I am perpetually being told that "there must be hundreds" of foundations and/or organizations that would fund such a project. Afterall, it's timely; it's important; it's politically correct....au contraire, mes amis. I'm running out of money, so if you know any of these philanthropers, show them this page.

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RESTRUCTURING THE INDIAN HEALTH SERVICE: A QUALITATIVE INQUIRY INTO THE DYNAMICS OF RE-INVENTING GOVERNMENT

PART A: AREA OF WORK The Indian Health Services (IHS) exists as an anomaly within the national health care system. While funded through American tax dollars, tribal sovereignty is maintained, so that each tribal confederation is treated as a separate political entity. Eligibility is "universal", yet access is questionable. The health status of American Indians has improved greatly in the past 40 years, yet many health indicators show that Indian health lags behind that of the general population. The dedication of funds to this ethnic group is similar to dedicated funds for the poor or elderly and shares with these programs the implication and reality of not only inadequate delivery, but also cultural and political tensions.

In October of 1994, a diverse group of Indian leaders and representatives was brought together by the IHS to look at ways Indian health programs could respond to calls for change. Given the reality of shrinking federal resources, their charge was to streamline the IHS into a more effective system. This group, the Indian Health Design Team (IHDT), produced a document with a list of over 50 recommendations that is currently slated for implementation by the IHS. This document has received strong initial endorsement by not only government officials, but also leaders in the Indian Community. It is remarkable that this agenda for sweeping changes was developed by the IHDT through a consensus process in less than one year. Even more remarkable is that the IHDT process was a "bottoms-up" movement that plainly recommends the dismantling of its sponsor, the current IHS federal system. The analogy to the "new federalism" ideology of returning power to local structures is unmistakable, yet the evolution of events in Indian health affairs is unique.

Whereas major legislation in the late 1960's and early 1970's may be seen as establishing the foundation for many aspects of the current American health care system (for example Medicaid and Medicare), the corresponding legislation affecting Indian health addressed a different issue, self-determination. The intent of self-determination policies for Indian nations had a strong impact on decisions made by the IHDT.

PART B: SIGNIFICANCE OF THE STUDY In recent times, much has been said about the role that government should play in delivering services to the people. Health care is an area of government that is under continual scrutiny. The explosion of public expenditures on health care following the introduction Medicare and Medicaid led to the emergence of cost containment as an independent policy objective (Arnould, Rich and White, 1993). While federal per capita health care expenditures for Native Americans remain below that of the general US population, the federal contribution is nearly the same as the per capita expenditure for Medicaid and Medicare, however in order to rise to these levels, IHS appropriations had to increase 136% in the past ten years.

While the escalation of costs (cost efficiency) should be reason enough to study this restructuring process, the more salient issue should be that of health outcome (cost effectiveness). The Indian Health Service is restructuring in order to find some equilibrium in this challenging environment. The IHS is part of the administrative bureaucracy which the IHDT has plainly recommended needs to be dismantled and reorganized.

The belief that the system in which government operates is inadequate has spawned numerous commissions and writings. The 1989 Volcker Commission issued its report, "Leadership for America: Rebuilding the Public Service" recommending that a new power system be created:

Control through multitudes of regulations and procedures, administered by a central agency removed from service delivery, has created managers with limited power but full responsibility for any problems that occur. Greater congruence between operating responsibility and managerial authority is absolutely necessary (Volcker 1989, p. 288).

Gaebler and Osborne in "Reinventing Government" promote the notion that government should be catalytic, enterprising, anticipatory, decentralized, community owned, competitive, mission driven, results oriented, customer driven and market oriented (1992). Taking all of the above into consideration, this became an animating theme of Vice President Al Gore’s 1993 report, the National Performance Review. In here, the four goals of cutting red tape, putting customers first, empowering employees in a results oriented environment and getting back to basics are enunciated.

The Indian Health Design Team met for the first time in October 1994, shortly after Vice President Gore’s report. The resulting recommendations that they made for redesigning the Indian Health Service clearly reflect the call for "reinventing" government. This study will examine this process, describe the motivations, depict the constraints, and elicit a prognosis for the future for this timely experiment in reinventing government.

PART C: PURPOSE AND STRATEGIES This purpose of this study is to explore and describe the decision-making process of the IHDT members. To understand the developments leading to the IHDT report and its recommendations, it is necessary to examine the contexts in which these decisions were made. In short, it will examine the recommendations (output) and the factors (input) that influenced this process. This project will conduct face-to-face interviews with selected members of the 28 decision makers of the IHDT. The make up of this team is a cross section of key players in the Indian health care community. Of the twenty-eight members, 22 of them are not part of the existing Indian Health Service structure. Interviews have already been conducted with one of the co-chairs of the IHDT and with the meeting facilitator for all of the past IHDT meetings.

Daniel Fox states simply and elegantly that "history matters" (Fox, 1995). For the past two centuries, the US government has stated that it should interact with the Indian nations in the "utmost good faith" (Northwest Ordinance, 1787), yet history has shown that in many cases, policy intent and policy outcome with the Indian nations have not lived up to that faith. With the passage of the Indian Self-Determination Act of 1975 (PL 93-638), a vehicle was created to build the foundations from which the US government would transform its relationship with Indians from one of wardship to one of empowerment and a real and not just symbolic role in re-creating an institution. This study of the IHDT team is more than just a study of a symbolic transfer of power. In the context of reinventing government, it is a look at how that power is actually redistributed and exercised. It is a study on the test of the will of a people and a re-examination of the intentions and utmost good faith of a government. It is history in the making.

PART D: EXPECTED OUTCOMES The findings of this study will add to the political science literature on decision-making processes and organizational theory. Also, understanding how eloquent rhetoric is actually transcribed into practice will be the primary outcome. The implementation of the IHDT plans are already in progress. The first phase has been to reduce the size of the federal role. That has occurred. The subsequent phases are the restructuring and redefining of the twelve regional offices. That process is occurring right now. The final and most critical phase is the reallocation of authority and accountability to the local health units. Since legislation that allowed for the Tribal operation of formally federally run health units was enacted, more than a third of the Tribes have exercised that option. This study is following a radical change in the way US and Indian governments relate to each other in planning and administering health care services.

More importantly, these findings will set the stage for future research into the implementation process. While this first phase of research establishes a look at the theoretical structural basis of reorganization, it will provide a road map for those researchers (and I include myself) in the future that will explore the main point of this reorganization—improved health status outcome for Native Americans.

PART D: PERSONAL QUALIFICATIONS I will be the principal investigator in this dissertation project. As an academic, my background in political science, history and public health provides a multidisciplinary approach for theoretical analysis. As a qualitative researcher, I have had experience in survey analysis and also coding, interpretation and writing of interview findings. As a practitioner, I have experience in working with diverse governmental and community organizations including being a member of the Idaho Health & Welfare Reorganization Team in 1995. I have attached a curriculum vitae to provide highlights.

PART E: BUDGET AND FUNDING REQUEST: The expected time required to complete this project is approximately two years or less (see attached timetable). Of the IHDT members to be interviewed (approximately twelve of the twenty-eight), some reside in the Eastern, Midwestern Southern parts of the US, but most live in the West or within driving distance from my home base in Boise, Idaho. The nature of this funding request is to acquire adequate funding to defray the cost of travel and to provide subsistence-level income for the duration of the project. I expect to continue to use my savings to augment any funds allocated through your organizations. I do not currently receive any additional funding from other sources other than from part-time teaching at the University of Illinois which will terminate in December 1997.

Itemized Funding Request

Travel: $6,120 Eight interviews in Western US (Oregon, Idaho, Montana, New Mexico, Arizona). Mode of Travel is by auto. Approximately average of 1500 each RT for a total of 12,000 miles.*

Fuel (@$1.40/gal divided by 15 MPG) 1,120 Lodging (16 nights @$75/night) 1,200 Per diem (16 x $25/day) 400

Four interviews in South and Eastern US (Washington DC, New York, Wisconsin, Alabama)

RT Plane fare (4 trips @ $600) 2,400 Lodging (8 nights @$95/night) 760 Per diem (8 x $30/day) 240

Stipend/Living Expenses: $24,840 Twenty-four months minimal expenses include current mortgage, utilities and food.

Mortgage (@ $700/month) 16,800 Utilities (@$85/month) 2,040 Food (@250/month) 6,000

TOTAL FUNDING REQUEST:

Travel 6,120 Stipend 24,840 TOTAL 30,960

*If it proves to be more cost efficient to fly to certain destinations, then these monies will be used accordingly.

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