The state of Navajo – sort of – and other health care experiments

Congress passed the health care reform legislation – and President Barack Obama signed the bill into law. The Indian Health Care Improvement Act was included – and now we can put this debate to rest. Right?

Actually no. There are many more debates about health care reform to come – probably for years – and much work remains before this law can be implemented.

“Opponents will continue, and probably intensify, their opposition. They have promised legal challenges and are likely to seek repeal of all or part of the legislation. Moreover, formidable implementation hurdles must be surmounted if health care reform is to achieve its goals,” Henry J. Aaron, Ph.D., and Robert D. Reischauer, Ph.D., recently wrote in the New England Journal of Medicine’s Health Care Reform Center blog. “On the political front, Republicans unanimously opposed the final bill in both the House and the Senate. They have expressed outrage at the Democratic leadership’s decision to “ram through” reform using budget reconciliation to modify the Senate-passed bill sufficiently to make it acceptable to the House. The outrage is baseless, but the fury is real and will poison future debate.”

On top of that fury there are thousands of pages of federal regulations – words that will define complicated ideas like “quality” in the legislation – that still must be written and debated in draft form, before they can be implemented. And, as I’ve written before, this bill is only authorizing legislation. The appropriations process is on a different track that requires congressional action before some of the new ideas can be implemented.

The legislation also sets up many experiments, requiring either demonstration projects or feasibility studies.

One of the exciting studies will look at treating the Navajo Nation as a state for purposes for Medicaid, Medicare and Children’s Health Insurance. This could be a huge win-win-win. It’s a win for the states of Arizona, New Mexico and Utah because they would no longer have to process the paperwork for Navajos living on the reservation; the government should save money because the rules could be made simpler and easier to process with Navajo rules for eligibility instead of three different state standards, and the Navajo Nation should be able to better serve its citizens.

You’d think states would embrace Medicaid and Children’s Health Insurance for American Indians and Alaska Native served by the Indian Health System because the federal government picks up the cost. But there has always been a fear, I guess, that these constituents would somehow end up on the state’s expense. Treating Navajo as a 51^st state would, at least, remove that worry from three states. And, if the process works, perhaps other tribes or tribal regional authorities could make it work too.

Another change in the law allows more facilities in the Indian Health system to provide services to non-Indians “so long as there is no diminution in services to eligible Indians.” This means that tribes can decide, as many have, to serve their neighbors (which could be employees or rural residents). On one hand, some Native American patients might feel that their clinic is already short on personnel and service. Then, on the other hand, by broadening the base of patients, smaller clinics could actually grow and have more resources to spend on every patient. Because the Indian health system is low-cost, many tribal and urban facilities often make money on Medicaid patients and are eager to accept new ones (which is really interesting because the larger narrative is that more and more clinics are refusing Medicaid patients because they are money losers).

One change that’s not experimental: The new law directs the Secretary of Health and Human Services to submit a plan to Congress creating a new Nevada IHS Area Office. No other state gets its own area office through the new law. Then again, no other state has the Senate majority leader as its champion.