Trahant: Health care dualism: Control costs and expand access

One of the most difficult elements in the health care reform debate is the philosophical notion of “dualism.” In order to reach consensus we, as a nation, have to balance equally reasonable, yet competing ideas about how to expand coverage and control costs.

Indian country has experienced duality in many forms – often described as a “love-hate” relationship with the federal government and its programs. An example of this would be the way Native Americans are the first to point out what’s wrong with IHS or the BIA, but on the other hand, if you really want an argument, try taking those programs away.

While there’s debate in Congress about the role of government in the health care arena, funding for the corps has already been expanded in a big way.

The same could be said for the men and women who wear the uniform of the Commissioned Officers Corps of the Public Health Service. If you think about this country’s history – and the wars fought between American Indian tribes and the United States – it makes no sense at all for a military-like unit to provide health care services on reservations.

Yet this government agency may be the most effective (and the most quiet) provider of direct health care services. Indeed, while there’s debate in the Congress about the role of government in the health care arena, funding for the corps has already been expanded in a big way.

The commissioned officers corps – and the National Health Service Corps (another agency) – are both in expansion modes.

“Currently 4 million people, many of whom have no health insurance, rely on (corps) … clinicians to keep them healthy and treat their medical, dental and mental health ills,” according to the National Health Service Corps. The agency provides 3,800 primary health care workers in underserved communities across the country. And the agency says, “By the end of next year, those numbers are expected to grow to 8,108 clinicians serving almost 9 million people, as American Recovery and Reinvestment Act (ARRA) funding more than doubles the National Health Service Corps field strength.”

IHS is a direct beneficiary beginning with the agency’s transfer from the Interior Department in 1955. “Actually, the Public Health Service and the Commissioned Corps even predated the establishment of the Bureau of Indian Affairs,” said Forrest J. Gerard, a Blackfeet tribal member, who wrote the Indian Health Care Improvement Act while working for Sen. Henry Jackson in the 1970s. “Their original mission was to check sailors on incoming ships to guard against them bringing in infectious diseases.”

The Reagan administration wanted to eliminate the corps in the 1980s. Gerard, then a lobbyist, was hired to lead the opposition.

“The Indians saved the commissioned corps,” Gerard said. “I pointed out that the whole Indian staffing for the IHS would be hit severely (if the plan went through).”

It’s fine for government-run health care when it’s part of the military or for veterans. But when it’s civil service, whoa.

During the Vietnam War – and even later – many who served in the corps did so only because it counted as military service. But now the corps represents more people, especially those from Indian country, who see the service as a career. The salaries for doctors, dentists and dietitians are not nearly as good as they would be the private sector, but they are good wages back home on the reservation. And a career, like military service, requires 20 years before being eligible for retirement. The service has some 7,000 openings for jobs. And, even better, the scholarships will help fund the education of medical professionals in exchange for employment. This is win-win on many levels.

President Obama’s nominee for surgeon general, Regina M. Benjamin, already understands the importance of the Public Health Service. She served in the corps for three years early in her career.

The Public Health Service is government-run health care at its best. Yet if you Google “commissioned corps,” you’ll discover that it’s not even part of the current reform conversation. Medicare and Medicaid dominate the discourse as massive insurance pools (instead of direct service programs).

The current rancor in the health care debate is limiting our reform options. It’s fine for government-run health care when it’s part of the military or for veterans. But when it’s civil service, whoa.

But the National Health Service Corps is military; sort of. And the Obama administration’s expansion is a smart, if small step. But what if the corps were the given the mission of expanding services to the uninsured beyond the nine million? What if the number matched those uninsured for at least primary care? Then the duality in debate would have to end because this government agency would be cost-effective while expanding access to the health care system.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. An audio interview with Forrest J. Gerard is posted at www.marktrahant.com.