Progressives plan to make a big push for single-payer health care in the midterms, hoping to force Democrats even harder Left than in the past four Congressional election cycles. They want a Medicare-for-all system that will eclipse private health insurance, similar to what Bernie Sanders laid out in his 2016 Democratic primary campaign. The Center for American Progress has put pressure on current officeholders to take up the cause of single payer, with considerable success; 2020 presidential hopefuls such as Elizabeth Warren, Cory Booker, and Kamala Harris have all signed onto Sanders’ latest legislative effort to create the program.

Before they start creating new single-payer systems, though, perhaps they should fix the broken single-payer systems already in place. The scandals at the Veterans Administration get plenty of coverage, especially given that the VA locks veterans into its own providers and forces them to pay retail for any outside medical care. But a report on the other major system, the Indian Health Service (IHS), shows much worse performance and for a longer period of time, The Hill reports:

“The number of doctors, nurses, and dentists is insufficient,” said a report prepared for the Interior Department. “Because of small appropriations the salaries for the personnel in health work are materially below those paid by the government in its other activities concerned with public health and medical relief.”

Clearly this must be a new development, one on which advocates have not yet been briefed … right? Wrong. As Andrew Siddons notes, that report first came to Congress ninety years ago — and it’s been true every year since then as well:

That report was from 1928 and was written by the Institute for Government Research, the precursor to the Brookings Institution. But when it was cited by an HHS inspector general report nearly 90 years later, every word still rang true. … The health disparities between American Indians and the rest of the United States population are stark. American Indians are 50 percent more likely than others to have a substance use disorder, 60 percent more likely to commit suicide, twice as likely to smoke, twice as likely to die during childbirth, three times more likely to die from diabetes and five times more likely to die from tuberculosis. They die on average five years sooner than other Americans. The Trump administration has pledged to make tribal health care systems more effective. During one of his confirmation hearings, new Health and Human Services Secretary Alex Azar told senators the administration would welcome opportunities to improve the $5 billion Indian Health Service, which provides care for 2.2 million American Indians. “It’s unacceptable for us to not be providing high-quality service,” Azar said.

Siddons does a good job in laying out the problems in IHS, from funding to infrastructure to staffing. Long story short: IHS is woefully inadequate in every aspect, even though its budget comes to $2,000 per year per covered patient. Almost all of that is allocated for primary care, though, which means IHS has to contract out for most specialty referrals. What happens then?

Because most of the service’s physicians are trained in primary care or family practice, the service must contract out most of its specialty care. But Congress has provided enough money for IHS to cover only about two-thirds of these referrals, forcing IHS to ration care for the most urgent, life-threatening needs. The approximately $914 million spent on these referrals in 2016 fell about $372 million short of what was needed, resulting in a denial of about 80,000 service requests for procedures considered less urgent, like mammograms or joint replacements. Despite the acknowledgement of this shortfall in the administration’s budget proposals, it’s only requested $955 million for 2019.

In other words, nothing has changed in ninety years in this single-payer system, nor in the nine years that have passed since the Associated Press offered a very similar exposé on IHS. That’s because the same basic structure remains — a single-payer system in which government has to ration care based on allocated funds rather than a free-market system in which providers are incentivized to expand to meet market demand.

In the case of IHS, there may be no easy way around this. Treaties dating back to the beginning of this country (1787) require the federal government to provide “free” health care to residents on tribal reservations. With those obligations in law, there is no way around a single-payer system that uses rationing as a basis for operation. It would take a repeal of the treaties and new agreements put in place to use a new system, and one can hardly blame the native Americans on reservations for being somewhat skeptical that abrogating treaties will benefit them in the long run; we have a long history of those broken promises, too. That leaves us with the legal and moral responsibility to provide proper levels of funding and infrastructure restoration to improve health care for the 2.2 million Americans trapped in that system.

However, it should serve as a stark lesson about single-payer, government-controlled health care (and the VA is another example of the same issue). We shouldn’t even allow a discussion of this in Congress until we put IHS back on its proper footing, which will require so much capital investment that it will make plain the risk for health care if that model gets adopted broadly. We already have two failing, corrupt, and bankrupt single-payer systems. We don’t need to make that a universal experience.