The Indian Health Service (IHS) is the principal Federal health care provider and health advocate for American Indian/Alaska Native people, and its goal is to raise their health status to the highest possible level. The IHS currently provides health services to approximately 1.4 million American Indians and Alaska Natives who belong to more that 545 federally recognized tribes in 34 states.

The IHS administers a health care system for American Indians/Alaska Natives which includes 49 hospitals in 12 states, 180 health centers in 27 States, and eight school health centers and 273 health stations in 18 States. The health care system is operated through the cooperative efforts of Federal and American Indian and Alaska Native entities.

• The IHS holds an unprecedented number of meetings with tribes. Many meetings are with tribes that visit the Washington, D.C. area for the specific purpose of meeting with IHS officials. In some instances, tribal delegations come seeking information on initiatives and activities. In other instances, they request an IHS assessment of the impact of pending decisions within the Executive and Legislative branches of Government. Often they come to ask the IHS to work with them to develop ways to address identified issues.

• We believe that meetings with tribes have increased as a result of “endorsement by action” of the principles articulated in the Presidential Memorandum on Government-to-Government Relations with Native American Tribal Governments. They also have increased as a result of the emphasis Michael H. Trujillo, M.D., Director, IHS, has placed on the agency being open, responsive, and supportive of tribes and Indian organizations.

• The 1995 Annual Meeting of the National Indian Health Board (NIHB), Tampa, Florida, is a prime example of the agency’s working relationship with tribes. Throughout the meeting, there was a strong sense of inclusion and appreciation for the programs of the IHS. Tribal presentations focused on the many ways tribes were working with the IHS to address tribal and Indian priorities and the exploration of ways to involve the IHS in tribal programs and advocacy.

• A significant proportion of the American Indian and Alaska Native population lives in urban areas. Although urban Indian health programs do not constitute a tribal government, the IHS considers them to be a major component of the Indian health care system. The IHS regularly consults with urban Indian health programs and their national associations.

• The fiscal year (FY) 1997 appropriation demonstrates the commitment to improving the health of American Indians and Alaska Natives and to Indian self-determination, which includes assisting those tribes who wish to assume the administration of local health programs and services that would otherwise be provided by the IHS. The FY 1997 budget provides an overall increase of $70 million. This increase includes $13.1 million for personnel related cost increases, $26.7 million for annualization of staff costs for new facilities, $3.2 million for care for new tribes, $7.5 million for Indian self-determination activities, $4.2 million for restoration of fixed cost reductions, $2 million for Indian health professions, $3.9 million for special health initiatives, $13.5 million for replacement of the Lame Deer health facility, and $6.5 million for various facilities improvements and equipment.

The IHS used a total of 14,401 full time equivalent (FTE) positions in FY 1996; a decrease of 499 FTEs from the FY 1995 usage of 14,856. This reduction occurred as a result of the residual effects of the buyouts, difficulty in recruiting for doctors and nurses, (especially in remote areas) and downsizing because of the transfer of tribal shares to tribes. The IHS anticipates Federal employment will remain steady as new facilities come on line and federally operated facilities continue to be turned over to tribal organizations in accordance with Titles I and III of P.L. 93-638, as amended. It is important to note that these reductions are transfers of employment to tribal organizations and are not a reduction in our commitment of providing quality health care to IHS beneficiaries. Any reduction in staffing levels which do occur will be taken so as to minimize any negative impact on the delivery of health care services at the local level.

• The Director of IHS invited tribes and urban Indian health programs to work with the IHS to redesign the Indian health system and to ensure that recommendations for streamlining reflected their priorities. With their concurrence, the Indian Health Design Team (IHDT) was formed. The IHDT is structured with majority representation from tribes and urban Indian health programs. It continues to directly involve tribal and urban Indian health leaders in the implementation phases of restructuring the IHS.

• The IHDT submitted its report, “Design for a New IHS,” to American Indian and Alaska Native people, tribal leaders, tribal health directors, and IHS employees in December 1995. The report includes more than 50 recommendations. The recommendations provide ways to give power and authority to the local health care delivery site and outline structural changes for IHS at the Headquarters and Area levels. No recommendations were made for changes to the local delivery site, because the IHDT believes that any changes at the local site should be decided locally. The recommendations for IHS Headquarters and Area levels emphasized a role that supports and advocates for the local health services delivery level instead of controlling it.

• Implementation of IHDT recommendations is proceeding in two phases. Phase I streamlining efforts at IHS Headquarters are focused on essential core functions that are consistent with the advocacy and leadership role of the Agency. Other functions, and the resources to carry them out, will be delegated to the field. Phase I restructuring is scheduled for completion by the end of FY 1997.

