Deep within the pages of the Affordable Care Act is a section that is now a permanent fixture, the Indian Health Care Improvement Act, thanks to the U.S. Supreme Court ruling.
DEEP within the pages of the Affordable Care Act is a section that is now a permanent fixture, the Indian Health Care Improvement Act, thanks to the U.S. Supreme Court ruling. This is an important part of the law and its success has broad implications for health-care reform.
The Indian Health Care Improvement Act first became law in October 1976. It may be the most successful piece of legislation ever.
Consider life expectancy: Before the law was enacted, the average age at death for American Indians and Alaska Natives was about 48 years, compared with about 72 years for white Americans. That more than 20-year gap has been reduced to less than five years, or an age at death of about 72 years for Native Americans, compared with the U.S. average of nearly 77 years for all races.
But the 1976 act expired in 2001 and Congress unsuccessfully debated reauthorization. By the time the larger health-care-reform debate began, the Indian Health Care Improvement Act was stuck.
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In October 2009, U.S. Rep. Nick Rahall, D-W.Va., chairman of the House Resources Committee, and George Miller, D-Calif., chairman of the House Education and Labor Committee, added Indian health provisions to the president’s reform package.
Rep. Doc Hastings, R-Pasco, and then the ranking member on the Resources Committee, said “tying reauthorization of the Indian Health Care Improvement Act to the controversial government takeover of the nation’s health care does a serious disservice to tribes and individual Indians and Alaska Natives across the country.” He said the Indian health-care provisions should move forward in a bipartisan manner.
Nonetheless, the Indian Health Care Improvement Act was rolled into the Affordable Care Act and made permanent. (This is the same legal standing as the primary authorization for federal American Indian programs, the 1917 Snyder Act.)
There are fewer than 2 million American Indians and Alaskan Natives in the Indian health system, but there are lessons applicable to health-care reform.
Congress created the Indian Health Service, a federally operated chain of clinics and hospitals, as an early model for government-run care. It was always seriously underfunded.
But those funding shortages created a culture of doing more with less. Donald Berwick, the former head of the Centers for Medicare and Medicaid, has said the Indian Health Service’s ability to execute is “stunning.” He said, “The Indian Health Service is trying to deliver the same or better care with half the funding of other systems in the United States.”
There’s another lesson from the Indian health experience that ought to be a part of the larger discourse.
The entire Indian health system was federally operated until 1976, when tribes, nonprofit organizations and community groups began to assume some operations and control. Today the most successful clinics and hospitals, such as the South Central Foundation’s Alaska Native Medical Center in Anchorage, are managed locally.
South Central’s clinics begin with their philosophy that “customer-owners” should design their own health care. That shift in language is critical in an era when managing chronic diseases — diabetes, hypertension and heart disease — requires more than a simple prescription to a patient from a doctor.
The results have been remarkable. South Central sees more people than ever while at the same time showing improved patient outcomes. Key metrics include substantial drops in specialty care, hospital admissions and emergency-room visits.
Critics of “ObamaCare” fear a massive bureaucracy that’s ineffective. There are many underfunded clinics in the Indian Health Service that represent all that is wrong with government-run health care. But there are also models that are community-managed, low-cost and excellent. That innovation will continue now that the Indian Health Care Improvement Act is permanent.
Mark Trahant is a former Seattle journalist who now lives in Idaho. He is a member of the Shoshone-Bannock Tribes and a former Kaiser Family Foundation media fellow.