Health Diversity, Equity and Inclusion

The Importance of Indian Health Care Services

Trustee Tony Davis provides unique perspective on the state of Indian Health Services

By Sue Ellen Wagner

Interview

Sue Ellen Wagner, vice president, trustee engagement and strategy at the American Hospital Association, spoke with Everett Anthony “Tony” Davis, board member, Tsehootsooi Medical Center, Fort Defiance, Ariz. and member of the 2023 AHA Committee on Governance, to learn more about Indian health care services.

Sue Ellen Wagner:The Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes.

What should Trustee Insights readers know about Indian Health Services?

Tony Davis: As you noted, the IHS is one of a number of agencies that come under the HHS. Within the IHS, there are 12 areas/regions across the lower 48 and Alaska, plus a headquarters office in Rockville, Md. The regions include Nashville, Tenn.; Bemidji, Minn.; Oklahoma City, Billings, Mont., Portland, Ore., Phoenix, Tucson, Ariz., Albuquerque, N.M., Alaska, California, The Great Plains and the Navajo.

For information purposes, I would like to share a few significant facts:

In FY-2023, the IHS serves about 2.75 million people, spread throughout 574 federally recognized Tribes.
IHS health care facilities come under one of three programs: which are IHS, Tribal and Urban.
One major issue is that IHS is continually underfunded compared to other U.S. health care systems.
The Indian Self-Determination & Education Assistance Act provides Tribes and/or Tribal organization setup contacts and/or compacts with the IHS, with 60% of IHS funding administrated by Tribes.
Three major health care challenges for IHS are ending HIV and Hepatitis C, opioid use and improving mental health.
There is a major initiative underway to modernize the IHS Information Technology (IT) health care infrastructure. The current system is over 40 years old.
Additional information can be found at www.ihs.gov.

Wagner: Thank you for that overview. Please inform us about the community your medical center serves and some of the services offered.

Davis: Certainly. Within the Navajo Area IHS (NAIHS) there are eight service areas across the Navajo Nation. These include Gallup, Crownpoint, Shiprock, Kayenta, Chinle, Tuba City, Winslow and Fort Defiance. In addition, there is a Navajo Area Office located in Window Rock, Ariz. where I worked for 30 years as an IT Supervisor.

Each of these service areas may have 2-3 health care facilities within their respective area. It should be noted that the Navajo Nation is about the size of the state of West Virginia, with an estimated registered Navajo population of 425K people, and about 245K living on the Navajo Nation. There is also a large number of Navajo people living off the Navajo Nation.

In our Ft. Defiance region, we have three health care facilities: Teehootsooi Medical Center and Nihi Dine E Ba Wellness Center in Ft. Defiance, and Nahata’dziil Health Center in Sanders, Ariz. A large number of our community folks, which includes a large portion of our Navajo people across the Navajo Nation, have an annual income that is well below the national average and may not have electrical service and running water in their homes. Additional information may be obtained at our web site: www.fdihb.org.

In addition, there is a real concern regarding reliable or no transportation which becomes a real issue in obtaining the basic needs for their respective families. This may include but is not limited to: food supplies; home repair supplies; livestock feed and supplies; not to mention access to health care. Other issues and concerns include bad or no roads and limited telecommunication service(s) for landline phones, cell/mobile phones and Internet.

Wagner: Please describe your organization’s governance structure.

Davis: Sure. The Tsehootsooi Medical Center has a governance structure of responsibility, accountability, awareness, impartiality and transparency. Our mission/vision/values and our policies and procedures play a very important part of governance in meeting and complying with associated regulatory bodies (federal, state, and tribal). This is all being accomplished in coordination and collaboration with our CEO/Leadership Council.

Wagner: In terms of disparities, the American Indian and Alaska Native people have long experienced less desirable health outcomes when compared with other Americans. Shorter life expectancy and the disproportionate disease burden exist perhaps because of inequities in education, disproportionate rates of poverty, discrimination in the delivery of health services and cultural differences. Can you elaborate more?

Davis: First, I would like to note that I truly believe there is a lack of understanding and knowledge of our Native America health care situation and challenges. Other challenging issues, including those that you have noted, are: access to health care; traditional medicine versus western medicine; insufficient broadband telecom services to support telehealth requirements; challenges in the school system; transportation issues (to/from clinic); families not having running water and utilities in their homes; dirt roads accessing main highways during winter/rain season; limited funding resources from the government and health care issues associated with alcohol/drugs/mental health.

It is hard to believe, but the U.S. prison system provides better health care resources to inmates than our Native Americans!

Wagner: What are the top three challenges your board is encountering?

Davis: Over the years we have experienced a number of challenges. In my personal opinion, the most pressing are:

Professional recruitment and retention
Lack of housing resources
Continued 3rd party billing collection process (e.g., Medicare/Medicaid, private insurance)

In closing, I would like to comment on a couple of very important issues and concerns with our Native Nations health care. It should be noted that there are a number of other issues and concerns within our American Indian and Alaska Native (AI/AN) communities that most may not be aware of within the health care industry.

First, I do want to thank the National Indian Health Board (NIHB) for taking the initiative in keeping our Native Nation health care organizations aware of a number of issues and concerns that will have an effect on health care services to our AI/AN communities at the federal and state level. I do believe people within the health care industry are aware that the Administration for Community Living (ACL) has been requesting comments from our Native leadership associated with the proposed updates to the regulations that have also been known as its Older Americans Act (OAA) programs. These programs are focused on improving community social services for aging populations. A lot of Elders may receive services with federal programs; the OAA has a major initiative for the organization in the delivery of social and nutrition services to this group and their associated caregivers.

The issue is that the funding formula does not work for our Elders. There is a template letter that goes into detail in the gaps that exist in the current formula, essentially leaving many Elders uncounted and underserved. The ACL has noted that for them to revisit this formula, ACL will need to hear from our Tribal leadership. Please reference www.nihb.org for additional information associated with NIHB that includes but is not limited to: AI/AN health care programs, initiatives and activities.

Second, I do want to thank tribal, federal, state and private organizations and programs for addressing the major issue of missing and murdered American Indians and Alaska Natives. As most might be aware, the Office of Justice Services has created the “Missing and Murdered Unit” (MMU) that focuses on analyzing and solving missing and murdered cases associated with AI/AN. It should be noted that AI/AN people are at a disproportionate risk of experiencing violence, murder, or going missing, and make-up a large portion of the missing and murdered cases which we have experienced on the Navajo Nation. The Joint Commission on Reducing Violent Crime Against Indians continues to coordinate prevention efforts, grants and programs associated with the murder of, trafficking of and missing Indians across various Federal agencies.

As you can understand, this matter has a major effect on the health care for those Native families and communities — physically, mentally and spiritually.

Sue Ellen Wagner (swagner@aha.org) is vice president, trustee engagement and strategy, at the American Hospital Association.

Please note that the views of interviewees do not always reflect the views of the AHA.

Tsehootsooi Medical Center board member Tony Davis discusses Indian health care services.