Early Monday morning the Senate moved health care insurance reform one step closer to becoming law. But the steps ahead, in political terms, must be perfect.

But I don’t want to bury the lede: The Indian Health Care Improvement Act is now in both the Senate and House version of health care reform. That means it’s off the table when the Senate and House iron out differences in Conference Committee (probably in early January). If health care reform becomes law, so does the Indian Health Care Improvement Act. That should open up a new revenue stream for the Indian Health system with new money for long-term care, more cancer screening and better mental health treatment options.

Other provisions in the health care bill itself should open up further resources, ranging from broader eligibility for Medicaid to higher reimbursement rates in rural areas.

Make no mistake: Indian country benefits significantly from this health care reform legislation.

Now back to the politics. The Senate has the 60 votes for passage. Monday’s test vote means the countdown has started. There will be more Senate votes, probably ending just hours before Christmas. Then the House and Senate versions will need to be reconciled, then two more votes, a majority in the House and a super majority in the Senate of 60 votes. Then the bill goes to the White House for the president’s signature.

Exhausted? Think we’ve had enough of health care reform? Time to move on to the next issue, right? Sorry, but even if all that happens (I’ll explain the “if” shortly) then the debate begins again on two separate tracks.

First, the Executive Branch will have to write regulations that define how the bill will be implemented. Take the word, “quality” for example. What does that mean? What are the standards for quality care? Is it different in the Indian Health system? The answers to many such questions will surface in thousands of pages of regulations issued by government agencies.

The second track would be the structure for an independent cost cutting panel for Medicare. The House and Senate have different ideas about that, so the mission remains up in the air. But there will probably be a panel that will recommend where Medicare trims future costs (so much easier for an independent body to do that than Congress). This is where health reform could produce savings – something that is essential given the nation’s demographics.

At this point it’s a bit like a long cross-country drive with young children: “Are we there yet? Are we?”

Well it depends. A few weeks ago I pointed out that the Indian Health Care Improvement Act failed in the last Congress because of abortion-related politics. Guess what’s hot on the agenda again? Abortion-related politics as it relates to the Indian health system. Those who are against abortion rights say the language in the Senate bill doesn’t go far enough to limit abortions (or more likely, abortion referrals) by the IHS. They want a specific prohibition along the lines of the Vitter amendment, language that doomed the Indian Health Care Improvement Act in the last Congress.

The test of all this will be when the final bill reaches both houses of Congress; will the anti abortion rights advocates (from both parties) have enough votes to stop health care insurance reform?

I’m more optimistic about this bill. When the president signs it into law it, this will be a signal sent to every patient, doctor, hospital, clinic, insurance company, and taxpayer that the entire health care delivery system is being reshaped. The bill itself won’t make our health care better, but it launches a process that could do just that.

We’re not there yet. But we are moving.


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 at www.marktrahant.com.