The shame of a nation
Native Americans paid tribute to their ancestors last week at the opening of the National Museum of the American Indian. A few blocks from the Capitol, the sound of drums, whoops, and chants rolled across the grassy Mall. But if their ancestors were looking on proudly, at the same time they must have been weeping for the countless Indians who have died because the same government that erected a showpiece of a museum has flagrantly ignored its moral and legal responsibility to provide the Native American population with decent healthcare.
The health of American Indian tribes became the government's responsibility long ago, through treaties and other covenants signed in exchange for hundreds of millions of acres of tribal land. After generations of neglect, in 1955 the Indian Health Service took over, creating an independent, single-payer, government-funded system. After half a century, there have been small improvements, but the large picture, as described in "Broken Promises," the U.S. Commission on Civil Rights' July draft report evaluating the Native American healthcare system, remains bleak.
The health status of the more than 2.5 million tribal members is worse than that of any other U.S. minority or majority group. Native Americans have a life expectancy of 71, roughly 5 years less than all others. They face higher maternal and infant mortality rates and are many times more likely to die from tuberculosis, diabetes, and alcoholism. During flu season, they die far more often. Indian teenagers kill themselves at a higher rate. The rate of kidney failure from diabetes is staggering; heart disease is rising. Native American cancer patients have the poorest survival rates of any group.
The Indian Health Service is everyone's worst nightmare of what government healthcare would look like. The system is riddled with crumbling facilities, mindless regulations, ancient equipment, and far too few nurses, doctors, pharmacists, and dentists. Long waits choke clinics and emergency rooms. Patients have to fight to see specialists. Everything is rationed--eyeglasses, dental visits, gallbladder operations, kidney dialysis, CT scans, basic psychiatric services. Almost half of "urban Indians" who have moved off the reservation to cities, usually in search of economic betterment, have no medical care because they are too far from a reservation and have little access to private insurance. Although the government's trust responsibilities extend to this group of about 1 million Native Americans, they have been largely abandoned by the health agency created in their name.
But the Indian Health Service can't spend money it doesn't have, and it doesn't have much. America spends an average of about $5,000 per person per year on healthcare. For government programs that deliver healthcare directly, the per-person expenditure varies enormously: $5,200 by the Veterans Administration, more than $3,300 by the armed forces, $3,800 per federal prisoner, and $1,900 by the Indian Health Service. Money isn't everything, but without it you can't buy healthcare. And without it a dent will never be made in the health disparities of these people to whom our government has given its word.
Endangered. In his remarks on the Mall last week, outgoing Sen. Ben Nighthorse Campbell, the lone Indian member of Congress and one of the few champions of legislation to improve Indians' healthcare, described the native people of this land as America's "first endangered species." Now, more than a hundred years after the U.S. Congress proclaimed peace with Indian country, it is fair to say that the American Indian is America's most health-endangered minority.
The Native American celebrants would have been justified if they had held a mass sit-in under the Capitol dome or in the grand marble-clad lobby of the Department of Health and Human Services, which oversees the Indian Health Service, to protest the shameful years of broken healthcare promises. Perhaps they felt it would strike a disharmonious note. That it would have done. But in a nation that prides itself on honor and fairness, living up to the healthcare obligations we have to the first Americans should not be an option. How have we come to this?
This story appears in the October 4, 2004 print edition of U.S. News & World Report.