The Sioux San Hospital is an Indian Health Service facility in Rapid City, South Dakota. Photo: Colorado National Guard Medical Detachment

Tribes prepare for takeover of troubled Indian Health Service hospital

Citing chronic underfunding and inaction at the federal level, tribes in the Great Plains are planning to take over a troubled Indian Health Service facility in South Dakota.

The Sioux San Hospital in Rapid City was placed in "immediate jeopardy" in May 2016 after an audit uncovered problems that placed patients in danger. Four months later, the IHS shut down the emergency room without consulting the tribes most affected by the decision.

Though Sioux San is no longer in jeopardy, conditions have not improved significantly. The IHS is planning to permanently close the emergency room and halt all inpatient services by this July, again over tribal objections.

The crisis has prompted the Cheyenne River Sioux Tribe, the Oglala Sioux Tribe and the Rosebud Sioux Tribe to undertake what is being called “a historic, self-governance effort at a magnitude never before initiated in the Great Plains.” They believe they can improve patient care and services by cutting the IHS out of the picture and taking matter in their own hands.

“The tribes declaratively stated that they are choosing to exercise their rights for the tribal assumption of the IHS,” the Great Plains Tribal Chairmen’s Health Board said last week in announcing the move.

Instead of the IHS, the tribes want the health board, a non-profit based in Rapid City, to manage Sioux San, “citing a desire to assure continuity of care as well as confidence in GPTCHB’s proven experience and expertise in program administration.”

An administrative building at the Sioux San Hospital, an Indian Health Service facility in Rapid City, South Dakota. Photo: Colorado National Guard Medical Detachment

In asserting self-determination, the tribes also aim to take over the pending demolition of Sioux San and the construction of a replacement facility on the grounds. While the project has been more than a decade in the making, the IHS had tied the shutdown of emergency and inpatient services to the ongoing effort.

According to IHS, the tribes have known long in advance about the changes in service while demolition and construction takes place. Sioux San has only been funded to provide “ambulatory care” in the last three budgets, the agency said in a report to Congress.

“Because the facility will not be providing inpatient services, the replacement facility is ineligible to participate in Medicare as a hospital,” the report stated.

The IHS also says tribes were told a decade ago that the Sioux San will no longer be known as a “hospital.” The replacement facility's proposed name -- the Rapid City Health Center -- speaks of a dramatic change in what will be offered there.

“The use of inpatient services at Sioux San Hospital is very low and has been very low for a number of years,” the report to Congress said.

But all of that is on the table as the tribes authorize the health board to move forward with the takeover under the Indian Self-Determination and Education Assistance Act, the federal law that ushered in a new era of Indian policy.

“The next steps will be for the GPTCHB to provide notice to the IHS requesting pre-award and start-up funding for the planning and implementation of this historical transition from federal to the tribal management of the service unit,” the non-profit said.

Michael D. Weahkee, the "acting" director of the Indian Health Service, testifies before the Senate Committee on Indian Affairs in Washington, D.C., on September 13, 2017. Photo: SCIA

Hundreds of tribes across Indian Country have utilized the self-determination law to manage health facilities in their communities. The effort has been slow to catch in on the Great Plains but tribes are taking action in response to what lawmakers have called “substandard” conditions in a region that includes South Dakota, Nebraska and North Dakota.

In 2016, the Spirit Lake Nation became the first in the Great Plains to enter into a self-governance compact with the IHS. The tribe is managing the Spirit Lake Health Center in North Dakota.

The Winnebago Tribe is hoping to do the same with the hospital on its reservation in northeast Nebraska. The facility there bears the distinction of being the only one in IHS history to see its certification revoked, a status that remains unresolved almost three years later

“This is the worst kind of chicken and egg problem,” Rep. Jack Bergman (R-Minnesota) said at a March 20 hearing on Capitol Hill that focused on the IHS, arguing that the agency faces an uphill battle in correcting problems at Winnebago and others in the Great Plains due to bureaucratic holdups on the federal level.

