WASHINGTON, DC—Advocates for Native Americans who are working on the frontlines of providing health care to Native veterans describe the relationship between the VA and the IHS as problematic and full of service gaps. This is despite a signed agreement between the two agencies to partner on Native veterans’ health.

“Despite dual-eligibility for VA and IHS health care, American Indian and Alaska Native veterans report unmet health care needs at four times the rate of other veterans,” declared Sen Daniel Akaka, D–HI, chairman of the Senate VA Committee, at a hearing last month. According to VA statistics cited by Akaka, Native Americans are 50% more likely than other veterans to have a service-connected disability and twice as likely to be unemployed, increasing the overall need for health care from one or both agencies.

Sen Jon Tester, D–MT, echoed Sen Akaka’s concerns, noting that if achieving seamless transition for veterans between VA and the DoD is difficult, it must be doubly so between VA and IHS, an agency whose underfunding has been a topic of discussion in Congressional hearings for several years. “We’ve all heard the horror story of a veteran walking into an IHS facility only to be told to go to a VA facility hundreds of miles away. And of a veteran walking into a VA facility told to go to an IHS facility,” Sen Tester said.

More Symbolism Than Action

“Most reservations are remotely located, under-funded, and under staffed, resulting in a very real rationed care scenario. While tribal and IHS clinics do the best they can, the level of care is quite often less than needed. This is amplified by a severe shortage of clinical personnel evident in virtually every clinic setting,” testified Kevin Howlett, a member of the Salish and Kootenai Tribes and Director of the Tribes’ health and human services department.

When care is not available at a local clinic, IHS utilizes its contract health services program to refer patients to non-IHS facilities. “The CHS program has operated on a shoestring budget for many years,” Howlett said. “The care that can be approved utilizing CHS funds must be life-threatening if IHS assumes financial responsibility. Consequently, these services are not provided.”

This deficit in care makes VA assistance even more necessary for those Native Americans who qualify for it. VA and IHS signed a memorandum of understanding in 2003 stating that the agencies would work towards five mutual goals:

• Improving access to benefits and services
• Improving communication among VA and tribal governments
• Encouraging partnerships and sharing among VA, IHS, and tribal governments
• Ensuring availability of appropriate support for programs serving Native Americans
• Improving access to health promotion and health prevention for Native veterans

Howlett accused the MOU of being more symbolism than action. While the goals identified in the MOU would certainly benefit Native veterans if they were achieved, he does not believe the agencies are really serious about initiating meaningful change. “I think it takes a real commitment from the agency…not a piece of paper saying how great we are,” he declared. “VA and IHS need an honest and candid discussion of legislative barriers, policy barriers, distance barriers, and weather barriers. All of these things are going to have a reflection on the capacity of how to provide care. If you don’t factor these things in or discuss them, there’s a tendency to pretend they don’t exist, and when you come up against them, you can’t deliver.”

A task force of VA, HIS, and tribal health employees looking first at Native veteran health care nationally, then focusing in on local concerns, would go a long way to identifying what needs to be done, Howlett said. “It would take a lot of time and a lot of energy, [but we need to] really sit down and analyze the issues affecting health care for Native American veterans.”

Barriers to Sharing

Asked whether the goals of the MOU are being measured, and to quantify improvements in IHS/VA cooperation nationwide, VA and IHS officials had difficulty answering. “The MOU is purposefully vague so that we can work in individual areas [and] address unique circumstances of each community, tribe, or nonprofit organization, ” explained James Floyd, VA’s VISN 15 director. The agencies have made strides in the areas outlined in the MOU, and while he could name specific programs, he could not provide information on the big picture.

“I’m not aware of a national database that rolls all of those [figures] up. I know that recently VA [headquarters] has asked for more specific information from these facilities about what [programs] are in place,” Floyd told legislators.

Also, while VA asks enrolled veterans to identify themselves by race, a method by which they can self-identify as Native American, there is no method by which VA can access IHS’s database to see what Native Americans enrolled there could qualify for VAservices.

There is also no nationwide method by which IHS and VA could share health records of those patients being seen by both agencies. Dr Theresa Cullen, IHS director of information technology, described one method underway at a small number of IHS facilities by which IHS physicians could sign into the VA electronic medical record system and view patient files, but that access is very limited.

“If patients are referred [to VA] we have a software application that can track the referral out. The question is can we get the records back in,” Dr Cullen said. “IHS providers that have been credentialed can dial in to the VA VISTA system and get a read-only access to that patient’s chart.” However, this program, which Cullen described as a success, is in place only at five facilities where VA and IHS have local sharing agreements in place. Asked why it was not a model that could be used nationally, IHS officials said that it was a matter of funding, and that money was being requested for it as part of overall IHS health IT funding.

Neither VA nor IHS officials knew of a similar program by which VA physicians could view IHS records online.

Rep Richard Burr, R–NC, wondered if both agencies were ignoring the forest for the trees, lauding isolated successes while the overall barriers to a health care partnership remained firmly in place. “I think we have a tendency to focus on certain successes and certain partnerships,” Burr noted. This is not the overriding theme of VA—to live up to all the standards in [an] agreement. I’m not sure there’s an overriding commitment from VA to ensure there’s excellent access to health care across the country for Native Americans.”

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