Phase II, which focuses on the restructuring of Area level functions, is currently under way. Tribes in each IHS Area are meeting to consider changes to the functions of Area Offices and will submit recommendations to the IHDT. The Phase II Area plans for change are due in July 1996. Phase II is scheduled for completion by the end of FY 1998.

• The development of an IHS business plan is part of the broad strategy initiated by the Director of IHS to redesign the IHS to meet the challenges of the future. Together with a commitment to culturally sensitive community-oriented care, pragmatic business planning is an essential ingredient to ensure that Indian health programs are both solvent and a valued asset to Indian people well into the twenty-first century.

• The business plan, now under development by a workgroup composed of elected tribal leaders, tribal health directors, business managers, accountants, physicians, nurses, Federal executives, and private sector consultants, is drawing on lessons learned from the business community. This inclusive mix is indicative of a new leadership style within the agency, where all major policy is developed in partnership with Indian people.

• The business plan focuses on four primary issues: revenue generation, cost control, tribal shares, and internal business improvements. It is expected to be completed in FY 1996.

• The Indian Self-Determination Contract Reform Act, P.L. 103-413, was enacted in October 1994. The Act simplifies the self-determination contracting processes and facilitates the assumption of Federal programs (e.g., IHS) by tribal governments and tribal organizations. It is important to note that tribes exercising self-determination may elect any of three options: to enter into a contract with the Federal Government to provide services it would have provided, to compact to provide these services, or to have the Federal Government continue to provide services through Federal programs.

• In compliance with P.L. 103-413, the HHS and the Department of the Interior (DOI) have developed proposed regulations.

• The Notice of Proposed Rule Making (NPRM) was developed by one of the largest committees ever convened for negotiated rulemaking, and included 48 representatives of tribal governments and organizations, 9 DOI representatives, and HHS representatives. The NPRM was published January 24, 1996. Public comments were reviewed April 29-May 3 by the Negotiated Rulemaking Committee. The Final Rule to implement P.L. 103-413 was published in June 1996, and became effective 60 days after publication.

• At the end of FY 1995, the IHS transferred more than $730 million to support health delivery programs of tribal nations through self-determination contracts and self-governance compacts. This represents approximately one-third of the IHS services budget for that year.

• The IHS is currently in its third year of the self-governance compacting demonstration project. The Agency has negotiated 29 self-governance compacts and 42 annual funding agreements for FY 1996, and transferred approximately $300 million to 197 tribes in Alaska and 28 tribal governments in the lower 48 States. The process to select an additional 30 tribes to participate in self-governance compacting has been initiated.

• Tribes are currently advocating for legislation to make the self-governance compacting demonstration project a permanent option for IHS programs, as it is for Department of Interior programs. They are also advocating that opportunities to compact for IHS programs be extended beyond the IHS and encompass the entire HHS. The IHS is actively supporting the tribes’ efforts in this endeavor.

• Pilot projects have been initiated with two compacting tribes, the Jamestown S’Klalam and the Mille Lacs Band of Ojibway Indians, to assess the impact of stable funding on a tribe’s ability to plan for and manage health services programs. The pilot project encompasses cooperative IHS and tribal action to determine a tribe’s base budget at a specific point in time, to negotiate an agreement for the IHS to fund the compact at the base budget level for a 3-year period, and an agreement that further funding negotiations will not be needed for the 3-year period, except when increases are authorized by the Congress. We anticipate that these two pilot projects will provide the information needed to permit the agency to implement stable funding for other compacting tribes.

• The Director of IHS, in consultation with self-governance tribes, recently selected Ms. Paula Williams, a member of the Sac and Fox Nation of Oklahoma, as the first permanent Director for the Office of Tribal Self-Governance (OTSG). The OTSG is currently establishing a Self-Governance Advisory Committee composed of nine elected leaders from compacting tribes.

• A number of tribes have selected the third self-determination option, which is to have the Federal Government continue to provide health services to their people and represent 65 percent of the IHS annual budget. When a tribe elects this option, the IHS provides a range of services that may include hospital and outpatient care, preventive and rehabilitative services, and the development and maintenance of health-related community infrastructures such as sewage treatment facilities. Although the IHS continues to provide health services in many American Indian and Alaska Native communities, the agency works closely with local tribal leaders to plan needed services.

• The HHS, the IHS, and the NIHB sponsored a series of five regional meetings with Indian tribal governments and State governments in 1995 to discuss State health reform as well as related Federal public health issues and Indian health issues. These meetings provided an unprecedented opportunity for representatives of Indian tribes, States, IHS, the Health Care Financing Administration (HCFA), and the Public Health Service Regional Offices to discuss common issues related to State-initiated health care reform. The meetings produced new State, tribal, and Federal partnerships to address the health care needs of American Indians and Alaska Natives and further advocate for the government-to-government partnership that is actively supported by this administration.

