IHS Archives » Native Voice One

Vaccines

February 1, 2021 By Bob Petersen

The headline in a story last week from Alaska Public Media that caught my eye: “Eligibility differences between state and tribal health systems frustrate some Alaskans waiting for vaccines.”

In other words: People are jealous of the Indian health system.

Seriously.

This is Trahant Reports.

There is a lot of background to the roll out of coronavirus vaccines in Indian Country. The pandemic is still lethal. The rates of infection in Indian Country are significantly higher than in other communities. A new study by the Urban Indian Health Institute points out the incidence rate among American Indians and Alaska Natives is 3.5 times higher than that of non-Hispanic Whites and the mortality rate is 1.8 times higher. The reasons go far beyond this pandemic: Chronic diseases, crowded housing, the lack of clean water and healthy foods as well as an underfunded Indian health system.

Tribal communities were hit hard early. There was not enough data, equipment and medical teams available to treat the pandemic.

But tribal governments were far more inclined to implement public health orders, including lock downs and mask requirements.

The thing is tribal governments, unlike their state counterparts, already have a culture of public health.

One clear reason is that the Indian health system is just that, a system. There are mechanics in place to distribute vaccines efficiently to a population. That’s something that is missing from most of the U.S health system where doctors and hospitals are scattered about without any real logic.

A recent report by NBC News put it this way: “All 50 states in the U.S. are reporting shortages as America’s fragmented administrative and health care systems struggle to distribute even the limited vaccine stocks that have been produced.”

The report said “what makes the U.S. especially troubled, according to experts, is that its health care system is not centralized, and the administration of President Donald Trump failed to build a proper national vaccine rollout plan to fill the void.”

But Indian Country is different. The Indian health system — a combination of federal clinics and hospitals, plus those run by tribes and nonprofits — is a system serving a distinct population and so a distribution plan could be properly executed.

The Cherokee Nation announced that it passed its first 10,000 vaccinations, including a priority for first-language Cherokee speakers, and it’s now adding Phase 2 priority patients to its distribution. The Navajo Nation lifted its weekend lockdowns so that more people can take the shot. Already more than 40,000 have received either the Pfizer or Moderna vaccines. And in Alaska more than 30 percent of all vaccines have been administered through the Alaska Native health system.

Then one key finding from the Urban Indian Health Institute study: Nearly three quarters of those surveyed said getting vaccinated is their responsibility to their community.

Sovereignty in action.

I am Mark Trahaht.

Data – What’s the Story?

April 27, 2020 By Bob Petersen

The numbers are stark.

Last week Navajo Nation health officials reported six new deaths Friday and 180 new cases of COVID-19. That adds up to 1,590 known coronavirus infections across the Navajo Nation and some 58 deaths.

That topline number places the Navajo Nation at 45 out of 55 states and territories, ahead of ten other jurisdictions.

What’s the story behind the data?

Trahant Reports · TR042720DATA

This is Trahant Reports.

The state and territory data from the Centers of Disease Control and Prevention includes three columns: Column A for the state or territory (which should include tribal nations, by the way); the number of confirmed cases; and the number of deaths. But if you insert a new tab, a filter for population, then the story grows even more significant.

Welcome to the world of the denominator. As one source put it: ‘‘Physicians lie awake at night worrying about numerators. Epidemiologists lie awake at night worrying about the denominators’

As Indian Country Today’s Jourdan Bennett-Begaye reported “denominators are key” to understanding the big picture of COVID-19 in Indian Country.

What population is counted determines our understanding about how widespread the disease is and where it will go next.

Take the Indian Health Service “service population” at 2,562,000. That means the reported infection rate is 0.08 percent. But if you calculate based on the IHS user population of 1.662 million, then the rate is 0.12 percent.

But that’s only the reported cases. We know this disease can be without symptoms and we don’t have enough testing to know how many people are really infected,

And that will be a much larger number.z

If you use the World Health Organization framework and the IHS service population that means we will eventually reach 5,778 cases and 275 deaths.

But numbers again are different if the 2010 Census with the American Indian and Alaska Native population at 5.2 million is used. Then the Indian health system could expect 12,017.2 cases and 572 deaths.

But all of that changes if a different denominator is used. The problem here is that we know the Census undercounts Indian Country. We don’t know by how many people, though.

