CASE Indian Health Service: 7 Creating a Climate for 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 great grandfather, Osara, meaning 'the sun',\" Dr. Michael Trujillo told the United States Senate Committee on Indian Affairs in 1994 during his conrmation hearing as Director of the Indian Health Service (see Exhibit 7/1). He told the committee that he had known the remoteness of Neah Bay at the northwest tip of Washington on the Makah reservation, lived in the Dakotas, and experienced the winters and geographic barriers to health care in Eagle Butte, Rosebud, and Twin Buttes. He had come before them, he also told them, \"as the President's nominee for the Director of a national health care program that is essential to the well-being of 1.3 million American Indians and Alaska Natives belonging to 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 at Birmingham; and Peter M. Ginter, University of Alabama at Birmingham. All quotes are taken from statements made before committees of Congress or the houses of Congress by the person quoted. Used with permission from Terrie Reeves. Copyright by Robert J. Tosatto, Terrie C. Reeves, W. Jack Duncan, and Peter M. Ginter and the North American Case Research Association. Reprinted by permission from the Case Research Journal. All rights reserved. both07.indd 569 11/11/08 11:42:51 AM 570 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/1: Dr. Michael Trujillo: Chief Advocate for Indian Health Dr. Michael H. Trujillo was named Director of the Indian Health Service on April 9, 1994. His appointment was noteworthy for two reasons: (1) he was the rst IHS Director appointed by the President of the United States and conrmed by the Senate; and (2) he was the rst full-blooded American Indian to be appointed Director of the IHS. Dr. Trujillo was a member of the Sun Clan in the Laguna Pueblo in New Mexico. His parents were elementary school teachers for the Bureau of Indian Affairs and were active in the political life of the pueblo. His grandfather was a governor of the pueblo and was instrumental in drafting the rst Laguna Pueblo constitution. From an early age, Dr. Trujillo had been taught and shown by example to feel an obligation to the Indian people. The rst 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 practice and 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 Director and Chief Medical Ofcer for the Phoenix, Aberdeen, and Portland areas, as well as a Clinical Specialty Consultant to the Bemidji area. He initiated nationwide quality assurance programs and a medical provider 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 best primary care, rural health system in the world; one that recognized the contributions and dedication of employees, as well as the active participation of tribal members; one that was redesigned to be more effective, efcient, and accountable. Trujillo cautioned that any change must be accomplished in 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 matters regarding health. Not only did he want to improve IHS, but he also wanted improvement for the entire Indian health care system. IHS leadership and direction would provide the course the agency would take in making these improvements. Three years later, Trujillo was in front of the same Committee discussing the scal year 1998 budget request for the Indian Health Service (IHS). For the fourth consecutive year, the IHS would receive no after-ination increase in its budget allocation. But what Trujillo said in 1994 was still true: \"We, who are involved in Indian health care, are facing a changing external environment with new demands, new needs, and a shifting political picture. The changing internal environment demands increased efciency, effectiveness, and accountability.\" Dr. Trujillo knew that in order to accomplish the agency's mission, IHS must honor past treaties as well as respect the beliefs and spiritual convictions of the various 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 payor billing system, it faced difculty recruiting professional staff, and it served a population whose health status was below that of the rest of the United States. both07.indd 570 11/11/08 11:42:52 AM HISTORICAL PERSPECTIVE 571 IHS was considered a discretionary agency in the congressional budget process. Dr. Trujillo recognized the need to increase the health status of IHS's population in order to gain continued congressional funding and support. He needed to answer some difcult and complex questions. How could Indian self-determination be implemented? What should be IHS's role in the future? How should IHS change to best serve the self-determination of the Indian people? Dr. Trujillo knew that his most difcult task was to provide additional, much needed health services to a growing and