American Indians view their chief means of financing healthcare as hanging by fraying threads.
The federal government provides healthcare to the more than 540 recognized Indian tribes and their 1.4 million members under the rubric of treaties the tribes signed with the government. The government offered assistance to the tribes in exchange for land and peace.
But federal budget deficits and the growth of Indian gaming and other economic development activities have heightened congressional scrutiny of tribes' financial portfolios.
Moreover, the increased scrutiny has spurred fears that Congress in the future may try to determine how much healthcare assistance it provides through the Indian Health Service based on the relative affluence or poverty of a tribe, a policy known as "means testing."
Although no member of Congress has proposed formally to means test Indian healthcare dollars, an early draft of appropriations legislation last year wanted to make the Bureau of Indian Affairs inventory what tribes received from gaming and from the federal government.
Although the proposal did not explicitly mention reducing federal assistance because of tribes' income, some fear it was an omen of means testing.
"There are those in Congress who feel we may be paying too much for Indian healthcare," Sen. Daniel Inouye (D-Hawaii), senior Democrat on the Senate Indian Affairs Committee, said at a recent hearing on the IHS budget.
A Republican aide to the Senate Indian Affairs Committee, who asked not to be identified, acknowledged the treaty obligation but said part of the reason Indian healthcare funding may come under attack is because it's not a legal entitlement like Medicare and Medicaid. Instead, it's subject to year-to-year appropriations as a discretionary budget item.
"Treaties have, under constitutional law, the highest sacred standing," the aide said. "But in the treaties there was not a specific dollar amount. Unfortunately for the Indians, (healthcare) is in a discretionary account."
Keller George, a top official of the Oneida Indian Nation of New York, recognized the danger of using casino revenues to supplement IHS spending at a time when the federal government is looking to cut costs.
"What's the natural reaction? Cut the funding back," George said.
But he said all tribes would fight to keep their IHS allocations.
"Probably, these things we will never let go because our ancestors saw to it many, many years ago that we got these things," George said.
"The gaming tribes are taking the responsibility of the federal government," agreed JoAnn Chase, executive director of the National Congress of American Indians. "That doesn't mitigate the responsibility to adequately fund Indian healthcare.
"To look at a tribe's revenue stream and say, `Your revenue is such-and-such, and you're no longer eligible for these services' undermines tribal sovereignty," Chase said.
Meanwhile, others see dangers for Indian healthcare-particularly between tribal healthcare facilities and Medicaid programs-emerging from the sometimes contentious negotiations that develop between states and tribes over gambling.
Under the 1988 Indian Gaming Regulatory Act, states cannot prohibit tribes from opening gaming facilities on their land if such activities are allowed elsewhere in the state. But the law requires that tribes negotiate compacts with the states to determine what gambling activities will be permitted.
Those negotiations often end up in court. But the ruling of the U.S. Supreme Court in Seminole Tribe of Florida vs. Florida limited tribes' ability to sue when they believe the states are negotiating in bad faith.
Indian officials fear the negotiations between both parties will become tougher. And they fear it may poison negotiations between states and tribes with gaming facilities when the Indians seek inclusion in the Medicaid managed-care networks many states are forming.
Indian gambling itself also is being scrutinized by Congress.
One bill, sponsored by Reps. Gerald Solomon (R-N.Y.) and Robert Torricelli (D-N.J.), calls for a two-year moratorium on new Indian casino gambling. Two other bills call for the creation of national commissions to study the effects of gambling, including tribal gaming.