• The Director of IHS recently established a State Initiatives Workgroup (SIWG). Tribal representatives to the SIWG are being recruited from each of the NIHB designated areas. Urban representatives will also be included.

• The SIWG is the focal point for information, correspondence, policy, and legal perspectives on State health reform specific to American Indian and Alaska Native issues. The SIWG reviews 1915(b) and 1115 Medicaid waiver requests submitted by States proposing to implement a Medicaid managed care health system. The SIWG has provided technical assistance to several States and local tribal leaders for the development and implementation of Medicaid waiver proposals.

• As an example, the Oklahoma Health Care Authority submitted to HCFA for approval, a 1115 Medicaid waiver proposal to organize Medicaid managed health care plans, known as Soonercare. The HCFA developed, in consultation with the SIWG, a term and condition requiring the State to consult with Oklahoma tribes to develop an implementation plan specifying how the Indian health programs would operate under Soonercare. State officials and tribal leaders met several times and successfully developed an implementation plan. In accordance with the plan, all Medicaid clients, including American Indians, will be required to enroll in one of the health plans under the Soonercare program. However, Soonercare enrollees eligible for IHS services may obtain health services from any IHS, tribal, or urban Indian provider, even if these programs are not providers in the Indian enrollee’s health plan network. Indian health program providers will bill Medicaid on a fee-for-service basis. Billed amounts will be deducted annually from capitation funds allocated to the various health plans.

• In FY 1996, Philip R Lee, M.D., Assistant Secretary for Health, held a series of four regional meetings on Performance Measurement in Selected Public Health Programs with tribes, States, and other local public health organizations. Tribes and States are providing input to the HHS on the development of program performance measures for Federal public health programs proposed for consolidation by the Performance Partnership Grants proposal. Tribal participation in the HHS’s consultation ensures the inclusion of Indian health concerns in the development of a national set of public health program outcome objectives.

• A Public Health Service/IHS Steering Committee has identified several important issues that require research and discussions with HCFA. The Director of IHS is appointing workgroups composed of tribal representatives and IHS staff to address these issues, which include managed care, long-term care, home health, and reimbursement for traditional medicine.

• Recently, HCFA and IHS published a memorandum of agreement (MOA) to implement a change in payment policy for Medicaid-funded health services to American Indians and Alaska Natives. New policy supported through the MOA reinterprets section 1905(b) of the Social Security Act to allow the Federal medical assistance percentage to be 100 percent for Medicaid-funded services provided in health care facilities owned and operated or leased and operated by a tribe or tribal organization, pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended. Before the MOA was signed, it was circulated to tribes and States for review and comment.

Indian Women’s Health Initiative

• The IHS Director’s 1994 vision statement established Indian women’s health as a high priority for the IHS.

• The Indian Women’s Health Steering Committee, composed of 20 tribal women, 2 tribal men, and 3 Federal employees, was established to advise the IHS leadership about Indian women’s health needs, promote healthy lifestyles in American Indian communities, and develop stronger community-level networks for Indian women.

• The committee has sponsored Indian Women’s Health Conferences and provided exhibits at national meetings of the NIHB and the Headstart Program. It has developed a Women’s Health Chart Series and an American Indian and Alaska Native Health Resources Directory. It has recommended performance standards for the IHS Area Directors specific to women’s health issues and continues to provide important leadership for Indian Women’s Health.

• In 1995, the Director of IHS launched the Traditional Medicine Initiative. The agency has since met with traditional healers across Indian Country to solicit advice about addressing traditional medicine practices within the IHS programs.

• Many local programs have successfully blended modern philosophy and medical practices with traditional healing practices of American Indian and Alaska Native people. In addition, the IHDT is considering ways the IHS can support relationships between practitioners in local Service Units and traditional healers.

• A national advisory board, composed of tribal traditional medicine people, is currently being established to assist the IHS in strengthening ties between the locally recognized healers and the Indian health system clinicians and chief medical officers.

• Individual Indian people, tribes, and Indian organizations have long provided the leadership necessary to address the problems of alcoholism and substance abuse in American Indian and Alaska Native communities.

• The “Expanding the Circle 1996” national conference was held in San Diego, California, June 1-2, 1996. It addressed alcoholism and subsequent abuse issues of importance to American Indian and Alaska Natives communities. It was planned by Indian organizations and representatives of tribal groups, and was jointly funded and co-sponsored by the IHS and the Substance Abuse and Mental Health Services Administration (SAMHSA), HHS.

