Off-Reservation Native
American Access to Healthcare in Albuquerque
Table of Contents
1.
Executive
Summary
2.
Healthcare
Crisis for Urban Indians
a.
Albuquerque’s Urban
Indian Community
b.
Healthcare
Challenges Facing Urban Indians in Albuquerque
3.
Federal
Responsibility to Provide Native
Americans with Healthcare
a.
Snyder
Act
b.
Indian Health
Care Improvement Act
4.
How
the
Federal Government Delivers Healthcare to Native
Americans in Albuquerque
a.
Indian
Health
Service- An Overview
b.
Contract
Health Services
c.
Urban
Indian
Healthcare Program
d.
Public
Law
638
e.
Albuquerque Service Unit
5.
UNMH
and the
1952 Contract
a.
History
b.
Current State of Affairs
6.
Possible
Solutions
a.
Advocate
for
Full Federal Funding for Native
American Healthcare Services
b.
Increase
Enrollment of Urban Indians in Existing Healthcare Coverage Programs
c.
Require
UNMH
to Promulgate and Implement a Specific Policy for Native
Americans
d.
Enforce
the
1952 Contract
e.
Charter a
Council – City or County
f.
Recommendations
Proposed by the Native
Healthcare
Council of New Mexico
7.
Conclusion
1.
Executive
Summary
Over the course of two centuries, Native
Americans ceded 400,000,000 acres of land to the federal government in
exchange
for certain promises, protections and services.
Among these was guaranteed cradle-to-grave healthcare coverage,
which
should be the most comprehensive pre-paid healthcare plan in the
country. Despite acknowledging this
contractual
obligation, however, the federal government has never fully delivered
on it.
Currently, the federal Indian Health Service (IHS)
is being
systematically defunded and dismantled, with nothing set to take its
place. The situation is acute for all Native Americans, the great majority of
whom do not
live on tribal lands. These so-called
“Urban Indians” have been both recognized and ignored by the federal
government.
In the Indian Health Care Improvement
Act of 1976, the federal government explicitly determined that Urban
Indians
have special access-to-healthcare needs.
However, those needs are regularly and dangerously unmet, as
evidenced
by the fact that while approximately 65% of all Native
Americans are considered Urban Indians (meaning they don’t live on or
near
their reservation or tribal lands), only about 1% of the IHS budget is
designated for urban clinical facilities.
Albuquerque
has one of the largest Native
American
populations in the country. Following
the virtual shutdown of the federally run Albuquerque Indian
Health Center
in 2005, their lack of access to healthcare has become dire. There is a single medical services clinic in Albuquerque that
receives
federal funding for Native
American
healthcare. (A second facility receives
federal funding to provide dental care to Native
American children in Albuquerque). The clinic, First Nations Community
Healthsource, does not have the capacity to deal adequately with the
healthcare
needs of the tens of thousands of Native
Americans living in Albuquerque. This community should have another
option.
The University of New Mexico Hospital (UNMH) is
bound by a
1952 contract to provide healthcare to Native
Americans free of charge. This same
contract binds the federal government to reimburse UNMH for its costs. Since the Albuquerque Indian
Health Center
closed its urgent care services, the healthcare promised by the 1952
contract
has become critically important. Yet, to date, the federal government
is not
reimbursing UNMH for its costs and the Hospital is not providing full
service
treatment to Native
Americans free
of charge.
While it is unclear how the contract can or will
be
enforced, one thing is clear: the federal government is in breach of
its
contractual obligation to provide comprehensive healthcare to all Native Americans, and those living
off-reservation
are bearing the brunt of this failure.
How to enforce that obligation, or find solutions in its
absence, is the
challenge Albuquerque’s
Urban Indians face.
2.
Healthcare
Crisis for Urban Indians
Albuquerque’s
Urban Indian Community
Generally, Urban Indians are Indians who have left
their
tribes and are living in urban areas around the United States. Indian Health Service (IHS) data indicates
that Albuquerque
has the highest percentage of Native
Americans in its population of any American city (10.5%), with the
third
highest raw number of Native
Americans.
