Driving south into Winnebago, a billboard sponsored by the tribe reads: “Meth & Suicide … Is Not Our Tradition.” Both issues have plagued the community.

Families here are relieved to hear their teenage kids are drinking alcohol instead of getting high on crystal meth. Meanwhile, the hospital has sent suicidal walk-in patients back home, giving those people a new chance to follow through on an act that public health officials are trying to thwart. Community members want to offer more mental health and substance abuse treatment.

“We’re just trying to provide better healthcare, the best, for our people,” said Curtis St. Cyr, a Winnebago Tribal Council member who’s been hounded by a collections agency for a medical bill tied to care he received outside of IHS. “They deserve that, you know? It’s in our treaty, and we feel let down.”

Winnebago tribe members are now gradually turning to what they see as the most viable solution—taking over hospital operations.

Many other tribes have already done it. Nineteen of the 45 IHS hospitals are now tribally owned and managed, and about 60% of agency funding goes to tribal-operated systems. In 1994, tribes operated just nine of 40 IHS hospitals.

Tribes are able to take full control of hospitals and health centers through a portion of the Indian Self-Determination and Education Assistance Act known as “638 compacting.” Under this provision, tribes receive all the federal dollars that would’ve gone to the IHS facility, and they organize and run the hospital on their own, often by establishing a not-for-profit corporation.

“The only way we’re going to improve the quality of healthcare in Indian country is when we as Indians take responsibility for it,” said Whiting Sorrell, the health leader in Montana who has supported compacting. Her tribes have compacted most of their system since the 1990s and will manage the system fully by the end of this year.

But Great Plains tribes have resisted compacting. They fear it will give the federal government a pass on its commitments to tribes, who will then be left with the responsibility for maintaining an underfunded network.

In Winnebago, the concern has fractured the neighboring communities that use the hospital. The Omaha tribe supports the Winnebago tribe’s decision to pursue compacting, but it has no intention of following suit for its share of the hospital.

“We have a treaty that says Omaha tribe, because you gave up land and water and air space and lives, we’re going to promise you certain things. And one of them was a building and a doctor,” said Stabler, the health center CEO.

“We don’t want to relieve the government. They have a trust responsibility. They have an obligation to every one of us that are federally recognized tribal members that have a treaty. It was a handshake from the government.”— Wehnona Stabler, CEO of Carl T. Curtis Health Education Center

Before the Winnebago tribe compacts, it needs to reclaim quality certification and third-party billing privileges. Smith, the interim hospital chief, said officials are in the process of submitting the application to the CMS and hope to get certification back by the end of this year or at the beginning of 2017.

Danelle Smith, a Winnebago tribe member and an attorney at Fredericks Peebles & Morgan, is not as sanguine about the timeline. From her office in the town’s small but growing housing and economic plaza called Ho-Chuck Village, she has advised the tribe on the compacting process and has detailed sporadic and incomplete communication with IHS. The hospital has moved the recertification date multiple times this year already, and IHS’ projections assume “everything goes perfectly,” she said. But she’s hopeful for the compacting process.

“The whole community is going to be better off because the tribe knows best what the community needs,” Smith said. “It has the ability to design its healthcare system in a way that makes sense for the Winnebago people, a lot better than IHS ever could.”

At council headquarters, Kitcheyan, who prepared to dart off to another meeting with two smartphones in hand, expressed confidence the tribe was doing the right thing. “We know what we’re talking about now, and we’re capable of running our own affairs,” she said. “It shouldn’t have to be so hard.”

Story by: Bob Herman

Videography, graphics, code and design by: Fan Fei

Additional video/audio editing by: Gregg Blesch

Print design and graphics by: Pat Fanelli

Additional geocoding by: Art Golab

Edited by: Merrill Goozner, Julie Johnson and Dave May