Improving Health Care Access in Native

American Communities: What Can

Tribes Do?

What happens to the health of American Indians when Indian nations take over management of reservation health care?

This is the question at the heart of a research project currently underway at the Native Nations Institute for Leadership, Management, and Policy (NNI) at the University of Arizona. Founded by the Udall Foundation and the University of Arizona, NNI serves as a self-determination, governance, and development resource to Indigenous nations in the United States and elsewhere through research and educational services. NNI researchers recently set out to determine the impact that tribal management of health care has on reservation access to quality care.

The health of reservation residents has long been a matter of enormous concern to tribal citizens and their leaders. Native American health—particularly on reservations—has consistently lagged behind the health of the U.S. population as a whole, often dramatically so. While recent decades have seen some major improvements, notably in infectious disease and infant and maternal mortality, Native Americans still have some of the poorest health outcomes in the U.S. For example, despite recent progress, infant mortality rates remain higher than for the U.S. population as a whole, and tuberculosis occurs at more than four times the U.S. rate.

Chronic diseases are a particular problem. Type 2 diabetes is epidemic in a significant number of Native American communities. Heart disease, cancer, liver disease, and obesity are major problems and appear to be increasing. Behavioral and mental health problems also are severe. Suicide rates are 60 percent higher than the national average and higher still among the young. Fetal alcohol syndrome is rampant in some communities.

One of the primary determinants of health outcomes is access to quality health care. Here, too, the Native American population lags well behind the rest of the country. Factors such as inadequate funding, distance from health care facilities, lack of transportation, language and cultural barriers, and under- or poorly staffed facilities are just some of the barriers that Native Americans face when seeking quality health care services. Retention of skilled staff in sometimes remote facilities has been a recurrent problem. Ambulance response times and other aspects of public safety also hinder quality care, while those who reach health facilities often encounter very long wait times.

As for preventive care, in many cases federal Indian Health Service (IHS) and tribal staff have enough difficulty providing adequate clinical services, much less engaging in preventive programs that could significantly affect health status. While it is widely accepted that an effective preventive care program can both improve quality of life for community members and can save money in the long run, the shortage of IHS funding has made the creation, management, promotion, and availability of prevention programs difficult in many Native communities. Added to all of this is the fact that in 2005, an estimated 30% of the American Indian and Alaska Native population had no health insurance of any kind.

Since the 1970s, some American Indian nations have been trying to address these issues by taking over—to one degree or another—the management of health care delivery in their communities. Among other things, passage of the Indian Self-Determination and Education Assistance Act in 1975 and subsequent legislation made it possible for those nations that so desired to assume significant roles in the organization and management of reservation health care. Tribal health service self-management has become an attractive option for nations concerned about the quality and extent of existing health care services or about the responsiveness of IHS to tribal health care priorities.

Not all tribes have taken advantage of these opportunities, but a growing number are doing so. In some cases this involves little more than administering existing programs formerly run directly by IHS. At the other end of the continuum, it has involved wholesale reorganization of health care delivery, with tribes hiring doctors, managing clinics, supplementing federal funds with funds of their own, and creating innovative treatment regimes.

To date, however, no one has examined in any systematic way the impact that this has had on tribal health care access or on health outcomes. Does tribal management of health care improve access to quality care? Does it improve health outcomes? Is tribal self-management part of the answer to the continuing problem of poor health in Indian Country?

NNI approached the Nathan Cummings Foundation with a proposal for a preliminary look at these questions. Nailing down the consequences of this development in health indices requires long time horizons, so what NNI proposed was a look at the effect of tribal management on access to quality care. With Nathan Cummings Foundation support and additional support from the Udall Foundation and the University of Arizona, NNI researchers were able to carry out a preliminary phase of this project: a comprehensive review of published and unpublished materials to determine the current state of knowledge about the impacts of tribal control on reservation health care, plus a set of interviews with eighteen Indian Country health care professionals, including tribal health directors and other officials from seven tribes, federal officials, and academics working in the health-care field.

While the results are by no means conclusive—more robust findings await a comprehensive and more systematic second-stage research effort for which NNI is now seeking funding—the preliminary findings are intriguing. There is persuasive evidence that tribal control of health care does indeed improve access to quality care. Interviewees from all seven tribes reported increased levels of access to culturally competent, high quality health services under self management. Some also reported reduced bureaucracy, increased utilization of third-party billing, leading to increased revenues, and the inclusion of traditional healing practices and spiritual leaders in the provision of health care, leading to greater comfort for many tribal citizens.

