HSM 691 As an enrolled member of the Laguna Pueblo in New Mexico

CASEIndian Health Service:7Creating a Climatefor Change“As an enrolled member of the Laguna Pueblo in New Mexico,I am a member of the Sun Clan and have the name of my greatgrandfather, Osara, meaning ‘the sun’,” Dr. Michael Trujillotold the United States Senate Committee on Indian Affairs in1994 during his confirmation hearing as Director of the IndianHealth Service (see Exhibit 7/1). He told the committee that hehad known the remoteness of Neah Bay at the northwest tip ofWashington on the Makah reservation, lived in the Dakotas, andexperienced the winters and geographic barriers to health care inEagle Butte, Rosebud, and Twin Buttes. He had come before them,he also told them, “as the President’s nominee for the Director ofa national health care program that is essential to the well-beingof 1.3 million American Indians and Alaska Natives belongingto more than 500 federally recognized tribes.”This case was written by Robert J. Tosatto, US Public Health Service; Terrie C. Reeves,University of Wisconsin, Milwaukee; W. Jack Duncan, University of Alabama atBirmingham; and Peter M. Ginter, University of Alabama at Birmingham. All quotesare taken from statements made before committees of Congress or the housesof Congress by the person quoted. Used with permission from Terrie Reeves.Copyright © by Robert J. Tosatto, Terrie C. Reeves, W. Jack Duncan, and PeterM. Ginter and the North American Case Research Association. Reprinted by permission from the Case Research Journal. All rights reserved.both07.indd 56911/11/08 11:42:51 AM570C A S E 7 : I N D I A N H E A LT H S E R V I C EExhibit 7/1: Dr. Michael Trujillo: Chief Advocate for Indian HealthDr. Michael H. Trujillo was named Director of the Indian Health Service on April 9, 1994. His appointmentwas noteworthy for two reasons: (1) he was the first IHS Director appointed by the President of theUnited States and confirmed by the Senate; and (2) he was the first full-blooded American Indian tobe appointed Director of the IHS. Dr. Trujillo was a member of the Sun Clan in the Laguna Puebloin New Mexico. His parents were elementary school teachers for the Bureau of Indian Affairs andwere active in the political life of the pueblo. His grandfather was a governor of the pueblo and wasinstrumental in drafting the first Laguna Pueblo constitution. From an early age, Dr. Trujillo had beentaught and shown by example to feel an obligation to the Indian people.The first American Indian to graduate from the University of New Mexico School of Medicine,Dr. Trujillo received both his undergraduate and medical degrees from that institution. Family practiceand internal medicine were his specialties but he was also chosen for a clinical fellowship in preventive medicine at the Mayo Clinic. In addition, he received an MPH in Public Health Administration and Policy from the University of Minnesota School of Public Health.Dr. Trujillo had numerous assignments within the IHS prior to becoming Director. As an IHS physician,he worked with many tribes in diverse locations. As an IHS administrator, he was Deputy Area Directorand Chief Medical Officer for the Phoenix, Aberdeen, and Portland areas, as well as a Clinical SpecialtyConsultant to the Bemidji area. He initiated nationwide quality assurance programs and a medicalprovider recruitment program for urban Indian health centers.Shortly after being sworn in as Director, Trujillo released his vision for the Indian Health Service.He envisioned a new IHS: one that adapted to the challenges it faced, yet continued to be the bestprimary care, rural health system in the world; one that recognized the contributions and dedicationof employees, as well as the active participation of tribal members; one that was redesigned to bemore effective, efficient, and accountable. Trujillo cautioned that any change must be accomplishedin such a way that the Indian people noticed only improved quality of care.Trujillo’s position as IHS Director allowed him to be a strong advocate for Indians in all mattersregarding health. Not only did he want to improve IHS, but he also wanted improvement for theentire Indian health care system. IHS leadership and direction would provide the course the agencywould take in making these improvements.Three years later, Trujillo was in front of the same Committee discussing thefiscal year 1998 budget request for the Indian Health Service (IHS). For the fourthconsecutive year, the IHS would receive no after-inflation increase in its budgetallocation. But what Trujillo said in 1994 was still true: “We, who are involved inIndian health care, are facing a changing external environment with new demands,new needs, and a shifting political picture. The changing internal environmentdemands increased efficiency, effectiveness, and