July 12, 2006 – Despite the federal governmentâ€™s own admission that the health of American Indians is below US averages, lawmakers may once again fail to reauthorize one of the principal mechanisms for funding Native healthcare programs.
When the federal government brokered treaties with American Indian tribes during the 19th Century, it promised to provide health care and medical services in exchange for millions of acres of land.
But today, Native Americans â€“ one of the most marginalized demographic groups in the US â€“ continue to experience higher rates of chronic diseases, mortality, suicide and alcoholism. According to public-health advocates, a deficient healthcare infrastructure and lack of qualified providers largely contributes to tribesâ€™ inability to provide their communities with the level of care they need.
The Indian Health Care Improvement Act (IHCIA) was originally passed in 1976 to enhance the Snyder Act of 1921, another bill providing legislative authority to fund Native American health programs. But the IHCIA expired in 2000, and thirteen years after the last reauthorization, Congress has yet to renew it.
Congress has continued to fund the act through budget appropriations of about $3 billion per year. But indigenous advocates say this sum is inadequate, and that without reauthorization, it also remains uncertain. They point to President Bushâ€™s proposal to eliminate the Urban Indian Health Program in the 2007 budget. Funding for the program, which provides health care for Native Americans living in urban areas, was only recently restored by the Senate.
Native Americans â€“ one of the most marginalized demographic groups in the US â€“ continue to experience higher rates of chronic diseases, mortality, suicide and alcoholism.
Health advocates also say that tribes need a new bill to address changing health problems and needs on reservations.
Jim Roberts is a policy analyst with the Northwest Portland Area Indian Health Board who has worked on reauthorization issues for the last six years. "Itâ€™s been particularly during this administration that we have met with a number of objections related to different provisions of the bill," he told The NewStandard. "Unfortunately we donâ€™t have the political clout that a lot of other groups have to influence members of Congress, to put pressure on the administration to get these folks to the table to address our concerns."
The current reauthorization proposal would fund numerous programs, including those that recruit, train and maintain American Indian health professionals; address mental and behavioral health treatment and community education on mental illness; and provide disease prevention and cancer screenings.
After several years of education campaigns, negotiations and compromises, a version of the IHCIA Reauthorization of 2006, introduced by Senator John McCain (Râ€“Arizona), passed out of the Committee on Indian Affairs and was placed on the legislative calendar in March. It has yet to be called to the floor for a vote.
The Indian Health Care Improvement Act expired in 2000, and thirteen years after the last reauthorization, Congress has yet to renew it.
Representative Don Young (R-Alaska) introduced a companion bill in the House a few months later, though advocates for the bill are concerned it could be held up in various committees and fail to come to a vote this session.
Similar legislation was introduced in 2004, but conflicts between lawmakers were not resolved before the 108th Congress ended.
Most recently, the bill was held up by opposition from some lawmakers and interest groups to the Dental Health Aide Therapist Program, which trained people to provide dental care in rural parts of Alaska where there is a severe shortage of dentists. The pilot program was supported by the Alaska Department of Health and Social Services and the federal Indian Health Service, an arm of the Department of Health and Human Services that provides health care and related assistance to tribes.
However, the American Dental Association, the trade group that protects dentistsâ€™ interests, led a vigorous campaign opposing the program, citing the "principle of patient safety" and arguing that the new class of dental-health therapists was receiving inferior training.
Though such specialists are used in dozens of countries around the world, the tribes had to compromise on that provision, limiting the program to Alaska and subjecting it to review after four years.
Tribal advocates say other provisions that held up the bill related to co-payments for Medicare and Medicaid and the extension of the Federal Tort Claims coverage to third-party providers of health care to tribes.
The bills â€“ both more than 300 pages long â€“ begin by stating, "Federal health services to maintain and improve the health of the Indians are consonant with and required by the federal governmentâ€™s historical and unique legal relationship with, and resulting responsibility to, the American Indian people." The language also states that a major national goal of the US is to raise the health status of American Indians to "the highest possible level."
"We have a federal governmentâ€¦ [that] is essentially turning their head on a population of the US that is increasingly getting sicker."
But some Native health advocates see this as empty rhetoric. "We have a federal governmentâ€¦ [that] is essentially turning their head on a population of the US that is increasingly getting sicker," said Joe Finkbonner, executive director of the Northwest Portland Area Indian Health Board and member of the Lummi Nation in Washington.
According to the Indian Health Service, American Indians experience drastically higher rates of many health problems than the rest of the US population. According to January 2006 statistics on the agencyâ€™s website, American Indians have seven times the rate of tuberculosis, more than six times the rate of alcoholism, nearly three times the rate of diabetes and a 62 percent higher rate of suicide.
The Indian Health Service also estimates that more than two-thirds of health care that is needed for American Indians and Alaskan Natives is denied.
A 2004 report on Native American health issued by the US Commission on Civil Rights connected these divergent realities to a continued climate of racism in the US.
â€œWhile some disparities result from intentional discrimination based on race or ethnicity, more frequently discrimination must be inferred from the continued existence of a chronically underfunded, understaffed and inadequate healthcare delivery system,â€� wrote the reportâ€™s authors. â€œFor Native Americans, the existence of glaring disparities across a wide range of health-status, outcome and service indicators â€“ combined with the manner in which the disparities mirror patterns of historical discrimination â€“ makes a convincing argument that the current situation is in fact discriminatory.â€�
The report found that inadequate federal funding was a major obstacle to eliminating disparities in Native American health care. It stated that annual increases in funding for the Indian Health Service did not include adjustments for inflation or population growth and were significantly less than those allocated to other arms of the Health and Human Services Dept.
The lack of funding often means Native health providers can only offer so-called "life or limb" services to the most desperate.
Speaking on the Senate floor in June, Senator Byron Dorgan (Râ€“North Dakota) shared the message of a tribal chairman in his state: "Don't get sick after June," because the funding has run out for Contract Health Services.
Dorgan, who has visited reservationsâ€™ health facilities and talked to tribes about their experiences, told his colleagues, "It is not uncommon to see 75 people stand in line waiting to have a prescription filled." Dorgan added that he also visited a health care facility where one dentist was in charge of serving 5,000 people from a small trailer house.
Finkbonner and Roberts believe the biggest barrier to securing an adequate level of funding for Native health care goes back to the federal governmentâ€™s failure to uphold the federal trust obligation.
"This administration is treating the American Indian population as a special-interest group," said Finkbonner. "This administrationâ€¦ [chooses] to look at it as a civil-rights issue of not wanting to treat Indians differently from other races. So in that regard, whether thatâ€™s a true belief or whether theyâ€™re using that as an argument to justify less spending, the result is the same: itâ€™s still an underfunding of the Indian health system."