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Friday, February 19, 2010


I swear, folks, the more that I learn about the horrid plight of the Native Americans, the more angry I become. It’s not enough that most of the tribal populations live in abject poverty, or that their populations are in the 88% unemployed category. It’s not enough that the water and sewerage systems are completely antiquated and just about completely unable to provide clean water or decent removal of human wastes. It’s not enough that most of them starve most of the time because their soil is too worn-out to grow anything worth eating. Oh, no. Now, their Medicaid coverage is going to be cut to the bone and beyond – because, it seems, nobody cares enough to try and stop it.

Native Americans are currently treated as second class citizens, and this is very painfully evident in the type and quality (HAH!) of health care they receive. Although the federal government provides limited funding to Indian Health Service (IHS), it isn’t enough to even begin to provide any sort of appropriate types of health care to this particular segment of our American population. It's important to note that IHS is a residual payer, which means that all other payment sources for which a Native American patient is eligible (i.e. Medicaid) must be exhausted before IHS will pay for services – any services of any sort.

There are many problems with IHS, such as accessibility and funding, that can't be rectified without efforts from state and federal governments - which most of the state governments can't be bothered to make, and, after all, the FedGov has the BIA to do its dirty work of denial FOR it. On top of this, Medicaid reform has added to the enormous amount of problems, instead of improving the Native American health care delivery system. Although Native Americans compose a small percentage of the Medicaid population, even that small percentage could be reduced if the Indian Health Care Service (IHCS) providers were included in the networks of Managed Care Organizations. If a successful health care system for Native Americans could be created, then there is a really excellent possibility of utilizing the IHCS for dealing with the nation’s Native AmericansMedicaid population.

Here’s a paper that I found, from the Kaiser Institute, circa 2001, which I am quoting from (

“The Medicaid program's historic shift from fee-for-service to managed care presents critical policy issues for the IHS, for tribes and their health programs, and for urban Indian health programs. Because state Medicaid programs differ from one another, and because local circumstances vary considerably, these issues will take different forms in different communities. The Balanced Budget Act of 1997 overrides the right to freedom of choice of provider for most Medicaid beneficiaries by giving the states express authority to require Medicaid beneficiaries to enroll in MCOs or PCCMs. However, states under this authority may only force eligible American Indians and Alaska Natives to enroll in MCOs or PCCMs if these managed care entities are operated by the IHS, by a "638" tribe, or by an urban Indian organization(see? So, since most of the population that would be served by Medicaid is RURAL, where’s the equity?).

“The purpose of this limitation on state flexibility is not so much to assure that Native American Medicaid beneficiaries have choice of providers; they will generally have a choice because IHS and tribal providers cannot refuse to treat Indians who are eligible for their services. Instead, the purpose of this provision is to assure that, when these beneficiaries obtain care from IHS or tribal providers, the providers, rather than MCOs or PCCMs unaffiliated with the IHS or the tribes, receive Medicaid reimbursement for the covered services they deliver. The provision does not bar Medicaid-eligible Indians from voluntarily enrolling in an MCO or PCCM that is not affiliated with the IHS or a tribe.

“For many Native American Medicaid beneficiaries, the issue of choice of provider is more theoretical than practical, especially in sparsely-populated rural areas with few physicians or clinics or hospitals. Medicaid coverage that allows beneficiaries to choose from among all participating providers means little in underserved areas that have few providers of any kind, much less providers that participate in Medicaid.”

There’s a lot more in this white paper, which I’d recommend that everybody that has a VERY strong stomach read. It’s pretty sickening; if you’re a Native American, the IHS is, basically, the only way that you’re going to get any sort of health care – and it’s a pretty weak reed to lean on, since, apparently, the IHS doesn’t seem to either care, or have the clout to do anything about, the health care problems on the reservations. As I said earlier, t was written in 2001 and since then, things HAVE changed quite a bit. For, I’ll add, the worse.

