"Challenges and Change"

By Michael H. Trujillo, M.D., M.P.H.
Assistant Surgeon General
Director, Indian Health Service

Submitted to U.S. Medicine

Last year the Indian Health Service responded to dramatic changes taking place inside and outside the government. The causes for change included budget reductions, the greater and welcome involvement of American Indian and Alaska Native governments in the Indian health care system, and technological innovations.

Every year brings pressures for change. Some pressures are more constant than others. As an example of this, almost twenty years ago I wrote a paper and identified pressures facing the Indian Health Service. They were: an increasing number of beneficiaries for health services; demand for all services; costs for health care, other goods, and staff; number of elderly; and increasing mandates for cost containment. I saw politics begin to play a larger role in the health care arena replacing the historic health-based focus of the Indian Health Service. Changing patterns of disease to more chronic conditions were influencing social and economic factors and the quality of life for American Indians and Alaska Natives.

Today those pressures of twenty years ago still exist, but have been intensified by an environment of unparalleled federal budget reductions, the transfer of many federal programs and resources to individual states, decreases to discretionary programs in the federal budget, and the overall erosion of resources. These are the forces that challenge our ability to provide quality health care services to American Indian and Alaska Native people.

In addition, leaders in government and health care are talking about changes in services that affect public health, the poor, and the underprivileged. There are a large number of public, social, and welfare programs that are being considered for budget cuts or elimination. Another pressure facing government agencies and programs is the strong anti-government sentiment across the nation and in Congress. The sentiment that the government is the major problem affects programs that directly serve American Indians and Alaska Natives on and off the reservations. We are seeing an erosion of resources and services that go to Indian Country to benefit our people. Indian health is greatly affected when the budgets of other agencies and Indian programs are reduced. Anti-government sentiment must not be allowed to be the reason the federal government ignores its responsibilities and treaty obligations to American Indian and Alaska Native people.

We are working with Indian people to change and restructure the agency. The Indian Health Service is an Indian health program and the concept of being an Indian program has to be reemphasized and acknowledged within the health care delivery system of the nation. One of the early contracts of the United States was with the sovereign governments of American Indians and Alaska Natives. American Indians and Alaska Natives believe in the treaties their forefathers signed. They gave up land, water rights, minerals rights, forests, and also their lives.

This year, for the fourth consecutive year, it appears the Indian Health Service will have a level budget appropriation. A level budget is a reduction of resources of approximately $100 million to account for mandatory cost increases, inflation, population growth, and providing services to newly recognized tribes. This year the budget will be further reduced because of the impact of the federal government shutdown. To keep essential health services continuing and to meet the federal government's obligations to sovereign tribal governments during the shutdown, the Indian Health Service redirected existing and carryover funds into direct service programs. It will be necessary to reimburse those accounts from this year's appropriation. Also, under the reduced and restricted funding levels of the continuing resolutions the Indian Health Service lost bulk and volume purchase discounts.

There will be continuing discussions of decreases to discretionary federal programs. It is the discretionary items that are being looked at very closely as Congress and the Administration attempt to balance the budget. The Indian Health Service is a discretionary program of the federal budget. Most of our programs are funded at only 60 or 70 percent of the level of need, and in some programs, mental health for example, it is at 30 to 40 percent of the level of need for Indian Country.

In addition to what is happening with budgets and the federal deficit, there is a shift in the administration and funding of federal programs by transferring administrative control and funding to the states. States are taking a larger role in the development and financial aspects of their service programs. States sometimes do not consider tribes or the Indian population when developing their programs, though states will count Indians as part of their population base and use that data for revenue generation. States often forget that American Indians and Alaska Natives are entitled to the same privileges and resources as any other state citizen. They make the assumption that Indian people have a relationship only with the federal government and their health and welfare is a only federal responsibility. That is not the case. This common misperception is one of the reasons tribes and Indian organizations must participate and be involved in discussions about health care at the state and federal level. It is a necessity for Indian tribes and organizations to be involved in the process of managing and directing their health care programs.

