Announcement

**Historian** · 02-24-2006, 01:38 PM

Part 2 of 3

Urban Indian health programs provide unique and non-duplicable assistance to urban Indians who face extraordinary barriers to accessing mainstream health care. What Urban Indian health programs offer cannot be effectively replaced by the HRSA’s Health Centers program which, even according the President’s FY 2007 budget could only address the needs of an additional 25,000 Native Americans, at a loss of the nearly 150,000 Native Americans served by Urban Indian health programs.

Urban Indian health programs overcome cultural barriers. Many Native Americans are reluctant to go to health care providers who are unfamiliar with and insensitive to Native cultures. Some Indians may be reluctant or unable to describe their health needs to strangers outside their own culture. Frequently, mainstream providers misunderstand or misinterpret the reticence and stoicism of some Indians. Urban Indian programs not only enjoy the confidence of their clients, but also play a vital role in educating other health care providers in the community to the unique needs and cultural conditions of the urban Indian population.

Urban Indian health programs save costs and improve medical care by getting urban Indians to seek medical attention earlier. Without Urban Indian programs, many urban Indians would not seek or otherwise would dangerously delay seeking proper medical care. Such a delay in seeking treatment can easily result in a disease or condition reaching an advanced stage where treatment is more costly and the probability of survival or correction is lower. Urban Indian programs reduce the number of emergency room visits and otherwise raise the standard of care for a marginal additional cost to the system.

Urban Indian health programs are better positioned to identify health issues particular to the Native community. Urban Indian programs are experienced in those health issues, whether physical or mental, that are prominent in the Native community. They are able to diagnose more quickly and more accurately the needs of the patient, as well as more readily point a patient to the appropriate medical resource to address his or her condition.

Urban Indian health programs are better able to address the fact that movement back and forth from reservations has an impact on health care. Indian movement back and forth between the reservation and the urban environment is common and can significantly affect the ability of health professionals to provide prompt, quality follow-up care. Urban Indian programs understand this issue and account for it in their work with patients.

Urban Indian health programs are a key provider of care to the large population of uninsured urban Indians who might not go elsewhere. Many Urban Indians, particularly those employed at or near minimum wage, have no insurance coverage or have coverage through plans that do not cover preventive or major medical care. For example, in Boston, 87% of the Boston Indian Center's clients have no health insurance, and two out of every three urban Indians in Arizona are uninsured. Coming to an Urban Indian health clinic provides an open door for urban Indians in this situation who otherwise would be very reluctant and even afraid to seek care in a non-Indian health facility.

Urban Indian health programs reduce costs to other parts of the Indian Health Service System by reducing their patient load. Many urban Indians, if they cannot seek medical advice at an Urban Indian health clinic, will return to their reservation to access far costlier services.

The Congress has long recognized that its obligation to provide health care for Indians, includes providing health care off the reservation.

“The responsibility for the provision of health care, arising from treaties and laws that recognize this responsibility as an exchange for the cession of millions of acres of Indian land does not end at the borders of an Indian reservation. Rather, government relocation policies which designated certain urban areas as relocation centers for Indians, have in many instances forced Indian people who did not [want] to leave their reservations to relocate in urban areas, and the responsibility for the provision of health care services follows them there.”

Senate Report 100-508, Indian Health Care Amendments of 1987, Sept. 14, 1988, p. 25 (emphasis added).3 Congress has “a responsibility to assist” urban Indians in achieving “a life of decency and self-sufficiency” and has acknowledged that “it is, in part, because of the failure of former Federal Indian policies and programs on the reservations that thousands of Indians have sought a better way of life in the cities. Unfortunately, the same policies and programs which failed to provide the Indian with an improved lifestyle on the reservation have also failed to provide him with the vital skills necessary to succeed in the cities.” House Report No. 94-1026 on Pub. Law 94-437, p. 116 (April 9, 1976).

Congress enshrined its commitment to urban Indians in the Indian Health Care Improvement Act where it provided: 4

“that it is the policy of this Nation, in fulfillment of its special responsibility and legal obligation to the American Indian people, to meet the national goal of providing the highest possible health status to Indians and urban Indians and to provide all resources necessary to effect that policy”

25 U.S.C. Section 1602(a)(emphasis added). In so doing, Congress has articulated a policy encompassing a broad spectrum of “American Indian people.” Similarly, in the Snyder Act, which for many years was the principal legislation authorizing health care services for American Indians, Congress broadly stated its commitment by providing that funds shall be expended “ for the benefit, care and assistance of the Indians throughout the United States for the following purposes: . . . For relief of distress and conservation of health.” 25 U.S.C. Section 13.

