Universal health care in the US is about 60 years overdue.

However, to see what will actually happen when government bureaucrats take over health care, you need to look at the Federal systems that are actually in existence, and who already use guidelines on what care you are allowed to get, and how “budgetary” restraints end up limiting your care.

The Federal government runs three systems: The VA, the Military system, and the Indian Health Service. My expertise is number three.

How the Indian Health service is run is important, for it is an example on how to supply medical care to the uninsured, in areas where it is difficult to recruit physicians and other medical personnel, and who have to follow limited budgets and guidelines.

So one is glad that the New York Times has decided to look at the Indian Health Service’s problems. The article is mainly about the Navajo area, which is actually one of the better areas to work. Yes, it is short of money, and distances are far, but they tend to fill most of their positions, and morale among staff is better than in some other areas that I will not name. So imagine if they visited one of the less favored areas.

The newspapers do an “ain’t it awful” article every year or two about the problems of medical care in Indian country, then move on. Actually, things have improved since my first stint with the IHS in 1977, when I had to deliver a baby in a delivery room heated by space heaters because the heating system broke down and it was 90 miles to the next hospital. No more, thank the Lord and the bureaucrats (all such cases now are referred to hospitals with Obstetricians, so that complications like emergency Cesarean sections can be handled if the problems arise.)

But problems remain, and the main one is lack of money.

The chronic lack of money often meant inadequate older facilities, with limited lab and X ray availability.Because there are “budgetary restraints”, you are supposed to handle the patients in the clinic or hospital. The next level is the local Indian Hospital, if available, which can do most routine specialty care. The level after that is referral to local specialists in the private sector, if the medical problem is severe and no other option is available.

But some areas, there simply are no Indian Hospitals with the specialist you need, so at one hospital we had regular runs to the “cities” for appointments with specialists: Three hundred miles each way: the distances involved are mindboggling for those who live in cities with a hospital on every corner. A lot of the “problems” discussed in the New York Times article are not about lack of money as much as the problems of getting patients from A to B in a sparsely populated area.

Let me walk you through a referral. Mrs. A has problem X, a non emergency problem. I can’t handle her problem in our clinic, and think she needs to see a specialist.

Problem one: who pays for the care?

If there is an IHS hospital with the specialist you need nearby, and it is not an emergency, we’ll send you there. Waiting lists are long, but you will get care.

If you only have IHS payment,and you need to see an “outside” specialist, and it is a “non emergency”, this means first the referral has to go through a rationing board (named the “contract care committee”)  to see if the problem has to be taken care of right away, if it can wait a little, or you can live with the problem. There simply is not enough money for quality of life care such as back pain, knee arthritis, etc.

Problem three: Getting the patient to see the physician.

A lot of local specialists might be hundreds of miles away, and since they are paid poorly (and often patients skip appointments) it is not always easy to get someone to see your patient. Some physicians also dislike Indian patients. This is not “racial” prejudice, but cultural: some Indian patients don’t keep appointments, so some specialists get annoyed.

So the secretary has to find someone to get you an appointment, usually from a list of specialists who will see our patients for X amount of money, usually an amount that is less than what they can get from a private insurance company.

Even then, if the appointment is far away, the patients might not have gas money to get there. Some IHS clinics will have twice weekly “clinic” runs, to the big city for those who need to be seen by a specialist.

One way around the limited budget is to get your patient on Medicare/Medicaid. That allows them to use outside referrals, without using clinic money. We also have more of a choice of specialists.

It also allowed us to bill Medicare/Medicaid for our care in the clinic, increasing the budget so we could buy equipment that we needed. Everyone is hoping that the new “Health care bill” will allow us to bill the insurance companies, without taking away our own clinic budgets. The end result might be adequate care.

In some tribal areas, the tribe has outside revenues to pay for a private insurance company for all their members, to cover inpatient care.  This allowed us to transfer to the local community hospital 20 miles away, rather than transfer  40 miles to the IHS hospital in our region. In other tribal areas, the tribes are using profits to take over their clinics. Often IHS personnel continue to work there, but the tribes now can decide on where to spend their health care money.

The bad news of this is that I also worked in an area where our Hospital’s budget was kept low and the lack of equipment etc. was blamed not on inadequate Federal funding, but on the tribe’s decision to use their profits to expand business opportunities for their people instead of paying for what they figured was owed to them by the white man, i.e. medical care.

So if a health care bill is passed, it should ease the rationing done at Indian clinics.

Yet that alone won’t solve the problem.You see money is not the only problem.

The bureaucracy is a major problem.

You still have the problems of equipment, and the bureaucracy that means it takes years from proposal to completion of a project. I worked at one clinic for four years, and was told when I started that they were extending the clinic space and hiring a Physician assistant. The year I left, they had completed part of the extension (a new lab). Three years later, they have the PA to help in the busy clinic.

Similarly, to hire a new physician or nurse or PA takes months. It’s easier if they already work in the system, but if you are hiring a new graduate or an outside physician, figure six months. And the really bad news: They can’t start the search for a replacement until the person actually leaves. So the result is saving a lot of money in the budget (you don’t have to pay the salary) but a lot of burnt out overworked staff, or worse. I worked in one clinic where the X ray tech left in November and wasn’t replaced until April, so we had to send all our fractures and possible pneumonia cases 30 miles over mountain roads to get routine X rays.

So who do you hire to do a job that requires cross cultural sensitivity, low salary,long hours, and daily frustrations with paper work?

In the “good old days”, physicians could chose IHS as their military service. Nowadays, it usually means people who don’t mind working in isolated areas. There are lots of “second career” physicians (age 40 to 50) who decided to leave private practice and  work where their skills were needed. There are local people, who like to work near their homes. There are ex military personnel, who are familiar with the system, and don’t mind the challenge. And then there are an increasing number of Native Americans to run the clinics.

The good news is that many Native Americans are educated and work as nurses, lab techs, physicians, dentists, and administrators. The even better news is that some tribes have just said the heck with it and are using casino profits to take over medical care, and do their own hiring and take over of many of the positions in the clinics and hospitals.

So what does the IHS do right?

They do a lot of preventive medicine. They allow outreaches into the community, with nurses and nurses aides to help do care in the homes.

Without the IHS, things would be worse. Even when tribes take over the facilities, they cooperate with IHS personnel, who are culturally sensitive and able to work in such isolated areas.

Yes, I know that the President met with tribal leaders and increased the budget. So did President Bush and President Clinton. And each time, it got a lot of headlines, but only a limited improvement in care.

So one hopes that the Health Care bill will improve care in the long run, but I am cynical after all these years of promises.

_____________________

Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes about medical problems at HeyDoc Xanga Blog.

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