|Operating Division overview|
|Preceding Operating Division|
|Jurisdiction||U.S. federal government|
|Headquarters||5600 Fishers Lane, North Bethesda, Maryland, U.S., 20857|
(Rockville mailing address)
|Annual budget||$5.9 billion (2017)|
|Operating Division executive|
|Child Operating Division|
The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally-recognized Native American Tribes and Alaska Native people. IHS is the principal federal health care provider and health advocate for Indian people.
The IHS provides health care in 36 states to approximately 2.2 million out of 3.7 million American Indians and Alaska Natives (AI/AN).As of April 2017, the IHS consisted of 26 hospitals, 59 health centers, and 32 health stations. Thirty-three urban Indian health projects supplement these facilities with a variety of health and referral services. Several tribes are actively involved in IHS program implementation. Many tribes also operate their own health systems independent of IHS.
The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders.
Health services for the needs of American Indian and Alaska Natives in the United States were first provided through the Department of War from the early 1800s until the Office of Indian Affairs came into creation and took over the mission. After the mission again changed departmental authority to the Department of Health, Education, and Welfare's Public Health Service in 1955, the IHS was established.
The original priorities were stated to be
IHS employs approximately 2,650 nurses, 700 physicians, 700 pharmacists, 100 physician assistants and 300 dentists, as well as a variety of other health professionals such as nutritionists, registered medical-record administrators, therapists, community health representative aides, child health specialists, and environmental sanitationists.It is one of two federal agencies mandated to use Indian Preference in hiring. This law requires the agency to give preference to qualified Indian applicants before considering non-Indian candidates for employment, although exceptions apply.
IHS draws a large number of its professional employees from the U.S. Public Health Service Commissioned Corps. This is a non-armed service branch of the uniformed services of the United States. Professional categories of IHS Commissioned corps officers include physicians, physician assistants, nurses, dentists, pharmacists, engineers, environmental health officers, and dietitians.
Many IHS jobs are in remote areas as well as its headquarters outside of Rockville, Maryland, and at Phoenix Indian Medical Center. In 2007, most IHS job openings were on the Navajo reservation. 71% of IHS employees are American Indian/Alaska Native.
The IHS also hires Native/non-Native American interns, who are referred to as "externs". Participants are paid based on industry standards, according to their experience levels and academic training, but are instead reimbursed for tuition and fees if the externship is used for an academic practical experience requirement.
The Snyder Act of 1921 (23 U.S.C. 13) was the first formal legislative authority allowing health services to be provided to Native Americans.In 1957, the Indian Facilities Act authorized funding for community hospital construction. This authority was expanded in 1959 with the Indian Sanitation and Facilities Act, which also authorized construction and maintenance of sanitation facilities for Native American homes, communities, and lands.
ExpectMore.gov lists four rated areas of IHS: federally administered activities (moderately effective), healthcare-facilities construction (effective), resource- and patient-management systems (effective), and sanitation-facilities construction (moderately effective). All federally recognized Native American and Alaska Natives are entitled to health care. This health care is provided by the Indian Health Service, either through IHS-run hospitals and clinics or tribal contracts to provide healthcare services.
The passing of the Indian Health Care Improvement Act of 1976 expanded the budget of the IHS to expand health services. The IHS was able to build and renovate medical facilities and focus on the construction of safe drinking water and sanitary disposal facilities. The law also developed programs designed to increase the number of Native American professionals and improve urban Natives' health care access.
Title V of the Indian Health Care Improvement Act of 1976 and Title V of the Indian Health Care Amendment of 1980 have increased the access to healthcare Native Americans living in urban areas receive. The IHS now contracts with urban Indian health organizations in various US cities in order to expand outreach, referral services, and comprehensive healthcare services.
The Indian Health Service is headed by a director; as of mid-2017 the agency has seen five different directors since the beginning of 2015.
