The Indian Health Service (IHS) is the agency within the U.S. Department of Health and Human Services responsible, since 1955, for providing federal health services to American Indian and Alaska Native (AI/AN) people. Its charge as the principal healthcare provider and health advocate for AI/ANs is to collaborate with federal entitlement programs, state or local healthcare programs, and private insurance providers to mobilize the necessary funding and adequate healthcare provision for the AI/AN population. This includes approximately 1.8 million of the nation’s estimated 3.3 million AI/ANs who belong to more than 562 federally recognized tribes. Most IHS services are designated for AI/ANs who live on or near reservations/villages located in 35 states, primarily in the western United States. However, some AI/ANs who live in urban areas are served by this agency.
The provision of health services to members of federally recognized tribes grew out of a special government-to-government relationship between the federal government and Indian tribes established in 1787. This unique relationship is based on Article I, Section 8 of the U.S. Constitution and has been given substance through numerous Supreme Court decisions, treaties, legislation, and executive orders that acknowledge the federal government’s obligation to provide free health care to AI/AN people in exchange for their cessation of over 400 million acres of tribal land.
In 1975, the U.S. Congress passed the Indian Self-Determination and Education Assistance Act (Public Law 93-638) to provide tribes the option of either assuming from the IHS the administration and operation of health services and programs in their communities or remaining within the IHS direct healthcare system. Congress consequently passed the Indian Health Care Improvement Act (IHCIA; Public Law 94-437) in 1976. The IHCIA is a health-specific law that provides appropriate authority for the delivery of health services to AI/ANs and supports the options of P.L. 93-638. The goal of this legislation is to provide comprehensive directives to the federal government regarding the delivery of services to AI/ANs and to encourage the maximum participation of tribes in the planning and management of those services.
The stated mission of the IHS, in partnership with AI/AN people, is to raise their physical, mental, social, and spiritual health through comprehensive and culturally acceptable personal and public health services. To that end, it assists tribes in developing their health programs through activities such as health management training, technical assistance, and human resource development. It provides hospital and ambulatory medical care and preventive and rehabilitative services. The agency also helps develop community sanitation facilities for Indian homes that have neither a safe water supply nor an adequate sewage system. Preventive measures involving environmental, educational, and outreach activities are combined with therapeutic measures. Within these broad categories are special initiatives in areas such as injury control, alcoholism, diabetes, and mental health.
The operation of IHS programs is overseen by 12 regional administrative units called area offices. Each area office provides administrative support in the forms of distributing funds, monitoring programs, evaluating activities, and providing technical support to the hospitals, clinics, and other facilities within its region. IHS-funded services are delivered through three mechanisms: direct IHS services, tribal services, and Urban Indian Health Programs. These services are provided to those qualified AN/ANs who meet IHS eligibility criteria. For those qualifying, health services are delivered directly at IHS facilities, through tribally contracted and operated health programs or at IHS contract health service facilities. The federal system consists of 49 hospitals in 12 states, 180 health centers in 12 states, 273 health stations in 18 states, and 8 school health centers. In addition, 34 Urban Indian Health Programs provide limited health and referral services to approximately 150,000 AI/ANs living in cities throughout the country.
As of 2003, the IHS staff was 64% non-Indian and 36% Indian. The IHS clinical staff consists of approximately 840 physicians, 380 dentists, 100 physician assistants, and 2,580 nurses. The mental health government employees with the IHS include 71 psychologists, 33 psychiatrists, and 127 social workers, not including tribal psychologists and social workers. The agency also employs allied health professionals, such as nutritionists, health administrators, engineers, and medical records administrators. There is approximately a 10% vacancy rate for health professional positions in the IHS.
