When asked to name her top priority as the new director of the Indian Health Service, physician Yvette Roubideaux said she believes her first task is to listen.
Land of opportunity
Roubideaux takes over at a time when stimulus funding and a proposed boost to the agency’s budget could be forthcoming. However, she still says her main concern is that IHS is ‘underresourced’ and ‘underfunded’
Roubideaux, 46, should have no problem doing just that, given that money talks and members of the American Indian community have expressed their opinions on two large, recently announced sums of money for this HHS agency: the $500 million allocated to IHS from this years American Recovery and Reinvestment Act, and President Barack Obamas proposal to boost the IHS budget by 13% to $4.03 billion for 2010. The early consensus seems to be that even with these added funds, more resources are needed to improve the healthcare system for the nations American Indian and Alaskan Native population.
Within a one-week period last month, the Indian Health Service announced the Senates confirmation of Roubideaux, Obamas request for expanding the agencys budget, and the allocation of the stimulus funding to the states.
At the top point of this triangle of events is Roubideaux, the three-time Harvard University graduate who will be the first woman to oversee the HHS agency that serves about 1.9 million of the nations estimated 3.3 million American Indian and Alaskan Natives on a budget of about $3.58 billion. From her office at the University of Arizona College of Medicine in Tucsonwhere, until her appointment, she served as assistant professor of family and community medicineRoubideaux told Modern Healthcare in a phone interview that she is preparing to consult with the American Indian tribes and her staff to find out what lessons have been learned in order to make both large- and small-scale improvements at the agency. Sworn in on May 12, Roubideaux said that she expects to move to Washington soon.
My major concern was the fact that its pretty clear that IHS is underresourcedits underfunded, said Roubideaux, who is a member of the Rosebud Sioux tribe in South Dakota. Im really grateful to the president for his recent budget proposal, she added. Its really clear that in order for us to improve, were going to need a significant increase in resources.
Obamas proposal for an expanded budget next year is a starting point. The request includes an increase of $167 million to cover costs associated with pay raises, population growth, inflation, and staffing and operating costs for new and expanded facilities; an increase of $117 million in contract health funds, which are used to purchase healthcare that the IHS is unable to provide through its own network; $104.4 million for contract-support costs to assist tribal facilities in administrative functions to manage health programs; and $16.3 million to expand the agencys health IT system. (Tribal facilities are operated under the Indian Self-Determination and Education Assistance Act, which allows them to administer and operate healthcare services in their communities, rather than through the IHS directly.)
Jim Roberts, a policy analyst for the Northwest Portland Area Indian Health Board, said that the 2010 budget really is good news, but he referred to the allocation of the $500 million in stimulus funds as a boondoggle, because, he said, it heavily favors two states: Alaska and South Dakota. Together, both states received the total $227 million for health facilities construction that was allocated in the recovery act.
There is a maintenance fundthat was probably the smartest thing that they did, Roberts said of the money allocated for this purpose. They would be better off putting $500 million in maintenance and equipment, he added. Everybody has maintenance and improvement. We all have facilitiesthis would have been much better.
According to Roubideaux, there are a few reasons why these particular facilities received the funds. Theres a facilities construction priority list that has been developed over the years that ranks facilities in terms of their priorityconstruction and additional resources, she said. When the funding came along, this priority list was reviewed, and the stimulus funding required that the projects that would be funded for health facilities construction be shovel ready.
That money will be used to complete the new IHS Eagle Butte (S.D.) Health Center, which serves about 9,300 American Indians who live on the Cheyenne River Reservation, and also to build a new Norton Sound Regional Hospital in Nome, Alaska. Scheduled to open in 2012, the Norton Sound facility replaces a 61-year-old hospital that serves about 10,000 people, according to IHS.
In addition to funding for new construction, the stimulus act calls for $100 million for more than 300 maintenance and improvement projects, $85 million for health information technology, $68 million for sanitation facilities construction, and $20 million to purchase more than 200 pieces of medical equipment, distributed to 24 states. The IHS posted a 44-page list on its Web site to show how the recovery act funds will be allocated by state.
