Mark Trahant
Mark Trahant, former editorial page editor for the Seattle Post-Intelligencer is a Kaiser Media Fellow spending the next year examining the Indian Health Service and its relevance to the national health reform debate. Mark is a member of Idaho’s Shoshone-Bannock Tribe. www.marktrahant.com.
INDIAN COUNTRY & HEALTH CARE REFORM
Simple math: Health Care Reform = Jobs
Monday, April 26, 2010
This is simple math: Health care equals jobs. And the new health care reform law means even more jobs. In many communities across the United States, the health care industry is the region’s top…
Detroit’s geography of despair include many seeds of hope
Monday, April 19, 2010
DETROIT – It’s hard to communicate the failure of public policy in this great American city (especially in a few hundred words). A drive around town highlights the consequences from decades of…
The state of Navajo – sort of – and other health care experiments
Monday, April 12, 2010
Congress passed the health care reform legislation – and President Barack Obama signed the bill into law. The Indian Health Care Improvement Act was included – and now we can put this debate to rest….
By Mark Trahant
The enactment of health care insurance reform raises a thorny (and complicated) question for Indian Country: Should American Indians and Alaska Natives eligible for services in the Indian health system buy their own insurance?
The first answer ought to be a resounding “no.” Clearly the United States has an obligation for health care because of promises made through treaties and statutes. Indeed, the very enactment of the Indian Health Care Improvement Act is a legal restating of this principle. Health and Human Services Secretary Kathleen Sebelius said it this way on March 26: “This administration is intent on honoring the obligations of our government-to-government relationship with American Indian tribes, including the promise of adequate health care.”
But adequate health care is not an insurance plan; especially when that promise is so limited by money. And there is no possibility that Congress will fully fund the Indian health system anytime soon.
So where does that leave us? The Government Accountability Office said in a 2005 report: “There remain concerns about the extent to which health care services are available—that is, both offered and accessible—to Native Americans served by IHS.” One key issue here is the underfunding of Contract Health Services, money that is used to pay for health care providers outside of the Indian health system. Remember unlike Medicare, Medicaid or the Children’s Health Insurance Program, IHS operates on an annual budget instead of an entitlement and it’s a limited source of funds. This budgeting notion will not change with health care reform.
But when private or government insurance money (or third party billing in government-talk) is added into the Indian health system that could improve services for all. The new law opens up all sorts of avenues for tribal and urban Indian clinics to bill insurance plans. Third party billing is supposed to add new money; so current funding shouldn’t be limited by these dollars.
There’s been a lot of talk about a national mandate to buy health insurance under the new law. That’s true. But the issue is far more complicated for Indian Country because there also is a specific exemption from the penalties associated with the mandate. As IHS Director Dr. Yvette Roubideaux recently wrote on her blog: “Health reform just means that in general, American Indians and Alaska Natives can continue to be eligible for and use IHS, Tribal, or urban Indian health programs, but if they want to, they will be able to purchase health insurance through the exchanges, which should have more affordable options. If they don’t want to purchase health insurance, as long as they get their care through our I/T/U system, they won’t have to pay a penalty.”
So should individuals – despite U.S. promises – buy health insurance to pay for care in the Indian health system?
I see several “yes” answers developing.
First, it will be easier for individuals who are eligible for other government programs, such as Medicare and Medicaid to medical services for veterans. Medicaid, the program designed for people on low-income, will enroll single adults for the first time. The glitch here is that states aren’t keen on Medicaid expansion even though there’s a 100 percent match for clients in the Indian health system.
Most tribal governments already offer health insurance for employees and the new law expands the potential for tribes to purchase insurance for tribal members as well (without tax consequences).
Other native people will buy insurance for their families because it unlocks choices. Bringing health insurance into the Indian health system could eliminate some of the delays or denials of care associated with Contract Health.
“We can bill for third party reimbursements and help better fund our health services,” Dr. Roubideaux wrote. “However, they could also choose to leave us and get their healthcare somewhere else. Then we would lose our patients and potential reimbursements.”
Dr. Roubideaux says this is “All the more reason for us to change and improve the IHS, and emphasize customer service! We have to remain competitive and be the first and best choice for our patients.”
I’ve talked to many people who’ve given up on the Indian health system. They say it’s much better for their families to use their private insurance and go elsewhere. I understand that. It’s a choice for every family. But the only way the Indian health system will be better for our children and grandchildren is for us all to stick with it and to add whatever resources we can. Even if that means buying insurance.
