A thorny question: Should American Indians and Alaska Natives buy their own health insurance?

The enactment of health care insurance reform raises a thorny (and complicated) question for Indian Country: Should American Indians and Alaska Natives eligible for services in the Indian health system buy their own insurance?

The first answer ought to be a resounding “no.” Clearly the United States has an obligation for health care because of promises made through treaties and statutes. Indeed, the very enactment of the Indian Health Care Improvement Act is a legal restating of this principle. Health and Human Services Secretary Kathleen Sebelius said it this way on March 26: “This administration is intent on honoring the obligations of our government-to-government relationship with American Indian tribes, including the promise of adequate health care.”

But adequate health care is not an insurance plan; especially when that promise is so limited by money. And there is no possibility that Congress will fully fund the Indian health system anytime soon.

So where does that leave us? The Government Accountability Office said in a 2005 report: “There remain concerns about the extent to which health care services are available—that is, both offered and accessible—to Native Americans served by IHS.” One key issue here is the underfunding of Contract Health Services, money that is used to pay for health care providers outside of the Indian health system. Remember unlike Medicare, Medicaid or the Children’s Health Insurance Program, IHS operates on an annual budget instead of an entitlement and it’s a limited source of funds. This budgeting notion will not change with health care reform.

But when private or government insurance money (or third party billing in government-talk) is added into the Indian health system that could improve services for all. The new law opens up all sorts of avenues for tribal and urban Indian clinics to bill insurance plans. Third party billing is supposed to add new money; so current funding shouldn’t be limited by these dollars.

There’s been a lot of talk about a national mandate to buy health insurance under the new law. That’s true. But the issue is far more complicated for Indian Country because there also is a specific exemption from the penalties associated with the mandate. As IHS Director Dr. Yvette Roubideaux recently wrote on her blog: “Health reform just means that in general, American Indians and Alaska Natives can continue to be eligible for and use IHS, Tribal, or urban Indian health programs, but if they want to, they will be able to purchase health insurance through the exchanges, which should have more affordable options. If they don’t want to purchase health insurance, as long as they get their care through our I/T/U system, they won’t have to pay a penalty.”

So should individuals – despite U.S. promises – buy health insurance to pay for care in the Indian health system?

I see several “yes” answers developing.

First, it will be easier for individuals who are eligible for other government programs, such as Medicare and Medicaid to medical services for veterans. Medicaid, the program designed for people on low-income, will enroll single adults for the first time. The glitch here is that states aren’t keen on Medicaid expansion even though there’s a 100 percent match for clients in the Indian health system.

Most tribal governments already offer health insurance for employees and the new law expands the potential for tribes to purchase insurance for tribal members as well (without tax consequences).

Other native people will buy insurance for their families because it unlocks choices. Bringing health insurance into the Indian health system could eliminate some of the delays or denials of care associated with Contract Health.

“We can bill for third party reimbursements and help better fund our health services,” Dr. Roubideaux wrote. “However, they could also choose to leave us and get their healthcare somewhere else. Then we would lose our patients and potential reimbursements.”

Dr. Roubideaux says this is “All the more reason for us to change and improve the IHS, and emphasize customer service! We have to remain competitive and be the first and best choice for our patients.”

I’ve talked to many people who’ve given up on the Indian health system. They say it’s much better for their families to use their private insurance and go elsewhere. I understand that. It’s a choice for every family. But the only way the Indian health system will be better for our children and grandchildren is for us all to stick with it and to add whatever resources we can. Even if that means buying insurance.