New Challenge for States: Indian Health Care.

Devolution has given states a role in making sure Indian tribes have adequate health care. Along with these new opportunities comes greater responsibility--for both states and tribes.

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 (IHS) 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.

Of all the racial and ethnic groups in the United States, Native Americans have long been among the most disadvantaged, in terms of their health and their ability to get medical care. 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.

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 (IHS) and expand its existing services are already under debate.

* The State Children's Health Insurance Program (SCHIP) 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 IHS 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 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. Georgia tapes brochures to pizza delivery boxes and drops them in women and children's shoe boxes. 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 1990s. 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 waive 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."

Michigan Department of Community Health spokeswoman Geralyn Lasher says they have not yet waived copays because the SCHIP regulations are still in draft form. "We're waiting until they are finalized," she said.

Those regulations are likely to be final this summer.

Copays are also an issue in states that are expanding SCHIP to cover adults. Massachusetts, Mississippi and Wisconsin are currently the only states approved by HCFA to cover parents, but there's been no federal ruling on copayments.

"Wisconsin has premiums in their expansion for family coverage. They're reluctant to waive copays for adults, but it's not like it will break the bank," said Kitty Marx, senior policy analyst for the IHS Division of Regulatory and Legal Affairs. "We're working with the state and HCFA officials to convince them that the entire family should be exempt."

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 (HCFA) 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 cosponsor, 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 Wesely, 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 lifespan 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."

Mary Guiden is an editor of NCSL's State Health Notes. Susan Johnson is NCSL'S expert on Indian affairs.

FIVE LEADING CAUSES OF DEATH FOR INDIANS IN HEALTH SERVICE AREAS VS. ALL RACES (BOTH SEXES, ALL AGES)

IHS SERVICE AREA INDIANS (1989-1991)

1. Heart disease

2. Accidents

3. Cancer

4. Diabetes

5. Chronic liver diseases and cirrhosis 

U.S. ALL RACES (1990)

1. Heart disease

2. Cancer

3. Strokes

4. Accident

5. Chronic lung diseases

Source: IHS

A POPULATION AT RISK

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 Alida Monteil of the Intertribal Council of Arizona.

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.

FEDERAL TRUST RESPONSIBILITY FOR INDIAN HEALTH CARE

The foundation of the federal government's trust responsibility for the health needs of American Indians and Alaska Natives stems from a long history of treaties and federal laws.

More than 370 treaties were signed by Indian tribes and the United States prior to 1871, in which the tribes ceded land in exchange for services including health care.

More recent legislation includes:

* The Snyder Act of 1921, which authorized expenditures for all Indian services, including health care.

* The Indian Self-Determination and Education Assistance Act of 1975, which provides tribes the option of managing their own health care services and programs.

* The Indian Health Care Improvement Act of 1976, which made it the nation's policy to "provide existing Indian health services with all resources necessary."