But that data… Read more…
Insurance for the family selling pinions | July 27, 2009
GALLUP, New Mexico – My family and I walked around the flea market here Saturday. I’ve always thought this is the ideal representation of unabashed capitalism. It was hot, dusty and there were hundreds of booths and thousands of people buying and selling a remarkable range of goods, animals and services.
On one hand there are the types of items you’d find at any flea market: Used car parts, clothes, and carnival-quality toys. But add to that mix native foods such as Acoma bread, mutton stew or dried corn; plus traditional products such as mountain tobacco, Navajo and Pueblo jewelry, live sheep and horses, and CD’s loaded with musical selections from traditional to Rez-style Hip Hop.
Gallup may be a tourist town, but not many travelers venture from I-40 into the hot summer market. That’s too bad – they’d find great bargains, but it’s a lot easier to buy Indian jewelry from a modern air-conditioned trading post. No, this market is directed at primarily Navajo and Zuni customers, local people serving local people. That, to me, is the essence of small business.
Yet I don’t suspect the family selling pinion nuts is thought about as a small business in the context of health care reform. Small businesses are viewed as much bigger enterprises, for example a construction company with a dozen or so employees.
“Small businesses play an important role in the U.S. economy,” says a new report released by the White House last week. “… the vast majority of firms in the United States are small, and these firms account for a substantial share of private sector employment.”
Indeed these are the very firms that cannot afford to pay health insurance premiums for their employees. As the White House report points out: “The current U.S. health care system is not working well for small businesses. Most obviously, small businesses pay substantially more to provide insurance for their workers. On average, small businesses pay up to 18 percent more than large firms for the same health insurance policy.”
Of course this issue is even more complicated in Indian Country. Let’s use the construction company as an example. If most of your employees are Native American (and eligible for IHS services), or seasonal hires, it’s awfully difficult to justify paying private insurance premiums. Then there is the growing number of Native American families that ranch or farm (the Census reported a significant rise in this category in 2007). Or the family business that gathers rice or pinions, operates a booth at the flea market, travels through the summer to powwow to sell fry bread and tacos. For these ventures, there is no incentive to buy health insurance. Consider the philosophical question: Should (or even can) a reservation-based entrepreneur subsidize a treaty right to health care?
While I was walking around the market, the president talked about the needs of small businesses. He’s right to focus on the health care needs of small businesses – but I think this conversation must also include the changing nature of work.
As more and more of us leave the corporate working world – complete with health care benefits – and venture into our own version of the flea market. We will need a health care system that includes a viable self-insurance option, both in the larger community and for people in reservation-based economies. That’s why a public plan is essential to any reform.
But it must be a public option that recognizes the variety of work in this country. The definition of “affordable” needs to satisfy people who might earn a fabulous paycheck during fishing season – and then coast for months after that. The public option will have to include people who might use the Indian Health Service for primary care, but who would be willing to pay extra for some services.
To say that the current system isn’t working well for small businesses is an understatement. But it’s much deeper than that: We’re looking at the very proof that this country made a mistake by linking health care to employment.
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. www.marktrahant.com
Serendipity and a correction | July 13, 2009
FORT HALL, IDAHO – This is a story about how one thing leads to another – or the reason I am writing about health care reform for the next year or so.
A few months ago the Hearst Corporation announced that the Seattle Post-Intelligencer, my professional home for the past six years, was for sale. Unless a buyer was found – something unlikely – then the print product would be closed. As bad as this sounds, I can’t complain. This came at a good time for me. I loved my job – and I have had a great ride in journalism. But I viewed this as an opportunity to push myself in a new direction.
That’s where serendipity played a role.
First I applied for the Kaiser Media Fellowship. I thought it would be intellectually challenging to dive deep into a subject and to write about it consistently. Health care seemed a natural fit for several reasons. I’m grateful that Kaiser agreed – because now I have the gift of time.
