State of Change When federal health care falls short, tribes improvise A growing number of tribes manage their own clinics and behavioral programs.

This story is part of the State of Change project, produced in partnership with the Solutions Journalism Network.

The Indian Health Service — the federal agency tasked with providing health services to Native American communities — has long been the go-to health care provider for tribes in New Mexico and across the country.

But in recent years, that has started to change, and a growing number of tribes are deciding that managing their own clinics and behavioral health programs will help build healthier, more resilient communities.

Allen Barlow, who runs the Kewa Health Corporation in Santo Domingo Pueblo, says for a long time, tribes didn’t have much of an option when it came to health care. “IHS has gotten away with being the only game in town for decades,” Barlow said.

For some tribes, that’s been a problem. IHS is notoriously underfunded.

Another sticking point is that large federal health programs aren’t always able to address nuances of public health in diverse tribal communities. “Tribes want to be able to tailor their programs to meet the needs of their population. IHS is able to do that sometimes and sometimes they’re not,” Barlow said.

But the Affordable Care Act changed the equation.

Ed Williams/KUNM

Since the ACA, Santo Domingo became one of many tribes to use an old sovereignty law that lets them opt out of IHS care and instead get a check for the money the agency would have spent on them. With the expansion of Medicaid, tribes are able to get more federal dollars to cover the costs of running their own health programs. Over the last three years, Santo Domingo’s health program has grown by almost 70 percent.

And that’s translated into better health outcomes for the community. Santo Domingo now does better than the average tribe on childhood obesity, hepatitis, and access to dental care, among other things.

They’ve also grown their economy by creating health care jobs for tribal members.

But making the switch from IHS can be a risky move.

“I think that the tribes really need to look at themselves internally first,” said Anthony Yepa, a former IHS manager who now works as a consultant to tribes transitioning to self-run programs. “Once you get to take over a clinic or the doctors and the nurses, and even the lab and the pharmacy, that becomes a very administratively burdensome as well as clinically burdensome task for a lot of the tribes that do not have the resources to do that.”

So going it alone can mean being stuck with the logistics of managing clinics and pharmacies and losing all of IHS’s expertise and infrastructure.

But for some tribes, there’s a more attractive option: keep IHS in charge of running clinics and hospitals, but make their behavioral health program an independent and tribally run.

Melissa Martinez is a native of Taos Pueblo who works in the tribal behavioral health program there. “The move from IHS has been the best thing for this tribe ever,” she said. “Because it gives it more independence and not so many red tape to go through with IHS. So it’s benefitted the community quite a bit.”

Martinez says one major benefit is the freedom to experiment, and to figure out how their addiction recovery program can be most helpful to the community.

Ed Williams/KUNM

At a local gym where clients of the program come to exercise, Mark Mash, a clinical psychologist who runs Taos Pueblo Behavioral Health Services, said that customizing their recovery program had made it possible for the tribe to incorporate regular exercise into their approach. “In order to really overcome addiction and sustain recovery, people have to really get excited about their health,” Mash said.

Mash has designed Taos Pueblo’s program to emphasize holistic health treatments, Pueblo culture and community resilience. They’ve also teamed up with the tribal judicial system and created a wellness court, a kind of tribal drug court.

It’s an approach most outpatient programs don’t have. And Mash says it has meant patients are more able to be productive members of their community.

“Yeah I feel good, my mind’s clear, I got a lot of energy. My wife says she can’t keep up with me,” said Dwayne Kopepassah is a client at Taos Pueblo’s recovery program. “Coming over here just helps me take away my anger, all those negative thoughts I’m having, if I feel like drinking I just come and burn a sweat and it’s all gone, you know?”

It’s hard to know exactly how much more effective these tribally run behavioral health programs really are. There isn’t much data to back up the benefits you hear about from clients and employees.

And given the risks, breaking away from IHS might not be a wise move for some tribes.

But it is clear that here in Taos Pueblo — like in other tribal behavioral health programs — using Medicaid reimbursements to customize and grow has made it possible to treat a lot more people.

Ed Williams is the public health New Mexico reporter for KUNM. He has reported on environmental, social justice, immigration and Native American issues in the U.S.



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