needy population when there was little prospect of increasing resources. Simultaneously, he had to ensure that local health needs were recognized and addressed. Indian Self-Determination In 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 facilitate Indian self-determination, the process by which the Indian people may choose to assume some degree of the administration and operation of their health services. The Indian Self-Determination and Education and Assistance Act was passed by Congress in 1975 and gave federally recognized tribes the option of stafng, managing, and operating the IHS programs in their communities. Dr. Trujillo was on record as fully supporting greater self-determination of all tribes as a means of enabling Indian people to operate their own health care systems. He emphatically stated that \"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.\" Dr. Trujillo knew that self-determination was far from complete. Although IHS still had many important functions to fulll, putting health care back into the hands of the tribes was proving to be difcult. Each tribe had different concepts of health, and it was difcult to accommodate such variety in a government agency. Moreover, in the face of scarce resources there was always an inclination to centralize rather than decentralize decision making, and Dr. Trujillo knew that if the IHS created the impression that it could fulll all the needs of local communities, it would contribute to false expectations and disappointment. Historical Perspective IHS had a clear mandate: to provide high-quality health services to American Indians and Alaska Natives (AI/ANs). The basis for this responsibility was established and conrmed by numerous treaties, statutes, and executive orders. The rst treaty between the US government and an American Indian tribe was signed in 1784 and promised that the federal government would provide physician services to members of the Delaware Nation as partial payment for rights and property ceded to the United States. Treaties were signed with many individual tribes and both07.indd 571 11/11/08 11:42:52 AM 572 C A S E 7 : I N D I A N H E A LT H S E R V I C E periodic appropriations were made by Congress to control specic diseases such as smallpox and tuberculosis and to educate the tribes about disease. Recurring appropriations were not made until the Snyder Act of 1921, which authorized health care services for AI/ANs by an act of Congress. Health care for Native Americans was originally the responsibility of the Bureau of Indian Affairs; however the services provided were, in general, very poor. Despite the employment of eld nurses, the building of hospitals for Native Americans, and the addition of dental services, the health status of AI/ANs remained far behind that of the general population. For example, Indian infant mortality was more than double that of the general population and life expectancy for Indians was ten years less than that of the rest of the United States. The major health problems found in the Native American population became evident during World War II when thousands of Indians volunteered for service in the US armed forces. The poor health of many Indian volunteers was noted during induction physical examinations. Citing the AI/AN health statistics, various state, medical, and professional groups began a push to put the US Public Health Service (USPHS) in charge of health care for Native Americans. They argued that the Bureau of Indian Affairs could not run a quality health care system because health was only one of its many concerns. Years of debate and political maneuvering followed. Finally the IHS ofcially became a division of the USPHS on July 1, 1955. The Transfer Act stated \"that all functions, responsibilities, authorities, and duties relating to the maintenance and operation of hospital and health facilities for Indians, and the conservation of Indian health shall be administered by the Surgeon 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 among AI/ANs had decreased 60 percent and death due to tuberculosis dropped 80 percent. During the same period, life expectancy for AI/ANs increased by more than 12 years; life expectancy for AI/ANs was just 2.6 years below that of the general population in the early 1990s. Over the years after the transfer, the IHS developed a model for the provision of high-quality, comprehensive health services. A major component of this model was 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 tribes improved, more tribal members began to get involved in the provision of health care which, in turn, allowed the tribes to provide even more services. Congress followed up the Indian Self-Determination and Educational Assistance Act with the Indian Health Care Improvement Act in 