..  . . .
THE URBAN INDIAN HEALTH PROGRAM 
A Bridge to Mainstream Health Care Delivery 
C;UlVIClS. 
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OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS 
JULY 1988
 OFFICE OF INSPECTOR GENERAL 
ssion of th  Off e of Inspector c;eneral (c;nG) is to promote the efficiency, 
The 
effectIvenesS and Ilteg ty of programs II the Um,ted statesDeparment of Health
and Human Servces (HHS). It does this 
by developing methods to detect and
prevent fraud, waste and abuse. Created by statute in 1976, the Inspector General
keeps both the 
Secretar and the Congress fully and currently informed about
programs or management problems and recommends corrective action. The 
OIG
performs its mission by conducting audits, investigations and inspections with 
approximately 1 200 staff strategically located around the country. 
OFFICE OF ANALYSIS AND INSPECTIONS 
This report is produced by the Office of Analysis and Inspections (OAl), one of the
three major offices within the OIG. The other two are the Office of Audit and the 
Office of Investigations. The OAl conducts inspections which are, typically,
short-term studies designed to determine program effectiveness
, efficiency and
vulnerability to fraud or abuse. 
THIS REPORT 
Entitled ''Te Urban Indian Health Program--A Bridge to Maintream Health Care 
Delivery," this inspection recommends changes in the title V Urban Indian Health
Program and suggests improvements in program plang 
and evaluation as well as
in Federal contract monitoring and management. The report was prepared under 
the direction of Kaye D. Kidwell, the RegIOnal Inspector General, Office of Analysis
and Inspections, Region IX. 
Participating in this project were the following people: 
Thomas Purvs, National Project Director
Alan Levine, Project Liaison, Headquarters
Caroline Tsen, Program Analyst
Ruth E. Carlson, Program Assistant  ,\:,,,,.,.,_         -;,;..,,,.
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THE URBAN INDIAN HEALTH PROGRAM 
A Bridge to Mainstream Health Care Delivery 
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Kusserow 
Richard  P. 
INSPECTOR GENERAL 
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OAI-09-87 -00027  JULY 1988 
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EXECUTIVE SUMMARY 
PURPOSE 
The objectives of this inspection were to determine, in select communities, (1) the
extent to which commumt, health servces, other than the Urban Indian Health
(Ul), 
Pro  ram  are aVaIlable and accessible to low-income and indigent urban
IndIans, (2) the extent ofIndian and non-Indian utilzation and (3) the factors
infuencing utilization. An additional objective
, which developed during the
inspection, was to identify program plannng and management problems. 
BACKGROUND 
Over the past four decades, increasing numbers of American Indians have left
reservations to live in cities. More than half of the 1.4 millon Indians in the United 
. 1  States are currently estimated to live in cities or metropolitan areas. National and
communi  studies in the late 1960s and early 1970s documented barriers faced by
urban IndIans in obtaining necessary health care servces
f r
 , in part because of their
low income levels and complex social problems. In recognitIOn of these needs
Congress enacted the UIHP through Title V of the Indian Health Improvement Act 
of 1976. The intent of title V was to provide improved access to health care for
urban Indians through outreach and referral efforts and, where necessary, direct
health care servces.
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The Indian Health Care Improvement Act, including title V, expired in 1984. From
fiscal years (FY) 1984 through 1987, the Administration did not request funding for
the program, which is admimstered by the Public Health 
Servce (PHS). 
Appropriations have continued through joint resolutions of Congress. Currently, the
UIHP accounts for $9 millon of the FY 1987 PHS Indian Health Service (IHS)
budget authority of $848 Inllon. For FY 1988, the AdInnistration requested
$8 Inllion and recommended a phase-out of the program by 
1991. 
This inspection was designed to complement a statistical evaluation of the UIHP 
which was completed by the Office of Inspector General (OIG), Office of 
The objective of the OA review was to determine whether direct
Audit  (OA). 
health care provided by the UIHP was justified based on an 
analysis of nationwide
UIHP reporting data for fiscal years 1984 through 1986. This Office of Analysis and
i .
 Inspections (OAl) study expanded on the OA data review by undertaking 
suprlemental fieldwork to gain further information on the need of Indian for UIHP 
sefVces. 
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MAJOR FINDINGS 
INADEQUATE  Uniform national criteria for monitoring projects are lacking,
i.  MONITORING	 and there is inconsistent management oversight of the UIHP.
AND TECHNICAL 
Budgetary decisions are not necessarily based on documented
ASSISTANCE
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 need or organizational effectiveness. This has resulted in
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	 inequitable and fluctuating funding of some projects, which
to the projects. 
hampers their abilty to plan or provide 
conSIstent levels of 
sefVce. Finally, IHS provides only liInted technical assistance
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ESSENT The title V legislation called for detailed needs assessment and
PLAING DATA  program plannng processes. In recent years, most UIHP
AR LACKING 
projects nave not implemented this requirement. Only two 
local needs assessments have been carried out in the past 
3 years. Standardized national statistics on urban Indian health 
needs do not exist. 
UTILIZATION  Accurate population statistics do not exist in many areas and 
RATES LACK  are skewed in others. If the indigent and low-income Indian 
ACCURATE  population were used as the base and defined consistently,
POPULTION 
utilzation rates in many areas would be considerably higher
BASE 
than shown in the IHS statistics for the UIHP program. 
INDIAS FACE  Urban Indians who are indigent or who lack health insurance
BARERS TO  face barriers in attempting to gain access to health care.
