Aug 05 2014

Rethinking a medical system

Published by at 8:44 am under Trahant

trahant MARK
TRAHANT

 
Austerity

At a Billings hearing in May, Sen. Jon Tester expressed frustration about the management of the Indian Health Service.

The Montana Democrat said: “We need to live up to our trust responsibility and offer tribes the health care they deserve. Ongoing issues around service delivery, transportation for critical care, billing and reimbursement issues abound. We need to prioritize these issues and solve them.”

Tester, of course, is chairman of the Senate Indian Affairs Committee. So his call for improving the agency is worth considering.

Then again, when former Sen. Byron Dorgan (D-ND) was chairman of the same committee, he also held hearings and published a report about the poor management record at IHS. “The investigation identified mismanagement, lack of employee accountability and financial integrity, as well as insufficient oversight of IHS’ Aberdeen Area facilities. These issues impact overall access and quality of health care services provided to Native American patients in the Aberdeen Area. Many of these issues may stem from a greater lack of oversight by the area office and IHS headquarters fostering an environment where employees and management are not held accountable for poor performance.” The year was 2010.

So what kind of progress has the Indian Health Service made during those four years? Unfortunately that’s the wrong question.

In the blink of an eye, the very structure of health care has changed and is continuing to change dramatically in the United States. Yet the structure of the Indian Health Service is the same.

Take the name: Indian Health Service. On the agency’s web page it adds the descriptive line, “The Federal Health Program for American Indians and Alaska Natives.”

Yet some 40 percent of the agency funds go directly to tribes, independent medical nonprofits or urban health programs. The federal health program is a mechanism for funding, not a federal health program. And that percentage is likely to grow because the system is no longer equal. The IHS has less access to a variety of funding pots that are available to tribal and urban health clinics.

A second problem with the IHS structure is that the United States for many policy reasons picked an insurance framework under the Affordable Care Act. And much of that insurance is built on an expansion of “entitlement” programs.

But the IHS is a health care delivery system, not an insurance regime. And, unlike the entitlement programs of Medicare, Medicaid, and Children’s Health Insurance, the IHS is funded through congressional appropriations. So the agency’s primary source of funding is subject to the whims of a Congress that is deeply divided about priorities and the role of government.

This funding mechanism was made worse by the Affordable Care Act when the Supreme Court said states could choose to expand Medicaid (an insurance partnership for people on low incomes) or not. State-based “optional” insurance is creating a divide within the Indian health system. Under current law, IHS rewards facilities for bringing in third-party payers from either private insurance or Medicaid dollars. It’s money that’s added to a local clinic or hospital budget. But most of that money is from Medicaid and if a state rejects the expansion, that becomes, in effect, a structural deficit.
Almost half of the states, many with large American Indian or Alaska Native populations, have not expanded Medicaid.

So what should the Indian Health Service look like in the age of Obamacare? That is the conversation that should be occurring, but is not. It’s so much easier to blame underfunding or management instead of rethinking the entire IHS organization.

What would IHS look like if it’s primary role was to act as a funding agent with the goal of sending maximum resources — you know, money — directly to tribally-run and other health care delivery agencies? Or what if Medicaid was administered directly for tribes, leaving states out of the equation?

One thing I would change is The Story. As I have written before, it’s important that Congress know that past efforts worked. The creation of the Indian Health Service in 1955 and the Indian Health Care Improvement Act of 1976 both improved the health of American Indians and Alaska Natives. Yes, there remain health care disparities when compared to the general population but the gap is far less than it was. And IHS did this by spending less money than just about any other health care delivery system in the United States.

Sure, there are management challenges at the Indian Health Service as noted by Senators Tester and before that Dorgan. But as we near the 50th anniversary of the Indian Health Care Improvement Act, it’s time rethink the agency’s structure and demand reform. It’s time to imagine what success looks like.

Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Share on Facebook

Comments Off

Comments are closed at this time.