The current acting director is Rear Admiral Michael D. Weahkee, a Zuni.Rear Admiral Chris Buchanan, a Seminole, served as acting director from January–June 2017, and presently serves as deputy director. Prior to Buchanan, the office was headed by attorney Mary L. Smith (Cherokee). Yvette Roubideaux (Rosebud Sioux), was appointed director of IHS by President Obama in 2009; she was re-nominated for a second four-year term in 2013 but was not re-confirmed by the Senate. After she stepped down in 2015, she was briefly replaced by Robert McSwain (Mono). Roubideaux was also preceded by McSwain, who had served as director for eight months. Trump's nominee for the post, Robert M. Weaver, withdrew from consideration after questions arose about his resume.
Reporting to the director are a chief medical officer (Michael Toedt, as of 2018 [update] ), deputy directors (Operations, Government Affairs, Management, and Quality), and Offices for Tribal Liaison, Urban Health, and Contracting. Twelve regional area offices each coordinate infrastructure and programs in a section of the United States.
A 2010 report by Senate Committee on Indian Affairs Chairman Byron Dorgan, D-N.D., found that the Aberdeen Area of the IHS is in a "chronic state of crisis"."Serious management problems and a lack of oversight of this region have adversely affected the access and quality of health care provided to Native Americans in the Aberdeen Area, which serves 18 tribes in the states of North Dakota, South Dakota, Nebraska and Iowa," according to the report.
In July 2017, Director Weahkee was severely chastised during the Senate Interior Appropriations Subcommittee budget hearings by Senator Jon Tester [D Montana].Weahkee refused to answer repeated direct questions about whether the 2018 IHS budget proposal was adequate to fulfill the Service's remit. In the December 11, 2019 Senate Committee on Indian Affairs hearing on the nomination of Weahkee as Director of the Indian Health Service, Sen. Tester, a former chairman and former vice chairman of the committee, told Weahkee, ""I think you're going to get confirmed ... And you should get confirmed."
A network of twelve regional offices oversee clinical operations for individual facilities and funds. As of 2010, the federally operated sites included twenty-eight hospitals and eighty-nine outpatient facilities.
The IHS provides a variety of health services in outpatient and inpatient settings, with benefits including pharmacy, dental, behavioral health, immunizations, pediatrics, physical rehabilitation, and optometry.A more extensive list can be found at the official IHS website, and it is recommended for patients to contact their particular IHS facility to confirm services provided since benefits may differ by location.
To qualify for health benefits from the IHS, individuals must be of American Indian and/or Alaska Native descent and be a part of an Indian community serviced by IHS. Individuals must be able to provide evidence such as membership in a federally-recognized tribe, residence on tax-exempt land, or active participation in tribal affairs. Federally-recognized tribes are annually defined by the Bureau of Indian Affairs (BIA). Non-Indians can also receive care if they are the child of an eligible Indian, the spouse (including same-sex spouses) of an eligible Indian, or a non-Indian women pregnant with an eligible Indian’s child. The exact policy can be found in the IHS Indian Health Manual (IHM).
To apply for benefits through the IHS, individuals can enroll through the patient registration office of their local IHS facility. Individuals should be prepared to show proof of enrollment in a federally recognized tribe.
"Direct Care" refers to medical and dental care that American Indians and Alaska Natives receive at an IHS or tribal medical facility.If patients are referred to a non-IHS/tribal medical facility, there is the option to request for coverage via the IHS "Purchased/Referred Care (PRC) Program". Due to limited funds from U.S. Congress, referrals through PRC are not guaranteed coverage. Authorization of these payments are determined through several factors, including confirmation of AI/AN tribal affiliation, medical priority, and funding availability.
The IHS National Pharmacy and Therapeutics Committee (NPTC) is composed of administrative leaders and clinical professionals, including pharmacists and physicians, who regulate the IHS National Core Formulary (NCF) to reflect current clinical practices and literature.The NCF is reviewed every quarter and revised as needed based on arising health needs within the Native American communities, pharmacoeconomic analyses, recent guidelines, national contracts, and clinician advice. Fibric acid derivatives and niacin extended release were removed from the formulary in February 2017, but there were no changes made to the NCF during the May 2017 meeting. The complete National Core Formulary can be found on the IHS website.
