By Taylor Sisk
On Oct. 15, the Eastern Band of Cherokee Indians snipped the ribbon on their $82 million hospital. Next Monday, the hospital is scheduled to open its doors.
The new 155-000-square-foot Cherokee Indian Hospital is the latest product of an ongoing initiative to enhance health care services on the tribe’s Qualla Boundary, a little over an hour west of Asheville.
Casey Cooper, the hospital’s chief executive officer, is now looking ahead to the next objectives. Among his priorities are reducing disparities between American Indians and the general population in a number of critical measures. He also intends to continue advocating for the expansion of Medicaid in North Carolina.
Cooper stresses the significance of the tribe taking direct ownership of the provisioning of its own care, to which, he said, the new hospital stands as a monument.
The state-of-the-industry facility represents “success and self-determination,” Cooper said. “It’s a symbol of this evolution from being dependent on a paternalistically provided service that was grossly inadequate.”
“We are not here today because of the federal government’s commitment to Indian health,” he told those who gathered for the hospital’s ribbon-cutting in October. “Rather, we stand here today in spite of it.”
Assuming control
In 2002, the Cherokee tribe took over administration of the hospital and most health care services from the federal Department of Health and Human Services’ Indian Health Service.
Cooper said the IHS had proposed significant cuts to the health care budget for both 2003 and 2004 that could have led to closure of the hospital’s inpatient unit as well as substantial cuts to the pharmacy budget and revenue used to buy specialty care from outside the reservation.
The prospect, Cooper said, was “dire.” Service cuts were unacceptable. So the Eastern Band of the Cherokees assumed control.
The tribe was able to do so thanks to casino revenues. In 1997, the tribe opened a video-poker parlor; today the Qualla Boundary is home to Harrah’s Cherokee Casino Resort, featuring 150,000 square feet of gambling and a 21-story hotel.
Gambling revenues, Cooper said, have “infused a significant amount of cash into the system to allow us to, first of all, shore up the system, and then to begin to expand the services.”
Those services now include an immediate-care clinic, dialysis center and eye clinic. Currently under construction are a residential treatment facility, recovery-support housing and a recovery and outpatient counseling center.
The tribe also has a program called Cherokee Choices that addresses diabetes, an issue of particular concern on the Qualla Boundary.
When gambling was proposed as a source of revenue, Cooper said he was confident the benefits would outweigh potential negative effects.
With training and experience in both nursing and public health, he said he’d come to believe that as important to health outcomes as the system itself are “socioeconomic status and access to community capital and average education level.”
“Those are the real drivers of health – that and genetics and behavior,” he said.
“And so the idea that you could take an entire community of people and raise them up out of poverty and bring them up in the socioeconomic strata – that means more for public health than anything else we can do.”
Trust
Cooper said of his community, “I would describe it as a community that still manages to hold some of its most critical resources in common … for the entire tribe to use as they need, to share in them.”
A prime example is the hospital.
“We have a commitment to an elevation of the entire community’s health,” minimizing the “stratification between the wealthy and the poor.”
And it’s done, he said, at a substantial savings per capita. He cited two primary sources of those savings: vigilant control of pharmacy benefits and access to specialty care.
The health care system, Cooper said, is the tribe’s inheritance. “We’re simply the stewards of their inheritance.”
“If we didn’t have the trusting relationship with them to manage their inheritance, the model would not be possible,” he said.
‘Mama calls’
Born and bred in the Cherokee community, Cooper seems to have been destined to sit where he does today. He had offers elsewhere, but declined.
He said he often recounts something he heard legendary University of Alabama coach Bear Bryant say about leaving the NFL to return to coach for his alma mater.
“He said, ‘Well, Mama called. And when Mama calls, you go home.’”
“There’s nothing more intrinsically motivating, and nothing that connects you more to purpose, than going home when Mama calls, and contributing,” Cooper said. “There was an opportunity in the community where I could be significant, and it was just an opportunity I never considered passing up.”
“I don’t know that I ever desired to be anywhere other than here,” he said. “This is home.”
The new hospital signals the launch of the next phase of his vision for Cherokee health care, accelerating “our strategy of improving population health by being a more influential partner with our community,” Cooper said. It engages the power of tradition with evidence-based practice.
Lynne Harlan, public relations officer for the hospital authority, described the hospital’s “River Walk” – the facility’s primary passage, lined with scenes of Cherokee legend – as being designed to help “maintain the cultural continuum that gives people strength. The story of how we came into being validates that we belong where we are.”
Cooper echoed that. The hospital, he said, “is helping us heal the community by transcending the negative legacy” that was associated with the previous health care system.
Addressing disparity
Going forward, Cooper said, “We’re interested in developing more influential relationships with our patients so that we can be more influential in their lives in helping them make better choices to stay healthy, and really attack the real determinants of their health.”
Ten years from now, he’d like to see a dramatic reduction in the health disparities, but there’s a lot to do. The Cherokee have significantly higher rates than the general population in a number of chronic diseases. Cooper cited alcoholism, depression, diabetes, heart disease and obesity.
“We are seeing improvements down at the detailed level, like an increased number of patients that have better blood pressure control, better cholesterol control … earlier cancer screening, Pap smears, mammography.”
And a study by Duke University researchers that’s followed 1,420 youth in Western North Carolina, a quarter of them Cherokee, for more than two decades found that four years after tribal members began receiving per-capita gambling-revenue checks, behavioral issues with Cherokee kids had declined by 40 percent. Minor crime convictions fell and high school graduation rates improved.
Cooper hopes to see a diversification of the Cherokee economy: “Any threat to gaming is a significant threat to us.” He feels a solid infrastructure is in place, “not just physical but organizational structure, core competency of our workforce, good leadership.
“We’re better prepared to face future threats as a result of developing these things.”
He adds that a particular legislative decision at the state level would help in efforts to provide more comprehensive health care in the region.
“Certainly, we have an access problem in Western North Carolina, and a coverage problem. And when the General Assembly makes the decision to expand Medicaid, I think that’s going to be one of the greatest things we can do to reduce disparities.
“We will never have adequate access to primary care in rural communities until we have better coverage. And it’s just a real disappointment that North Carolina is dragging its feet so bad on Medicaid expansion.
“There’s just too much health inequity in this state, and it doesn’t need to be that way.”
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