In 1976, the United States undertook in the Indian Health Care Improvement Act (IHCIA), 25 U.S.C. § 1601 et seq., a commitment to provide “the highest possible health status for Indians.” That commitment, which was preceded by many treaties promising health care to Indian tribes, was reaffirmed in 1992. Portions of the act expired in 2001. While the authorization to provide federal funds for Indian health problems still exists in a broad 1921 statute providing for federal health care for Indians, the failure of Congress to reauthorize the health care act (including amendments to strengthen the Indian health program) for the past five years has clouded the federal commitment.
In some sections of the public, a view apparently exists that the entire federal effort to improve the health status of Indians has failed and should be abandoned. For example, Dr. David Eichler, the president of the Alaska Dental Society, has denounced the entire concept of a federally funded health program for Indian and Alaska Native peoples in the January 2006 Alaska Dental Society newsletter.
“One reason for failure,” he commented in a version of his article available on the Internet, “is because the socialist model removes any responsibility from the client and breeds resentment because of dependency. . . . We establish the Natives as de facto slaves . . . The most effective action we could take would be to remove all special federal assistance for all American Indians” in order to allow “their integration into American society as dignified citizens.” See Posting of Dr. David Eichler, northpoledentist@gci.net, to owner-dental-publichealth@list.pitt.edu (Mar. 1, 2006)(copy on file with author). Eichler’s lack of knowledge about the origins and reasons for the federal commitment to Indian and Alaska Native health care is revealed by his statement, “For some reason in the 1920’s [sic] the federal government decided to establish by legislation that it would take upon itself the role of health care provider for American Indians.”
His point of view ignores both the federal obligation to provide health services to Indians in exchange for the relinquishment of vast tracts of Indian land and the impressive improvement in Indian and Alaska Native health care that the Indian Health Service (IHS) has made since it was founded in l955. For example, between the early 1970s and 2002, the tuberculosis mortality rate for Indians and Alaska Natives was reduced by 80 percent, the cervical cancer rate by 76 percent, the infant mortality rate by 66 percent, and the maternal mortality rate by 64 percent.
Eichler asserts that abolishing the IHS program would improve Indian health status. Yet many Indians and Natives live in remote areas where access to non-IHS health care is very limited or nonexistent. And, notwithstanding the accomplishments of the IHS, Indians remain afflicted by many diseases at higher rates than other Americans.
In addition, since native people now live longer, they face increasing risks from certain diseases that come with age. They are in greater need of nursing care, long-term care, and home health care, which the IHS has provided rarely and reluctantly. In addition, diabetes is one of the fastest growing threats to native health. The Indian death rate from diabetes is 3.3 times that of non-Hispanic whites. Cervical cancer death rates are still 3.8 times higher.
I have been actively involved in the administration of Indian health programs, serving as chair of the board of the Bristol Bay Area Health Corporation, a tribal organization that provides health services to Natives in the 45,000-square-mile Bristol Bay region of Alaska. I have also been chair of the Alaska Native Health Board, and I am currently chair of the Alaska Native Medical Center Joint Operating Board and the National Indian Health Board. It boggles my mind that anyone can describe the agency that has accomplished so much to improve Indian health status as “enslaving” native people. While I have been involved in addressing Indian health problems, a major innovation has been the decentralization of the IHS program through the transfer of responsibilities from the federal bureaucracy to Indian tribes and tribal organizations. In Alaska, the entire delivery of federally funded health care to Native villages is in the hands of the villages themselves or their designees.
The United States needs to stay the course. The pending Senate bill to reauthorize the IHCIA broadens authorization to meet contemporary health-care needs in Indian Country, including strengthening the present diabetes program and express authorization for long-term care, home health care, hospice, and assisted living. The latter are especially important in remote rural areas because the elderly should be able to stay home among their friends and family during their last years.
The bill also includes provisions to address the deterioration of federally owned Indian health facilities, including water and sewer facilities. In Alaska Native villages, due to minimal water facilities, the infant pneumonia hospitalization rate is eleven times the national average. The shocking state of many of the buildings in which Indians receive the federal health care to which they are entitled is a particularly appalling feature of the contemporary scene in Indian Country.
Congress not only needs to authorize these programs, it also needs to fund them. There is at present a backlog of $429 million for essential maintenance, alteration, and repair of Indian health facilities. This has not been a priority with the budget people in the Bush administration, who asked Congress for $52,668,000, an increase of only $1 million, an adjustment for inflation, in the 2007 budget request.
The pending bill also includes provisions designed to increase the number and effectiveness of health-care professionals in Indian Country. Building on the experience with the effective community health aide program in Alaska, it would authorize the extension of that program to Indian Country throughout the United States. The bill would also encourage the government to expedite the construction of new health-care facilities, including water and sewer facilities, to serve Indian and Alaska Native communities, addressing the serious deficiencies in both the number and condition of existing facilities, and it would strengthen the ability of Indian people to recover reimbursement for the costs of healthcare from nationally available programs such as Medicare and Medicaid, in which they are entitled to share but frequently encounter barriers to enrollment.
Without diminishing the federal commitment to health care in Indian Country, the bill would also address the availability of health care for some 650,000 Indians who live in urban areas in the United States by eliminating some of the disparities between programs for reservation Indians and urban Indians.
Indians are grateful to the American Bar Association for calling on Congress to pass the IHCIA reauthorization in 2004 and again in 2005. While gains in Indian health over the past fifty years are evident, the shortages in both staffing and facilities call for a renewed legislative initiative. Even as the United States faces the many challenges of the twenty-first century, Indian and Alaska Native health care should not be relegated to the back burner.
As published in Human Rights, Spring 2006, Vol. 33, No. 2, pp.22-23.