CASE
Indian Health Service:
7
Creating a Climate
for Change
“As an enrolled member of the Laguna Pueblo in New Mexico,
I am a member of the Sun Clan and have the name of my great
grandfather, Osara, meaning ‘the sun’,” Dr. Michael Trujillo
told the United States Senate Committee on Indian Affairs in
1994 during his confirmation hearing as Director of the Indian
Health Service (see Exhibit 7/1). He told the committee that he
had known the remoteness of Neah Bay at the northwest tip of
Washington on the Makah reservation, lived in the Dakotas, and
experienced the winters and geographic barriers to health care in
Eagle Butte, Rosebud, and Twin Buttes. He had come before them,
he also told them, “as the President’s nominee for the Director of
a national health care program that is essential to the well-being
of 1.3 million American Indians and Alaska Natives belonging
to more than 500 federally recognized tribes.”
This case was written by Robert J. Tosatto, US Public Health Service; Terrie C. Reeves,
University of Wisconsin, Milwaukee; W. Jack Duncan, University of Alabama at
Birmingham; and Peter M. Ginter, University of Alabama at Birmingham. All quotes
are taken from statements made before committees of Congress or the houses
of Congress by the person quoted. Used with permission from Terrie Reeves.
Copyright © by Robert J. Tosatto, Terrie C. Reeves, W. Jack Duncan, and Peter
M. Ginter and the North American Case Research Association. Reprinted by permission from the Case Research Journal. All rights reserved.
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Exhibit 7/1: Dr. Michael Trujillo: Chief Advocate for Indian Health
Dr. Michael H. Trujillo was named Director of the Indian Health Service on April 9, 1994. His appointment
was noteworthy for two reasons: (1) he was the first IHS Director appointed by the President of the
United States and confirmed by the Senate; and (2) he was the first full-blooded American Indian to
be appointed Director of the IHS. Dr. Trujillo was a member of the Sun Clan in the Laguna Pueblo
in New Mexico. His parents were elementary school teachers for the Bureau of Indian Affairs and
were active in the political life of the pueblo. His grandfather was a governor of the pueblo and was
instrumental in drafting the first Laguna Pueblo constitution. From an early age, Dr. Trujillo had been
taught and shown by example to feel an obligation to the Indian people.
The first American Indian to graduate from the University of New Mexico School of Medicine,
Dr. Trujillo received both his undergraduate and medical degrees from that institution. Family practice
and internal medicine were his specialties but he was also chosen for a clinical fellowship in preventive medicine at the Mayo Clinic. In addition, he received an MPH in Public Health Administration and Policy from the University of Minnesota School of Public Health.
Dr. Trujillo had numerous assignments within the IHS prior to becoming Director. As an IHS physician,
he worked with many tribes in diverse locations. As an IHS administrator, he was Deputy Area Director
and Chief Medical Officer for the Phoenix, Aberdeen, and Portland areas, as well as a Clinical Specialty
Consultant to the Bemidji area. He initiated nationwide quality assurance programs and a medical
provider recruitment program for urban Indian health centers.
Shortly after being sworn in as Director, Trujillo released his vision for the Indian Health Service.
He envisioned a new IHS: one that adapted to the challenges it faced, yet continued to be the best
primary care, rural health system in the world; one that recognized the contributions and dedication
of employees, as well as the active participation of tribal members; one that was redesigned to be
more effective, efficient, and accountable. Trujillo cautioned that any change must be accomplished
in such a way that the Indian people noticed only improved quality of care.
Trujillo’s position as IHS Director allowed him to be a strong advocate for Indians in all matters
regarding health. Not only did he want to improve IHS, but he also wanted improvement for the
entire Indian health care system. IHS leadership and direction would provide the course the agency
would take in making these improvements.
Three years later, Trujillo was in front of the same Committee discussing the
fiscal year 1998 budget request for the Indian Health Service (IHS). For the fourth
consecutive year, the IHS would receive no after-inflation increase in its budget
allocation. But what Trujillo said in 1994 was still true: “We, who are involved in
Indian health care, are facing a changing external environment with new demands,
new needs, and a shifting political picture. The changing internal environment
demands increased efficiency, effectiveness, and accountability.”