HEALTH CARE  Barriers to mainstream care include complex and restrictive 
eligibility requirements for State and local assistance programs 
i. 
lack of outreach or targeted servces from other commumty 
providers and, on occasion, direct prejudice. These are siInlar 
to barriers faced by other indigents, but include some cultural 
factors unique to Indians. 
For all centers, 37 percent of users are non-Indian. The 
NON-INDIAS  utilization rate for non-Indian users ranged from 1 percent to
USE THE URBAN  55 percent for the UIHP sites visited. Multiple funding sources
INDIA HEALTH 
require nonrestrictive servces. Reasons given for use of the
PROGRAS 
UIHP by non-Indian clients are convenience, low cost and 
accessibili ty. 
RECOMMENDATIONS 
. The Public Health Service should strengthen management of the UIHP 
by (1) implementing a monitoring and evaluation system with uniform 
i. J;	 natIOnal criteria for all area offices, (2) completing an updated 
standardized national needs assessment (based on a standardized updated 
, 1	 needs assessments in each local area) and (3) continuing the effort to 
improve the collection and disseInnation of uniform national aggregate
ic 
and comparative statistics. 
. The PHS should use needs assessment and evaluation data to decide 
future funding allocations and individual project-level funding. 
. The PHS should provide more explicit guidelines concerning adequate
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information and referral programs, including assistance in gaining access 
to Medicaid, other medical assistance programs and mainstream health 
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providers. 
. The PHS should complete a detailed analysis of the barriers which inhibit 
Indian access to mainstream health care and develop an action plan to 
overcome the barriers. 
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. The Public Health Service should:

1. move the UIHP from IHS to the Bureau of Health Care Delivery and 
Assistance (BHCDA) where it could be integrated with the community
health servces program and other programs providing health care to 
urban residents il

2. develop explicit linkages locally between UIHP clinics and community 
health centers (CHCs) and nationally between IHS and BHCDA so that 
the clinics and IHS staff can take full advantage of the urban community
health care expertise of the CHCs and the BHCDA. 
AGENCY COMMENTS 
The PHS concurred with all of the OIG recommendations and has taken steps to
implement the recommended changes. Of the alternatives presented in our fifth
recommendation, PHS has chosen to adopt the second option. 
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TABLE OF CONTENTS 
Page 
EXECUTIV SUMMAY 
r r  INTRODUCTION 
FINDINGS 
SERVICE DUPLICATION 
PROGRAM UTILIZATION 
PROGRA MAAGEMENT 
RECOMMENDATIONS 
APPENDICES 
APPENDIX A: RECEIPTS BY SOURCE AN PROGRAM 
APPENDIX B: MEDICAL RECORD REVIEW 
APPENDIX C: COMMUNITY HEALTH CENTERS 
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APPENDIX D: INDIA POVERTY POPULATION 
APPENDIX E: INFORMATION AN REFERRA COSTS 
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l.. INTRODUCTION 
BACKGROUND 
Legislative Perspective 
The Snyder Act of 1921 and the Indian Health Care Improvement Act of 1976 form 
the principle statutory bases for the provision of health care programs by the Indian
Health Servce (IHSI The Snyder Act broadly describes the Federal role in Indian 
health care matters I for the benefit, care, and assistance of Indians throughout the
United States...for relief of distress and conservation of health." The IndIan Health 
Care Improvement Act further defines the scope of Federal responsibilty to raise 
Indian health status to the highest level possibfe. Congress passed the act to address 
the unmet health needs of both reservatIOn and urban Indians. Title V of the act 
established the Urban Indian Health Program (UIHP) to provide outreach and 
referral services and, where necessary, direct health care services. The funding for 
the program is a separate budget line item under the IHS appropriation. 
The legislative authority for the Indian Health Care Improvement Act expired in 
1984. Congress has extended appropriations through continuing resolutions. A bil 
for the reauthorization of the act has been introduced in Congress. A portion of this 
bil would continue the UIHP under the general authority of the Snyder Act thereby 
ensuring its permanent inclusion in the Indian health care delivery network. 
Factors Contributing to Urban Indian Growth 
Approximately 50 percent of the total 1.4 Inllion American Indians are 
concentrated II urban areas, compared with 24 percent remaining on reservations 
and 26 percent in nonmetropolitan areas. Between 1950 and 1960, the size of the 
urban fndian population nearly tripled from 56 900 to 166 000. This rapid growth 
was infuenced oy Federal polIcy in the 1950s which relocated many tribes and 
individual Indian faInlies from rural areas to cities. Escalating unemployment and 
poverty on reservations contributed to voluntary urban IngratIOn by IndIans seeking 
, the Indian population in urban areas has grown 
Jobs and other services. Since 1950
more than sevenfold. 
Title V Urban Indian Health Program 
National policy has long emphasized Federal responsibilty for providing health care 
to Indians living on or near reservations where tfiey are part of a total care service 
system. The assumption has been that urban Indians can obtain servces at the local 
level the same as non-Indians. In cities, however, experience has shown that Indians 
are il-prepared to use local health and social services. The difficulties encountered 
by many Indians in gaining access to and using mainstream resources prompted the 
establishment of the UIHP. 
The origins of the UIHP predate the title V program. The UIHP began in the late 
1960s as a grassroots effort by Indian community leaders in response to growing 
health problems of urban Indians. The origins of some urban Indian projects were 
part of community efforts sponsored by the Office of EconoInc Opportunity. 
