HMOs are in disrepute in many areas of the U.S., but among California's Indian tribes there is growing interest in shifting from government-run health care programs to a self-managed HMO. PNS associate editor Koren Capozza writes on Native American trends for New California Media, PNS' ethnic news media collaborative and web site (NCMonline.com).

SACRAMENTO, CA -- In a move that could effectively transform Native Americans' health care, the California Rural Indian Health Board (CRIHB) is preparing to launch the nation's first Indian-controlled Health Maintenance Organization (HMO).

Historically, Native Americans have been covered by federal insurance programs and treated at Indian Health Service facilities. Often woefully under-funded and geographically isolated, IHS clinics have been routinely criticized by patients as grossly inept, and access to specialists and more costly treatments is limited.

"This is a way for us to gain financial control of a broader piece of the continuum of care for our clients. And it's a way to recycle funds back into the Indian community that are otherwise lost to Wall Street," said Jim Crouch, executive director of CRIHB, and the driving force behind the proposed HMO.

On Jan. 15, CRIHB tribal board members voted to move ahead with the HMO development process. In the upcoming months, CRIHB will apply for insurance licensure, hire consultants and bring staff on board to forge the landmark HMO. The plan could cover over 85,000 California Indians and employees of tribal-owned businesses.

Those who back the HMO claim there is a huge incentive for California Indians to join. Coverage could be tailored so that diseases that affect Native Americans disproportionately, like diabetes and hypertension, would be managed more closely. The proposed plan would cut costs by lowering administrative spending and concentrating service options in areas that are important to American Indians.

The Indian-managed HMO is part of a larger movement to sever ties to government-controlled programs. In California's Central Valley, the Santa Rosa Rancheria, Viejas, Toiyabe, and Table Mountain, are using gaming profits to develop and operate top-notch, reservation-based health facilities. In the process, they are inaugurating a new era in Indian-managed medical care.

The Santa Rosa Rancheria opened a new clinic last November 8 in Lemoore using casino dollars. "We graduated from a two room clinic, to a portable to a trailer, and now finally to our own clinic," said Dan Glen, physician assistant and long time care provider to the tribe. "It wouldn't have happened without gaming money."

And in Trinidad, United Indian Health Services secured private funding for a ground-breaking "Potawot Health Village" that combines traditional and modern medical approaches. "Tribes are taking care back into their own hands in California because the government is just not providing it," says Jerry Simone, director of the new facility.

Recent studies show that California, Arizona and Oklahoma receive fewer IHS dollars than those in other states. "California tribal health programs receive funding from Congress for only about 15 percent of what is estimated nationally to be the average cost of health care for every man, woman and child living in the United States," says Simone. The IHS is allocated approximately $700 per eligible California Indian per year whereas the actual cost of providing health care for each American last year was between $3500 to $4000, according to Simone.

And lack of funds translates to skimpy care. "Because of limitations in funding we can provide only outpatient care," says Paul Banes, fiscal officer for the Central Valley Indian Health Clinic, an IHS facility. "We cannot afford to do inpatient care."

"If there is a feeling [among California Indians] that IHS has failed to adequately provide health care it's related to the funding issue more than anything," says Paul Redeagle, deputy area director for the California Indian Health Service.

But care providers like Glen say access to care has improved significantly under private insurance. Patients can see specialists and are not limited by government-set capitations.

So far, the response to the CRIHB HMO proposal has been lukewarm among California's 40 tribes. Some wonder why they should get into the business of insurance when HMO's across the country are losing money.

Others don't see an advantage to switching coverage when they have high quality private insurance already in place.

"The tribal government would use what's best for the tribe. They wouldn't vote for something simply because it's Indian-run," says Glen.

On April 15, all 40 tribes will be invited to cast their vote to determine if they will join the CRIHB HMO. But whatever they decide, the push to assume control of health care will likely accelerate. This year, California Rep. George Miller (D-CA-7th) coaxed a bill through the House that could allow Indian tribes to take over management of IHS programs. A pilot program in Oklahoma was highly successful and the law looks likely to pass the Senate. And if it does, tribes across the country will see an unprecedented degree of control in the management of their own health care.