Failure at one Indian Health Service hospital reveals a system in crisis

The Winnebago struggle

December 2, 2016

WINNEBAGO, NEB. — In April 2011, Tori Kitcheyan returned home from a business trip to Washington, D.C., to be with her 45-year-old diabetic aunt, who was recuperating in the Indian Health Service hospital here after having several toes amputated at a different hospital in Sioux City, Iowa, about 20 miles to the north.

The 13-bed facility is the only hospital serving the reservations of the Winnebago and Omaha tribes. The Winnebago tribe, in particular, has 5,000 Native American members and roots in Wisconsin. They were forced to move roughly 150 years ago to this isolated territory on the Missouri River near the Nebraska-Iowa border.

The farmland surrounding the town stretches for miles. It has a Dollar General store, a high school and three casinos. The most vital structure in Winnebago is the hospital, which is a stone’s throw away from the mini-mart-sized Native Star Casino.

The IHS hospital in Winnebago, Nebraska, has had at least five unneccesary patient deaths since 2011. The aunt of Tori Kitcheyan (right) was one of them.

Exhausted from her trip, Kitcheyan planned to visit her aunt the next day. It wasn’t a life-or-death situation, she thought. But overnight, her aunt, Debra Free, died after being overmedicated.

Federal reports later showed Free’s death, which stunned Kitcheyan, their family and the close-knit community, was avoidable. And it was not an anomaly.

The IHS refused to discuss individual cases due to medical privacy laws. But since 2011, there have been at least five unnecessary deaths at the tiny IHS hospital and countless other instances of deficient care, according to federal survey reports and testimony.

In May 2015, a 30-year-old Winnebago patient who entered the emergency department after drinking heavily for three weeks was discharged within hours without alcohol counseling or treatment to prevent withdrawal. That patient returned the next day in a state of delirium and later suffered two seizures at home.

Multiple pregnant women who visited the hospital in 2015 encountered clinicians who couldn’t read a fetal heart monitoring test, according to a federal survey. In some cases, the batteries in the fetal monitor had been dead for days.

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In 2014, the Centers for Medicare and Medicaid Services ordered the hospital to institute corrective action. But by July 23, 2015, the government had seen enough. The staffing and oversight flaws posed “immediate jeopardy to patient health and safety,” the CMS said as it revoked the hospital’s Medicare and Medicaid certification. The Winnebago facility became the first IHS hospital to lose its right to collect payment from the two government programs.

“Losing a loved one there and knowing that many of our other tribal members have lost their lives or have been misdiagnosed hits home,” says the 34-year-old Kitcheyan, who is now the leading advocate for fixing the hospital’s problems. “It hurts to know that our people still have to go there.”

This past February, she took her tribe’s concerns to Washington. Kitcheyan, who has long, straight black hair with brown highlights, appeared before the U.S. Senate Committee on Indian Affairs to detail the problems at the hospital and IHS, whose mission is to provide the comprehensive care to Native Americans that is guaranteed by treaty rights. It’s “the only place you can legally kill an Indian,” she declared.


“Until those systematic changes take place, the Winnebago hospital and many others throughout the IHS system will continue to be places where you can only legally kill an Indian.”— Tori Kitcheyan, treasurer of Winnebago Tribal Council

More than 10 months have passed since that committee hearing. It’s been more than a year since the hospital was stripped of its right to bill Medicare and Medicaid. And it’s been six years since former Democratic Sen. Byron Dorgan of North Dakota unveiled a scathing report acknowledging that IHS’ lapses have festered for decades and called the IHS bureaucracy in the Great Plains a “big morass of glue.”

Legislation introduced in May by Republican Sens. John Barrasso of Wyoming and John Thune of South Dakota, which would make some changes to IHS management and discipline without offering new funding, languishes in Congress. “After years of inaction at IHS, there are still more questions than answers for the tribal members who depend on the agency for their healthcare needs,” Thune said in May. A Barrasso staffer said the committee is “optimistic” the bill will pass eventually.

In other words, nothing has changed, tribal advocates say.

Many Winnebago and Omaha tribe members who live on and off their reservations still go to the IHS facility, but they do so out of necessity, not choice. Many can’t go to a private hospital because they don’t have transportation, or they don’t have private health insurance, Medicare or Medicaid.

More than a quarter of Native Americans nationwide are uninsured. Many don’t have money to pay for care out of pocket and don’t have access to private financial assistance programs.

That makes them dependent on the federally funded IHS for basic services, much like veterans in many parts of the country are dependent on the Veterans Health Administration. Yet while poor care or long wait times at VHA facilities ignited a national furor, few people pay attention to even worse conditions at the IHS.

“My level of trust and respect for IHS went from good to poor to pitiful,” says Terry Medina, an adult probation officer who is enrolled in the Santee Sioux tribe and whose wife and kids are Winnebago.

Medina, a bespectacled man with a slicked-back coiffure and a dusting of facial hair, faced his own scare two years ago. He was watching the San Francisco Giants and Kansas City Royals in the World Series when it felt like his head “was going to explode.” Medina, a diabetic, went to the IHS emergency room and discovered his blood sugar was six times higher than the normal level. Doctors and nurses there failed to stabilize him, and he woke up in an ambulance heading to Sioux City to find out his blood sugar had since cratered to 11 times lower than the norm.

The health problems of Native Americans, who represent 2% of the U.S. population, are largely invisible to the broader public. Congress rarely investigates conditions at IHS facilities. The last piece of wide-ranging legislation to tackle its problems—the Indian Health Care Improvement Act—was passed in 1976 and was permanently reauthorized as part of the Affordable Care Act.

But it never succeeded in righting the underfunded agency. Frustrated by the failure of the federal government to take their concerns seriously, tribes in other parts of the country over the past several decades have forced out IHS by creating not-for-profit community organizations to run their local facilities.

Kitcheyan and other patient advocates here are now looking to do the same. “The healthcare that we have here, it’s like Third World healthcare,” Kitcheyan said.