By Taylor Sisk
Enter the front foyer of the Cherokee Indian Hospital, look to your right, and there you’ll see a large placard that reads, “Ni-hi tsa-tse-li,” which translates to, “This belongs to you.”
It was mounted in 2002, when the Cherokee tribe took over administration of the hospital from the federal Department of Health and Human Services’ Indian Health Service.
But that placard may soon be moving, because in a couple of months members of the Eastern Band of Cherokee Indians will begin receiving care in a new, $80 million, 155,000-square-foot hospital right next door.
(Also; under the new state budget passed last week, the tribe will assume responsibility for covering the costs of Medicaid, N.C. Health Choice, which covers low-income children, and many social services for its members.)
In recent years, the tribe has opened an immediate care clinic, a dialysis center, a diabetes clinic and an eye clinic; begun construction on a $13 million residential treatment facility, recovery-support housing and an 8,000-square-foot recovery and outpatient counseling center; amped up health care programs and services for tribal members both on the reservation and beyond; and expanded free services for many elders and others.
The benefactor of this good fortune? A casino.
In 1988, Congress passed the Indian Gaming Regulatory Act, paving the way for the tribe to introduce, in 1997, video poker here on the Qualla Boundary, a little over an hour west of Asheville.
Today, Harrah’s Cherokee Casino Resort – now featuring 150,000 square feet of gambling and a 21-story hotel – towers over the community from the edge of the village. It’s about a mile and a lifetime from the curio shops and mom-and-pop motels, catering to Great Smoky Mountains National Park visitors, that once were the tribe’s primary source of income.
Not everyone in the Cherokee community was happy about the arrival of legalized gambling. Some were concerned about gambling addiction and the effects of the inevitable introduction of alcohol, others about traffic. Interviews conducted throughout the community suggest that today far fewer tribal members complain.
Gambling has been a tremendous boon to the economy and, consequently, to public health.
“Gaming has made so many things possible that just were completely unheard of prior,” said hospital CEO Casey Cooper.
Waning resistance
In an average year, some 3.5 million visitors to the Oconaluftee River Valley will spend about a half-billion dollars on slots, cards and dice.
Half of the gaming revenue received by the tribal council funds tribal operations and infrastructure; the other half is allocated equally to its 15,000 enrolled members. The per-capita payments are sent out every six months, and most recently have climbed to “north of $9,000” a year, according to Chief Michell Hicks.
Children receive a full share, but their money is invested until they reach adulthood. Kids also receive instruction in financial management.
Hicks served as the tribe’s chief financial officer before being elected chief. He said that in 2003, about 50 people refused to accept their per-cap checks, but that there are fewer who do that now.
Jerry Wolfe was among those who were initially against the idea. Wolfe is a veteran of the World War II invasion of Normandy. He grew up in the Big Cove community – just the other side of Rattlesnake Mountain – and has lived all but his Navy days on the Qualla Boundary.
He sees now the benefits of the revenue. “It’s a great help,” he said. “If we didn’t have it, we’d be in bad shape.”
The only complaints he said he hears now are from those who’d like more.
Team-based approach
With the opening of a second casino in Murphy later this month, the hospital is projected to receive a little more than $10 million in gaming revenues next year. Casey Cooper knows how to spend it.
Cooper received a bachelor’s degree in nursing from Gardner-Webb University and an MBA from UNC-Chapel Hill. Health care professionals in the community say he’s played a major role in shaping the tribe’s approach to health care.
The new hospital will offer a lot under one roof.
“We’ve completely redesigned the way we deliver primary care,” Cooper said. “We’re doing it more on a team-based approach, which we refer to as being more reciprocal interdependent, rather than sequential – just more patient centered.”
Integrated with primary care are behavioral, dietary, dentistry, optical and other services. The design of the new hospital facilitates this approach by keeping team members in proximity to one another.
