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Section 3: The Twentieth Century Indian policies of the 19th century were primarily about acquiring lands. By 1900, the manifest destiny of transcontinental expansion was complete. Legal, if not ethical, acquisition of Indian Country through treaties (until 1871) were followed by the placement of Indians onto reservations through 1886. A total of 174 million acres of Indian lands was acquired between 1853 and 1857 alone. With this foundation laid, government interests now became focused on what to do with these new wards of the state. The previous policies of temporary close-ended aid and assistance needed to be replaced with more permanent and enduring ones.

The scope of this paper precludes a thorough discussion of important sovereignty and tribal termination issues as it relates to overall Indian policy even though the development of Indian health care emerged within the context of these ideas. The direction of U.S. policy in the early 20th century was to assimilate Indians into the American mainstream, by force, if necessary. Recognizing the cultural trauma inflicted by a history of dependency and wardship policies, a new declaration of policy was put forth by Indian Commissioner Cato Sells in 1917, stating that "the time has come for discontinuing guardianship over all competent Indians and giving even closer attention to the incompetents" (BIA, p. 9). Federally sponsored competence boards were established to determine this ambiguous quality. The goal of this policy was to enable the Indian "to transact his own business as the average white man" (BIA, p. 9). This effort culminated in the Indian Citizenship Act of 1924, granting citizenship to all Indians who had not previously acquired it, (although full voting rights were not granted to all Indians until 1948).

The Indian Health Division was established in 1924 year as a separate entity within the Indian Bureau in recognition of the need to address the special needs of these newly acquired citizens. In 1926, the Institute for Government Research was funded to examine the needs of the Indian population. The resulting Meriam Survey of 1928 urged that policy be designed for Indians to "merge with the social and economic life of the prevailing civilization as developed by the whites or to live in the presence of that civilization at last in accordance with a minimum standard of health and decency" (Brookings Institute, 1928, quoted in Washburn, 76).

This report transformed U.S. policy for Indians in two important ways. First, it reversed the trend established since 1871 whereby the United States government chose to ignore Indian sovereignty as an issue by now providing a choice for co-existence in white society. Secondly, it re-emphasized the once again ignored federal obligation developed through treaties for at least minimum standards of health and decency. "He who wants to remain Indian and live according to his old culture should be aided in doing so" (Brookings, p. 77). Policy statements alone, however, do not necessarily translate into action. Advocates and entrepreneurs are required to move concepts and ideas "whose time have come" onto decision-making agendas.

Stalwart white defenders of Indian rights pressed for the congressional ear for business-not-as-usual. Jennings Wise wrote an impassioned essay, A Plea for the Indian Citizens of the U.S., in 1925 for presentation to Congress.

It is time now for a non-partisan commission, composed of the ablest men, to be entrusted with a complete survey of Indian affairs, in order that the Nation may not be misled into enacting laws designed merely to give expression to the white man’s aspirations...For once, the first time...let the Nation hear what [Indians] have to say as well as what comes from the departmental bureaus and...debates of congress (Deloria, p. 194).

One of those "ablest men" who emerged was Secretary of Interior Harold Ickes. In his Secret Diary of the first thousand days of Roosevelt’s administration, he wrote of a presentation he gave before a congressional delegation in 1933 of the unconscionable exploitation of Indians.

[He claimed] that the diseases that [Indians] were suffering from were due in large measure to contacts with the whites and were not unrelated to under-nourishment...that Congress had assisted in despoiling them and that the man who was largely responsible for Indian appropriations...had gone publicly on record to the effect that eleven cents a day was enough to feed an Indian child. (Washburn, p. 79).

The Indian Reorganization Act (IRA) of 1934 which restored tribal sovereignty and ended wholesale allotments of Indian lands was a consequence of this agitation. John Collier, a contemporary of Ickes and Commissioner of Indian Affairs, remarked that the IRA "makes a decided shift of American Indian policy...", however, "it stops short of the ultimate goal. It is merely a beginning in the process" (BIA, p. 10). This process was a short one.

The mood of Congress and the nation changed after World War II. Buoyed by the euphoria and unprecedented economic boom from the post-war period, Americans felt confident that any and all things were possible. Senator Arthur Watkins (R-Utah) led the congressional crusade to "free" the Indians from guardianship. His goal was to "terminate" federal responsibility for Indians so that they, as individuals similar to new immigrants, could rejoice and join in the American mainstream of economic prosperity and abundance. Michael Harrington’s The Other America, exposing the fallacy of universal prosperity, had not been written yet and Watkins’ sentiments carried the day. Senator Watkins dismissed a century of treaties by cavalierly saying "It is like the treaties with Europe. They can be removed at any time" (Washburn, p. 91). As far as Indian rights, he professed that they had abdicated those rights when they accepted citizenship in 1924.

