A generation ago Indian Country wasn't included in the conversation about health care reform. When Congress enacted Medicaid and Medicare it pretended that the Indian Health Service didn't exist. It was as if it had never occurred to the government, that it, too, ran a major health care delivery system.
Say what you like about health care reform, the fact is that Indian Country is included in a big way this time around. If either the House or the Senate bill becomes law, there will be a significant boost in resources for the Indian Health system.
The largest single line item is the reauthorization of the Indian Health Care Improvement Act, included in H.R. 3962, the Affordable Health Care for America Act. The Congressional Budget Office "scores" the cost at $100 million through 2014 and $200 million over a decade. Most of that cost is attributed to the "expansion of payments under Medicare." This is important because American Indians and Alaskan Natives have the highest percentage of any population over 65 not currently enrolled in Medicare programs.
But the bigger ticket is the expansion of eligibility for Medicaid and the Children's Health Insurance Program. The House approach is to expand Medicaid to individuals, couples and families with incomes up to 150 percent of the federal poverty level or about $33,000 a year for a family of four.
The expansion of Medicare, Medicaid and CHIP is important to the Indian health care delivery system because IHS and tribal or urban clinics can bill the federal government for every eligible patient without regard to federal budgets. If a person is eligible, the money is there. (Contrast that with the contract health care fund that is an appropriation and always short of funding.) This is also significant because single adults will be eligible for the first time based on income. The House legislation would also improve payments made to medical providers under Medicaid and CHIP. That, too, could add dollars to the Indian health system. On top of that there will be new money available to fund urban clinics, including those serving American Indians and Alaskan Natives.
It's unclear what the legislation would mean to American Indians and Alaskan Natives who earn more than the federal poverty guidelines. The bills provide an exemption from the insurance mandate, so a lot would depend on what type of insurance is offered by their employer.
The House legislation requires employers with payrolls more than $500,000 a year -- including tribal governments -- to offer insurance or pay a penalty. The Senate bill does not require coverage, but does levy a fee for medium and large businesses. This could be an issue for tribes with self-insurance programs, depending on the final language.
It's also worth noting that the Senate bill includes a significant funding stream for education and workforce training. Even tribal colleges are on track to get a share in order to prepare more health professionals.
But beyond Indian Country and beyond the headline material -- the public option, abortion coverage and insurance mandates -- there are ideas in health reform that really ought to be front and center.
We know that the care of chronic diseases, including diabetes, is increasing faster than the capacity of the system and even now accounts for some three quarters of spending. Nearly four in ten Americans are dealing with at least one chronic illness such as diabetes, heart disease, cancer and arthritis. And if you look at the growth rates for diabetes (and the trend ahead from pre-diabetes) it's clear there must be a systemic reform. Quickly. The richest opportunity for "bending the cost curve" comes from money spent on programs that prevent these chronic diseases (and their complications).
To say the process ahead is challenging is an understatement. Health care reform remains a difficult sale. But its passage, if it can be done, will signal to Americans, the insurance companies, and the medical community about the inevitability of dramatic change.
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 Race-Talk contributor. He is a member of Idaho's Shoshone-Bannock Tribes. Comment at www.marktrahant.com