Besides Sioux San and Winnebago, two other hospitals in the Great Plains have suffered from major problems. The IHS shut down the emergency room that serves the Rosebud Sioux Tribe for seven months, during which seven people died while being transported to facilities farther away from the reservation.

Indianz.Com on SoundCloud: FY 2019 Budget Hearing - Indian Health Service

The hospital that serves the Oglala Sioux Tribe was also in jeopardy. At another Capitol Hill hearing, the temporary leader of the IHS reported what he said was “progress” at the Pine Ridge Hospital.

The facility is “back in compliance” with federal standards and is awaiting a “full survey” to determine whether it has maintained those standards, Michael Weahkee said on April 17. He did not offer a prognosis on Winnebago, however.

Weahkee, who is a career bureaucrat at the IHS, is serving as its “acting” director because the Trump administration has so far failed to secure a permanent leader for the agency, more than a year after the new president took office.

The IHS has seen “four acting directors since 2015,” noted Rep. Betty McCollum (D-Minnesota), who serves as the top Democrat on the House subcommittee that writes the agency's funding bill. She is also the co-chair of the Congressional Native American Caucus, a bipartisan group of lawmakers with a strong interest in Indian issues.

“I think it's safe to say that an overall cut to the Indian Health Service budget continues to be a non-starter for this Congress,” said Rep. Ken Calvert (R-California), who chairs the subcommittee.

The #Omnibus spending bill that was signed into law last month provides more than $5.5 billion to the IHS, reversing cuts which President Trump had sought a year ago.

Indianz.Com on SoundCloud: Senate Committee on Indian Affairs Business Meeting April 11 2018

But funding alone won't address all of the issues and that's why some tribes, mainly those in the Great Plains, are supporting bills in Congress to reform the IHS. Earlier this month, the Senate Committee on Indian Affairs approved S.1250, the Restoring Accountability in the Indian Health Service Act.

The bill includes provisions that address tribal consultation, recruitment and retention of qualified staff and removal and discipline authorities for troublesome employees. Some leaders in the Great Plains have called the region a “dumping ground” for bad actors.

“The IHS has consistently failed to provide quality health care throughout Native American communities,” Sen. John Hoeven (R-North Dakota), the chairman of the committee, said on April 11l. “System-wide reforms are necessary to address these longstanding issues and restore meaningful oversight at the agency. This legislation will improve the delivery of care at IHS facilities and help ensure the federal government is upholding its trust responsibility to provide quality health care for Native Americans.”

Yet the rest of Indian Country hasn't been pushing as strongly for the reform bills as those in the Great Plains. And the top Democrat on the committee voiced concerns that S.1250 might actually make it more difficult to remove or discipline troubled employees.

“The health care crisis facing many IHS facilities in the Great Plains and in Indian Country is a concern this committee takes very seriously,” said Sen. Tom Udall (D-New Mexico), the panel's vice chairman, at a business meeting.

Some of Udall's concerns about the original version of S.1250 were addressed with amendments that were adopted into the bill at the meeting. But he said “new” provisions in a substitute version were troublesome because he believes they could lead to abuses of power at the IHS. The substitute, along with the amendments, were approved by the committee.

Separately, a facility in Udall's home state of New Mexico is facing quality of care issues. The emergency department at the Gallup Indian Medical Center, which primarily serves citizens of the Navajo Nation and the Pueblo of Zuni, has been determined to be “out of compliance,” Weahkee said last week.

“We moved quickly to address those findings,” Weahkee, who incidentally hails from Zuni, said at the April 17 hearing. He said the center will be undergoing a “full” survey to determine whether it complies with federal requirements. Failure to comply could lead to a termination of certification, which happened at Winnebago.

Over in the House, the companion to S.1250 is H.R.2662. The bill got a hearing last June but has not advanced further in the chamber.

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