New Challenge for States: Indian Health Care.

• Author: Guiden, Mary
• Position: Brief Article

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...