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New Indian Health Head Works to Heal Agency

WASHINGTON - Growing up in Rapid City, S.D., Yvette Roubideaux remembers visiting the local Indian Health Service clinic - and waiting. She never saw the same doctor twice and often heard relatives gripe about the poor care they got.

As a young, Harvard-trained doctor, she worked long days at an IHS rural clinic in Arizona with half the staff it needed. It was some 30 miles from the nearest hospital and far removed from medical school, where she used state-of-the-art equipment and learned the latest techniques.

Now 46, Roubideaux is in charge. The Rosebud Sioux Tribe member is the first woman to run IHS, an agency that still lacks much of the money it needs to make sure all its patients get adequate, timely care and all of its hospitals are fully staffed.

"This agency has probably never been funded at a level that can address the growing needs of the population," she said. "We're facing a lot of challenges related to the budget. The demand for services is rapidly increasing. Our buying power has gone down over the years."

Indians as a group suffer like few others, despite long-standing agreements between the U.S. government and tribes guaranteeing free health care.

They experience substantially higher rates of diabetes, alcoholism, tuberculosis and suicide than the rest of the nation. Life expectancy for an Indian is more than four years shorter than for the average American. It's even shorter for those living on rural reservations where care often is delivered by overtaxed medical staff working with outdated equipment in aging buildings.

IHS officials say the $3.6 billion they received this year is a little more than half of what they need to fully fund the agency's mission. Tribal residents only half kid when they say, "Don't get sick after June," when federal money seems to run out until the new fiscal year begins Oct. 1. Stories of substandard care and misdiagnoses that have killed patients ricochet across reservations.

Roubideaux is a self-described optimist who is quick to point out the gains IHS has made over the years in such areas as Indians' life expectancy, which has increased nine years since 1973. She agrees with many critics of the agency, such as tribal leaders and Senate Indian Affairs Chairman Byron Dorgan, D-N.D., who say reforms are needed.

Roubideaux also has met with tribes and asked them to recommend changes, but she declines to say what she would like to do.

"Instead of coming in and saying we're doing X-Y-Z, I'm (asking) the tribes, 'If we're going to improve the Indian Health Service, where should we start? What are your priorities?'" she said. "I have a sense from meeting with tribes of what I think those priorities are, but I would like to ask the question of the people we serve."

Dorgan, whose state includes several Great Plains tribes, agrees IHS needs more money. But he also calls the agency "unbelievably bureaucratic" and scolds it for not getting rid of incompetent workers, losing track of important medical equipment and not responding to patients quickly enough.

"There are children and Indian elders who are dying because of inadequate care," he said. "I told (Roubideaux), 'You've got to pick this up, shake it, turn it upside down and change it.' Indian Health Service has a lot of problems, the most significant of which is a lack of adequate funding. But ranking right up there is the stifling bureaucracy."

The Government Accountability Office has sharply criticized IHS in recent years, pointing to millions of dollars in lost medical equipment. Roubideaux said some equipment was simply misplaced and she has instituted a new accountability system to track agency resources better.

Dorgan calls Roubideaux "a good person (with) a terrific background," but he said it's too early to judge her performance.

Gerald Hill, president of the Association of American Indian Physicians, lauded Roubideaux during her confirmation hearing as someone who "not only understands Western medicine but how to apply this knowledge in native communities."

Created in 1955, IHS is the primary federal health care provider for about 1.9 million American Indians and Alaska Natives who belong to 562 federally recognized tribes in 35 states.

Roubideaux's expertise is in diabetes prevention and management. For several years, she co-directed an IHS initiative that has focused on diabetes and cardiovascular disease prevention and case management in 66 sites around the country. It's the kind of program that could go a long way toward closing disparities between Indians and the rest of America, but Roubideaux says Indians need to do more to help themselves.

"Diabetes is not just a disease of an individual. It's a disease of a family and a community," she said during a recent interview at IHS headquarters, a nondescript office building in a Maryland suburb. "If I tell a patient in the exam room: You need to eat healthier and less fatty foods, they go home. If their family doesn't want to change their eating habits, then they have a much harder time."

Most agree that funding remains the biggest obstacle. Health care expenditures nationally are $6,538 per capita compared to $2,349 for IHS clients. Tribal leaders often note that the government spends more caring for federal inmates.

"It boils down to money, whether we want to believe it or not," said Robert Cournoyer, chairman of South Dakota's Yankton Sioux Tribe, more than half of whose members live at or below the poverty level. "Good health care can't be had unless you have money, and we serve the poorest of the poor."

The agency desperately needs funds for raises and staffing. Hundreds of medical jobs remain vacant, including 21 percent of slots for doctors, 24 percent of dentists' jobs and 26 percent of openings for nurses, according to the agency.

President Barack Obama, who campaigned last year for the Indian vote, has proposed a 13 percent increase in IHS funding for 2010 - the biggest proposed jump in years - to cover pay raises, staffing of new facilities and equipment upgrades. More than $100 million would be spent contracting with private companies who provide medical care the IHS can't. And the economic stimulus package Congress passed earlier this year includes $500 million for Indian health.

Roubideaux is encouraged.

"We have all the elements in place to really address these health disparities," she said. "It's just that we need two things: If we can begin to address the problem of resources, we can do a lot. But the second area is how we're providing that care and making sure we're doing it in the best way possible."

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