Dr. Trujillo knew that in order to accomplish the agency’s mission, IHS must
honor past treaties as well as respect the beliefs and spiritual convictions of the
various tribes. The need to respect local traditions and beliefs was formally recognized in Indian self-determination.
The Indian peoples had always managed with very scarce resources. However,
Dr. Trujillo was concerned. IHS had not developed an adequate third-party payor
billing system, it faced difficulty recruiting professional staff, and it served a
population whose health status was below that of the rest of the United States.
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HISTORICAL PERSPECTIVE
571
IHS was considered a discretionary agency in the congressional budget process.
Dr. Trujillo recognized the need to increase the health status of IHS’s population in
order to gain continued congressional funding and support. He needed to answer
some difficult and complex questions. How could Indian self-determination be
implemented? What should be IHS’s role in the future? How should IHS change
to best serve the self-determination of the Indian people?
Dr. Trujillo knew that his most difficult task was to provide additional, much
needed health services to a growing and needy population when there was little
prospect of increasing resources. Simultaneously, he had to ensure that local
health needs were recognized and addressed.
Indian Self-Determination
In January 1994, Dr. Trujillo told the same Committee that the local tribes and communities needed to be more involved in the decision-making process to facilitate
Indian self-determination, the process by which the Indian people may choose to
assume some degree of the administration and operation of their health services.
The Indian Self-Determination and Education and Assistance Act was passed
by Congress in 1975 and gave federally recognized tribes the option of staffing,
managing, and operating the IHS programs in their communities. Dr. Trujillo was
on record as fully supporting greater self-determination of all tribes as a means of
enabling Indian people to operate their own health care systems. He emphatically
stated that “During my tenure, there is going to be continued emphasis throughout the agency and in our interactions with other health partners for complete
recognition of the Indian self-determination process.”
Dr. Trujillo knew that self-determination was far from complete. Although
IHS still had many important functions to fulfill, putting health care back
into the hands of the tribes was proving to be difficult. Each tribe had different concepts of health, and it was difficult to accommodate such variety in a
government agency. Moreover, in the face of scarce resources there was always
an inclination to centralize rather than decentralize decision making, and Dr.
Trujillo knew that if the IHS created the impression that it could fulfill all
the needs of local communities, it would contribute to false expectations and
disappointment.
Historical Perspective
IHS had a clear mandate: to provide high-quality health services to American
Indians and Alaska Natives (AI/ANs). The basis for this responsibility was established and confirmed by numerous treaties, statutes, and executive orders. The first
treaty between the US government and an American Indian tribe was signed in
1784 and promised that the federal government would provide physician services
to members of the Delaware Nation as partial payment for rights and property
ceded to the United States. Treaties were signed with many individual tribes and
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periodic appropriations were made by Congress to control specific diseases such
as smallpox and tuberculosis and to educate the tribes about disease. Recurring
appropriations were not made until the Snyder Act of 1921, which authorized
health care services for AI/ANs by an act of Congress.
Health care for Native Americans was originally the responsibility of the
Bureau of Indian Affairs; however the services provided were, in general, very
poor. Despite the employment of field nurses, the building of hospitals for Native
Americans, and the addition of dental services, the health status of AI/ANs
remained far behind that of the general population. For example, Indian infant
mortality was more than double that of the general population and life expectancy
for Indians was ten years less than that of the rest of the United States.
The major health problems found in the Native American population became
evident during World War II when thousands of Indians volunteered for service
in the US armed forces. The poor health of many Indian volunteers was noted
during induction physical examinations. Citing the AI/AN health statistics, various
state, medical, and professional groups began a push to put the US Public Health
Service (USPHS) in charge of health care for Native Americans. They argued that
the Bureau of Indian Affairs could not run a quality health care system because
health was only one of its many concerns. Years of debate and political maneuvering followed. Finally the IHS officially became a division of the USPHS on July 1,
1955. The Transfer Act stated “that all functions, responsibilities, authorities, and
duties relating to the maintenance and operation of hospital and health facilities
for Indians, and the conservation of Indian health shall be administered by the
Surgeon General of the United States Public Health Service.”
