The provision of services to American Indians and Alaska Natives (AI/AN) is an entrusted responsibility of the United States. Nonetheless, due to a longstanding pattern of underfunding, the Indian Health Service (IHS) faces considerable difficulties in delivering these services.

The way health services are provided has been influenced by laws from the twentieth century, such as the Snyder Act, Transfer Act, Indian Self-Determination and Education Assistance Act, and the Indian Health Care Improvement Act (IHCIA). The reauthorization of IHCIA was included in the Patient Protection and Affordable Care Act (ACA).

The text below explains that there are certain provisions in the ACA that could enhance access to services for AI/AN populations. Despite encouraging policy advancements, it is essential to address the issue of underfunding of IHS to guarantee better health outcomes for AI/AN individuals.

The United States has had a distinct relationship with American Indian and Alaska Native (AI/AN) tribes, characterized by a blend of conflict, warfare, cooperation, and partnership in their shared history.

The complex history has led to a network of federal Indian policy, treaties, and relationships between governments. Treaties, executive orders, and other legal foundations have ensured the provision of services to AI/AN individuals, including housing, education, and healthcare.

Between the years 1778 and 1868, a minimum of 367 treaties received ratification from the federal government. The US Constitution’s Supremacy Clause designates the Constitution itself, federal statutes, and treaties as the highest prevailing law in the nation.

In numerous treaties signed between the United States and tribal nations, it was customary to incorporate language such as the “commitment to providing adequate care and safeguard” in return for tribal land and natural resources.

The outcome is that the federal government has a duty to provide services to AI/AN individuals due to a trust responsibility. This trust responsibility, mandated by law, entails the government assuming moral obligations of great responsibility and trust towards Indian tribes.

In 1831, Chief Justice John Marshall first defined this duty in relation to the Supreme Court case Cherokee Nation v Georgia. Trust responsibility also entails a legally executed financial duty of the US government to protect tribal treaty rights, lands, assets, and resources, alongside the responsibility to provide healthcare services.

However, the Indian Health Service (IHS) and its predecessor agencies have faced significant challenges in delivering adequate care and protection due to a longstanding history of underfunding.

The present article offers a concise summary, historical background, and development of AI/AN health policy, alongside current trends and contemporary issues.

Policy History

Since the signing of the last treaties in 1871, the provision of health services to AI/AN individuals has been hindered by a lack of resources.

According to the 1890 Annual Report of the Commissioner of Indian Affairs, physicians serving Indian populations received an average annual salary of $1028, which was lower in comparison to the salaries of $2823 and $2622 received by Army and Navy physicians, respectively.

To this day, the underfunding of the Indian Health Service persists, as expressed by Warren K. Moorehead, a commissioner for the Bureau of Indian Affairs in 1914 who found it difficult to understand the insufficient allocations towards disease control.

The way health services are provided to AI/AN persons has been greatly influenced by the implementation of several laws in the 20th century.

Here are descriptions of various acts, including the Snyder Act, Transfer Act, Indian Self-Determination and Education Assistance Act, and Indian Health Care Improvement Act.

These 4 laws cover only a fraction of the extensive collection of laws and policies that impact the provision of healthcare services to AI/AN individuals.

Snyder Act

The Indian health program was under the management of the Bureau of Indian Affairs (BIA)—a department within the Department of the Interior—until 1955. As per the Snyder Act of 1921, this arrangement was established.

The Indians throughout the United States shall be directed, supervised, and financially supported by the Bureau of Indian Affairs, which operates under the supervision of the Secretary of the Interior, using funds allocated by Congress for their benefit, care, and assistance.

On a recurring basis, this law became the initial provision that authorized Congress to allocate funds towards addressing AI/AN health.

The Snyder Act forms the basis for the funding authority of several ongoing IHS activities, including those aimed at providing relief from distress, conserving health, and employing physicians, as indicated in the list of acceptable uses of Congressional appropriations.