This is when that number is absolutely critical.

I am Mark Trahant

Medicaid

November 19, 2018 By Bob Petersen

Valerie Davidson is Alaska’s Lt. Governor and the principal architect of the state’s Medicaid expansion.

The Indian Health system was on the ballot across the country last week (even if the words were not explicit.) A few wins. And Alaska is at risk for a big loss.

This is Trahant Reports.

Voters in three states added new money that will go directly to clinics and basic health services through Medicaid expansion. One of the most important provisions of the Affordable Care Act was to allow states to expand Medicaid making it easier for citizens to quality for basic health insurance. Medicaid is a third-party insurance fund that directly benefits Indian health clinics and hospitals.

But in other states there were costly setbacks. Montana rejected a funding mechanism for Medicaid expansion sending it back to the legislature for further debate.

And the election of Mike Dunleavy as the new governor in Alaska means changes ahead for Medicaid in that state. (And Republicans, who never did favor Medicaid expansion, now control both houses in the state legislature.)

Medicaid has become a significant funding stream for the Indian health system, it’s particularly important for the non-profit and tribally-operated clinics and hospitals because by law that money remains at the local unit. And, unlike federal appropriations for the U.S. Indian Health Service, the amount of money grows as more patients become eligible for services. What’s more: The federal government reimburses states 100 percent for treatment at Indian health clinics or tribal facilities.

This is how it works: The Indian Health system — the federal Indian Health Service and the facilities operated by tribes and non-profit organizations — gets funding directly from Congress through appropriations. That appropriation is currently $5.5 billion but Medicaid is a partnership with state governments, and thus, must be approved by each state.

Nebraska is one of the states that voted for expansion.

The Winnebago Tribe of Nebraska recently assumed operational control of the Indian Health Service hospital and renamed it the 12 Clans Unity Hospital. Medicaid expansion could add revenue streams to this facility because more patients would qualify for the insurance. One specific benefit is that Medicaid claims are processed on a regular basis to help facilities cover operational costs, including infrastructure.

Medicaid expansion could also benefit urban clinics in Lincoln and Omaha (as well as a clinic in Salt Lake City). According to the Kaiser Family Foundation one urban Indian health program in Arizona reported that its uninsured rate fell from 85 percent before the Affordable Care Act to just under 10 percent after.

Alaska’s election could result in the biggest changes to Medicaid and the Alaska Native medical system. Nearly 40 percent of Medicaid clients are Alaska Natives and one in five Alaskans is now covered by Medicaid. Last month at the Alaska Federation of Native convention, Lt. Gov. Valerie Nurr’araaluk Davidson, Yup’ik, said Medicaid expansion has benefited every community in the state. As director of the state’s health agency, Davidson was the architect of the state’s Medicaid expansion.

I am Mark Trahant.

Read Full Story

What Qualifies a Leader? The Nominee Director for IHS with Nominal Experience

January 8, 2018 By Bob Petersen

IHS Director Nominee, Robert Weaver

What qualifications are needed to manage (and possibly reform?) the Indian health Service?

This is Trahant Reports.

The Indian Health Service is Indian Country’s largest employer with more than 15,000 people on the payroll and many, many more people who work in health care for tribes, non-profits and other related agencies. The IHS budget is $6.1 billion. Yet it’s also the least funded national health care delivery system.

The Wall Street Journal published a story last week about the controversial nomination of Robert Weaver, the Trump Administration’s pick to head the Indian Health Service. The Journal raised questions about Weaver’s role at St. John’s Regional Medical Center in Joplin, Mo.

Weaver is a member of the Quapaw Tribe of Oklahoma.

These are the facts. Weaver will be the least educated director of the Indian Health Service ever. If confirmed, Weaver will the tenth permanent director. All but one prior to Weaver have been physicians, most with multiple degrees in public health, science, and health administration. Weaver is not a college graduate. His background is insurance. In a September 2016 profile in Native Oklahoma magazine he said his business saved the Quapaw Tribe more than $5 million a year.

The problem here is one of scale. He was owns a business where he can hire and fire at will. But at the Indian Health Service most of the key personnel decisions are made by folks in the chain of command. Sometimes even as a favor to a United States Senator. And firing? Just one such action could take up more time than the three years left in this administration.