Other reported effects included better retention rates of physicians, reduced patient wait times, and a sense among tribal citizens of ownership of health centers and programs. Said one tribal official, "The availability, quality, and quantity of services have improved. We manage our own third party collections and revenues so we have been able to provide more services than when the Indian Health Service was involved with the program." Said another, "We've kind of streamlined what we do and cut out a lot of the intermediary steps, and I think that's one of the reasons why we provide better access. We've expanded the scope of our practice substantially."

Another benefit of tribal self-management noted by a number of the tribal interviewees was the enhanced sense of tribal efficacy. Tribal management of health care involves tribes taking direct responsibility for how health care—regardless of the funding source—is provided to citizens. Both citizens and tribal leadership see this as an assertion of self-governing power. Finally, a number of people pointed to the ability of tribes to alter health-care programming to match tribal concerns and to incorporate Native cultures in the administration and practice of health care. As one tribal interviewee pointed out, "there is more of an incentive for [tribes] to provide culturally appropriate services than there might be for IHS. I think that IHS could do it but I don't know that they have the relationships or the knowledge or the expertise to be able to do some of that as well as tribes do it." As tribes move into the driver's seat in the organization of health-care services, they can shift resources to fit tribal priorities and shift treatment regimes to take local knowledge and Native cultures into account.

All that said, tribal management of health care also involves substantial challenges that both tribal and other health-care professionals were quick to point out. While the challenges are manifold, four received particular attention in both the interviews and the published materials NNI researchers reviewed.

The first is funding. Indian health care is severely underfunded and has been for a very long time. The U.S. Commission on Civil Rights reported in 2003 that "“the U.S. government spends 50% less money on health care for Native Americans than for any other group including prisoners and Medicaid recipients." The Harvard Project on American Indian Economic Development noted in a 2008 publication that "for two decades or more, the Indian health system has witnessed an increasing service population, rising per-patient demand for services, increasing costs of labor and goods, and stagnant budgets." When tribes take over management of health care, these enormous budget shortfalls don't change. Furthermore, successful clinics draw patients, increasing the patient load without increasing the resources with which to deliver services. Such funding shortfalls put great pressure on tribes to come up with funds of their own, and some tribes with discretionary revenues have improved health care access by supplementing federal funds. But this is not an option for most Indian nations.

A second challenge has to do with governance. As a number of interviewees pointed out, tribal health care programs are components of tribal governance and service delivery systems, and their success—including their ability to increase access to quality care—depends in part on the overall quality of those systems. Successful management of health care delivery requires tribes to provide a stable and capable tribal governance environment. This includes, as one interviewee said, "business infrastructure, leadership, consistency and continuity."

Third, many American Indians and tribes fear that as tribes take over increased responsibility for delivering health-care services, they will find the federal government stepping away from its trust and treaty obligations to provide health care for American Indians. As some interviewees noted, they already tend to be penalized for success. In some cases, the more successful a tribal health clinic is, the less federal money it receives. Tribes with the option of supplementing federal funds wonder if they'll be penalized for that as well. As their investments grow, will the federal government pull back further from its commitments, leaving Indian health care as poorly funded as ever?

Finally, there's an informational challenge. Numerous tribes are trying to address the health-care problem, and some are coming up with innovative, effective strategies in programming, administration, treatment, the incorporation of Indigenous cultures, and a variety of other areas. But at present there's no easy way for them to share their dilemmas or successes. Few interviewees had any idea what other Indian nations were up to in the health-care arena. They knew there were successes out there and wanted to know the details, but had little time and few resources with which to find out. Most were well aware that they could shorten their own learning curves if they had an easy way to discover what was working and where.

NNI is now pursuing funding for a more comprehensive research effort on the impacts of tribal control. Anticipated activities include a systematic examination of data on prevention and screening, where tribal control can produce relatively quick improvements, as well as a set of tribal case studies to determine which specific health-care strategies are producing positive results. The project also will explore ways to make strategies and results more accessible across Indian nations, so that tribal health-care professionals can more easily share with each other the strategies they’re developing and the results they're achieving.

The bottom line appears to be that tribal control works, but it is a challenging thing to pull off successfully. This research sets out to learn what's working, why it's working, and how tribes can do it better.

For additional information on the Native Nations Institute, visit: http://nni.arizona.edu/.