Financing a First Nations and Inuit Integrated Health System - A Discussion

Aboriginal/Indigenous Health Systems

The United States Experience

The United States has already implemented the concept of block grants which encompass all functions and activities of the Bureau of Indian Affairs (BIA) and the Indian Health Service (IHS). In 1975, the Indian Self Determination and Educational Assistance Act initially gave tribes a limited scope to negotiate 'self-determination contracts' for the planning, implementation and administration of federal programs for their benefit. The 1988 amendments to this Act have included a block grant provision, providing a limited number of tribes with the option of complete responsibility over all services from the Bureau and the IHS, in a self-government style arrangement.

These self-government arrangements are commonly known as 'compacts.' They are analogous to the reforms suggested in this paper, as self-government in the American context refers to the devolution of control of programs delivered by the BIA and IHS (the Canadian counterparts are the Department of Indian Affairs and Northern Development (DIAND) and the Medical Services Branch (MSB).) Compacting is very contentious among tribes, and the concerns raised about self-government are very similar to those raised among Canadian First Nations to Health Transfer and self-government. These criticisms include:(Note 33: Concerns have been summarized from the following reports published by the National Indian Health Board and posted on its web site: Southwest Regional Forum on Health Care, Scottsdale, Arizona, June 14-16, 1995; Minneapolis Regional Forum, Bloomington, Minnesota, May 31 - June 2, 1995; Aberdeen Regional Forum, Bismark, North Dakota, July 19 - 21, 1995.)

• Compacting is being forced on tribes due to budget cutting. Why should a tribe want to take over a system that presently does not have enough funding to make it work?
• It is a harbinger of termination. Tribes are worried that the federal trust responsibility will diminish with compacting, similarly to other federal policies which led to termination of Indian status.
• It will pit tribes against each other, competing to get limited resources.
• The time is not right for self-government, and some tribes want to undergo such a change on their own terms.
• Tribes are worried that if they wait to negotiate a self-government agreement, there will be less funds available to them. As tribes access compacting resources from the IHS, they are entitled to charge an indirect cost on those funds. Because there is no additional funding for this support, the Indian Health Service must divert funding from other programs to meet this additional need. Tribes still receiving services from IHS are concerned that their programs are being cut to fund the indirect costs of compacting.

Despite these concerns, many tribes have entered into self-government arrangements. The compacting tribes which were in the initial demonstration phase, have reported success in increasing the health services that tribal members receive. One tribe, the Mississippi Band of Choctaw Indians which participated in the demonstration project and then signed a self government compact in 1994, has reported an increased immunization rate to above 90%, reduced teen pregnancy from 50% to 17% and reduced mortality rates.(Note 34: National Indian Health Board. South and Eastern Forum on American Indian Health Care, Nashville, Tennessee, July 31 - August 2, 1995. (Mitchell, Alba et al. undated. Utilization of Nurse Practitioners in Ontario: Executive Summary. School of Nursing, McMaster University: Hamilton.)) Success in compacting with the IHS and BIA has prompted tribes to consider compacting other programs in the Department of Health and Human Services and the Department of the Interior. Such funding would include Head Start, the Administration for Native Americans, and programs on aging, rehabilitation, welfare and other funding. Tribes, similarly to their Canadian counterparts, find that too much time and resources are taken up in dealing with multiple funding agencies. An expanded self-government arrangement would enable tribal organizations to expand and strengthen services in a comprehensive and consolidated manner. The authority to do this already exists in legislation and executive orders. (Note 35: National Indian Health Board. (Mitchell, Alba et al. undated. Utilization of Nurse Practitioners in Ontario: Executive Summary. School of Nursing, McMaster University: Hamilton.)..

The IHS has had to accommodate budget cuts from government downsizing. Furthermore, the new financing arrangements are removing its mandate as a direct care delivery system. Future roles for the IHS that have been suggested include a continued presence in national health data collection, training and technical assistance to tribes, development of standards of care, and the creation of new purchasing arrangements to facilitate individual tribes in gaining purchasing power previously enjoyed by IHS.

United-States (US) tribes have also had experience with direct contracting for services, as this is an alternative option to compacting funds for health services. Tribes which have chosen contracting are no longer required to receive services from the IHS and instead receive direct funding. Problems with this system include escalating costs of contractors in areas where there are no market forces to control costs and inability of small tribes to absorb costs of catastrophic cases or major illnesses. Although there is a Catastrophic Health Emergency Fund, it does not provide an adequate safety net for these tribes, as this fund generally runs out of money mid way through its annual budget.(Note 36: National Indian Health Board. Minneapolis Regional Forum, Bloomington, Minnesota, May 31 - June 2, 1995.) This will be an emerging concern in the Canadian context as the non-insured health benefits (NIHBs) are transferred to community control. (Note 37: The federal government is proceeding with a five-year transitional approach to transfer of the NIHB program.)