Posts Tagged ‘Health care reform’

Mark Trahant


Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s recent book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.

Just over a year ago President Barack Obama signed the health care reform bill into law, the Patient Protection and Affordable Care Act. That measure, of course, also includes the permanent authorization of the Indian Health Care Improvement Act.

So what has happened since the president signed the bill into law on March 23, 2010? That question cannot be answered. Not yet. Part of the answer is working its way through the court system with legal challenges. And other parts of the answer are stuck in a political debate even as federal agencies continue to write rules for its implementation.

The administration has lived up to the spirit and the intent of the health care reform law. A new report by the National Congress of American Indians, National Indian Health Board and the National Council of Urban Indian Health says it this way: “… the President’s budget was a true commitment to the successful implementation of the Affordable Care Act. The FY12 budget shows increased funding for IHS, Administration on Aging, and Health Resources and Services Administration.”

Indeed the president asked Congress for a 14 percent increase for programs such as the always underfunded Contract Health Services, alcohol and substance abuse, facility construction and to implement the Indian Health Care Improvement Act.

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3
Jan

Trahant reports: The health care repeal exception

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Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s recent book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.

Will Republicans muster enough votes to repeal the health care bill? A Michigan Republican said over the weekend that he sees “significant” bipartisan support for repeal, possibly even enough votes to override a presidential veto.

U.S. Rep. Fred Upton, R-Michigan, said on Fox News Sunday, “If we pass this bill with a size-able vote, and I think that we will, it will put enormous pressure on the Senate to do the same thing.”

An outright repeal, however, requires two-thirds majority in both the House and the Senate. A hurdle that is about as close to impossible as it gets in Washington, D.C.

That’s why the Republican strategy includes three other elements: Investigate, repeal sections and refuse to limit the money needed to implement the law.

“The so-called Patient Protection and Affordable Care Act (PPACA) has been widely criticized by the American public, and for good reason,” Upton wrote last month. “… Real oversight is needed, and the Energy and Commerce Committee will work closely with other committees of jurisdiction to reveal, repeal and replace this law.”

And to use Upton’s phrase, these “so-called” probes already know what they will uncover. As Upton himself put it: “Our investigations will demonstrate the need to repeal this law and replace it with common sense reforms that lower costs and increase accessibility to health care without increasing government.”

But this is where the story gets complicated. Too bad there’s not that same passion for oversight when it comes to the historical underfunding for Indian health programs. Or, in general, what will any of these investigations say about American Indian and Alaska Native health? Will there even be a question about the impact of “reveal, repeal and replace” for Native American communities?

I doubt it.

Yet many Republicans – often with districts with large numbers of American Indian or Alaska Native voters – say they don’t like and will vote to repeal the health care reform law, but they do like the Indian Health Care Improvement Act. New South Dakota Rep. Kristi Noem said as much during her election campaign.

But that logic is flawed: if there is a repeal of the health care reform bill, there also will be a repeal of the “permanent” status found in the Indian Health Care Improvement Act. The two laws are one.

There is no way, politically at least, to repeal health care reform except for the Indian health care provisions (or for that matter, other popular measures, such as relief for the donut-hole in Medicare). This is a simple way of pleasing folks back home that means nothing. There is no exception; there is only a divide between those who would work with this law, complicated as it is, and those that would start over with nothing.

Beyond that stark rhetoric however is a practical question: Will the new Republican majority support stable funding the Indian Health Care Improvement Act? The law is only an authorization to spend money – it must be implemented by an appropriations from Congress.

This is where the seeds of tragedy are being planted. The Republicans are creating a new powerful budget post, chaired by Paul Ryan from Wisconsin. He will have the authority to set a ceiling for federal spending. The spending committees, then, would have to spend below that ceiling. Some Republicans in Congress have promised to roll back that spending as much as 20 percent. Imagine the impact on an already starved Indian health system. (Ryan has also called for abolishing Medicare for those under 55 years old as well as the Children’s Health Insurance Program and Medicaid. All three are key elements of funding the Indian health system.)

Republicans promised a frugal government. If that’s really what they want, then the Indian health system should be fully funded because it’s the most efficient health care delivery system in the country.

But that would require an exception to flawed logic.