Initially, small clinics were operated on a part-time basis and staffed by volunteers.  In 1972, Congress appropriated funds for a pilot urban Indian project in 
Minneapolis. Congressional interest grew over the next few years, leading to the 
passage of the 1976 authorization which established and funded additional projects 
in several cities. As of Fiscal Year (FY) 1986, there were 37 tite V sites located in 
18 States. A listing of these sites is shown in appendix A. 
Justification for separate Indian health centers in urban areas has been given 
several sources, including UIHP staff, board members and patients as well as 
community providers. The following points were presented by these sources: 
. For urban Indians, cultural barriers are not easily surmountable. Indian 
may be reluctant or unable to describe their health needs to strangers 
outside their own culture. Frequently, mainstream providers 
misunderstand or misinterpret the reticence and stoicism of Indians. 
. Some health care providers are reluctant to serve Indians because they 
believe Indians cannot or wil not pay. In some cases, outright prejudIce 
is a factor. 
. The UIHP is designed to bridge reservation and urban mainstream health 
care. The UIHP staff are faITliar with the special needs of Indians and in 
most cases are Indians themselves. They recognize endeInc Indian 
health problems and are able to offer immediate, appropriate and 
cost-effective medical attention. Urban Indian climcs not only provide 
essential primary health care, but also contribute to the overall mental 
and social well-being of urban Indians. 
Title V requires UIHP projects to implement the following plannng activities: 
1. deterInne the size of the local urban Indian population
2. 
identify public and private health care resources
3. 
identify gaps between unmet health needs and the resources available to 
meet such needs 
4. help Indians to become faInliar with health resources and 
5. recommend ways to improve urban Indian health projects. 
In FY 1986, the title V funding for 37 sites in existence at that time was $8.
6 Inllion. 
Since most sites have additional funding from other sources, their aggregate funding 
was $19 Inllon. The following table shows funding sources and amounts since 1984. 
URBAN INDIAN HEALTH PROGRA RECEIPTS BY SOURCE 
1984-1986 
(Milions of dollars) 
1984  1985  1986 
Title V 
Other Federal 
State  2.3 
County 
2.3 
TOTAL  17.4  19.  18. 
SOURCE: Urban Indian Health Care Program, FY 1986 Charts and Graphs, American 
Indian Health Care Association, Minneapolis, 1986, p. 3  Since 1982, title V has contributed between 45 and 49 percent of the projects
budgets. Other funding comes from other Federal, State, city and county sources. 
For FY 1986, title V funds constituted 45. 1 percent of the total funding. Appendix A
contains a complete breakdown of funding by source and by UIHP project. 
The following table shows servces provided, as measured in encounters, which IHS
defines as a discrete servce given. An individual user may have multiple encounters
during a year. According to IHS, the decrease in total servces shown since 1982 
may bea result of improved 
accuracy in reporting to eliInnate duplicate counting,
rather than an actual reduction in numbers served. 
YEAR 
SERVICES PROVIDED BY UIHP CENTRS
1982 582
1983 534
TOTAL NUMBER OF ENCOUNTERS
1984 487
1985 504
567
1986 472
157 
153
133
009 
SOURCE: Urban Indian Health Program, FY 1986 Charts and Graphs, p. 16 
Direct Health Servces Provided by UIHPs 
The UIHP program defines direct health services as "delivery of outpatient medical
dental and mental health servces adInnistered by licensed health care 
professionals." The following table shows 1986 total funding amounts for direct
health services by major functional areas including optometry and inpatient care. 
FUNDING FOR DIRECT HEALTH SERVICES 
1986 AMOUNT 
FUNCTIONAL AREA  (Millons of Dollars) 
Medica 
Dental 
Inpatient 
Mental Health  1.0 
Optometry 
Alled Health

TOTAL 
13.4 
SOURCE: Urban Indian Health Program, FY 1986 Charts and Graphs, pp. 7
OBJECTIVES 
The principal objectives of this inspection were to deterInne (1) whether the Urban
Indian Health Program duplicates other sources of health care by 
analyzing the
extent to which community health servces are available and accessible in select 
communities, (2) the extent ofIndian and non-Indian utilzation and (3) the factors
which influence utilization. Another objective, which developed during the course
of the inspection, was to identify program plannng and management problems.  METHODOLOGY AND SCOPE 
The 37 title V sites funded in FY 1986 were stratified into 7 tiers based on the level 
of pro$ram funding and utilzation. Selection of sites was based on an analysis of
historIcal data, current funding and health servce delivery patterns and practices.
Nine sites were selected to include at least one site from each stratum. In order to
determe if direct health servces are justified, the OIG staff identified available
health care providers and reimbursement mechanisms in each site and the extent to 
which these are accessible to Indians. Intervews were conducted with urban Indian 
health program staff, community health centers, representatives of hospitals and
other health care providers, advocacy and public interest groups and Indian clients. 
In seven out of the nine sites, a random sample of medical records was drawn and
data were analyzed to assess utilzation patterns and client characteristics (see
appendix B). 
This inspection was not intended to be a comprehensive assessment of urban Indian 
health needs or a definitive program evaluation. Some observations on project 
accessibilty and health care barriers for urban Indians have been made. While this 
inspection exaInnes some of the factors contributing to high/ow utilization, it does
not provide new or comprehensive data on urban Indian health needs, population
characteristics or health resources available. 
