Health care is all about the funding

RAPID CITY, S.D. -- While some health care organizations presented
information on research, data collection and surveys at the recent Aberdeen
Area Tribal Chairman's Health Board annual meeting, tribal and IHS
officials focused on money -- or the lack thereof.

Budgets for IHS facilities in the Aberdeen Area and elsewhere in the
country have been flatlined for the past decade, putting the funding at
about 40 percent of the actual need, IHS officials said. The Aberdeen Area
covers North Dakota, South Dakota, Nebraska and Iowa.

No one denied the disparities in Indian country health care.

More money is spent per capita on federal prisoners than on American
Indians, which is a treaty obligation of the U.S. government. Funding is
under $2,000 per American Indian, while federal prisoners receive just
under $3,000. The national average is more than $5,000 per person.

"That's why Indians want to go to prison," one tribal person joked.

The underfunding of American Indian health care is nothing new, yet the
service is critical. Attempts to increase funding are ongoing, with
congressional hearings and by individual tribal representatives working
one-on-one with congressional leaders.

The solution remains: lobby Congress for more funding, said John Blackhawk,
chairman of the Winnebago Tribe of Nebraska and president of the AATCHB.
The method of lobbying may change, with the collection of more data and

The bottom line is that some people do not even try to access health care
because funds for it have run out and the red tape involved with the
collection of fees intimidates many tribal members in need of health care.

Now, veterans on reservations are being told to access medical needs at
veterans facilities, which would require a lengthy drive from most of the

Funding is so critical that tribal members who need services such as hip or
knee replacement surgery may have to wait until the next budget cycle.
Priority payments go to heart patients. Contract Health Service, part of
the IHS, distributes funding to the service units for medical needs.

If the CHS referral committee denies payment for services, the patient is
held responsible for the bill, Jesse Taken Alive, Standing Rock Sioux Tribe
council representative, said. Health officials said it is best if the
patient seeks pre-approval for any procedure to determine if it is covered.

"We need to hold the government to the treaty obligations," said Carole
Anne Heart, executive director of the AATCHB. "We need to think of
strategies to tell people our health is not taken care of, that people are
dying because we don't have any money."

Heart said people have to resort to using the ambulance as a substitute for
a doctor's appointment.

The tribes in the Aberdeen Area have direct-service health care; they do
not contract, as do many tribes. The large land-based treaty tribes that
constitute the Aberdeen Area assert that the federal government needs to
fulfill its fiduciary and treaty obligations.

The now-completed 2006 budget consultation process includes a majority of
policy benefits recommended by tribal officials. More than 300 comments
were incorporated, the most of any final budget document, Gena
Tyner-Dawson, senior adviser for tribal affairs in the Office of
Intergovernmental Affairs, said.

But with the comments in place, there still is no guarantee of increased

In the shadow of underfunding, additional frustrations may be headed Indian
country's way. Congress is in the process of working on a deficit reduction
policy in which Medicaid is on the hit list for funding cuts.

If that is the case, Indian country -- already on the bottom rung of the
funding ladder for health care -- will be hit very hard.

Eric Broderick, DDS, senior adviser for tribal health policy in the Office
of Intergovernmental Affairs, said the reduction in Medicaid funding is a
valid concern and any cuts will affect states and tribes. Medicaid funding
is pass-through from the state to the tribes. With the poverty rate on the
reservations very high, Medicaid becomes an important source of funding for
childrens' and elders' health care needs.

Data collected by the IHS and tribes form a foundation with which to
approach Congress. The tribal leaders were told frequently that Congress
wants the data; if that is the case, the goal is to get congressional
leaders to take a hard look at it.

Jon Perez, director of the Division of Behavioral Health, said funding is
all about politics. Funding for Veterans Administration medical health care
facilities, with half the patients, is four times greater than that for
IHS, he said.

"We are now getting the data that will go to Congress," he said.
"Information is power and data is a weapon. You can't go hat in hand and
expect anything.

"If you can count coup, you can count services."

Data reduces people to numbers, Roger Trudell, chairman of the Santee Sioux
Tribe of Nebraska, said: "People are not data -- we deal with real people.

"Where is the money to help people? There is money to collect data."

One frequent and longtime complaint from the tribal leaders is that the
budget for direct health care has to compete with administrative and other

In the Aberdeen Area, the chief executive officers of three service units
were relocated. Other people transferred in to cover those positions and
others moved around -- a series of expensive maneuvers.

To cover the expenditure, IHS estimates the cost and submits the request to
the Department of Health and Human Services. Most of the cost does not come
out of the IHS budget, officials said.