For years, the Mille Lacs band of the Ojibwe Indian tribe provided healthcare for its members at a small clinic that doctors visited for just two half-days a week. The facility had just three examination rooms and the ability to perform only minor laboratory tests.
Today, residents of the Mille Lacs reservation in central Minnesota receive healthcare in a clinic more than three times the size of their old one, with a federally certified laboratory. Now, primary-care doctors or physician assistants treat patients far more hours each week, and specialists such as vascular surgeons and ophthalmologists see patients periodically.
You can bet on what has made the difference in the Mille Lacs' healthcare fortunes: gambling revenues.
The Mille Lacs' Ne-Ia-Shing Clinic stands as a symbol of the changing relationship between Indian tribes and the federal government brought on by greater self-governance and the growth of tribe-sponsored casinos and other gaming activities.
Like many Indian tribes throughout the country, the 2,900-member Mille Lacs band has used the authority of a 1987 U.S. Supreme Court decision and the 1988 Indian Gaming Regulatory Act to establish casinos and other gambling operations.
Under the gaming act, Indian tribes must use gambling profits to fund charitable or governmental functions, such as healthcare facilities and schools.
Some 130 of the more than 540 federally recognized tribes in 34 states operate casinos, while about 200 run bingo operations, according to the National Indian Gaming Association. Gambling industry estimates put gross revenues from Indian casinos and bingo at $3.3 billion in 1994.
The Mille Lacs are using revenues from their two casinos to pay off the $2.1 million in bonds they sold to finance construction of the Ne-Ia-Shing Clinic. Furthermore, about 10% of the clinic's $3 million operating budget is funded through gambling revenues.
Without the casinos, say tribal officials, the Mille Lacs couldn't have built the Ne-Ia-Shing Clinic in 1993 on the shores of Mille Lacs Lake (Ne-Ia-Shing means "point of land" in the Ojibwe language), about a two-hour drive north of Minneapolis-St. Paul.
"The casino is instrumental. It's the backbone of everything we've been able to do," said Sharon Gislason, clinic administrator.
"The casino enabled us to take a look at our community, see our needs" and fund programs to address those needs, said Lester Morris, the Mille Lacs' acting commissioner of health and human services.
There are no solid estimates of all the tribes' healthcare activities financed by gaming. But many tribes have built or funded clinics, nursing homes and specialized programs. Among them:
The Gila River Indian Community south of Phoenix is spending $250,000 to establish a four-year podiatry program specializing in foot care for diabetics. That money will send a physician to a year of advanced surgical training. Ongoing costs of the program will be $50,000 a year. Casino revenues are paying for the training and operation of the program. Gila River also is hoping to use casino revenues to pay for other future healthcare activities at the community's 12-bed Huhukan Memorial Hospital, the management of which the two Gila River tribes assumed from the Indian Health Service in October 1995 through a federal contract.
The Oneida Indian Nation of New York, near Syracuse, bankrolled construction of a 5,000-square-foot health clinic where none existed before. In the late 1980s, the IHS had given the New York Oneidas a grant to plan the facility, but then it placed a moratorium on new construction. In 1991, the tribe used its own funds, a majority of which are casino profits, to build the clinic. It continues to supplement operations from its own revenues. The tribe wouldn't disclose what it spent to build and operate the clinic. The IHS' allocation to the New York Oneidas was about $2 million in federal fiscal 1995.
The Oneida Nation of Wisconsin, near Green Bay, finances half the $1.8 million annual operating budget of a 52-bed nursing home through contributions from tribal enterprises, which include gambling proceeds.
The combination of greater flexibility for tribal-run healthcare facilities and their ability to draw upon such resources as gambling revenues comes at a pivotal time for Indian healthcare. Like nearly all other federal programs, the IHS, which provides healthcare to 1.4 million Indians, is under pressure to keep a lid on spending because of mounting budget deficits.