9
Nov

Trahant reports: Bring on health care reform relitigation

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Mark Trahant

Mark Trahant


Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s new book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.

The election is over. Now what? What are the next steps when it comes to health care reform? Just what did the people say Nov. 2?

As you would expect there is no agreed answers. Republicans say this election was about health care. Tea party favorite Sen. Jim DeMint, R-S. C., said on NBC’s Meet the Press this weekend. “We have to stop the funding of Obamacare and over the next two years show the American people what the real options are to improve the system we have now.”

But President Barack Obama, in his news conference said, “I think we’d be misreading the election if we thought that the American people want to see us for the next two years relitigate arguments that we had over the last two years.”

The polls are interesting. The Kaiser Family Foundation surveyed the surveys. “Over the course of the past month, at least eight well-respected polls have asked Americans whether they support the idea of repealing health reform, and” Kaiser reports, “responses have been all over the map, ranging from a high of 51 percent in an NBC News/Wall Street Journal poll to a low of 26 percent in our September Kaiser Health Tracking survey. Why the wide range? After a close look at the data collected below, our take is that question wording is driving the differences. At the same time, recent polling suggests that for at least some Americans, a vote for repeal means a vote to eliminate certain provisions of the health reform law while also keeping many of its benefits, rather than representing a desire to overturn the law completely.”

But the political divide remains stark. So we are going to (as the president puts it) relitigate the health care law.

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27
Sep

TRAHANT REPORTS – What the GOP’s Pledge to America means to Indian Country

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Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s new book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.

By Mark Trahant

Mark Trahant

Mark Trahant

We hate health care reform. The bill was too many pages, too complicated and didn’t fix all the problems right now, this minute. (One of America’s core democratic values is our impatience.)

But the why is fascinating. Many of us hate the reform bill because it went too far; but most of us are unhappy because health care reform didn’t go far enough. We wanted more action, a smarter health care system, even, more government to make our health care system work smarter.

Yet that voter angst – both for and against – set the stage for this November election and the Republicans’ Pledge to America. “In a self-governing society, the only bulwark against the power of the state is the consent of the governed, and regarding the policies of the current government, the governed do not consent,” the pledge says. (Except that some of us do give our consent.)

Elections are policy choices. And this GOP Pledge is a clear guide about what Republicans would do if given power. There are significant implications for Indian Country in this document (even though American Indians and Alaska Natives aren’t mentioned at all).

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Dr. Yvette Roubideaux, director of the Indian Health Service, penned the following opinion piece on Mark Trahant’s yearlong series of columns on Indian Country and health care reform. Trahant’s work has been featured every Monday in Buffalo Post, as well by news organizations, websites and other publications around the country:

By Yvette Roubideaux, M.D., M.P.H.

yvetteMark Trahant is completing a comprehensive and unprecedented series of columns on health reform and the Indian health system. These columns have shed new light on the Indian Health Service (IHS) and how it is influenced by and impacted by the rest of the U.S. healthcare system. These columns were made more timely and relevant by the historic passage of the Affordable Care Act and reauthorization of the Indian Health Care Improvement Act that occurred during Mr. Trahant’s work this past year

These columns have helped put the spotlight on the IHS, which is a health care system that serves 1.9 million American Indians and Alaska Natives from 564 Tribes in 35 states. The IHS rarely is mentioned in the national media, but it serves a critically important role to address the health disparities faced by American Indians and Alaska Natives. Many Americans do not understand the role of this health care system, or the treaty obligations and trust responsibilities that led to its formation over 50 years ago.

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2
Sep

Now that Indian Health Care Act has OK, group pushes for funds

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A visitor walks through the new health clinic on the Flathead Indian Reservation in Montana. Such state-of-the-art facilities are in sort supply. (Linda Thompson/Missoulian)

A visitor walks through the new health clinic on the Flathead Indian Reservation in Montana. Such state-of-the-art facilities are in sort supply. (Linda Thompson/Missoulian)

For months, the Health Rights Organizing Project had a mission – the coalition of 30 grass-roots community organizations around the country worked hard to convince Congress to pass the Indian Health Care Improvement Act.

Among its pitch, writes Susan Olp of the Billings Gazette, was a publication by the group titled “An American Debt Unpaid: Stories of Native Health.”

