October 23, 2009

INDIAN COUNTRY AND HEALTH CARE REFORM Le o J. Nolan Indian Health Service U niversity of North Dakota Indian Health Research Conference

RELATIONS WITH INDIAN TRIBAL NATIONS  Recognition  Sovereignty, Treaty Making (800 treaties – 380 ratified), Containment, Disintegration/Annihilation  Assimilation/Termination/Relocation

 Self Self--Determination

 Johnson 1968, Kennedy 1969, Nixon 1970

 Consultation  Clinton 1998 & 2000, Bush 2004

BASIS FOR FEDERAL HEALTH BENEFITS TO INDIANS  Treaties exchanged aboriginal lands for federal trust responsibilities and benefits.  Snyder Act authorized funds “for the relief of distress and conservation of health … [and] for the employment of … physicians … for Indian tribes throughout the United States.” (1921)  Transfer Act placed Indian health programs in the PHS. (1955)  Indian Sanitation Facilities Act (P.L. 86-121) (1959)  Indian Self-Determination and Education Assistance Act (P.L. 93-638) (1975)  Indian Health Care Improvement Act (P.L. 94-437) (1976)  Political relationship...domestic sovereign...not race based

INDIAN HEALTH SERVICE MISSION, GOAL, & FOUNDATION The Mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and spiritual health to the highest level. The Goal is to ensure that comprehensive, culturally acceptable personal and public health ser vices are available and accessible to all American Indian and Alaska Native people. The Foundation is to uphold the Federal Government’s obligation to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

The mission of the DHHS is to enhance the health and well being of Americans by providing for effective health and human ser vices and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social ser vices.

* WWW.HHS.GOV * 2010 Budget in Brief *

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2009 Food and Drug Administration

$2.1b

Health Resources and Services Administration

$7.0

Indian Health Service

$4.0

Centers for Disease Control and Prevention

$6.3

National Institutes of Health Substance Abuse and Mental Health Services

$33.0 $3.4

Agency for Healthcare Research and Quality

$.372

Centers for Medicare and Medicaid Services

$701.0

Administration for Children and Families

$56.0

Administration on Aging

$1.5

Office of the Secretary – IGA, OCR, OIG, Assistant Secretaries

$1.3 __________ $816 Billion

HHS TRIBAL CONSULTATION  Apr 29, 1994

President Meets with Tribal Leaders (Executive Memorandum - May 1994)

 Aug & Sep 1997

HHS Consultation Policy (2005)

 Jan 1998

IGA Designated Lead for HHS Consultation (Executive Order - Aug 1998)

 1999-2008

HHS Tribal Budget Sessions

 FY 2006 FY 2007

$394 m. increase

 Barriers Study ASPE  Nat. AI/AN Health Research Adv. Council  Intradepartmental Council on Native American Affairs

IHS – HHS COMMITTEES AND WORKGROUPS I nd ian Health Service T r ibal Leaders Diabetes Advisory Committee H P /DP Advisory Committee D ir ect Service Tribes Advisory Committee T r ibal S elf-Governance Advisory Committee I H S Budget Formulation Workgroup C ontract Support Cost Workgroup Facilities Appropriations Advisory Board Behav ioral Health Advisory Committee HHS C MS Tribal Technical Advisory Group C D C’s Tribal Consultation Advisory Committee H H S American Indian/Alaska Native Health Research Ad v isory Council S AMH SA Tribal Technical Advisory Committee

ICNAA  Purpose 

1974 Native American Programs Act



Coordination and Consultation Trans-HHS

 Membership  HHS Tribal Liaisons  White House Indian Affairs Executive

Work Group

A QUICK LOOK AT INDIAN HEALTH SERVICE  564 federally recognized tribes in 35 states.  IHS provides a comprehensive health service deliver y system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives. FY 2009 appropriation is approximately $4.0 billion. Inpatient: 59,000; Outpatient: 9.8 million; Dental: 3.2 million  Federal system – 31 hospitals, 50 health centers, 31 health stations, 34 urban Indian health projects serving 600,000 American Indians (direct, CHS)  Tribal system – 15 hospitals, 254 health centers, 112 health stations, 166 Alaska village clinics (contract, compact $1.5 billion).  IHS staffing - total 15,450 employees, 2,600 nurses, 900 physicians, 400 engineers, 500 pharmacists, 300 dentists, 150 sanitarians, and physician assistants, allied health professionals - nutritionists, health administrators, and medical records administrators.