1976 and attempted to elevate the health status of AI/ANs to a level equal to that of the general population. This Act gave IHS a larger budget, allowed expanded health services, and provided for new and renovated medical facilities and construction of safe drinking water and sanitary disposal facilities. In addition, it established scholarship and loan payback programs to increase the number of Indian health professionals. IHS was elevated to agency status within the USPHS in 1988.This reected the improving reputation of IHS as an institution, as well as the growth of support for Indian self-determination and the IHS mission. See Exhibits 7/2 and 7/3. both07.indd 572 11/11/08 11:42:52 AM T H E S E R V I C E P O P U L AT I O N 573 Exhibit 7/2: Timeline of Key Events in IHS History 1784 First treaty between the US government and an American Indian tribe signed. 1849 Bureau of Indian Affairs transferred from War Department to Department of the Interior. Physician services extended to Indians. 1880s First federal hospital built for Indians. 1908 Professional medical supervision of Indian health activities established with position of chief medical supervisor. 1921 The Snyder Act authorized Indian health services by the federal government (under control of the Bureau of Indian Affairs). 1955 The Indian Health Service ofcially became a division of the United States Public Health Service (USPHS). 1975 Congress passed the Indian Self-Determination and Education Assistance Act. 1976 Congress passed the Indian Health Care Improvement Act. 1988 IHS was elevated to agency status within the USPHS. IHS was allowed to bill thirdparty payors where applicable. 1994 Dr. Michael Trujillo appointed as Director of the Indian Health Service. 1995 Preliminary recommendations of the Indian Health Design Team (a task force composed of Tribal leaders and IHS employees) published. 1997 Final recommendations of the Indian Health Design Team published. Exhibit 7/3: IHS Mission The mission of the Indian Health Service, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level. The Service Population: American Indians and Alaska Natives Traditional AI/AN beliefs concerning wellness, sickness, and treatment were different than the modern public health approach or the medical model. American Indians' 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 to integrate 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 1.4 million belonged to the 545 federally recognized Indian tribes. All American Indian tribes were sovereign nations. Therefore, AI/ANs were citizens of both their tribes and of the United States. This meant that AI/ANs had a unique relationship with the federal government. Based on the \"treaty rights\" established between most tribes and the United States, the federal government had a \"trust responsibility\" to these both07.indd 573 11/11/08 11:42:53 AM 574 C A S E 7 : I N D I A N H E A LT H S E R V I C E tribes 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 than two-thirds of all people with an Indian heritage were eligible to participate in the federal programs. Since October 1978, the Bureau of Indian Affairs had received 215 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 approximately 1.43 million and increased about 2.2 percent each year. Selected demographics of the service population are shown in Exhibits 7/4 through 7/10. Tribal members lived mainly on reservations and in rural communities in 34 states. Exhibit 7/4: Service Population Area 1990 (Census) Population Aberdeen Alaska Albuquerque Bemidji Billings California Nashville Navajo Oklahoma Phoenix Portland Tucson 1997 (Estimated) Population 74,789 86,251 67,504 61,349 47,008 104,828 48,943 180,959 262,517 120,707 127,774 24,607 1,207,236 All Areas 94,313 103,713 78,851 79,930 55,630 119,976 73,042 215,232 297,888 140,969 148,791 27,612 1,435,947 Exhibit 7/5: Age Distribution (by percentage of total population) Percentage of Total Population 25 Age Distribution 20 15 10 5 0 <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 age in years aian all races>85 White Source: Adapted from Trends in Indian Health 1996. both07.indd 574 11/11/08 11:42:53 AM Exhibit 7/6: Median Household Income (1990 Census) $36,784 Median Household Income $40,000 $31,435 $35,000 $24,156 $30,000 $19,758 $19,897 Black $25,000 $30,056 AI/AN $20,000 $15,000 $10,000 $5,000 $0 Hispanic White Asian All Races Source: Adapted from Trends in Indian Health 1996. Percent of Total Population Below Poverty Level Exhibit 7/7: Percent of Total Population Below Poverty Level 35 29.5 31.6 25.3 30 25 20 15 14.1 13.1 9.8 10 5 0 White Asian Hispanic Black Al/AN All Races Source: Adapted from Trends in Indian Health 1996. Rate per 1,000 Live Births Exhibit 7/8: Infant Mortality Rates 70 60 50 40 30 20 10 0 1955 