SUMMARY 
UIHP FUNDING AND UTIIJZATION (FY 1986)

FUNDING  UTILIZATION 
TI V

INIA 
45% 
63% 
NON-TI V

55% 
INIAS - 74 
TITLE V - $8.6 MIUJON  230 
OTHER - $10.4 MION  NON-INDIAS - 43 188  , "
FINDINGS

SERVICE DUPLICATION 
Access to Community Health Programs Is Limited for Indigent and Working Poor
Indians 
A variety of health care financing mechanisms and health providers are potentially 
available to urban Indians in most sites. All communities visited have physicians 
hospital emergency rooms and public health clincs, and most have community 
health centers. All States have Medicaid and most States or counties have 
medically'-needy or medically-indigent adult eligibilty cat gories. The avaqabilty of
such seivces does not mean, however, that they are accessible to urban IndIans. As
is true of many other low-income or indigent groups, urban Indians face a variety of
problems in gaining access to health servces. 
Few Urban Indians Receive Medicaid 
Although the Indian unemployment rate is 50 percent or more in some urban areas 
fewer than 15 percent of urban Indians are enrolled in Medicaid. In 1986, according
to statistics from the Health Care Financing AdInnistration, 174 000 out of 
1.4 millon Indians, or 12 percent nationally, were Medicaid recipients. Many 
low-income Indians do not enroll in Medicaid. Some do not make the effort to 
deterInne if they are eligible. Others do make the effort but find they do not 
qualify. 
There are several reasons why Indians do not apply for Medicaid. Eligibility
requirements are complex and growing increasmgly restrictive. For example, in
Anzona, the Medicaid eligibilty forms are 25 pages long. An Indian affairs director
in one State explained  You have to be an attorney to wade through the Medicaid
application form. Many Indians won t bother." Enrollment assistance is sought in
crowded and unpleasant waiting rooms. To some, especially pregnant women 
returnin~ to the reservation may seem like a more attractive alternative. Others 
forgo pnmary care, seeking health services only when their ilness becomes severe or 
when true medical emergencies develop. 
Some States have eligibility standards more stringent than the Federal poverty
standards. Reports from several UIHP sites indicate that some Indians either resign
from jobs or move back to the reservation in order to become eligible for Medicaid 
or IHS health services. An Indian multi-servce center director explained that 
taking a low-income job with no health benefits is more costly than staying on 
welfare. Many Native Americans go back on welfare to keep their benefits. 
A few jurisdictions provide help in overcoming enrollment barriers. In Salt Lake 
City, the Maternal and Child Health program brought social servces and health 
department personnel together with patient advocates to deal with barriers to the 
application process  As a result, Medicaid participation by Indians and other 
indigents increased by more than 40 percent. In Phoeni, a full-time UIHP 
community reJ?resentative offers direct and intensive help to overcome individual 
eligibilty barners.  Other Medical Assistance Programs Offer Highly Restrictive Coverage and
Benefits to Urban Indians 
Many States offer medically-needy or medically-indigent adult (MIA) programs to
those not eligible for Medicaid. Even with assIstance in completing the ehgibility 
process, many Indians do not qualify for these servces because employment, even
though margmal, puts them over the income criteria. Urban Indians are largely the
worklng poor. Many have only part-time jobs. Although their jobs are low-paying,
they pay salaries sufficiently hIgh to place them just above the income scale for 
MedIcaid or medically- indigent adu1t programs. In addition, these jobs do not
usually offer health insurance. The lacK of financial assistance severely restricts
accessibilty to these programs. 
MI 
In several Californa locations  funding once received by the UIHP projects has
been redirected to county facilties. Some UIHP center directors stated that Indians 
covered by the MIA program must now use a source of care that is often less 
accessible or forgo needed health care altogether. 
Indians Face Problems in Access to Private Physicians 
Problems for Medicaid beneficiaries in obtainin  primary health care were
documented in a service delivery assessment on Access to Physicians for Medicaid
Beneficiaries " conducted by the OIG Dallas Regional office in 1980. Physicians and
staff in many UIHP sites report that access to pnvate providers continues to be a
problem for Indian and other Medicaid reciJ?ients. Physicians increasingly refuse to 
accept new Medicaid patients. This is especIally true of key specialist fields, such as
obstetrics and weco logy. Reasons for physician refusal to accept Medicaid patients
continue to be (1) perceIved low reimbursement rates, (2) complex claims forms and
(3) payment processing delays. 
Physician access is equally difficult, or more so, for non-Medicaid assistance 
programs. San Francisco UIHP staff report that it can take up to 4 months to see a
physician under the county-operated MIA program. For an Indian to see a private 
practice physician, having insurance or the abilty to pay fees is paramount. Most
physicians are not willng to see indigent patients as charity cases except in very
special circumstances. One of the UIHP staff physicians in Montana reported that 
private practice physicians had exercised peer pressure to stop a few who had been 
providing charity care to Indian patients, evidently because of fears that this could
affect their fees. Medical staff at UIHP sites also reported that most private 
physicians are not aware that Indians are specially prone to certain disorders such as 
oiabetes and otitis media and, therefore, do not always provide the necessary testing
for these diseases. 
Non-urgent Care through Hospital Emergency Rooms is Costly and Lacks
Continuity 
Many urban Indians use hospital emergency rooms (ERs) for non-urgent care. 
Hospital ERs, particularly public ones, have traditionally served as a source of care
to indigents. As a 1983 OIG Servce Delivery Assessment on "Use of Hospital
Emergency Rooms for Non-Urgent Care" showed, non-urgent care offered through
emergency rooms is very costly and tends to be episodic in nature. Follow-through
servces may be sporadic, and preventive care is not given. Long delays in waiting 
rooms and additional referrals are common.  In many areas, the UIHP projects are alternatives to the more costly hospital ERs.
