Who should run the Indian Health Service? Not “who” exactly, but what kind of leader? What kind of skills and experience?

This is Trahant Reports.

The Trump administration has withdrawn the nomination of Robert Weaver to lead the agency. Weaver, a member of the Quapaw Tribe of Oklahoma, had a background in private insurance working with tribes to set up plans to cover tribal members. Weaver’s nomination was sidetracked after The Wall Street Journal reported serious misstatements on his resume.

In a letter to tribal leaders, Weaver said the president has been an “ardent supporter of fixing Indian Health throughout this process.” And he said “he will fight to give voice to the change needed at IHS until the mission is complete … the delivery of timely, high quality healthcare for Indian Country no matter where you live.”

The mission? That is the key word here. The mission of the Indian Health Service has become so distorted that even policy makers cannot or will not articulate the challenges. All of the discourse about the Indian Health Service continues to be about a federal agency that delivers health care to American Indians and Alaska Natives. And, within that story, there are so many clinics and hospitals that only require more order and funding in order to carry out even basic health care. The system is failing.

Only the IHS story is much more complex. We need to think differently about the Indian health.

Most of the Indian Health system is managed by tribes or non-profits. The federal role is that of a funding agent and it sets standards. But even that is misleading because it is Medicaid, not the Indian Health Service, that’s often the largest source of funding for tribal and nonprofit facilities. The administration claims it’s protecting the Indian Health Service budget … all the while proposing deep cuts into Medicaid.

There is a disconnect and the proof is found in the budget. The line item for “collections,” that is money from Medicaid, Medicare and private insurance, is roughly $1.2 billion. That’s a number that has not changed much despite a huge expansion of Medicaid under the Affordable Care Act. But when you talk to tribal and non-profit administrators, as I have, there is a different story to tell. Medicaid is now more important to local budgets than the IHS itself.

The expansion of Medicaid explains a lot about the shortages within the Indian health system. The federal Indian Health Service will take Medicaid funds, but it’s not growing the pot. Tribes and non-profits have done that. And there is more money for Indian health in states that have expanded Medicaid.

This is not the Indian Health Service we grew up with. And the next director of the Indian Health Service needs to acknowledge this complexity and own the new story. If I had my way: the next IHS director would have a solid background in medicine and Medicaid.

I am Mark Trahant.