Health and the Urban Indian: An Interview with Ralph Forquera

TC:  What does your core funding come from?

RF:  Our core funding, about thirty-five percent of our funding comes from the Indian Health Service. The remainder of it is a whole variety funding sources. We have federal money and we have some city money. So, it's a combination. We probably have 40 or 50 funding sources, not to mention Medicare, Medicaid and some private insurance, not a lot, but a little bit of private insurance. Plus we provide care on a sliding scale, so we do collect some patient fees. Not very much. But we do collect some patient fees in the process of that. The real limitation that we're running into right now here is the fact that we basically provide primary care. So we provide doctor's office kind of activity. If a person needs a specialist, for example, a cardiologist or an orthopedist right now, it is getting increasingly more and more difficult to get people into those kinds of specialty services, especially if they happen to be uninsured. It's difficult even for people that are insured in this day and age. And it's getting even worse as time goes by. There are fewer and fewer private providers out there that are willing to take uninsured patients. Primarily because their own profit margins are pretty narrow. And so they really can't afford to take too many of those patients. And many of them are gun shy about lawsuits, which is a huge problem for us. We're paying almost a quarter of a million dollars just for malpractice insurance for our providers. And it's a huge chunk of money that we just give away to an insurance company someplace.

TC:  But you can't open the doors without it.

RF:  Yeah. You can't open the doors without it. You know, it's amazing to me the amount of costs that go into just having our doors open. When you think about, you know, the facilities costs and the licensing costs and the insurance costs and all those kinds of things, not to mention, you know, salaries for the staff and fringe benefits and all the things that go along with that. It's just amazing to me how much that takes to be able to open the door across the street.

TC:  Does that mean the future for Indian health boards in general is not very bright? Or are you stabilized? Or what's the situation with those kinds of costs?

RF:  I think that there are some of us, some of our larger programs, like us here and San Francisco and Minneapolis that are relatively stable. The fact that we've diversified our funding provides us with a certain amount of stability because when you lose a piece here you can kind of juggle it around and we've got something to work with. In other parts of the country there are smaller organizations that I think are probably having more difficult times. I don't know that for sure. But in talking to my colleagues around the country, their issues are the same as ours; it's just the magnitude is much greater for some of them. And they have fewer resources available to work with not only in terms of sheer numbers, but also in terms of opportunity. You know, one of the reasons that programs like mine and San Francisco and Minneapolis have done well, I think, is the communities that they operate in.

It's kind of an indication of how important the communities that you develop these programs in also are in terms of your ability to be able to develop an effective program. You know, Seattle's been, you know, a really good place to work because there's been collaboration between the African-American community and the Asian community and the Native American community here. I mean, people talk to each other. We have the Minority Executive Directors' coalition. And, you know, there isn't a place anywhere in the country that has a coalition like that, of people of color sitting down together and talking about these issues collectively. You know, that's a pretty unique circumstance. And I think it adds a particular responsibility to those of us that have that privilege to do the best that we can in our own community so that we can demonstrate to other communities that things can be achieved, because, you know, political climates change.

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