Progress and Reform in the Indian Health Service

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By Yvette Roubideaux, MD, MPH
Acting Director, Indian Health Service

The Indian Health Service mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

The Indian Health Service (IHS) has made significant progress in improving the health status of American Indian and Alaska Native people since it was established in 1955.  Providing greater access to healthcare services in rural and remote communities has resulted in significant improvements in the health and well-being of the people we serve.

For example, the rates of many diseases have dropped considerably in our service areas since the IHS was established.  In 1955, approximately 2.3% of our service population suffered from trachoma infections, and now, in part due to a comprehensive program of improved access to water and sanitation and intensive efforts to treat eye disease, trachoma is nearly non-existent.  Tuberculosis infected about 5.8% of our service population in 1955, but thanks to a number of medical interventions and improved drug therapies, this disease is also practically nonexistent. Rates of sexually transmitted diseases have also declined significantly in our patients since 1955. For instance, gonorrhea rates decreased approximately 325% from 1955 to 2007.

The Indian Health Service has launched a Baby Friendly Hospital Initiative (BFHI). Here is a scene, in the Phoenix Area, from a kick-off event in 2011.

The Indian Health Service has launched a Baby Friendly Hospital Initiative (BFHI). Here is a scene, in the Phoenix Area, from a kick-off event in 2011.

And just in the span from 1972 to 2007, mortality rates decreased approximately, 85% for cervical cancer, 29% for maternal deaths, 58% for accidental deaths, and 68% for infant deaths. And life expectancy increased by approximately 10 years, from 63.6 to 73.6 years. However, this is still 4.1 years less than the comparable U.S. all races population rate of 77.7 years.

We continue to face significant challenges as we work to fulfill our mission. Health disparities continue to persist for American Indians and Alaska Natives compared to other populations.  For example, diabetes mortality rates are still nearly three times higher for American Indians and Alaska Natives than for the general U.S. population.

Addressing these disparities is complicated. In addition to the challenges of delivering healthcare in a primarily rural location, the Indian healthcare system also faces a number of other challenges that are driven by a host of medical, cultural, and socio-economic factors.  Despite all these challenges, we continue to work to change and improve the IHS, and we view implementation of the Affordable Care Act (ACA) as a top priority, since it can help increase access to quality healthcare for our patients.

In 2014, IHS will focus a major effort on the implementation of the ACA in our facilities through enhanced outreach, education, and enrollment efforts to ensure that our patients understand and have access to the benefits of the ACA.   IHS will also continue its focus on preparing our employees and facilities for the changes and potential improvements that the ACA will bring to the Indian health system.

Making sure that our patients understand the benefits of the ACA is extremely important.  Even though the IHS will continue to be a source of healthcare for them as a result of the permanent reauthorization of the Indian Healthcare Improvement Act, the additional benefits of the ACA may help increase their healthcare coverage while increasing access to services for all patients. They can benefit from all the reforms, whether they have insurance already, want to purchase affordable insurance through the “Health Insurance Marketplace,” or can take advantage of the Medicaid expansion in states where it has been implemented.

Sometimes tribes and patients ask me why they should care about the ACA, since they already get their healthcare through the IHS. The answer is that while the IHS is here to stay and will remain a healthcare system that our patients can access, the ACA is about options for additional health coverage. It’s another way the government meets its responsibility for healthcare for American Indians and Alaska Natives.

Right now, about 23% of our patients have private insurance; that means when they come to us for a visit, we can bill their insurance, which means more resources at the local level for services for all our patients. The same is true for other coverage.  About 38% of IHS patients are currently on Medicaid.  With the ACA, many more of our patients may be eligible with the Medicaid expansion in their state, if available.  Medicare and VA healthcare account for a smaller portion ‒ less than 10% ‒ of the health coverage that our patients have.  However, a good proportion ‒ approximately 30% of our patients ‒ have no health coverage other than the IHS.  This is the group that may benefit the most from the ACA.

All these changes could result in increased third-party reimbursements and therefore increased resources for the IHS, which means more services for all our patients. In fact, we’ve estimated that we could see an additional $95 million in third-party collections in fiscal year 2014.  While some of our patients might choose to use their new coverage elsewhere, we are working on improving our customer service and access to care to encourage our patients to continue using our facilities.

There are also special provisions for American Indians and Alaska Natives who are members of tribes. They won’t have copays or deductibles if they obtain their healthcare services at the IHS, or anywhere if their income is below a certain level.  Given the tax credits available, American Indians and Alaska Natives may be able to pay very little in premiums for insurance after they determine their eligibility.  So we have been working on education and outreach to ensure that all American Indians and Alaska Natives will at least take a look at their individual eligibility through the Marketplaces.

Since it was established in 1955, the IHS has made great strides in reducing health disparities for the American Indian and Alaska Native patients we serve.  However, there is much more to do, and we plan to continue changing and improving the IHS through our agency reforms and by focusing on implementation of the ACA in the coming year.  By continuing to work to increase access to quality healthcare for our patients, we can continue our progress towards eliminating health disparities in the communities we serve.

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