accountability.”Dr. Trujillo knew that in order to accomplish the agency’s mission, IHS musthonor past treaties as well as respect the beliefs and spiritual convictions of thevarious tribes. The need to respect local traditions and beliefs was formally recognized in Indian self-determination.The Indian peoples had always managed with very scarce resources. However,Dr. Trujillo was concerned. IHS had not developed an adequate third-party payorbilling system, it faced difficulty recruiting professional staff, and it served apopulation whose health status was below that of the rest of the United States.both07.indd 57011/11/08 11:42:52 AMHISTORICAL PERSPECTIVE571IHS was considered a discretionary agency in the congressional budget process.Dr. Trujillo recognized the need to increase the health status of IHS’s population inorder to gain continued congressional funding and support. He needed to answersome difficult and complex questions. How could Indian self-determination beimplemented? What should be IHS’s role in the future? How should IHS changeto best serve the self-determination of the Indian people?Dr. Trujillo knew that his most difficult task was to provide additional, muchneeded health services to a growing and needy population when there was littleprospect of increasing resources. Simultaneously, he had to ensure that localhealth needs were recognized and addressed.Indian Self-DeterminationIn January 1994, Dr. Trujillo told the same Committee that the local tribes and communities needed to be more involved in the decision-making process to facilitateIndian self-determination, the process by which the Indian people may choose toassume some degree of the administration and operation of their health services.The Indian Self-Determination and Education and Assistance Act was passedby Congress in 1975 and gave federally recognized tribes the option of staffing,managing, and operating the IHS programs in their communities. Dr. Trujillo wason record as fully supporting greater self-determination of all tribes as a means ofenabling Indian people to operate their own health care systems. He emphaticallystated that “During my tenure, there is going to be continued emphasis throughout the agency and in our interactions with other health partners for completerecognition of the Indian self-determination process.”Dr. Trujillo knew that self-determination was far from complete. AlthoughIHS still had many important functions to fulfill, putting health care backinto the hands of the tribes was proving to be difficult. Each tribe had different concepts of health, and it was difficult to accommodate such variety in agovernment agency. Moreover, in the face of scarce resources there was alwaysan inclination to centralize rather than decentralize decision making, and Dr.Trujillo knew that if the IHS created the impression that it could fulfill allthe needs of local communities, it would contribute to false expectations anddisappointment.Historical PerspectiveIHS had a clear mandate: to provide high-quality health services to AmericanIndians and Alaska Natives (AI/ANs). The basis for this responsibility was established and confirmed by numerous treaties, statutes, and executive orders. The firsttreaty between the US government and an American Indian tribe was signed in1784 and promised that the federal government would provide physician servicesto members of the Delaware Nation as partial payment for rights and propertyceded to the United States. Treaties were signed with many individual tribes andboth07.indd 57111/11/08 11:42:52 AM572C A S E 7 : I N D I A N H E A LT H S E R V I C Eperiodic appropriations were made by Congress to control specific diseases suchas smallpox and tuberculosis and to educate the tribes about disease. Recurringappropriations were not made until the Snyder Act of 1921, which authorizedhealth care services for AI/ANs by an act of Congress.Health care for Native Americans was originally the responsibility of theBureau of Indian Affairs; however the services provided were, in general, verypoor. Despite the employment of field nurses, the building of hospitals for NativeAmericans, and the addition of dental services, the health status of AI/ANsremained far behind that of the general population. For example, Indian infantmortality was more than double that of the general population and life expectancyfor Indians was ten years less than that of the rest of the United States.The major health problems found in the Native American population becameevident during World War II when thousands of Indians volunteered for servicein the US armed forces. The poor health of many Indian volunteers was notedduring induction physical examinations. Citing the AI/AN health statistics, variousstate, medical, and professional groups began a push to put the US Public HealthService (USPHS) in