Tighter tribal membership policies could shrink Indian health care rolls

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DENVER – Blood quantum rules could infuse some life into an Indian health system that is “starved, but not broken,” answering an oft-repeated theme at a recent IHS summit.

The use of Indian blood quantum as an indirect requirement for IHS service eligibility might reduce demand on the already-strapped health system, but it would be an incursion on tribal sovereignty, said a National Council of Urban Indian Health official.

“There have been moves to diminish sovereign rights that echo past efforts to diminish sovereignty,” said Geoffrey Roth, NCUIH executive director, in connection with the Indian Health Summit held July 7 – 9.

Use of the tighter eligibility standards was the topic of informal discussions held by various legislators and health care professionals concerning IHS funding and the wider health care debate.

“It’s potentially something Congress wants to look at, and I don’t think that’s right. All of Indian country is going to have to deal with this in a meaningful way.”

At present, eligibility for IHS services does not depend directly on blood quantum, but tribal membership, a key eligibility criterion for those services, may or may not require a certain blood quantum, depending on the tribe. Many tribes rely solely on lineal descent from earlier tribal rolls.

“Using blood quantum is part of a conservative ideology to limit the federal government’s responsibility regarding Indian people,” Roth said, recalling that the previous administration proposed zero funding for urban Indian health care. “It’s not just an ‘Indian issue’ – it’s about that trust responsibility.”

One amendment to the Indian Health Care Improvement Act reauthorization and later withdrawn was proposed by Sen. Tom Coburn, R-Okla. The amendment would have required a blood quantum minimum for enrollment in a federally recognized tribe, but it drew criticism from those who noted it would be counter to existing law and policy for the federal government to set tribal citizenship requirements.

“We support tribes’ inherent sovereign rights to determine who is a member of their tribe,” Roth said.

While more restrictive tribal membership eligibility rules could indirectly reduce IHS demand, at least at present, shrinking dollars from a weakened economy and health care reform for the overall population could take a toll on already insufficient funds.

Despite a proposed IHS budget increase of about 13 percent, shortages are anticipated, especially in the nation’s 34 urban programs which receive approximately 1 percent of IHS funds. They serve some of the many city-dwelling Natives who make up 64 percent of the total Indian population, and the programs remain among the hardest-hit health providers.

The urban programs received zero money from stimulus funds, an occurrence Roth attributes to the fact that “urbans are still a relatively small program” and the funds were allocated in a rushed three days. IHS funds to the urban Indian programs are supposed to be used to bring in other sources of support, he added.

If reservation and urban programs were adequately funded, there would not be an issue of their programs competing for a shrinking pool of money, an important point, because “every Indian person has a right to services, from trust responsibility.”

At one Montana reservation Roth visited, health facilities were in “terrible” condition, with no running water the day he was there, and a Wyoming clinic he checked was 110 years old.

Inadequate data, as well as inadequate funding, was a repeated theme at the IHS summit, but the lack of information is, paradoxically, a possible source of improvement.

Roth said a nationwide Indian health needs assessment is mandated for 2010, including population figures, the kind of access people have to health care and its location, and the kinds of facilities that exist for substance abuse, mental health and diabetes.

The assessment will also reveal where programs are lacking, who accesses care and how best to support it, how to support relevant research, and how to ensure transparency, inclusiveness and accountability.

Under the American Recovery and Reinvestment Act, urban program-targeted changes include an end to enrollment fees, premiums, deductions or similar charges under Medicaid. In addition, Indian property – such as lands held in trust – cannot be used in Medicaid estate calculations nor can they be used to determine Medicaid eligibility.

There are also stronger provisions for urban Indian organizations to be included in consultation on Medicaid and other programs.