Difficulties in Native health care

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Political, social and competing national interests, compounded further by
rising health care costs, inflation and the increasing population make it
difficult to manage health care for the American Indian population.
Operating in a "health crisis" mode makes for challenging choices for
health care providers. The consequences are dire for patients under the
Indian Health Service system. This is just one concern of the newly formed
Direct Service Tribes (DST) coalition.

Originally an alliance of tribes owning at least 1 million acres of land
that met to form a stronger voice for health care delivery, DST is
comprised of tribes from nine of the 12 IHS areas. Northern Plains tribes
met with the Navajo Nation and other southern tribes to discuss forming a
coalition of tribes with similar issues. This new voice looked to the past
to build an organization that would take an all-encompassing look at
failures and successes to formulate an effective organization to meet
tribal health care needs. The past provides the key to the future.

HISTORY OF SELF-DETERMINATION

There have been many attempts in the past to solve the "Indian problem."
One credible and constructive venture was the 1928 Meriam Report, still a
useful tool in guiding policy. It found that Indians were excluded from
management of their own affairs and received a poor quality of services,
especially in health and education, from public officials who were supposed
to serve their needs.

Another report, "A National Tragedy - a National Challenge," was released
in 1969 and uncovered similar findings consistent with a widespread
practice in which a tiny number of American Indians held management or
administrative positions.

Congress' response to these findings resulted in the passage of the 1972
Indian Education and Self-Determination Act which allowed tribes to
operate, manage and administer BIA-operated programs. The Rosebud Sioux
Tribe from the Aberdeen area was one of 30 tribes that participated in the
original demonstration project under the Indian Health Care Improvement Act
(IHCIA) to compact/contract IHS programs, after the proven success of
self-determination within the BIA.

CONTRACT V. DIRECT SERVICE

Fewer than half of the 560 tribes in the U.S. chose to compact/contract
under the IHCIA, while more than half remain direct service. Consequently,
two health systems exist within the IHS: tribes that have
compacted/contracted health programs from the IHS to be tribally managed
and administered, and tribes that maintain a relationship with the federal
government and allow HIS to deliver health care.

In so doing, many tribes feel the pinch to contract and compact. Direct
service tribes' reluctance to do so is at the very foundation of operation
and management of hospitals, clinics and health programs. With the current
funding for hospitals at 60 percent in the Aberdeen area, tribes wonder
whether their ability to manage at 60 percent funding is worth the effort.

In choosing this option, direct service tribes observed a troubling trend:
dwindling resources, staffing cutbacks, clinic closures and decreasing
budgets for community health representatives, regionalization and
consolidation of programs as well as rising health care costs associated
with the diabetes epidemic and increases in suicide rates, methamphetamine
use, Sudden Infant Death Syndrome and more.

Funding is the major concern. For the past decade, the IHS budget's modest
funding increases have quickly been dispersed to meet shortfalls or just
basic health care needs.

The first DST conference was held last June in Phoenix with the theme "As
long as the grass grows and the rivers flow." The theme represented all
tribes, their ties to and belief in the treaties and the fact that the
federal government must adhere to those treaties as a contract.

This year's DST conference is scheduled for April 25 - 27 at the Hyatt
Regency in Albuquerque, N.M. Unique about this conference is its
incorporation of work sessions/caucuses with specific outcomes for each
area. This year's conference will develop a report card to measure how well
states and tribes work together in many areas of health care delivery and
assess how well the centers for Medicare and Medicaid perform in direct
service tribes' areas. These crucial issues allow direct service tribes to
develop plans for future sustainability and increased participation in DHHS
programs.

Carole Anne Heart is the executive director of the Aberdeen Area Tribal
Chairmen's Health Board. She can be reached at (605) 721-1922 or
execdir@aatchb.org. Visit www.aatchb.org for more information.