Although the overall health status of AI/ANs did not improve immediately,
much progress appeared over the longer term. Since 1973, infant mortality among
AI/ANs had decreased 60 percent and death due to tuberculosis dropped 80
percent. During the same period, life expectancy for AI/ANs increased by more
than 12 years; life expectancy for AI/ANs was just 2.6 years below that of the
general population in the early 1990s.
Over the years after the transfer, the IHS developed a model for the provision
of high-quality, comprehensive health services. A major component of this model
was the involvement of the tribes in the provision of health services to their people. This provision had a “snowballing” effect. As the health status of their tribes
improved, more tribal members began to get involved in the provision of health
care which, in turn, allowed the tribes to provide even more services.
Congress followed up the Indian Self-Determination and Educational Assistance
Act with the Indian Health Care Improvement Act in 1976 and attempted to elevate
the health status of AI/ANs to a level equal to that of the general population. This
Act gave IHS a larger budget, allowed expanded health services, and provided
for new and renovated medical facilities and construction of safe drinking water
and sanitary disposal facilities. In addition, it established scholarship and loan
payback programs to increase the number of Indian health professionals. IHS was
elevated to agency status within the USPHS in 1988.This reflected the improving
reputation of IHS as an institution, as well as the growth of support for Indian
self-determination and the IHS mission. See Exhibits 7/2 and 7/3.
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T H E S E R V I C E P O P U L AT I O N
573
Exhibit 7/2: Timeline of Key Events in IHS History
1784
First treaty between the US government and an American Indian tribe signed.
1849
Bureau of Indian Affairs transferred from War Department to Department of the Interior.
Physician services extended to Indians.
1880s
First federal hospital built for Indians.
1908
Professional medical supervision of Indian health activities established with position
of chief medical supervisor.
1921
The Snyder Act authorized Indian health services by the federal government (under
control of the Bureau of Indian Affairs).
1955
The Indian Health Service officially became a division of the United States Public
Health Service (USPHS).
1975
Congress passed the Indian Self-Determination and Education Assistance Act.
1976
Congress passed the Indian Health Care Improvement Act.
1988
IHS was elevated to agency status within the USPHS. IHS was allowed to bill thirdparty payors where applicable.
1994
Dr. Michael Trujillo appointed as Director of the Indian Health Service.
1995
Preliminary recommendations of the Indian Health Design Team (a task force composed
of Tribal leaders and IHS employees) published.
1997
Final recommendations of the Indian Health Design Team published.
Exhibit 7/3: IHS Mission
The mission of the Indian Health Service, in partnership with American Indian and Alaska Native
people, is to raise their physical, mental, social, and spiritual health to the highest level.
The Service Population: American Indians and Alaska Natives
Traditional AI/AN beliefs concerning wellness, sickness, and treatment were different than the modern public health approach or the medical model. American
Indians’ and Alaskan Natives’ beliefs included close integration within family,
clan, and tribe; harmony with the environment; and a continuing circle of life–
birth, adolescence, adulthood, elder years, the passing-on, and then rebirth.
Individual wellness was conceived of as the harmony and balance among mind,
body, spirit, and the environment. Effective health services for AI/ANs had to
integrate the philosophies of the tribes with those of the medical community.
Of the more than 2.4 million AI/ANs in the United States, approximately 1.4
million belonged to the 545 federally recognized Indian tribes. All American Indian
tribes were sovereign nations. Therefore, AI/ANs were citizens of both their tribes
and of the United States. This meant that AI/ANs had a unique relationship with
the federal government. Based on the “treaty rights” established between most tribes
and the United States, the federal government had a “trust responsibility” to these
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tribes that entitled the Indian people to services such as education and health care.
However, because not all tribes signed treaties with the United States, less than
two-thirds of all people with an Indian heritage were eligible to participate in the
federal programs. Since October 1978, the Bureau of Indian Affairs had received
215 letters of intent and petitions for federal recognition. Forty-one of these petitions have been resolved with 21 “new” tribes being recognized.
The total number of AI/ANs eligible for IHS services in 1997 was approximately
1.43 million and increased about 2.2 percent each year. Selected demographics of
the service population are shown in Exhibits 7/4 through 7/10. Tribal members
lived mainly on reservations and in rural communities in 34 states.
