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An interview with IHS Director Dr. Yvette Roubideaux

Dr. Yvette D. Roubideaux, of the Rosebud Sioux Tribe, was confirmed as the director of the IHS by a unanimous vote of the U.S. Senate in early May. She is the first woman to serve in this position in the department’s 54-year history. The IHS is an agency within the U.S. Department of Health and Human Services, and is the principal federal health care advocate and provider for about 1.9 million American Indians and Alaska Natives. As IHS director, Roubideaux will administer a $4.3 billion national health care delivery program composed of 12 administrative regional offices. Indian Country Today spoke with her soon after her confirmation.

Indian country Today: Congratulations on your nomination and confirmation as director of IHS. It sounds like a wonderful step in your career. What are your top priorities?

Yvette Roubideaux: As Indian Health Service director I have four top priorities. The first is to renew and strengthen the IHS partnership with tribes. I really feel the only way we can improve health care in our communities is to work in partnership with the tribes, so I’m hoping to talk with the tribes about our consultation process and ways we can work together over the next several years.

I really feel the only way we can improve health care in our communities is to work in partnership with the tribes.

ICT: And you’ve had experience on the other side of that equation too, haven’t you?

YR: Yes, I have. In a number of projects I’ve worked on I’ve had the privilege of sitting in and participating in tribal consultation sessions, and I’ve also worked with a number of tribes on various projects. So I’ve seen the tribal perspective and I’ve seen how tribal consultations worked in a variety of settings and formats, and I’m really, really interested to see if the tribes have recommendations for how we can change and improve our tribal consultation process.

ICT: What is your second priority?

YR: The second priority is to bring reform to the IHS especially in the context of how the president is bringing health reform to our national health system. This priority involves working with our tribes and health care providers and patients, and looking at our system and seeing if there are areas where we can improve, and doing more of what we’re doing well. And if we’re not doing well in certain areas what can we do to make improvements there as well.

ICT: Overall, do you favor a nationalized health care system

YR: In my position as IHS director it wouldn’t be appropriate for me to comment on the current debate on the national health care reform.

ICT: Okay, let’s go on to the third priority then.

YR: My third priority is improving the quality of and access to health care in the IHS. This has been a goal of mine since I decided to become a physician long ago. And so I’m looking forward to seeing what we’re doing to improve quality and access in the system and seeing if there are areas where we can improve because I know our patients want to have the best quality of health care.

I do believe we do provide really outstanding care in some of our facilities and I’m hoping we can look at some of the best practices and see if other programs can learn from some of our very successful programs. I always felt when I was a provider in the system that our hospital and clinic provided better care than what could be provided in the surrounding area, and I think that we need to look at ways we can not only provide that care but help our patients understand how we’re providing that care in a quality way.

ICT: There are huge disparities between American Indian communities in terms of health care and the dominant society, but do you also find health disparities among the American Indian communities?

YR: Well, we see evidence of health disparities in some of the IHS data that looks at mortality rates by area, looks at the prevalence of certain conditions and diseases. For example, diabetes is a huge problem especially in the Southwest. The rates of diabetes in some areas of the country are less. It’s a significant problem wherever it is, but we do know that, for example, where I worked in Arizona diabetes is a huge problem. So, there are disparities around the country for a variety of different things, and as we think about reform and improvement in IHS we have to take into account those disparities. What works in some areas may not be a priority in others.

ICT: I’ll come back to diabetes, but for now, what is your fourth priority?

YR: My fourth priority is to make sure everything we’re doing is transparent, accountable, fair and inclusive, so that we’re considering the needs of all of our patients, whether they’re in IHS tribal or urban Indian health programs, and this is just sort of a priority about how we’re doing our business and how we’re making decisions.

ICT: That seems to be a priority of the Obama administration.

YR: Yes, absolutely, so we want to do the same thing.

ICT: Funding shortfalls are sort of a perennial issue with IHS. How will you deal with that?

YR: It’s clear based on a number of independent estimates that the IHS is under-resourced, that it hasn’t had enough funding to meet the demands of the population it serves. That’s a result of a number of things including rapid growth of the population, skyrocketing medical costs, and the budget IHS has had over the past several years has not met the huge level of needs. But I’m really grateful and excited that the president has proposed a 13 percent increase in the IHS budget for fiscal year 2010.

You know, one of the exciting things about being in this position now is that there really seems to be more hope for IHS. President Obama during his Senate career supported increases in the IHS budget and the IHS Improvement Act and one of his campaign promises was that our First Americans receive quality and accessible health care, so I have a lot of hope that with this new administration and an increase in IHS funding, it will become more and more possible for us to meet our mission. And while we all understand that money isn’t the entire solution, the budget proposed by the president is definitely an excellent first step.

ICT: What does the 13 percent increase bring the budget up to?

YR: Just over $4 billion and for fiscal year 2009 it was about $3.5 billion, so it’s really a significant proposed increase. I say ‘proposed’ because it still has to go through Congress and sometimes what the president proposes isn’t the same as what comes out of Congress, so we’re certainly hoping the proposed budget request remains as strong as it goes through the budget process.

ICT: If it all goes well, what do you have planned for the increased funding?

YR: The IHS submitted a budget justification with its request and a certain part of the increase is just to keep us at the level of current services to meet mandatory pay costs, population growth, medical and non-medical inflation.