Infant Mortality Rate AI/AN All Races White 1975 1980 1985 Calendar Year 1990 1992 Source: Adapted from Trends in Indian Health 1996. both07.indd 575 11/11/08 11:42:54 AM 576 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/9: Overall Measures of Health AI/AN Life Expectancy at Birth (Years) Years of Productive Life Lost (Rate per 1,000 population) Age-adjusted Mortality Rate (per 100,000 population) All Races White 73.5 75.5 76.3 83.0 55.6 49.9 598.1 513.7 486.8 Source: Adapted from Trends in Indian Health 1996. Exhibit 7/10: Leading Causes of Death, Hospitalization, and Outpatient Visits Leading Causes of Death Heart Diseases Accidents (Motor Vehicle and Other) Chronic Liver Disease and Cirrhosis Pneumonia and Inuenza Chronic Obstructive Pulmonary Diseases Cancer Diabetes Mellitus Cerebrovascular Disease Suicide Homicide Leading Causes of Hospitalization Obstetric Deliveries and Complications of Pregnancy Injury and Poisoning Genitourinary System Diseases Endocrine, Nutritional, and Metabolic Disorders Respiratory System Diseases Digestive System Diseases Circulatory System Diseases Mental Disorders Skin Diseases Leading Causes of Outpatient Visits Respiratory Diseases Endocrine, Nutritional, and Metabolic Disorders Musculoskeletal System Diseases Complications of Pregnancy and Childbirth Nervous System Diseases Injury and Poisoning Skin Diseases Circulatory System Diseases Source: Adapted from Trends in Indian Health 1996. Similar to the nation's health care system, IHS operated in an environment of increasing health care costs, growing numbers of beneciaries, and excess demand for services. The shift in disease patterns (from acute to chronic diseases) and the increasing elderly population played an important role in health planning for the IHS as well. As with the Veterans Administration, IHS was a health care provider within the US governmental system - though unlike the VA, the IHS was not a Cabinet department and had no voice in policy making at the White House. Unlike any other health care system in the country, IHS was subject to both the mandates of Congress and the approval of more than 540 sovereign Indian Nations. both07.indd 576 11/11/08 11:42:55 AM I H S T O D AY 577 IHS Today: A Key Component of the Indian Health Care System Health care for AI/ANs was delivered through a system of interlocking programs. The system was composed of the IHS, the Tribal Programs, and the Urban Programs. IHS programs, called service units, were those projects and facilities that were directly staffed, operated, and administered by IHS personnel. As of October 1995, there were 68 IHS-operated service units that administered 38 hospitals and 112 health centers, school health centers, and health stations. Tribal programs were those developed through the process of Indian self-determination. Administered through 76 tribal-operated service units were 11 tribal program hospitals and 372 health centers, school health centers, health stations, and Alaska village clinics. Urban programs were relatively new, but were expected to face a future of brisk demand because of the relocation of signicant Indian populations from reservations to urban settings. The urban programs ranged from information referral and community health services to comprehensive primary health care services. As of October 1995, there were 34 Indian-operated urban programs. IHS headquarters and the IHS area ofces had ties to the tribal governments as well as to the Indian-operated urban projects. The Indian and Alaskan tribal governments had input into the decisions of IHS-operated Service Units. This interrelation between the federal government, tribal governments, and urban 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 System IHS Headquarters Indian and Alaskan Tribal Governments Indian-Operated Urban Projects IHS Area Ofces Service Units Service Units Hospitals, Health Clinics, and Extended Care Facilities Hospitals, Health Centers, and Other Clinics Health Clinics, Outreach, and Referral Facilities Note: Solid lines reect formal relationships; dashed lines (-----) reect important but less formal relationships. Source: Adapted from Trends in Indian Health 1996. both07.indd 577 11/11/08 11:42:56 AM 578 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/12: Executive Branch Organizational Chart The President of the United States Department of Health and Human Services Ofce of the Secretary Administration for Children and Families Administration on Aging Agency for Health Care Policy and Research (AHCPR) Agency for Toxic Substances and Disease Registry (ATSDR) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Health Care Financing Administration (HCFA) Health Resources and Services Administration (HRSA) Indian Health Service (IHS) National Institutes of