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HEALTH CARE CRISIS ON THE RESERVATIONS
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By Susan Johnson,
NCSL's Indian
Affairs
and Mary Guiden,
NCSL's State Health Notes
"State
Legislatures" journal
National Conference of
State Legislatures
HEALTH CARE TRAGEDY
When
you go to the doctor's office, you may expect a long wait, but you don't expect
to see a message that the doctor will only see you if you're on your
deathbed. But that happens to Native Americans. Indian Health
Service clinics often run out of money midway through the year, forcing
officials to post "priority status" signs. This means care is available
only "if you're about to lose your life or a limb," says Alida Monteil, health
system analyst for the intertribal Council of Arizona. In terms of their
health and their ability to get medical care, Native Americans have long been
among the most disadvantaged groups in the United States. In addition,
they often live in rural, isolated areas with few doctors. Centuries ago,
explorers introduced disease and ecological changes that took a heavy toll on
the native population. Today even as tribal councils are gaining strength
and taking over more government functions, poor nutrition, unsafe water
supplies, inadequate waste disposal facilities, and the twin plagues of alcohol
and drug addiction damage the health of many people of the Indian nations.
Standard health indicators reveal glaring disparities between the estimated 2.3
million American Indians, Eskimos and Aleuts, and the general population.
Mortality rates for Native Americans and Alaska Natives are significantly
higher, according to the Indian Health Services. In addition, age-adjusted
alcoholism death rates for Indians are 440 percent higher than that for the
general population; accidents, 165 percent higher; homicides, 50 percent higher;
and suicides, 43 percent higher. For diseases like cancer, the record of
early detection among Native Americans is poor. Once someone is diagnosed,
it's basically a death sentence, says Monteil. Federal officials say per
capita spending on Indian health still falls short: $1,650 compared with
$3,600 for the population as a whole. U.S. Census data show almost
one-third of American Indians live below the federal poverty level, as opposed
to 14 percent for the general U.S. population. Nonetheless, there's
optimism that things may improve as some states and tribes take specific steps
to address the situation. Three factors could bring meaningful
change:
---The Indian Health Care Improvement
Act of 1976 is scheduled for reauthorization next September. Proposals to
extend the scope of authority of the Indian Health Service and expand its
existing services are already under debate.
---The State Children's Health Insurance Program has potential to
improve the medical care for thousands of Indian children living in
poverty.
---Medicaid managed care policies are
evolving---which in some cases may result in better and more regular access to
services.
DEVOLUTION GIVES STATES A ROLE
Indian health was once the sole responsibility of the federal Indian
Health Service, which operates almost 200 health facilities across the
country. Now, with federal powers being handed to the states and tribal
self-determination on the rise, the responsibilities are shifting. Some
tribes have made great strides in developing administrative capacities in the
past decade. For instance, a few tribes own and operate their own clinics
or contract to run Indian Health Service facilities under "self-determination"
agreements. But many tribes simply cannot provide services to their
communities. With devolution, states have been given added
responsibilities regarding Native American citizens, and are working to develop
different kinds of relationships with neighboring tribal governments.
Developing these relationships, however, is easier said than done. The
shift in oversight and collaboration promises to be a real "learning process,"
says Michael Mahsetky, Indian Health Services legislative affairs
director. States have not had the historical experience of working with
tribes, he says, and, "as a result, sometimes the relationship can be
hostile." Although the health care Indians get from the federal government
is largely inadequate, Native American leaders worry that devolution may
undermine the federal government's responsibility to the tribes. "The
Indian Health Service has never been funded at the level that tribes need.
Now, as states try and fill in the gap, it's a big gap to fill," says Judy
Edwards, Utah Department of health and coordinator for the Western Governors
Association's Annual Summit on Indian Health Care. Pending federal
legislation may lessen the gap. The 1976 Indian Health Care Improvement
Act, which funds Indian Health Services, expires in September.
Reauthorization affords IHS, Native American governments and states the
opportunity to increase flexibility for the tribal and urban Indian health
programs. What makes this year's battle important, said Mahsetky, is that
the agency is taking a unified message to Congress about the effectiveness of
existing programs and what needs to be changed. "For the first time in the
history of the act, IHS had a very specific process of consulting with tribes,"
he says. Similarly, among the proposed changes are provisions for state
consultation with tribes. Also proposed is creation of a "qualified Indian
health program." Programs with that designation would be eligible for
Medicare and Medicaid reimbursement. They could also include in their
rates such things as preventive care, SCHIP services and transportation.
Currently, only IHS programs receive such payments; the provision extends them
to both tribal and urban clinics (in the absence of an IHS facility).