According to the IHS, however, in FY2003 there
were 46,883 individuals
representing 407 tribes from across the country living in Albuquerque
and listed as patients at the Albuquerque Indian
Health Center. First Nations Community Healthsource which
provides a variety of primary care services, primarily to Urban
Indians,
estimates there are between 45,000 and 51,000 Native
people in Albuquerque
representing more than 150 different tribes.
According to U.S. Census data, the median
household income for
Native Americans in Albuquerque in
1999 was
$23,440 and per capita income was $8,679 compared to $38,272 and
$20,884 for
non-Indians. On average, at that time, 25.8% of
Albuquerque’s Native
American
population lived below poverty level, but there were neighborhoods in
which as
many as 64.6% of the population lived below poverty level.
Native
Americans
make up 13.5% of the state’s uninsured population, while consisting of
10% of
the population as a whole. First Nations Community Healthsource, Albuquerque’s only Urban Indian health clinic,
estimates
that 70% of Albuquerque’s
Native American population
is
uninsured. In 2000, 18% of the off-reservation community
reported attaining a 4 year college degree or higher compared to 30.5%
for all
races. The unemployment rate was 13.1%, compared to
5.7% for all races, and 56.1% of Native
American households consisted of a single parent, compared to 35.2% for
all
races.
Healthcare
Challenges Facing Urban Indians in Albuquerque
The federal government has long recognized the
problem of
poor health among off-reservation Native
Americans, and, until recently, provided money to local healthcare
facilities
to provide primary healthcare services to Urban Indians, mainly through
the IHS. This arrangement, however, has
been
deteriorating. Funding has been
increasingly
reduced, even as Urban Indian populations have grown, leaving these
individuals
with fewer and fewer options for care.
For example, the Albuquerque Indian Health Center (AIHC), which
at one
time supplied urgent care to over 36,000 people per year, has been
reduced to a
shell of its former self, operating currently with less than a third of
its
previous staff. Since shuttering its
urgent care facilities in 2005, no other entity has been able to fill
the gap in
healthcare access for Native
Americans.
Because most federal healthcare dollars for
Indians are
distributed through tribes, Urban Indians often must return to their
tribal
homes to seek healthcare. However,
tribal resources are generally inadequate. Tribes
must ration the care they provide,
giving priority to those who live on tribal territories.
As a result, Urban Indians commonly cannot
avail themselves of tribal care, either because their tribes cannot
afford to
care for them, or because their home tribes are too far away. As a result, most Urban Indians end up
seeking care at the nearest public hospital or emergency room, or
foregoing
care altogether. In Albuquerque, this situation has lead
to dire
results.
The off-reservation community in Albuquerque
experiences higher rates of disease
and death than other communities. For
example, that community’s diabetes rate is 67.6 per 100,000, compared
to 13.5
for all races in the United
States.
Between 1990 and 1999, the rate of chronic liver diseases for Albuquerque’s Native American population was 38.6 per
100,000, as compared
to 14.8 for all races, and the diabetes death rate was 43.4 per
100,000, as compared
to 23.6 for all races. The need for
preventative and therapeutic care is great and largely unmet.
3.
Federal
Responsibility to Provide Native
Americans with Healthcare
The federal trust responsibility for healthcare,
enshrined
in numerous treaties and agreements,
is codified by the Snyder Act of 1921 and, subsequently, the Indian
Health Care
Improvement Act (IHCIA) of 1976.
Snyder
Act
The Snyder Act gave Congress the authority to
appropriate
money for Indian healthcare. It specifically recognized that the federal
trust responsibility includes healthcare concerns. The Act provides
that the
Bureau of Indian Affairs (BIA) under the direction of the Secretary of
the
Interior “shall direct, supervise, and expend” money that Congress
appropriates
“for the benefit, care, and assistance of the Indians throughout the U.S.
for the
following purposes” including “for the relief of distress and
conservation of
health.”
