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New IHS director shares his vision

WASHINGTON - Robert McSwain, who was sworn in as director of the IHS May 7, begins his reign at a difficult time. Budget cuts are having immediate impacts, new health issues in Indian country are on the rise, and the federal climate in which he;s trying to make his goals a reality is as complicated as ever. And still, McSwain, a member of the North Fork Rancheria of Mono Indians of California, feels more than up to the job. Now in his 22nd year with IHS, he shared his vision with Indian Country Today.

Indian Country Today: What are your immediate challenges?

Robert McSwain: I think the main challenge is much the same as what we've been dealing with, which is certainly a very limited budget outlook because of the president's vision about the deficit reduction budgets ... and of course that means that the discretionary programs are very, very limited. ...

I think the other challenges are the continued progress of self-determination, and working with the tribes on their decisions to assume the programs. Over half the program is currently contracted to tribes under self-determination, but I'm also reminded that there's still a significant - a little less than half the program - that's still direct. So we must provide direct care, and the biggest challenge is going to be the balancing of the two, ensuring that the tribes who choose to have us deliver the care are not treated any less than the tribes that have decided to take over their programs. ...

And the fact that we're dealing with some new health challenges in health care. We're dealing with the behavioral health issues. While we have the old issues of alcoholism and substance abuse, we have some new issues. ... On the behavioral health side, the health challenges are about methamphetamine abuse, certainly suicides amongst our youth - those are challenges that we didn't have 20 years ago, so those are the new challenges as we move forward. Plus, how do we continue to work smartly in the system, how do we become more effective and efficient?

I think the challenge is, given the budget constraints, how do we continue to expand the program through quality improvement in the health care delivery?

ICT: How do you feel about President Bush's proposed 2009 budget?

McSwain: ... It's a budget that is flat. But ... if you look inside at the detail of the changes, you'll see that the budget demonstrates maintenance of the program for basic primary care on Indian reservations. And less on infrastructure, less on those populations like the urban Indians that are in the cities, and it's a focus on and a shift in the program towards those folks who do not have alternate resources out on or near reservations in more isolated parts of the country.

ICT: But many urban Indians could be hurt by this budget ...

McSwain: I am concerned about the urban folks - approximately 600,000 Indians are estimated to live in urban areas, and we're only in 34 of those urban sites. And I guess the overarching concern is that those Indian people in urban areas are not a different kind of Indian. They are, in fact, American Indian and Alaska Natives who had to leave their reservations for a lot of reasons, probably chiefly is where they can find work. They've either gone to school, and they've decided that's where their careers are for those that have left their reservations. So it is a difficult issue.

The bottom line is it's a matter of choices, and if you choose to continue providing care to the reservation on or near folks, or do you want to try to spread it to taking care of both groups; and when you have to maintain one, it's not an easy choice. It's the most difficult choice, but it's the choice that we've made.

ICT: How do you deal with a lack of facilities funding?

McSwain: We've had a pause in construction for about three years now. What's helped see us through the pause is our robust joint venture program, whereby we partner with tribes who can build and replace facilities, and we agree to staff the facilities. We're sort of weathering the storm with the tribes that have been able to step forward.

ICT: What about the many tribes that can't afford to build facilities?

McSwain: A lot of it depends on hope. We hope to get through this particular pause in construction soon. Our average facility age is 33 years. The bottom line is that if we can't build it, then we do all we can to maintain our maintenance and repair budget.

ICT: What are your thoughts on the Indian Health Care Improvement Act?

McSwain: I see the Indian Health Care Improvement Act as a framework that really proscribes the special relationship that the federal government has with Indian tribes. It's a complex bill, clearly; but the fact is that fundamentally, it is a very important legislation that proscribes that special relationship. I've been around the country and I know that tribes have articulated that this law is really the backstop for many of the treaties that were signed about health care. ... It hasn't been reauthorized for a period of time, and it needs to be to continue that special relationship, particularly as it pertains to health matters. There are certainly other pieces of legislation that are important to Indian country, but for our mission, the Indian Health Care Improvement Act is vital.

ICT: Do you think the IHCIA will be reauthorized anytime soon?

McSwain: I was very optimistic at the beginning of the year when the Senate was able to, Sen. [Byron] Dorgan was able to marshal his energy and forces, if you will, to get it passed by, and rather overwhelmingly passed by, the Senate. And so then it moved to the House, and there are issues in the House that folks have. It's a bigger body ... so you have more views to be expressed, more committees of jurisdiction, and those issues, it seems to bog down a bit.

I guess my optimism goes from one week to the next to the next - one week it's very high, and the next week it's very low as I begin to hear that some issues are dragging it on. Now, this is an election year and Congress' attention is going to turn to the general election in November, and that means that if it doesn't get done soon, unfortunately it could wind up not getting reauthorized this year and what then happens is, I'm advised, that the process will have to begin totally anew in January again. And so that special relationship is still there under current law, but it's so important and vital to Indian people that it be done.

ICT: What do you think the holdup in the House is?

McSwain: I think there are just a lot of other things going on in such a tight legislative agenda ... I think we may be just getting lost in the shuffle on the House side.

ICT: In your mind, what's the drop deadline for reauthorization?

McSwain: I'm gauging it's either June or July at the latest.

ICT: Are tribal officials telling you that IHS needs to be doing more in terms of prevention?

McSwain: They are very vocal about it. ... Prevention is a forefront issue. The tribal leaders are there, and we listen very closely to them as to what they think will work.

ICT: Is it important for the director of IHS to be Indian?

McSwain: I believe it's very important. Half have been non-Indians, and now half have been Indians. What it really signifies is the maturation of the Indian health system. Today, all of our senior-level professionals are Indians, and about 70 percent of our work force is Indian. It's appropriate that the leadership of Indian Health Service be an Indian person. It has linkage back to the tribes we serve. I think it's another form of self-determination, although we're all still federal employees.

ICT: You've been confirmed for a four-year term, but this fall, you will see a transition to a new president. Does the change concern you?

McSwain: I look at it as an opportunity. You go into it with the notion that they don't know much about IHS. But, in consultation with tribal leaders, we plan to be more proactive, getting our issues lined up and presenting a strong face to the new administration. We will teach the new group. And we can tell them not only what our needs are, but the kind of system we have.

ICT: Which candidate in the running for president could best help IHS?

McSwain: I think it's up to tribal leaders to decide. After all, I've got an agency to run.