Why health care reform? First, I believe that this country made a mistake with employer-based health care insurance. It worked fine when people went to work for one company – and stuck it out for a long stretch of time. But the world has changed. In Seattle, for example, there is an entire workforce of contractors who must buy their own, individual health insurance policies. Or what works for a major manufacturer doesn’t fit for a small construction company where employees are hired only after successful bids. Employer-based care doesn’t seem to work for a growing number of companies. Second, over the years I have been struck by how little discussion there has been about how existing federal health care agencies should be a part of the new structure, such as the Indian Health Service. Third, for a long time I have been fascinated by demographics. This country (indeed, the world) is going through an aging in a way that’s unprecedented. We have to come up with a health care plan that is sustainable for both ends of the system: Those who pay for it, the workers, as well as the ginormous Baby Boom who are mostly at the receiving end.
After the P-I ended its print product, I was offered a Maymester teaching post at the University of Colorado at Boulder. This was more serendipity because I taught (read this: learned a hell of a lot) a course on social media and democratic institutions. Now I want to design my health care reporting – and posting – on a social media model.
Here is how I plan to proceed:
I plan to write a column on a topic every Monday. This debate is moving fast – but I am relieved that Congress is going home without a resolution. I’ll also cover meetings from time to time with daily reports. I’ll also post video commentary.
I’ve already heard from readers – and will begin posting comments soon. I think interactivity is essential, the more ideas the better. Early in the fall I plan to add a wiki page with an outline of what health care should look like. We’ll see where that goes (the great thing about social media is that the experiment is as important as the answer).
My Twitter page for this project is TrahantReports. Because I’m traveling until early August this is the best place – at least right now – for immediate feedback. Email works well too.
Finally, this project is “open” architecture. Everything I write is free to be picked up, reposted, reprinted, retweeted, retransmitted, or any other rebroadcast form that I haven’t thought of yet. The ideas are more important than a pride of authorship. It’s great if you give me credit – especially since this is a reflection of my opinion – but if you’d don’t, I won’t squawk. Some of these posts I will respin (another “re”) as op-ed pieces for newspapers. Others I will pitch as TV news stories. I may, eventually, collect material for a book.
Open architecture also means being transparent. I have already – and will continue to make mistakes. But thanks to the speed of social media – and web communication – I will correct mistakes immediately. Last week I posted a wrong email address for those wanting to comment about health care reform. In case you missed it: the correct address (already fixed on the original post) is healthreform@ihs.gov
Thanks. I look forward to hearing from you – and I’ll be back next week with another letter. My next step is to write about the delivery of Indian Health at the clinic level.
Talking and tinkering, standard fare for Indian Health Care legislation | July 20, 2009
More than three decades ago another health care debate focused on Indian Country. At the time, there were too many dilapidated medical facilities, an inability to recruit and retain health professionals (especially American Indians), as well as a host of other structural deficits, Congress responded in 1976 by passing the $1.6 billion Indian Health Care Improvement Act.
The Office of Management and Budget recommended a veto. OMB’s deputy director Paul O’Neill said the Indian Health Service didn’t need the money because there was “no evidence that a vast infusion of funds … would achieve better or faster results than are being achieved under orderly program growth.” O’Neill argued that extra money would not be effective because Indian health statistics were “especially in connection with causes of death, e.g., alcoholism, accidents and suicide, associated with reservation social conditions, i.e., poverty, isolation and inadequate housing. Unfortunately, we have not been especially successful in combating alcoholism and suicides in non-reservation areas.”
Fortunately President Ford had other advisers, including Dr. Ted Mars who responded directly to O’Neill in a memo. “Admittedly, I am biased as a physician in favor of equity in length of life so you will have to excuse my considering the humanitarian aspect along with the budgetary, pragmatic and political,” Mars wrote. “Failure to adjust the present course is in my opinion a flagrant deprivation of human rights in a measurable as well as dramatic way.”
President Ford did the right thing. “I am signing this bill because of my own conviction that our First Americans should not be last in opportunity.”
Indeed since that October 1976 signing, the evidence is that the Indian Health Care Improvement Act worked and helped significantly improve care for American Indians both on reservations and in urban areas. But, perhaps, more important was President Ford’s notion that First Americans should not be last in opportunity when it comes to health care.
That very phrase was rolling around in my mind as I listened to President Barack Obama talk about reform last week.
“This is what the debate in Congress is all about: whether we’ll keep talking and tinkering and letting this problem fester as more families and businesses go under and more Americans lose their coverage. Or whether we’ll seize this opportunity – one we might not have again for generations – and finally pass health insurance reform in 2009,” the president said in his urging for action.
Talking and tinkering has been the standard fare for congressional reauthorization of the Indian Health Care Improvement Act. This is not a new proposal, it’s not particularly complicated, and it certainly ought to find a way to travel from the Capitol to the president’s desk in less time than a rewrite of the entire health insurance system in the United States.