The National Health and Nutrition Examination Survey provides national prevalence data for hepatitis C but excludes several high risk populations including federal prisoners, homeless individuals and over one million Native Americans residing on reservations.To address this concern, in 2012 IHS implemented a nationwide hepatitis C virus (HCV) antibody testing program for persons born between 1945 and 1965. This resulted in a fourfold increase in the number of patients screened. IHS facilities of the Southwest reported the largest gains in number of patients tested and the percentage of eligible patients that received testing. Currently, the incidence rate of acute hepatitis C in Native Americans is higher in comparison to any other racial/ethnic group (1.32 cases per 100,000). Additionally, Native Americans have the highest rate of hepatitis C related deaths (12.95% in 2015) in comparison to any other racial/ethnic group.
Despite this prevalent need, IHS currently does not include any new direct acting anti-retroviral (DAA) hepatitis C medications on its National Core Formulary. [ original research? ] New DAA drugs provide a cure to hepatitis C in most cases but are costly. Due to their lack in funding and quality of care, the IHS has not been able to effectively combat the Native American HCV issue, unlike the Veterans Affairs system, which was able to eradicate much of the disease through adequate resources from the federal government.[ citation needed ]
In 1954, the Indian Health Transfer Act included language that recognizing tribal sovereignty and the Act additionally "afforded a degree of tribal self-determination in health policy decision-making."The Indian Self Determination and Education Assistance Act (ISDEAA) allows for tribes to request self-determination contracts with the Secretaries of Interior and Health and Human Services. The tribes take over IHS activities and services through an avenue called ‘638 contracts’ through which tribes receive the IHS funds that would have been used for IHS health services and instead manage and use this money for the administration of health services outside of the IHS.
The benefits and drawbacks of Tribal Self Determination have been widely debated. Many tribes have successfully implemented elements of health-related Self Determination. An example is the Cherokee Indian Hospital in North Carolina. This community-based hospital, funded in part by the tribe's casino revenues, is guided by four core principles: “The one who helps you from the heart,” “A state of peace and balance,” “it belongs to you” and “Like family to me” “He, she, they, are like my own family”.The hospital is based on the adoption of an Alaska Native model of healthcare called the “Nuka System of Care,” a framework that focuses on patient-centered, self-determined health service delivery that heavily relies on Patient participation.
The Nuka System of Care was developed by the Southcentral Foundation in 1982, a non-profit healthcare organization that is owned and composed of Alaska Natives.The Nuka System’s vision is “A Native community that enjoys physical, mental, emotional and spiritual wellness”. Every Alaska Native in the health system is a “customer-owner” of the system and participates as a self-determined individual who has a say in the decision-making processes and access to an intimate, integrated, long-term care team. When a customer-owner seeks care, their primary care doctor’s foremost responsibility is to build a strong and lasting relationship with the beneficiary, and customer-owners have various options through which they can give input and participate in decisions about their health. These options include surveys, focus groups, special events and committees. The board is made up entirely of Alaska Natives who helped design the system and actively participate in running it effectively. Following the implementation of the Nuka System of Care in Alaska Native health, successes in improved standards of care have been achieved, such as increases in the number of Alaska Natives with a primary care provider, in childhood immunization rates, and customers satisfaction in regard to respect of culture and traditions. In addition, decreases in wait times for appointments, wait lists, emergency department and urgent care visits, and staff turnover have been reported. The North Carolina Cherokee Indian Hospital in 2012 as well as other tribes have implemented the Nuka System approach when planning their new or revamped health centers and systems.