The Supreme Court and lower Federal courts have held that the Federal government’s obligations to Indians extends beyond reservation boundaries. “The overriding duty of our Federal Government to deal fairly with Indians wherever located has been recognized by this Court on many occasions.” Morton v. Ruiz, 415 U.S. 199, 94 S.Ct. 1055, 39 L.Ed.2d 270 (1974) (emphasis added), citing Seminole Nation v. United States, 316 U.S. 286, 296 (1942); and Board of County Comm’rs v. Seber, 318 U.S. 705 (1943). In other areas, such as housing, the Federal courts have found that the trust responsibility operates in urban Indian programs. “Plaintiffs urge that the trust doctrine requires HUD to affirmatively encourage urban Indian housing rather than dismantle it where it exists. The Court generally agrees.” Little Earth of United Tribes, Inc. v. U.S. Department of Justice, 675 F. Supp. 497, 535 (D. Minn. 1987).

The Federal courts have also stated that there is a trust responsibility for individual Indians, including urban Indians. “The trust relationship extends not only to Indian tribes as governmental units, but to tribal members living collectively or individually, on or off the reservation.” Little Earth of United Tribes, Inc. v. U.S. Department of Justice, 675 F. Supp. 497, 535 (D. Minn. 1987). “In light of the broad scope of the trust doctrine, it is not surprising that it can extend to Indians individually, as well as collectively, and off the reservation, as well as on it.” St. Paul Intertribal Housing Board v. Reynolds, 564 F. Supp. 1408, 1413 (D. Minn. 1983).

“As the history of the trust doctrine shows, the doctrine is not static and sharply delineated, but rather is a flexible doctrine which has changed and adapted to meet the changing needs of the Indian community. This is to be expected in the development of any guardian-ward relationship. The increasing urbanization of American Indians has created new problems for Indian tribes and tribal members. One of the most acute is the need for adequate urban housing. Both Congress and Minnesota Legislature have recognized this. The Board’s program, as adopted by the Agency, is an Indian created and supported approach to Indian housing problems. This court must conclude that the [urban Indian housing] program falls within the scope of the trust doctrine . . . .”
Id. At 1414-1415.

This Federal government’s responsibility to urban Indians is rooted in basic principles of Federal Indian law. The United States has entered into hundreds of treaties with tribes from 1787 to 1871. In almost all of these treaties, the Indians gave up land in exchange for promises. These promises included a guarantee that the United States would create a permanent reservation for Indian tribes and would protect the safety and well-being of tribal members. The Supreme Court has held that such promises created a trust relationship between the United States and Indians resembling that of a ward to a guardian. See Cherokee Nation v. Georgia, 30 U.S. 1 (1831). As a result, the Federal government owes a duty of loyalty to Indians. In interpreting treaties and statutes, the U.S. Supreme Court has established "canons of construction" that provide that: (1) ambiguities must be resolved in favor of the Indians; (2) Indian treaties and statutes must be interpreted as the Indians would have understood them; and (3) Indian treaties and statutes must be construed liberally in favor of the Indians. See Felix S. Cohen's Handbook of Federal Indian Law, (1982 ed.) p. 221-225. Congress, in applying its plenary (full and complete) power over Indian affairs, consistent with the trust responsibility and as interpreted pursuant to the canons of construction, has enacted legislation addressing the needs of off-reservation Indians.

continued...

**Historian** · 02-24-2006, 01:44 PM

Part 3

The Federal courts have also found, that the United States can have an obligation to state-recognized tribes under Federal law. See Joint Tribal Council of Passamaquoddy v. Morton, 528 F.2d 370 (1st Cir. 1975). Congress has provided, not only in the IHCIA, but also in NAHASDA, that certain state-recognized tribes or tribal members are eligible for certain Federal programs. 25 U.S.C. Section 4103(12)(A).

