Indian Health Services Can’t Be Fixed Overnight

W. Ron Allen, Lynn Malerba & Jefferson Keel

When the United States government signed treaties with Indian nations in the 1800s, it established a trust relationship to provide certain funding and services in exchange for tribal lands. But for nearly 200 years, American Indian and Alaska Native (AI/AN) health care has been chronically underfunded. This has led to systematic challenges with disastrous results. It is time to fix this.

It will take strong leadership and support from Tribes, Congress and the Administration to change the culture within the Indian Health Services (IHS) agency. It will take a firm commitment to providing adequate funding to address the quality of AI/AN health care. It is imperative that we improve the effectiveness of the system that delivers critical health services to our Nation’s most under-served people.

AI/AN people enter into the health system late and with higher acuity needs, not through lack of concern for their own wellbeing, but due to chronic underfunding and severe barriers to care. Within Indian Country, relentless results from the underfunding of promised services all impact health status: joblessness of 7%, poverty rates up to 40%, 8-24% of households that lack plumbing, 7-33% that lack a complete kitchen , 14-24% have overcrowded living conditions, and 18% with no telecommunication ability all.

The funding allocation for Indian Health buys less actual care each year because, unlike other federal health care programs, Indian Health is on the discretionary side of the budget rather than mandatory. Mandatory program funding increases with population growth, new technologies and inflation. Indian Health does not. Further, mandatory programs are protected from the cuts of sequestration. Indian Health is not. Because Indian Health is a trust obligation, it must be fully funded. The current situation of financial care rationing is unacceptable. If the United States can spend over $50 billion in non-defense foreign aid to virtually every other nation, it must fully fund its treaty obligations to our first nations.

Currently the IHS is engaged in an intense and public struggle to improve the level and quality of health care being delivered in the Great Plains region. While the problems that have been exposed are both immense and troubling, it must be noted that these problems and the current state of affairs within the IHS did not happen overnight. And the changes and improvement in health care delivery will not happen overnight.

This is the climate that Mary Smith inherited when she agreed to become Principal Deputy Director at IHS. In her short time at IHS, Mary Smith has worked to move tribal sovereignty ahead by seeking innovative solutions to long-standing problems. For this she has been attacked, both personally and professionally, by some in Congress and even in Indian Country. Instead of being criticized, Mary Smith should be applauded for confronting the problems head-on. She has made positive and creative changes to help alleviate the lack of service delivery in the region. The issues with health care in the Great Plains region have exposed a myriad of problems, challenges and concerns which will take time and resources to resolve.

It is incumbent on leadership at all political levels — Tribal, Federal, and Congressional — to ensure that Mary Smith has their full support. The IHS must receive the required funding and resources to complete the task of improving health care for all American Indians and Alaska Natives. There are discrete steps to make this a reality.


Secure Funding: Fully fund Indian Health programs in the federal budget process and make the programs mandatory instead of discretionary. Fund all unfunded mandates in the Indian Health Improvement Act. Establish a high level Indian program position at OMB to educate OMB on program needs.

Centralize Funding: Find the funding located in other agencies designated for Indian Health and centralize them for easier access within the I/T/U system. Within IHS alone there are 557 grants available to Indian Tribes. It is impossible to meaningfully address the social determinants of health using competitive grant funding, which does not uphold the trust and treaty obligations of the United States.

Centralize Indian Medicaid through CMS: It is estimated that if all states expanded Medicaid another 200,000 Native people would be covered. Tribes have unequal benefits and Medicaid services depending on the State of their residence. The Affordable Care Act now provides Tribes with the opportunity to access health care for all of our Tribal citizens. The Centers for Medicaid and Medicare Services (CMS) must have adequate funding to provide technical assistance to these citizens outside the IHS service area.

Recruit and Retain: Aggressively recruit students from reservations into health professions. Provide scholarships or loan forgiveness programs with the promise to return to the reservation to practice. This helps address the recruitment and retention issue and greatly improves cultural sensitivity and accountability within the health care workforce. Provide appropriate housing and support services to make recruitment successful.

Control Costs: Work with health economists to understand the true cost of chronic underfunding and to also understand the savings that could be realized by health promotion, care management and prevention. Use telemedicine as a less expensive option for expert consultation.

Measure Success: Develop standard metrics to measure progress in improving health status among AI/AN peoples. Encourage and fund sharing of data and distribution of results.

It took years for systemic issues in Indian Health to materialize, and it will take years to turn them around. But it must start today.

W. Ron Allen is the chairman of the Jamestown S’Klallam Tribe; Lynn Malerba is the chief of the Mohegan Tribe; and Jefferson Keel is the Lt. Governor of the Chickasaw Nation.

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