charge of health care for Native Americans. They argued thatthe Bureau of Indian Affairs could not run a quality health care system becausehealth was only one of its many concerns. Years of debate and political maneuvering followed. Finally the IHS officially became a division of the USPHS on July 1,1955. The Transfer Act stated “that all functions, responsibilities, authorities, andduties relating to the maintenance and operation of hospital and health facilitiesfor Indians, and the conservation of Indian health shall be administered by theSurgeon General of the United States Public Health Service.”Although the overall health status of AI/ANs did not improve immediately,much progress appeared over the longer term. Since 1973, infant mortality amongAI/ANs had decreased 60 percent and death due to tuberculosis dropped 80percent. During the same period, life expectancy for AI/ANs increased by morethan 12 years; life expectancy for AI/ANs was just 2.6 years below that of thegeneral population in the early 1990s.Over the years after the transfer, the IHS developed a model for the provisionof high-quality, comprehensive health services. A major component of this modelwas the involvement of the tribes in the provision of health services to their people. This provision had a “snowballing” effect. As the health status of their tribesimproved, more tribal members began to get involved in the provision of healthcare which, in turn, allowed the tribes to provide even more services.Congress followed up the Indian Self-Determination and Educational AssistanceAct with the Indian Health Care Improvement Act in 1976 and attempted to elevatethe health status of AI/ANs to a level equal to that of the general population. ThisAct gave IHS a larger budget, allowed expanded health services, and providedfor new and renovated medical facilities and construction of safe drinking waterand sanitary disposal facilities. In addition, it established scholarship and loanpayback programs to increase the number of Indian health professionals. IHS waselevated to agency status within the USPHS in 1988.This reflected the improvingreputation of IHS as an institution, as well as the growth of support for Indianself-determination and the IHS mission. See Exhibits 7/2 and 7/3.both07.indd 57211/11/08 11:42:52 AMT H E S E R V I C E P O P U L AT I O N573Exhibit 7/2: Timeline of Key Events in IHS History1784First treaty between the US government and an American Indian tribe signed.1849Bureau of Indian Affairs transferred from War Department to Department of the Interior.Physician services extended to Indians.1880sFirst federal hospital built for Indians.1908Professional medical supervision of Indian health activities established with positionof chief medical supervisor.1921The Snyder Act authorized Indian health services by the federal government (undercontrol of the Bureau of Indian Affairs).1955The Indian Health Service officially became a division of the United States PublicHealth Service (USPHS).1975Congress passed the Indian Self-Determination and Education Assistance Act.1976Congress passed the Indian Health Care Improvement Act.1988IHS was elevated to agency status within the USPHS. IHS was allowed to bill thirdparty payors where applicable.1994Dr. Michael Trujillo appointed as Director of the Indian Health Service.1995Preliminary recommendations of the Indian Health Design Team (a task force composedof Tribal leaders and IHS employees) published.1997Final recommendations of the Indian Health Design Team published.Exhibit 7/3: IHS MissionThe mission of the Indian Health Service, in partnership with American Indian and Alaska Nativepeople, is to raise their physical, mental, social, and spiritual health to the highest level.The Service Population: American Indians and Alaska NativesTraditional AI/AN beliefs concerning wellness, sickness, and treatment were different than the modern public health approach or the medical model. AmericanIndians’ and Alaskan Natives’ beliefs included close integration within family,clan, and tribe; harmony with the environment; and a continuing circle of life–birth, adolescence, adulthood, elder years, the passing-on, and then rebirth.Individual wellness was conceived of as the harmony and balance among mind,body, spirit, and the environment. Effective health services for AI/ANs had tointegrate the philosophies of the tribes with those of the medical community.Of the more than 2.4 million AI/ANs in the United States, approximately 1.4million belonged to the 545 federally recognized Indian tribes. All American Indiantribes were sovereign nations. Therefore, AI/ANs were citizens of both their tribesand of the United States. This meant that AI/ANs had a unique relationship withthe federal government. Based on the “treaty rights” established between most tribesand the United States, the