And that’s the easy stuff. The agency’s operations are complicated by Congress, law, regulation, tribal relations, the Veterans Administration, Medicare, Medicaid, and private insurance.

To his credit, Weaver has been outspoken about the underfunding of the Indian health system. (My question: Will he say so again in his confirmation testimony?)

Perhaps the Indian Health Service should be led by someone with an insurance background. It would surely help if the agency could come up with a better funding model, including a mix of insurance funds. But it’s a complex organization and he would be managing jobs that he himself could not be qualified to run, such as a hospital administrator.

Just what are the qualifications necessary to run the Indian health system? I have a bias. I met some of the great physicians who ran the agency. I remember Emery Johnson’s passion and thoughtfulness about what IHS could be. So the standard for me, at least, is high.

Then the Trump administration likes the idea of shaking up government. And, appointing someone to run the IHS with a very different background, does just that.

We would do well to remember a phrase that medical doctors learn early in their training, First, do no harm.

I am Mark Trahant.

Senate Health bill would cut jobs in Indian Country

July 10, 2017 By Bob Petersen

The Indian Health Service is Indian Country’s largest employer. Proposals in the House and Senate would significantly cut Medicaid — a program that accounts of IHS jobs. (Trahant photo)

The Senate is back this week and Republican leaders are once again looking for votes for their health care plan. It’s a tough sell for lots of reasons. The bill tips towards conservatives and moderates say no. Rewrite the language so that moderates are happy — and the conservatives bolt. And it only takes three GOP no votes for this bill to fail.

Both the Senate bill, and the House counterpart, are supposed to be about repealing the Affordable Care Act. But for Indian Country there is something else at stake, jobs.

This is Trahant Reports.

Some history. I am not sure of the exact year. It probably happened around 1996. That’s when the Indian Health Service became the single largest employer in Indian Country.

This makes sense when you think about it: Indian health was once a small (unappreciated) division of the Bureau of Indian Affairs. But by 1996 the agency’s budget was larger than the BIA’s — and there were likely more workers. The administration estimates that next year the BIA will have some 6,770 full-time employees while the Indian Health Service will have more than 15,119 employees.

Big numbers, right?

A fast-growing category of jobs is called “healthcare support jobs.” The list here would include Community Health Representatives (long a staple in Indian Country), medical record keeping and coding jobs, as well as different kinds f medical technicians. These can be good gigs in a rural, tribal community.

That’s an area of jobs where Medicaid funding is key and it’s a resource that would go away in both the House and Senate plans.

Alaska is a prime example. More than half of Medicaid spending serves rural constituents. Medicaid covers two-thirds of all American Indian and Alaska Native children and more than one in four of American Indian and Alaska Native adults. The Urban Institute estimates that the kind of block grants found in the Senate’s Better Care Reconciliation Act would cost the state $590 million in federal funding — a number that would decline even sharper after 2025. And, of course, the job losses would be substantial.

Medicaid already directly accounts for 24 percent of IHS’ workforce, but even that is short of the kinds of jobs that serve tribal communities. It does not include school-based programs. Or those private companies that bill Medicaid for transportation of patients or other patient services.

So as the debate heats up this week, remember that the Senate bill is about a lot more than just how healthcare is delivered. It’s also about jobs. Thousands of jobs. I am Mark Trahant.

Save

Senate Healthcare Bill

June 26, 2017 By Bob Petersen

Alaska Sen. Dan Sullivan will have to decide what’s more important: Tax cuts or Medicaid? The Senate vote is expected to be close. Both Sullivan and Sen. Lisa Murkowski have said they remain undecided about the legislation because of its impact on Alaska.

The Senate healthcare bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions of dollars away from public health insurance and passes that savings to wealthy Americans via tax cuts.

This is Trahant Reports.

How bad could the legislation be? The official financial review from the Congressional Budget Office is expected soon. The scoring of a similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured.

The important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) — a public insurance program for people who are poor or disabled — and gives that money back to high-income taxpayers ($664 billion).

The Senate bill takes a little longer to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid is automatic: If you are eligible, the money is there.)

Medicaid accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.

But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or especially, what’s covered by insurance.

This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent match. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. The states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.

The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity.”

The Senate vote is expected to be close. And that means the bill could change again as leaders try and round up enough votes for passage. I am Mark Trahant.