The hospital or the county has to absorb the costs for non-urgent ER use by 
indigents. Many jurisdictIons 
have set up a system of satellte outpatient clmics at
the hospital or other locations to provide alternatives to ER servces. In a few areas 
such as San Francisco and Alameda Counties, the UIHP and the hospiUtal sla tellites
are part of a consortium of neighborhood clinics. In some sites, if the  clinics 
did not exist, most of their clients would turn to much more expensive care through 
the emergency rooms, unless they were served by community health centers. 
Even public hospitals expect payment for services. If there is no third party coverage 
for an individual patient, a sliding scale fee is applied. Letters are frequently sent
demanding payments. 
Federal Hil-Burton construction funding obligates hospitals to provide indigent 
care. Nearly all hospitals built or modernized through f975 are under this obligation.
In several sItes, the OIG team was told that hospitals seek to provide only Inmmal
servces to fulfil their Hil-Burton obligations. ln one of the sites; the single
community hospital budgets a liInted amount for Hil-Burton obligations which is
usually expended by Ind-year. 
Community Health Centers Have 
Few Indian Patients 
Community health centers (CHCs) do not constitute a significant source of primary 
care for urban Indians. Of the 10 CHCs visited by the OAI team, none had more
an an estimated 3 percent Ipdian patient population. Most CHCs noted th  they
dId not serve any Indians, while others Ildicated that they had very few. Statistical 
data on Indian utilzation of CHCs are not available since these facilties do not 
keep records of patients by ethnic identity. The chart in appendix C 
shows the 
location and funaing of federally-funded CHCs in those cItIes where there are also 
UIHP projects. 
Community health center directors, staff and others highlighted several reasons why
Indians do not use CHC services: 
Indians represent a small percentage of the total population of the 
communitIes included in this inspection. In Los Angeles, Indians 
represented less than 1 percent of metropolitan area residents. In none 
of the other sites do Indians represent more than 3 percent of the total
metropolitan population. 
. The CHCs generally tend to serve clearly defined neighborhoods and 
those individuals living near the facilities. Indians, unlike most other 
ethnic groups, tend to be scattered throughout metropolitan areas. This
liInts the potential of CHCs to provide outreach to Indians. In addition
targeting the Indian population would require a formal and structured 
outreacn program--a costly servce that most CHCs indicate they cannot 
afford. 
. The CHCs are not free clinics. Most 
bil for services as aggressively as
hospitals and private physicians. The OIG staff was told that while no 
CHC wil refuse servIce to an indigent client because of inabilty to pay,
Indians, as well as other indigent individuals, are often intiIndated or 
discouraged from seeking CHC servces. 
A CRC in San Francisco, located near the UIHP clinic, voiced concerns siInlar to 
other CHCs. Staff stated that given liInted resources and pressing demands, they do
not have the capacity to serve an additional population group, whether it be Indians  or others. With additional resources, the center director indicated that this would be
possible. The director stressed, however, that even if the staff and budget were
Indians 
Ilcreased, the center does not have staff currently trained to appropriately address 
the health and social needs of Indians. 
Public Health Clinics Lack Capacity to Provide Adequate Primary Care to Urban
Public health clinics face problems siInar to CHCs in servng Indians. Clinc staff 
and others report that they' have little outreach capacity and find Indians, who do not
congregate in easily identified community groups, a difficult population to target.
County budgets, like Federal funds, are also shring, thereby Ilcreasing the
budgetary constraints placed on public health centers. 
PROGRAM UTILIZATION 
Utilzation Rates Are Not Fully Accurate 
Utilzation rates for the UIHP need to be carefully interpreted before they can be
fully understood. The IHS utilzation rate 
are  ased on the 19 0 census dat
IndIan populatIOn beyond the census year 
IS projected through lInear regressIOn
techniques using IndIan birth and death data provided by the National Center for 
Health Statistics. 
Census data are the only comprehensive data available. They are subject to
data-gatherin$.imper ections, however, as India  are highly mobiI  diffi 
track. In addItion, uSIlgthe total number of IndIans to  !ind  ult
calculate utIlIzatIOn dIsguIses
the fact that the actual target population is, or should be, indigent, unemployed or
marginally-employed Indians who are not covered by health insurance and who have 
difficulty II gaIning access to mainstream health care. The Census Bureau publishes
data on Indian population by metropolitan and urbanized areas. These data are
broken down to show Indian population in 1979 for all income levels as well as those 
below the poverty level. The IHS uses the figures for all income levels as its base;
however, data for Indians living below the poverty level Inght be a more accurate
base. A table showing these data for several California cities is contained in 
appendix D. 
There are also anomalies in calculating the base rates since some UIHP catchment 
areas are not synonomous with the census areas. 
Population figures utilzing
Standard Metropolitan Statistical Areas (SMSAs), for example, include multi-county
areas which may extend well beyond the tJHP catchment areas. Population figures
shown for some areas include Indians living on reservations. Finally, only a fraction 
of Indians or any other population group Will be sick and in need of health servces 
in a given year. 
The IHS has been working for several years with the American Indian Health 
Care
Association to improve data gathering and utilization statistics for the program.
Much progress has been made, but further improvements would ensure greater 
accuracy in utilzation and other needed data. 
