"INDIAN COUNTRY HEALTH CARE, THE UGLY REALITY "

By TERRY ANDERSON
Bozeman, Mont.

Montana Sen. Max Baucus , a leading architect of national health-care reform, visited the Flathead Indian Reservation near Pablo, Mont., in May, and he was confronted with a surprising critique. "I hope any [new health-care] plan does not forget the nation's first people," Dr. LeAnne Muzquiz told the senator. Another person in the audience, according to the newspaper the Missoulian , followed up by telling the senator that the legislation pending in Congress would in fact do just that.

Native Americans have received federally funded health care for decades. A series of treaties, court cases and acts passed by Congress requires that the government provide low-cost and, in many cases, free care to American Indians. The Indian Health Service (IHS) is charged with delivering that care.

The IHS attempts to provide health care to American Indians and Alaska Natives in one of two ways. It runs 48 hospitals and 230 clinics for which it hires doctors, nurses, and staff and decides what services will be provided. Or it contracts with tribes under the Indian Self-Determination and Education Assistance Act passed in 1975. In this case, the IHS provides funding for the tribe, which delivers health care to tribal members and makes its own decisions about what services to provide.

The IHS spends about $2,100 per Native American each year, which is considerably below the $6,000 spent per capita on health care across the U.S. But IHS spending per capita is about on par with Finland, Japan, Spain and other top 20 industrialized countries—countries that the Obama administration has said demonstrate that we can spend far less on health care and get better outcomes. In addition, IHS spending will go up by about $1 billion over the next year to reach a total of $4.5 billion by 2010. That includes a $454 million increase in its budget and another $500 million earmarked for the agency in the stimulus package.

Unfortunately, Indians are not getting healthier under the federal system. In 2007, rates of infant mortality among Native Americans across the country were 1.4 times higher than non-Hispanic whites and rates of heart disease were 1.2 times higher. HIV/AIDS rates were 30% higher, and rates of liver cancer and inflammatory bowel disease were two times higher. Diabetes-related death rates were four times higher. On average, life expectancy is four years shorter for Native Americans than the population as a whole.

Rural Indians fare even worse, as data from Sen. Baucus's home state show. According to IHS statistics, in Montana and Wyoming, Indians suffer diabetes at rates 20% higher, heart disease 12% higher, and lung cancer rates 67% higher than the average across all IHS regions in the country. A recent Harvard University study found that life expectancy on a reservation in neighboring South Dakota was 58 years. The national average is 77.

Personal stories from people within the system reveal the human side of these statistics. In 2005, Ta'Shon Rain Little Light, a 5-year-old member of the Crow tribe who loved to dress in traditional clothes, stopped eating and complained that her stomach hurt. When her mother took her to the IHS clinic in south central Montana, doctors dismissed her pain as depression. They didn't perform the tests that might have revealed the terminal cancer that was discovered several months later when Ta'Shon was flown to a children's hospital in Denver. "Maybe it would have been treatable" had the cancer been discovered sooner, her great-aunt Ada White told the Associated Press.

Such horror stories are common on reservations, where the common wisdom is "don't get sick after June"—the month when the federal dollars usually run out. Late last year, the Montana Quarterly interviewed Tommy Connell, a member of the Blackfeet tribe and a worker in the IHS hospital in Browning, Mont. He didn't pull any punches in his assessment of the IHS. "They're lying to us," he said of promises over the years of more funds and better care. "You can pass just about any bill you want, but to appropriate money to that bill, that's another thing."

Dismal statistics prompted Mr. Baucus to declare a "health state of emergency" on the Fort Peck Reservation in northeastern Montana and to order an investigation of the IHS's use of funds. In July 2008, the Government Accountability Office reported that the IHS simply lost $15.8 million worth of equipment such as trucks and Jaws of Life machines between 2004 and 2007. It also found that $700,000 worth of computers were ruined by bat dung.

Tribal contracting—the alternative to IHS-run hospitals and clinics—offers some hope for improvement by giving tribes more flexibility in administering their own hospitals and clinics. Kelly Eagleman, vice-chairman of the Chippewa Cree Band on Montana's Rocky Boy's Reservation, understands the effect of a top-down bureaucracy. Of his tribe, he says, "We tend to want to blame a system, but we don't look at ourselves. We all smoke. We lay on the couch. But when something happens to us, we're the first to point and say that the clinic should have fixed us."

The Chippewa Cree Band has opted to provide its own health care with funding from the IHS. Dr. Dee Althouse, a physician at the Rocky Boy's Reservation, is still frustrated by funding constraints. She told the Montana Quarterly that she often finds herself working to save lives and limbs, deferring routine health care until there is money available. Yet even with limited funds, ongoing research by the Native Nations Institute reported earlier this year that tribal management leads to better access and better quality care than relying on the IHS-run system.

The Chippewa Cree Band runs its own hospital and has hired a registered dietician who has gotten the local grocery store to implement a shelf-labeling system to improve consumer nutritional information. They've also built a Wellness Center with a gym, track, basketball court, and pool. These are small steps that won't immediately eliminate heart disease or diabetes. But they move in the direction of local control and better health.

At a time when Americans are debating whether to give the government in Washington more control over their health care, some of the nation's first inhabitants are moving in the opposite direction.

Mr. Anderson is executive director of the Property and Environment Research Center in Bozeman, Mont., and a senior fellow at Stanford University's Hoover Institution.

Printed in The Wall Street Journal, page A11