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Then, there are increases for a number of proposals. One of the biggest priorities is to put more funding toward contract health services – how IHS pays for private health services in those facilities that can’t provide them directly, for example, if someone has a heart attack or needs surgery. Another tribal priority was tribal support costs so tribes can take over the management of their health programs. And there’s a variety of other things – health promotion, chronic disease and disease prevention type programs. There’s also a proposed amount for the Indian Health Care Improvement Fund, which helps reduce disparities in funding between programs.

ICT: Does IHS provide any kind of education grants for American Indian students going into health care?

YR: They do. They provide small grants to tribes to help professional recruitment, and they also have the Indians into Medicine program. They try to do a lot to increase the number of American Indians and Alaska Natives in the health professions; they’re our greatest source of recruitment.

ICT: Reading some of your biography, it seems that your motivation, at least in part, to become a physician was because you never saw Indian doctors when you were growing up.

YR: Right. I didn’t even realize it was possible until one day I just decided, hey, well, might as well try. Why wouldn’t it be better to have an American Indian become a physician and practice either in their own community or another community? You sort of wonder what would be the difference for the patients in terms of seeing physicians from their community and also to motivate young students in the community to become health professionals as well.

There are a lot of powerful things that can result when an American Indian physician goes back to or enters an Indian community to provide health care. I really worked a lot on programs to recruit American Indians and Alaska Native students into the health profession because there’s such a significant shortage of them in IHS and there’s been lots of studies that show minority physicians are more likely to go back to and stay in underserved communities.

ICT: How does traditional medicine and healing play into IHS?

YR: Traditional Indian medicine is just another valid source of care for American Indians and Alaska Natives. When I was a health care provider, patients would sometimes tell me they were seeing a traditional healer and sometimes they wouldn’t and I never did anything to discourage them because I know it’s a valid option, and for some patients it’s their primary source of health care.

There are a lot of powerful things that can result when an American Indian physician goes back to or enters an Indian community to provide health care.

In terms of how it fits in with the IHS system, I think there’s a lot of potential there for partnership between health care providers and traditional healers. I think there’s an opportunity for education about what traditional medicine is and how it fits into the lives of our patients. My experience has been that it’s a very positive thing and we should make sure we’re not doing anything to discourage it, and also to make sure we know as much about it as possible because it’s clear that in many instances it’s important for the Western health care professional to know the patient is seeing a traditional healer, and it’s also important for the healer to know the patient is also going to the clinic. It allows them both to provide better care.

ICT: How much will you focus on preventive care?

YR: I think preventive care is extremely important. It’s important in both the discussion of health care reform and the discussion of what a health care system does, because not only does preventive care improve the health of the population, but it also reduces costs in the long run. If we could prevent even half the people who will get diabetes from getting diabetes we would save millions of dollars. So preventive care is an extremely important part of what we do.

ICT: You have such an intensive background and specialization in diabetes. Will that be a special focus and what strategies will you develop both to prevent diabetes and for preventive care in general?

YR: I have had a big focus on diabetes over the last 12 years or so because diabetes is such a huge epidemic for our people, especially here in the Southwest where the rate is so much higher than in other parts of the country.

ICT: Why is that?

YR: We don’t know for sure, but there seems to be both genetic and environmental factors playing into it. We’re talking about Type 2 diabetes. There’s evidence it runs in the family, but it’s also clear that there’s significant environmental and contextual components.

When you think that none of our tribes really had any substantial or even recognizable problem with diabetes 100 years ago, and now in some of our communities, one out of every two adults had diabetes here in the Southwest, you think about what’s the difference between then and now? The whole way people live their lives is different. With modernization comes decreased physical activity, with our Western diet comes larger portions and higher rates of obesity and all of these things are contributing to the problems we’re seeing with chronic diseases – heart disease, cancer, obesity, diabetes.

I’m really honored to have worked on the Special Diabetes Program for Indians – the congressional funding to prevent and treat diabetes that’s been around since 1988. I think we have great examples of both prevention and treatment activities in very diverse communities across the country and I’m hoping, as we look at how to improve care in the system and how to increase access to services and how we’re providing care, that we can take some of the lessons learned from programs we already have, and that will help us know where we need to increase resources in the future.

ICT: Regarding the General Accountability Office report that came out recently about $16 million worth of items missing from IHS, how will you manage problems like that?

YR: I believe as part of the process we’ll go through to look at reform for the IHS and how to improve what we do, I think we’ll find some areas where we’re doing well and some where we’re not doing well, and it’s clear that there are areas where we’re not doing well.

So, we need to come up with a very clear plan to manage and improve those areas and to demonstrate that we are making progress. It’s important to note that the GAO report wasn’t final. We’re not able to comment on it until it’s published in its final form and there’s going to be an IHS response published in the final GAO report.

ICT: It seems you chose your career very early and you’ve been on this steady path forward with no starts or stops right to the directorship of the IHS. Is this the pinnacle? What do you see yourself doing after this job?

YR: Well, ever since I decided to become a physician, I’ve always had the goal of wanting to improve the quality of health care for American Indians and Alaska Natives, and I’ve always made decisions about my career based on that goal. I’ve been very fortunate to have a really supportive family and a close supportive network of friends over the years that have helped me through all the challenging and difficult times.

You know, it’s certainly an honor and a privilege to be in this position at this point of time and have an opportunity to impact the quality of health care for American Indians and Alaska Natives, and I’m really grateful for this opportunity, and I hope to do the best job I can. Who knows what’s next for me? I can’t foresee what’s next, but whatever it is, I know I’ll have the same goal in mind.