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Thursday, October 22, 2009

Indian Care May Suffer With Reform

By Robert Valdez
RWJF Center for Health Policy
      The spirited debate on health insurance reform has moved center-stage in Congress with the recent passage of the Senate Finance Committee bill with a single Republican vote.
       When Congress is asked to vote on health care reform bills we will see anything but consensus. This division is both partisan and philosophical. However, there is consensus across our nation and the political spectrum that our health care structure is not sustainable.
       Doing nothing yet again will have increased negative fiscal and quality of care consequences for us all. Nowhere will this impact be felt more than in Indian Country, where a highly complex web of public and private arrangements go far beyond the direct services provided by the severely underfunded public health agency, the Indian Health Service. Yet the situation could get worse under certain health reform proposals that expand Medicare and Medicaid participation.
       IHS — like many federal health programs — operates with annual appropriations from Congress. The growth of Medicare and increasing enrollments in Medicaid and other entitlement programs plus paying down our national debt creates increased competition for a shrinking share of the federal budget.
       Yet, of all the federal programs that receive appropriations to provide medical care directly to patients, IHS receives the least funds per patient.
       For example, per-patient spending on diabetes care by our three federal health care systems — IHS ($2,130), federal prisons ($3,242) and Veterans Administration ($4,653) — illustrates the inequities that already exist in the appropriations process.
       The federal government and Indian tribes as “domestic dependent nations” share a unique “trust relationship” long recognized in the Constitution, statutes, regulations, case law, presidential executive orders and agency policies. Similarly, the Constitution bestows many powers to state governments not specifically identified as federal responsibilities, such as health and health insurance regulation.
       These relationships between different levels of government often create complex policy environments that are difficult to navigate. Promoting and protecting the health and well-being of the American Indian and Alaskan native populations across jurisdictional boundaries often requires cooperation and collaboration by all levels of government, including local government.
       We hope to provide insights about the complexity of health policies affecting American Indians and Alaskan natives so better mechanisms and approaches for resolving issues can be identified and partnerships strengthened through increased understanding.
       A historic gathering of national leaders for the 2009 American Indian and Alaskan Natives Health Policy Conference meets in Albuquerque this week to try to illuminate the complexities of health reform and Indian health care. It will provide national political leaders the opportunity to explore the unique and complex federal, state and tribal policy issues that affect the health and well being of the American Indian and Alaskan Native populations across our nation.
       With a better understanding of the policy nuances and complexities of health care in Indian country, our leaders can craft better legislation and avoid unintended consequences.
       Robert Valdez is executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico.
       

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