HHS consolidation surfaces at Senate health care hearing

WASHINGTON - A Senate Indian Affairs Committee hearing on health care April 2 introduced a one-department consolidation initiative of Health and Human Services to the realpolitik of Indian country.

"Downsizing the Indian Health Service," the branch of the parent HHS that delivers health services to Native communities, "is just a catastrophe for us," said Julia Davis-Wheeler, chairperson of the National Indian Health Board in Denver. She added that tribal leaders "almost walked out on the whole process of consultation" on the initiative, in aggravation over the prospects of further cuts to IHS.

The brief here is that Secretary of Health, Tommy Thompson, widely praised as the spearhead of a successful campaign for welfare reform while serving as Wisconsin's first four-term governor, hopes to bring an "enterprise approach" to health care. Part of the program would be to consolidate the Indian Health Service so that all divisions of HHS become more responsible for Native health care. In theory this would both direct more resources to Indian country and bring about the budgetary efficiencies the Bush administration - with Congress the ultimate boss in all this - is demanding.

Dr. Charles Grim, interim director of IHS, commented on the initiative at the committee's request. In a written statement he explained the secretary's view of it: "The fundamental premise of this initiative is that the Department of Health and Human Services must speak with one consistent voice. Nothing is more important to our success as a department. With regard to our tribal constituents the Secretary observed on his first trip to Indian country that tribal programs were often 'stove-piped' and that there existed within HHS an assumption that the IHS had sole responsibility for the health issues facing tribes."

Don Kashevaroff, president and chairman of the Alaska Native Tribal Health Consortium, made the case that the very characteristics of Indian Health Service - delivering direct service to remote rural communities that have difficulty competing for care providers, along with cultural singularities and some of the nation's worst statistics on health - may defy both the sprawling HHS bureaucracy and the "enterprise approach" of its current secretary.

Keeping his comments brief like all the witnesses, Kashevaroff explained himself more fully in written testimony: "? as much as we trust the Secretary's intentions, we have some concerns about the potential impact of several elements of the consolidation, that in actuality will not improve service or create efficiencies ?" Among these he listed the consolidation into HHS of Indian Health Service information technology, the legislative affairs and human resources offices.

Characterizing certain aspects of the proposed consolidation measures as "sound at the macro-level," Kashevaroff encouraged HHS "to acknowledge the unique status and functions of the Indian Health Service, and make exceptions to the consolidation plan in the case of the Indian Health Service because of this status."

Sen. Ben Nighthorse Campbell, R-Colo., chairing the session, had at the outset pointedly questioned Dr. Grim of IHS on the meaning of his expressed hopes to meet the Bush administration's budget reduction requests with "economies" and "efficient use ? of coverages in certain areas," or as a last resort only to "touch the health care and service delivery levels."

Now he urged HHS to extend its consultation period with tribes on the initiative. At the tail-end of exchanges much less contentious than those he presided over on trust funds reform in March, he sounded a considered warning of his own: "I have to tell you though, I'm really worried about this one IHS proposal."

Expressing a general appreciation for "efficiencies" Thompson is seeking in the HHS budget, he said that in his experience the priority on tribal programs is often lost when larger bureaucracies try to absorb their smaller Indian divisions. This "folding things into things being more efficient" doesn't often work for Indian country he concluded, and adjourned a meeting that had been more productive on its main agenda item - S. 556, the Indian Health Care Improvement Act Reauthorization of 2003, reintroduced by Campbell from the last congressional session along with co-sponsors Daniel Inouye, D-Hawaii, and John McCain, R-Ariz.

All witnesses expressed strong support for the bill once it can be refined, even Dr. Grim who noted a number of technical and budgetary problems regarding payment practices and administration of Medicaid and Medicare - the latter, in his words, already "a program that is approaching insolvency." He added that the bill's proposed "detailed provisions for a Qualified Indian Health Provider" for Native-specific health care providers in both programs "would not be feasible to administer."

Kashevaroff identified the germane tribal issue the bill attempts to redress: "? if there is a payment advantage or reimbursable activity available to any other provider, it should be equally available to the Indian health system."

Wheeler-Davis of the National Indian Health Board noted that perhaps only a dozen experts in all the world understand S. 556 in its 350-plus pages, many of them technical in content. Increasing that number won't be a cakewalk, but for anyone willing to do their bit - go to http://indian.senate.gov, click on "Legislation" at left of the splash page and scroll down to the bill in its numerical order, then click on the number.

One sidebar item bears mention. Dr. Grim, interim director at IHS, has been nominated to the post in its full authority. He received praise from all sides at the hearing for a business-like approach to the service, invaluable it seems at a time when the federal treasury is on a war footing.