Depending on where you live, you might be seeing TV commercials every few hours warning about the dangers of health care reform. The U.S. Chamber of Commerce is spending millions to stop this legislation. Most people live in districts where the members have already decided. If they’re Republicans, their vote is an automatic no. And, most Democrats are solid on the “aye” side, so the debate boils down to a few dozen Democrats who could vote either way.

 South Dakota Rep. Stephanie Herseth Sandlin is a Democrat who’s on the fence. She said last month: “Since the outset of the health care reform debate last year, I’ve said that any health care proposal must meet the dual goals of increasing access to quality care while decreasing cost. I voted against the House version of the health care bill because it failed to meet these goals for South Dakota.”

 She’s also said the Senate bill doesn’t meet this test. But is that a no? We don’t know. Yet. We’re waiting for her final answer this week.

 There are political considerations. Herseth Sandlin represents a conservative-leaning state (John McCain carried South Dakota by 8 points over President Obama). A poll last month by Rasmussen Reports shows her ahead of the G.O.P. challenger by 7 points, with 11 percent of those surveyed saying they were undecided. And these are not good numbers for her because she’s an incumbent who’s polling less than a 50 percent majority.

 But these polls miss Indian Country. While South Dakotans vote about 3-to-2 Republican, counties where American Indians are in the majority vote almost 80 percent in favor of Democratic candidates. Herseth Sandlin did even better than that, winning Pine Ridge with nearly 97 percent of the vote. Even with a smaller turnout than the rest of the state this is critical because it helps a candidate make up ground quickly from the counties lost by a narrow margin. Make no mistake: a Democrat cannot win in South Dakota without the American Indian vote.

 But this is where this story gets confusing. Herseth Sandlin is trying to be a conservative Democrat to most South Dakotans – her web page describes the fiscal requirements for a yes vote. Then, on another web page, she says separately how important the Indian Health Care Improvement Act is and why she supports its passage.

 She wants both constituent groups to be happy. Sorry, it doesn’t work that way. The key here is that the health care reform legislation will boost resources for the Indian health system. In fact: the health care bill that comes before Congress is the only path for passage of the Indian Health Care Improvement Act in this Congress. A vote no on one is a nay on both.

 Opponents of health care reform could have made this a non-issue by enacting the Indian Health Care Improvement Act when they had the chance – say, when it was a single bill, or in the last Congress or in Congresses before that. They didn’t and so health care reform is the only viable route to improve the Indian health system. (Wouldn’t it be great if TV ads were on the airwaves saying this as often as the Chamber of Commerce ads attacking health care reform?)

 This should not be a free vote for any member of Congress. Indian Country voters ought to make this a scorecard issue – yes a litmus test – because it’s a life or death situation for so many people who are officially categorized as uninsured because they rely on the Indian health system.

 There are lots of reasons for Democrats to vote no on this bill: It’s messy; it leaves lots of loose ends; and there will be a lot of hard work left uncompleted even after its passage.

 But there are two huge reasons for going forward. First, it sends a signal that our system will (and must) change forever. This is step one. And, second, in the words of President Ford (when he signed the original Indian Health Care Improvement Act) “because of my own conviction that our first Americans should not be last in opportunity.”

 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

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