Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment at www.marktrahant.com

As we talk about health care: Substitute “either, or” for “if … then”

What’s the most important element missing from our national conversation about health care reform? I’ll boil it down to one word, governance.

Consider the story so far. We’ve known for decades that our health system is unsustainable; there is no question that it cannot continue on its present course. So Congress finally rounds up enough votes to pass the Patient Protection and Affordable Care Act and what happens? The debate starts over as if there’s a magic wand out there somewhere that will let us have everything we want in health care without any cost.

There is no magic wand. What’s more, this whole discussion is a test of our ability to govern ourselves. How can we govern when we’re so divided over complex and philosophical questions? How can we govern ourselves when we don’t even agree on the basic facts?

Read the rest of this entry »

Tags: buffalo post, Center for Economic and Policy Researc, CEPR, Concord Coalition, Gwen Florio, Health care reform, Mark Trahant, Medicaid, Medicare, Patient Protection and Affordable Care Act, President Barack Obama, Rep. Eric Cantor

Each Monday, Buffalo Post – along with numerous other websites and newspapers – features former Seattle Post-Intelligencer Editorial Page editor Mark Trahant’s columns on Indian Country and health care.

As if that isn’t enough to keep Trahant busy, he’s also been writing a book: “The Last Great Battle of the Indian Wars: Henry M. Jackson, Forrest J. Gerard and the campaign for the self-determination of America’s Indian tribes.”

Amazon describes it thusly, here:

It’s a preposterous title: “The Last Great Battle of the Indian Wars.” How can that be? Well, there were two great battles in our era: The defeat of termination and the campaign for self-determination. First, a terrible, disastrous policy had to be rejected – and then it had to be replaced by a new progressive policy course for American Indians and Alaska Natives. This is the context for this story about Henry “Scoop” Jackson and Forrest Gerard. Team Jackson and Gerard so changed the landscape of Indian Affairs that virtually every member of the body politic today agrees with the premise that American Indians and Alaska Natives have the right to govern themselves.

Self-determination is a topic that’s been much in the news the past week, what with the Iroquois Nationals’ ultimately unsuccessful fight to travel overseas to the World Lacrosse Tournaments on their Haudenosaunee Confederacy passports.

The incident captured the attention of a lot of people, some of whom will no doubt want to learn more on the subject. Trahant’s book is wonderfully timed.

The book has its own Facebook page, where you’ll find this review by Pete Jackson that includes the following:

[Trahant] leavens analysis of his hero and friend, Forrest Gerard, with enough anecdotes of political horse trading to avoid hagiography. This is a story about failure, hubris, political creativity, and trying, whether sincerely or not, to make things right.

The final, broader takeaway to Trahant’s book: Politics (but no one tell academe this) is not a science. It’s what makes Trahant’s story as rich as human nature is inscrutable.

Gwen Florio

Tags: buffalo post, Forrest Gerard, Gwen Florio, Haudenosaunee Confederacy, Henry Jackson, Iroquois Nationals, Lacrosse, Mark Trahant, Native American news, Scoop Jackson, self-determination, The Last Great Battle of the Indian Wars, tribal sovereignty, World Lacrosse Tournament

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment at www.marktrahant.com

If the United States government were a corporation, then the health insurance reform debate would have completely moved into its implementation phase. Essentially, the management and the board would have figured out the course of action, and then figured a way to execute that plan.

If that sounds easy, it’s not.

In the corporate world there’s a lot of thought given about how to take an idea and then make it so. Everett Rogers and his 1962 classic book, The Diffusion of Innovations, shows how “innovation is communicated through certain channels over time among members of a social system.” When you have a good idea (or a bad one) the execution runs up against deeply ingrained obstacles. So really smart people spend a lot of time on the implementation of ideas.

In my newspaper career I worked at large newspapers and small ones. In small ones we could execute lots of approaches, even trying ideas that flopped badly. (The great thing about a small newspaper is if an idea doesn’t work, try, try again.) But at large newspapers, well, change of any kind was difficult, slow and you had to sell the idea over and over.

Rogers demonstrated this problem in graphic form. He divided people in an organization into five groups: Innovators, early adopters, early majority, late majority and laggards.

So you convince innovators and early adopters until you build enough of a success story in order to convince the next group. Of course, some people will never be convinced and that has to be a part of the planning, too.

I’d like to think the Medicare and Medicaid debate followed the Rogers’ curve. On July 30, 1965, when the act was signed into law there was much opposition, a majority of Republicans in the Senate and just under half of the Republicans in the House voted “no.” There was no consensus – indeed the bill was as labeled (as Obama’s is now) as “brazen socialism.”

Read the rest of this entry »

Tags: buffalo post, Everett Rogers, Harvard University, Health Affairs, Health care reform, Mark Trahant, Medicaid, Medicare, Native American news, President Barack Obama, The Diffusion of Innovations, Theda Skocpol

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment here.

The health care reform law should significantly boost the amount of money pumped into the Indian health system. That’s the good news. Now brace for the bad: Really bleak budgets are coming soon.

The reasons are global: Governments all across the world are cutting spending and restricting eligibility for programs that people now take for granted. This trend is a wave gathering force like a tsunami. The first notice of this massive wave was when Greece could no longer support its debts with new borrowing. But that country is not alone because the trend is worldwide.

The new government in the United Kingdom is a stark example. The Liberal-Conservative coalition last week said some agencies could face budget cuts of up to 40 percent. According to The Guardian in London, “the only departments not included in the Treasury trawl will be health and international development, which have been ‘ringfenced’ for the current parliament.” Interesting word and concept: a ringfence is a transaction, or in this case a budget, walled off from the rest of the government’s budget. In other words: The National Health Service is supposed to be protected.

But this, too, is a reflection of the tsunami. The cuts to the National Health Service will be more targeted around the issue of efficiency. But there will be cuts.

Read the rest of this entry »

Tags: buffalo post, COBRA, Health care reform, Kaiser Commission on Medicaid and the Uninsured, Liberal-Conservative coalition, Mark Trahant, Medicaid, Native American news, President Barack Obama, United Kingdom

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment here.

This past weekend the Coeur d’Alene Tribe celebrated the 20th anniversary of the Benewah Medical Center in Plummer, Idaho. “In 1987, the BMC Web site reports, “the Coeur d’Alene Tribe began to search for ways to improve the health care services at their small Indian Health Service satellite clinic. It was located at the Tribal Headquarters, several miles from the City of Plummer, Idaho. Many tribal members were dissatisfied with 15 years of fragmented care delivered in a semi-condemned building and with poor continuity of care.”

Indeed, the complaints about the IHS facility and its operation were similar to those heard across Indian Country. And, like many tribes, the Coeur d’Alene proceeded to create its own health care network. But this was a broader vision, one that went beyond just replacing and recreating IHS; there was also a sense of something new. Prevention was made a priority and a wellness center complimented patient care. There also was recognition of the gap in rural health care services. As Benewah Medical Center describes it: “None of the ambulatory care facilities in the four surrounding counties of the Northern Idaho town were providing services to the medically underserved on a sliding fee basis.”

So a tribal community health center was created – launching two decades of innovation.

Read the rest of this entry »

Tags: American Recovery and Reinvestment Act of 2009, Benewah Medical Center, buffalo post, Coeur d’Alene Tribe, Federally Qualified Health Centers, FQHC, Gwen Florio, Health care reform, Health Resources and Services Administration, Indian Health Service, Mark Trahant, Native American news, Patient Protection and Affordable Care Act, President Barack Obama, President George W. Bush, The New England Journal of Medicine, U.S. Department of Health and Human Services

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes and writes from Fort Hall, Idaho. Comment here.

A philosophical question: How much medical training is needed to treat patients? Some say it’s the full course as proscribed by existing medical, nursing or dental schools. But when the shortages of doctors, nurses and dentists are ginormous, does the need require a different answer?

Consider oral health. “Shortages of dental practitioners and affordable dental care are hurting the health of millions of Americans, many of whom live with pain, miss school or work, and, in extreme cases, face life-threatening medical emergencies that result from dental infections. The situation is particularly severe for poor children and families and in communities of color,” writes Burton L. Edelstein, DDS, MPH Columbia University and Children’s Dental Health Project in a Dec. 200, report for the W.K. Kellogg Foundation.

And, like most health issues, the data shows that Indian Country is at the low end of the spectrum. One study described it this way: “The American Indian / Alaska Native “population has the highest tooth decay rate of any population cohort in the United States: 5 times the US average for children 2–4 years of age. Seventy-nine percent of AIAN children, aged 2–5 years, have tooth decay, with 60% of these children having severe early childhood caries (baby bottle tooth decay). Eighty-seven percent of these children, aged 6–14 years, have a history of decay—twice the rate of dental caries experienced by the general population.”

Read the rest of this entry »

Tags: Agency for Healthcare Research and Quality, Alaska Dental Society, Alaska Native, Alaska Native Tribal Health Consortium, Children’s Dental Health Project, Columbia University, dental care, Indian Health Care Improvement Act, Indian Health Service, Mark Trahant, merican Dental Association, University of Kentucky, University of Washington, W.K. Kellogg Foundation

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment here.

A family member and I visited a clinic over weekend. First, a nurse, then the doctor, then X-ray, back to the nurse and finally back to the doctor. The patient took lots of steps. The providers were earnest, carefully asking good questions then filling in the details on the patient’s chart.

But what if one or more steps are eliminated? Well, two things happen: costs drop and patient care often improves.

How does less produce more? The answer is to shift the focus of the story – the programming – from the “doctor” to the patient.

For example, at the Alaska Native Medical Center in Anchorage, that relationship is described as working, “With the patient as the hub, the team includes the patient’s family, the primary care physician, a nurse case manager, certified medical assistants, case management support, a social worker, and a behavioral health specialist. Additional ‘virtual’ team members include health educators, midwives, nutritionists, and pharmacists. Many specialists (including chiropractors, massage, acupuncture and ‘usual’ medical specialists) are ‘layered’ in.

Read the rest of this entry »

Tags: Affiliated Computer Services Inc., Alaska Native Medical Center, American Medical Association, buffalo post, Fort Defiance, Gwen Florio, Health care reform, Mark Trahant, National Congress of American Indians, Native American news, Navajo Nation, The Indian Health Service

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment here.

“I need to see a doctor.” These six words have been written into our programming as modern humans. We wait in line at the clinic. We make an appointment. We know instinctively that this is the one person to see who can check out our health, fix us up when it can be done or design a treatment course when we are facing complicated health issues.

But that programming no longer works: There are not enough doctors, and, even if this goes against what we’ve been trained to think, seeing a physician is not always the best medical choice.

The shortage of primary care physicians is one of the larger trends that made health care reform necessary. Some 56 million Americans don’t have a regular doctor. And when you open up more health care access, that scarcity increases. When Massachusetts enacted universal coverage it exacerbated the primary care shortage – something that is expected to occur nationally when some 30 million who have been uninsured seek regular care.

Read the rest of this entry »

Tags: buffalo post, Gwen Florio, Health care reform, Indian Health Service, Jack Colwell, Mark Trahant, Native American news, New England Journal of Medicine, Patient Protection and Affordable Care Act, University of Missouri School of Medicine

Mark Trahant is a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment here.

It’s amazing how fast a year goes by. Last May, when I met with the selection committee for the Kaiser Media Fellowship, I outlined my project. Several folks on the committee said I shouldn’t wait until fall to begin. The health care reform debate might be over by then – or so we thought.

Of course it didn’t work out that way. My year as a Kaiser Fellow has been amazing because it’s paralleled so much of the legislative debate. I started writing columns (or blog posts, depending on your point of view) on July 6, 2009.

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. And, now a different kind of debate begins. Federal agencies, primarily at the Department of Health and Human Services and Treasury are writing regulations to implement the new law. There will be fights over words like “quality” or how we define and measure success.

Read the rest of this entry »

Tags: Congress, Consumer Price Index, Gwen Florio, Health care reform, Kaiser Family Foundation, Kaiser Media Fellowship, Mark Trahant, Medicare, Medicare Part D, Mitch McConnell, Patient Protection and Affordable Care Act