The legislation became effective when in March, when President Barack Obama signed the the Patient Protection and Affordable Care Act, which permanently reauthorizes the Indian Health Care Improvement Act.

Just one thing:

    The act is no longer dependent on annual reauthorization. And the new law authorizes the Indian Health Service to continue its programs and add some new ones, such as mental and behavioral health services, long-term care, dialysis, health care for Indian veterans and urban Indian health programs.

    What the bill didn’t do was allocate the money to fully fund the present programs or any new ones.

So the coalition is back at work with a new booklet: “Native Health Underfunded & Promises Unfulfilled: The Importance of Investing in the Indian Health Service.”

“I have seen people walking around with severe pain, with orthopedic malformations that were never addressed, people addicted to painkillers because they can’t get procedures, people who need substance abuse treatment but can’t receive it, and even people taking their own lives because of a number of factors, including depression,” says Kevin Howlett, health director of the Confederated Salish and Kootenai Tribal health Department.

To read the publication, go to http://www.nnaapc.org/publications/20100814NativeHealthUnderfunded.pdf.

Gwen Florio

Mark Trahant has spent the past year as a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment at www.marktrahant.com. His new book is “The Last Great Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest Gerard.

Mark Trahant

Mark Trahant


What will the Indian health system look like a decade from now?

That’s an impossible question to answer. There is the potential of a court ruling striking down at least part of the Patient Protection and Affordable Care Act. And, there is always the possibility of Congress will rewrite the law (I view this as remote because there would have to be a Super Majority to enact something else.)

But in the meantime there is a new foundation already under construction. The building that will rest on that structure will not be the same as the one in place now.

Let’s start with the patient. Right now, according to the Kaiser Family Foundation, nearly half of all American Indians and Alaska Natives are either uninsured or rely solely on the Indian Health Service. But health care reform changes that. Big time. Beginning in four years, hundreds of thousands of people will become eligible for insurance through government programs (such as Medicaid) because of new income rules. This insurance can be used to pay for services at Indian health system facilities – or at competing health care centers. (Think about how many private walk-in clinics promise no waiting.)

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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 member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment at www.marktrahant.com. His new book is “The Last Great Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest Gerard.

Mark Trahant

Mark Trahant

A fast year: Lessons from the Indian Health system

A year goes by fast. Way too fast. Thirteen months ago I plunged into my “year-long” exploration of the Indian health system. It’s been fascinating because there has so much activity: Congress enacted the Patient Protection and Affordable Care Act and included with that bill the permanent authorization of the Indian Health Care Improvement Act.

My idea was to explore two basic questions. First, what lessons from the Indian Health Service ought to be a part of the national health care reform debate? And, second, what is the impact of health care reform on the Indian Health system? (I’ll write about that next week.)

In some ways the first question is the most difficult because of its complexity. The “story” of the Indian Health Service told in Congress and by news organizations is primarily the story of how the government runs a health care delivery system.

Sometimes that even reflects a positive message.

“It may come as a shock to many that when I compare the private insurance industry to the Indian Health Service, VA, Medicare and Medicaid, it is the private insurance industry that is the worst,” writes Dr. Richard Anderson in the Cody Enterprise. “The reason for this is that when compared to government agencies, insurance companies are not in the business of providing health care benefits as much as the denial of such benefits to make a profit for shareholders. That’s why government agencies have much lower overhead and are more efficient in delivering services.”

Far more often, however, the story is about how government fails as a provider. A recent post on KevinMd.com is an example of that narrative: “So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.”

What’s interesting to me about both these posts is that they were written after Congress enacted health care reform legislation. We’re still fighting over a law that already passed (and, as I have written before, one that will be impossible to repeal until at least 2012).

But this narrative – Indian Health as a single-payer (success or failure) – misses the complexity. It’s hard to find many news stories at all that describe the role of Indian Health Service as a partner and funder of tribal, non-profit and urban health care organizations. Even though that activity represents more than half the IHS budget.

That’s why I would change the name of the Indian Health Service. It’s no longer a “service,” it’s a system. And in the coming decades I believe the IHS will provide even fewer direct health care services, while continuing to grow in areas associated with funding or the support of medical innovation and practices.