Indian
Health Care Improvement Act
The Indian Health Care Improvement Act of 1976 is
a federal
statute that transferred the responsibility of overseeing Indian
healthcare
concerns from the BIA to IHS. It also
explicitly recognizes Urban Indians as a distinct group for the first
time. The IHCIA states that “[i]t is the
policy of this Nation, in fulfillment of its special responsibilities
and legal
obligation to the American Indian people, to assure the highest
possible health
status for Indians and urban Indians and to provide all resources
necessary to
effect that policy.”
The IHCIA specifically directs the Secretary of
the Interior
to expend funds allocated by Congress to the Indian Health Care
Improvement
Fund for the purpose of “meeting the health needs of Indians in an
efficient
and equitable manner.” But while the
IHCIA authorized appropriations,
it did not identify levels or goals for
funding.
A large portion of current IHS programs were
either started
or sustained through the use of IHCIA appropriations. As
a result, the language of the IHCIA
provides useful insight into Congress’ intent for IHS responsibilities
and
activities vis-a-vis Urban Indians.
Urban Indians, as distinct from Indians who live
“on or near
[a] reservation,” are defined by the IHCIA as any Indian who resides in
an
urban center. An urban center is “any community which has a
sufficient Urban Indian population with unmet health needs to warrant
assistance under Title V as determined by the Secretary.”
Title V of the IHCIA recognizes that Urban Indians
have
particular healthcare needs, and provides for certain programs in urban
centers
to “make health services more accessible to urban Indians.” Specifically, Title V established the Urban
Indian Health Program, which is a vehicle for channeling appropriations
directly to medical facilities that serve Urban Indian populations
exclusively,
bypassing other existing IHS funding streams.
The IHCIA sunsetted in 2000, but Congress is
currently in the
process of reauthorizing it.
Reauthorization will once again confirm and codify the federal
responsibility to provide comprehensive healthcare to all Native Americans, and will reassert special
recognition of the status and needs of Urban Indians.
Even if successful, however, the
reauthorization will not include an appropriation.
4.
How
the
Federal Government Delivers Healthcare to Native
Americans in Albuquerque
In order to
understand how Native
Americans in
the Albuquerque area are supposed to receive healthcare, it is
important first
to understand the basic structure of the IHS, the Contract Health
Service,
programs designated specifically for Urban Indians, and a law that
allows
tribes to withdraw their share of funding from the IHS pool and
administer
their own healthcare programs directly.
Also, and not incidental, all Indian healthcare programs
are
discretionary and funded at the will of Congress, effectively allowing
the
federal government to abrogate its trust responsibility by withholding
funds.
Indian
Health Service
The IHS is charged with providing a comprehensive
healthcare
service delivery system for approximately 1.8 million of the nation’s
estimated
3.2 million American Indians and Alaska Natives. However, it is funded at only 54% of the level
necessary to provide full services in the 35 states in which it
operates. While funding for IHS has increased every
year, studies have found that the IHS budget has failed to even keep
pace with
inflation and population growth.
Between 1990 and 2005, total IHS
appropriations increased approximately 5.8% on average.
However, the bulk of those increases were
eaten up by mandatory pay raises for the nearly 14,500 federal
employees that
make up the delivery system.
IHS provides care directly to members of federally
recognized tribes as well as their children. Formal tribal enrollment
is not
required to establish eligibility. Enrollment can be used
to establish eligibility, but other acceptable evidence
includes participation in tribal affairs or residence on tax exempt
property. IHS will also provide care to non-eligible
women, pregnant with the children of eligible men.
Direct health services, excluding those operated
by tribes,
are administered through a decentralized system of 12 Service Area
offices and
155 IHS and tribally managed Service Units.
Service Areas are typically funded based on their ‘user
population,’
which counts the number of potential users as determined by tribal
enrollment
figures, rather than by ‘active users’ which would track the number of
individual patients seen annually in a Service Area and allocate funds
accordingly. The use of the less
accurate ‘user pop’ method creates even further disparities across the
system
by not distributing resources based on actual need.
