Bureau of Indian Affairs Paiute Tribe elders navigate a faltering health care system As federal funding dwindles, remote Nevada tribes struggle for access.

Dennis and Betty Smartt live in a neatly painted white-and-blue home on the Fort McDermitt Paiute and Shoshone Reservation, on the Nevada-Oregon border. They’ve spent their entire lives here, in this small tribal community of 600 people.

The Smartts, members of the Paiute Tribe, exemplify the challenges Native elders face as they get older in remote communities with poor health-care access. Recently, I visited their home. Dennis’ handcrafted eagle feather headdress adorned a stand in the living room. He’d just returned from a trip to Fort Bidwell, California, where he spoke at a traditional gathering of elders for prayer and cultural talks. That trip illustrated some of the challenges the Smartts and other elderly community members face every day. Their only working vehicle blew its engine the week before they were scheduled to leave. “I had to sell it for salvage,” said Dennis Smartt, 71. “We had to call my cousin and give her gas money to get us back home from Winnemucca,” Nevada, a 70-mile drive from their home. Dennis and 74-year-old Betty then paid the cousin to drive them to Fort Bidwell, more than four hours away.

A trim lady with short gray hair, Betty would like to retire, but can’t afford to. Transportation is a real problem: The Smartts need a car to get Betty to and from her job at the general store in McDermitt, an unincorporated town on the Nevada-California border, as well as to Winnemucca for groceries. Sometimes, Dennis needs more specialized care than the small tribal primary care clinic can provide. Increasingly, the Smartts rely on the help of their family and community. Their vehicle breakdown that crisp fall morning meant that Betty had to call Rose Curtis, her niece, to drive her to work. Dennis and Betty, who have been married for 48 years, are just two of the more than 90 elders in the Paiute Tribe who struggle to make ends meet, obtain medical, nutrition and social services, and live dignified lives in one of Indian Country’s most remote communities.

About 3 percent, or more than 1,400 of Nevada’s 47,000 Native people, are 65 and over, according to the U.S. Census. Most of the state’s reservations are isolated, hours away from major hospitals and long-term care facilities, and many tribes also have limited economic opportunities, due to their low populations and remote locations. Even as Fort McDermitt struggles to deliver more support services, federal funding for senior services and other necessities is likely to shrink. “We see grants being cut; (Washington is) shifting resources right out from under our feet,” said Randella Bluehouse, executive director of the National Indian Council on Aging. “We’re having to cut our elder programs.”

Tracy Barbutes

In 2004, Dennis Smartt suffered a heart attack and, four years later, underwent a quadruple bypass. It took two ambulances and a helicopter to deliver him to Reno, Nevada, more than three hours away, for treatment. The former wildland firefighter now wears a defibrillator. “One time (after it was installed), my chest started buzzing,” Dennis said. “We couldn’t figure out why until I went to the clinic, and they said my battery was dead.” Replacing the battery required a trip to Winnemucca, more than an hour away.

Dennis served as Fort McDermitt’s chairman in the early 2000s. In 2000, he approached the Indian Health Service and brought a clinic to his remote community. “But they never did put in a pharmacy,” he said. Filling or refilling prescriptions through IHS isn’t easy; patients must call the clinic at least two weeks before their pills run out. “Approximately 90 percent of Fort McDermitt patients receive their medication via the mail,” according to Leonda Levchuk, Indian Health Service spokesperson.

Given the difficulties involved in getting local care, Dennis says, “Sometimes it’s just faster to drive to Fallon or Elko to get my prescriptions filled.” Both clinics are at least three hours away, though. And so Dennis sometimes goes without his meds. His heart condition forced him to give up firefighting, and he now relies on Social Security. “I’d like to pay off some things, but the government raised my Medicare Part B premium,” Dennis said. “It’s like we just can’t get ahead.”

Tracy Barbutes

The wind-swept high desert of the 18-square-mile reservation, with its rugged hills and bone-dry grass, contrasts sharply with the lush fields of alfalfa just across the road. Houses built by the U.S. Department of Housing and Urban Development line the streets, in various stages of repair.

The tribe’s remote location on ancestral lands doesn’t lend itself to the kind of economic development that could support more services for elders and other tribal members. The latest endeavor is a truck plaza, which doesn’t see much business despite the steady stream of hunters driving one-ton pickups and large camp trailers up the highway. The median household income on the reservation is a meager $15,192, according to the U.S. Census, and 46 percent of the residents live in poverty.

The Smartts, who live only about four miles from town, are relatively lucky. “Some elders live far away from services,” said Ryan Lia of the Inter-Tribal Council of Nevada. Lia, who manages grants that help aging residents for nine northern Nevada tribes, serves nearly 400 elders scattered throughout northern Nevada. “We have one person who travels from Fallon to Yomba, a two-and-a-half-hour drive, to care for an elder,” Lia said. “Younger people would be better able to work as caregivers, but they oftentimes live far away from the elders.”

The Inter-Tribal Council funds respite services for homebound caretakers, provides information about free medical equipment, and searches for resources to provide meals and other services. Lia, a Pyramid Lake Paiute, manages the grant that pays for Fort McDermitt’s senior center meals and a cook to prepare them. Meals are available for free to seniors and with a $4 charge to others. The building, a red-brick structure enclosed by a low fence, houses senior and housing services. “We also provide funding for home delivery meal services,” Lia said. “Fort McDermitt is interested in starting its delivery program again, but its van needs maintenance.”

Finding assisted living or long-term care is even more challenging. The Indian Health Care Improvement Act authorized funding for long-term services and support, including home and community-based services, hospice, adult day health and nursing home care. But that money has not been appropriated, Levchuk said. “The IHS does not operate any long-term care facilities in Nevada.” The Smartts are still in reasonably good health; despite Dennis’ heart condition, he stays trim and walks for exercise. But they worry about the day when they will need assisted living, as neither wants to leave the land their people have inhabited for generations.

Tracy Barbutes

In 2016, the tribe assumed management of its clinic under a self-governance compact with IHS. Now, it’s searching for a full-time physician willing to live and work “in the middle of nowhere,” developing programs that meet the community’s needs, said Tildon Smart, the Fort McDermitt tribal chairman. The self-governance compact allows Fort McDermitt’s clinic to keep more money, Smart said, since the Phoenix and Schurz area offices no longer take a portion of its funding for administrative purposes. But, despite the compact, Smart said that Nevada tribes, including his, badly need more funding. Smart is even considering cannabis cultivation as an economic remedy.

Smart is also planning more elder services. “We just got a grant to put tires on the van,” he said, putting the vehicle, which was donated by the Humboldt County Senior Center, back on the road. He wants to organize biweekly trips to Winnemucca for elders to stock up on supplies and avoid the high prices in McDermitt. “It’s a real hardship for elders on fixed incomes,” Smart said.

Dennis and Betty Smartt know they’ll need more services as they age. But one problem has been solved: “Our grandson, Raymond Crutcher, just bought Betty a 2016 Jeep,” said Dennis. “He grew up with us, and now that he’s working, he said he wanted to pay us back for putting him on the right path.”

“Our elders are our future,” said Curtis, Fort McDermitt’s housing coordinator, who is Betty Smartt’s niece. “They are the ones who teach us their wisdom. The foundation they lay for us is how we’ll live.”

This article was written and produced with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Commonwealth Fund.

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