Some tribes are less optimistic about the role of Self Determination in Indian healthcare or may face barriers to success. Tribes have expressed concern that the 638 contracting and compacting could lead to “termination by appropriation,” the fear that if tribes take over the responsibility of managing healthcare programs and leave the federal government with only the job of funding these programs, then the federal government could easily “deny any further responsibility for the tribes, and cut funding”.The fear of potential termination has led some tribes to refuse to participate in Self Determination contracting without a clear resolution of this issue. Some tribes also renounce Self Determination and contracting because of the chronic underfunding of IHS programs. They do not see any benefit in being handed the responsibility of a “sinking ship” due to the lack of a satisfactory budget for IHS services. Other tribes face various barriers to successful Self Determination. Small tribes lacking in administrative capabilities, geographically-isolated tribes with transportation and recruitment issues, and tribes with funding issues may find it much harder to contract with the IHS and begin self-determination. Poverty and a lack of resources can thus make Self Determination difficult.
The IHS receives funding as allocated by the United States Congress and is not an entitlement program, insurance program, or established benefit program.
The 2017 United States federal budget includes $5.1 billion for the IHS to support and expand the provision of health care services and public health programs for American Indians and Alaska Natives. The proposed 2018 budget proposes to reduce IHS spending by more than $300 million.
This covers the provision of health benefits to 2.5 million Native Americans and Alaskan Natives for a recent average cost per patient of less than $3,000, far less than the average cost of health care nationally ($7,700), or for the other major federal health programs Medicaid ($6,200) or Medicare ($12,000).
Life expectancy for Indians is approximately 4.5 years less than the general population of the United States (73.7 years versus 78.1 years).
In 2013, the IHS experienced funding cuts of $800 million, representing a substantial percentage of its budget.Over the past twenty years, the gap between spending on federally recognized American Indian/Alaska Natives and spending on Medicare beneficiaries has grown eightfold. This inequity has a large impact on service rationing, health disparities and life expectancy, and can lead to preventive services being neglected. Other issues that have been highlighted as challenges to improving health outcomes are social inequities such as poverty and unemployment, cross-cultural communication barriers, and limited access to care.
Data from the 2014 National Emergency Department Inventory survey showed that only 85% of the 34 IHS respondents had continuous physician coverage.Of these 34 sites only 4 sites utilized telemedicine while a median of just 13% of physicians were board certified in emergency medicine. The majority of IHS emergency department from the survey reported operating at or over capacity.
Since its beginnings in 1955, the IHS has been criticized by those it serves and by public officials.
Native Americans who are not of a federally-recognized tribe or who live in urban areas have trouble accessing the services of the IHS.
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The Bureau of Indian Affairs (BIA) is an agency of the federal government of the United States within the U.S. Department of the Interior. It is responsible for the administration and management of 55,700,000 acres (225,000 km2) of land held in trust by the United States for American Indians, Indian Tribes and Alaska Natives.
The Alaska Native Tribal Health Consortium (ANTHC) is a non-profit health organization based in Anchorage, Alaska which provides health services to 158,000 Alaska Natives and American Indians in Alaska. Established in 1997, ANTHC is a consortium of the tribal regional health organizations. The Board of Directors for ANTHC equally represent all tribal regions of Alaska and each region has parity. The foundation of tribal region unity and equality provides for the best health care service access for all Alaska Native people.
Native American self-determination refers to the social movements, legislation, and beliefs by which the Native American tribes in the United States exercise self-governance and decision making on issues that affect their own people.
The Native American Housing Assistance and Self-Determination Act of 1996 (NAHASDA) simplifies and reorganizes the system of providing housing assistance to federally recognized Native American tribes to help improve their housing and other infrastructure. It reduced the regulatory strictures that burdened tribes and essentially provided for block grants so that they could apply funds to building or renovating housing as they saw fit. This was in line with other federal programs that recognized the sovereignty of tribes and allowed them to manage the funds according to their own priorities. A new program division was established at the Department of Housing and Urban Development (HUD) that combined several previous programs into one block grant program committed to the goal of tribal housing. The legislation has been reauthorized and amended several times since its passage.
