Broken Promises: Despite treaty assurances, health care remains underfunded

— This is the third in a series of stories examining childhood health on the Wind River Indian Reservation, as part of our reader-supported Generation of Hope project. See below the story for more details. — Ed

Belva Day knew she was in trouble the instant she heard the loud pop and felt the blinding jolt of pain in her lower leg. Her first thought was for her little sister, and how to land without hurting her, too. With that accomplished, she next had to devise a one-legged route off of the trampoline and to the emergency room. Less immediate concerns, like who would pay for the health care to which she is entitled, had to wait.      

There is a common misconception that Native Americans receive free, comprehensive health care. They do not. Despite treaty assurances to the contrary, the services Day receives as an enrolled member of the Eastern Shoshone tribe are no more complete than her damaged left knee.

X-rays and manual stability tests of that knee point to a torn ACL. Her Indian Health Service physician can’t be sure, though, without money for an MRI or orthopedist’s consultation. Further tests would be moot, though. Funding for reparative surgery is out of the question. For treatment beyond painkillers and a walking brace, the otherwise fit and healthy 20-year-old Day is on her own. Just as she is with the $2,400 bill that came with her ER visit. So, for now, she limps.

Day’s experience is typical of the estimated 1.9 million American Indians and Native Alaskans who rely on the Indian Health Service for their health care. IHS is, by any measure, chronically underfunded, a circumstance that contributes to long waits, difficulty in getting appointments, and denied or delayed care. One popular yardstick places IHS budgets at 45 percent of need. As a result, the agency is forced to ration services severely.

Nothing free about Indian health care

Alice Moore, CEO of the IHS Wind River Service Unit, is the person responsible for translating limited resources into maximum health care on the Wind River Indian Reservation. An enrolled Northern Arapaho who left the reservation for a Torrington orphanage at age six, Moore emerged from the foster care system determined to improve the lives of native people.

Equipped with a wealth of first-hand experience, and a master’s degree from the University of California Berkeley, she served Indian communities in California and Arizona as a clinical social worker, before returning with her husband — a third generation traditional Lakota healer — to her Wyoming roots. She’s writing her PhD thesis on the effects of trauma. It’s hard to imagine a personal or professional background better suited to the challenges faced by her community. But that doesn’t make the job easy.   

She and her colleagues wrestle with an ongoing lack of investment grown in part from garden-variety federal budget politics. Like most federal agencies IHS’s mandate is rarely matched by the funding it receives. “There is a difference between authorizing legislation and appropriating legislation,” as Moore’s predecessor Richard Brannan points out.

At heart, though, the gap between needs and funding that IHS must straddle is created by fundamental disagreement over one primary question. Who is responsible for providing health care for Native Americans?

The Northern Arapaho and Eastern Shoshone tribes assert that, based on commitments made in the Fort Laramie and Fort Bridger treaties, along with a broader “trust responsibility” born from the unique legal relationship between tribes and the United States, the federal government should get the bill. As Northern Arapaho healthcare consultant Glen Fowler explains the position, “We’re not talking about free, here. There’s nothing free about Indian health care. We’ve already sacrificed plenty in holding up our end of the deal.”

“Is health care a right of citizenship or a privilege of wealth?” Wyoming Department of Health Director Tom Forslund asked during a health policy discussion at the Wind River Health Equity Summit in June.

But that question in the well-worn debate over the role of government is, in the case of Native American health care, beside the point. Tribal claims to service aren’t born of political philosophy. Rather, they’re rooted in historical agreements, made between sovereign nations, under threat of continued violence. Promises were made. At issue is the nature of those promises and whether or not they will be honored by the nation that made them.

The United States, for its part, acknowledges that there is a binding federal obligation to provide health care for native populations, thus the existence of IHS. But the extent of that obligation isn’t clearly defined by policy or regulation, and the cumulative case law is equally grey.

The result, in practice, is an agency with a split personality. IHS is set up as the primary provider of health care for Wyoming’s Native Americans, and it is partially funded to perform as such. But in carrying out its duties, IHS behaves, much like a private clinic does, as the payer of last resort.

The agency provides a host of in-clinic services at its Fort Washakie and Arapahoe clinics, including primary care, pharmacy, pediatrics, obstetrics, gynecology, behavioral health services, physical therapy, podiatry, basic dentistry and ophthalmology. Then, whenever possible, it bills Medicaid, Medicare, the Veterans Administration or private insurance for any services provided.

If, as in Day’s case, a diagnosis warrants treatment or testing that can’t be provided at an IHS clinic — surgery, advanced radiology or consultation with a specialist for example — then the patient is referred elsewhere. The necessary expertise can often be found in Lander or Riverton. Referrals to Casper, Denver, Billings and Salt Lake City are also common. Referrals and actual treatment,  though, are not the same thing. IHS only has the resources to pay for referred care in the most dire cases, those where loss of life, limb or eyesight is expected within the next 72 hours. By the end of some fiscal years, IHS offices are forced to choose between these “Priority 1” cases.