So what are some lessons from the Indian Health System that ought to be a part of the national health care reform debate? Three quick ones:
• A demonstration of what it takes to support and operate a rural health network, even in remote locations, using practices such as telemedicine;
• Experiences with an early implementation of an electronic record system for patients, information that will be valuable as other providers move away from paper records;
• Searching for a financial model that is frugal, yet fully funded. Neither the IHS (nor any private or government provider) has discovered the right balance. Not yet, anyway. But the topic should be a part of the discussion.

But perhaps the most important lesson is the Indian Health system’s history with the care and management of chronic diseases, especially diabetes.

Diabetes is the most expensive disease in America. It’s the fifth leading cause of death, surpassing AIDS and breast cancer combined. It represents nearly a quarter of all hospital spending and as much as one out of five health care dollars are spent on caring for someone with diabetes.

Unfortunately this epidemic is not news in Indian Country. American Indian and Alaska Natives are three times more likely to have diabetes than the white population (and four times more likely to die as a result).

Because of these grim statistics, the Indian Health system has much practical experience in disease management. For example the Special Diabetes Program for Indians supports community-directed programs, ranging from increased training to “best practices.” Over the decade the program reports a reduction in mean blood sugar levels of 13 percent in IHS patients as well as reduced LDL (or bad) cholesterol and significant reductions in protein in urine (a sign of kidney dysfunction). There are also promising statistics on fewer cases of end-stage kidney disease and other complications.

The diabetes crisis is not over – but Indian Country’s experiences could be helpful to the larger debate showing the importance of education and community-based efforts.

Additional resources:

New England Journal of Medicine: Article by Surgeon General Regina Benjamin on “Finding My Way to Electronic Health Records.

Financial Times: New report shows diabetes costs $83 billion a year in hospital bills.

Mark Trahant, a member of Idaho’s Shoshone-Bannock Tribes, is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. Comment at www.marktrahant.com. His new book is “The Last Great Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest Gerard. This column can also be read on the Missoulian website.

TrahantThere’s an old joke: A Native American student comes home from a geography lesson, shows his grandfather a map, and then asks, “What did we call the United States before it was a country?” His grandfather answers, “Ours.”

I thought of this joke recently in the context of the U.S. Indian Health Service. Perhaps the agency’s history, its shortcomings and its chronic underfunding have all been acceptable to Indian Country because the system itself is “ours.” It’s been “ours” for most of our generation – a little more than five decades – where American Indian and Alaska Natives could receive health care in a system that was, and is, unique.

A quick look at the history: Since 1955 the Indian Health Service was transferred from a rickety network of hospitals and clinics run by the Bureau of Indian Affairs to a real health care system. In that same time frame, the agency went from being a slice of the BIA to being larger than the BIA with a budget of $4.4 billion and some 15,000 employees. During that time there were substantial improvements in Indian health, including reducing overall mortality by 28 percent in the past 30 years, while still falling short in health parity for Native Americans.

That brings me back to the definition of “ours.”

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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 member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment at www.marktrahant.com. His new book is “The Last Great Battle of the Indian Wars,” the story of Sen. Henry Jackson and Forrest Gerard.

(Material for this column was originally published in December and March.)

Mark Trahant

Mark Trahant

Daniel Patrick Moynihan once said: “If you’ve been in government a long time, as I have been, then the most exciting thing you encounter in government is competence. Why is this exciting? Because it’s rare.” When I read the quote, even today, I can hear the late New York senator’s voice booming, his last word full with extra punctuation.

Today, I’m excited for the government. Health care reform should bring nutrition to a starving Indian health system. And, if the next test for health care reform is execution, then the government might be on the right course. President Barack Obama used his authority to give Dr. Donald Berwick a recess appointment to head the Centers for Medicaid and Medicare Services.

This is a choice that exceeds Moynihan’s rareness of competency. Berwick represents the ideal, the one person you think could help the government, the people and the medical profession come together around the idea of excellent health care. Last December, at the Institute for Healthcare Improvement conference I watched hundreds of professionals cheer on Berwick as they would a rock star. This is a doctor who’s willing to talk about what’s really important to people. “Health care has no intrinsic value at all. None, health does. Joy does. Peace does,” he said in December. “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”

Imagine that. Doctors we don’t need.

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