From Gaps to Ravines

At 18, Nick Montoya, a member of the Taos Pueblo, exuded health, he says. But that changed after a year of duty in Vietnam, where he was exposed to Agent Orange. Since 1969, Montoya has dealt with post-traumatic stress, alcoholism, depression, diabetes, kidney disease, a heart attack and, last September, open-heart surgery. Disappointment, frustration, disgust and anger are some of the words that Montoya uses to describe how he feels about the health services he's received since he was a young man.

Montoya says that his health problems sometimes worsened because of bureaucratic hold-ups and gaps in services. This happened even though the federal government promised him and all other Native Americans health services as part of peace treaty agreements.

"Early on, I would go to Indian Health Service and they would say, 'You're a vet; go to the Veteran's Administration.' Then, I'd go there and they would say, 'Go to the Indian Health Services,'" he says. The New Mexico Indian Council on Aging (NMICoA) Health Committee, a group advocating for quality health services for Native Americans, has been bringing state and national attention to how incompetent and inadequate health services have contributed to the alarming health problems that are tearing relentlessly through Native American communities. According to a 2009 report by the National Indian Health Board, 13 percent of Native American deaths occur in those younger than 25, a rate three times higher than the rest of the US population, and Native American youths are twice as likely to commit suicide. Compared with other population groups, Native Americans are 550 percent more likely to die from alcoholism, 200 percent more likely to die from diabetes and 150 percent more likely to suffer accidental death. Tribally enrolled Native Americans make up 9.4 percent of the total population of New Mexico.

In February, the New Mexico Human Services Department unveiled a proposal to address the problem of inadequate health care for Native Americans. But critics say HSD's proposal is flawed and that the state's public hearing process failed to incorporate meaningful input from Native American tribal governments.


Delivering health care to Native Americans is a federal treaty obligation, Dr. Ron Lujan, a retired surgeon and an NMICoA spokesman, explains. Health care and education were promised to tribes when they were forced onto reservations at the end of the Indian wars in the late 1800s. To honor the agreements, the US government built Indian hospitals and clinics throughout the country. But over time, the funding for IHS—the federal agency charged with providing health care to Native Americans—drastically decreased, Lujan says, forcing people to wait months, if not years, for surgeries and exams.

"More and more in this day and age, rather than Indian Health Service living up to the level of private sector medicine, we are falling back," Lujan says. "It is becoming more and more a basic primary care delivery system. Indian Health Service hospitals no longer have intensive care units, obstetric services, X-ray services, CT scans or MRI scans. A lot of these cancers that could be detected early are not being detected."
As federal services and funding for health care went steadily downhill, Native Americans were encouraged to sign up for Medicaid, a state-administered federal health program for people living at or below the poverty level ($1,863 a month for a family of four). Approximately one-fourth of the Native American population qualifies for Medicaid, but many Native people don't know it; 33 percent of Native Americans lack any kind of health insurance.


At a Feb. 21 press conference in Albuquerque, Sidonie Squier, the New Mexico Human Services Department Secretary, rolled out her proposal for improving the health options for the state's poorest people: a Medicaid reform plan called Centennial Care. The plan has been in development since the Medicaid modernization process began last summer, with a series of public hearings and work groups led by HSD and Alicia Smith and Associates, a Washington, DC-based health policy group. (The state paid $1.7 million for ASA's services.)

Although Medicaid recipients worried that the proposed plan would alter their eligibility or benefits, it does not, nor will providers receive rate reductions. Other proposed changes aim to increase health literacy and responsibility by providing incentives such as gift cards. In some cases, co-pays will be required in order to discourage emergency room use for nonemergency care. As a way to reach rural communities, Squier has also proposed an extended version of Project ECHO, the University of New Mexico’s telemedicine system.

None of these changes came as a surprise to advocates like Quela Robinson, a staff attorney for the New Mexico Center on Law and Poverty. What did was a proposal requiring Native Americans to join one of the state's managed care organizations—private, for-profit, national companies such as Lovelace and Presbyterian. Once an MCO lands a state contract, it subcontracts out for services to doctors or health clinics located in towns like Grants, Gallup, Farmington and Albuquerque—miles away from tribal homes. Under the current Medicaid program, Native Americans can opt out of joining an MCO and use a private provider. Lujan says many Native Americans choose this option because they receive better services.

"They want services in their own language and from people who are familiar with their tribal communities," Olivia Ortiz, a translator for Acoma Pueblo elders who speak the Keres language, explains. Communication between tribal elders and MCOs is often difficult, she adds; most MCOs use the internet to communicate their services, and many tribal people don't have internet (or even phones) to find a provider or to participate in ongoing health discussions. (Roughly 30 percent of Native Americans do not have phones, and more than 90 percent don't have access to the internet, according to national reports.)

