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PART C: SIGNIFICANCE OF THE STUDY PART C: SIGNIFICANCE OF THE STUDY In recent times, much has been said about the role that government should play in delivering services to the people. Health care is an area of government that is under continual scrutiny. The explosion of public expenditures on health care following the introduction of Medicare and Medicaid led to the emergence of cost containment as an independent policy objective (Arnould, Rich & White, 1993). While federal per capita health care expenditures for Native Americans remain below that of the general US population, the federal contribution is nearly the same as the per capita expenditure for Medicaid and Medicare, however in order to rise to these levels, IHS appropriations had to increase 136% in the past ten years.
While the escalation of costs (cost efficiency) should be reason enough to study this restructuring process, the more salient issue should be that of health outcome (cost effectiveness). The Indian Health Service is restructuring in order to find some equilibrium in this challenging environment. The IHS is part of the administrative bureaucracy which the IHDT has plainly recommended needs to be dismantled and reorganized.
One observation is that "the problem with the current system is that public officials cannot use common sense and good judgment in ways that would promote better…performance" (Kelman, 1990, pg.1). There is a feeling that the current bureaucratic structures are not able to perform the social functions that they were intended to do (Downs, 1967). And yet, the nature of bureaucracy is to promulgate more rules and regulations to address problems and stabilize the environment. It emerged "out of a need for more predictability, order and precision" (Bennis, 1967, p. 325).
The belief that the system in which government operates is inadequate has spawned numerous commissions and writings. The 1989 Volcker Commission issued its report, "Leadership for America: Rebuilding the Public Service" recommending that a new power system be created:
Control through multitudes of regulations and procedures, administered by a central agency removed from service delivery, has created managers with limited power but full responsibility for any problems that occur. Greater congruence between operating responsibility and managerial authority is absolutely necessary (Volcker, 1989, p. 288).
This was followed by the Winter Commission on state and local reforms in 1993 which recognized that the "pattern and the problem are clear. The face of America outside government is changing faster than the face of the work force inside. " (Winter, 1993, p.293)
Gaebler and Osborne in "Reinventing Government" promote the notion that government should be catalytic, enterprising, anticipatory, decentralized, community owned, competitive, mission driven, results oriented, customer driven and market oriented (1992). Taking all of the above into consideration, this became an animating theme of Vice President Al Gore’s 1993 report, the National Performance Review. In that document, the four goals of cutting red tape, putting customers first, empowering employees in a results oriented environment and getting back to basics are enunciated (Gore, 1993).
Because the calls to "reinvent" and "streamline for efficiency" have been heard before, there is understandable skepticism about whether rhetoric can be translated into action.
[T]he federal government has long suffered from an organizational strain of attention deficit disorder, an affliction that has led to an almost endless series of reform efforts, blue ribbon commissions, special studies and reports. Each begins with great fanfare only to atrophy out of frustration, neglect, and even boredom (Sanders, 1996, p.47).
The Indian Health Design Team met for the first time in October 1994, shortly after Vice President Gore’s report. The resulting recommendations that they made for redesigning the Indian Health Service clearly reflect the call for "reinventing" government. Unlike recommendations of other blue ribbon panels and commissions, the significance of the IHDT report is that those recommendations are being implemented at this writing. Dismantling of the perceived ineffective bureaucracy and plans for implementing the plan are underway. The "bureaucratic blitzkrieg" (Sanders, 1996, p.47) necessary for reinvention to sustain momentum is operational. Business is being conducted not-as-usual. This study is follows the development of this exception to the rule. It is timely in that this process is unfolding as it is being written.
Besides the political aspects of reorganization, this study will add to the literature on the federal position on Indian self-determination. The Indian Self-Determination and Education Assistance Act (PL93-638) and the Indian Health Care Improvement Act (PL94-437) have been in place for over twenty years. Their intents were to build capacity and to make clear "that Indians can become independent of Federal control without being cut off from Federal concern and Federal support" (Nixon, 1970). The reorganization of the Indian Health Service is the next step in the evolution of the relationship between the federal government and the Indian tribes that "638" and "437" laid out as policy position. This study will examine this process, describe the motivations, depict the constraints, and elicit a prognosis for the future for this timely experiment in reinventing government. It will also re-examine the relationship between sovereign nations as they continue to negotiate in the "utmost good faith".