For example, changes in Medicaid and Medicare reimbursement funding will affect the ability of all of us to provide services. About 40% of the cost of running urban Indian clinics come from Medicaid reimbursements. For tribal, urban and Indian Health Service programs, collections from third party payers like Medicaid, Medicare, and private insurance programs will be the only new revenue sources for our programs. Indian tribes and organizations must follow and influence changes in the administration of this vital funding stream.

Another development that I view with concern is the reliance on managed care programs. Some programs that are being developed are backed by investors and are profit motivated. Those programs are market driven, which may not be consistent with the public good or public health. When priorities are profits, it often can be at the expense of individual and community wellness. Managed care programs can also define their area operations and the populations they serve to increase their profits. Sometimes Indian populations are not within the managed care areas of concern and are often not viewed by managed care programs as a profitable segment of the population.

There will be continuing emphasis on decentralizing, reorganizing, and decreasing the bureaucracy within the federal government. Any change to the Indian Health Service must recognize and honor the unique relationship between the federal government and Indian Nations and tribes, and strengthen those relationships. It must be emphasized that American Indians and Alaska Natives are not "just another ethnic minority." Many of our ancestors lost their lives to establish the legal, legislative, executive and constitutional basis for the unique federal government-to-tribal government relationship. The trend to reduce the size of the federal government cannot result in the reduction or dilution of historic trust and treaty obligations.

The Agency must continue changing the way it does business so that it will remain a quality health care program for Indian people. For the Indian Health Service, I will continue to address priorities and shift resources to the service levels. We have transferred or lost more than 900 people from the Headquarters and Area Office levels. The local service units have gained about 400 staff in the process. Those efforts will continue along with working closer with tribal and urban programs so that better health care is provided to American Indians and Alaska Natives. Those changes are in the best interests of all Indian people.

To help the Agency become more efficient and effective will involve the participation of a number of other partners, in addition to Indian organizations. We have to look to foundations, universities, independent organizations, and others who can assist us in the delivery of care. We must expand our search for partners in the health care arena.

During my tenure, there is going to be continued emphasis throughout the Agency and in our interactions with other health partners for complete recognition of the Indian Self-Determination process. All tribes will be included in the processes of the Agency to ensure fairness and balance. Major decisions of the Agency will include all tribes; those that contract, those that compact, and those that choose to stay within the federal system of health care delivery. I also want the development of the Indian Health Service budget to reflect the commitment to Self-Determination by including tribal participation in the budget process. At the present time, almost one-third of the Indian Health Service budget is going to tribes through contracts and compacts. I expect over the next 3-5 years for that to increase to at least half, if not more while maintaining the direct delivery services of the Agency.

Changing the Indian Health Service is only a part of improving the Indian health system. The Agency and the DHHS have been involved in a number of initiatives. We are participating in the Domestic Policy Council, headed by Secretary Babbitt of the Department of the Interior (DOI), and are looking at issues related to the protection of elders and children, telecommunication systems to provide information to remote and rural areas of our country, and the sharing of services for non-medical functions of our agencies. We are participating and are bringing along with us tribes and organizations to ensure that the DOI and other federal departments understand that they have to work directly with the American Indian and Alaska Native sovereign governments.

I will continue to emphasize elderly care, women's health issues, youth substance abuse prevention programs, mental health services, and ways to incorporate traditional healing methods into our programs. There is also a necessity for continuation of epidemiology and data systems in finance and health care programs so we can assess where we have been and where we hope to go.

It is essential that the Agency become involved in the development of clinical and administrative management leadership programs. We need to look at who is coming up the line in many of our programs, who will be taking responsibility, and who will be the Indian health leaders of tomorrow. We need to provide opportunities for them to develop their abilities so they are prepared when the time comes to take a leadership role in Indian health.

This year will be very important and challenging for the Indian Health Service and American Indian and Alaska Native people. Federal budget reductions, transfer of programs vital to the Indian Health Service to the states, and anti-government sentiment by the American public are relatively new and vastly different from the pressures we faced years ago. These external pressures are a challenge to the quality of life for all American Indians and Alaska Natives. We are responding to these pressures by strengthening our priority and commitment to patient and preventive health care. This coming year the Indian Health Service will meet these challenges and continue to be the best primary care health system in the world.