The volatile period of the 1950's also produced a strong unified voice by the American Indians. Although there had been a history of Indian activism, Congressional leaders of the 1950's had asserted that there was "no expression of overall Indian public opinion, within the local communities, or the nation as a whole" (House Report 2680, 83rd Congress, 1954, as quoted in Deloria, p. 208)).

The National Congress of American Indians (NCAI) responded with a scathing retort to Congress. "The comparison of Indians to immigrants becoming citizens is, of course, irrelevant and insulting to Indians--the First Americans" (Deloria, p. 211). It also emphatically condemned the proposals of decentralization of responsibility from federal to state jurisdiction as Congress’s way of washing its hands of the situation, stating that "many states are unwilling or financially unable to accept this burden" (Deloria, p. 211). Its closing remarks are instructive:

For years the National Congress of American Indians has been insisting that what is needed most basically to help the Indian people of the U.S. and Alaska [are programs] which will provide educational and health benefits in adequate measure and promote the economic well-being of the Indian...Relieving poverty, ill health, educational deficiencies will directly benefit every community in which Indians reside. "Assimilation", in fact, and "termination", with honor will then follow (Deloria, p. 212).

The 1950's brought forth major health legislation in regards to Indian health. The transfer of Indian health from the Department of the Interior to the Public Health Services in 1955 was a move toward decentralization. There are currently 12 regional offices. Although opposition of this transfer was lodged by HEW, enactment of PL83-568 eventually assured sufficient personnel to staff IHS hospitals. It also resulted in a sizable increase in appropriations for Indian health activities.

PL85-71 (1957) later assured the construction of new hospitals (under Hill-Burton) that would be utilized by both Indian and white populations. PL86-121 (1959) appropriated dollars for construction, improvement and extension of sanitary measures on reservations.

The 1960's was the era of Medicaid, Medicare and civil rights for the United States. While having a major impact on health care for the nation as a whole, all Indian eyes were on the outcome of the "termination" experiment fostered by Senator Watkins. The Menominees of Wisconsin were the first tribe to relinquish its tribal rights and enter the American mainstream. The result of this experiment was a disaster. Although Richard Nixon was a strong proponent of reducing the size of government, he recognized the issue of autonomy of the Indian Nations was a complex matter. Termination, while attractive political rhetoric, was not a panacea for restructuring relationships between the federal government and the Indian nations. Nixon made it an issue in his Presidential campaign to repudiate the premature ideas of termination and re-iterated tribal sovereignty and Indian self-determination.

Legislation in the 1970's reflected President Nixon’s tone. PL93-580 (1974) established an American Indian Policy Review Commission that consisted of 3 senators, 3 representatives and 5 Indians. A three year bipartisan congressional effort resulted in PL94-437 (1976), providing a $475 million additional appropriation for Indian health activities through 1980. Included in that legislation were funds for Indians seeking training in health care professions. It also allowed Indian reimbursement under Medicare and Medicaid if IHS facilities were used. Rather than just eloquent rhetoric, a system was being built that enabled self-sufficiency.

The legislation of the 1970's put together the necessary tools for American Indians to take an active role in deciding their future. The Indian Policy Review Commission established in 1974 provided for a strong representation for Native Americans. The Self-Determination Act provided funding for not only Indian hospitals, but also for training of Indian health professionals to staff them. Allowing tribes to operate their own clinics with federal funds was a step toward self-sufficiency in this field.

The 80s was a time for the implementation of these public laws. Under the Self-Governance Amendments to PL93-638 (1989) the contracting process for Tribes to take over health operations from the IHS was streamlined. What does contracting health services under the Self-Determination Act (PL 93-638) really mean? (US GAO report HRD-86-99). This report found that IHS perceptions of the meaning and intent was different from what Tribal health administrator thought. Funding patterns to IHS regions were also found to be based on historical patterns and not based on need and that this type of tops-down formula based allocation was not efficient or ethical (US GAO report HRD-91-5). Transfer of dollars meant a transfer of power and re-distributive policies can be controversial.