Rep. Kristi Noem is South Dakota’s at-large representative in the U.S. House. In early June, she took on the Indian Health Service, introducing two major pieces of legislation, and more could be in the wings. She talked with ICTMN about her work on behalf of tribes in her state. Interview edited for clarity and length.
You introduced theHEALTHH Act on June 8, calling for major changes to the way IHS operates. Senate Committee on Indian Affairs Chairman John Barrasso, R-Wyo., introduced similar legislation, theIHS Accountability Act of 2016, in May. What are some of the differences between your bill and the Senate bill?
One of the things in my legislation that isn’t touched on in the Senate bill is requiring IHS to develop a new formula for allocating PRC (purchased/referred care) dollars. Every year about June IHS runs out of PRC money. Then they tell people they can’t treat them unless it’s a life-threatening situation. We would require IHS to develop a new formula that would take into account those areas or tribes that have the greatest need for the dollars. Getting that new formula would ensure that we get more money to those regions that really do need the help.
And my bill would also change rates at which those dollars go out the door. It would require IHS to negotiate Medicare-like rates for services from private providers. IHS currently pays a premium for those services, so those dollars spend faster. An April 2013 GAO report found that IHS could have saved an estimated $32 million out of $62 million that was spent on physician services, so reduced rates would stretch their dollars, which would get us much further into the year.
When you say a new formula would get money to the tribes that need it most, isn’t the need extreme everywhere?
No. In fact there are many tribes in the nation that provide their own healthcare. They find that they get much better healthcare or healthcare coverage if they insure their own people. Not every tribe in the country utilizes IHS dollars or utilizes them to the extent we do. Unfortunately, because our tribes in South Dakota are in such remote areas where there’s a lack of access to care they rely heavily on IHS facilities. That’s really their only option.
When you spoke at the SCIA hearing oversight/legislative field hearingon “Improving Accountability and Quality of Care at the Indian Health Service though S. 2953” held in Rapid City, S.D. on June 17, you said IHS should get out of the hospital business. What would the alternative be?
The alternative is that we would contract with private providers to run those hospitals. That is essentially what the tribes want to do. They would prefer to have local providers like Rapid City Regional or Sanford Health or Avera Health do a long-term contract with those facilities to run them.
My legislation starts us down that path. Eventually what the tribes would like to do is stand on their own two feet. They would love to be able to [take control of their hospitals] and run them themselves [using federal dollars] when they get the ability to do that. But in the meantime what my legislation does is allow there to be longer-term contracts with local providers.
Courtesy Office of Rep. Kristi Noem
Rep. Kristi Noem was honored to receive a Star Quilt from the Oglala Sioux Tribe. On the left is Donna Salomon, Legislative Liaison to the Tribal President, and Kevin Steele, Public Relations Specialist.
How would longer-term contracts be helpful?
Right now the biggest problem we have with IHS and how they do their contracting is that they contract with a staffing service for a year or two so we have a constant flux of doctors and nurses and there’s no consistency. And then it’s not even people invested in the community. If you’re contracting with a local provider they are people from South Dakota, they’re licensed in South Dakota and they want to be successful here.
Regarding the IHS mandatory random drug testing legislation you introduced on June 9—it seems a bold move. Can you tell me what led to that?
It was because of complaints I heard from tribal members and other people involved with these facilities. There have been repeated instances of medical staff coming to work intoxicated or stealing narcotic medicine. What this [bill] would do is make those who work with patients subject to randomized drug testing. Mary Wakefield [Health and Human Services Acting Deputy Director] has told me they are implementing something like this—where the supervisor suspects drug use they can have [personnel] tested. My bill goes a little further in saying there will be mandatory random drug tests of anyone who is responsible for delivering care to patients.
And this would include doctors?
Overall, what do you think are the factors that underlie IHS’s failures in Indian country?
It has been decades of mismanagement. I think it’s a culture within the administration of IHS that needs to be changed, but whenever you push hard and start trying to hold people accountable, IHS moves them to a different position. They don’t fire folks, they just move them around and it gets even harder to get the answers you need. The culture within IHS is probably the most toxic I’ve seen in any federal agency recently.
Could you elaborate on “toxic”?
The discouragement among people who work for IHS, the discouragement and lack of communication with tribal leaders, not knowing where the money really goes once it flows into the Great Plains region. There is a lot of doubt and questions about what’s happening to those dollars.
You have facilities where people are hand-washing surgical instruments and doctors are intoxicated when they’re working with patients and you have the theft of narcotics. This would never be acceptable in a private hospital in the United States. To allow this Third World country type of delivery of health care is unacceptable.
The fact that CMS [Centers for Medicare and Medicaid Services] came in and waved a red flag is how we became aware of how bad the situation really is. If it was up to IHS they would never have disclosed the real life situation. My staff has talked with a lot of people and they’re scared to be a whistleblower because they feel as though they’ll lose their jobs or be demoted if they really share what the situation is in these facilities.
You’ve been in Congress for just 5 years. Why did you take on this issue, instead of someone from, say, Oklahoma or Arizona or New Mexico?
My tribes have told me for several years that they have been getting poor care. So we’ve been working with them on separate issues. I did not realize until this came up in the last 8 to 10 months how bad it was. This is an issue of life and death. I’ll do anything to fix this situation. I just need my tribes working with me and supporting me as I go to war with IHS over this situation.
When you say “my tribes” you are referring to South Dakota tribes?
Yes, my South Dakota tribes are my number one priority. I’m concerned about the whole system, but there is agreement in Washington, D.C., that the Great Plains region is by far the worst situation. This region is in crisis right now.
Courtesy Office of Rep. Kristi Noem
Rep. Kristi Noem meets with tribal members in Rosebud to discuss the IHS crisis.
What do think will be the outcome of your efforts in working with Sen. Barrasso?
It’s our hope that we can end up getting elements of both bills into a comprehensive piece of legislation that can be signed into law. We’ve had conversations and by them allowing me to be a part of their Senate Indian Affairs Committee last week it certainly gave us an opportunity to talk about both pieces of legislation and what the different elements are.