What Current Indian Patients Say 
About Utilzation 
The OIG inspection team talked to approximately 50 Indians. Intervews were 
conducted randomly with patients waiting for services at the UIHP projects visited.  Nearly all (46 of the 50) were current users of the Indian health centers. The other 
four were former patients who accompanied friends to the project. The Seatte 
Indian Health Board also conducted a survey early in 1987 of 613 patients, 18 years 
or older, who lived in Kin~ County and who had used the Health Board' s servIces 
medical records in seven of the nine sites 
within the past 3 years. FIlally, analyses of 
visited provides further indicators of utilzation. 
Urban Indians Use the UIHP Centers Because They Are Afordable and Accessible 
Affordability, presence of qualified "caring" staff and perception of the UIHP as a 
special place for Indians were the primary reasons given by current patients who 
utilize tbe projects. 
WH PATIENT COME TO UIOP FOR CARE 
Percent  Percent 
OAf Client  Seattle UIHP 
" StafSfample (N = 46) * Sample (N=613)*
Affordabilty/SlidingFee
QSupaliefedc ainad "lC Parinlgace for Indians
Friend or Relative Goes There 
t Know of Other Programs
Don 
Convenient/Accessible Location 

*The percentages total more than 100 because patients could give more than one response. 
Indian UIHP patients intervewed by OIG staff were mostly satisfied with the 
services, Only seven respondents expressed dissatisfaction. Those who were 
dissatisfied gave reasons such as "had to travel too far" and "disliked director. 
Word-of-Mouth Referrals Are a Key Utilzation Factor 
Most Indians heard about the UIHP from a friend or relative (39 percent), from 
other Indians" or individuals (26 percent) or from a referral from another health 
center (13 percent). Six percent said they "always knew of the center" and only 
2 percent said they became aware of the program from the phone book, newsletters 
or from former staff members. 
Other Sources of Care and Barriers 
Respondents were asked what sources of care would be used if the UIHP centers 
were not available. While many ansered th se private p  ysicians 
ey would 
hospItal emergency rooms or other commumty or publIc health clImes, the most 
common answer (36 percent) was that they did not know. When asked what barriers 
existed at other sources of care, long waits (34 percent) was mentioned most often. 
Other barriers mentioned included overworked, uncaring staff (15 percent) and " 
understanding of Indians. 
Many Factors Limit Utilzation 
Several factors prevent greater utilization of the UIHP centers. The highly mobile 
makes outreach more diffcult and thus 
and Ingratory nature ofthe population 
decreases utilization. Budgetary and staffing liIntations constrain the maxmum 
capacity of many UIHP centers to provide services. In Boston, for example, there 
are funds to maIltain a primary care physician for only 4 hours per week, during  which time no more than 10 to 15 patients are seen. The Boston project does not
advertise or employ active outreach for fear that its liInted capacIty would be 
overwhelmed. Other UIHP projects curtailed outreach because of siInlar concerns. 
Even when the centers operate at full capacity, they reach only a small percentage of 
the Indian population. 
Finally, many Indians return to their reservations for health care. This is particularly 
true of pregnant women who want to deliver their babies on the reservation or who
encountered difculty in accessing the UIHP or maintream servces. 
Utilzation Could Be Improved 
Many respondents felt that more could be done to improve outreach and utiliation 
rates. The Maternal and Child Health (MCH) and Women and Infant Care (WIC) 
program are among the most popular and successful UIHP-operated programs. 
These are magnet program which bring in faIlies who then use general medical 
servces. Several projects reported that outreach for these two programs had been 
cut sharply with aoverse effects on general utilzation rates. Greater outreach 
efforts for MCH and WIC would immediately increase  UIHP 
utilzation. Several 
staff reported that word-of-mouth was the most effective means of inforInng urban 
Indians about health services. More effective use of Indian organizations 
newspapers and powwows would result in increased utilzation. 
Many of the UIHP projects are housed in run-down facilities in less desirable 
neighborhoods. ClInic location in the most run-down areas deters many Indians 
especially the working poor, from seeking services. In recognition of this factor 
several centers have plans to move or to upgrade their present facilities. 
Many Non-Indians Use UIHP Centers 
The following table shows non-Indian utilzation for the 9 sites visited and for the 
37 sites funded in 1986. Over one-third of the users of the UIHP program are 
non-Indian. Nearly one-half of the total UIHP budget comes from sources other 
than tite V. In most sites, those projects where title V is a smaller proportion of the 
total budget have a higher percentage of non-Indian users. For some, such as 
Seattle, San Francisco, Phoeni and Los Angeles, title V represents less than 
one-half of the total project budget. Although some of the non-title V funding is 
earmarked for Indians, most funding sources do not perInt restriction of client 
populations to a particular ethnic group. 
UIHP CLIENT POPULTION 
Non- Percent  Title V 
Indian  Indian  Non- Percent of 
Users User6s  .Indian  Budget 
Al 37 UIHP  721 
BSites oston  4188  31 36.  45. 
Selected sites
054 
Seattle 5895 1 160 7.  100.
Salt Lake City 250966 5 6781288 35 5 1.9. 5 4782..  
SLaons  FAranngceilsecso  34 986983 3 255  33.
TPhuocesnoi n8  48.4  50.
710 
Helena  38.4
586 220 23. 
22.2  92. 
Missoula  148 20. 
75.3
100. 
Source: Urban Indian Health Program, FY 1986 Charts and Graphs, pages 47 Non-Indian patients did not express any concern about using a clinic that was 
designated Indian. They were attracted by the same considerations as Indian 
patients, but with slightly different prioritIes: the low fees that were charged if the
patient had no source of third party payment and the accessibilty of the UIHP 
center. Two of the most popular programs, MCH and WIC, were particularly
attractive to non-Indian as well as Indian patients. 