The urban Indian is an Indian who has become physically separated from his or her traditional lands and people, generally due to Federal policies. Some of these federal policies were designed to force assimilation and to break-down tribal governments; others may have been intended, at some misguided level, to benefit Indians, but failed miserably. The result of this “course of dealing,” however, is the same - a Federal obligation to urban Indians.5

The Federal Relocation of Indians. The BIA's Relocation program originated in the early 1950s as a response to adverse weather and economic conditions on the Navajo reservation. A limited program was initiated to relieve the crisis by finding jobs for Navajos who wanted to work off the reservation as little or no job opportunities existed on the reservation. Shortly afterward, the BIA converted its Navajo program into a full-fledged Bureau of Indian Affairs program applicable to many Indian tribes. Solving reservation economic problems by relocating Indians off of their tribal lands is roughly the equivalent of the Federal government, during the Depression, sending Americans overseas to find work – something the Federal government would never have done. All told, between 1953-1961, over 160,000 Indians were relocated to cities, where they quickly joined the ranks of the urban poor.6 Today, the children, grandchildren and great-grandchildren of the 160,000 Indians relocated by the BIA are still in the cities.

Failure of Federal Efforts to Economically Develop the Reservations. The second major reason Indians have moved to the city is the near total failure of Federal programs to promote economic development on Indian lands, coupled with the ongoing success of the Federal efforts in the 1800's to undermine the economic way of life of Indian peoples, locking nearly all Indians into hopeless poverty which still plagues most reservations today. The long history of treaty-breaking by the Federal government is an important part of this tale. As a result, out of desperation, a number of Indians have left their homelands to go to the cities in search of work, even without the dubious benefit of the BIA’s relocation program. Generally, these Indians were no better equipped to handle life in the city than the BIA relocatees and quickly joined the ranks of the urban poor. Congress has noted the correlation between the failure of Federal economic policies and the swelling of the ranks of urban Indians: “It is, in part, because of the failure of former Federal Indian policies and programs on the reservations that thousands of Indians have sought a better way of life in the cities. His [urban Indians] difficulty in attaining a sound physical and mental health in the urban environment is a grim reminder of this failure.”7

Termination of Tribes. In 1953, Congress adopted a policy of terminating the Federal relationship with Indian tribes. Essentially, this was an abrogation of the Federal government’s numerous commitments, in treaties, laws, executive orders, and through the “course of dealing” with Tribes, to protect their interests. Many tribes were coerced to accept termination in order to receive money from settlements for claims against the United States for misappropriation of tribal land, water or mineral rights in violation of treaties. The results of termination were devastating: having lost Federal support, and without tribal sovereign authority over an established land basis, and with tribal members no longer eligible for Federal programs and IHS services, the Tribes collapsed. Some members remained in the area of their old reservations; many went to the cities, where they, too, joined the ranks of the urban poor.

Indian Patriotism -- World War I and World War II. Many Indians served the United States in time of war8 and, subsequently, were stationed in or near urban centers. At the end of their service to the United States, seeing the poor economic conditions on their reservations (resulting from the Federal war on Indians), many chose not to go back. The fact that they chose to stay in an urban area did not make them any less Indian, nor did it reduce the Federal government's obligation to them.

The General Allotment Act. The General Allotment Act (“Dawes Act”) had two principal goals: (1) by allocating communal tribal land to individual Indians it would breakdown the authority of the tribal governments while encouraging the assimilation of Indians as farmers into mainstream American culture; and (2) it provided for unalloted land (two-thirds of the Indian land base) to be transferred to non-Indians. CITE. The General Allotment Act succeeded at transferring the majority of Indian land to non-Indians and further disrupting tribal culture. For the purposes of this testimony, we only need to note that some Indians who received allotments became U.S. Citizens and, after losing their lands, moved into nearby cities and towns.

Non-Indian Adoption of Indian Children. The common practice for many years of placing Indian children up for adoption into non-Indian families has created another group of Indians in urban areas who, because of the racial bias of the courts, have lost their core cultural connection with their tribal people and homelands. Many of the adopted Indians have successfully sought to restore those connections, but because of their upbringing are likely to remain in urban areas.

Federal Indian Boarding Schools. The Federal program of taking Indian children and educating them away from their reservations in boarding schools where they were prohibited from speaking their native language and otherwise subject to harsh treatment, created a group of Indians who struggled to fit back into the reservation environment. Eventually, some moved to the cities. The boarding school philosophy of “Kill the Indian, Save the Man” epitomizes the thinking behind this approach and the racist Federal effort to assimilate American Indians which, as a result, led to a number of Indians moving to urban areas.