Modern social statistics of Native Americans serve as defining characteristics of Native American life, and can be compared to the average United States citizens’ social statistics. Areas from their demographics and economy to health standards, drug and alcohol use, and land use and ownership all lead to a better understanding of Native American life. Health standards for Native Americans have notable disparities from that of all United States racial and ethnic groups. They have higher rates of disease, higher death rates, and a lack of medical coverage.
In pre-Columbian times, a variety of diseases existed in the Americas. The limited populations and interactions between those populations hampered the development of widespread, deadly diseases in the Americas. One notable disease of American origin is syphilis; aside from that, most of the major epidemic diseases we are familiar with today originated in the Old World. The American era of limited disease ended with the arrival of Europeans in the Americas and the Columbian exchange of organisms, including those that cause human diseases. European diseases and epidemics, while still present among Native American populations today, were especially influential in Native American life of the past. European diseases devastated entire tribes. In more modern times, these diseases still plague Native American populations. Current diseases and epidemics are being addressed by many different groups, both governmental and independent, through a multitude of programs.
Southcentral Foundation (SCF) is an Alaska Native health care organization established by Cook Inlet Region, Inc. (CIRI) in 1982 to improve the health and social conditions of Alaska Native and American Indian people, enhance culture, and empower individuals and families to take charge of their lives. Alaska Native and American Indian people own, manage, direct, design, and drive our Southcentral Foundation. Under the leadership of President and CEO Katherine Gottlieb, Southcentral Foundation has distinguished itself as one of Alaska’s largest federally recognized tribal health organizations, serving the needs of Alaska Native and American Indian people populating a geographical area of 107,413 square miles (278,200 km2). A wide range of medical services and human services are provided to Alaska Native and American Indian people living in the Municipality of Anchorage and Matanuska-Susitna Borough.
The Alaska Native Medical Center (ANMC) is a non-profit health center based in Anchorage, Alaska, United States, which provides medical services to 158,000 Alaska Natives and other Native Americans in Alaska. It acts as both the secondary and tertiary care referral hospital for the Alaska Region of the Indian Health Service (IHS). Established in 1997, ANMC is jointly owned and managed by the Alaska Native Tribal Health Consortium and Southcentral Foundation as well as tribal governments, and their regional health organizations.
There is a lack of dental care in rural Alaska because many Alaska Natives live in rural villages, most of which are only accessible by boat or bush plane. There are many programs to help Alaska Natives understand the importance of dental care while helping them to receive the professional care and guidance that is needed. There are many problem issues within the rural Alaska Native population such as tooth disease. To help with these health issues there are dentists, as well as dental therapist aides, who travel to these villages to perform care. These programs are funded by the United States federal government and the Alaska Native Corporations.
Oklahoma Tribal Statistical Area is a statistical entity identified and delineated by federally recognized American Indian tribes in Oklahoma as part of the U.S. Census Bureau's 2010 Census and ongoing American Community Survey. Some of these areas are also formally recognized as reservations, while the reservation status of others is less certain. Many of these areas are also designated Tribal Jurisdictional Areas, areas within which tribes will provide government services and assert other forms of government authority.
Yvette Roubideaux is an American doctor and public health administrator. She is a member of the Rosebud Sioux Tribe of South Dakota.
The Northwest Portland Area Indian Health Board (NPAIHB) is a non-profit tribal advisory organization in Portland, Oregon, run and organized by participating tribes. It was established in 1972 to focus on four areas as they pertain to the health of Native people: health promotion and disease prevention, legislative and policy analysis, training and technical assistance, and surveillance and research. It serves 43 federally recognized tribes in Oregon, Washington and Idaho, with each tribe appointing a delegate to the board that oversees the NPAIHB. The board meets quarterly to discuss current projects and issues.
Southeast Alaska Regional Health Consortium (SEARHC) is a non-profit medical, dental, vision and mental health organization serving the health interests of the residents of Southeast Alaska.