Health (NIH) Program Support Center Substance Abuse and Mental Health Services Administration (SAMHSA) Department of the Interior Bureau of Indian Affairs Other Executive Branch Departments Agriculture Commerce Defense Education Energy Housing and Urban Development Justice Labor State Transportation Treasury Veterans Affairs To further complicate the organizational structure, IHS was an Operating Division within the Department of Health and Human Services (DHHS). Exhibit 7/12 shows the position of the IHS (in bold) on the organizational chart of the executive branch of the federal government. Within IHS, the organizational structure consisted of three levels: headquarters, area ofces, and service units. IHS headquarters, located in Rockville, Maryland, both07.indd 578 11/11/08 11:42:56 AM I H S T O D AY 579 Exhibit 7/13: IHS Area Ofces id m en de gs Be lin Cali nia for Phoenix r Abe an B il r tl Po d ji Navajo Nashville Albuquerque Tucson Alaska Oklahoma Source: IHS Homepage (www.ihs.gov). was ultimately responsible for all policy, operations, and management decisions. The 12 area ofces (see Exhibit 7/13) represented geographical regions and were responsible for performing various roles in administrative and program support for 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 and circumstances, these service units could exist as single entities or as combinations of facilities. For example, the Fort Hall Service Unit in Idaho included only a single 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 small health stations in Allen and Manderson. IHS Programs and Initiatives In many (but not in all) cases, IHS provided comprehensive health care services to eligible AI/ANs. To be eligible for services, AI/ANs had to be members of 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 initiatives focused on timely issues such as care of the elderly, women's health, AIDS, both07.indd 579 11/11/08 11:42:57 AM 580 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/14: IHS Programs and Initiatives IHS Services and Programs Preventive Health: Prenatal and Postnatal Care Well Baby Care Immunizations Family Planning Services Women's Health Program Nutrition Program Health Education Program Community Health Representative Program Accident and Injury Reduction Program Medical: Inpatient Hospitalization Outpatient Services Emergency Services Pharmacy Program Laboratory Program Nursing Program Contract Health Services IHS Initiatives: AIDS Initiative Traditional Medicine Initiative Indian Youth Initiative Maternal and Child Health Initiative Sanitation Facilities Initiative Indian Women's Health Initiative Injury Prevention Initiative Elder Care Initiative Otitis Media Initiative State Initiative Environmental Health and Engineering: Water and Waste Treatment Food Protection Environmental Safety and Planning Pollution Control Insect Control Occupational Safety and Health Facility Construction and Maintenance Behavioral Health: Mental Health Program Social Services Alcohol and Substance Abuse Program Diabetes Program traditional medicine practices, and injury prevention, as shown in Exhibit 7/14. However, in some locations, the IHS did not have the necessary equipment or facilities to provide comprehensive services. In these instances, services which were not readily accessible to AI/ANs could be provided under contracted health services with local hospitals, state and local health agencies, tribal health institutions, and individual health care providers. In its relatively short history, the IHS had contributed to tremendous improvements in the health status of its service population. Some of the many reasons for these status improvements included increased primary medical care services, sanitation facility construction, and community health education programs. The IHS was often instrumental in the infrastructure changes. Exhibit 7/15 shows some of the more impressive accomplishments of the IHS. IHS Personnel The Indian Health Service employed a workforce of approximately 15,000 people. Of these, more than 62 percent were of American Indian or Alaska Native both07.indd 580 11/11/08 11:42:58 AM I H S T O D AY 581 Exhibit 7/15: Program Accomplishments Percent Decrease in Selected Mortality Rates (since 1972) 23 Suicide 35 Alcoholism 40 Homicide Pneumonia/Inuenza Accidents Infant Deaths Maternal Deaths GI Diseases Tuberculosis 0 10 20 40 30 50 53 56 60 75 76 80 60 70 80 Source: Adapted from Trends in Indian Health 1996. Exhibit 7/16: Percentage of Outpatient Visits by Type of Provider Other Primary Care Providers 6% Optometrist 3% All Other Providers 14% Physician 45% Clinic RN 4% Nurse Practitioner 6% Physician Assistant 7% Pharmacist 15% Source: Adapted from Trends in Indian Health 1996. heritage. IHS personnel consisted of nearly every