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Obamacare may bring Indian health into new era

The logo of the pioneering Benewah Medical Center in Idaho

This past weekend the Coeur d’Alene Tribe celebrated the 20th anniversary of the Benewah Medical Center in Plummer, Idaho. “In 1987,” the BMC web site reports, “the Coeur d’Alene Tribe began to search for ways to improve the health care services at their small Indian Health Service satellite clinic. It was located at the Tribal Headquarters, several miles from the City of Plummer, Idaho. Many tribal members were dissatisfied with 15 years of fragmented care delivered in a semi-condemned building and with poor continuity of care.”

Indeed, the complaints about the IHS facility and its operation were similar to those heard across Indian Country. And, like many tribes, the Coeur d’Alene proceeded to create its own health care network.

But this was a broader vision, one that went beyond just replacing and recreating IHS; there was also a sense of something new. Prevention was made a priority and a wellness center complimented patient care. There also was recognition of the gap in rural health care services. As Benewah Medical Center describes it: “None of the ambulatory care facilities in the four surrounding counties of the Northern Idaho town were providing services to the medically underserved on a sliding fee basis.”

So, a tribal community health center was created — launching two decades of innovation.

Fast forward to the Patient Protection and Affordable Care Act, the new health care reform law. Between now and 2015, the law significantly expands resources — funding — for community health centers (described in the law as Community Health Clinics, Federally Qualified Health Centers, or FQHCs in federal jargon, and Rural Health Clinics). There are technical differences in these definitions. Basically, the details relate to how various medical services are paid for by the federal government.

But my view is that tribally managed health networks now have a significant financial advantage over IHS-run facilities. There are more pots of money to tap, ranging from the IHS contract under the Self-Determination Act to money from the Health Resources and Services Administration, in the U.S. Department of Health and Human Services.

Funding for community health centers started growing under President George W. Bush, who doubled the spending in 2008 to $2.8 billion. Since then, President Barack Obama has added money under the American Recovery and Reinvestment Act of 2009 for community health centers, as well as an additional $12.5 billion for expansion of these efforts over the next five years as part of health care reform.

“With an eye toward meeting the primary care needs of an estimated 32 million newly insured Americans, the recently passed Patient Protection and Affordable Care Act underwrites the CHCs and enables them to serve nearly 20 million new patients while adding an estimated 15,000 providers to their staffs by 2015,” write Drs. Eli Y. Adashi, H. Jack Geiger, and Michael D. Fine in the May 11 edition of The New England Journal of Medicine. “The new CHCs have arrived.”

The law identifies community health centers as a priority. There are new resources for the expansion, construction, or renovation of clinics and to hire more medical providers. Nationwide, some 19 million people now use services at community clinics and the goal is to double that number (or about ten percent of the U.S. population).

And, this time around, Indian Country is included, if tribes and urban organizations choose to participate.

Community health centers generally operate by charging patients on a sliding scale and have historically served the uninsured population. In Indian Country this takes on a different twist because for eligible American Indian and Alaska Native patients, the Indian Health Service still picks up the cost as the payer of last resort (non-eligible patients would still be billed based on what they can pay).

The significance of all this is that the community health center model represents an improved funding stream for the Indian health system. Currently, a little more than half of the total Indian Health Service budget funds tribal or urban Indian facilities; a decade from now I could see that number at 90 percent or even higher. But IHS would only be a portion of the funding story: Money would also come from insurance companies or the new insurance exchange; on top of that there would be Medicaid and Medicare; perhaps add in a foundation grant or two; and, finally, the funding would be completed by appropriations designated for community health centers. The total might not be full funding of the Indian health system, but it will be a lot closer to that goal.

There are those that will argue that Indian Health Service should be fully funded, as is. But one can also make the case that this new opportunity — tapping money from a number of revenue sources — is recognition of tribal sovereignty, too. And a promise fulfilled.

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