federal government had a “trust responsibility” to theseboth07.indd 57311/11/08 11:42:53 AM574C A S E 7 : I N D I A N H E A LT H S E R V I C Etribes that entitled the Indian people to services such as education and health care.However, because not all tribes signed treaties with the United States, less thantwo-thirds of all people with an Indian heritage were eligible to participate in thefederal programs. Since October 1978, the Bureau of Indian Affairs had received215 letters of intent and petitions for federal recognition. Forty-one of these petitions have been resolved with 21 “new” tribes being recognized.The total number of AI/ANs eligible for IHS services in 1997 was approximately1.43 million and increased about 2.2 percent each year. Selected demographics ofthe service population are shown in Exhibits 7/4 through 7/10. Tribal memberslived mainly on reservations and in rural communities in 34 states.Exhibit 7/4: Service PopulationArea1990 (Census) PopulationAberdeenAlaskaAlbuquerqueBemidjiBillingsCaliforniaNashvilleNavajoOklahomaPhoenixPortlandTucson1997 (Estimated) Population74,78986,25167,50461,34947,008104,82848,943180,959262,517120,707127,77424,6071,207,236All Areas94,313103,71378,85179,93055,630119,97673,042215,232297,888140,969148,79127,6121,435,947Exhibit 7/5: Age Distribution (by percentage of total population)Percentage of TotalPopulation25Age Distribution20151050<11–45–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84Age in YearsAI/ANAll Races>85WhiteSource: Adapted from Trends in Indian Health 1996.both07.indd 57411/11/08 11:42:53 AMExhibit 7/6: Median Household Income (1990 Census)$36,784Median Household Income$40,000$31,435$35,000$24,156$30,000$19,758$19,897Black$25,000$30,056AI/AN$20,000$15,000$10,000$5,000$0HispanicWhiteAsianAll RacesSource: Adapted from Trends in Indian Health 1996.Percent of Total PopulationBelow Poverty LevelExhibit 7/7: Percent of Total Population Below Poverty Level3529.531.625.33025201514.113.19.81050WhiteAsianHispanicBlackAl/ANAll RacesSource: Adapted from Trends in Indian Health 1996.Rate per 1,000 LiveBirthsExhibit 7/8: Infant Mortality Rates7060504030201001955Infant Mortality RateAI/ANAll RacesWhite197519801985Calendar Year19901992Source: Adapted from Trends in Indian Health 1996.both07.indd 57511/11/08 11:42:54 AM576C A S E 7 : I N D I A N H E A LT H S E R V I C EExhibit 7/9: Overall Measures of HealthAI/ANLife Expectancy at Birth (Years)Years of Productive Life Lost(Rate per 1,000 population)Age-adjusted Mortality Rate(per 100,000 population)All RacesWhite73.575.576.383.055.649.9598.1513.7486.8Source: Adapted from Trends in Indian Health 1996.Exhibit 7/10: Leading Causes of Death, Hospitalization, and Outpatient VisitsLeading Causes of DeathHeart DiseasesAccidents (Motor Vehicle and Other)Chronic Liver Disease and CirrhosisPneumonia and InfluenzaChronic Obstructive Pulmonary DiseasesCancerDiabetes MellitusCerebrovascular DiseaseSuicideHomicideLeading Causes of HospitalizationObstetric Deliveries and Complicationsof PregnancyInjury and PoisoningGenitourinary System DiseasesEndocrine, Nutritional, and Metabolic DisordersRespiratory System DiseasesDigestive System DiseasesCirculatory System DiseasesMental DisordersSkin DiseasesLeading Causes of Outpatient VisitsRespiratory DiseasesEndocrine, Nutritional, and Metabolic DisordersMusculoskeletal System DiseasesComplications of Pregnancy and ChildbirthNervous System DiseasesInjury and PoisoningSkin DiseasesCirculatory System DiseasesSource: Adapted from Trends in Indian Health 1996.Similar to the nation’s health care system, IHS operated in an environment ofincreasing health care costs, growing numbers of beneficiaries, and excess demandfor services. The shift in disease patterns (from acute to chronic diseases) and theincreasing elderly population played an important role in health planning forthe IHS as well. As with the Veterans Administration, IHS was a health care providerwithin the US governmental system – though unlike the VA, the IHS was not aCabinet department and had no voice in policy making at the White House. Unlikeany other health care system in the country, IHS was subject to both the mandatesof Congress and the approval of more than 540 sovereign Indian Nations.both07.indd 57611/11/08 11:42:55 AMI H S T O D AY577IHS Today: A Key Component of the Indian Health Care SystemHealth care for AI/ANs was delivered through a system of interlocking programs. The system was composed of the IHS, the Tribal Programs, and the UrbanPrograms. IHS programs, called service units, were those projects and facilities thatwere directly staffed, operated, and administered by IHS personnel. As of October1995, there were 68 IHS-operated service units that administered 38 hospitals and112 health centers, school health centers, and health stations. Tribal programs werethose