discipline involved in the provision of health, social, behavioral, and environmental health services. The IHS clinical staff was composed of primary care professionals and other providers, as well as clinical technicians and assistants. Primary care providers included physicians, physician assistants, dentists, nurse practitioners, and nurse midwives. Other providers included pharmacists, optometrists, public health nurses, clinic nurses, physical therapists, and dietitians (see Exhibit 7/16). Over several years, because both07.indd 581 11/11/08 11:42:58 AM 582 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/17: IHS Stafng Trends 14,000 12,392 Number of Employees 12,000 11,730 10,000 1996 8,000 1995 1994 6,000 1993 4,000 2,806 1,799 2,000 742 509 0 Service Units Area Ofces Headquarters Source: Adapted from Trends in Indian Health 1996. of the \"Reinventing Government\" initiative of the Clinton Administration resulting from a national preference for moving government decision making closer to \"the people,\" as well as the IHS redesign process initiated by Dr. Trujillo, the trend in IHS stafng was towards an increase in personnel at the service unit level and decreases at the area and headquarters levels (see Exhibit 7/17). An ongoing personnel problem concerned the recruitment and retention of dedicated, qualied professionals. Most IHS sites were remote and many lacked adequate schools, stores, and amenities. To compensate for some of these quality-of-life imbalances, IHS offered nancial incentives in the form of scholarships, loan payback agreements, and summer employment to selected health care professionals. For most professionals, however, the pay scales continued to lag behind those in the private sector. Further exacerbating the personnel recruitment and retention problems, many employees were concerned about the changes that were occurring within the IHS. Federal employees at the service unit level wondered how long they could remain in their positions once the local tribes assumed responsibility for health services. Area and headquarters employees were concerned about the future of their careers because there were so many cuts being made in these programs. All such issues concerning the organizational changes were addressed often by IHS leaders in memorandums, reports, and speeches. Information technology resources, particularly the Internet and electronic mail, were also used to disseminate information. Upper management felt that it was imperative to keep the lines of communication open and to involve IHS personnel at all levels of the change process, but the uncertainty could not be eliminated. both07.indd 582 11/11/08 11:42:59 AM I H S T O D AY 583 Exhibit 7/18: Tribal Contract and Compact Funding (in millions of dollars) Fiscal Year Contracts 1987 1988 1989 1990 1991 1992 1993 1994 1995 $200.9 217.2 306.6 320.7 410.1 511.6 491.5 648.1 297.5 Compacts $9.8 13.1 23.5 27.4 40.1 50.9 59.9 114.5 335.0 Total $210.7 230.3 330.1 348.1 450.2 562.5 551.4 762.6 632.5 Source: Adapted from Trends in Indian Health 1996. The Indian Self-Determination and Education Assistance Act gave federally recognized tribes various options for their involvement in stafng. The original Act allowed tribes to contract with the federal government. These contracting tribes could redesign and assume responsibility for any aspect of their health care services. Some tribes made the choice to contract all of their health care services. A limitation of the contracting process was that IHS had to approve and allow all redesign proposals. Amendments to the Act removed this limitation by creating the Tribal SelfGovernance Demonstration Project. This project allowed selected tribes to compact their health care services; that is, they took over complete responsibility without the need for IHS approval or oversight. The project originally called for 30 tribes to be selected for inclusion, but by 1997 there were already 34 participating tribes with several more anticipating their inclusion. The number of tribes choosing to deliver at least some portion of their own health care had increased steadily. Although contracts and compacts accounted for only an estimated 22 percent of the total IHS budget in 1987, these obligations grew to over 32 percent by 1995, and were expected to reach 50 percent by 2000. Exhibit 7/18 shows the trend in funding for tribal contracts and compacts. IHS Funding Sources of funding for IHS included appropriations from the federal budget and collections from third-party billing. Congress passed the Indian Health Care Amendments of 1988, which authorized the IHS to bill third parties for both inpatient and outpatient services. Medicaid, Medicare, and other insurance payors were all dened as third-party payors and these were