Good morning. I am very pleased to be here this morning and to share with you my experiences with the United States health delivery system for Native Americans. I am a former professor of Engineering Management of the University of Missouri of Rolla and of Cherokee ancestry. I will talk today about services provided by the United States federal government to American Indians and Alaska Natives, a little bit about how the system started and how it has changed over the years with experience to better individual community needs. I will present some outcomes which indicated progress in the health status of American Indians and Alaska Natives and end with a discussion of some current issues and challenges.
The preferred term in the Indian Health Service is American Indian/Alaska Native.From the US Census Bureau: “people whose ancestry derives from any of the original peoples of North and South America, and who maintain Tribal affiliation or community attachment”The Census counts anyone who will declare themselves to be this wholly or partially to be “AI/AN”No single Federal or Tribal Criterion establishes a person’s identity as an Indian; Tribes vary in their rules for membership
This map shows the geographic areas covered by indigenous peoples around 1600
They are in yellow outline.
565 Tribes including 223 plus Alaska Native villages currently have recognition by the US Federal governmentTribes are thought of as separate sovereign nations to be dealt with on a government to government basisThe internal affairs of a Tribe are its own responsibilityRelations with Tribes are considered to be between two Nations and are handled by the central, Federal government, the principal agent of the US government is the Bureau of Indian Affairs, Department of the InteriorA Tribal Member is a US Citizen but also a member of his or her Tribe and thus have dual citizenship
Mineral rights and timber: As the population increases, the areas where oil, lumber, and minerals can be obtained are on or near Tribal landsTimber cut on Indian Land was worth $4.8 million in 1948 at a rate of $8.06 per board foot; seven years later in 1955, it was worth $11.7 M at a rate of $15.05 per board footIn the 1970s, over 1 million board feet of timber was cut from Indian lands from 1972-4 and 1976-9. During that time the price of timber went from $43.89 to $128.77 per board foot. In 1994, it peaked at $251.26 per board foot for a value of $164 MIn 1998, the sales value of oil and gas operations on Indian lands was $710.9 M and royalties of $106.5 M were paid. In 1982, the peak year for which we have information, sales value was $983 M and royalties were $147 MIn 1998, an additional $565.9 M of sales of minerals and $69 M of royalties was paid. The resulting $1.3 billion in combined sales value and corresponding $179 M in combined royalty value would pay for approximately 25% of the budget of the Indian Health Service in 2010
It is also much younger and more rural than the population as a whole.
Tribes use the revenue to build a clinic and government buildings/services usually.
The Tribe from which I am descended has helped to develop high technology weapons among other things. I myself invented the valve in the butane cigarette lighter, the system by which astronauts now eat in outer space, and made possible with the package I developed the long distance export of refrigerated goods using water ice packs.
This varies significantly from Tribe to Tribe depending on the resources and business developments described above.
Many Tribal members who do not have proof of their membership are still given care if it is urgently needed on a humanitarian basis.
52% of the budget went into contracts in the last budget year. This is money given to Tribes on contracted obligations to provide health care.
Where the facilities are located
The basic structure of the care provided is a primary care model based on population based needs assessment. The IHS has developed its own planning tools which reflect standards for population based primary care. These tools are available at http://www.ihs.gov/planningevaluation/index.cfm?module=dsp_pe_facilities_planningThis is not the general model used for health care in the US private sector which is market driven and financed mostly by private insurance given by employers.
Community health representatives are specially trained people who provide health care. Very often, they do not have a degree in a health profession or similar field.
No one knows if it is because of better health care, an overall improvement in standards of living, or a general economic improvement in the whole US. Still, it has occurred.
Examples from White Earth Ten Year Follow-up Evaluation for a small center in rural Minnesota:Workload increased 89%Staff increased 31%Six new services were addedDecreased death rates for many causes including cancer, heart disease, and diabetes300 Square meters added to physical structureAdditional revenuesNew Tribal Council Building
The Tribes of the Northern US suffer more.