Service Units provide care within defined
geographic areas
typically centered around a reservation or, in Alaska, a population concentration. The base of operations for a service unit is
typically a small hospital or health center. IHS
does not always provide ancillary and
specialty services, including laboratory and X-ray services,
obstetrics/gynecology services, or outpatient mental health; nor do IHS
facilities offer catastrophic healthcare services.
In New
Mexico
there are two IHS ‘Service Areas:’ Albuquerque and Navajo. The Albuquerque Service Area includes counties
throughout central New Mexico and
also
includes parts of Texas and Colorado.
Within this service area there are eight ‘Service Units,’
including the
Albuquerque Service Unit, which is responsible for serving the
healthcare needs
of over 30,000 Urban Indians, as well as the tribal land-based Native Americans in the area.
Chronic under-funding has resulted in these
unfortunate
statistics: in 2005 the federal government spent $3,945 per capita for
federal
prisoners, as compared to $2,130 per capita for Native
Americans. In 2003, the federal government expended
$2,007 per Native American
client,
compared to $4,487 for Medicaid clients and $7,145 for Medicare clients. In that same year, the overall per capita
expenditure for healthcare in the United States was $5,952. An under-funded IHS routinely reduces
programs and services, which increases the number of patients that must
seek
care outside the IHS system through Contract Health Services (CHS).
Contract
Health Services
Services not provided through IHS direct care
facilities may
be provided to eligible patients through contracts with non-IHS
caregivers. Because many Indian
communities are isolated, the IHS and tribal healthcare programs make
extensive
use of contracts with other hospitals and specialists to supplement
direct
services. These contract health costs
comprise about a quarter of the total cost of clinical services
provided by IHS.
Insufficient funding, however, often
results in failure to provide services for all but the most life
threatening
conditions.
IHS has sought to reduce contract health costs by
limiting
its obligation to provide contract healthcare to Indians not living
near their
reservations. If a Native
American does not live on a reservation but does live within a Contract
Health Service
Delivery Area (CHSDA) that serves his or her reservation, and he or she
maintains close social and economic ties with his or her tribe, then he
or she remains
eligible for contract health services.
In most cases a CHSDA consists of the county or
counties in
which a reservation is located, as well as any counties it borders. The Albuquerque CHSDA includes only Sandia,
Isleta and Laguna pueblos, as well as the Navajo Nation through its
settlement
at Tohajilee. Albuquerque
residents from any other tribe are ineligible for CHS services. Still, since funds are insufficient to cover
the volume of contract health services needed by eligible Urban
Indians, priorities
for service are determined based on relative medical need. Since the closing of the urgent care unit at
the Albuquerque Indian
Health Center
in 2005, most Albuquerque
area CHS dollars are now being spent for urgent care at non-IHS
facilities. Even these needs are not fully
met, as more
than two-thirds of urgent care needs are currently denied by CHS.
If the entire state of New
Mexico
was a CHSDA, as is the case with Oklahoma,
all
Native Americans from New Mexico
tribes would
be eligible for contract care. But for New Mexico to
become a
statewide CHSDA, a tribe would have to petition the IHS.
This has not happened.
Urban
Indian Healthcare Program
The Urban Indian Health Program (UIHP),
established by the
Indian Health Care Improvement Act, provides funding for 34 urban
Indian
clinics in 19 states serving around 1,000,000 off-reservation Native Americans. In 2004, these clinics provided healthcare
access to around 78,000 Native
Americans. The program is severely under-funded: the
entire UIHP budget is just $34 million, which is approximately 1% of
the total
budget for the Indian Health Service, despite the fact that the
off-reservation
Native American community
has grown
to comprise over 65% of the total number of Native
Americans in the US.
In Albuquerque
is only one facility that receives funding through the UIHP: First Nations Community Healthsource. First Nations, established in 1972, provides
primary care, dental care and behavioral healthcare to approximately
1120
patients per month with a current budget of around $2.4 million. It receives approximately $380,000 per year
in UIHP funds. In 2006, First Nations treated 5769 primary
care patients, 3163 of whom were Native
American.
Federal funding for Urban Indian Healthcare
clinics has been
under assault by the current administration.
