A fast year: Lessons from the Indian Health System

A year goes by fast. Way too fast. Thirteen months ago I plunged into my “year-long” exploration of the Indian health system. It’s been fascinating because there has so much activity: Congress enacted the Patient Protection and Affordable Care Act and included with that bill the permanent authorization of the Indian Health Care Improvement Act.

My idea was to explore two basic questions. First, what lessons from the Indian Health Service ought to be a part of the national health care reform debate? And, second, what is the impact of health care reform on the Indian Health system? (I’ll write about that next week.)

In some ways the first question is the most difficult because of its complexity. The “story” of the Indian Health Service told in Congress and by news organizations is primarily the story of how the government runs a health care delivery system.

Sometimes that even reflects a positive message.

“It may come as a shock to many that when I compare the private insurance industry to the Indian Health Service, VA, Medicare and Medicaid, it is the private insurance industry that is the worst,” writes Dr. Richard Anderson in the Cody Enterprise. “The reason for this is that when compared to government agencies, insurance companies are not in the business of providing health care benefits as much as the denial of such benefits to make a profit for shareholders. That’s why government agencies have much lower overhead and are more efficient in delivering services.”

Far more often, however, the story is about how government fails as a provider. A recent post on KevinMd.com is an example of that narrative: “So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.

What’s interesting to me about both these posts is that they were written after Congress enacted health care reform legislation. We’re still fighting over a law that already passed (and, as I have written before, one that will be impossible to repeal until at least 2024).

But this narrative – Indian Health as a single-payer (success or failure) – misses the complexity. It’s hard to find many news stories at all that describe the role of Indian Health Service as a partner and funder of tribal, non-profit and urban health care organizations. Even though that activity represents more than half the IHS budget.

That’s why I would change the name of the Indian Health Service. It’s no longer a “service,” it’s a system. And in the coming decades I believe the IHS will provide even fewer direct health care services, while continuing to grow in areas associated with funding or the support of medical innovation and practices.

So what are some lessons from the Indian Health System that ought to be a part of the national health care reform debate? Three quick ones:

• A demonstration of what it takes to support and operate a rural health network, even in remote locations, using practices such as telemedicine;
• Experiences with an early implementation of an electronic record system for patients, information that will be valuable as other providers move away from paper records;
• Searching for a financial model that is frugal, yet fully funded. Neither the IHS (nor any private or government provider) has discovered the right balance. Not yet, anyway. But the topic should be a part of the discussion.

But perhaps the most important lesson is the Indian Health system’s history with the care and management of chronic diseases, especially diabetes.

Diabetes is the most expensive disease in America. It’s the fifth leading cause of death, surpassing AIDS and breast cancer combined. It represents nearly a quarter of all hospital spending and as much as one out of five health care dollars are spent on caring for someone with diabetes.

Unfortunately this epidemic is not news in Indian Country. American Indian and Alaska Natives are three times more likely to have diabetes than the white population (and four times more likely to die as a result).

Because of these grim statistics, the Indian Health system has much practical experience in disease management. For example the Special Diabetes Program for Indians supports community-directed programs, ranging from increased training to “best practices.” Over the decade the program reports a reduction in mean blood sugar levels of 13 percent in IHS patients as well as reduced LDL (or bad) cholesterol and significant reductions in protein in urine (a sign of kidney dysfunction). There are also promising statistics on fewer cases of end-stage kidney disease and other complications.

The diabetes crisis is not over – but Indian Country’s experiences could be helpful to the larger debate showing the importance of education and community-based efforts.

Additional resources:

New England Journal of Medicine: Article by Surgeon General Regina Benjamin on “Finding My Way to Electronic Health Records.

http://healthpolicyandreform.nejm.org/?p=3736&query=home

Financial Times: New report shows diabetes costs $83 billion a year in hospital bills.