All new facilities now include Wellness Centers and StaffStaff at a University Medical Center in Arizona read X-rays from many IHS facilities via teleradiology
Approximately 51% of its budget goes directly into Tribally contracted and administered health careIHS first developed a process to regularly consult with Tribes it serves in 2001Currently, the IHS Director’s Tribal Advisory Workgroup on consultation (established in 2009) contains 24 elected Tribal officials. A Tribal Consultation summit was held most recently in July 2011
Health Care for American Indians in the United States
Health Care for American Indians in the United States<br />Gerald Greenway, Ph.D. Analytical Chemistry<br />Member, Rotary Club of Rolla, Missouri, USA<br />September 15, 2011<br />
Who is Indigenous in the United States?<br />Ancestry from any of the original peoples of North and South American<br />Anyone who self identifies on the Census <br />Tribal membership – rules vary<br />Preferred term is American Indian/Alaska Native (AI/AN)<br />
United States Federal Recognition<br />Currently 565 tribes and 223 Alaska Native villages have met the special requirements to be recognized by the US government<br />These tribes are sovereign nations and deal with the federal agencies on a government to government basis<br />After 1924, Congress granted American Citizenship to all Indians born in the Territorial limits of the US<br />
American Indians are Important to the US Society and Economy<br /><ul><li>There are currently over four million American Indians/Alaska Natives (Census 2000)
Some tribes have lands with oil, lumber and minerals
World Opinion: The US is judged by other nations depending on how well it treats its least privileged groups</li></li></ul><li>The AI/AN Population is Growing<br />
Casino Operations<br />In 2001, 201 of 562 Federally Recognized tribes participated in gaming operations aka casinos resulting in Tribal revenue from 354 casinos in 2002 of $14.5 Billion<br />It is a regulated industry in the US established under the Indian Gaming Regulatory Act of 1988 <br />http://en.wikipedia.org/wiki/Gambling_in_the_United_States#Indian_gaming<br />
Defense Contracting<br /><ul><li>Cherokee Nation Businesses received more than $40 Million for a 2011-2013 contract to provide logistics, services and support for military hardware
Cherokee Nation Industries was awarded a Gold Status rating by the Boeing corporation for its superior performance and on time delivery, operating a 120,000 plus sq ft of expandable manufacturing space in Stillwell, Oklahoma, employing 150 people, 70 of which worked under Boeing subcontracts</li></ul>http://savethetribe.org/2011/08/14/cherokee-nation-businesses-gets-its-largest-federal-contract-ever/<br />
US Government Provides Health Care <br /><ul><li>Historical Treaty obligations from 1793 have required the US government to provide free health care to every Federally recognized Tribal member in perpetuity, regardless of economic advantage or disadvantage
Tribes are the First Americans; they are not viewed as mere occupants at contact with the Europeans but as unfortunate recipients of maltreatment to whom the US owes compensation</li></li></ul><li>Providing Health Care to AI/AN<br />The current Indian Health Service moved to the Department of Health and Human Services in 1955 following the passage of the Transfer Act <br />Open Door Policy: Provides direct care to any AI/AN who belongs to a Federally recognized Tribe <br />
The Indian Health Service Today<br />Provides healthcare to approximately 2 million of the 3.4 million AI/AN in hospitals, clinics, and other settings throughout the US<br />$ 4 Billion Nationwide Health Care Delivery Program with 16,159 employees of whom 70% are AI/AN<br />Dental: $152.6 million for a population with more tooth decay and gum disease than the general population of the US<br />Mental Health/ Substance Abuse: $267 million<br />Contract Health: Reimburses for care from another facility when IHS cannot provide that care itself. $779.3 million was budgeted for this in the last year.<br />
Primary Care Model<br />Population based Needs Assessment<br />Planning process that is community based<br />Provision of staffing, equipment and space for comprehensive primary care including dental for all patients<br />
Community Public Health Principles<br />Community Health staff included with all facilities<br />Health education staff<br />Sanitation and other engineering services available <br />
Health Inequalities or Disparities<br /><ul><li>IHS develops many measures of how different health conditions are for AI/AN than for the general population
These differences also called inequalities or disparities are used by the agency to go before Congress to justify receiving more money for health care
Without this information, the budget of IHS could not be justified, but with this information, the agency regularly receives funding under a bill called the Indian Health Care Improvement Act</li></li></ul><li>Selected Disparities<br />
Since IHS came into being, there has been a steady increase in the number of years an AI/AN can expect to live<br />
Impacts of New IHS Facilities<br />Increased access<br />More services and staff<br />More equipment and space<br />Increased resources<br />Individual health status<br />Increased patient satisfaction<br />Increased in community infrastructure<br />
These vary significantly by Tribe and Region<br />
Dental Improvements<br />Increases in the number of 5-19 year old children with no decay<br />Increase in the number of dental sealants placed on children’s molar teeth<br />And increase in the number of older patients with 20 or more teeth<br />
New Models<br />Wellness – to address issues of obesity,<br />Telehealth – to provide needed services and consultation not available locally<br />Traditional Healing – to augment services and respond to patient needs<br />Improving Patient Care – to realign services to focus on individual patient needs<br />
New organizational Models<br />Self Governance<br />Tribes manage their own systems with funds from the government<br />Joint Ventures<br />IHS and Tribes share resources to build and staff new facilities<br />
Future Challenges<br /><ul><li>Providing opportunities to provides new types of care – Nursing Home, Dialysis, Inpatient Psychiatric
Future increases in funding may be limited because of US economic issues
New lifestyle and other disease challenges which require new types of care such as Obesity</li></li></ul><li>Lessons Learned for Planning<br />Work closely with local leaders and community<br />Communicate and outreach through indigenous representatives, mobile units<br />Employ Tribal members<br />Incorporate indigenous culture and knowledge<br />Focus on primary care and conserve resources<br />