Share on Facebook

 


 

Introducing one of Ridenbaugh Press' latest authors, Nathalie Hardy - introducing her new book, Raising the Hardy Boys.

 

 
owb1444

WASHINGTON-OREGON-IDAHO
Our acclaimed weekly e-pubs: 35-45 pages Monday mornings getting you on top of your state. Discounts for multiple subscriptions. Samples available. Contact us by email or by phone at (208)484-0460.

 

RIDENBAUGH BOOKS catalog


 
Many critics said it could not be done - and it often almost came undone. Now the Snake River Basin Adjudication is done, and that improbable story is told here by three dozen of the people most centrally involved with it - judges, attorneys, legislators, engineers, water managers, water users and others in the room when the decisions were made.
Through the Waters: An Oral History of the Snake River Basin Adjudication. edited by the Idaho State Bar Water Law Section and Randy Stapilus; Ridenbaugh Press, Carlton, Oregon. 300 pages. Softcover. $16.95.
See the THROUGH THE WATERS page.


 
Oregon Governor Vic Atiyeh died on July 20, 2014; he was widely praised for steady leadership in difficult years. In this book, writer Scott Jorgensen talks with Atiyeh, traces his background and recounts some of what he had to say – and others said about him. “He was a good man ... In many ways, Vic Atiyeh was more than a man – he was a link to a past that I could barely even imagine.”
Conversations with Atiyeh. by W. Scott Jorgensen; Ridenbaugh Press, Carlton, Oregon. 140 pages. Softcover. $14.95.
The CONVERSATIONS WITH ATIYEH page.

Atiyeh
 
"Salvation through public service and the purging of awful sights seen during 1500 Vietnam War helicopter rescue missions before an untimely death, as told by a devoted brother, leaves a reader pondering life's unfairness. A haunting read." Chris Carlson, Medimont Reflections. ". . . a vivid picture of his brother Jerry’s time as a Medivac pilot in Vietnam and contrasts it with the reality of the political system . . . through the lens of a blue-collar, working man made good." Mike Kennedy.
One Flaming Hour: A memoir of Jerry Blackbird. by Mike Blackbird; Ridenbaugh Press, Carlton, Oregon. 220 pages. Softcover. $15.95.
See the ONE FLAMING HOUR page.


 
Back in Print! Frank Church was one of the leading figures in Idaho history, and one of the most important U.S. senators of the last century. From wilderness to Vietnam to investigating the CIA, Church led on a host of difficult issues. This, the one serious biography of Church originally published in 1994, is back in print by Ridenbaugh Press.
Fighting the Odds: The Life of Senator Frank Church. LeRoy Ashby and Rod Gramer; Ridenbaugh Press, Carlton, Oregon. 800 pages. Softcover. $24.95.
See the FIGHTING THE ODDS page.


 
JOURNEY WEST

by Stephen Hartgen
The personal story of the well-known editor, publisher and state legislator's travel west from Maine to Idaho. A well-written account for anyone interested in Idaho, journalism or politics.
JOURNEY WEST: A memoir of journalism and politics, by Stephen Hartgen; Ridenbaugh Press, Carlton, Oregon. $15.95, here or at Amazon.com (softcover)

 

 

NEW EDITIONS is the story of the Northwest's 226 general-circulation newspapers and where your newspaper is headed.
New Editions: The Northwest's Newspapers as They Were, Are and Will Be. Steve Bagwell and Randy Stapilus; Ridenbaugh Press, Carlton, Oregon. 324 pages. Softcover. (e-book ahead). $16.95.
See the NEW EDITIONS page.

How many copies?

