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APHA Presentation on the IHS Reorganization
DISPLAY SLIDE I: RESTRUCTURING THE INDIAN HEALTH SERVICE (IHS) Reinventing Government A Qualitative Inquiry into the Decision Making Process Good morning. I’d like to first thank APHA for giving me the opportunity to present this paper. This paper reflects some of the preliminary work that I’ve done in preparing my dissertation. As most of you know, the Indian Health Service is currently under a process of reorganization. This process is timely in light of the push to "reinvent" government into a more effective and efficient entity. 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 of Medicare and Medicaid led to the emergence of cost containment as an independent policy objective. At the same time, government agencies have been challenged to adequately perform the social functions that they were designed to perform while confronting the constraints of shrinking budgets. Currently, the Indian Health Service is the primary provider of health care in Indian Country. They are not only the primary provider of health services, but also the administrative arm of the government here. As a result of budget constraints and "reinventing government" ideology, the IHS has become the focus for examining efficiency and effectiveness. The subjects of my study are the members of the Indian Health Design Team, or IHDT. They are the people charged with the task of examining how this bureaucratic agency works, and then to make recommendations on ways to improve performance. My research 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 employees of the IHS. This is significant in itself for in the language of reinventing government, the people who are the beneficiaries of government programs should be the ones that have a say in what those benefits should be. Those outside of government should be involved in government. While the specific purpose of my thesis is to follow the restructuring process of the Indian Health service, I find it first necessary to examine the context in which these processes are taking place. So it seems that as the first speaker this morning, I should give an overview of what the IHS is about. I feel that the contexts in which decisions and programs are created are extremely important …that the IHS is truly unique and that the call for change in Indian country must be answered with the ideas and solutions that reflect this unique status. I would like to highlight some key terms here. Let me put these up for you to gaze upon. DISPLAY SLIDE II KEY TERMS: IHDT (INDIAN HEALTH DESIGN TEAM) RE-INVENTING GOVERNMENT COST CONSTRAINTS IMPROVED PERFORMANCE EFFECTIVENESS V. EFFICIENCY TRIBAL SOVEREIGNTY While concerns over escalation of costs and diminishing appropriation should be reason enough to study this restructuring process, the more salient issue should be that of health status outcome. Will recommended changes to control costs, (or cost efficiency) result in better health outcomes, (or cost effectiveness)? Both ends of this question are goals that the IHS must address if it is to carry out the social function that it was designed to perform. And so, the Indian Health Service is restructuring in order to find that equilibrium in this challenging environment. At the beginning of this year, the IHDT presented its recommendations to the IHS. The recommendations of the IHDT has plainly stated that in order to accomplish those goals, the current IHS structure needs to be dismantled and reorganized. One observation is that "the problem with the current system is that public officials cannot use common sense and good judgment in ways that would promote better…performance". There is a feeling that the current bureaucratic structures are not able to perform the social functions that they were intended to do. The belief that the way in which the current system operates is inadequate reflects a finding of the 1989 Volcker Commission Report. 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. The IHDT recommendations echo findings of the 1993 Winter Commission report which stated that the "pattern and the problems are clear. The face of America outside government is changing faster than the face of the work force inside. " Taking all of the above into consideration, this became an animating theme of Vice President Al Gore’s 1993 report,the National Performance Review, OR NPR. 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 language of "reinventing" government. TRANSISTION: So if it is to be "reinvented", then let’s take a look at what it is currently. The Indian Health Service (IHS) is a bureau within the Public Health Service, formed in 1954 by a transfer of health services from the Office of Indian Affairs (PL83-568)). In the subsequent 40 years, IHS has grown larger and more complicated and has become a truly complex national organization that is responsible for direct and contract health care services to approxi- mately 1.4 million Indian people. Unlike other "minority" groups, the relationship between the Indian tribes and the federal government is a government-to-government one. Provision of health care services by IHS is based on various treaties signed in the 18th and 19th century, whereby Indians ceded lands to the US in trade for these and other services. DISPLAY SLIDE III (an organizational chart is displayed here. I was unable to duplicate it on html. sorry) Organizationally, the headquarter office is located in Rockville, Maryland. There are three entities on the next level of the organizational chart. First, there are 12 IHS administrative Area Offices located regionally throughout the United States. Within each Area jurisdiction are Service Units which consist of hospitals and Health Centers. While these made up most of the traditional delivery system, there has been a shift toward Tribally run units. These were the result of the 1975 Self-Determination Act. which allowed Tribes the option of managing and operating IHS programs in their communities on a contractual basis. These were normally set up within tribal geographical boundaries (or