Healthcare for 1.3 million American Indians may be entering a new era.
The primary source of healthcare for American Indians is the federally funded Indian Health Service, which this year received an allocation of about $1.9 billion. But the American Indian community believes it continues to get an inadequate share from Congress.
The IHS spends about $1,500 per capita annually on American Indian healthcare, which is half the amount the federal government spends on all other Americans, according to HHS.
That gap has tribes looking for alternatives. Healthcare reform and gaming revenues are among the more prominent resources eyed as possible supplements to IHS healthcare dollars.
Recently released data from a national study of American Indians and the IHS supports the notion of change.
"Given current IHS resource limitations, other sources of healthcare financing likely will play an increasingly important role in meeting the healthcare needs of the IHS-eligible population," said Peter Cunningham, a research analyst who authored the study for the federal Agency for Health Care Policy and Research.
The IHS, part of the U.S. Public Health Service since 1955, operates a network of inpatient and ambulatory-care facilities across the continental United States and Alaska. It also provides funding for services and facilities managed by some 500 American Indian tribes and Alaskan native organizations.
The IHS is responsible for providing healthcare through a network that includes 42 hospitals, 66 health centers, 53 health stations and four school health centers. The IHS also sponsors other healthcare services through contracts with private providers.
Eligibility for IHS services is based predominantly on membership in a federally recognized Indian tribe.
The Clinton administration also recognized IHS' importance. The president's Health Security Act is the only healthcare reform proposal currently before Congress that specifically addresses American Indians and Alaska natives. It preserves tribal sovereignty to directly operate their own health systems under "self-determination" contracts or offers an option to continue to have IHS operate their health systems.
IHS operates differently from Medicare and Medicaid. It isn't an entitlement and can provide services only to the extent of its annual appropriation by Congress. "They get an annual appropriation from Congress and that defines what they are given. Every year there is a big battle," Mr. Cunningham said.
"People use the Indian Health Service considerably, but they also go outside the IHS and consequently use more healthcare overall," Mr. Cunningham said. "There are certain limitations in the types of services IHS provides. One common complaint is that the waiting time can be quite long."
Primary care and preventative programs are seen as the best way of improving healthcare for Indians, who suffer a mortality rate 11% higher than all other Americans.
In states with high American Indian populations, healthcare statistics show an even more alarming problem. In New Mexico, for example, one in three American Indian males dies before reaching the age of 35, according to a recent study by the University of New Mexico.
American Indians, who are rebounding economically from a windfall resulting from gambling on tribal lands, are making an effort to funnel those proceeds toward healthcare.
Through the Indian Gaming and Regulatory Act of 1988, tribes are contributing money to tribal services, non-profit entities and other donations to their communities, according to Linda Hutchinson of the National Indian Gaming Commission, which is part of the U.S. Department of the Interior.
"The amount of money allocated is up to the tribe," Ms. Hutchinson said. "They don't have to specify where it is going and the amount."
The gaming commission estimates that gambling on tribal lands generates $6 billion annually.
In Arizona, $5 million in casino revenue was pledged to pay for part of a new Arizona State University Medical School that would focus on primary-care needs for minorities. The money was offered by the Fort McDowell-Apache Indian Community to help the ASU venture, which is being conducted with 473-bed Maricopa Medical Center in Phoenix.
The proposal was voted down earlier this year by the Arizona Board of Regents, which didn't want to fund a second medical school. But American Indian forces aren't giving up because ASU would recruit 50% of its students from minority populations and medically underserved areas.
The use of the gaming money has been controversial in some states where federally recognized Indian tribes are allowed more liberal gaming operations than state-regulated casinos.
But the American Indian community cites the inequitable treatment their group receives from today's healthcare system and asks if it is fair to criticize them for profiting on the best option available to them: gambling.
Mr. Cunningham's study indicates healthcare reform could improve services available to those getting care through IHS because financing and coordination of non-IHS money would improve.
"If IHS eligibles were included in a system of universal healthcare coverage, the IHS could encourage greater use of private medical-care providers in areas in which they are available and could coordinate IHS and non-IHS services to ensure continuity of care and to avoid duplication of services," Mr. Cunningham said in his report. "This would allow more resources to be allocated to areas in which private providers are not available and where reliance on the IHS as the sole provider of health services is high."