Is it time for tribes to take over Indian Health Service, not just the agency, but the actual task of providing services? Maybe there is no time like the present for tribes to do it. This administration and congressional majority love privatization. But, we’ll call it tribalization.
We all know that there are good people who work within Indian Health Service who really care about their Indian patients and other health care recipients served through congressional appropriations for Indian health care. We also know there are a few bad eggs who need to be weeded out, which can be very hard to do under the federal personnel system. They pretty much have to commit a crime to get weeded out. We also know that the Indian Health Service bureaucracy sucks up a lot of monetary resources and personnel and encourages engagement in what I call empire building, especially at the regional and national level of the bureaucracy. The accompanying protectionism encourages the politicization of the entire system from top to bottom. It becomes a political basketball in a game of who can control the ball to score the most political points, but with everyone supposedly playing on the same team and playing defense on each other. It encourages the formation of little teams within the team to help each other score or keep the others from scoring.
What is the solution? I don’t know, but here’s my game plan:
- Privatize/tribalize Indian health care;
- Abolish Indian Health Service and place Indian health care under a commission selected by Congressand the tribes with administration involvement only in fiscal compliance. (Perhaps a majority of the commission being tribal from what we now call the regions.) The commission would answer to the appropriate congressional committees but not to the administration. An inspector general would also have to be appointed to assure fiscal compliance within normal accountability processes and to prevent fraud, waste and abuse;
- Tribal representatives would be held accountable by the tribes in their region subject, of course, to the scrutiny of the inspector general;
- Tribal non-profit health corporations would serve the local level with the ability to bill third parties such as Medicaid and insurance. Insurance would be purchased for anyone not fully covered by Medicaid. Non-Indians covered by Medicaid would be eligible for services as would be non-Indians who have insurance. Every clinic visit would be billed to either source;
- In those states where state government does not pick up part, or an adequate part of the costs of Medicaid, reimbursement of those costs to the tribal corporations would be mandated by Congress in federal appropriations;
- Also billable would be hospitalization costs and cost of specialists, surgery, disease therapy, long-term care, mental/behavioral/addiction health care and institutionalization, preventative care and community health programs. All would be billable by the tribal health corporations;
- Tribes could still require a local clinic referral for care that is now supposed to be covered under contract care such as hospitalization, emergency care, specialists, surgeries and therapies;
- Tribal health corporations would be authorized to use profits for improvement to health systems, health related infrastructure, expansion of direct care and pooling with other tribal health corporations for development of regional health care centers, including specialty hospitals;
- Tribal health corporations would be authorized to create pooled loss risk management and coverage, as has been done with housing and unemployment insurance;
- International agreements with Canadian tribes and the Indian health care system(s) in Canada for care (and billing) of either country’s Indian health care eligible patients. (It’s a Cree thing.);
- Native and Native Hawaiians, and other indigenous populations under U.S. Jurisdiction could also participate in the system but under separate appropriations.
If the United States eventually goes to a single payer system, the tribes will be ready for it, with just a few adjustments to their fiscal and administrative systems.
My purpose here is not to imply that I have the answers, but to start a discussion/dialogue in Indian country about a forward-thinking policy on Native American health care that comports with self-determination and self-governance. One, that does not let the United States off the hook for its trust obligations to Indians. We have a right to the benefits of the trust relationship into perpetuity and the right to exist into perpetuity as tribal nations. Those with opinions to the contrary that think we need to disappear—get over it.