The priority system itself is riddled with flaws and equity issues, Roberts said. Its based on an antiquated model of building huge hospitals. The system has gone to a smaller, ambulatory-care model and the private sector doesnt build facilities like that anymore, so the fact that the government does is beyond comprehension.
The current facilities priority methodology was established in 1991, according to Thomas Sweeney, a spokesman for the IHS. In 2000, Congress directed the agency to work with tribes to make revisions to the health facilities construction priority system, the Northwest Portland Area Indian Health Board said in a policy brief released two years ago. In June 2004almost five years after Congress directed IHS to revise its construction prioritythe agency sent out for public comment a draft of a revised health facilities construction priority system, the policy paper noted. The IHS received over 1,200 comments during the comment period.
After consulting with tribes, the IHS sent a new methodology to the Office of Management and Budget in 2007. It still rests there, as a new list has yet to be used. In its policy paper, the Northwest Portland Area Indian Health Board said that the dated methodology is unfair because it tends to favor only a few tribes that tend to score well.
But Jacqueline Johnson Pata, executive director of the Washington-based National Congress of American Indians, said that her organization focuses less on the equity of the priorities list and more on lobbying for additional funding. Every time you revise the facility priority list, youre having to address the priority based on what the needs aresomebody drops on, somebody drops off, Pata said. Everybody scrambles to figure out how they can adjust the need criteria to make it higher on the list, she said, adding that Congress needs to appropriate more funding to address the current need for American Indian healthcare facilities.
According to Sweeney, there are 19 projects left on the priority list, totaling $2.3 billion. Additional funding from Congress will be necessary to fund that backlog, and a new priority list cannot be implemented until all of the current lists projects have been completed.
If you go to many of the facilities in Indian country, they were developed in the 1930s, but they havent had the upgrades or the maintenance that non-Indian facilities have had in the same timeframe, Pata said, adding later that she thinks the funding allocation from the stimulus act was relatively fair, given that the law required so-called shovel-ready projects. In addition to more funding, Pata said that her groups other top priority is to advocate for the passage of the Indian Health Care Improvement Act.
According to IHS, the Indian Health Care Improvement Act was passed in 1976 based on findings that showed the health status of Indians ranked below the general population. After four reauthorizations, the legislation expired in September 2000 and was extended through 2001 with the expectation that Congress would reauthorize it again. Congress has held hearings on the reauthorization proposals, and versions of the bill have been considered, but it has yet to be reauthorized.
In the last session, it passed in the Senate, but not the House, Roubideaux said of the act. I am awarewith the Senate Committee on Indian Affairsthere is great interest in reintroducing this act, she said, adding that tribal leaders also have great interest in seeing this legislation passed. Im really looking forward to seeing them introduce a bill this year.
Linda Frizzell, a project director and policy analyst at the Northwest Portland Area Indian Health Board, recalled when the IHS consulted Indian tribes in the late 1990s about amendments to the improvement act and the 562 tribes at the time came to a consensus. We thought Congress would be embarrassed, she said, referring to the delayed legislation. In addition to advocating for this legislation, there should be a strong focus on improving areas other than general healthcare in Indian country, Frizzell said.
The biggest underfunding is behavioral health, Frizzell said. Its literally a catastrophe. If you have access issues, and the data is based on clinic visits, how can the people with the need ever be counted? Frizzell said she would also like to see an expansion of midlevel healthcare providers, such as nurse practitioners, midwives and physician assistants. All of this, she acknowledged, is dependent on more appropriated dollars to IHS.
Access to care is one of the four areas that Roubideaux said she will address in her new role. As the director of IHS, I plan to focus on four priority areas: to renew and strengthen IHS partnership with tribes about how we can better work together and improve the consultation process; raise reform to IHSin consultation with tribes and staffin (the) greater context of healthcare reform and what we can do to improve what we do in meeting our mission; to improve quality and access to care in all of our work in IHS; make sure everything we do is transparent and accountable.
Despite the uncertainty of the Indian Healthcare Improvement Act, and the need for greater resources and more funding, Roubideaux said she sees a lot of hope and a renewed call for change at the agency that will turn 55 next year.
I think, Roubideaux said, its a pivotal time in the history of the IHS.
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