The proposed plan also presents another hurdle: Under Centennial Care, MCOs will be required to contract with tribal programs.

"We believe that our system of coordinated care will make sure that [Native Americans] not just get the services, but the outcomes they need to benefit them," Squier said at the press conference.

But Paul Fragua, chairman of the Jemez Pueblo Health Board, told SFR during a break at the Feb. 23 NMICoA meeting that such a system could be problematic for Jemez Pueblo.

"We already are self-managing. We design and direct our own programs. Under this plan, tribes will have to deal with at least two middlemen," Fragua explained. Holding up a $1 bill, he asked, "How much of this will really trickle down to Indian programs after the state and the MCOs get their cuts? Not much."

Rather than being forced to add a bureaucratic layer, Fragua says, "We would like to see the federal dollars come [directly] to the tribes instead of going through the middle men. We can provide better services to our community."

Squier, however, says the state has no choice.

"There is one reason we are doing this: Native Americans have the largest health disparities in the state compared to any other population in New Mexico," Squier said at the press conference. "The sad truth is that this disparity is getting larger and larger and not smaller and smaller. Whatever they have been doing, it's not working."

But even if the state's hand was forced, many critics say tribal leaders weren't sufficiently involved in the process of creating a new system.

Tamaya Pueblo Tribal Councilman Manuel Cristobal, also a member of the NMICoA, says the proposed mandate that Native Americans join MCOs was decided upon without full tribal discourse and agreement with New Mexico's tribal leadership.

"There was none. It was misleading," he says, referring to the references to tribal consultation in the Centennial Care plan. Only one of 20 pueblo governors and two lieutenant governors attended an Aug. 3 tribal-state consultation, he notes; the meeting was held during a time of pueblo traditional activities.

Shelly Chimoni, former head councilwoman for Zuni Pueblo, says the state even got one pueblo governor's name wrong in the Centennial Care plan.

"They refer to Gov. Lujan of the Laguna Pueblo. There is no Governor Lujan," she says. (The governor of Laguna is Richard Luarkie.)

Cristobal adds that the state has so far failed to address the issues in a way that would work for tribal people. Issues brought up at NMICoA meetings include, but are not limited to, accessible health, medical and dental services, along with long-term care, education, in-home care, outreach, prevention, translation services, veterans' services and direct funding from the federal government. How these services are delivered requires tribal leadership consensus demonstrated in the form of a jointly signed tribal resolution, he says.

Squier has said there is still time for tribes to provide input into the plan. She has scheduled a second tribal-state consultation for March 20 at the All Indian Pueblo Cultural Center in Albuquerque.

But critics say inviting 22 Native American tribal leaders—each of whom has the responsibility to govern a sovereign nation—to a one-day session to decide on health policy is too little, too late. Like the leaders of other sovereign nations such as France or Germany, tribal leaders have a host of pressing issues before them: public safety, water, land, taxation, utilities, housing, environment, social services, health and elder care. Their nations are also unique; no single health plan is likely to work for all of them.

"It's impossible," Cristobal says. "This is medical genocide. They are trying to break up the tribes. In the spirit of Popé, now is the time for the pueblo leadership to unite," he says. (Popé led the Pueblo Revolt against Spanish invaders in 1680.)

The best way to improve Native American health care, Cristobal says, requires a more individualized approach. Rather than imposing a top-down plan, he says, the state should sit down with each tribal leader to find out what will work for each individual community.


While the fight for Native American health care improvement goes on, Montoya's health is failing. We are sitting in the dining area of his home in Isleta Pueblo. The walls are covered with collage-type artwork he's created using a mixture of paintings and cutouts from magazines. He says the artwork helps him to keep going even on days like this. He has just come back from a dialysis treatment, which he receives three times a week for four hours a day at the Fresenius Medical Care Dialysis Center in Albuquerque. It has left him feeling very weak. He points to a place on his arm where needles have been inserted so many times that the vein collapsed. He's now on a list for a kidney transplant.

The state of New Mexico has submitted the proposed Centennial Care plan to the federal government's Centers for Medicare and Medicaid Services. After a negotiation period, the state will request proposals from interested health care providers and award contracts by September 2012, with programs going live by September 2013.

Indian Health Service is in the process of reviewing the state's proposal. Capt. Russel Pederson writes in an email to SFR that IHS is analyzing the Centennial Care information released by the state. "Indian Health Service in partnership with pueblo and tribal leadership will assess the impact of this plan on the Indian health system," Pederson writes.

Santa Fe Reporter