Indian health care: Separate, unequal
Photos by Mark Henle
Federal care spending low, death rates high for tribes
By Judy Nichols
The Arizona Republic
April 14, 2002
Native Americans are dying at shocking rates. Of alcoholism, tuberculosis and diabetes. From accidents, suicide and homicide. At rates up to seven times higher than other Americans.
In Arizona, the average age at death for Whites is 72, compared with 55 for Native Americans. That's younger than for residents of Bangladesh.
The federal government, which promised in treaties to provide health care for Native Americans, spends less than half as much per tribal member as it does for programs covering other Americans. Private health plans spend more than twice as much per person.
"If this were happening in any other part of America, there would be Senate hearings, commissions," said Sergio Maldonado Sr., an Arapaho who is a program coordinator in the American Indian Studies program at Arizona State University.
They would be asking, 'Why are these people dying? Is it the water? The air? Anthrax? But because it's Arapaho, Sioux, the border towns around reservations, no one blinks an eye."
Maldonado said the lack of health care and differences in life span are a sign of continuing discrimination.
The leading causes of death for Native Americans are heart disease and cancer, the same as for other populations. But while those rates are closer to the norm, they are increasing as other populations are seeing improvements.
Native Americans die in accidents at more than three times the rate of other Americans, a fact so discouraging that federal officials say facetiously they wish for more disease.
"We'd love to have higher cancer rates," said Alan Dellapenna, deputy director of the Indian Health Service Office of Environmental Health and Engineering in Rockville, Md. "That would mean young people were living long enough to develop those kinds of diseases."
Promise madeIn the early 1800s, the push for westward expansion resulted in war between the United States and many Native American tribes. Treaties, which stripped Native Americans of more than 400 million acres of ancestral lands, promised health care, as well as peace.
"When people say, 'You get free health care,' I say, 'Bear sweat,' " Maldonado said. "There's no 'Free.' Blood was spilled."
Today, the Indian Health Service, part of the U.S. Department of Health and Human Services, provides care for about 1.5 million Native Americans, living on or near reservations, some of the most remote and impoverished parts of the country.
But it has never been fully funded.
This year's budget is $3.2 billion. But according to a study conducted by a group of tribal and Indian health leaders, more than $7 billion annually would be needed to provide care similar to that other Americans receive. And $15 billion would be needed to add and improve facilities to make the system equal.
The Indian Health Service spends about $1,920 per person annually. That compares with more than $4,390 that private insurance budgets for most Americans' health plans, or the federal government's $3,859 for Medicaid, $5,600 for Medicare and more than $5,700 that veterans receive.
"Health care for Native people has never been a high priority nationally," said U.S. Sen. Ben Nighthorse Campbell, R-Colo., a Cheyenne chief and the only Native American in the Senate.
Campbell, a member of the Senate Committee on Indian Affairs, said most Americans feel a moral debt of gratitude to veterans, but do not understand the "unique legal, moral and historic relationship with Indian tribes."
Funding also has suffered because of the evolving misconception of the "rich Indian," the mistaken belief that Native Americans were raking in money first from land and oil, and now, from casinos, Campbell said.
"These headline-grabbing myths lead policymakers to conclude that most Native Americans do not need federal assistance for health care," Campbell said. "Of course, the opposite is true. The vast majority of Native Americans remain mired in poor economic conditions and continue to suffer from significant health problems."
Sen. Tom Daschle, D-S.D., whose state has some of the highest death rates for Native Americans, is so concerned that he plans to request an additional $4.4 billion for the Indian Health Service this year.
"While Congress debates how to allocate trillions of dollars, medical treatment for American Indians and Alaska Natives is being rationed," said Daschle, who called the situation inexcusable.
Dr. Craig Vanderwagen, chief medical officer for the health service, acknowledges that the system is seriously flawed.
"We don't feel good about the number of patients who need care who are rejected because their problem is not life-threatening," said Vanderwagen, based in Rockville, Md. "It's rationing. We hold them off until they're sick enough to meet our criteria. That's not a good way to practice medicine. It's not the way providers like to practice. And if I were an Indian tribal leader, I'd be frustrated."
But there is little or no support from others in Congress, said Dr. Stephen Kunitz, a professor of community and preventive medicine at the University of Rochester School of Medicine who worked for IHS and has studied it for many years.
"Virtually no one has an interest in funding it except the Indians themselves," Kunitz said.
The bulge was small at first. Just a bump, really. Sticking out near Felipe Robles' backbone. But it grew. It grew until it was the size of his fist. Until he had to struggle to get out of bed. Until he couldn't stand without his carved rattlesnake-head cane.
At first, doctors thought it was cancer. They were wrong.
The disease lodged in his spine, gnawing away at his vertebra, was something you expect to see in someone's lungs: tuberculosis.
The rate of TB in Native Americans is more than five times greater than for other Americans.
"I got it three years ago, when I was in jail," said Robles, 46, a Pima. "I was stuck in a cell for three days with a guy who was coughing a lot. I finally asked him what was wrong and he told me he had TB. I called the guards and they pulled me out of there, but I guess it was too late."
When the lump appeared, Robles went to a clinic in Guadalupe, but was turned away because he had no insurance. Eventually, he ended up at the Phoenix Indian Medical Center, where his name is on a growing list of patients who are closely monitored, watched each time they take their medication, for one year. Any less, and the TB might not die, might spread to someone else.
Robles can't work any more and may need surgery to stabilize his spine.
"I'm scared," Robles said. 'I'm afraid a slight move in the wrong direction and I'll be paralyzed from the waist down."
For now, he spends his days reading the Bible at the Phoenix halfway house where he lives.
"I'm not proud of my past," said Robles, who has been in prison for drug charges. "But I'm born-again now. I'm trying to do the right thing."
