THE AMERICAN INDIAN HEALTH CARE SYSTEM
By Doris Nelson
The American Indian health care system is a completely separate system and is largely unknown outside of Indian Country. To understand this system, we need to learn about the historical relationship between Native Americans and the federal government, and why the United States has the responsibility to provide health care for 3.3 million American Indians and Alaska Natives belonging to 564 federally recognized Tribes.1
For most of the 19th century the federal government was at war with the many tribes of American Indians. Native Americans were dispossessed of their lands, and efforts were made to wipe out their traditions, beliefs and culture. “A good example of this dispossession policy is the Dawes Act of 1887, which effectively replaced group or tribal ownership of land with individual ownership and made available to white homesteaders land not allotted to individual Native Americans. The assimilation policies of this era sometimes made it illegal to speak traditional languages or practice traditional customs, contributing to the decline in health of many Native Americans. This attempted eradication of native people and their culture was rooted in the belief that they were racially, ethnically, and culturally inferior.”2
Over the past 300 years, Native American nations have ceded over 400 million acres to the federal government in exchange for benefits to guarantee the survival and integrity of their Tribes, including health care. “This health care obligation requires the government to provide medical treatment to all Native Americans living in the United States”3
In 1803, the federal government assigned the responsibility for Native American health to the Office of Indian Affairs in the War Department. In 1849, the health care duties were transferred to the Department of the Interior and re-named Bureau of Indian Affairs (BIA), which administered funding for health care programs provided by Congress. Complaints were made during the 1920s that the BIA was poorly equipped to combat public health emergencies such as TB, trachoma, small pox and other contagious diseases. In response, a Commission was formed to inspect reservations, schools and hospitals. The Commission‟s Meriam Report documented “substandard health conditions resulting from government inefficiency and inadequate funding.”4
In 1955, the division responsible for Native American health care was transferred to the Department of Health and Human Services (HHS). Today, the Indian Health Service (IHS) is the principle federal health care provider and health care advocate for Native Americans.3
The Indian Health Care System
Mission and Goal:
“The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.”1
Members of 564 federally recognized Tribes; 1.9 million American Indians and Alaska Natives residing in or near reservations.5
Administration of direct health care services:5
“IHS services are administered through a system of 12 Area Offices and 161 IHS and tribally managed service units.” Over half of the IHS budget authority appropriation is administered by Tribes.
Urban Indian Health Care Services and Resource Centers:5
“There are 34 urban programs, ranging from community health to comprehensive primary health care services. Approximately 600,000 American Indians and Alaska Natives reside in counties served by urban Indian health programs.”
31 IHS and 14 Tribal
61 IHS and 257 Tribal
Alaska Village Clinics
30 IHS and 102 Tribal
School Health Centers
2 IHS and 13 Tribal
Per Capita Personal Health Care Expenditures Comparison:5
IHS user population: $2,349
Total U.S. population: $6,538
Legislative History Assigning Federal Responsibility for Health Care
The Snyder Act (1921) was the first major legislation authorizing funding for health care services. It was the first time Congress developed a broad Native American health policy.
In 1976, Congress enacted the Indian Health Care Improvements Act (IHCIA) establishing the basic structure for the delivery of health services to Native Americans and authorizing the construction and maintenance of health care and sanitation facilities on reservations.6 This legislation “clearly acknowledged the legal and moral responsibility for „providing the highest possible health status to Indians…with all the resources necessary to effect that policy.‟”4
The IHCIA included specific language that:
1) Addressed the recruitment and retention of health professionals serving Native American communities;
2) Focused on health services for urban Native Americans; and
3) Addressed the construction, replacement and repair of health facilities.
The Act has been amended and reauthorized several times. Although it expired in 2001 and is not yet reauthorized, Congress continues to appropriate funds for programs under the Snyder Act.6
There have been health improvements since 1973, though Indian people continue to experience major health disparities compared to the general U.S. population. “Death rates are significantly higher in many areas…including tuberculosis (750% higher), alcoholism (550% higher), diabetes (190% higher), unintentional injuries (150% higher), homicide (100% higher), and suicide (70% higher).”1
In 2009, the effort to reauthorize the IHCIA was connected to federal health care reform legislation.7 In its June 11, 2009, testimony before the Senate Committee on Indian Affairs, the National Congress of American Indians made the following statement:
…the IHS has been characterized over the past decade as a ‘broken’ system. The truth is that the IHS system is not so much broken as it is ‘starved.’ The IHS has been grossly underfunded for decades and as such, cannot be expected to function optimally. Such inadequate funding has created the perception that the system is broken.
Despite these desperate statistics, the reauthorization of the Indian Health Care Improvement Act, the baseline authority for providing direct health care to American Indian and Alaska Natives, has not been reauthorized for ten years. The bill establishes objectives for addressing some of the basic and overwhelming health disparities confronting Indians as compared with other Americans and provides progressive approaches to health care delivery that will help move Indian health care into the 21st century. Passage of this much needed legislation is not only necessary to fulfill the Federal government’s responsibility of health care to Indian people; it must happen so that Indian people are placed on parity with the majority population and able to engage meaningfully in national health care reform.7
On December 11, 2009, the Senate Committee on Indian Affairs unanimously passed a strengthened and improved Act.8
3 Ibid, p. 23.
4 Ibid, p. 24.
7 Senate testimony: Reforming the Indian Health Care System, National Congress of American Indians, Senate Committee on Indian Affairs, Hearing on Reforming the Indian Health Care System, pp. 1-2, June 11, 2009.
8 Senate Committee on Indian Affairs, Press release, December 11, 2009.
Doris Nelson (LWVCA) is a member of the LWVUS Health Care Education Task Force. Produced by the LWVUS Health Care Education Task Force, 2010
©2010 by the League of Women Voters of the United States