“Medicaid is the lifeblood of IHS,” said Richard Brannan, former CEO of the Wind River Service Unit. “They depend on people being so poor that they qualify for assistance.”

In 2014 the federal government contributed nearly $14.9 million to the Wind River Service Unit’s baseline budget. In the same year, third party billing brought in $11.4 million, most of it from Medicaid. Without those external revenues, IHS’s difficult financial realities would quickly become unworkable. Even with them, a lot of health care needs remain unmet.

Day was enrolled in Medicaid as a minor, but as a single, childless, young adult with a full-time job, she no longer qualifies, putting her within the “Medicaid gap.” As a Native American, she is exempted from the insurance mandate of the Affordable Care Act, so she’s not required to purchase insurance — in theory, she can rely on IHS services. Without third party coverage, though, those services, she’s learned, are limited.

“You may wait and wait to get an appointment to be seen, then finally get in and learn that you have a severe illness, a dangerous disease, but that there aren’t any funds available for treatment,” said Gary Collins, former Wyoming Tribal Liaison for the Northern Arapaho, expressing a common frustration. “Folks have grown used to getting help in October [the start of the federal fiscal year, when IHS has the most funding available] and sucking it up the rest of the year.”

Understaffed and overburdened

In addition to being resource-strapped, IHS bears the burden of being part of the federal bureaucracy. The glacial pace and cumbersome administrative overhead of government systems are particularly ill-suited to the dynamic and rapidly evolving healthcare field. The only other federal agency providing direct care to American civilians, the Veteran’s Administration, famously struggles with the same challenges. Yet a 4-hour drive to the VA hospital in Sheridan remains a popular alternative to IHS among Native American veterans on the Wind River Indian Reservation.

“I probably spent 60 percent of my time [as the Wind River Service Unit CEO] navigating and responding to the bureaucracy,” explained Brannan. “Imagine if that time and attention could go instead into planning for and providing patient care.”

Compounding the challenges further, IHS is regularly understaffed, even by the standards of its meager budget. The same hiring difficulties that face rural American providers everywhere make it difficult to find and attract qualified medical professionals to work on the Wind River Indian Reservation as well. The IHS website currently lists 21 job openings for its Fort Washakie and Arapahoe locations. Some positions, like a pediatric dentistry specialist, have gone unfilled for more than a year.

Critics of the agency are quick to point out that their frustrations are directed at the institution, not the individuals who comprise it. In much the same way that the majority of Americans disapprove of the job done by Congress, but support their individual congressman, patients listing complaints about the care they receive often use the next breath to express appreciation for the doctors and nurses who provided it.

“I love my doctor,” said Day. “She really cares, and she knows how to get things done. But she can only do so much with what she has to work with.”

The Wind River Service Unit is often singled out for exemplary achievement. Defenders from inside and outside of the unit describe it as the least-funded service unit in the region, per capita, but also the highest-performing by federal metrics. The WRSU was the first in the IHS system to fully integrate electronic medical records, and continues to make systemic improvements and incremental gains in efficiency.

“I left IHS because I saw it for the slowly sinking ship that it is,” said Brannan. “But I’m still proud to tell people I worked for the Wind River Service Unit. I know how hard the professional and highly-trained people there work. They know what they’re doing, and they do the very best they can for their patients.”

For Day, the best they can do is suggest that she not hold her breath waiting for IHS to meet the federal government’s treaty obligations. She’s young and healthy. Delaying curative treatment any longer is medically inadvisable. Perhaps, her well-meaning advisors tell her, she should bite the bullet, enroll in a private insurance plan and take her now preexisting condition elsewhere.
Day is resigned to doing just that. As Obamacare’s healthcare marketplace enrollment window opens in November, she’ll consider her options, their related costs and the family budget to figure out what she can afford to sacrifice. Then she’ll make some difficult decisions, not unlike those made and paid for by her ancestors nearly 150 years ago.

Read the entire Generation of Hope series:
Generation of Hope: Future of Native health depends on kids, Oct. 20, 2015
Pure Poverty: ‘If you don’t have money, you don’t have health care,’ Oct. 27, 2015
Broken Promises: Despite treaty assurances, health care remains underfunded, Nov. 3, 2015
With low expectations, many Natives go without health care, Nov. 10, 2015
Leaders confident Native community can reorder status quo, Nov. 17, 2015

— Generation of Hope is a special project of WyoFile, focusing on childhood health on the Wind River Indian Reservation. It is made possible by generous readers who donated to WyoFile’s crowdfunding effort in March, via the Beacon crowdfunding platform. Please share these stories with your friends, and tell us about your experiences regarding childhood health and well-being on the Wind River Indian Reservation. If you enjoyed this story, please consider making a tax-deductible donation to WyoFile. We could not have done this series without the support of our readers. — Ed.

WyoFile writer Matthew Copeland and WyoFile editor-in-chief Dustin Bleizeffer discussed the Generation of Hope series with Miranda Birdahl and Sean Ingledew, who produce Rally Casper‘s No Label Roundtable podcast. Take a listen: