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Native health care, Alaskan-style

ANCHORAGE, Alaska - In 1975, when President Ford enacted Public Law 93-638 (P.L. 638), the American Indian Self-Determination and Education Assistance Act, he consummated a longstanding Nixon vision by definitively bringing an end to the Termination/Forced Assimilation Era and ushering in the Era of Self-Determination.

No more would Native Americans be considered dependents or wards of the government; no more would the U.S. government pursue a policy of extermination through compulsory assimilation or by depriving tribes of federal recognition.

The law profoundly impacted Native American educational programs, re-emphasized a government-to-government relationship between tribes and the U.S. government and, perhaps most importantly, revolutionized Indian health care.

Prior to P.L. 638, Indian Health Services clinics were universally abject: inadequate care abounded; often, medical care was simply unavailable; and patients were frequently maltreated. In the 1960s and early 1970s, 40 percent of Native American women of childbearing age were surgically sterilized in IHS clinics.

P.L. 638 afforded tribes new choices in health care administration. It enabled them to operate independent contract facilities in cooperation with the government, to construct compact tribal health consortiums or retain IHS-run clinics. Contract and compact health care systems afford tribes more latitude in funding allocation and staffing management.

In Alaska, which is widely regarded as having one of the nation's best and most efficient Native health care systems, all Native medical facilities are either contracted or compacted. The compact facilities are administered by consortiums of tribes that work together to ensure that all Alaska Natives receive quality care.

Alaska's smaller facilities are generally contracted, whereas larger facilities are compacted, said Alaska Native Tribal Health Consortium (ANTHC) CEO Tim Gilbert.

ANTHC, a compact health care consortium, was formed in the 1990s to run the Alaska Native Medical Center (ANMC), one of Alaska's largest hospitals.

"There was a series of meetings and negotiations among Alaska tribes to determine how ANMC ought to be operated and managed," Gilbert said. "Out of that came ANTHC."

ANMC services a 100,000 square-mile area, has 150 beds and handles more than 375,000 outpatient visits annually. ANMC patients are guaranteed same-day access to their own primary care provider if they call by 4 p.m. Since ANTHC was formed, use of ANMC's Urgent Care Center for primary care has been reduced by 50 percent.

In addition to running ANMC, ANTHC has taken on other obligations, Gilbert said.

"Not only did we assume management of ANMC, but we also assumed other statewide responsibilities," he said.

Compact health care, rather than IHS-run or contract facilities, enables Alaska to provide superior care to Native patients, said Southeast Alaska Regional Health Consortium President Ken Brewer.

"Contracting requires that the contractor perform the services in the manner of the government," he said. "Compacting allows the contractor to reallocate resources as they see fit."

"We can focus on local priorities, rather than the one-size-fits-all approach," Brewer said.

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Brewer attributes the success of Alaska's Native health care system to tribal assertiveness.

"Ever since P.L. 638 passed, Alaska has been aggressive in taking advantage of it," he said.

Gilbert said cooperation is also a vital aspect of Alaska's success.

"There is a lot of emphasis placed on tribes' abilities to get together and talk about issues," he said.

"We chose to work together to improve the system," Gilbert said. "I think that's key."

Sharon Lincoln is a registered nurse at the Southern Ute Health Center in Ignacio, Colo. The Southern Ute tribe is one of the nation's most successful, with a lucrative casino and vast reserves of natural gas, coal and other resources.

The tribe plans to transfer its health care management from IHS to tribal contract care within the next year.

"The Southern Ute tribe has submitted an application to consider 638," Lincoln said. "The next step is to put together a viable, workable proposal."

"Putting together a proposal to contract your own health care is a very important and difficult process," she said.

IHS in Albuquerque currently determines the amount of funding the Southern Ute Health Center receives each year.

"We've had a historical disagreement with Albuquerque regarding how many patients actually access care here," Lincoln said.

In addition to Southern Ute tribal members, the health center provides care to other American Indian residents of Southwest Colorado and students at nearby Fort Lewis College, which has a high Native American student population.

Alaska has an impressive Native health care system, Lincoln said.

"Their model seems to have been very successful," she said. "I think they have very competent professional guidance."

In Alaska, high-quality Native health care continues to be a model for the rest of the nation.

Dave Stephenson, a Tlingit Indian, is Indian Country Today's Alaska correspondent. He can be reached at