In each of the last several years, President Bush has attempted
to zero
out all IHS funding for the 34 non-profit Urban Indian clinics. To date, that funding has always been
restored, though at an extremely low level given the population base it
is
meant to serve
Public
Law 638
Since the passage of PL 93-638, the Indian Self
Determination Act and Education Assistance Act of 1975, tribal
governments have
had the opportunity to contract directly for their own programs and
services,
including healthcare services, with the federal government. These are generally referred to as “638
contracts,” and permit tribes to administer a full spectrum of
services,
including both direct and contract healthcare services, facilities
construction, community health representatives programs, mental health
and drug
abuse services and health education initiatives.
Tribes
may withdraw up to 100% of their tribal share of the IHS funding in
their
service area. Nationally, in FY 2006, tribes controlled
approximately
$1.8 billion, or 55 percent of IHS's total budget, through 638
contracts.
These healthcare centers are required to provide
care to any
person who is otherwise eligible for IHS services. Currently, we have no information about what
policies the local 638 clinics have in place regarding the treatment of
non-member and off-reservation Native
Americans.
Albuquerque Service
Unit
The
Albuquerque Service Unit of the IHS is severely under-funded, and has
had to
cut back substantially on the services it provides.
The most recent blow was the 2005 closing of
the AIHC urgent care unit, which had been treating between 100 and 200
patients
daily. One significant reason for the lack of
resources lies in the way in which IHS calculates and distributes its
funding
of local healthcare providers.
When the IHS was created, most Native
Americans still lived on or near their tribal lands.
Its purpose was to provide healthcare in
remote areas where no other options existed.
Federal healthcare dollars were therefore allocated based on a
tribe’s
enrollment numbers, and allocated to the service areas where those
tribes are
located – or to the tribes directly – based on those numbers. Even though in the intervening years many Native Americans have migrated for various
reasons
from their tribal lands, that formula continues to guide IHS spending.
The money doesn’t follow the patient; it goes to
the
wherever that patient is tribally enrolled.
So Native Americans
from
non-local tribes who live in the Albuquerque
area – and make up 75% of the local Native
population – are not accounted for when the Albuquerque Service Unit is
funded.
As a result, services for the entire
Albuquerque
Urban Indian community must be funded by allocations intended to serve
only the
tribes located in the Albuquerque area,
which
happen to be three of the smaller tribes in New
Mexico:
Sandia, Santa Ana,
and Zia Pueblos.
In FY2005, federal allocations to the Albuquerque
Service
Unit for direct medical services amounted to just $542 per capita,
because of
the need to serve those Native
Americans not officially accounted for on the local tribal rolls. This figure is well shy of the national IHS
per capita spending average of $2,130.
In
order to fund local Urban Indian healthcare services at that level, the
Albuquerque Service Unit would need an annual budget of around $58
million. It has always operated with
much less and, due to recent events, that amount has plummeted.
More and more local tribes have recently
contracted with IHS
under PL 638.
The good news is that these tribes were
then
able to spend an average of $3,136 on treatment for their people.
However, as a result of these funds leaving
the IHS direct service pool, the Albuquerque Service Unit was left with
$10
million in tribal allocations, in addition to about $4 million a year
from
Title V funding. This created a
substantial operational shortfall, as, in 2005, AIHC needed $15 million
to
operate at full capacity.
The devastating
impact of these
funding shortfalls in the Albuquerque
area is significant and widespread. In
2006, a resident at the University of New Mexico Hospital, Dr. Dan
Waldman,
completed some preliminary research into the effects of the closure of
urgent
care services at AIHC. Based on
interviews with 110 participants, 83.8% of whom live in Albuquerque, he
learned that:
·
56.9% of the respondents
self-identified as
Navajo (remember, the Albuquerque Service Unit gets NO funding based on
appropriations for Navajos).
·
57% had no health insurance, 19% had
private
insurance, 1% were enrolled in the UNM Care charity plan, and 23% had
Medicaid
or Medicare.