The Fracturing of the Indian Nations. The result of these, and other Federal Indian policies, has been the fracturing of Indian tribes and the creation, in the urban setting, of highly diverse Indian communities with members who fall into one or more of the following categories: Federal relocatees; economic hardship refugees; members of Federally recognized tribes, terminated tribes, and state recognized tribes.

continued...

**Historian** · 02-24-2006, 01:47 PM

Part 4 (END)

Rather than the President’s proposal, NCUIH urges this Committee to support a $12 million increase for Urban Indian programs in the FY 2007 budget. Even as the percentage of Indians living in urban areas has climbed, the percentage of IHS funding to urban Indian health programs has declined from 1.48% in 1979 to 1.06% in 2005. With its current funding level of approximately $31 million, the urban Indian health programs, amazingly, are able to serve 150,000 urban Indians. However, additional funding is needed as there are more than one million urban Indians. Moreover, there is a need to enhance existing programs, expand the urban Indian health program epidemiology center in Seattle, Washington, conduct a planning study on the 18 new urban Indian health programs and establish an automated mutually compatible information system to capture health status and patient care data for urban Indian health programs. This increase will elevate the Urban Indian Health Program funding from $31,816,000 to $44,016,000 and represents a great step towards addressing the funding gap for urban programs. While this cannot address the total need, it will make a huge difference in access to and quality of care for American Indians/Alaska Natives living in urban areas.

Conclusion. Notwithstanding the difficulties, urban Indian health organizations, working with limited funds, have made a great difference in addressing the unique circumstances and health care needs of the urban Indian population. NCUIH thanks the Committee for its support in the past and urges the Committee to oppose the President’s proposal to zero out funding for this critical program.

1. See The Health Status of Urban American Indians and Alaska Natives, Urban Indian Health Institute, March 16, 2004, www.uihi.org.

2. Ibid.

3. “The American Indian has demonstrated all too clearly, despite his recent movement to urban centers, that he is not content to be absorbed in the mainstream of society and become another urban poverty statistic. He has demonstrated the strength and fiber of strong cultural and social ties by maintaining an Indian identity in many of the Nation’s largest metropolitan centers. Yet, at the same time, he aspires to the same goal of all citizens—a life of decency and self-sufficiency. The Committee believes that the Congress has an opportunity and a responsibility to assist him in achieving this goal. It is, in part, because of the failure of former Federal Indian policies and programs on the reservations that thousands of Indians have sought a better way of life in the cities. His difficulty in attaining a sound physical and mental health in the urban environment is a grim reminder of this failure.”

“The Committee is committed to rectifying these errors in Federal policy relating to health care through the provisions of title V of H.R. 2525. Building on the experience of previous Congressionally-approved urban Indian health prospects and the new provisions of title V, urban Indians should be able to begin exercising maximum self-determination and local control in establishing their own health programs.”

Pub. L. 94-437, House Report No. 94-1026, June 8, 1976, reprinted in 1976 U.S. Cong. & Admin. News (USCAN) 2652 at p. 2754.

4. As originally conceived, the purpose of the Indian Health Care Improvement Act was to extend IHS services to Indians who live in urban centers. Very quickly, the proposal evolved into a general effort to upgrade the IHS. See, A Political History of the Indian Health Service, Bergman, Grossman, Erdrich, Todd and Forquera, The Milbank Quarterly, Vol. 77, No. 4, 1999.

5. The unique legal relationship of the United States with Indian tribes and people is defined not only in the Constitution of the United States, treaties, statutes, Executive orders, and court decisions, but also in the “course of dealing” of the United States with Indians. As the Supreme Court noted in a major Indian law case, “[f]rom their very weakness and helplessness, so largely due to the course of dealing of the federal government with them, and the treaties in which it has been promised, there arises the duty of protection and with it the power.” United States v. Kagama (1886) (emphasis added).

6. “Unfortunately, far too many Indians who move to the cities, because of inadequate academic and vocational skills, merely trade reservation poverty for urban poverty.” H.Rep. No. 9-1026, 94th Cong., 2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News (USCAN) 2652, p. 2747.

7. Pub. L. 94-437, House Report No. 94-1026, June 8, 1976, 94th Cong., 2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News (USCAN) 2652,at p. 2754.

8. It is in part because of their gallant service in World War I that the U.S. Congress granted U.S. citizenship as a group to American Indians in 1924.

end

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