PROGRAM MANAGEMENT 
The Indian Health Servce Has Not Managed the Program Adequately 
The IHS has not provided resources to properly manage the UIHP. 
Until recently,
there were no full-time staff in IHS heaaquarters or in the area offices with
responsibilty for the urban projects. Each area office has its own system for
monitoring projects. Some area office staff conduct on-site visits two or three times 
a year, whIle others may conduct only one or none. The IHS uses standard 
procedures for review and approval of contracts, but has no national procedures
prepared for specific use in managing the UIHP. Clinical reviews of urban projects
have been done on an individual basis, but there is no required schedule or protocol. 
Basic Program Planning and Evaluation Is Lacking 
The ori~inal models for the programs were supposed to be based on locally 
determIled needs. It is not clear to what extent such needs assessments were done 
during the initial stages of the program. Once the initial allocations were made 
however, they frequently became the basis for all subsequent allocations. Variations 
in funding have not been based on changing needs or on evaluations of effectiveness. 
The last national compilation of Indian health needs was conducted in 
1976 with the 
subInssion of the IndIan Health Care Improvement Act. Updated needs 
assessments have not been required by IRS as a condition of continued funding. 
Until 1985 there was no uniform statistical reporting for the urban programs to show
comparative data on utilization, servces provIded, sources of funding or
expenditures. Although the annual national census data have been useful in aiding 
the health plannng process for urban Indians, these data are inadequate. 
One of the few urban Indian needs assessments to be carried out in recent years was 
conducted in 1986 by the San Francisco UIHP with assistance from the Robert 
Wood Johnson Foundation. This survey encompassed a 5 percent sample of Indians
living in the San Francisco Bay area and represented both users and non-users of the
San Francisco UIHP. Findings from this assessment show a disparity between
Indian socio-econoInc status and that of the general population, even for Indians
who had lived in the city for many years. The methodology for this Bay Area 
assessment is available for replication by other UIHP centers. 
Inadequate Criteria Exist for Evaluating Information and Referral Servces 
Information and referral (I & R) was a primary purpose of the UIHP program set 
forth in the 1976 Indian Health Care Improvement Act. The table in appendix E 
shows the amount expended for I & R services for each of the nine sites In this 
inspection and for air sites funded in 1986. 
Neither the Act nor IHS guidelines delineate what 1& R services should encompass.
In some locations, they consist of little more than compiling a directory of health  servces that are available in a community and handing this to clients. 
Other centers
provide much more comprehensive services. These include counseling, 
Identification of individual needs and available community resources
, help with the
preparation of eligibilty documents and follow-through. 
For this reason, many of the projects have negotiated written agreements with public
or private hospitals. These agreements make adInssion to the hospital (or transfer
back to the UIHP center) much easier. Transfer and referral forms sent with the 
patient include information about current medical findings, diagnosis, rehabiltation
potential cmd pertinent adInnistrative and social information. While the transfer 
agreements state that the patient is responsible for the payment of hospital bils 
written documents simplity the hospita1 adInssion process for indigent 
patients. 
Lack of Permanent Legislation Impedes Effectiveness 
Lack of permanent legislative authorization since 1984 has impeded effective 
operation of the UIHP projects. Funding is available only on a year-to-
year basis 
and funding levels have been uncertain. This impedes program plannng, especially
for those who have depended on tite V monies for most or all of their funding. This
has compounded the problems which stem from lack of consistent monitoring by 
IHS. 
Variation Exists in Licensing and Accreditation 
There is considerable variation concerning the licensure and accreditation status of 
the UIHP projects. Those that provide only information 
and referral are usually
located in an Indian multipurpose center and do not need licensing 
as a health
facility. At the other extreme are four centers which meet the exacting standards of 
the Joint ComIssion on the Accreditation of Healthcare Organizations (JCAHO).
The remaining centers meet Innimal State and local requirements for the licensure 
of an outpatient health facility.  RECOMMENDATIONS 
RECOMMENDATION #l--PROGRA PLANING AND MAAGEMENT 
FINDING: Uniform national criteria for moUnitolri.n g projects are lacking, and there 
is inconsistent management oversight of the  Budgetar decisions are not 
necessarly based on documented need or organizational effectiveness. Ths has 
resulted in inequitable and fluctuating funding of some projects which hampers their 
abilty to plan or provide consistent levels of servce. Furthermore, IHS provides 
only limited techical assistance to the projects. 
RECOMMENDATION: The PHS should strengthen management of the UIHP by 
monitoring and evaluation system with uniform national criteria 
0) implementing a 
for all area offices, (2) completing an updated standardized national needs 
assessment (based on a standardized updated needs assessments in each local area)
and (3) contIluing the effort to improve the collection and disseInnation of uniform 
national aggregate and comparative statistics. 
PHS COMMENTS: We concur. The IHS has already taken action to strengthen 
management by refining the UIHP evaluation criteria which wil be included in the 
IHS manual. These criteria will define the responsibilities of IHS headquarters and 
area offices regarding monitoring and review of the adInnistrative and clinical 
components of the health care delivery system. 
The IHS has also established a monitoring and evaluation system and has initiated 
on-site quality assurance program reviews of UIHP clinics. These reviews are using a 
structured review protocol patterned after that used by the JCAHO. 
The IHS eXJects to complete the development of a standardized national needs 
assessment II FY 1989. The IHS expects that the standardized needs assessment wil 
be in use for all UIHP clinics by the end of FY 1989. 