The first health care for Native Americans, provided by the U.S. Army, was designed to protect Whites from uncontrolled epidemics of smallpox, measles, diphtheria and malaria. The diseases, brought by Whites, devastated the Native populations, which never had been exposed, and threatened to boomerang into the ranks of the military and the settlers.
Eventually, health care was taken over by the Bureau of Indian Affairs, then moved to the U.S. Department of Health, Education and Welfare, now Health and Human Services.
Model of efficiencyThe blueprint for the Indian Health Service is seen as a model of efficiency, studied by countries around the world. It offers cradle-to-grave care and one-stop shopping at its hospitals, where medical, dental, podiatry, psychiatry, optometry and even pharmacy services are available. And its public health arm builds water and sewer systems on far-flung reservations.
Through efforts to reduce infectious disease, increase immunizations and improve water system, the service greatly upgraded Native American health in the 1950s and '60s, significantly reducing infant mortality rates and deaths from gastrointestinal diseases.
The system has been less successful dealing with behavioral health problems like alcoholism, drug abuse and obesity.
Native Americans have the worst diabetes rates in the world, nearly four times greater than other Americans, and the worst alcoholism rates in the country, more than seven times greater.
"When you're dealing with these conditions - consuming food, alcohol, tobacco - you're dealing with people's beliefs, values and behaviors," said Kunitz,of the University of Rochester. "It's very hard for the health system to address these as effectively as they could address the contaminated water supply."
Some Native Americans say they must do more for themselves, eat right, exercise more, restore balance, all teachings of their elders.
"We have a moral imperative to take care of ourselves," said Maldonado, of ASU. "We can't point all the fingers at the Indian Health Service."
Inequalities exist in the system, sometimes for logical reasons, sometimes because of politics. For example, in Alaska, where it costs more to deliver care to remote Native villages accessible only by plane, IHS spends more than $6,080 per person annually for health care. But in the Kayenta area of the Navajo Nation, it spends only $766 per person.
The limited funding, isolated locations and lack of support staff all make it difficult to recruit and retain doctors, nurses, dentists, pharmacists and other health professionals.
Many in the system call the pay abysmal, offering examples like ophthalmologists, who make $100,000 at IHS, but can make twice that in private practice. And there are high vacancy rates - 17 percent for nurses at Phoenix Indian Medical Center.
"The people who are here are not here for the money," said Dr. Ken Steward, head of the Emergency Department at the Gallup Indian Medical Center. "They're hardworking, conscientious. Money is a secondary consideration."
The tight budget also forces the system to focus on primary care. Patients needing specialists, for things like heart operations, hand surgery and neurology, must be referred to doctors and hospitals in the private sector. The service has limited funds for this "contract" care, however, and the money runs out each year.
So the service often guarantees payment only for people who may die. Others must pay for the care themselves, or qualify for Medicare, Medicaid or other private insurance.
Lita Piffero quit worrying about her dignity long ago.
"I was down there at the clinic crying, literally begging for help," said Piffero, 48, who lives in Southern Bands, near Elko, Nev.
When Piffero's 14-year-old daughter hurt her foot in gym class in November, Piffero took her to the Indian Health Service clinic near Elko because there are no IHS hospitals in Nevada.
An X-ray revealed a deformity of the bone, Piffero said, and the doctor recommended magnetic resonance imaging, possibly surgery, services not available through the Indian Health Service. Piffero was told her daughter was being referred out, but that the service wouldn't pay for it. Piffero, who is unemployed, was told to apply for Medicaid.
"Medicaid took the full 45 days to decide," Piffero said. "We had to wait."
Her daughter limped through school on crutches.
When Piffero finally was approved for Medicaid, Piffero said the private doctor refused to do the MRI, saying he would lose money on a Medicaid patient. He referred them to Elko Hospital. Piffero said they still are waiting for an appointment. "I worry about what else they won't do because it's Medicaid," said Piffero, crying.
"She's only 14. She doesn't deserve to be treated any less than anyone else. This is her foot. I don't want her to be deformed.
"It just seems like unless you're on your deathbed, you can't go for services."
Her legs, which peek out from her traditional three-tiered calico skirt, are wrapped in cotton stockings, but they're still cold. She has high blood pressure and thyroid problems, but otherwise Nettie Yazzie, 92, who lives on the Navajo reservation, is remarkably healthy.
She gets B-12 shots from a public health nurse who visits her home, and occasionally sees a doctor for a check-up. But she attributes her longevity to eating lots of corn, the symbol of life for many Native Americans, and childhood visits to medicine men who taught her to make medicinal teas from herbs.
In fact, Native civilizations had extensive knowledge of diseases and medicines, knowledge that has contributed to Western medicine. And many still use a combination of Native and Western medicine.
As part of a move toward self-determination, many tribes are taking over their own health care, running their hospitals and clinics and deciding how to spend federal dollars.
More than 40 percent of the system now is run by tribes or the non-profit groups they have hired. In February, the Navajo Nation rejected a takeover of its $500 million system, but is considering running the programs in three small communities.
"IHS is going to continue to exist," the University of Rochester's Kunitz said. "What is unclear is whether it will increasingly be a pass-through program or continue to be a provider of services."
Either way, more money is needed.
Although the Native American population served by the Indian Health Service is growing by about 2 percent each year, and medical costs are rising at about 10 to 12 percent a year, the agency's budget has remained nearly flat, which means services fall farther and farther behind.
"If Congress in its wisdom, or malevolence, or thoughtlessness holds funding constant or at a 1 to 2 percent increase, things will get worse," Kunitz said.
Reach the reporter at mailto:judy.nichols@arizonarepublic.comor (602) 444-8577.
CheyFire
No comments:
Post a Comment