Transfer Act

that the Public Health Service took over the Indian health program as a result of the Transfer Act of 1954.

The Surgeon General of the United States Public Health Service is responsible for administering all functions, responsibilities, authorities, and duties regarding the maintenance and operation of hospital and health facilities for Indians, as well as the conservation of Indian health.

In addition, the legislation also stipulates that

The Secretary has the authority to enter into contracts with any institution that provides Indian hospitals or health facilities, whenever it would improve the health needs of the Indians.

The language acknowledged the autonomy of the tribe and provided them with a level of control in health policy decision-making, stating that a transfer could not occur without the approval of the tribe’s governing body.

The powers provided by the Snyder Act were also transferred to the Secretary of Health, Education, and Welfare, presently known as Health and Human Services.

Indian Self-Determination and Education Assistance Act

In 1975, the Indian Self-Determination and Education Assistance Act (ISDEAA) came into effect, exerting significant influence on the provision of health services to AI/AN tribes.

Any tribe has the ability to request self-determination contracts as this act serves as the foundation for tribes to take over BIA and IHS programs while also instructing the Secretaries of Interior and Health and Human Services to partake in such contracts.

A tribe has the option to take over any program, function, service, or activity of the IHS related to health services through a “638 contract.” According to Title I of the ISDEAA, the tribe can become a federal contractor and deliver services specified in the IHS line item budget for a particular service unit, such as a clinic or hospital.

ISDEAA provides the tribes with various financial and administrative benefits, including a “638 compact” funding agreement that functions as a block grant, allowing tribes to reprogram resources as needed to address local health needs.

Carry-Over Funding, in contrast to several federally funded programs mandating full budget utilization within a specific fiscal year, allows for the retention of unspent funds for subsequent fiscal years under the ISDEAA. These funds can be obligated or expended in the designated succeeding fiscal year without any additional justification requirement from the tribal organization, as long as they were originally appropriated, contracted, or granted for said year.

The revenue obtained from private or public insurance is considered as additional income and does not impact the agreed upon dollar amounts in 638 funding agreements.

There are various federal grants that Tribal 638 programs are eligible for, which the IHS, being a federal agency, cannot receive. For instance, a tribe can receive Community Health Center grants from the Health Resources and Services Administration under Section 330 of the Public Health Service Act.

Many Indian reservations are included in the health professions shortage areas that receive support from these grants to health centers.

By combining contracted or compacted funds from ISDEAA with Section 330 grants, along with the collection of third-party revenue, a tribe is able to obtain significantly more resources to address community health.

Contract Support Costs (CSCs) are funds allocated for administrative purposes in managing a contract and are determined by applying the tribes’ indirect cost rates. To illustrate, in a scenario where a tribe’s indirect cost rate is 30%, the ISDEAA contract would encompass the direct expenses of contracted services in addition to a 30% provision for CSCs.

The lack of similar line items for administrative costs is evident within the IHS. Nonetheless, the tribes have faced substantial controversy due to federal budgets not fully covering 100% of their owed CSCs in recent years.

Prioritizing Health Care Services

IHS offers a wide range of healthcare services across a network consisting of more than 679 hospitals, clinics, and health stations situated either on or near Indian reservations.

Despite an 18 percent reduction to the overall HHS discretionary budget, the Budget demonstrates a strong dedication to Indian Country, ensuring the preservation of direct healthcare investments.

In the FY 2018 Budget, there is an allocation of $3.3 billion for clinical services, representing an increment of $22 million compared to the FY 2017 Continuing Resolution. This increase brings the funding for direct health care services back to the levels seen in FY 2016.

Outpatient and inpatient care in hospitals and clinics, behavioral health services, and dental health services are all examples of direct health care services. The IHS anticipates providing assistance to around 2.2 million American Indians and Alaska Natives during FY 2018.

Care that was either purchased or referred to a healthcare provider is what the text is referring to.