 
THE OREGON POLITICAL
FIELD GUIDE 2014

The Field Guide is the reference for the year on Oregon politics - the people, the districts, the votes, the issues. Compiled by a long-time Northwest political writer and a Salem Statesman-Journal political reporter.
OREGON POLITICAL FIELD GUIDE 2014, by Randy Stapilus and Hannah Hoffman; Ridenbaugh Press, Carlton, Oregon. $15.95, available right here or through Amazon.com (softcover)

 
 
THE IDAHO POLITICAL
FIELD GUIDE 2014

by Randy Stapilus and Marty Trillhaase is the reference for the year on Idaho Politics - the people, the districts, the votes, the issues. Written by two of Idaho's most veteran politcal observers.
IDAHO POLITICAL FIELD GUIDE 2014, by Randy Stapilus and Marty Trillhaase; Ridenbaugh Press, Carlton, Oregon. $15.95, available right here or through Amazon.com (softcover)

 
 
without compromise
WITHOUT COMPROMISE is the story of the Idaho State Police, from barely-functioning motor vehicles and hardly-there roads to computer and biotechnology. Kelly Kast has spent years researching the history and interviewing scores of current and former state police, and has emerged with a detailed and engrossing story of Idaho.
WITHOUT COMPROMISE page.

 

Diamondfield
How many copies?
The Old West saw few murder trials more spectacular or misunderstood than of "Diamondfield" Jack Davis. After years of brushes with the noose, Davis was pardoned - though many continued to believe him guilty. Max Black has spent years researching the Diamondfield saga and found startling new evidence never before uncovered - including the weapon and one of the bullets involved in the crime, and important documents - and now sets out the definitive story. Here too is Black's story - how he found key elements, presumed lost forever, of a fabulous Old West story.
See the DIAMONDFIELD page for more.
 

Medimont Reflections Chris Carlson's Medimont Reflections is a followup on his biography of former Idaho Governor Cecil Andrus. This one expands the view, bringing in Carlson's take on Idaho politics, the Northwest energy planning council, environmental issues and much more. The Idaho Statesman: "a pull-back-the-curtain account of his 40 years as a player in public life in Idaho." Available here: $15.95 plus shipping.
See the Medimont Reflections page  
 
Idaho 100 NOW IN KINDLE
 
Idaho 100, about the 100 most influential people ever in Idaho, by Randy Stapilus and Martin Peterson is now available. This is the book about to become the talk of the state - who really made Idaho the way it is? NOW AN E-BOOK AVAILABLE THROUGH KINDLE for just $2.99. Or, only $15.95 plus shipping.
 

Idaho 100 by Randy Stapilus and Martin Peterson. Order the Kindle at Amazon.com. For the print edition, order here or at Amazon.


 

    Top-Story-graphic-300x200_topstory8
    Monday mornings on KLIX-AM

    watergates

    ORDER IT HERE or on Amazon.com

    More about this book by Randy Stapilus

    Water rights and water wars: They’re not just a western movie any more. The Water Gates reviews water supplies, uses and rights to use water in all 50 states.242 pages, available from Ridenbaugh Press, $15.95

    intermediary

    ORDER IT HERE or on Amazon.com

    More about this book by Lin Tull Cannell

    At a time when Americans were only exploring what are now western states, William Craig tried to broker peace between native Nez Perces and newcomers from the East. 15 years in the making, this is one of the most dramatic stories of early Northwest history. 242 pages, available from Ridenbaugh Press, $15.95

    Upstream

    ORDER HERE or Amazon.com

    The Snake River Basin Adjudication is one of the largest water adjudications the United States has ever seen, and it may be the most successful. Here's how it happened, from the pages of the SRBA Digest, for 16 years the independent source.

    Paradox Politics

    ORDER HERE or Amazon.com

    After 21 years, a 2nd edition. If you're interested in Idaho politics and never read the original, now's the time. If you've read the original, here's view from now.


    Governing Idaho:
    Politics, People and Power

    by James Weatherby
    and Randy Stapilus
    Caxton Press
    order here

    Outlaw Tales
    of Idaho

    by Randy Stapilus
    Globe-Pequot Press
    order here

    It Happened in Idaho
    by Randy Stapilus
    Globe-Pequot Press
    order here

    Camping Idaho
    by Randy Stapilus
    Globe-Pequot Press
    order here