There'ês 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 Indians 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 an 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 with the rest of the population for Native Americans.
That brings me back to the definition of "ours."
Since 1955 that definition has meant government-run health care, mostly in the form of direct services operated by the Indian Health Service. But that definition has been changing slowly since the enactment of the Indian Self-Determination and Education Assistance Act of 1975. That law gives tribes as well as tribal and urban Indian organizations the right to contract for the management of these federal programs. Already more than half of IHS is run under contract — and that number should grow even more quickly because of changes under the new health reform law, the Patient Protection and Affordable Care Act.
In a way I suspect the future of IHS is almost like its past, after its break from the BIA. The BIA was the largest agency that served American Indians and Alaska Natives, then it recent years that biggest agency has become the IHS. This will probably remain true for the next few years. But look at the budgets for some of the clinics or hospitals run under contract and it'ês clear there are new big players coming into the picture. IHS will remain a funder of last resort for patients from Indian Country, but more native patients are eligible for funding from the Centers for Medicaid and Medicare as well as the Health Resources and Service Administration funding rural health clinics and Federally Qualified Health Centers.
This is what a possible budget at a so-called 638 facility — one that is either managed directly by a tribe or a nonprofit foundation — might look like in coming years: 40 percent of its revenue from CMS reimbursements; 30 percent from HRSA programs; another 25 percent from IHS and 5 percent from everything else, including private insurance. These percentages could be managed up or down depending on nature of the clients, but my point is that Indian Health Service will be a significantly smaller player. (Its primary mission might focus more on oversight and as a funding mechanism as well as data collection.)
Does this mean that these new government-wide health bureaucracies are overrunning the treaty and trust rights of American Indian and Alaska Natives for health care? Perhaps. You could certainly make that case.
But you could also make the case that the federal government is, finally, coming up with a formula for adequate funding for every patient. Even better there is a stronger case that this health care system will work better and more efficiently when it's designed and controlled at the local level through self-determination.
If we do this right, the Indian health care system will truly be called "ours."