For instance, the Clinton administration's IHS budget request includes only about $3 million in health facility construction funding for fiscal 1997, which begins Oct. 1. Meanwhile, there's a backlog of about $600 million worth of Indian health facility construction requests, according to a Republican aide to the Senate Indian Affairs Committee who asked not to be identified.
"Tribes and urban Indian programs (realize) that federal resources are going to be limited," said IHS Director Michael Trujillo, M.D., a member of the Laguna Pueblo of New Mexico who has served in that post for two years.
Trujillo said Indian healthcare administrators must ask themselves, "What other opportunities do we have to enhance our healthcare delivery systems?"
Statistics strongly suggest that it's critical for tribes and the federal government to enhance that care; the health of American Indians is among the poorest of any ethnic group in the country.
The population served by IHS facilities has higher rates of death and infant mortality and lower overall life expectancy than the general U.S. population. American Indians served by the IHS die more often from accidents, suicide, homicide and such diseases as cirrhosis, diabetes, pneumonia, influenza and tuberculosis, although they have lower death rates from heart disease and cancer.
As evidenced by the Gila River community's program, diabetes is a particular concern for Indian healthcare. In 1991, Indians served by the IHS died from diabetes at a rate more than 2.5 times that of the general U.S. population. The problem also is persistent: The 1991 death rate of 30 per 100,000 population was slightly greater than the 1973 death rate of 28.1 per 100,000, while death rates for most other diseases have declined.
The IHS points to some successes in reducing death rates, however. Between 1973 and 1991, death rates from such diseases as pneumonia, influenza, tuberculosis and gastrointestinal diseases have dropped significantly. Infant mortality rates have dropped 58% over that time.
Trujillo credits community-oriented primary and preventive care for those improvements in Indian health.
But American Indians' access to healthcare still appears limited. The 91,542 admissions of American Indians to IHS, tribe-managed or contract hospitals in fiscal 1993 represented a rate of 767.6 per 10,000 IHS users, well below the 1,202 admissions per 10,000 people in the general U.S. population that year.
American Indians, who often live in remote rural areas, also have fewer doctors who can see them, the IHS said. In federal fiscal 1994, there were 89.8 physicians per 100,000 American Indians, according to the IHS. By comparison, there were 263 physicians per 100,000 people in the general U.S. population in 1994.
Policy analysts, activists and government officials agree that the federal government has woefully underfunded Indian healthcare. And Uncle Sam shows no sign of spending more in the future to meet the needs of the reservation population.
Like the Department of Veterans Affairs, which is the biggest federally owned provider system, the IHS' budget has grown only slightly in recent years. In constant 1994 dollars, its budget has climbed from about $1.6 billion in federal fiscal 1986 to about $2.1 billion in fiscal 1995.
But since fiscal 1991, the IHS' budget has grown by just $50 million. And it's actually dropped $72 million from a peak in fiscal 1994, using constant 1994 dollars (See chart, this page).
In fiscal 1996, congressional spending bills have funded the IHS at $2.2 billion. The Clinton administration has called for $2.4 billion in its 1997 budget request, a figure supported by the Senate Indian Affairs Committee. The IHS distributes money to tribes primarily on a per-person basis.
Per-person spending for Indian healthcare was about $1,153 in 1995, compared with $2,912 for the general U.S. population, the IHS said.
"The Indian Health Service....is wholly inadequate and wholly underfunded," said JoAnn Chase, executive director of the National Congress of American Indians.
"We have grossly underfunded the healthcare of this population, and the statistics bear that out," said the Senate Indian Affairs Committee Republican aide. "When you look at indices of Indian health, they still lag as the worst of the worst. When you're the worst of the worst, you ought to be the highest priority at every point."
From the Indians' perspective, that underfunding of the IHS has left a vacuum that the tribes are trying to fill when they use gambling profits to fund tribal healthcare activities. But they're adamant that the federal government not back out on treaty obligations to provide for tribes' healthcare (See story, p. 44).