Exhibit 7/4: Service Population
Area
1990 (Census) Population
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
1997 (Estimated) Population
74,789
86,251
67,504
61,349
47,008
104,828
48,943
180,959
262,517
120,707
127,774
24,607
1,207,236
All Areas
94,313
103,713
78,851
79,930
55,630
119,976
73,042
215,232
297,888
140,969
148,791
27,612
1,435,947
Exhibit 7/5: Age Distribution (by percentage of total population)
Percentage of Total
Population
25
Age Distribution
20
15
10
5
0
<1
1–4
5–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84
Age in Years
AI/AN
All Races
>85
White
Source: Adapted from Trends in Indian Health 1996.
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Exhibit 7/6: Median Household Income (1990 Census)
$36,784
Median Household Income
$40,000
$31,435
$35,000
$24,156
$30,000
$19,758
$19,897
Black
$25,000
$30,056
AI/AN
$20,000
$15,000
$10,000
$5,000
$0
Hispanic
White
Asian
All Races
Source: Adapted from Trends in Indian Health 1996.
Percent of Total Population
Below Poverty Level
Exhibit 7/7: Percent of Total Population Below Poverty Level
35
29.5
31.6
25.3
30
25
20
15
14.1
13.1
9.8
10
5
0
White
Asian
Hispanic
Black
Al/AN
All Races
Source: Adapted from Trends in Indian Health 1996.
Rate per 1,000 Live
Births
Exhibit 7/8: Infant Mortality Rates
70
60
50
40
30
20
10
0
1955
Infant Mortality Rate
AI/AN
All Races
White
1975
1980
1985
Calendar Year
1990
1992
Source: Adapted from Trends in Indian Health 1996.
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Exhibit 7/9: Overall Measures of Health
AI/AN
Life Expectancy at Birth (Years)
Years of Productive Life Lost
(Rate per 1,000 population)
Age-adjusted Mortality Rate
(per 100,000 population)
All Races
White
73.5
75.5
76.3
83.0
55.6
49.9
598.1
513.7
486.8
Source: Adapted from Trends in Indian Health 1996.
Exhibit 7/10: Leading Causes of Death, Hospitalization, and Outpatient Visits
Leading Causes of Death
Heart Diseases
Accidents (Motor Vehicle and Other)
Chronic Liver Disease and Cirrhosis
Pneumonia and Influenza
Chronic Obstructive Pulmonary Diseases
Cancer
Diabetes Mellitus
Cerebrovascular Disease
Suicide
Homicide
Leading Causes of Hospitalization
Obstetric Deliveries and Complications
of Pregnancy
Injury and Poisoning
Genitourinary System Diseases
Endocrine, Nutritional, and Metabolic Disorders
Respiratory System Diseases
Digestive System Diseases
Circulatory System Diseases
Mental Disorders
Skin Diseases
Leading Causes of Outpatient Visits
Respiratory Diseases
Endocrine, Nutritional, and Metabolic Disorders
Musculoskeletal System Diseases
Complications of Pregnancy and Childbirth
Nervous System Diseases
Injury and Poisoning
Skin Diseases
Circulatory System Diseases
Source: Adapted from Trends in Indian Health 1996.
Similar to the nation’s health care system, IHS operated in an environment of
increasing health care costs, growing numbers of beneficiaries, and excess demand
for services. The shift in disease patterns (from acute to chronic diseases) and the
increasing elderly population played an important role in health planning for
the IHS as well. As with the Veterans Administration, IHS was a health care provider
within the US governmental system – though unlike the VA, the IHS was not a
Cabinet department and had no voice in policy making at the White House. Unlike
any other health care system in the country, IHS was subject to both the mandates
of Congress and the approval of more than 540 sovereign Indian Nations.
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I H S T O D AY
577
IHS Today: A Key Component of the Indian Health Care System
Health care for AI/ANs was delivered through a system of interlocking programs. The system was composed of the IHS, the Tribal Programs, and the Urban
Programs. IHS programs, called service units, were those projects and facilities that
were directly staffed, operated, and administered by IHS personnel. As of October
1995, there were 68 IHS-operated service units that administered 38 hospitals and
112 health centers, school health centers, and health stations. Tribal programs were
those developed through the process of Indian self-determination. Administered
through 76 tribal-operated service units were 11 tribal program hospitals and 372
health centers, school health centers, health stations, and Alaska village clinics.