INDIAN HEALTH SERVICE USER POPULATION BY AREA

Alaska 136,065

Portland 101,690

Billings 70,507 Aberdeen 120,639

California 77,532

Bemidji 101,022

Phoenix 156,803 Navajo 239,814

Albuquerque 85,778

IHS Headquarters Rockville, MD Oklahoma 316,940

Tucson 25,234

Nashville 51,399

TOTAL IHS USER POPULATION FOR FY 2008: 1,483,423

THE INDIAN POPULATION WE SERVE 1, 90 0,0 00 1, 80 0,0 00

1.4m AI/ANs Unserved

1, 70 0,0 00 1, 60 0,0 00 1, 50 0,0 00 1, 40 0,0 00

1.9 m AI/ANs Served

1, 30 0,0 00 1, 20 0,0 00 1 996 19 97 19 98 199 9 2 000 20 01 200 2 2 003 20 04 20 07

3.3m AI/ANs

IHS Ser vice Population Growth  Population growth rate of 1.6% per year  71% high school graduates (80% U.S.) & 12% college graduates (24% U.S.)  26% of AI/ANs fall below poverty standard  Unemployment is 3.0 times the US rate

COMMUNITY ORIENTED PRIMARY CARE Cultural & Spiritual Behavioral & Social

Medical Care Public Health Water & Sanitation The Indian health care system is built on a broad spectrum approach to health. It starts with a base of fundamental public health and sanitation infrastructure. It provides inpatient and ambulator y medical services. It also integrates communitycommunity- oriented programs including traditional medicine to promote healthy behaviors and lifestyles.

CLINICAL CARE PATTERNS IHS HOSPITAL 1°/2° CARE CLINIC

1°/2° Care • I n creased R e venue • D e creased CHS Ex p enditures

PRIVATE HOSPITAL QUALITY ASSURANCE STAFFING PHARMACEUTICALS, ETC.

2°/3° Care • C H S $$ • I n surance Of f sets

OUTREACH/PATIENT EDUCATION PHN CHR

COMMUNITY HEALTH

MSW Health Education Headstart School Health

ENVIRONMENTAL SURVEILLANCE

ENVIRONMENTAL PROTECTION

Toxic Exposures Outbreak Assessment Vector Control

Food Safety Solid Waste

Water Safety Sewage

PERCENT OF DECREASE IN MORTALITY RATES FOR INDIAN PEOPLE SINCE 1973

Suicide Pneumoni a/Influe nza Alcohol -related Cerebrovascular

CY 20022002 -2004

14% 36% 44% 4 9%

Infant Deaths

53 %

Homicides

54 %

Accidental

58%

Maternal Deaths

68%

Cervical Cancer

75 %

Tuberculosis

84% 0%

20% 40% 60% 80% Percent Decreas e in Mortality Rates

1 00%

COMMUNITY ORIENTED PRIMARY CARE HAS REDUCED AI/AN MORTALITY 25

American Indians & Alaska Natives

20

15

US All Races

10

US White 5

93 20 02

89

91

85

87

8 1 83

9

7 7

7

3 19 7

75

0

Infant Mortality Rates 1973 – 2002 (25.0 to 8.5/1,000) 66% Reduction

Sanitations Facilities for AI/ANs Gastrointestinal Disease and Postneonatal Mortality Rates Compared with the Percent of American Indian and Alaskan Native Homes with Potable Water 25

100 90

20

80

10 5

Percent

15

Rate

70 Gastr ointestinal Disease Death Rate per 100,000 Postneonatal Mor tality r ate per 1000 bir ths % of AI/AN Hom es w/ potable water

60 50 40 30 20

The IHS SFC Program is a preventative health program. It is a significant factor in the decline in GastroGastrointestinal Disease Death Rate and Postneonatal Mortality rate

10 0 0 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 YEARS

 1959 potable

Yields positive benefits (>20 times) in excess of program costs.

water in 20% of AI/AN Homes  Currently 89% have potable water - compared to 99% of the general US population - 36,575 Indian homes without potable water  Goal: 94% with potable water by 2010 - OEHE part of IHS Strategic Plan to achieve parity in access - An OMB marginal cost analysis recommended additional project and Program (staff) funding to meet this goal  There is a total need of $2.4 Billion for Sanitation Facilities

Health Care Facilities Construction 2 ,000

Fiscal Year Fund ing

5-Ye ar Pla n Need

In M ill ion s o f $s

1 ,800 1 ,600 1 ,400 1 ,200 1 ,000 800 600 400 200 0 97

98

99

00

01

02

03

04

05

06

07

Efficient health care delivery requires modern facilities 33 years: average age of IHS Health Care Facilities 9.6 years: the average age of U.S. health care facilities*

 $6.5 Billion is total need for new or replacement facilities  $1.8 Billion (Chart) are prioritized on current funding plan Inf lation (3%) will increase this by $54 Million this y ear $37 Million = FY 2008 Federal f unding f or construction $50 Million = av erage Federal f unding since 1995

