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Indian Health Service A float made by the U.S. Public Health Service field health station won first place at a tribal fair in 1967.

There’s an old joke: A Native American student comes home from a geography lesson, shows his grandfather a map, and then asks, “What did we call the United States before it was a country?”

 His grandfather answers, “Ours.”

I thought of this joke recently in the context of the U.S. Indian Health Service. Perhaps the agency’s history, its shortcomings and its chronic underfunding have all been acceptable to Indian Country because the system itself is “ours.” It’s been “ours” for most of our generation – a little more than five decades – where American Indian and Alaska Natives could receive health care in a system that was, and is, unique.

A quick look at the history: Since 1955 the Indian Health Service was transferred from a rickety network of hospitals and clinics run by the Bureau of Indian Affairs (BIA) to a real health care system. In that same time frame the agency went from being a slice of the BIA to being larger than the BIA, with a budget of $4.4 billion and some 15,000 employees. During that time there were substantial improvements in Indian health, including reducing overall mortality by 28 percent in the past thirty years, while still falling short in health parity for Native Americans with non-natives.

That brings me back to “ours” — and how its definition might change over the coming years.

Since 1955 we have had government-run health care, mostly in the form of direct services operated by the Indian Health Service (IHS). But that system has been changing slowly since the enactment of the Indian Self-Determination and Education Assistance Act of 1975. 

That law gives tribes as well as tribal and urban Indian organizations the right to contract for the management of these federal health care programs. Already more than half of IHS’s services are run under contract – and that percentage should grow even more quickly because of changes contained in the new health care reform bill, the Patient Protection and Affordable Care Act.

In a way, I suspect the future of IHS will be almost like its past, after its break from the BIA. The BIA was the largest agency that served American Indians and Alaska Natives. Then, the IHS grew larger.

This will probably remain true for the next few years. But look at the budgets for some of the clinics or hospitals now run under contract: it’s clear there are new, “big” players coming into the picture. And IHS could well take a smaller and smaller role. Indian Health Service The Public Health Service Indian Hospital in Tucson, Arizona, in 1944.

IHS will remain a funder of last resort for patients from Indian Country, but more native patients are eligible for funding from the Centers for Medicaid and Medicare as well as the Health Resources and Service Administration’s rural health clinics and health centers.

This is what a possible budget at a tribal facility – either managed directly by a tribe or by a nonprofit foundation – might look like in coming years: 40 percent of its revenue from Medicaid or Medicare reimbursements; 30 percent from federal programs for the uninsured (the Health Resources and Services Administration); another 25 percent from IHS; and five percent from everything else, including private insurance. 

These percentages could be managed up or down depending on nature of the clients, but my point is that the Indian Health Service will be a significantly smaller player. Its primary missions might shift to oversight, distribution of funds and data collection.

Does this mean that these new government-wide health bureaucracies are overrunning the treaty and trust rights of American Indian and Alaska Natives for health care? Perhaps. You could certainly make that case. 

But you could also make the case that the federal government is, finally, coming up with a formula that will provide adequate funding for every patient. Even better, there is a stronger case that this health care system will work better and more efficiently when it’s designed and controlled at the local level through self-determination.

If we do this right, the Indian health care system will truly be “ours.”

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.