The conference brought together 293 participants representing grantees of the IHS and SAMHSA, tribal leaders, elders, and youth from grassroots communities involved in the fields of substance abuse and mental health. It explored effective methods for accomplishing the prevention and treatment of alcohol and substance abuse and mental health issues among American Indian and Alaska Natives. Conference participants interfaced with one another and with health care and agency personnel in developing dialogue and effective partnerships, and in sharing effective techniques and methods for treatment and prevention. The conference was a forum through which American Indian and Alaska Native grantees and programs could exhibit their successes and accumulate knowledge in substance abuse and mental health services treatment and prevention.

The “Expanding the Circle 1996” conference also served as a demonstration of a community healing process in an experimental format. This healing process is based on the premise that spiritual/community, total/individual healing is the most effective means for defeating alcohol and substance abuse within Indian communities. It is achieved through a process that uses five concepts that are essential to the maintenance of a healthy Native American culture: Traditional Practices, Holistic Wellness, Empowerment, Collaboration, and Integration.

The conference attendees participated in ceremonies and activities through which they shared program information and experienced belonging, interdependence, and generosity first-hand. As they shared themselves, their time, and their energy, attendees confirmed their capacity to become witnesses for sobriety and healing agents within their own communities.

• The Indian Health Injury Prevention Initiative has adopted “building tribal capacity in injury prevention" as its mission. Capacity building includes understanding the etiology of injuries and developing culturally appropriate solutions within the existing tribal infrastructures, including tribal leadership, health, safety, education, and social services.

Approximately a year ago, the Native American Injury Prevention Coalition was created by the four major tribes of North Dakota, with assistance from the IHS. This coalition is the first of its kind in the United States to advocate directly on behalf of its member tribes and all American Indians and Alaska Natives to increase awareness and promote solutions to traumatic injury. Numerous presentations on the coalition’s work and long-term goals have been made throughout the country.

A coordinating group, including tribes, Indian organizations, the IHS, the Centers for Disease Control, the Bureau of Indian Affairs, the National Highway Traffic Safety Administration, the Federal Highway Administration, and the National Association of Governors’ Highway Safety has been formed to host the “First Native American Lifesavers Conference” in Denver, Colorado. Standing Rock Sioux Tribal Chairman Jesse Taken Alive will be the Conference Chairman.

• The Director, IHS, is committed to addressing the challenges of protecting and promoting the health of American Indian and Alaska Native children and youth. A Youth Advisory Board composed of American Indian and Alaska Native youth is now being formed to provide advice and recommendations to the IHS. Unity National Indian TribalYouth, Oklahoma City, Oklahoma; the Boys and Girls Club of Northern Cheyenne, Lame Deer, Montana; and the National Indian Leadership Program, Gallup, New Mexico, have volunteered to assist with this effort and have recommended American Indian youth to serve on the Youth Advisory Board. A series of fact sheets on the health of American Indian and Alaska Native youth will be developed in FY 1996. Topics suggested for this series include: parent-child communication; physical activity and children; eating to stay strong and healthy; understanding the relationship between violence and substance abuse; and adolescent health services and benefits.

• The American Indian and Alaska Native Elder Health Care Initiative was launched in October 1995. Four representatives from tribes and Indian organizations and three IHS representatives provide the leadership for this initiative.

The team has had discussions with a number of government agencies, geriatric programs, and American Indian and Alaska Native programs concerning strategies for addressing the needs of elders and resources that can be developed for this population. A resource guide is now under development. Third-party billing options are being pursued with HCFA and the IHS Contract Health Services Program to provide financial resources for elder health care. Interdisciplinary Team Training in Geriatrics is being planned and recommendations to the Director of IHS are being developed for an Elder Health Care Program.

Networking with organizations, Government agencies, and foundations such as the American Association of Retired Persons, the Veteran’s Administration, and the Robert Wood Johnson Foundation is continuing and is expected to contribute to the development of additional information and resources for America Indian and Alaska Native elder health care.

The agency has also undertaken a demonstration project at five sites to assess the costs and utilities of implementing a swing bed policy. The goals of the demonstration are to assess the community acceptability of the implementation, the support services necessary to implement the policy and the costs of providing this service compared to the revenue generated. This may assist in filling a gap in low acuity hospital care for elders in isolated American Indian and Alaska Native communities.

Inquiries pertaining to this information may be directed to Dr. Michael Trujillo, Director, IHS, at 301-443-1083 or by fax at 301-443-4794.

In addition, information on issues and activities pertaining to American Indian/Alaska Native populations may be obtained from the IHS Area Directors listed below: