November election priority list.

November election priority list.

Elections 2012: Missing From the Debate – The Indian Health System

There is one public health “system” in the United States. Its cost per patient is lower than the rest of the country. Some of the clinics and hospitals are models of what health care could be … and at the same time some of the clinics are substandard and represent the worst of what we think of as government-run health care.

That system is, of course, the Indian Health Service.

On Wednesday night during the presidential someone ought to ask this: How would you grade existing government-run health care? Then, a follow up, how would that change by your administration over the next four years?

The context for these questions is that the government already has lots of experience running complicated health care insurance programs. The big ones are Medicare (most seniors love it); Medicaid, a state-federal partnership that does two things, provide basic insurance to 50 million low income people and pay for long term care for elders who cannot afford nursing homes; Tricare for active-duty military, their families and retirees; and the Veterans Administration. Each of these systems has its pluses and minuses. There is no perfect health care system. Anywhere.

Perhaps the presidential candidates will even talk about each of these systems and how they would improve their operation. Let’s check the list: Medicare? Certainly, there are lots of seniors. Medicaid? No, it’s not the kind of program candidates like to talk about. Tricare? Unlikely. Veterans? Possible, but remote. And the Indian Health Service? Not a chance.

The problem with national politicians in general, from Congress to the White House, is that most (with the exception of Rand Paul and a few others) will express the solemn treaty obligation to provide health care to American Indians. But when it comes to actually funding Indian health, well, the support disappears faster than frybread at a powwow.

The fact is the Indian health system would make a great debate topic. It’s rich because it’s complicated, it would force citizens to think about what kind of government we want, and what kind of results we could expect.

Most of the public discussion about IHS is about the funding mechanism that creates an underfunded system. As ProPublica put it in its grading of government health care: “The coverage is better than nothing … but just barely. Each year IHS receives about $600 million for Contract Health Services, which covers any services outside the IHS system. In places where IHS already has a hospital, this might pay for visits to a specialist. In locations that just have clinics, the funds have to cover more. But the problem is, the money runs out every year. So if you need to see your cardiologist, get a mammogram or get a colonoscopy, you’d better ask for it in January. Because by March, funds for these will start running low. By June, they will have run dry.”

That’s been the story for a long time. But what ProPublica missed – and really ought to be a part of the larger debate – is that IHS is no longer the only game in town. Half, that’s right, half of the agency’s budget now funds tribal or independent health care operations.

What that means from a policy perspective is that an independent clinic is funded by both IHS and agencies. This is quite different from the debate where IHS is measured as only a government-run entity. (For what it’s worth: IHS is still underfunded even as only a funding partner and always will be unless Congress moves it away from annual appropriations.)

Why should this matter to two candidates debating the future of health care on the University of Denver campus?

Because IHS is a model to think about. Not the government-run agency (what we call direct services) but a large U.S. government funding agency that then invests in and supports a community-designed health care system.

Many tribes now operate such clinics. A typical funding stream is roughly 50 percent Medicaid, 25 percent IHS grants, another 10 percent in other federal grants, 10 percent private insurance, and 5 percent from other sources. (One secret to the success: These clinics actually make money from Medicaid. Many even prefer Medicaid to private insurance because the cost is predictable.)

Now zoom out and think about the broader health care debate. What if the federal government (already nearly half of the $2.6 trillion spent on health care comes from government) was a funding source for community-based health? A system like that would use the Indian health system as a model. That’s a debate worthy of a Denver stage.

Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. He has been writing about Indian Country for more than three decades. His e-mail is:


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Elections 2012: Missing From the Debate – The Indian Health System