Make good on federal promise for Native health care

WHEN President Obama signed major health reform in March, many heralded it as a historic act. Indian people are part of this history, too, but how it will turn out for us depends on congressional action in coming months.

For Native people, health and history go hand in hand, going back to the country's earliest years, when the U.S. government began dispossessing indigenous nations to make way for expansion. In the process, it assumed responsibility for the health of Indian people, who were forced to bargain away land for such promises.

The government has fallen far short of fulfilling this obligation. The Indian Health Service (IHS) has done much to address serious health problems affecting Native people, but it's also severely and chronically underfunded, receiving a smaller federal investment than other health programs. In 2005, for example, the federal government spent $2,130 per capita for IHS beneficiaries, compared with $5,010 for Medicaid and $7,631 for Medicare recipients.

It's unlikely this gap reflects less need for care, since Indian people suffer among the worst health outcomes in the country. Rather, this shortfall means Indian people often can't get needed health care. The IHS acknowledges this reality, yet still underestimates what's really needed to support a health-care system for Native people.

The situation of urban Indians points to another connection between history and our health. In the 1950s, the government terminated federal recognition of hundreds of tribes, attempting to erase its obligations to them. During the same period, it relocated thousands of Indian people from reservations to faraway cities, an uprooting that was disastrous for the health of Indian people. Urban Indians now represent 67 percent of Indian people in the U.S yet receive barely 1 percent of the IHS's inadequate funding.

Nevertheless, the IHS system operates many excellent facilities and supports innovative health organizations. It has dedicated practitioners doing everything they can to deliver high-quality, culturally appropriate health care, with extremely limited resources.

The Seattle Indian Health Board, which I direct, is one of 32 Urban Indian Health Organizations serving Indian people in cities. Each year, about 4,000 Indian people and Alaska Natives come through our clinics' doors. We provide everything from primary medical care to substance-abuse treatment to youth and elder activities.

We try to be innovative, since improving the health of Indian people goes beyond direct medical care and encompasses a culturally specific approach. Our Traditional Health Liaison helps clients access traditional healing, and we conduct outreach and operate a family-medicine residency that has placed 18 graduates in Indian health sites nationwide. We also oversee the only national urban Indian epidemiology program, the Urban Indian Health Institute, which supports community-specific interventions to tackle health problems identified through careful research.

We've been able to do all this although just 1 percent of the IHS budget goes to urban Indian health.

But there's much more we could do. Our clients have to wait months for dental care, and there are many in our growing community we haven't yet reached at all. And, when our clients need care we don't provide, they often must go without. That's because IHS doesn't fund the entire spectrum of medical care for Indian people who've left their home reservations (and does so incompletely for those who remain).

We can't change history, but we can do better in the future. This year's health reform includes permanent reauthorization of the Indian Health Care Improvement Act (IHCIA), which provides the basic structure for the IHS. Before reform, Congress had let the IHCIA languish for years.

By reauthorizing the IHCIA, the federal government reconfirmed its moral and legal obligation to provide health services to Indian people. But Congress didn't include funding in the legislation. This has to happen through the appropriations process. President Obama has proposed an 8.7 percent increase in IHS appropriations, including an increase for urban Indian health. Congress should adopt this increase and move toward full funding of IHS. Otherwise, the promises made in health reform will soon look like old history.