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PART A: OVERVIEW 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.

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.

The contexts include an understanding of where the IHS is now, the nature and evolution of the relationship between the U.S. government and the Indian nations, and external factors such as shifting public opinion and national mood. Chapter II: Literature Review, is divided into four sections. Part A offers a description of the IHS as it exists today. The historical evolution of the IHS will be examined in Part B. The current status of the IHDT plan and its implementation will be discussed in Part C. Finally, the theoretical underpinnings of this process will be reviewed in Part D.

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.