The VA and the Indians: Business as usual

American Indians might be forgiven if they view the current Veterans' Administration "scandal" with a certain disbelief.

It's not that they'd begrudge veterans fair treatment at the hands of the government; quite the opposite.

For both Indian men and women, the warrior ethos, developed in antiquity, is alive and strong today. Indians seeking to honor their warrior heritage now enlist in the military at much higher rates than does the general population.

No, the problems being attributed to VA today are just things Indians have endured for decades.

Undoubtedly, there are some inefficiencies and weak administrators, but the VA is not adequately funded. The reason is simple. Their patient population is prone to "excess morbidity" -- a higher rate of disease and debility than the population at large.

With health care costs so high, and essentially no upper limit on the amount of disease that waging wars generates, any fixed budget immediately becomes inadequate. Hence Congress' recent highly publicized rush to declare their outrage and concern by passing supplemental funds to buy care from private-sector doctors, instead of requiring vets to get their care directly from VA facilities.

Welcome to the club, an Indian might say. You got "secret" waiting lists? We have long "deferred services" lists of our own, and they're not even secret.

Here's how it works. The U.S. government "negotiated" treaties with tribes -- often at gunpoint. These treaties committed the government to provide, among other things, health care for Indians whose cultures had nearly been obliterated by policies which included unapologetic genocide.

These "entitlements" were earned; far from being government handouts, they are reparations. The Indian Health Service is like an HMO, premiums paid in perpetuity in the currency of blood and land.

But the government won't allow so much as a clearly defined benefits package. Congress allocates Indian health care a budget which is inevitably far too small. It fluctuates from year to year, always falling short. If we establish a minimum benefits package, we would always run out of funds too early each year, and it's illegal for IHS workers to spend money they don't have. But when that budget does run out of money, they'd also be liable for failing to meet the stated obligations in the benefits package, so -- no package at all.

Hence the "deferred surgery" lists. Any services that can't be provided directly by IHS employees at IHS facilities have to be procured by referring patients to private-sector docs.

The downside of this, apart from travel distances, is the private sector is much less committed to constraining needless costs when the government will pick up the tab. Believe it or not, the government can do some things more efficiently and cost-effectively.

So private-sector referrals open the floodgates for uncontrolled expenditures. Of course, there's already a flood of pathology that necessitates such services. This too is a high-risk population, despite remarkable gains in disease prevention and public health during the last 50 years.

Since we always generated more referrals than the budget would cover, our IHS professional staff met once weekly to review and "prioritize" referrals. It was onerous for providers to decide "who goes and who stays," but better than delegating that responsibility to bureaucrats and bean-counters. At least we knew our patients and could serve as their advocates during this "rationing" process.

Priority criteria included urgency -- will the outcome be worse if services aren't rendered now? Is the condition even treatable, and has the proposed intervention been proven effective? To what degree does the condition threaten or impair health?

A numerical tally of these elements places the case on a list. If the number exceeds an arbitrary and fluctuating threshold, the patient's appointment "in town" proceeds immediately. If not, it goes on a waiting list, and might stay there for months or years, depending on how much money is available, and how many newer cases arise with greater urgency.

The list isn't secret, just oppressive. It does not meet the intent (on the Indians' part) or spirit of the treaties.

Then there's the "on-or-near rule." If an Indian is an "enrolled member" of a "federally recognized tribe," he is eligible for any services IHS can render at its own facilities using its own or contracted providers, regardless of his place of residence. However, if he seeks private-sector care without prior authorization from IHS, we won't pay for it, except in true medical emergencies.

What's more, an Indian who lives outside a reservation's borders by more than 20 or so miles is simply ineligible for coverage of any outside care, emergency or otherwise. He doesn't even go on the list.

One effect is to keep some people stuck on the Rez, because they can't afford to pursue lives outside without health care coverage. If you don't live on or near, the government doesn't consider you an Indian, for purposes of off-site services.

If you live across the street from a private facility, but 50 miles away from the IHS clinic, you travel 50 miles, or pay for care yourself. Or go without.

These shortcomings don't arise from lazy or self-serving administrators. You could demote them all, and congressional funding would still fall far short of covering all the care these "beneficiaries" will require.

We owe a great debt to our vets, and we should honor it. But the shameful practices now making headlines are just business as usual for the Indian community.

Jon Hauxwell, MD, is a retired family physician who grew up in Stockton and now lives outside Hays.

hauxwell@ruraltel.net