Urban Challenge

The U.S. government signed more than 350 treaties with tribes, many of them promising some level of health care. Over time, various attempts-some genuine, some not-were made by the federal government to assist Indians and improve their economic and health status, but the vast majority of programs have been inadequately funded and inconsistently executed, often with little or no input from the tribes they were intended to help. In 1970, President Richard Nixon issued a "Special Message to Congress on Indian Affairs," which established a rationale for a more enlightened policy toward American Indians and Alaska Natives. It was a watershed event, leading directly to the 1975 Indian Self-Determination and Education Assistance Act, and the 1976 Indian Health Care Improvement Act. The two laws and subsequent amendments would ensure tribal sovereignty and greatly increase tribes' ability to control programs affecting their welfare.

The Indian Health Care Improvement Act was intended to repair gaps in the health care delivery system. Besides bolstering funding and authority at the Indian Health Service, Title V of the law authorized IHS to assist nonprofit urban health centers in delivering care to American Indians and Alaska Natives. The needs of Indians living in urban areas have long vexed the Indian Health Service, which is primarily geared to assisting Indians on reservations in rural areas. The tremendous health needs of urban Indians is a legacy of a Bureau of Indian Affairs program that relocated up to 160,000 Indians from reservations to major metropolitan areas in the 1950s and 1960s in an unsuccessful attempt to improve their dismal economic prospects. Lack of support for job training and cultural and economic assistance consigned many of those Indians and their children to the ranks of the urban poor.

A June study by the Henry J. Kaiser Family Foundation found that as many as 70 percent of all Native Americans live in urban areas or do not reside on a tribal reservation. To receive health care, these people in many cases must return to their home reservation. The limited resources are reflected in the absence of even one Native American health clinic in Los Angeles County, the urban area with the greatest number of American Indians and Alaska Natives, according to the report, "Health Insurance Coverage and Access to Care Among American Indians and Alaska Natives." The Health and Human Services Department estimates that urban Indian health programs serve only about 149,000 of the more than 350,000 urban Indians belonging to federally recognized tribes. Such tribes signed treaties with the United States and are the only ones eligible for federal services. The federal government does not recognize the many tribes whose treaties with colonial governments or European governments predate the United States.

IHS provides financial assistance to Indian health centers in 34 cities throughout the country. Arguably the most successful urban program has been the Indian Health Care Resource Center in Tulsa, Okla. More than 48,000 American Indians, representing more than 140 tribes, live in the Tulsa metropolitan area, making the size of Tulsa's Indian population second only to that of Los Angeles.

The Tulsa center, which began with four employees providing outreach and referral services under a contract with IHS in 1976, has grown to a staff of 74, and provides a full spectrum of direct care. The center has its own X-ray, mammography and pharmaceutical services. Last year, it moved into an impressive new 27,000-square foot facility.

When Reagan administration policies jeopardized funding for the urban health centers, Carmelita Skeeter, the executive director of the center sought help from the Oklahoma congressional delegation. In a 1986 amendment to the Indian Health Care Improvement Act, the center was declared a demonstration program and designated as a service unit of the Indian Health Service. The designation allowed the center to retain its nonprofit status, yet receive annual funding through IHS. "We really have the best of all worlds," says Skeeter. This year, the center supplemented its $2 million budget from IHS with $3 million in private and other public grants and donations.

But there's a downside to the Tulsa center's status. Because the government has been encouraging tribes to contract with IHS to manage their own health care services, and because the center is on Creek tribal land, it could lose its federal status. In 1993, when it appeared the Creek Tribe would try to take over funding for the center, Skeeter again appealed to the Oklahoma delegation. The Indian Health Care Improvement Act was again amended, this time to protect the Tulsa center from tribal control.

But the Indian Health Care Improvement Act was up for renewal this year. While the legislative language would protect the Tulsa center's status, and the Creek tribe is now supportive of the center's federal status, the law was not taken up in the 2000 congressional session. The more time that elapses, the more time Tulsa has to lose its protection, says Skeeter. If the Creeks and the Cherokees, the largest tribe in Oklahoma, pulled out their share of funding, the center could not continue to exist, Skeeter says.

"Every time money comes down, we have to negotiate with IHS and negotiate with the tribes on what share comes to Tulsa. Sometimes that goes well, sometimes that doesn't go very well, because there just isn't enough money to go around," Skeeter says. "They all agree that we provide an excellent service. And they all agree that they don't want to see this service go away. But they do want control of it."