The Purchased/Referred Care program is highly important to American Indians and Alaska Natives due to its provision of vital healthcare services that cannot be offered by IHS and tribally-managed facilities through contracts with hospitals and other healthcare providers.

The Budget allocates $914 million for Purchased/Referred Costs, seeing a $2 million rise from the FY 2017 Continuing Resolution. This funding is intended to aid in medical care for catastrophic injuries, specialized care, and other crucial care services.

The field of study focusing on the connection between a person’s behaviors and their mental health is known as behavioral health.

American Indian and Alaska Native communities have been greatly affected by specific scourges including high rates of alcohol and substance abuse, mental health disorders, suicide, and chronic diseases, as they battle numerous chronic health problems.

To address the continuous behavioral health challenges in Indian Country, the FY 2018 Budget allocates $288 million for Mental Health and Alcohol and Substance Abuse.

There has been an increase of $1 million compared to the FY 2017 Continuing Resolution.

Services focused on preventing illnesses and maintaining good health.

The Budget allocates $157 million for preventive health services in FY 2018, representing a $2 million increase from the FY 2017 Continuing Resolution.

Using evidence-based practices at the local level, IHS collaborates with Tribes to decrease the occurrence of preventable diseases and enhance the health of individuals, families, and communities throughout Indian Country.

Services that are culturally appropriate are provided to American Indian and Alaska Natives through programs like public health nursing, health education, and community health representatives, serving as a means to connect with care for those residing in rural and secluded communities.

Provision of Workers for Recently Established Facilities

In the Budget request, there is funding allocated for the staffing of two recently established facilities. IHS will provide support for staffing in two collaborative projects, namely the Choctaw Nation Regional Medical Center in Oklahoma and the Flandreau Health Center in South Dakota during FY 2018.

IHS teams up with Tribal entities through Joint Venture agreements, wherein IHS offers financial support for the staffing, equipping, and operating expenses of a facility, while participating Tribes take charge of the design and construction expenses of the new facility.

Within the context of managing existing services countrywide, these funds will enable the new facilities to meet the heightened demand for healthcare in regions where the current capacity falls short.

The Indian Special Diabetes Program

An increase of $3 million above the FY 2017 Continuing Resolution, the Budget seeks $150 million in mandatory funding for the Special Diabetes Program for Indians.

Since the initiation of the Special Diabetes Program for Indians, which offers grants for evidence-based diabetes treatment and prevention services throughout Indian Country, there has been a significant improvement in diabetes health outcomes in American Indian and Alaska Native communities.

Between 1997 and 2015, American Indian and Alaska Natives with diagnosed diabetes have demonstrated a significant achievement – a reduction of eight percent in their average blood sugar level. This accomplishment has contributed to a decrease in diabetes-related complications due to improved blood sugar control.

Reimbursements for Health Insurance

The estimated health insurance reimbursements from third party collections for IHS in the FY 2018 Budget request amount to $1.2 billion.

IHS and contracting or compacting Tribes can enhance healthcare services, acquire new medical equipment, maintain and upgrade buildings, and meet accreditation standards by collecting health insurance reimbursements for caring for individuals covered by Medicare, Medicaid, the Veterans Health Administration, and private insurance.

Alternative Programs

In order to give priority to health services and staffing in new facilities, the Budget cuts funding for Self-Governance and Indian Health Professions, and ceases the Tribal Management Grant Program.

The FY 2018 Budget asks for $5 million for Self-Governance, which is $1 million lower than the FY 2017 Continuing Resolution.

Efforts are funded by the Indian Health Professions program to recruit and maintain health professionals who can deliver high-quality primary care and clinical preventive services to American Indian and Alaska Native communities.

The Budget allocates $43 million for Indian Health Professions, which is $5 million less than the previous fiscal year’s Continuing Resolution. This funding amount will ensure the continuation of scholarship and loan payments for existing recipients.

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