STATE SCHIP PROGRAMS MAY HELP
Another way to improve health care for Native Americans is by reaching
out to the children. One third of the Indian population is younger than
15, compared with 22 percent of the U.S. population. The State Children's
Health Insurance Program enacted by Congress in 1997 opened up new avenues by
providing low-cost or free insurance for low-income children who don't qualify
for Medicaid. Indian children are eligible for SCHIP on the same basis as
other kids, but so far enrollment figures are disappointing. An IHS
official in California, for example, says there are an estimated 20,500 eligible
Indian children, but only around 900 enrolled. Indian leaders say
enrollment is low in most states because of the complicated and lengthy
application process, the failure to list IHS clinics as sign-up sites and
because IHS facilities are often not designated as providers of SCHIP services,
forcing an enrolled family to go off the reservation for health care. And
too many Indians just don't know about the program. States are working to
fix these problems. The federal law allows money to be used for outreach
to low-income Native Americans. There are many ideas for reaching
parents---putting flyers and posters in fast-food restaurants and buses,
doctor's offices and neighborhood pharmacies, sending flyers home with school
children. California officials hand out information at pow wows. A
move that has made a "phenomenal difference" in Utah, according to Chad
Westover, SCHIP administrator for the Department of Health, has been hiring a
Navajo-speaking worker. "People have been very receptive," he says.
The idea came from members of tribal health boards who have met with the
Department of Health every month since the early 1990's. In addition, the
state has also placed SCHIP outreach workers on reservations once or twice a
week. One major obstacle to Indian families getting enrolled in SCHIP was
eliminated with last fall's decision to copayments. That "was a big
victory," Mahsetky says. Under the terms of treaties signed in the 1800s,
Indian people feel that health care is an entitlement and that they shouldn't
have to pay, he explains. Officials may think that $3 per office visit
isn't much, but on a reservation where unemployment is as high as 90, percent,
that's a barrier to care, he says. A few states haven't taken the federal
directive to waive copays seriously, but they should, says the Health Care
Financing Administration's Mary Kahn. "It's not an option," she says, "and
states should not be waiting to implement it."
OVERCOMING BARRIERS
Changes in Medicaid policy are also having significant effects on Indian
health care. One positive change is a recent Health Care Financing
Administration decision that allows states to recoup 100 percent of the matching
Medicaid contributions spent on Native American patients. States generally
only receive an average of 57 percent reimbursement for such costs. An
emerging issue is whether states should let individual Native Americans "opt in"
to Medicaid managed care, instead of being forced into such plans. As
states have learned about rural populations in general, people automatically
assigned to a plan may not find a provider close to home. For Indians in
particular, distance, culture and language may cause them to seek care
elsewhere. "native Americans will continue to use tribal clinics" if
merely because of proximity, Bonner says. "That's a proven fact."
The issue has already played out in New Mexico, where Governor Gary Johnson
reversed his veto of legislation to allow Native Americans to elect enrollment,
or "opt in," to Medicaid managed care plans. New Mexico Representative
James Roger Madalena, a Jemez Pueblo Indian and the bill's co-sponsor, is
pleased with the move. In executing his veto, Johnson was acting on bad
advice, Madalena says. Noting the geographic and cultural distance that
separates Indians from the rest of the population, Madalena says that the
"frontier" has been breached. But, he adds, "we've got a long ways to
go."
STATES WORK TO BRIDGE THE GAP
Some states have already started to recognize the special needs of their
Indian populations. Lincoln Mayor Don Wesley, a former Nebraska
legislator, says he spent 20 years on the health committee and "missed out on
how serious health problems are for Indians." In 1997, however, the
Legislature conducted a study of leading health indicators for tribal
groups. Wesley said he "was just appalled" at the findings. "I had
no idea how big the disparities were," he added. As an example, the
average life expectancy for a woman in Nebraska was 77, for a man, 73, and for a
Native American, 52. Diabetes among Indians was triple or quadruple the
state average. "When we saw these figures, the whole committee said this
is intolerable. How can you live with yourself knowing that some people
have one-third less of a life span just because of the race they're born into?"
Wesley asks. He sponsored health care legislation in 1998 that included
the Native American Public Health Act with $500,000 in funding for the first
year. Since then, the Legislature has appropriated the annual allocation
through 2002. Tribes are using the money for myriad projects---from
screening programs for cardiovascular disease to a youth health project to a
summer day camp for Indian children at risk for diabetes. Wesley refers to
the measure as one of the pieces of legislation he's most proud of. "It
took me 20 years to figure this out, but I hope other legislators don't take
that long," he says.
A CALL FOR COOPERATION
The State Children's Health Insurance Program, managed care reforms and
the impending reauthorization of the Indian Health Care Improvement Act all may
provide states with flexibility for assisting these unique populations.
The biggest help to states in effectively serving Native Americans without
breaking the bank, however, is likely to be cooperating with the tribes
themselves. "It's an interesting time for states and tribes to identify
what's common, instead of being on opposite sides," says Utah health
department's Judy Edwards. Sarah Hicks with the National Congress of
American Indians agrees: "States and tribes can only benefit from
collaboration."
This article was republished with permission from State
Legislatures.
Copyright 2000, National
Conference of State Legislatures.
(V. 26,
6/2000. 36-39)
TOPIC TWO