AI/ANs are at higher risk for mental health disorders than any other racial or ethnic group in the United States. Their overrepresentation might be due to the high rates of homelessness, incarceration, alcohol and drug abuse, and stress and trauma. More than one third of the demands made on health facilities in Indian country are related to mental health, alcoholism, and substance abuse concerns. The IHS is limited to basic psychiatric emergency care and does not provide ongoing, quality mental health care. Instead, the approach adopted by the IHS is one of responding to immediate mental health crises and stabilizing patients until the next episode (J. Perez, personal communication, July 21, 2003). Select examples of other AI/AN health disparities include the following: Their life expectancy is 6 years less than that of other U.S. citizens; their tuberculosis rate is 4 times the national average; complications due to diabetes are almost 3 times the national average; and their infant mortality rate is 1.7 times greater than the rate for European American infants.
In 2004 the U.S. Commission on Civil Rights censured the federal government for not living up to its treaty obligations through proper funding and effective administration of the IHS in a report based upon their fact-finding mission in New Mexico in 2003. The report, titled Broken Promises: Evaluating the Native American Health Care System, noted great disparities in the health and medical care of AI/ANs in general and even greater disparities for urban AI/ANs. The major contributor to health disparities in Indian country has been the chronic underfunding of the IHS. It is currently operating at an estimated 57% of the budget it requires. It received an appropriation of approximately $3.1 billion for fiscal year 2006. This amount rendered a per capita IHS personal healthcare expenditure of $2,133 as compared with $5,518 for the total U.S. population (the federal government spends $3,803 on average for prison inmates). Funding for urban programs, which serve 25% of the AI/AN population, is only 1% of the total IHS appropriation. In fiscal year 2005, the budget for the IHS mental health program was $55 million; for the Alcohol and Substance Abuse Program it was $139.1 million. In addition to this fiscal barrier, the U.S. Commission on Civil Rights report cited cultural, social, and structural barriers within the IHS that limit access to health care. For example, many AI/ANs are persistently dissatisfied with the IHS because of the constant turnover of care providers, remote and inadequate facilities, extensive wait time for services, lack of continuity of care, and misdiagnosis or late diagnosis of diseases. Furthermore, the IHS does not provide formal language assistance to its patients and relies on staff or family members to act as translators.
Nevertheless, despite having inadequate funds, the IHS has helped to reduce some health disparities. For example, the life expectancy for AI/ANs is now 71 years of age, up from 65 years in 1976. In many cases the agency has identified solutions to the health problems common in AI/AN communities, yet Congress has failed to provide the necessary resources to implement those solutions. The AI/AN professional staff within the IHS has increased 125% since the inception of the agency scholarship and loan repayment programs, established in 1981 to help reduce the shortage of health professionals within the IHS. Many of the recipients of these scholarships and loans are AI/ANs. The IHS is currently applying technology to distance education and service delivery to bring primary care and specialty medicine to remote areas through telemedicine programs and partnerships.
It appears as if the de jure response of the federal government to overcome the shortcomings of the IHS is to encourage increased local community control through tribal P.L. 93-638 self-determination contracts and compacting. The government also appears to rely de facto upon supplemental funding from tribes with gaming revenues from casinos for health care, human resource development, and health disparity research. Certain tribes have demonstrated the efficacy of economic development and community collaboration for the enhancement of the emotional, physical, spiritual, and social health of AI/AN people. However, many rail against these measures on the grounds that they facilitate the government’s continued neglect of its treaty obligations and rely on a means of economic development that may not be robust.
- Indian Health Service. (2002). Facts on Indian health disparities. Washington, DC: Author.
- Roubideaux, Y. (2002). Perspectives on American Indian health. American Journal of Public Health, 92, 1401-1403.
- Snyder, A. (2005). Reforming American Indian/Alaska Native health care functioning: The role of Medicaid. American Journal of Public Health, 95, 766-768.
- U.S. Commission on Civil Rights. (2004). Broken promises: Evaluating the Native American health care system. Washington, DC: Author.
- Zuckerman, S., Haley, J. M., Roubideaux, Y., & Lillie-Blanton, M. (2004). Access, use, and insurance coverage among American Indians/Alaska Natives and Whites: What role does the Indian Health Service play? American Journal of Public Health, 94, 53-59.