Analysis Health Systems

What Does It Take to Run the Indian Health Service? Questions Surround Trump’s Pick

Mary Annette Pember

President Donald Trump's pick to lead the Indian Health Service has left many wondering what qualifications the agency's director should meet.

The already beleaguered Indian Health Service (IHS), a federal agency within the Department of Health and Human Services (HHS) that is charged with providing health services for members of Native American tribes, has never received enough money from the federal government to do its treaty-mandated job. With such an entrenched history of inadequate funding, the agency is predetermined to fall short on many fronts—underscoring the need for its leader to be both informed and public-health focused.

And yet, President Trump’s pick for the agency’s next leader, Robert M. Weaver of the Quapaw Tribe, is alarming for a variety of reasons, leaving many to wonder what qualifications should the director of IHS meet.

Weaver’s background is in insurance; he founded an insurance firm in 2007. He first started selling insurance to his own tribe and has since expanded selling insurance to other tribes. In a 2016 article in the Tribal Business Journal, whose advisory board Weaver sits on, he is described as the “go-to guy” for health insurance in Indian Country.

But Weaver’s overall qualifications have been called into question. The Wall Street Journal published an article earlier this month suggesting that Weaver “misrepresented his work experience” on his resume and in documents provided to a Senate committee. Some former managers at St. John’s Regional Medical Center in Joplin, Missouri, where Weaver claimed to have worked from 1997 to 2006, did not remember him when contacted by reporters from the publication. Others at the hospital reportedly described him as working in an “entry-level” position, though a spokesperson for Sen. Tom Udall (D-NM) told the Journal that Weaver had said in a document to the Senate Indian Affairs Committee that he worked in “supervisory and management positions.”

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According to his resume, Weaver attended Missouri Southern State University and studied “international business w/ emphasis in marketing and accounting; minor in Spanish; minor in vocal music & piano.” As the Journal reported, “A spokeswoman for the university, Cassie Mathes, said Mr. Weaver attended from 1996 through the fall of 2001, pursued a BA in Spanish and was listed as ‘degree seeking’ as of 2001 but never graduated.”

Most IHS directors have been physicians “with multiple degrees in public health, science, and health administration,” explained Mark Trahant, a longtime journalist and expert on Indian health-care policy, in a January post to his website.

Some tribal leaders, especially those in the IHS Great Plains Area where several federal hospitals have long-standing dysfunctional histories, have suggested that IHS would fare better if led by an outsider.

William Bear Shield, council member of the Rosebud Sioux Tribe and chair of the tribe’s health board, stated at a House subcommittee hearing in June regarding HR 2662, the “Restoring Accountability in the Indian Health Service Act of 2017″: “The problems within IHS did not happen overnight.”

Bear Shield went on to suggest there were problems with the agency’s leadership and called for a new director from outside of the public health service with authority to rebuild the IHS.

Indeed, Trahant in his aforementioned article expressed the opinion that maybe IHS “should be led by someone with an insurance background” since it could help in creating “a better funding model” for the agency. He cautioned, however, that Weaver lacks experience with Medicaid and condemns the Affordable Care Act (ACA) overall.

In a white paper from January 2017, Weaver wrote that while the ACA had some provisions that helped Native Americans, it was generally “a failed effort on the part of the government to provide insurance coverage for all uninsured persons in the United States.” So it’s easy to see how he came to the attention of President Trump, who has tried repeatedly to kill the ACA.

The ACA’s expansion of Medicaid has helped Native Americans dependent on IHS to access services. Weaver acknowledges this in his white paper and notes that the ACA made affordable health care a reality for many Native people.

In fixing health care in Indian Country, Trahant warned that a continual narrative focusing only on failures of the IHS, such as the very real problems in the Great Plains Area, doesn’t create incentive to invest more money in the agency. A “narrative of failure,” he argued, ignores the agency’s successful models of innovation.

Indeed, IHS, like many organizations in Indian Country, has a scrappy history of making the most of limited resources. For instance, the Four Directions Clinic on the Pine Ridge Reservation in South Dakota is an IHS facility that offers both reproductive health care and a full range of services for survivors of sexual assault. The clinic’s staff worked with victims’ advocates to design a safe, one-stop clinic where victims can receive exams by Sexual Assault Nurse Examiners (SANE). Those nurses “can also conduct forensic examinations and provide expert testimony in court if assault cases go to trial,” according to Indian Country Today.

So, what do the 2.2. million Native people served by IHS need in the agency’s next leader?

After Weaver’s nomination, the Association of American Indian Physicians released a statement including the minimal qualifications any director of the agency should meet. Those qualifications include a career in the health profession “preferably as an MD or DO” (doctor of osteopathic medicine) and at least five years of clinical experience.

“The critical decisions upon which the health and, indeed, lives of American Indian/Alaska Native people depend cannot be left to political appointees who do not possess a comprehensive, experiential understanding of American Indian/Alaska Native health any more than the nation’s other health-related organizations, such as the [Centers for Disease Control] and the [National Institutes of Health], can be directed by those without knowledge and expertise in health, research, and epidemiology,” the criteria explained.

And, since adequate funding is clearly one of the greatest needs at IHS, as noted in a report from the National Congress of American Indians (NCAI), a successful director should possess the ability to secure funding for the agency from the federal government. A qualified director needs political, cultural, and medical knowledge of Indian Country and its unique relationship with the federal government in order to build a successful case for fully funding the IHS budget. Additionally, the agency’s leader clearly needs a complete understanding of Medicaid laws and how tribes can use this funding to help pay for health services.

If job turnover is an indicator, the duties of an IHS director must be daunting. The last person appointed to the position, Dr. Yvette Roubideaux of the Rosebud Sioux Tribe, who was selected by President Barack Obama in 2009, left her post in 2015 after the U.S. Senate failed to reconfirm her for a second four-year term. She later took another job inside HHS, advising the HHS secretary on Indian affairs, but left that job the same year.

Since 2015, four acting directors have been appointed to lead the IHS, according to online news reports.

Until IHS finds that qualified leader, the agency—and, perhaps, more importantly, the people it serves—will continue to suffer. Indeed, as noted in the NCAI report, “It is unconscionable that America’s first nations are often the last when it comes to health.”

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