Dr. Lynelle Noisy Hawk became clinical director of Crow-Northern Cheyenne Hospital almost two years ago, but some boxes still sit full on her office floor. She’s just not had time to unpack them.
“It’s tough,” she said. “Some days you’re like, ‘Why do I do this?’ because it gets so stressful.”
Health care jobs are tough anywhere, but Indian Country providers face unique financial, bureaucratic and community health challenges that add up to one stark fact: Native Americans, on average, live 20 years less than other Montanans.
Noisy Hawk and others working on Montana’s seven reservations have launched creative strategies to improve health in their communities. In the past year, the Affordable Care Act and recent state Medicaid expansion have come to the forefront of those discussions. If more people enroll for insurance, those patients can have more options for care while clinics can bill those policies to expand their budgets and therefore services offered. Yet, insurance alone cannot close the life expectancy gap.
Health experts and tribal leaders lay much of the blame at the feet of Indian Health Service, the primary provider of care on reservations. The federal agency remains underfunded by Congress, crippled by mismanagement and limited by regulations. Local clinic and hospital leaders nonetheless have found a handful of ways to expand care even as Montana’s senators debate which reforms would lead to the best improvements.
As it stands now, Northern Cheyenne Tribal Attorney William Walksalong says the typical Native American health care experience is “genocidal” and said as much in a letter to federal officials.
“We sent Sen. (Jon) Tester 68 stories of tribal miseries with IHS,” he said. “Horror stories. People died needlessly. It’s genocidal. It’s systematic. It’s an institution.”
The Indian Health Service formed in 1955, taking over health care from the Bureau of Indian Affairs whose task had been to prevent disease and assimilate tribal members. From its start, the agency has faced frequent criticism and undergone numerous changes. Early scandals included the secret sterilization of women at some hospitals, medical studies without clear patient consent and the placement of some disinterested doctors in IHS hospitals so they would not have to go to Vietnam.
More recently, the top leadership has been in flux at agency headquarters and several regional offices as federal officials investigate long wait times and problem physicians.
Care has certainly improved since the agency’s early days. For instance, more clinics and hospitals than ever have earned accreditation. One Montana facility reports filling dozens of vacancies thanks to new leadership. Another is leading tests for new uses of telemedicine. And off-reservation hospitals have improved relationships with Native American communities.
But the recurring theme presented at Senate Committee on Indian Affairs hearings this year has been that the good people on the ground are hampered by too little funding and too many rules.
In their testimony, tribal and IHS leaders say federal regulations make it harder to hire qualified people away from private hospitals or to fire workers who are under-performing.
It also can be tough to keep doctors on staff when their recommended treatment plans are denied for budget reasons, and if they must limit their daily appointments because they need to do referral and billing paperwork typically handled by support staff at private hospitals.
“The Indian Health Service should be held in the same light as the VA scandal,” said Northern Cheyenne Tribal Health Director Jace Killsback. “Health care is owed to us. We gave up our land and shed blood.”
It is unclear to what extent some of the challenges highlighted in congressional testimony affect IHS facilities in Montana. Agency public affairs officials in D.C. denied repeated Lee Newspapers requests to tour other clinics and speak to their leaders.
Several current and former agency employees interviewed asked not to be named for fear of reprisal or of damaging professional relationships critical to making improvements. In general, their stories paralleled the experience shared by Noisy Hawk and in records of congressional testimony. Some records requests to IHS were delayed, but the same information was later provided by congressional staff.
One document shared with Lee Newspapers highlights how underfunding one portion of IHS needs can create ripple effects.
A summary of equipment needs at IHS-managed clinics in Montana shared with Sen. Jon Tester’s office reports that the 4,115 pieces of biomedical equipment in use across Montana and Wyoming facilities have an average age of 10 years.
The useful life for such equipment is typically five to seven years, according to the document. Not replacing equipment in a timely fashion can cause clinics to lose accreditation, close down specialty units or revert to dated care strategies that do not require the tools.
For instance, the document lists the Crow Unit of IHS as needing 188 new pieces of equipment so it can offer labor and delivery services again, restart radiology at one clinic with an obsolete X-ray and replace dozens of aging IV pumps. The cost is estimated to be nearly $2.7 million, but the current fiscal year appropriation from Congress, along with local savings, adds up to just $184,000.
Across all facilities, equipment funding falls 79 percent short of the reported need, according to the document.
The proposed Indian Health Service Accountability Act would loosen hiring and firing rules at IHS, including more flexibility over pay and benefits. The bill introduced by Indian Affairs Chairman Sen. John Barrasso, R-Wyo., has yet to be endorsed by Montana’s senator on the committee. Vice Chairman Sen. Jon Tester, a Democrat, says he needs more input from tribal leaders about whether it’s the solution they need and that reforms must be comprehensive.
Sen. Steve Daines, a Republican, calls it a step in the right direction, but, like Tester, points to other issues that also need to be fixed at the agency.
Tester has supported IHS budget increases in recent years, including a proposed $122 million increase to clinics and hospitals in next year’s budget. His staff notes, however, that the increases were largely negated in 2013 by $220 million in forced sequestration cuts when Congress could not agree on a budget deal. In 2015, he introduced a bill to exempt IHS and other service agencies from sequestration cuts, but it has yet to be taken up for a vote.
“First of all, there are trust responsibilities and treaty obligations that we need to uphold. Right now, although there are some really good people in IHS, they certainly aren’t able to live up to their responsibility,” Tester said. “There are a number of things we need to deal with, but No. 1: I don’t think you can expect great outcomes when you’re spending about half of what you normally spend on health care, half as much on Indian health as we do on other health systems we fund.”
Daines disagrees that most of the agency’s problems boil down to funding.
“Throwing more good money at a bad system is not going to be a solution,” he said. “That’s why we’ve got to reform the system.”
He chalks up most of the challenges to a too-big bureaucracy that keeps money from reaching facilities and that limits how it can be spent once it’s there. He championed Barrasso’s bill as an example of how stepping out of the way could help clinics fill thousands of open positions and keep those workers long term.
Daines also said that a portion of the Affordable Care Act, which mandates coverage for tribal employees, is crippling budgets. In addition to broader concerns about the viability of the new health care market as a whole, he said tribes should be exempt from the insurance mandate.
Noisy Hawk will take any help she can get from Congress – the ability to offer more competitive salaries, more funding for equipment, etc. – but until then she has to find solutions with what she has.
Improved support staff training, increased third-party revenues and an updated appointment scheduling structure, among other procedural shifts, have helped Crow-Northern Cheyenne Hospital go from 35 percent staffed two years ago to more than 50 percent staffed today. By hiring midwives, the hospital might be able to offer some birthing services while it waits on funding for the equipment and nurses needed to reopen a complete OB/GYN unit.
“We’ve made a lot of improvements and are offering more services,” Noisy Hawk said. “We can do so much more, but it’s frustrating. I can’t do anything about my nurse shortage without more pay flexibility. … We’re running into space issues. I can’t really hire if I don’t have a place to put them.”
She’s surrounded by reminders of why she keeps doing the work anyway.
Noisy Hawk touched one of her beaded earrings and explained they were a gift from a woman she helped get the appointments she needed. Then she reached into one of the boxes on her office floor and pulled out a large quilt.
“He told me, ‘Nobody had helped me get off of pain pills. That’s all I wanted to do,’ ” she recalled. “He wanted the issues to be resolved. This was his gift. I need to get it up. I just haven’t had the time.”