reservations). As Indians moved off the reservation and into the cities, there was a need for Urban Units. Urban units did not own hospitals, but contacted with other existing providers for service. The Indian Health Service budget is authorized and appropriated through Congress. It has increased 135 percent from 1986 to 1995. The appropriated amount for FY 1995 was $2.1 billion. TRANSISTION: So, has it been effective? When IHS was transferred to the Public Health service from the Department of the Interior in 1955, mortality and morbidity rates for the Indian populations lagged far behind that of the general US population. As a result of IHS programs and advancements in medicine, many of the health indicators of this population have improved. Life expectancy at birth, age at death, maternal and child health and infectious diseases have all been affected positively. In the areas of infant mortality, maternal death rates, gastrointestinal disease and tuberculosis, the dramatic improvements for these areas far exceed those for the general population for this time period, and it is important to note that they have attained parity with health status of the rest of the nation. DISPLAY SLIDE IV Alcoholism - 447 percent greater Tuberculosis - 340 percent greater Unintentional Injuries - 168 percent greater Diabetes Mellitus - 154 percent greater Suicide - 42 percent greater Homicide - 34 percent greater Like the general US population, the causes for death and morbidity in the Indian population has shifted away from acute causes and toward chronic disease and behavioral impairments. While this is not a significant distinction by itself, the age-adjusted mortality rates for many of these conditions illustrate a different picture between the health status of Indian and US populations. (look at slide) A comparison of Indian rates to general US for these conditions illustrate enormous disparities between the populations. Most strategies to address these conditions parallel domains of public health rather than direct medical service. In the area of infectious diseases, (pause) adequate housing, sanitation, water supply, …are seen as the key to reducing these diseases. For injury prevention and chronic disease, community awareness/empowerment, health promotion , early screening and better surveillance systems are seen as the basic building blocks. At the same time, there is a need for some basic and acute medical services that are taken for granted off the reservation. DISPLAY SLIDE V Expressed in Percentages TYPE INSURANCE U.S. Wht Blk Hisp SAIAN Private 75 81 53 50 28 Public Only (not IHS) 10 7 25 18 17 Uninsured/IHS only 16 12 22 32 55 TRANSISTION: How important is the IHS to the Indian population as far as creating access to health services? Findings from the Survey of American Indians and Alaska Natives (SAIAN) disclose that in 1987, Indians had less private insurance coverage than any other ethnic group. Notice that over half of the Indian population depends on IHS services as its sole provider. (cunningham et al write) The generally low socioeconomic status of this population along with relatively low rates of private insurance suggests that few have the means to obtain health care other than what is provided free of charge from the Indian Health Services. For most of this population, a facility owned or operated by the Indian Health Service or a tribe is the usual source for care. TRANSISTION: A trend that is occurring is that the Tribes are taking a more active role in the provision of these health services. In fact, the premise of local control is an animating theme of the IHDT recommendations. I started this discourse by posing the question of whether reorganization would lead to not only more cost efficiency, BUT also more cost effectiveness. That is, will the changes improve the health status of Indians. After all, that is the mission of the IHS. A retrospective study (1973-1986) was conducted to assess health status amongst the three tribes, Umatilla, Cayuse, and Walla Walla, that make up the confederation of Umatilla Tribes in Washington state. A common data set available to the researchers was prenatal care in 1st trimester (prevention strategy) and low birth weight babies (outcome). Because these indicators are also used to asses general population, they provided a valid comparison group. Their relationship to national objectives was used as a point of reference. From an historical perspective, in the 1960’s, all medical services in the Confederation was performed on a contractual basis. Public health issues, the main focus of IHS during this time period were also contracted out to county health departments. In the 1970’s, tribal control was exercised over many of these services and a hospital was built under the auspices of the Indian Self-Determination Act. A more active role was then taken on by the tribes. DISPLAY SLIDE VI Indicator 1990 Objtve 1973-1976 1984-1986 LBW < 5% 5.8(6.1) 4.1 (5.0) PN care >90% 42.3 63.9) 62.6 (65.7) InPts 1,290 1,832 Outpts 709 12,710 LBW stands for Low birth weight. The 1990 objective was to be less than 5%. In the period 1973 to 1976, the percentage of LBW babies born in the Umatilla Confederation was 5.8 percent. The number in the parentheses is the percent of babies born in that same geographical area that were not part of the IHS system. Note than in the period 1984 to 1986, after Tribal control was exercised, the less than 5% goal was met by both the IHS and the non-IHS population. Although the objective of having 90% of all mothers seeking prenatal care in the first trimester did not meet the more than 90% objective, note that prenatal service usage increased substantially in the IHS population. The overall increase in utilization for outpatient services is the most dramatic finding for this study. Culturally more sensitive? Possibly, More efficient? Probably. More effective? Definitely. TRANSISTION: Where do we stand today? I have described the Indian Health Services as it existed prior to implementation of any of the IHDT recommendations. As of July 1997, many of the recommendations have already begun. Phase I of the recommendations was to reduce headquarter size. The IHS headquarters has reduced its nine major offices down to three. One hundred forty-five sub-organizational units have been consolidated into forty units. In 1993, there were 900 employees at the headquarter and regional level. In 1997, there are approximately 475. The next phase of the restructuring will occur at the Regional level where there are 12 administrative units. TRANSISTION: What have we learned so far? What are the lessons from reinventing government? Why is this attempt at reorganization continuing when others such as a the restructuring of the Bureau of Indian Affairs stalling? The first formal meeting of the IHDT was in October of 1994. While the IHS laid out its plans to restructure under the National Performance Review guidelines, tribal attendees had these comments to make. DISPLAY SLIDE VII ªTribes do not have agendas for reductions. The Administration’s agenda for reductions is not the agenda of Tribal leaders. ªThe treaties made with Tribes do not include a responsibility for paying for deficits. ªResources for Indian health care should be adequate to match the oaths this government made in exchange for millions of acres of land. ªCredibility for the design will earned if Tribes identify what the Agency is to be. ªParticipation of elders in the change process is important because of their role in maintaining the family unit. These comments did come without a recent and powerful precedent. In 1990, the Secretary of Interior created a Task Force to study reorganization of the BIA. Its charge was to come up with recommendations just like the IHDT. At that time, this Task Force was unique in that it sought full tribal participation in the planning process. Like the current IHDT, there was strong Tribal representation with 36 of 43 members coming from non-BIA employees. Under the auspices of NPR, another plan was created. While both plans agreed that decentralization of government involvement and the redistribution of authority to local levels was important, the NPR "ignored the work of the Task Force and in fact, failed to involve the tribal leadership, even on a consultative basis". Caleb Shields is Tribal Chairman of the Assiniboine and Sioux Tribes of the Fort Peck Reservation in Montana. He was a member not only of the BIA Task Force but is also a member of the IHDT. He very pointedly questioned the motivation of the NPR recommendations and wondered how their plan would benefit Indians. (he writes) while the task force sought to improve its performance while meeting the needs of the tribes and Indian people, NPR is forcing the reorganization of BIA (and IHS too) to meet the budgetary commitments of the Administration without regard to its impact on BIA performance or the needs of the tribes and Indian people. It was clear that if the federal government was going to solicit input from the Tribes to "reinvent" government, it would not be just symbolic participation. The agenda for restructuring was not going to be one where the outcome did not fulfill the social function of the agency that was designed to deliver it and that less than a full partnership in this process was unacceptable. This message was reinforced when the BIA tried to present its reorganization plan to tribal leaders in Billings, Montana three months later. Tribal leaders walked out of the meeting stating that the request for their input was "false involvement." One leader said "…as far as the consultation process, I feel it’s a done deal. Why did you even ask us to come here?" So far, I have explained the process of "reinventing government" as part of a national movement. I began this description however, by stating that the Indian Health Service process was different. Unique. The comments elicited from Tribal leaders make this very clear. A governmental agency like the IHS is not a self contained entity. The relationship between the US government and the Indian nations is one where separate nations are trying to forge a working inter-dependent structure where both can meet their constituent needs and values. In doing so, parties must negotiate in the "utmost good faith". Therefore, this reorganization is about more than just a reshuffling of layers of bureaucracy. It is even more than the consensual goal of raising the health status of Indians. It is a restatement of how the Indian nations and the United States government will define their future relationship. An admonition from Eric Bothwell to the IHDT members at the first meeting cuts right to the core. He asks if the recommendations that they will be making will be merely be cosmetic changes, or whether they will be the needed bone surgery. "The notion that organizational beauty is only skin deep but organizational ugliness (ineffectiveness) goes clear to the bone, appears true. A variety of reasons have been identified for this pattern of organization only achieving cosmetic surgery, or downsizing to nothing more than a smaller but still dysfunctional organization." He asks that "we [be] better than that! Time does not permit a thorough discussion of tribal sovereignty, the inner workings of bureaucratic behavior or the theoretical underpinnings of decision making processes. However, as I embark on the rest of my research, these are some of the awarenesses that I will bring with me. The agenda is set. The implementation is already occurring at a structural level. In the ensuing years, my intent is to follow not only the implementation process of this grand design, but to also scrutinize and evaluate the results of reorganization in terms of health status outcome. Concomitant with that, I expect to note, explore and analyze the politics of the US government and the Indian nations as they strive to negotiate in the "utmost good faith". As a social researcher, I must maintain a proper academic distance to my findings, however, as a subjective person living in a time of historical significance, I approach the journey of this research with great optimism and faith. ….and I invite you to come along with me on this journey. THANK YOU.
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