But as the National Indian Health Board points out on its Web site: “For ten years, Tribal leaders, members and advocates have worked tirelessly with Congress to pass a modern IHCIA but our efforts have not been successful. Reauthorization is long over due – it is time to pass H.R. 2708 this year.”
While the president and Congress struggle over rewriting the broader health care reforms, it seems to me this one measure is a test of the system. If Congress cannot (after a decade) enact a health care measure that has a track record of success, then how is it possible to rewrite the entire health care insurance system in a few legislative moments?
The answer is it’s impossible.
The health care reform proposal in the House, for example, has provisions that mandate health insurance for both employers and individuals (with exceptions). But how will that work in Indian Country? What is the impact on an already under-funded Indian Health Service? Does this health care reform plan end or limit treaty obligations? Or, on a practical level, will a family that fishes seasonally be required to buy health insurance?
There are far too many questions for any bill that requires debate at a frenetic pace. But here is one answer: If Congress rushes through this process, it will be likely that the First Americans will continue to be last in opportunity.
First, do no harm | July 9, 2009
DENVER – The last national health care reform conversation was one-sided when it involved Indian Country. The topic was simply how change would impact the Indian health system.
That conversation remains critical.
Reno Keoni Franklin, chairman of the National Indian Health Board, said at the Denver Indian Health Summit that the current funding model has created a crisis for California tribes. Because of the state’s financial implosion, it’s an outright conflict of interest for the state to tell tribes what’s a reimbursable expense under Medicaid and Medicare.
This very notion is a preview of the impacts that could come from any larger health care reform. If nothing else, tribes are major employers and that promises to be the foundation for health insurance mandates.
But that’s just the beginning. For example: On Wednesday Vice President Joe Biden announced a deal where hospitals will contribute $155 billion in savings in government reimbursements. Perhaps it’s a helpful contribution to the federal deficit on the national level – but what kind of impact will this, and other changes, make on an already under-funded Indian health system? It’s one thing to suggest cost-cutting in a system that costs twice as much as those in other developed countries; yet that same “savings” could be devastating when applied to the part of the system that takes frugal to a new level.
What if reform means a future insurance program – federal or private – further strips the funding base from the Indian Health Service? It’s absolutely possible that a new program would cover uninsured American Indians and Alaskan Natives – but without a full recovery for those costs to the IHS.
Of course, the best outcome would be a health care system that combined a variety of funding sources in a way that the Indian health system would get adequate support.
But, as Sally Smith, chairman of the Bristol Bay Health Corporation, said in Denver: “First, do no harm.”
The bottom line here is that the driving force in national health care reform is saving money because our current system is not sustainable. But it will be unfortunate – and with serious consequences for American Indian and Alaskan Native people – if that broad notion is applied wholesale to the Indian Health Service.
That’s why I think that the very conversation about health care reform needs its own reform. We need to pull back and look at the bigger picture – and at least examine one system that doesn’t have profit built into its model. Lessons from Indian Country could help the entire country improve its health care systems.
That means changing the conversation. Big time. And that’s pretty hard to do when the legacy news media isn’t aware of what’s possible. Even the idea of saying, you know, the Indian Health Service model is worth considering in the health care reform debate is preposterous. It generates a blank stare. If that.
Thursday morning I read the Associated Press’s four-paragraph story about the Denver Summit. “Diabetes is one of the main topics. The Indian Health service says about 16.5 percent of American Indians and Alaska Natives ages 20 and older have diagnosed diabetes,” the AP reported.
It could be a story from last year – or a decade ago. Yet here we are at this extraordinary moment where the whole country is talking about health care reform – and the conversation from Indian Country is reduced to one that can be read on TV in 10 seconds. There’s no room for this story because the news media is covering every twist and turn of the legislation in Washington, D.C.
The Denver Summit was planned a long time ago – long before any new that health care reform was thought possible. Indeed, the official position of the IHS is no position on health care reform. And for good reason: The agency is consulting with tribes and its constituents about what reform means to them. IHS Director Yvette Roubideaux is urging Indian Country to weigh in, saying that she’s reading emails sent to healthreform@ihs.gov.
“Looking forward, there is no secret plan,” she said earlier this week. The idea is to “really see how we can come together to improve the system.”