·
Since the closure of urgent care
services at
AIHC in 2005, respondents sought urgent care services at non-IHS
facilities an
average of 4 times.
·
61.6% of respondents answered that
they had not
sought medical care at least once in a situation where they would have
previously gone to AIHC’s urgent care.
·
45.5% of respondents stated that the
single
greatest barrier in seeking walk-in services was lack of insurance or
increased
costs.
·
22.8% of respondents stated they owe
more than
$500 for walk-in care received since the AIHC urgent care closure.
Finally, the Commonwealth Fund recently issued its
Scorecard on Health System Performance, 2007. In this report, it ranked each state
according to a number of different dimensions of their healthcare
systems. Unfortunately, New Mexico
ranked dead last in the category
of “Access.” This ranking was based on
metrics involving the entire state population.
When considering the extreme vulnerability of off-reservation Native Americans within the evident
shortcomings of New Mexico’s
healthcare delivery system, it becomes
logical to extrapolate that New Mexico’s
Urban
Indian population has the worst access to healthcare of any community
in the United States.
5.
UNMH
and the
1952 Contract
History
What we now know as the UNM
Hospital began in 1949, when
Congress
authorized the Secretary of the Department of Interior to transfer 5.33
acres
of BIA-controlled federal land to Bernalillo County
for the
construction and operation of a hospital by the county. The intention
was to
build a hospital for the approximately 18,000 Pueblo Indians living on
surrounding reservations. At the time, however, William W. Zimmerman,
Acting Commissioner of the Bureau of Indian Affairs testified, “the
hospital
would be open to Indians from many parts of the Southwest, and for that
matter,
to Indians from any part of the United States, and would
not be limited under this
bill to Pueblo Indians.” The costs of care and treatment of all
eligible Indians would be reimbursed by the federal government,
pursuant to
predetermined formulas.
On
January 18, 1952, Bernalillo
County signed a contract with
the United States,
‘acting by and through the Commissioner of Indian Affairs for the
operation and
maintenance’ of the hospital. The final
construction cost of the hospital of $3.25 million was shared by the
two
parties to the contract; $1.5 million from the BIA, $1.75 million from Bernalillo County.
In 1954, the Bernalillo
County Indian Hospital
was opened with
the mission of serving Indians and indigents (whose costs are provided
for by
the county mill levy). According to the
contract, the hospital was obligated to reserve at least 100 beds for
Pueblo Indian
patients. Subsequent Amendments in 1956
and 1957 reiterated the primacy of the contract’s intention to “assure
that
adequate medical treatment for qualified Indians is properly provided.”
The term “Indian” was explicitly used in the
contract to
mean all Native Americans,
not just
those from tribes in the Albuquerque
area or
even New Mexico. There was no distinction made between Pueblo and non-Pueblo Indians, let alone between
residents
and non-residents of either Bernalillo
County or the State of New Mexico. In other words, any member of any federally
recognized tribe from anywhere in the United
States was eligible for federally-reimbursed care
at the Bernalillo
County Indian Hospital.
In 1968, the name of the hospital was changed to Bernalillo County Medical
Center. In 1969, UNM assumed operation of the
hospital as a teaching hospital. In
1978, UNM assumed full control of the hospital under a 20-year lease
with the
county, which was renewed in 1999. In
each amendment and extension, UNM and Bernalillo County
have explicitly agreed to honor the responsibilities to Native
Americans identified in the original federal contract.
IHS has consistently signed off on amendments
and extensions, and in 1978 it made the All Indian Pueblo Council
(AIPC) a Native American
representative party to the
contract, able to participate in negotiations and consultations and
eligible to
receive all reporting previously owed to IHS. In 1987, the facility was renamed the
University
of New Mexico Hospital (UNMH).
However, in the course of amending and expanding
on the
original contract, some curious changes have been made.