Cooper said that when the idea of legalized gambling was first introduced, he welcomed what the revenue could deliver. Elevating general prosperity, he said, “means more for public health than anything else that we can do.”
“You look at the most impoverished communities in the country, and you have the highest rates of risky behaviors and addictive behaviors,” he said. “So bringing economic development into a community is not bringing more risk, in my opinion; it’s bringing more opportunity to improve health.”
A long-term view
In 1992, Duke University professor of psychiatry and behavioral sciences Jane Costello launched the Great Smoky Mountains Study. She and some colleagues began following 1,420 kids in rural Western North Carolina, aged 9 to 13, a quarter of them Cherokee.
Costello found that by 2001, four years after tribal members began receiving the per-capita checks, the number of Cherokee kids living in poverty had dropped by half. Behavioral issues among them had declined by 40 percent to approximately the same rate as those who had never been poor.
Over the years, on-time high school graduation rates improved and minor crime convictions fell.
When checking back with these kids after a decade, Costello determined that those who had been the youngest when the money started coming in were less likely to have developed mental health issues or substance disorders.
“[J]ust as environmental stresses can create mental illness,” Costello has said, “so environmental interventions can remove them.”
Mindset
In terms of primary care outcomes, Cooper said, “We’re seeing improvements down at the detailed level, like an increased number of patients that have better blood pressure control, better cholesterol control.” More people are now screened for cancer and receive Pap smears.
The revenue has allowed the hospital to expand its budget for specialty care off the reservation. Jody Bradley Lipscomb, a tribal member and longtime community-health professional, said that in the past only those with an immediate threat to life or life function were receiving surgeries from the Indian Health Service.
Now lower-level needs are met before they become harder to treat and more expensive.
And a lot fewer people are facing the day-in-day-out stress of not knowing how they’re going to make a living in the winter, as was the case when the community was dependent on summer tourism.
“That’s huge,” Hicks said. “That’s absolutely huge.” He said that when the Murphy casino opens, the tribe will be funding 5,500 jobs.
“Where the tribe was then to where we are today isn’t simply about having bigger pocketbooks,” Hicks said. He believes there’s been a “change of mindset,” people making better decisions because they now can – eating more nutritious foods, for example.
It’s also reflected in little things, he said, like upgraded appliances and landscaped lawns.
Chris Cruise, a psychologist who worked for the tribe from 1999 to 2010, primarily engaging with children, echoes that. He said the majority of the people he knew “did some of the most responsible things I’ve ever seen people do with money,” such as paying power and cable bills in advance and investing in their family’s health and well-being.
The tribe has also been able to address environment-related concerns: drinking-water issues, for example.
“Most major areas within the tribe now have access to Cherokee water and sewer,” Hicks said.
As for gambling addiction, a number of community members say that few of their neighbors have been attracted to the gaming – that it remains “separate” from their everyday lives.
‘Resiliency to stress and trauma’
Cooper believes the fact that the money is generated and administered from within makes a big difference. “Self-efficacy,” he said, helps “develop resiliency to stress and trauma and all those things that affect our health.”
Then there’s that sense of agency – that “Ni-hi tsa-tse-li” spirit – in the health care system in general and the hospital in particular.
When the Indian Health Service operated the hospital, Lipscomb said, community participation was prohibited.
“It’s really been a paradigm shift for our community to say, ‘Will you volunteer at the hospital?’” she said, “because Indian Health Service wouldn’t let you.” Those were the rules.
Hicks and Cooper agree the tribe must diversify its economy going forward. Hicks – who chose not to run for re-election in September after three four-year terms – would like to see more “family-oriented” enterprises introduced.
Cooper believes the infrastructure is now in place to build that future, “not just physical, but organizational structure, the core competency of our workforce, good leadership.”
“There are some things that we can’t change,” he said, genetic determinants, for example. But, he said, education and employment opportunities are being extended; there’s an investment now in “social capital.”
“We’re better prepared to face future threats as a result of developing these things,” Cooper said.
[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]
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