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Roubideaux: A continuing discussion to improve health care for First Americans

Mark Trahant is completing a comprehensive and unprecedented series of columns on health reform and the Indian health system. These columns have shed new light on the Indian Health Service and how it is influenced by and affected by the rest of the U.S. health care system. These columns were made more timely and relevant by the historic passage of the Affordable Care Act and reauthorization of the Indian Health Care Improvement Act that occurred during Mr. Trahant’s work this past year.

These columns have helped put the spotlight on IHS, which is a health care system that serves 1.9 million American Indians and Alaska Natives from 564 tribes in 35 states. The IHS rarely is mentioned in the national media, but it serves a critically important role to address the health disparities faced by American Indians and Alaska Natives. Many Americans do not understand the role of this health care system, or the treaty obligations and trust responsibilities that led to its formation more than 50 years ago.

One of the original questions for Mr. Trahant’s work was how the IHS can serve as a model for the U.S. health care system. IHS demonstrates that access to care can make a huge difference in remote and rural areas. The improvement in health status of AI/AN since the 1950s demonstrates how access to basic care can improve the health of a population.

IHS has also demonstrated that it can provide quality health care with limited resources and staff. But the IHS has faced increased challenges over the years, including population growth; rising health care costs; new health challenges such as diabetes, obesity, and other chronic diseases; and health care provider shortages. Through federal legislation, tribes now manage over half of the IHS budget, and are demonstrating how new ideas and increased flexibility in managing these health care services can result in innovative and more effective health care programs. However, the challenges faced by IHS are felt by all of its programs, whether they are administered by IHS, tribes, or urban Indian health programs.

Since I was appointed as the IHS director in May 2009, I have responded to a call from tribal leaders, staff, and patients to change and improve IHS. I set four priorities to guide the work of the agency over the next few years, and we are making progress in reform.

Our first priority is to renew and strengthen our partnership with tribes. I continue to believe the only way we are going to improve the health of our communities is to work in partnership with them. We have strengthened our partnership with tribes through formal consultations and numerous tribal meetings. Many of the health challenges we face are caused by factors in our communities that are outside the control of the health system, including poverty, unemployment, crime and public safety. The recent passage of the Tribal Law and Order Act highlights how multiple agencies must be involved in the solution to complicated problems such as violence against women in tribal communities. Strengthening our partnership with tribes is essential to healthier communities and reduced health disparities.

Our second priority is to reform IHS, in the context of national health reform. Passage of the Affordable Care Act benefits AI/AN by increasing access to quality and affordable health care while reducing health care costs. Some AI/AN don’t have access to IHS, especially in urban areas, so access to affordable insurance is critically important.

Our internal IHS reform efforts are focusing on improving the way we do business and how we lead and manage our staff. We are working on improvements in managing our finances, shortening our hiring process, managing the performance of our staff, and enhancing overall communication. Improvements in these areas will help us deliver better care by making us better at the business of health care.

Our third priority focuses on improving the quality of and access to care for the patients we serve. We are focusing on improving customer service and expanding our efforts to create a medical home for our patients with teams of providers focused on providing patient-centered care. We are expanding these activities to 100 more sites over the next three years.

Our fourth priority is to make all our work more transparent, accountable, fair and inclusive. Telling the story of what we are doing as an agency to change and improve will help reassure our patient population that health reform is also happening at IHS. Accountability for our programs and our staff is a fundamental part of our reform efforts.

The Affordable Care Act included the reauthorization of the Indian Health Care Improvement Act, which contains many new authorities for programs and services for IHS. Many of the new provisions in this reauthorization will help modernize and update IHS and contribute to our efforts to change and improve the service.

The IHS faces many challenges in providing health care to its growing patient population. However, I see much hope in the passage of the Affordable Care Act and with a new administration that supports our efforts to reform IHS. The president has demonstrated his support for meeting treaty obligations and has met with tribal leaders to discuss issues such as improving health care for AI/AN. I believe we have a unique opportunity during these historic times to make progress in reforming the IHS. As these columns have elevated the discussion about IHS to a new level, we all have the obligation to continue the discussion and actions to improve health care for our First Americans.

Dr. Yvette Roubideaux, M.D., M.P.H. is the director of the Indian Health Service.