What happens when American Indian nations, instead of the federal government, manage on-reservation health care? Do services improve? Do more tribal citizens gain access to health care?
These questions are at the heart of a research study recently initiated by the Native Nations Institute for Leadership, Management and Policy at the University of Arizona. Early findings, based primarily on interviews with tribal, regional and national-level Indian leaders, health professionals and providers indicate that tribal management can significantly improve tribal citizens’ access to health services. Nonetheless, major challenges remain.
Shift toward Tribal Management
Since enactment of the Indian Self-Determination and Education Assistance Act of 1975, many American Indian nations, determined to improve health conditions in their communities, have assumed control over portions – in some cases, nearly all – of their health care delivery. Today, less than half of the federal Indian Health Service budget is spent directly by IHS. More than half is spent by Indian nations themselves, and the majority of IHS facilities operate with some degree of tribal control.
Benefits of Tribal Management
For many American Indian nations, tribal management is an act of self-determination; the benefit is sovereignty. According to our interviewees, other benefits include increased community trust, improved retention of physicians, shorter patient waiting times, and critically, increased citizen access to health services.
Today, less than half of the federal Indian Health Service budget is spent directly by IHS.
“Like the IHS, we have limited amounts of funds, limited amounts of resources. But we’ve cut out a lot of the bureaucracy that’s in the Indian Health Service. We’ve kind of streamlined what we do and cut out a lot of the intermediary steps, and I think that’s one of the reasons why we provide better access. We’ve expanded the scope of our practice substantially,” explained Randy Hall, former director of health services for the Citizen Potawatomi Nation.
“The availability, quality and quantity of services have improved,” said Chuck Walt, human services associate director for the Fond du Lac Band of Lake Superior Chippewa. “We manage our own third-party collections and revenues so we have been able to provide more services than when the Indian Health Service was involved with the program.”
Services Reflect Tribal Priorities and Values
Under tribal management, tribal priorities and values more often shape the goals and methods of health programs. The most significant change connects culture to health care, through the inclusion of spiritual leaders, traditional healing practices, and cultural activities within tribal health programs. Such attention to the cultural and spiritual dimensions of health care makes it more likely that Native citizens will take advantage of the services already available to them and support a tribe’s overall health care program and plans.
But, integrating culture and health care is not easy. Most health care professionals are non-Native. Personnel turnover is high. And, the U.S. health care system is not organized to deal easily with cultural diversity. Tribes are responding by increasing the cultural competency of non-Native professionals and expanding the pool of skilled Natives.
Samuel Moose, commissioner of health and human services for the Mille Lacs Band of Ojibwe, underscored this priority: “We need to. … keep sending our kids to college and have them come back to our community to be those leaders that we’ve known in the past and will know in the future.”
Evidence demonstrates that tribal management of health services brings with it challenges as well as benefits. The four most important challenges relate to funding, tribal governance, balance and information.
Funding: Indian health care has been grossly underfunded for years. In 2003, the U.S. Commission on Civil Rights observed, “the U.S. government spends 50 percent less money on health care for Native Americans than for any other group including prisoners and Medicaid recipients.” Interviewees repeatedly pointed to a lack of resources as a major barrier to further service improvements.
With the U.S. economy now in a recession, resources are scarcer. “The [economic] impact you see in [the] U.S. is magnified when it comes to tribes. There’s no tax base. [Tribes] are not afforded the same type of funding mechanisms as states, counties and other federal agencies. Their funding is discretionary at the whims of Congress. Tribal programs are [often] operating at full capacity and stretched thin,” Moose said. Some tribes have addressed the resource problem by supplementing federal funds with their own discretionary revenues, but this approach is not an option for Native nations with substantial unmet needs and few funds.
Tribal governance: Tribal health care does not exist in a silo unaffected by tribal government as a whole. Rather, tribal health care capacity connects to the broader character and capacity of tribal governance. When tribal government is well organized, when it reflects the community’s core values, and when programs are sufficiently free from political interference, tribal health care management is better able to succeed. It can attract and retain talented staff, secure funding, improve the number and quality of service options, increase access, and win citizen support.
In other words, “self-determination” is not merely a financial arrangement for tribal programs and departments. It entails reshaping governing institutions to support tribal citizens’ goals, sustain culture and tradition, and improve the quality of life. In fact, we learned that some tribes are waiting until their governance systems improve before taking over health care services.
Balance: A third challenge is finding a balance between tribal management and preservation of the treaty and trust relationships. As tribes increase responsibility for delivering health care services through contracts, compacts, and supplemental funding, they do not want to find the federal government stepping away from its trust and treaty obligations to support health care. Already, some have found themselves in a kind of “Catch 22” with IHS and other agencies: The more successful their tribally managed clinics became, the less federal funding they tended to receive.
Information: While American Indian nations wrestle with health care issues, including whether or not to manage the delivery of health care services, few have the time or resources to learn from the experiences of other Indian nations. While acknowledging that what works for one Indian nation may not work for another, most people we talked to stressed the importance of sharing success stories and practices.
“I think it’s important to go out and find those other tribes that have experience and are already delivering care,” Walt said. “It’s not the type of thing where you want to reinvent the wheel if someone else is doing model programming already.”
As NNI continues this study of tribal health care access, we seek to answer three questions: What effect does tribal control have on preventive care? Which tribal health care strategies appear to be working? How can Indian nations most efficiently learn from each other’s experiences and innovations? Findings will be made available on our Web site (nni.arizona.edu) and elsewhere.
Jaime Arsenault is a research analyst and Stephanie Carroll Rainie is a senior researcher at the Native Nations Institute for Leadership, Management, and Policy at the University of Arizona. Initial funding for their research came from the Nathan Cummings Foundation, Morris K. Udall Foundation, and University of Arizona.