Spring 2004
Featured Article

Double Jeopardy: Advocating for Indian Elders

By Dave Baldridge

The principles of good advocacy are the same for most advocates, but from Indian Country, the task of getting there is more difficult.

"It is what it is," my friend Joaquin, a Buddhist, points out. I think he's right.

In the end, we advocates for elders are all mostly after the same things-a better deal for our underserved or disadvantaged constituencies. We're after parity; we're after a level playing field. We're after, for cripe's sake, a little social justice. And for the most part, we are convinced that the Great Spirit is on our side. It seems that what we mainly want for our constituencies is, in the end, a way of providing long-term care. Like the treaty language says, "for as long as the grass grows and the rivers flow"-and not just until it stops being convenient. As advocates, though, we almost always have to settle for less. Call it incremental opportunism.

For us all, the principles of good advocacy remain simple. First, gather your resources, as if you were heading for an Indian casino. Second, be focused, like a Lakota Dog Soldier sneaking up on a Pawnee horse herd. Third, be brief, like the Seventh Cavalry's stay at the Little Bighorn. And fourth, be persistent, like a mining company looking for a cheap federal lease on Indian land. But even with these common principles, the tactics of how advocates get to That Good Place from Indian Country are more complex and intricate than many might imagine.

1. Gather Your Resources

The first difficulty comes in trying to figure out exactly what it is that Indians want. We're talking about 558 independent, quasi-sovereign nations, each possibly with its own governmental structure, court system, spoken and unspoken boundaries (geographic and personal), local economy, and views on assimilation. Each with its own sense of destiny.

The United States boasts an American Indian-Alaska Native (AI/AN) population of 3.5 million, about half of whom live off-reservation, many of whom are now third-generation urban Indians-increasingly removed from their tribal roots, their cultures, and their eligibility for federal healthcare. We're talking about a population with arguably the poorest health and economic status in the nation-many of whom have a well-worn chip on their shoulders when it comes to U.S. government policies. These policies, for the past couple of hundred years, have fluctuated unpredictably between annihilation, assimilation, and disinterested neglect.

Indian advocates historically could claim that poverty is the single thread that weaves the fabric of Indian issues together-a handy means of claiming high moral ground with legislators of this, the world's wealthiest nation. However, that generalization is probably a little less true today, when something like 200 tribes generate $17 billion annually from gaming ventures. What's missing is any semblance of parity between tribes, making it very difficult to establish a baseline.

Tribal economies range from that of the Massantucket Pequots, which owns its own pharmaceutical company and is one of the largest employers in New England, to those of impoverished North Slope Alaska Native villages, which still may not have solid waste disposal or access to fresh water. In any case, something like two-thirds of Indian tribes-because of their rural isolation and other reasons-do not have casinos. Other tribes who do operate gaming are making marginal profits, at best. Finding common needs and priorities for a population that is increasingly diverse, urbanized, educated, and self-sufficient is less clear than it used to be.

2. Be Focused

The National Indian Council on Aging (NICOA), the national nonprofit advocate for older Indians, makes a dozen or so trips a year to discuss Indian aging issues with Congress. In comparison, one of the aging network's large nonprofits based in Washington, D.C., estimated a few years ago that its staff makes 900 visits a year to Congress. This kind of discrepancy places a good deal more responsibility on the shoulders of Indian advocates. There is little room for complacency or mistakes.

With something like a hundred Senate and House committees and subcommittees dealing with different aspects of aging, advocates for "peripheral" populations such as Indian elders cannot afford to be less than effective, cannot afford to invest excessive effort in mainstream issues that become decided by larger forces, cannot waste too much time talking with unsympathetic Congressmen and -women, or those not from the thirty-eight states where Indian tribes are located.

In Indian Country, the principles are the same as for most advocates, but the task is more complex and difficult.

NICOA's advocacy over the past decade has resulted in some significant gains-Title 6 of the Older Americans Act (OAA), the Indian equivalent of Title 3, has increased from $13.5 million to $30 million. In Title 5, the Senior Community Service Employment Program, NICOA's annual share has increased from $3 million to $6 million. In the recent Family Caregiver Support Program, NICOA's advocacy directly resulted in a $5- million increase for Indian funding.

For every battle won, however, others have been lost. In 1992, NICOA secured new language for a Part B in Title 7-Elder Protection Services-that would provide, and fund at $5 million, elder protection initiatives for Indian tribes. As of 2004, Congress has yet to appropriate a single penny for the provision, despite NICOA's ongoing advocacy.

Other losses involve statutory language rather than funding, but they are potentially crippling in the long term. These include the loss of earmarks for an Indian pre-conference as part of the next White House Conference on Aging, for Title 6 demonstration grants, and Part B of Title 7. Only by taking fall-on-your-sword advocacy positions was NICOA able to avoid the implementation of state oversight of Indian employment programs, which would have created difficulties for a program targeting sovereign tribal communities.

Indian advocates have learned to focus on appropriations committees rather than authorization committees. With only a couple of arrows in the quiver, you can't just go shooting up the whole countryside. In social marketing terms, it's the use of the rifle instead of the shotgun-and yes, it's the economy, Stupid. No money, no services. No services, no parity.

