Indian Health Service swept up in efforts to boost transparency, oppose Medicare for All

Problems at the Indian Health Service are snowballing as concerns about quality grow and a mishandled investigation into sexual assault allegations are pulling the agency into the battle over Medicare for All.

Scrutiny of the agency heated up in February when an investigation by the PBS documentary series “Frontline” and the Wall Street Journal reported that the IHS routinely hired physicians with troubled backgrounds. The investigation centered on the pediatrician Stanley Patrick Weber, who was allowed to treat children at multiple IHS facilities despite suspicions of misconduct and abuse.

As a result, lawmakers are renewing efforts to find a way to improve long-standing quality issues at the IHS. Some of the ideas include giving tribes more of an incentive to contract with private facilities and others include injecting more funding into the program.

But in the near term, members of the House Energy and Commerce Committee announced that they want the IHS to answer for quality deficiencies. “Despite repeated investigations by Congress and other federal watchdog agencies, these recent press reports indicate that patient care does not seem to be improving at these IHS-operated hospitals,” committee leaders wrote in a letter to IHS administrators. “We must find a way forward to protect IHS patients so that all American Indians and Alaska Natives receive the best care possible.”

An IHS statement said that the agency is making strides to boost quality at its facilities, including rolling out an Office of Quality in December 2018.

“Our dedicated staff at IHS continues to improve healthcare service delivery and critical public health services throughout the health system,” according to the statement. “For example, IHS has seen the rates of kidney failure from diabetes decline the fastest since it began using population health and team-based approaches to diabetes and kidney care.”

The agency is taking steps to address the mishandling of the abuse allegations, the statement said.

“New agency policies are being put into place to provide even more stringent professional standards,” the agency said in a statement. “A centralized credentialing system will help share information across IHS on clinician qualifications and practice history.”

But health advocates and lawmakers say that the recent investigation is just one example of the many problems facing the agency. “I know that nobody should be subjected to the kind of healthcare that IHS provides. It is a failed system,” said Sen. Mike Rounds (R-S.D.).

Native Americans born today have a life expectancy of around five years less than any other race in the U.S. and die at higher rates compared with other Americans due to preventable causes.

Rounds reintroduced a bill last month that would mandate that HHS conduct an assessment of IHS facilities where the agency provides direct healthcare to tribal members. “An assessment will allow us to take a close look at the failures of the IHS so that we can work in close consultation with the tribes to immediately solve these problems and begin providing the reliable, adequate care our tribal members deserve,” Rounds said in a news release in February when he reintroduced the bill.

The Senate Indian Affairs Committee advanced the legislation in the last Congress on a bipartisan basis but it wasn’t brought up for a vote in the full Senate.

Now Rounds is hoping to try again to get a full Senate vote and then send it to the House.

 Rounds said in an interview that the goal of the bill is to provide tribes with information on the quality and adequacy of IHS direct-care services. He hopes tribes can then use the information to decide for themselves whether to adopt what is called a 638 contract, in which the tribe contracts with an existing private healthcare organization to provide healthcare instead of going through a direct care facility.

The IHS is responsible for providing healthcare to 567 federally recognized American Indian and Alaskan Native tribes. The VA Mission Act of 2018 expanded that agency’s private healthcare network. The IHS and the Veterans Affairs Department are the only government agencies that directly provide care to Americans not in the military.

Some larger tribes like the Cherokee Nation run their own hospitals and health centers, while smaller tribes often contract with a nearby facility.

More than 60% of the agency’s congressional appropriation is administered by tribes, primarily through a self-determination contract. The tribe can use the money from the contract to either create its own healthcare facilities or contract with another entity.

Rounds’ bill is the latest criticism from Republicans of government-run healthcare services, a critique that has flared up as more than 100 Democrats recently proposed a bill to expand Medicare to every American. Medicare for All has also gained traction as a popular talking point among Democratic 2020 presidential hopefuls.

IHS’ quality of care is “the epitome of the reason why we should not be expecting government-run healthcare to be the norm in the U.S.,” Rounds said.

But he said that any decision to shift to a 638 contract must be made by the tribes, and the information from the assessment created under his bill will help in that decision.

“This really isn’t a philosophical thing to me. It is a practical thing,” he said. “We know this is the face of government-run healthcare, and it doesn’t work.”

Meanwhile, other lawmakers say that more funding is needed for the IHS.

The IHS gets far less funding than the VA or Medicare and Medicaid and spends less per beneficiary. The agency gets roughly $5 billion from the federal government, compared with larger programs such as the VA or Medicare, which got $583 billion in fiscal 2018.

According to a December 2018 report from the federal watchdog Government Accountability Office, in 2017 the IHS spent $4,078 per beneficiary compared with $8,109 for Medicaid, $10,692 for the VA and $13,185 for Medicare. “In each of the four programs, the per capita spending was relatively stable from 2013 through 2017,” according to the GAO.

There is a caveat that some of the programs overlap, such as if a veteran gets care from both an IHS facility and from the VA and is enrolled in Medicare.

Rep. Tom Cole (R-Okla.) said that part of the quality problem lies in where funding for the agency comes from. Even though the IHS is part of HHS, its funding comes from the congressional appropriations committees responsible for the Interior Department.

HHS has more funding flexibility than the Interior Department because it is a larger department with a larger budget.

“Democrats and Republicans are trying in a bipartisan way to do the best they can,” Cole said in an interview. “They just don’t have enough money.”

Regarding tribes adopting a 638 contract approach, Cole said that contracting with another facility or creating their own facility may be difficult for smaller tribes because they lack the funding. “We just have a lot of tribes that can’t do that,” he said. “It’s not mismanagement, they are just badly situated in a poor location.”

Rounds said he favors more funding for the IHS, but said that Congress must be able to better assess where the money is going. “To put more money into IHS without knowing that you are going to get an improvement in the quality would be really foolish,” he said. 

Democrats, meanwhile, have called for greater accountability from the IHS on the issues of doctors. “I think part of it is funding and part of it is recruitment of docs and nurses, and another part of it is accountability,” said Sen. Jon Tester (D-Mont.).

Democrats have also been battling the CMS over obtaining an exemption for tribal members from Medicaid work requirements.

A GAO report from August 2018 found that the IHS is having trouble finding enough healthcare workers. The watchdog said that agency data show the vacancy rate for physicians, nurses and other providers is 25% altogether. “One way the agency tries to fill vacancies is by hiring temporary providers, although officials said this is more costly and may result in less continuity of care,” according to the GAO report.

The CMS has taken action in recent years to penalize federally run IHS hospitals for quality and operational issues. In November 2017, the agency notified Pine Ridge Hospital in South Dakota that it can no longer participate in Medicare after finding that patients faced severe delays in getting care. The termination meant that Pine Ridge could no longer bill Medicare for services performed on Medicare patients.

 But lawmakers agree more work needs to be done to improve the agency.

“There is no excuse for the lack of healthcare being provided for these Native American communities,” Rounds said.