considered the only new revenue source for IHS programs. IHS did not collect the co-payments or deductibles that were required with some policies, and those eligible individuals who did not have insurance coverage were not charged for the services they received. Although both07.indd 583 11/11/08 11:43:00 AM both07.indd 584 11/11/08 11:43:00 AM $869 71 $940 Total Services Facilities Total Appropriations $1,009 $947 62 $817 70 60 FY 1988 $1,081 $1,019 62 $883 73 63 FY 1989 $1,251 $1,179 72 $1,031 78 70 $1,576 $1,410 166 $1,235 90 85 FY 1990 FY 1991 $1,705 $1,431 274 $1,276 65 90 FY 1992 $1,860 $1,526 334 $1,252 70 204 FY 1993 $1,943 $1,646 297 $1,325 75 246 FY 1994 $1,960 $1,707 253 $1,370 77 260 FY 1995 $1,999 $1,760 239 $1,418 78 264 FY 1996 Source: Adapted from Trends in Indian Health 1996. b All values are dollars ($) in millions. Other services include urban health, Indian health professions, Tribal health management, direct operations, self-governance, and contract support costs. a $748 66 56 FY 1987 Services: Clinicala Preventive Health Otherb Category IHS Budget (FY87-FY98) Exhibit 7/19: Trend in IHS Budget Appropriations $2,055 $1,807 248 $1,452 81 274 FY 1997 $2,122 $1,835 287 $1,468 82 285 FY 1998 I H S T O D AY 585 collections from third-party payors were increasing, there were still many concerns over the inability of IHS to bill and collect adequately for all of the services that it provided. In fact, a 1995 review published by the Ofce of the Inspector General of the Department of Health and Human Services estimated that the IHS underbilled by about $8.5 million each quarter because of untrained staff, shortage of staff, or lack of controls. Because the IHS was considered a discretionary program within the connes of the federal budget and because any attempts to balance the federal budget would involve cuts in discretionary programs, stakeholders of IHS were very concerned about the level of funding that the organization received from the federal government. The term \"discretionary\" referred to funds controlled by the annual appropriations process. This included most of the regular operating funds for the federal agencies, as well as funds for the thousands of large and small programs that have no binding legal obligations to their beneciaries. Estimates were made that many IHS programs were underfunded by 30 to 40 percent, although some went as low as 70 percent below their level of need. Exhibits 7/19 and 7/20 show the trends for these funding sources. The 1998 budget request allowed no fund increases to account for ination, population growth, or newly recognized tribes. Exhibits 7/21 and 7/22 show the nancial position of IHS for scal year 1996 and scal year 1997. The shift from direct federal funding to state block grant funding of health care programs (such as a Medicaid managed care program) was another great concern of IHS and tribal leaders. It was a common occurrence for states to overlook or ignore Indian concerns when developing programs. Many state governments had the misconception that Indian tribes had relationships only with the federal government and were not eligible for state resources, when in fact AI/ANs were entitled to the same privileges and resources as any other state citizen. In response to these concerns, a state initiative workgroup was created by the IHS to focus on the social, economic, legal, and policy issues pertaining to state health reform initiatives and Indian health programs. Also, a strategic business plan was being developed by a workgroup composed of tribal leaders, IHS personnel, and private sector consultants. This plan would focus on revenue generation, cost control, internal business improvements, and allocation of tribal shares. Although the business plan was still in the development stage, this committee represented the IHS commitment to a new style of Exhibit 7/20: Trend in Third-Party Collections Category FY 1988 FY 1989 FY 1990 FY 1991 FY 1992 FY 1993 FY 1994 FY 1995 FY 1996 Medicare/Medicaid Private Insurance $66 $75 $88 3.5 $94 8 $122 12 $141 18 $160 23 $162 31 $177 34 Total Collections $66 $75 $91.5 $102 $134 $159 $183 $193 $211 Note: All values are dollars ($) in millions. Source: Adapted from Trends in Indian Health 1996. both07.indd 585 11/11/08 11:43:00 AM 586 C A S E 7 : I N D I A N H E A LT H S E R V I C E Exhibit 7/21: Statement of Financial Position (in millions) 1996 Assets Entity Assets: Fund Balances with Treasury Investments Accounts Receivable, Net: From Federal Agencies From the Public Interest Receivable Advances: To Federal Agencies To the Public Inventories Property and Equipment, Net Non-Entity Assets: Accounts Receivable, Net: Total Assets Liabilities Funded Liabilities: Payables: Due Federal Agencies Due the Public Advances: From Federal Agencies