3. Be Brief

The ability to be brief on the Hill is an asset. Brevity isn't an essential component of most Indian interactions, however, and that is true for advocacy, as well. The long history of Indian interactions with states and the federal government has resulted in a complex array of service-delivery issues (The 106th Congress, for example, passed more than 400 laws specific to Indian Country). It becomes difficult, on occasion, to find common ground even regarding how services are delivered-through what agencies, with what parameters. These considerations don't lend themselves to brief encounters.

For example, the state of South Dakota has for more than a decade maintained a moratorium on new Medicaid-financed nursing home beds. Tribes in the state, several of whom want to build nursing homes on tribal land or even acquire an existing nursing home off-reservation, express heartfelt frustration at the state's refusal to approve tribal creation or acquisition of Medicaid beds. With less than full occupancy in non-Indian nursing homes, operators and their political allies seem loathe to risk loss of Indian residents who may relocate to an Indian-owned facility.

A challenge for Indian advocates is that every interaction with federal officials has an implicit dual purpose. The first-for the most part presumed-is to reaffirm the sanctity of the Federal Trust Responsibility (FTR). The unspoken acknowledgement driving the dialogue-that the United States owes something to Indians-both validates the advocate's mission and establishes common ground for the consideration of how to get it done. If the federal participant in this interaction does not particularly care about the FTR-whether through ignorance or political inclination-the Indian advocate might as well pack up and find a softer place to land.

The FTR, which refers to the commitment of the federal government to provide healthcare and human services to Indians, separates Indian issues from those of other racial/ethnic minorities, from those of other aging populations, and even from those of other Native Americans, such as Native Hawaiians. The FTR is based on some 800 treaties (most from the 1800s), on statute, and on case law, and provides legal assurance that the United States will provide services to Indians.

Because of the FTR, entire federal agencies have been created-most notably the Bureau of Indian Affairs, the Indian Health Service, and the Administration for Native Americans. Primarily dealing with tribal governments, none of these agencies, with the exception of the ihs Elder Health Care program, offers a focus on aging issues. The result, over several decades, has been a shortlist of uncoordinated, and often unimplemented, services.

The second purpose of an advocacy visit, a specific problem to be solved, is complicated by the unique nature of Indian Country's service-delivery mechanisms. For example, most of the aging network's funding streams flow through state governments. In addition to Medicaid, most Older Americans Act programs (Titles 3, 5, and 7) are targeted to state units on aging. The interface of these programs-between states and tribes-takes place on some still-rocky ground.

Because states consider the FTR to be a federal-not a state-responsibility, most states and counties do not acknowledge any obligation to provide specific services to Indians. Tribes and states historically have disagreed about legal jurisdiction, education, water and mineral rights, hunting and fishing rights, child welfare, and an array of other issues. Today, coexisting (often uneasily) as quasi-sovereign governments, some states and tribes have forged cooperative relationships for some issues, such as cross-deputizing law enforcement officers.

In other cases, relations remained strained. In almost all cases, states do not align themselves with the FTR. In ten or so states, Indian Area Agencies on Aging operate as state Title 3 programs, with varying degrees of success.

In the 1990s some 500 of the nation's tribes launched their own healthcare delivery with funds previously administered by the Indian Health Service. In addition to financially disemboweling the ihs, this "balkanization" is resulting in several unintended consequences-including the loss of national public-health initiatives for Indian Country, the impending loss of a national data picture, and the loss of economies of scale for the purchase of, say, durable medical goods and pharmaceuticals. Instead of one unique healthcare system, the ihs, Indians now are served by many dozens of unique systems.

4. Be Persistent

Because Indian elders constitute the most rural of all racial aging cohorts, their problems seldom appear on the radar screen of America's consciousness. Because they are historically stoic and soft-spoken, Indians have seldom asserted themselves in a political context. Yet they remain, for the most part, the only senior population for whom healthcare is an entitlement. And they remain among the most poorly served, invisible to much of the aging network.

It may well be that the greatest immediate danger for older Indians is not the loss of direct OAA services or cutbacks in federal funding. The greatest danger may not have anything to do with aging at all. It may consist of obscure, low-profile amendments, riders, and provisions in federal and state legislation that incrementally weaken tribal sovereignty and undermine tribal positions in relation to states, or the danger may come in the form of broad bills that fail to include provisions for Indian Country. The recent (and nearly total) omission of Indian participation in Homeland Security legislation comes to mind.

Persistence is required because the bad guys are persistent, and they're getting more sophisticated. It seems that Congress may stand out as the last frontier of Manifest Destiny-and as in the Indian Wars of the 1880s, Indian victories may have a retrograde aspect. More and more, successes serve only to maintain the status quo. Failures, small or large, result in irrevocable loss-a kind of reverse incrementalism.

Don't let anyone kid you. The Seventh Cavalry is still on the way. Instead of Gatling guns, though, they're bringing lawyers and corporate dollars. It's the job of Indian advocates to see them coming. It's the job of tribal leaders to use some of that $17 billion in gaming revenue in productive ways, and especially politically productive ways. I expect that Indian advocates will be persistent as long as the grass grows tall enough for a few cows and reservation rivers still manage a little uncontaminated flow. After that, America, you're on your own.

Dave Baldridge is director of the National Indian Project Center, based in Albuquerque, N.M.

From Generations Spring 2004 issue, 28(1): 75-78. © 2004 American Society on Aging

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