

Indeed, the complaints about the IHS facility and its operation were similar to those heard across Indian Country. And, like many tribes, the Coeur d’Alene proceeded to create its own health care network. But this was a broader vision, one that went beyond just replacing and recreating IHS; there was also a sense of something new. Prevention was made a priority and a wellness center complimented patient care. There also was recognition of the gap in rural health care services. As Benewah Medical Center describes it: “None of the ambulatory care facilities in the four surrounding counties of the Northern Idaho town were providing services to the medically underserved on a sliding fee basis.”

So a tribal community health center was created – launching two decades of innovation.

Fast forward to the Patient Protection and Affordable Care Act, the new health care reform law. Between now and 2015 the law significantly expands resources – funding – for community health centers (described in the law as Community Health Clinics, Federally Qualified Health Centers, or FQHCs in federal jargon, and Rural Health Clinics. There are technical differences in these definitions. Basically the details relate to how various medical services are paid for by the federal government.

But my view is that tribally managed health networks now have a significant financial advantage over IHS-run facilities. There are more pots of money to tap, ranging from the IHS contract under the Self-Determination Act to money from the Health Resources and Services Administration, in the U.S. Department of Health and Human Services.

Funding for community health centers started growing under President George W. Bush who doubled the spending in 2008 to $2.8 billion. Since then President Barack Obama has added money under the American Recovery and Reinvestment Act of 2009 for community health centers as well as an additional $12.5 billion for expansion of these efforts over the next five years as part of health care reform.

“With an eye toward meeting the primary care needs of an estimated 32 million newly insured Americans, the recently passed Patient Protection and Affordable Care Act underwrites the CHCs and enables them to serve nearly 20 million new patients while adding an estimated 15,000 providers to their staffs by 2015,” write Drs. Eli Y. Adashi, H. Jack Geiger and Michael D. Fine in the May 11 edition of The New England Journal of Medicine. “The new CHCs have arrived.”

The law identifies community health centers as a priority. There are new resources for the expansion, construction, or renovation of clinics and to hire more medical providers. Nationwide, some 19 million people now use services at community clinics and the goal is to double that number (or about ten percent of the U.S. population).

And, this time around, Indian Country is included, if tribes and urban organizations choose to participate.

Community health centers generally operate by charging patients on a sliding scale and have historically served the uninsured population. In Indian Country this takes on a different twist because for eligible American Indian and Alaska Native patients, the Indian Health Service still picks up the cost as the payer of last resort (non-eligible patients would still be billed based on what they can pay).

The significance of all this is that the community health center model represents an improved funding stream for the Indian health system. Currently a little more than half of the total Indian Health Service budget funds tribal or urban Indian facilities; a decade from now I could see that number at 90 percent or even higher. But IHS would only be a portion of the funding story: Money would also come from insurance companies or the new insurance exchange; on top of that there would be Medicaid and Medicare; perhaps add in a foundation grant or two; and, finally, the funding would be completed by appropriations designated for community health centers. The total might not be full funding of the Indian health system, but it will be a lot closer to that goal.

There are those that will argue that Indian Health Service should be fully funded, as is. But one can also make the case that this new opportunity – tapping money from a number of revenue sources – is recognition of tribal sovereignty, too. And a promise fulfilled.

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 and writes from Fort Hall, Idaho. Comment at www.marktrahant.com