The Indian Health Service Paradox

Call it the Indian Health Service paradox. The IHS is the largest direct provider of health care in the U.S. Public Health System. Yet it’s an agency either unfairly maligned as a “disaster” or absent from the discourse about health care reform. That’s too bad because the agency is a sustainable model for universal care.

The federal government’s delivery of health care for American Indians and Alaskan Natives began more than two centuries ago, first in the War Department and then at the Bureau of Indian Affairs. Congress transferred those functions to the Indian Health Service in 1955. Today, the agency is a comprehensive health delivery system for nearly two million American Indians and Alaskan Natives, mostly living on Indian reservations and in rural communities in 36 states.

IHS critics correctly point out the disparities between American Indian health and the general population. The General Accountability Office reported in 2005 that because of shortages in budget, personnel and facilities “the IHS rarely provides benefits comparable with complete insurance coverage for the eligible population.” Often that means a rationing of care, especially when it means contracting with doctors and hospitals outside of the IHS network.

So how could IHS be any sort of model for health care reform? The answer: The Indian Health Service is sustainable; the patchwork we call a health care system is not.

“The Indian Health Service can, and will be, one of the leading prototypes for health care in America,” said Dr. Donald Berwick, one of the nation’s leading authorities on health care quality and improvement, at a conference this summer. “The Indian Health Service is trying to deliver the same or better care with half the funding of other systems in the United States.”

Berwick acknowledged that the IHS needs more money – but added that the agency’s ability to execute is “stunning.” The very nature of the historical underfunding has resulted in a discipline that’s “an example for us all.”

For example, the IHS funds initiatives designed to improve the health of its clients rather than limiting expenditures to direct medical care. Beginning in the 1960s, it invested in reservation and rural water systems, sewage and solid waste facilities. It funds technical assistance for those facilities. The result, according to the Congressional Research Service, is an 80 percent reduction in gastrointestinal disease among American Indian and Alaskan Natives since 1973.

The same broad view of health care is the essence of a Special Diabetes Program for Indians that began in 1997. The $150- million-a-year project funds an extensive “best practices” network, incorporating the latest scientific findings into model and community- designed programs. This includes better training so patients can manage their treatment to get more access to physical fitness programs, diet education and early diabetes screening.

While diabetes remains at epidemic levels in Indian Country, there are hopeful signs of a turnaround. There has been a significant increase in the percentage of Indian diabetics that are maintaining blood sugar control and, more important, there has been a 40 percent reduction in complications such as kidney disease and retinopathy.

This has implications for the rest of the country. Diabetes-related costs were $174 billion in 2007. And unfortunately, the disease is increasing at rates all too familiar in Indian Country. About one-quarter of all Americans have pre-diabetes and if the disease fully develops, in 2002 the health care costs topped $13,200 per diabetic patient compared to $2,560 for people without diabetes.

The Special Diabetes Program for Indians is inventing less expensive alternatives to treat and prevent the disease.

It’s a way of doing business that reflects the frugal nature of the IHS. The agency spends roughly $2,130 per capita – about the same as the average for other industrial nations. But that compares to the $3,242 for federal prison inmates, $4,653 for veterans and $7,784 for Medicare beneficiaries.

It’s both ironic and maddening that the richest nation in the world appropriates far less for American Indian health care than it does for any similar program. But that, as tribal leaders have pointed out repeatedly, has resulted in a health care system that’s “starved, not broken.” Increasing those resources is something that could be fixed in the appropriations process.

If the Indian Health Service were reasonably funded the discussion about health care reform would be very different. The paradox is that we’d all see that “big” government health care has track record that is lean and efficient.

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.