There are an estimated 2.3 million Native Americans (American Indians and Alaska Natives) in the U.S. About half of the Native American population lives (if you want to call below-subsistence existence “living”, and I don’t) on or near reservations; the other half lives (again, IF you want to call it that, and I don’t) in other rural areas and in urban areas. VERY poor urban areas, truth be told. The Native American population includes 554 tribes recognized by the federal government as well as other tribes, largely in California, that for various reasons do not have federal recognition. The federally recognized tribes vary in size from less than 100 to more than 100,000 members. The economic status of these tribes varies substantially; some are wealthy, but most of the rest face conditions of high unemployment and high rates of poverty. Indians in urban areas, who are frequently not enrolled members of federally-recognized tribes, are often unemployed, and, like their counterparts on the reservations, starving. Some choice, eh? Stay on the rez and starve, or go to the big city and at least have access to "free clinics" and food pantries. Wow. What terrific choices.

The driving force for almost all of the health status and health coverage problems facing Native Americans as a whole is poverty. DUH, ya think? Not all Indians are poor, but a very large proportion of them are. U.S. Census data indicate that in 1996, 30.9% of Native Americans as a whole had family incomes below the poverty line, in comparison with 13.8% for the U.S. population as a whole. In 2010, more than 70% - that’s SEVENTY, seven zero per cent – have incomes below the poverty line. 88% - that’s eighty-eight, eight eight percent – are unemployed. So, if there’s no Medicaid available, the nearest clinic is a 4 hour ONE WAY drive from their homes, and they have to decide whether or not to feed their families or buy meds for ONE person, what sort of help are they getting? Answer: NONE. If you can’t afford the premiums, then you don’t get the insurance – and if there’s no IHS or Medicaid available, what do you do?

The IHS is, without a doubt, the bastard child of health care. Take a look at these facts: one doctor for 28 THOUSAND patients, very few ambulances, very few hospitals, and most of those in urban areas or on tribal lands, no real medical care other than a slap-dash system that requires at least a 2 and at most a 4 hour one-way ride for a minimum 2 – 4 hour wait to see that one doctor, and the Native American populations are told that IHS provides "quality medical care”. HOW is this quality anything? The Federal Government claims that IHS medical care is "quality medical care". How is this different from the rest of the uninsured population? It’s different because it’s worse. MUCH worse. This is an abomination that other minority groups are already screaming about, and have been for a long time. So, why isn’t something being done about the Native Americans? Here’s some statistics that WILL make your stomach churn:

LIFE EXPECTANCY: Almost 6 years LESS any other race or ethnic group in America. Life expectancy on the Pine Ridge reservation is 56 years.
Highest prevalence of Type 2 diabetes, which is rising 2.6 times the national average, and the death rate is 36.3 per 100,000.
1.5 TO 2.5 children per 1,000 live births are afflicted, compared to 0.2 –1.0 per 1,000 live births to the general population.
30% have had a serious psychological distress, compared to 11% of the general population.
The leading cause of death, with 133.5 per 100,000 – higher than the general population.
15-34 year olds make up 40% of all suicides
In the past 12 months there have been 213 suicide attempts on the Rosebud Sioux Reservation which makes at least 1 attempt every other day.

So, is there a solution? Yes, there is but nobody wants to tackle it. It’s really a simple one: Update and modernize the Indian Health Care Improvement Act. If it needs more funding, then make that funding available through the slush funds that every state already has. Make Medicaid and Medicare available to everybody on the reservations. Set up free clinics ON the reservations, along with low or no-cost medications to be dispensed through the clinics, and make sure that there are dentists as an integral part of the clinics. Make sure that there’s a doctor living within 10 miles of the reservation if not actually living ON the reservation – and make sure that the clinic is fully funded through health-care initiatives that are already in place. Get some of the foundations that aren't already working on the problems to get involved. Publicize the problems, and keep on publicizing them until something is done.

Used to be that doctors and dentists could work off their indebtedness through working on a reservation. They got paid, too, but they worked off their debts year-for-year by working with these poorest of the poor. Why isn’t something like that being done NOW? It could be offered through AmeriCorps, as it was through VISTA.

There are going to be billions and billions of dollars sent to Haiti, to rebuild their country. Why can’t we do the same thing here? Well, gangers, because Haiti is – in the judgment of most of the foundations and other funding sources, more in need of this. While I am not saying that Haiti doesn’t need the help, there are people here in this country, right her and right NOW, that would benefit even more from a billion dollars – and it would go a long way to showing the rest of the world that we take our responsibilities seriously when it comes to helping our own.

Nice dream. Won’t happen. Native Americans aren’t a priority here. That’s a true obscenity.

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