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Warne: A new hope for Indian health

In nearly fifteen years of practicing medicine and working in various capacities in American Indian healthcare, for the first time I feel a strong sense of hope. Senator Barack Obama has said that if he is elected President, he would ''fully fund'' the Indian Health Service. What does that mean to me and the other 4.1 million American Indians?

In this nation, people are not born with a legal right to healthcare. There are some laws like the Emergency Medical Treatment and Active Labor Act (EMTALA) that provide access to limited services in limited circumstances for all Americans, but we are not born with an inherent right to healthcare services. This is true for the majority of Americans with the exception of American Indians. We are the only population born with a legal right to healthcare.

This right is based on treaties, which are essentially contracts between the tribal nations and the federal government in which the tribes exchanged vast amounts of land and natural resources for certain social services, including housing, education and healthcare. This is why we have a Bureau of Indian Affairs (BIA) and an Indian Health Service (IHS). From this perspective, American Indians have the largest pre-paid health plan in the nation. The land and natural resources that have made this country as successful and powerful as it is was not won in a war with the tribes. It was exchanged for these services and programs. As a result, the federal government has a trust responsibility to provide healthcare to American Indians.

As a population, we suffer from among the worst health disparities in the nation. Death rates from preventable causes like diabetes, alcoholism and suicide are several-fold higher in American Indians than in the rest of the U.S. population. Nearly a third of our population lives in poverty as compared to approximately 12% of the rest of the country. In the State of Arizona, average age at death is 72.2 years for the general population, and it is 54.7 years for American Indians. This should be considered a crisis. It should be front-page news, but it is buried in reports from the IHS and state health programs.

The agency with the primary responsibility to address these disparities is the IHS. In the 2005 federal budget, per capita expenditures for IHS were $2,130. Every other federally funded healthcare program is funded at a significantly higher rate, including Medicare ($7,631), Veterans Administration ($5,234), Medicaid ($5,010) and Bureau of Prisons ($3,985). While I would not recommend it to my patients, if they go to federal prison they would have access to more healthcare resources.

Again, American Indians are born with a legal right to healthcare based on the exchange of the land and natural resources that have made this nation what it is, and we have been significantly shortchanged in healthcare and other services. I heard a tribal leader say it best a few years ago at a budget meeting when he said, ''If you want to get rid of the Indian Health Service, that's fine. Just give us our land back.''

So what would it take to fix the funding shortfalls in the IHS budget? The number of American Indians actively using IHS services is about 1.5 million, and clinical services for the IHS are funded at approximately $3B per year. Several studies have shown that the IHS is funded at approximately 60% of need. Therefore, to bring the IHS up to level of need funding would require an additional $2 billion. The budget for the Department of Health and Human Services, in which IHS is an agency, is approximately $700 billion, and the Department of Interior, in which BIA is an agency, is approximately $15 billion.

Relative to the rest of the budget, $2 billion is a small investment for the federal government to fulfill its trust responsibility in Indian health. It is remarkable to me how we can come up with $150 billion relatively quickly to send people $600 checks to stimulate the economy, or that we spend about $2 billion per week on the war in Iraq, but we can't fulfill our trust responsibility as a nation and honor our treaties with the country's first inhabitants with an additional $2 billion annually for IHS.

An argument against additional funding I have heard several times is that now that tribes have casinos, they should be able to pay for funding shortfalls themselves. There are numerous problems with this argument. First, most tribes do not have casinos, and most casinos are not making significant profits. Most tribes and reservations are located in rural areas and do not have a population base that could support gaming. People who live in urban settings like Phoenix have a skewed perspective on Indian gaming because the population base can support large and successful casinos. Second, successful tribal economic development does not absolve federal trust responsibility to provide healthcare to American Indians.

I have also heard the argument that the successful casinos should fund the other tribes. This is advocating for socialism, and until the rest of the nation is willing to socialize medicine and other services, tribes should not be held to a higher standard. We must remember that each tribe is a sovereign entity, and that it is not the tribes' responsibility to provide healthcare to each other, it is the federal government's responsibility.

Over the last couple of decades, the IHS budget has increased about 1 or 2 percent per year, including the Clinton years. This increase has not kept up with medical inflation, cost of living adjustments for employees or growth in population. Essentially every year that goes by, we are able to provide fewer services due to compounded and chronic under funding. At the same, health disparities are worsening.

When I read that Senator Barack Obama plans to fully fund IHS, I checked with the campaign to ensure that this is true. Could it be that we can elect a President who understands trust responsibility and truly cares about the health of Indian people? For the first time in my career, I have hope. Please join me in voting for this remarkable manhe has a vision for America that is bright for all of us, including the first Americans.

Donald Warne, M.D., MPH, (Oglala Lakota) is president and CEO of American Indian Health Management & Policy in Phoenix.