FACTORS THAT AFFECT HEALTH STATUS

Health Care (10% )

Genetic Predisposition (20%)

Environm ent (20%)

Behavior (50%)

20 t h CENTURY OF CHANGE

 Immunizations  Infection control  CVD reduction  Better food  Workplace safety  MV safety  Tobacco control  Child birth safety  Family planning  Fluoridation

SOCIAL DETERMINANTS OF HEALTH*          

Social gradient Stress Early life Social exclusion Work Unemployment Social Support Addiction Food Transport * World Health Organization: Social Determinants of Health The Solid Facts, 2nd Edition

Mor tality Rate Disparities Continue American Indians and Alaska Natives in the IHS Service Area 20022002-2004 (Age--adjusted mortality rates per 100,000 population) (Age

AI/AN Rate 2002-- 2004 2002

ALL CAUSES

U.S. All Races Rate 2003

1027.2

CVD Malignant Neoplasm Unintentional Inju ries Diabetes Motor vehicle crashes Alcoho lism Pneumonia/Influenza Suicide Homicide Infant deaths* Cervical cancer Tuberculos is

231.1 180.7 94.8 74.2 51.2 43.6 32.3 17.9 12.2 11.7 4.7 1.7

Ratio: AI/AN to U.S. All Races

832.7

1.2

232.3 190.1 37.3 25.3 15.3 6.7 22.0 10.8 6.0 6.9 2.5 0.2

1.0 1.0 2.5 2.9 3.3 6.5 1.5 1.7 2.0 1.7 1.9 8.5

*Infant deaths per 1,000 live births

2008 IHS Expenditures Per Capita and Other Federal Health Care Expenditures Per Capita

$8,000 -

$7,000 -

$6,000

Per Capita spending in the year for which data are published most recently – see base of bar $5,000

Medical

$4,106

$1,000

2004

2008

2007

2006

2007

$ 2,3 49

-

$3 ,24 2

$2,000

IHS -

$4,575

$6,130

$3,000

-

$6,538

$7,439

-

$4,000

1999

$-

M e dica re

Na tion al He alth Ex pe nd itu res

Vete ra ns Adminis tra tio n

Me dic aid

FEHB Me di cal Ben chma rk

M ed ica l fo r Fe de ra l Pri son s

See page 2 notes on reverse for data sources and extrapolation assumptions. 10/22/2009

2 00 8 IHS Exp en di tu re s

Nonmedical $53 7

IHS Health Initiatives  HPDP  Focus on best practices and promote standardization of interventions  Behavioral Health  reduce uncontrolled depression/sequelae  Improved Patient Care  use best practices in medical and social management of disease

Chronic Care Model Health System

Community

Health Care Organization

Resources and Policies SelfSelfManagement Support

Informed, Ac tivated P a tient

Delivery System Design

Clinical Decision Information Support Systems

Productive Interactions

P re pared, P roactive H e alth Team

Improved Outcomes

IHS Director’s Priority Areas  R enew/Strengthen partnership with

T ribes

 R eform of IHS system in context of

national health reform

 I m prove quality and access to care  Ens ure our work is transparent,

accountable, fair and inclusive

Call for Change  O b ama-Biden Transition Team  President Obama  Congress  Hop eful signs so far 

P re sident’s 2010 budget 



Al m ost 13% increase – largest in 20 ye a rs

ARRA funding - $590 million to IHS 

Fa c ilities & sanitation projects, m a i ntenance & improvement, medical e quipment, health IT

National Health Insurance Reform 

P r iority of President Obama I n creased access to quality and affordable healthcare Se c urity and stability for those that have insurance R e duce healthcare costs

  



C ur rent debate in Congress 3 H ouse, 2 Senate bill s V a rious provisions

 

 

H is toric Perspective C ur rent Situation 4 7 Mil lion+ - Uninsured & Underinsured M o ving Target H e a lth Literacy Pu b lic Option (Mandatory) A g e + Gender, Past Claims C o st

     

Health Insurance Reform

 Tribal consultation activities  Tribal recommendations  Administration role  IHS 

Personal Medical Care + Public Health



Uniquely Defined Population



Pub lic Option

Challenges  Pop ulation Growth  R ising costs/ medical inflation  I ncreased rates of chronic diseases  R ecruiting and Retaining Medical

Providers

 R ural Healthcare  Lack of Sufficient Resources  B alancing the needs of patients  Social Determinants

FYI www.ihs.gov Thomas Sweeney Public Affairs (301) 443443-3593 [email protected] http://info.ihs.gov/

Dr. Susan Karol Chief Medical Officer (301) 443443-1083 [email protected]

Leo J. Nolan Senior Policy Analyst for External Affairs (301) 443443-7261