Urban programs were relatively new, but were expected to face a future of brisk
demand because of the relocation of significant Indian populations from reservations to urban settings. The urban programs ranged from information referral and
community health services to comprehensive primary health care services. As of
October 1995, there were 34 Indian-operated urban programs.
IHS headquarters and the IHS area offices had ties to the tribal governments as well as to the Indian-operated urban projects. The Indian and Alaskan
tribal governments had input into the decisions of IHS-operated Service Units.
This interrelation between the federal government, tribal governments, and
urban Indian groups was a key component of Indian health care management.
Exhibit 7/11 shows various features of the Indian health care system.
Exhibit 7/11: Elements of the Indian Health Care System
IHS Headquarters
Indian and Alaskan
Tribal Governments
Indian-Operated
Urban Projects
IHS Area Offices
Service Units
Service Units
Hospitals, Health Clinics,
and Extended Care Facilities
Hospitals, Health Centers,
and Other Clinics
Health Clinics, Outreach,
and Referral Facilities
Note: Solid lines reflect formal relationships; dashed lines (—–) reflect important but less formal relationships.
Source: Adapted from Trends in Indian Health 1996.
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Exhibit 7/12: Executive Branch Organizational Chart
The President of the
United States
Department of Health and
Human Services
• Office of the Secretary
• Administration for Children
and Families
• Administration on Aging
• Agency for Health Care
Policy and Research
(AHCPR)
• Agency for Toxic
Substances and Disease
try (ATSDR)
• Centers for Disease Control
and Prevention (CDC)
• Food and Drug
Administration (FDA)
• Health Care Financing
Administration (HCFA)
• Health Resources and
Services Administration
(HRSA)
• Indian Health Service
(IHS)
• National Institutes of Health
(NIH)
• Program Support Center
• Substance Abuse and
Mental Health Services
Administration (SAMHSA)
Department of the
Interior
• Bureau of Indian Affairs
Other Executive Branch
Departments
•
•
•
•
•
•
•
•
•
•
•
•
Agriculture
Commerce
Defense
Education
Energy
Housing and Urban
Development
Justice
Labor
State
Transportation
Treasury
Veterans Affairs
To further complicate the organizational structure, IHS was an Operating
Division within the Department of Health and Human Services (DHHS). Exhibit
7/12 shows the position of the IHS (in bold) on the organizational chart of the
executive branch of the federal government.
Within IHS, the organizational structure consisted of three levels: headquarters,
area offices, and service units. IHS headquarters, located in Rockville, ,
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I H S T O D AY
579
Exhibit 7/13: IHS Area Offices
id
m
en
de
gs
Be
lin
Cali
nia
for
Phoenix
r
Abe
an
B il
r tl
Po
d
ji
Navajo
Nashville
Albuquerque
Tucson
Alaska
Oklahoma
Source: IHS Homepage (www.ihs.gov).
was ultimately responsible for all policy, operations, and management decisions.
The 12 area offices (see Exhibit 7/13) represented geographical regions and were
responsible for performing various roles in administrative and program support
for the local service units.
Service units were composed of several types of facilities, including hospitals,
health centers, health stations, and clinics. Depending on local preferences and
circumstances, these service units could exist as single entities or as combinations
of facilities. For example, the Fort Hall Service Unit in Idaho included only a
single health center, whereas the Pine Ridge Service Unit in South Dakota consisted of a hospital in Pine Ridge, health centers in Kyle and Wanblee, and small
health stations in Allen and Manderson.
IHS Programs and Initiatives
In many (but not in all) cases, IHS provided comprehensive health care services
to eligible AI/ANs. To be eligible for services, AI/ANs had to be members
of federally recognized tribes with whom the United States had treaty agreements. Services were provided through various programs and initiatives administered by the IHS, covering a full range of preventive health, behavioral health,
medical care, and environmental health engineering services. The initiatives
focused on timely issues such as care of the elderly, women’s health, AIDS,
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Exhibit 7/14: IHS Programs and Initiatives
IHS Services and Programs
Preventive Health:
Prenatal and Postnatal Care
Well Baby Care
Immunizations
Family Planning Services
Women’s Health Program
Nutrition Program
Health Education Program
Community Health Representative Program
Accident and Injury…