The self-reliance fostered by the new casino revenues is consistent with a trend of growing tribal authority over healthcare programs. Indians began asserting greater control with the passage of the self-determination law in 1975, which allowed tribes to run healthcare facilities under contracts with the IHS. That legislation has been expanded to give tribes increased flexibility.
As of March 1996, tribes operated 12 hospitals, 116 health centers and 226 other health facilities, while the IHS directly managed 37 hospitals, 64 health centers and 55 other health facilities, according to the IHS.
The IHS' fiscal 1997 request includes $212 million for management costs at tribe-operated healthcare facilities like the Mille Lacs clinic. Tribe-managed programs accounted for about $797.7 million of the IHS' $2.2 billion budget in fiscal 1995.
Although the Ne-Ia-Shing Clinic was built by slot machines and gaming tables, the Mille Lacs aren't totally dependent on gambling revenues. In fact, tribe officials credit greater self-governance for improving their facilities as much as they do gambling.
Under amendments to the self-determination legislation, the Mille Lacs in 1993 signed a compact with Congress giving them greater control over their own healthcare delivery system, allowing them to determine what services to provide and open some revenue floodgates.
"By virtue of the compact, we not only make our own decisions as to how our dollars are spent, but we also are able to have more dollars to spend on care and the programs we provide," Gislason said.
The compact provided for more direct payment of the tribe's IHS allocation, which means less of that money is lost to administration at IHS headquarters and area offices.
As a result, the amount of the Mille Lacs' IHS allocation that actually reaches the tribe has risen from 11 cents of every dollar to 50 cents of every dollar. The IHS allocation represents about 74% of the clinic's operating budget, the balance coming from casino revenues and third-party reimbursement.
In addition, the clinic under tribal management has sought to expand its third-party billing. It made an effort to increase the number of elders enrolled in Medicare. For Medicaid patients, meanwhile, the self-determination law requires that the clinic be reimbursed at 100% of cost, rather than at state-mandated rates.
The clinic also saw its insurance billings increase as many previously unemployed Mille Lacs found jobs at the casinos or in related enterprises that grew around the gaming or from gaming revenues.
"If it weren't for the casino, we wouldn't be doing as much third-party billing," Gislason said.
The widened revenue stream from the IHS joined the new revenue streams of gaming profits and third-party payments to produce an annual budget of about $3.2 million a year today, up from less than $2 million a year before the compact was signed.
The increased income has enabled the Mille Lacs to expand services. The tribe is able to provide home care for more than 200 of its older members. It also is planning to build an assisted-living facility with as many as 12 units to aid those elders for whom home care isn't adequate.
In addition, the compact with the federal government freed the Mille Lacs to use traditional tribal spiritual healers in conjunction with modern medical practices in treating members of the tribe. The use of traditional healers has made tribal elders more "receptive" to care, said David Matrious, the Mille Lacs' secretary-treasurer and speaker of its assembly.
Trujillo said the tribes that choose to follow the Mille Lacs' road are able to improve their own programs because the compacts allow them to manage a more comprehensive delivery system. It also allows the tribes to take advantage of whatever other income they might have, be it from natural resources or casinos.
"Any resources the tribe may have can certainly enhance their delivery systems," Trujillo said.
But if their facilities remain under direct IHS management, any other revenues that tribes want to spend on healthcare can only be spent outside the framework of the IHS-managed programs.
New revenues from gaming and self-government contracts have bought increased access and better facilities for some tribes, but measurable improvements may not be seen for several years, according to some experts.
"This is all very much a recent phenomenon," said the Senate Indian Affairs Committee aide. "It's going to be a couple of years before we see any measurable improvement in health status."
But Keller George, a top official with the Oneida Nation of New York, said because elders can see doctors at the tribe's 5-year-old clinic, they now are being diagnosed with such manageable conditions as diabetes that would have gone untreated before.
Women who before might not have seen a doctor during pregnancy now are receiving prenatal care, and as a result, George said, "we're getting healthier babies.
"Overall, the Oneida people are a lot healthier now than they were as little as four or five years ago," George said. "It's been eye-opening, the difference that facility has made."