developed through the process of Indian self-determination. Administeredthrough 76 tribal-operated service units were 11 tribal program hospitals and 372health centers, school health centers, health stations, and Alaska village clinics.Urban programs were relatively new, but were expected to face a future of briskdemand because of the relocation of significant Indian populations from reservations to urban settings. The urban programs ranged from information referral andcommunity health services to comprehensive primary health care services. As ofOctober 1995, there were 34 Indian-operated urban programs.IHS headquarters and the IHS area offices had ties to the tribal governments as well as to the Indian-operated urban projects. The Indian and Alaskantribal governments had input into the decisions of IHS-operated Service Units.This interrelation between the federal government, tribal governments, andurban Indian groups was a key component of Indian health care management.Exhibit 7/11 shows various features of the Indian health care system.Exhibit 7/11: Elements of the Indian Health Care SystemIHS HeadquartersIndian and AlaskanTribal GovernmentsIndian-OperatedUrban ProjectsIHS Area OfficesService UnitsService UnitsHospitals, Health Clinics,and Extended Care FacilitiesHospitals, Health Centers,and Other ClinicsHealth Clinics, Outreach,and Referral FacilitiesNote: Solid lines reflect formal relationships; dashed lines (—–) reflect important but less formal relationships.Source: Adapted from Trends in Indian Health 1996.both07.indd 57711/11/08 11:42:56 AM578C A S E 7 : I N D I A N H E A LT H S E R V I C EExhibit 7/12: Executive Branch Organizational ChartThe President of theUnited StatesDepartment of Health andHuman Services• Office of the Secretary• Administration for Childrenand Families• Administration on Aging• Agency for Health CarePolicy and Research(AHCPR)• Agency for ToxicSubstances and DiseaseRegistry (ATSDR)• Centers for Disease Controland Prevention (CDC)• Food and DrugAdministration (FDA)• Health Care FinancingAdministration (HCFA)• Health Resources andServices Administration(HRSA)• Indian Health Service(IHS)• National Institutes of Health(NIH)• Program Support Center• Substance Abuse andMental Health ServicesAdministration (SAMHSA)Department of theInterior• Bureau of Indian AffairsOther Executive BranchDepartments••••••••••••AgricultureCommerceDefenseEducationEnergyHousing and UrbanDevelopmentJusticeLaborStateTransportationTreasuryVeterans AffairsTo further complicate the organizational structure, IHS was an OperatingDivision within the Department of Health and Human Services (DHHS). Exhibit7/12 shows the position of the IHS (in bold) on the organizational chart of theexecutive branch of the federal government.Within IHS, the organizational structure consisted of three levels: headquarters,area offices, and service units. IHS headquarters, located in Rockville, Maryland,both07.indd 57811/11/08 11:42:56 AMI H S T O D AY579Exhibit 7/13: IHS Area OfficesidmendegsBelinCaliniaforPhoenixrAbeanB ilr tlPodjiNavajoNashvilleAlbuquerqueTucsonAlaskaOklahomaSource: IHS Homepage (www.ihs.gov).was ultimately responsible for all policy, operations, and management decisions.The 12 area offices (see Exhibit 7/13) represented geographical regions and wereresponsible for performing various roles in administrative and program supportfor the local service units.Service units were composed of several types of facilities, including hospitals,health centers, health stations, and clinics. Depending on local preferences andcircumstances, these service units could exist as single entities or as combinationsof facilities. For example, the Fort Hall Service Unit in Idaho included only asingle health center, whereas the Pine Ridge Service Unit in South Dakota consisted of a hospital in Pine Ridge, health centers in Kyle and Wanblee, and smallhealth stations in Allen and Manderson.IHS Programs and InitiativesIn many (but not in all) cases, IHS provided comprehensive health care servicesto eligible AI/ANs. To be eligible for services, AI/ANs had to be membersof federally recognized tribes with whom the United States had treaty agreements. Services were provided through various programs and initiatives administered by the IHS, covering a full range of preventive health, behavioral health,medical care, and environmental health engineering services. The initiativesfocused on timely issues such as care of the elderly, women’s health, AIDS,both07.indd 57911/11/08 11:42:57 AM580C A S E 7 : I N D I A N H E A LT H S E R V I C EExhibit 7/14: IHS Programs and InitiativesIHS Services and ProgramsPreventive Health:Prenatal and Postnatal CareWell Baby CareImmunizationsFamily Planning ServicesWomen’s Health ProgramNutrition ProgramHealth Education ProgramCommunity Health Representative ProgramAccident and Injury…