From the Public Accrued Payroll and Benets Unfunded Liabilities: Annual Leave Workers' Compensation Benets Other Liabilities Pensions Total Liabilities Net Position Unexpended Appropriations Invested Capital Cumulative Results of Operations Future Funding Requirements Total Net Position Total Liabilities and Net Position 1997 $1,172 $1,108 19 4 6 16 13 10 13 497 40 15 647 $1,728 $1,832 $24 42 $26 48 47 29 64 30 60 44 1 60 45 2 247 275 991 511 84 (105) 954 662 48 (107) 1,481 1,557 $1,728 $1,832 Source: DHHS website (http://www.hhs.gov). both07.indd 586 11/11/08 11:43:01 AM I H S T O D AY 587 Exhibit 7/22: Statement of Operations and Changes in Net Position (in millions) 1996 Revenues and Financial Sources Appropriated Capital Used: General Appropriations Matching Contributions Employment Taxes SMI Premium Collected Interest Revenue Sales of Goods and Services Imputed Financing Other Revenue and Financing Total Revenue and Financing Sources Expenses Operating: Personnel Costs Travel and Transportation Rent, Communications and Utilities Printing and Reproduction Contractual Services Supplies and Materials Grants Insurance Claims and Indemnities Other Operating Expenses Depreciation and Amortization Imputed Personnel Costs Other Non-Operating Expenses Total Expenses Excess of Revenues and Financing Sources Net Position, Beginning Balance Adjustments Net Position, Restated Beginning Balance Excess of Revenues and Financing Sources Non-Operating Changes Net Position, Ending Balance 1997 $1,991 310 $2,135 415 71 $2,301 $2,621 $745 46 43 2 738 80 516 81 24 $755 48 40 1 851 180 605 1 24 71 1 $2,275 $2,577 $26 $44 $1,464 $1,481 178 1,464 26 (9) 1,659 44 (146) $1,481 $1,557 Source: DHHS website (http://www.hhs.gov). both07.indd 587 11/11/08 11:43:01 AM 588 C A S E 7 : I N D I A N H E A LT H S E R V I C E leadership, one that focused not only on the efcient and effective use of resources, but also on the partnership with the Indian people. The Future of the IHS Dr. Trujillo knew that the IHS was a very dynamic organization, that it was staffed by professional personnel, that the AI/AN populations were unique, and that tribal cultures, values, religions, and traditions must always be considered and respected when delivering health services to them. In addition, he knew that the IHS was at a crucial juncture in its existence. Stakeholders in Indian health were calling for major changes in the organization. Various economic changes were signaling the need for new and innovative ways to fund programs. Tribes were asking for more control over the health care for their members. At the same time that the IHS was constrained by treaties, it was also considered a discretionary agency of the United States. Dr. Trujillo was committed to Indian self-determination and knew that the spirit of self-determination required local assessment and denition of health service requirements. At the same time, he was responsible for improving the health status of the American Indians and Alaska Natives to the highest level possible. Although there was no inherent conict between self-determination and improvements in health status of all the Indian peoples, in the face of scarce resources Dr. Trujillo knew there were limits to the services that could be provided to any single community. He needed to carefully manage the expectations created by self-determination while not discouraging local communities from becoming involved in their own health affairs. The creation of false expectations could be as damaging as not involving tribes in local health affairs. Balancing expectations with local support required some serious thinking about the future mission and role of the IHS. REFERENCES Kendrick, T. (1997). A Future of Possibilities for Health, Indian Health, and Indian Health Leaders. Available: http:/ /www.ihs.gov Trujillo, M. H. ( January 27, 1994). Conrmation Hearing Statement Before the United States Senate Committee on Indian Affairs. Available: http:/ /www.ihs.gov Trujillo, M. H. (May 11, 1995). Opening Statement Before the Interior Subcommittee of the Senate Appropriations Committee. Available: http:/ /www.ihs.gov Trujillo, M. H. (November 28, 1995). Time of Change . . . Time for Change: The State of the Indian Health Service (presented at the National Indian Health Board 13th Annual Consumer Conference). Available: http:/ /www.ihs.gov Trujillo, M. H. (February 20, 1996). Challenges and Change: The State of the Indian Health Service. Available: http:/ /www.ihs.gov Trujillo, M. H. (December 1996). \"Message From the Director: Looking to the Future of the Indian Health Service,\" IHS Primary Care Provider 21, no. 12, pp. 157-160. Trujillo, M. H. (March 1997). The Future Indian Health Care System. Available: http:/ /www.ihs.gov both07.indd 588 11/11/08 11:43:01 AM