Sometimes, the lack of money means postponed gallbladder or cataract surgery. Other times, it means a doctor worried about a patient's weak heart cannot send the patient to a specialist.
"They do know how to ration care," said Yvette Joseph-Fox of the Indian Health Board, a private group that represents the nation's tribes.
American Indians and Alaskan native people are entitled to free health care under treaties signed with the federal government in exchange for land. But that care is far below what is provided to poor people in the federal Medicaid program - not to mention what private insurance offers.
The administration's plan comes after criticism from the Republican-controlled Congress and Indian groups - and after increased lobbying from Indian groups who have become more savvy at working the system.
Pushed by stepped-up lobbying by Indian groups and major backing from Health and Human Services Secretary Donna Shalala, President Clinton plans to ask Congress for about $175 million more - an 8 percent jump over this year's $2.2 billion budget, according to administration officials who spoke on condition of anonymity.
The president also wants to increase the rates paid by Medicare and Medicaid to reimburse Indian hospitals - spending that falls outside the regular budget.
It is a striking request for an administration that asked for a meager 0.9 percent increase for 1999.
"They should have been embarrassed by what they did last year," said Rep. Ralph Regula, R-Ohio, chairman of the House subcommittee that appropriates the money. His committee upped the administration's request for a $19 million increase to $141 million.
The Indian system saw healthy budget increases in the early 1990s, but its budget for the last several years has been stagnant.
The ramifications are plain:
- In 1997, the health service spent an average of $1,382 a person, less than half the $3,261 spent per person nationally.
- In 1982, there were nearly 100 doctors for every 100,000 Indian people; by 1994, fewer than 90. That compares with 229 doctors for every 100,000 people nationally.
- It is a group with many needs: One in three Indians lives below the poverty line.
Even the most sophisticated Indian hospitals must refer patients with anything but routine troubles to outside hospitals and specialists, an expensive proposition.
The crunch is so bad that most clinics run out of money for such referrals in te first three months of the year.
"Pain has become the new standard for determining who can access basic surgery and other specialized care," Rolin said.
In Gallup, N.M., the Indian hospital eliminated 20 of its 99 beds and closed an outlying field clinic that saw 5,100 patients last year.
But Indians realized they needed more effective lobbying. They pumped up campaign donations to members of Congress and began reaching out to high-level administration officials.
Advocates acknowledge that the health service also has work to do, such as supplementing federal money by seeking reimbursements from Medicare, Medicaid and private insurers for eligible patients.
Written by Laura Meckler