For example, language in a 1999 amendment indicates
that the hospital was built on land conveyed to Bernalillo County by
the
federal government “for the purpose of providing a site for a hospital
for the
County that would also serve Native
Americans of New Mexico” (emphasis added). The hospital was originally conceived as an Indian Hospital,
and was never meant to provide treatment solely to Native
Americans from New Mexico
tribes. Though seemingly innocuous, this
kind of language shift can have serious consequences as the contract is
interpreted now and in the future – especially in light of the new
pressures
faced by UNMH to treat Native
Americans in the wake of the closure of urgent care services at AIHC.
Current State of Affairs
Though the contract and lease agreement have been
amended several
times, the gist of the original 1952 federal contract remains the same:
the
hospital is obligated to provide high quality healthcare services to
Indian
people and the federal government is obligated to pay for them.
In 2003, UNMH sought an extension of its lease
with Bernalillo
County, in order
to qualify for a
federal mortgage it needed to build a new wing.
This lease extension required IHS approval, which was ultimately
granted. However, the negotiations took
place without any Urban Indian input, with detrimental results. Several
new policies were introduced into the language of the contract, despite
the
fact that they might not comport with the intent of the original
contract.
For example, the UNMH payment policy for uninsured
patients
explicitly states that Native
Americans will be treated the same as other Bernalillo County
residents when presenting themselves for care.
This language was intended to ensure that Native
Americans are not turned away from UNMH and sent instead to the IHS for
treatment, as had apparently happened in the past.
However, that policy language also seems to
have the effect of equating Native
Americans with other patients in a way that is contrary to the
intentions of
the contract, insofar as it can be read to indicate that UNMH no longer
has to
provide Native Americans
with
healthcare free of charge.
Another new policy, regarding the UNMH charity
care program
(UNM Care) also appears to eliminate any responsibility to provide free
care to
Native Americans unless
they are indigent and live in Bernalillo County.
UNMH will enroll those indigent Native
American residents of Bernalillo
County who so
qualify in UNM
Care, not charge them a co-pay (as is required of other UNM Care
participants)
and absorb the costs, rather than charging IHS.
But the original contract never singled out either indigence or Bernalillo County residence as criteria for
care of
Native Americans, nor did it
ever
contemplate that any Native
American
would be ever charged anything for medical care at the hospital; those
costs
were always meant to be paid by the federal government, which seems to
have
left the equation entirely.
This new interpretation of the fiscal
responsibility for Native
American healthcare incurs new costs for Bernalillo
County
and the state of New Mexico. Moreover, restricting access to those
locally-funded charity care dollars to Native
Americans who are residents of Bernalillo County
raises other
questions. What are out-of-county Native Americans who now rely on UNMH to
provide
care supposed to do? If they are unable
to access the charity care dollars, is the federal government picking
up their
tab? Or are they being billed, contrary
to the intent of the original contract?
Furthermore, the designation of AIPC as the Native American entity of record for
negotiating and
reporting purposes raises other problems.
For example, AIPC is now invited to a contract-mandated annual
meeting
to discuss implementation of the contract’s elements.
No Urban Indians are invited to attend this
meeting. But the majority of the
off-reservation
Native Americans living in
the Albuquerque metro area (the vast
majority of whom are
Navajo) are not members of the Pueblo
tribes and, therefore, are not in any way represented by AIPC. AIPC has no real incentive to advocate on
their behalf.
In the process of amending the contract, IHS has,
with AIPC
support, become the payor of last resort for Native
American care. Although UNMH has
recently created a paid position of liaison to the tribes, it has done
little
to establish formal relations with the community to which it is most
likely –
and most obligated – to provide service: Albuquerque’s
Urban Indians.
According to UNMH, Native
American patient encounters
from FY 2004 to FY 2006 averaged around 1,100 emergency room visits,
1,800
inpatient encounters and 6,200 outpatient visits. Native
Americans made up from 5.1% to 5.6% of the total number of patients
seen at
UNMH, though they constituted between 11.8% and 12.6% of all UNMH
emergency
room visits. But it is still not clear
who is supposed to pay for that treatment, now that the federal
government
seems removed from the equation.
Increasingly, that burden appears to be falling on the very
people the
hospital was initially constructed to provide free service to – Native Americans.
UNMH has committed to creating a “storefront’ for
its Office
of Native A