Contemporary Native American issues in the United States are issues arising in the late 20th century and early 21st century which affect Native Americans in the United States. Many issues stem from the subjugation of Native Americans in society, including societal discrimination, racism, cultural appropriation through sports mascots, and depictions in art. Native Americans have also been subject to substantial historical and intergenerational trauma that have resulted in significant public health issues like alcoholism and risk of suicide.
The United States public policy agenda on issues affecting Native Americans under the Obama administration includes the signing of the Tribal Law and Order Act of 2010, which allowed tribal courts to extend and expand sentences handed down to them in criminal cases, strengthening tribal autonomy. Obama also supported and enforced the Executive Order 13175, which requires the federal government to consult with tribal governments when deliberating over policies and programs that would affect tribal communities. Under the Obama Administration was also the launching of Michelle Obama's program Let's Move In Indian Country, which aims to improve opportunities for physical activity, to increase access to healthy food in tribal communities, and to create collaborations between private and public sectors to build programs that will end childhood obesity in Native communities. Obama also supported tribal communities through certain provisions of the American Recovery and Reinvestment Act of 2009, which allocated $510 million for rehabilitation of Native American housing, and the settlement of the Keepseagle case, a lawsuit against the United States Department of Agriculture for discriminating against tribal communities by not allowing them equal access to the USDA Farm Loan Program. Most recently, Obama signed Executive Order 13592, which seeks to improve educational opportunities for American Indian and Alaska Natives. Obama has been praised by many tribal leaders, including those who claim he has done more for Native Americans than all of his predecessors combined.
The administration of Richard Nixon, from 1969 to 1974, made important changes in United States policy towards Native Americans through legislation and executive action. The Nixon Administration advocated a reversal of the long-standing policy of "termination" that had characterized relations between the U.S. Government and American Indians in favor of "self-determination." The Alaska Native Claims Settlement Act restructured indigenous governance in the state of Alaska, creating a unique structure of Native Corporations. Some of the most notable instances of American Indian activism occurred under the Nixon Administration including the Occupation of Alcatraz and the Standoff at Wounded Knee.
Raycen AmericanHorse Raines: Navy Veteran, Entrepreneur and Businessman. Enrolled member of the Oglala Sioux Tribe and advocate for local grass roots Tribal and community economic development.
The Native American Health Center is a non-profit organization serving California's San Francisco Bay Area Native Population and other under-served populations in the Bay Area since 1972.
Suicide among Native Americans in the United States, both attempted and completed, is more prevalent than in any other racial or ethnic group in the United States. Among American youths specifically, Native American youths also show higher rates of suicide than American youths of other races. Despite making up only 0.9% of the total United States population, American Indians and Alaska Natives (AIANs) are a significantly heterogeneous group, with 560 federally recognized tribes, more than 200 non-federally recognized tribes, more than 300 languages spoken, and one half or more of them living in urban areas. Suicide rates are likewise variable within AIAN communities. Reported rates range from 0 to 150 per 100,000 members of the population for different groups. Native American men are more likely to commit suicide than Native American women, but Native American women show a higher prevalence of suicidal behaviors. Interpersonal relationships, community environment, spirituality, mental healthcare, and alcohol abuse interventions are among subjects of studies about the effectiveness of suicide prevention efforts. David Lester calls attention to the existence and importance of theories of suicide developed by indigenous peoples themselves, and notes that they "can challenge traditional Western theories of suicide." Studies by Olson and Wahab as well as Doll and Brady report that the Indian Health Service has lacked the resources needed to sufficiently address mental health problems in Native American communities. The most complete records of suicide among Native Americans in the United States are reported by the Indian Health Service.
Marjorie Bear Don't Walk is an Ojibwa-Salish health care professional and Native American fashion designer. She is most known as an advocate for reforms in the Indian Health Service, and specifically the care of urban Native Americans. In addition, she was a fashion designer who targeted career women, designing professional attire which incorporated traditional techniques into her clothing.