Health-care nonprofits urge oversight by Council, not DOH
By Anne Griffis
Special to the Times
WINDOW ROCK, July 14, 2011
The chief executive officers and board presidents of three Navajo nonprofit health-care corporations met July 8 with the Health, Education and Human Services Committee and urged the committee not to shift its oversight responsibility for them to the tribe's Division of Health.
Committee member Joshua Lavar Butler (Tó Nanees Diz') confirmed, "There is a move to change oversight to NDH. In states, public health is usually handled by the state Division of Health."
Sounding a conciliatory note, Butler said, "It is usual for the Division of Health to oversee direct care. We want NDH involved."
Council committees are part of the legislative branch while the health division is part of the executive branch, its director appointed by the president.
The nonprofit health-care corporations, sometimes called "638s" after the federal enabling law, were created to take charge of health care services formerly provided by IHS. Their leaders believe oversight by a tribal bureaucracy would be a giant step backwards from self-determination and self-governance envisioned under Public Law 93-638, the Indian Self-Determination and Educational Assistance Act.
"To have oversight by them would minimize the benefits of 638," said Donna Singer, CEO of Utah Navajo Health Systems. "We were established by the legislative branch, and we should continue to have oversight by the legislative branch."
Introducing themselves as the 638 Association, representatives of Tuba City Regional Health Care Corp., Utah Navajo Health Systems, and Winslow Indian Health Care Center, were joined by Leland Leonard, CEO of Tséhootsoo' Medical Center, which is in the process of qualifying for self-governance under the act.
Their message: Keep health care governance local.
Leonard called Tséhootsoo" Medical Center "the newest kid on the block," but the Council delegates solicited his opinions on the law's self-governance provisions and whether 638s are the best way to ensure that the federal government meets its treaty obligations to provide free health-care for all Navajo citizens.
"We believe we're on the right course," Leonard stated. "We call the shots, not someone in D.C."
Esther Tsinigine, who serves on the TCRHCC board, said of the Division of Health, "They should stay out of direct care," and advised the delegates, "Leave direct care to the medical and administrative staffs of the hospitals. Only provide oversight."
Tsinigine works in an emergency care facility in Page, about 70 miles north of Tuba City, and knows how critical it is for patients to have access. She believes the health-care needs of Navajos living in remote places such as Coppermine, the chapter she represents, are best served by 638s.
"Start from the grassroots and you'll know the right direction to take. I serve on the board of TCRHCC because my people are involved," she said. "When your people are involved, you want the best care. You want it there and then."
The 638 Association said the will of the Navajo people is expressed in the tribal law. Last July, legislation passed unopposed by 67 members of the previous Council said qualifying contractors could enter into Title V Self-Governance status under the Indian Self-Determination Act.
The Navajo legislation (CJY-33-10), sets forth conditions intended to promote cooperation under the principles of k'é, between the Navajo Nation and 638s, defined as Health Care Self-Governance Tribal Organizations, to ensure that the health care needs of all Navajo citizens are fully met.
Among those conditions is that the Council's Health and Social Services Committee - as it was then called - would have oversight authority for the 638s. Under the new Council, the committee has been reconstituted at the Health, Education and Human Services Committee.
Committee member Dwight Witherspoon (Forest Lake/Hardrock/K'ts'''l'/Pi–on/Whippoorwill) said the 638s' mission can conflict with traditional treaty obligations, adding, "This is our first meeting with the 638 Association, and an opportunity for the redefinition of roles."
"The 638 nonprofit corporation is trying to carry out its mission to provide health care, but running it as a business," Witherspoon said. "We question why members of the tribe are required by some 638s to provide health insurance information. We have compacts with certain entities not to require members of the tribe to provide insurance information."
Witherspoon was also concerned that Title V of the law empowers the 638s to enter into direct negotiations with the government for federal contracts and dollars, yet they are neither federal agencies nor representatives of the tribe.
Butler said, "I feel we are being pushed toward 638. It's like the federal government is trying to sever responsibility for its treaty obligations."
Linda Nass, an attorney speaking on behalf of the 638 Association, assured Butler and other committee members that tribes cannot be forced to set up 638 corporations to take over for IHS.
Following the work session, Butler said, "The 638 is the result of the failure of IHS, over the years, to provide quality health care. My people have not been given proper diagnoses and care, and the facilities have deteriorated. There is apprehension about 638s, but I support them. I've seen the expansion of services and the construction of new facilities."
He also affirmed that oversight should remain with the Council committee.
Joe Engelken, CEO of the Tuba City corporation, countered misgivings about 638s by stressing their accomplishments. He agreed that the Navajo nonprofit health care organizations are run like businesses, but emphasized that this is benefits tribal members.
"The 638s are efficient organizationally, with more cents per dollar brought into health care. Overhead is only 30 percent of our cost, compared with 60 percent for IHS," he said.
Engelken cited the newly constructed 34,000-square-foot Outpatient Health Care Center in Tuba City, which houses well-staffed, well-equipped specialty clinics for family and internal medicine, pediatrics, women's health, diabetes education and nutrition, and a state-of-the-art pharmacy, as an example of what you can do as a 638 nonprofit.
"It is the first increase in space that Tuba City has been able to achieve in 30 years," Engelken said.
"We can offer well-paid health care professional jobs, and increase the ability to deliver all care, including specialty care, right here at home," he said. "It is a foundational goal to measure our success by how many Navajo patients don't have to go to Phoenix for cardiology or Albuquerque for cancer."
TCRHCC inpatient and outpatient visits increased by over 255 percent from 2002, the year of its incorporation, through 2010. An unaudited report of fiscal 2010 operating revenue shows that over $54 million comes from IHS, nearly $60 million from all third party sources, including Medicare, Medicaid, and private insurance; and nearly $3 million from grants and other sources.
"We are proof that Navajos can run hospitals," Leonard said.