The IHS has imI?lemented the Urban Common Reporting Requirements (UCRR) 
and is currently Improving the national data by collecting diagnostic and 
epideInological data for the UIHP. These efforts wil continue. 
RECOMMENDATION #2--FUNDING DECISIONS 
FINDING: Funding and budgetary decisions are not based on documented need or 
organizational effectiveness. The UIHP reporting and data system, which is now 
partially implemented, is not being fully utilzed as an accurate base for the 
equitable dIstribution of funding among urban Indian projects. 
RECOMMENDATION: The PHS should use the needs assessment and evaluation 
data to decide future funding allocations and individual project level funding. 
Projects that do not provide essential or cost-effective servces should have funds 
redIrected or reprogrammed to areas of greater need. 
PHS COMMENTS: We concur. The IHS will initiate shortly a process to document 
the need for direct services at each current or proposed UIHP clinic. This  assessment of need will include documentation of the availabilty of 
health care 
servces from providers not specifically funded to servce American Indians and 
Alaska Natives. Any cost savIlgs will be redirected or reprogrammed to areas of 
greater need. 
RECOMMENDATION #3--INFORMTION AND REFERR 
FINDING: Criteria concerning adequate information and referral servces are 
lacking. 
RECOMMENDATION: The PHS should provide more explicit guidelines 
concernng what constitutes an adequate iriormation and referral program 
including assistance in gaining access to Medicaid and other medical assistance 
programs and mainstream health providers. 
PHS COMMENTS: We concur. The IHS will develop a program guidance
reference which details the individual components of adequate information and 
referral programs. The guidance will include suggested methods for improving
access to Medicaid, Medicare, medical assistance and mainstream health provIders. , 
RECOMMENDATION #4--BARERS 
FINDING: Access to available community health services is liInted for Indians who 
are indigent or who lack health insurance, despite information and referral efforts
made by the UIHP. Barriers to care include restricted eligibilty and lack of 
outreach or targeted servces. 
RECOMMENDATION: The PHS should complete a detailed analysis of the 
barriers which inibit Indian access to mainstream health care and develop an action
plan to overcome the barriers. 
PHS COMMENTS: We concur. The IHS has taken the first step towards the 
achievement of this objective by comInssioning the Arizona access study. This study 
will determine the size of the urban Indian population in Arizona, barriers to health 
care and alternate health resource availabilIty. The methodology used in that study 
will be modified as necessary and implemented nationally in urban areas with a 
significant Indian population. Based upon those results, further efforts wil be 
undertaken to determine what steps can be taken to reduce the barriers to health 
care for urban Indians. The IHS expects to complete the analysis in late calendar 
year 1989.

RECOMMENDATION #5--UIHP AND COMMUNITY HEALTH 
CONSOLIDATION 
FINDING: The UIHP has many siInlarities to the CHC program. Many UIHP 
centers, in fact, serve a majority of non-Indian patients. While a few UIHP centers 
are members of local commumty health provider consortia, most UIHP centers have 
few formal or informal ties to other community health or public health programs. 
Federal technical assistance to UIHP centers on urban health issues has been very
liInted. The priorities of the Indian Health Servce are with Indians living on or 
near reservatIOns.
 RECOMMENDATION: The PHS should: 
. move the UIHP from IHS to the Bureau of Health Care Delivery and
Assistance (BHCDA) where it could be integrated with the community 
health servces program and other programs providing health care to 
urban residents il

develop explicit linkages locally between UlHP clinics and community
health centers (CHCs) and natIOnally between IHS and BHCDA 
so that 
the clinics and tHS staff can take full advantage of the urban community
health care expertise of the CHCs and the BHCDA. 
PHS COMMENTS: We concur with the second option. The IHS will direct the 
UIHP clinics to develop written memoranda of agreements and referral linkages 
with the local CHCs to share informatic;m, expertIse and facilitate patient referral.
The IHS will develop a general guideline for a memorandum of agreement for use at 
the local level between CHCs and UIHPs. The IHS and BHCDA wil develop 
linkages to enable the IHS to benefit from BHCDA' s experience in marketing and
program development.  -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------
Receipts by Source and by Progral, FY 1986  APPENDIX A

Progral  Section 330  "CH  WIC  IHS Title Y  IHS Other  Other Federal  "edicare  Kedicaid 
ALL PROGRA"S  $1, 514, 152  $179  181  $939, 253  $8, 575, 619  $1, 515, 918  $373 784  $127, 458  $880, 570 
Percent  45. 
Average  $378  538  $89  591  $83, 925  $245, 018  $216, 560  $93  446  966  $48 921 
"inilul  $186, 459  $62, 241  $24  557  $32, 946  $3, 990  $8, 150  $107  $634 
"axilul  $807, 614  $116, 940  $212, 807  $1, 186, 354  $854, 000  $261, 967  $24, 257  $227, 193 
Olaha $86,
551 $1,
ABPRDEEiN AReEA-r-----r-----e------ -----$------1-- 85,
000
600 $12, 
353 
ALBADUQUElReQ UbE AnuREAq--v-u---e-e--r--q-r--u---e- - --$--$-2---4-2--,---1-----7------
 ----------------------------------------------------

125 $6,
557 $132,000 
406
Chicago $151,
AREA----------------------------------------------------------------------------------------------------
BE" IDJ I 
693 
Green Bay $135,
Detroit
000 
"ilwaukee $807 60141 $602, 2 41 $$2172,8507 1$46,5,865  $28, 951  $16, 611  $110, 056 
"Ainneanpolais c$26o9 nda $32,395 
AREA---------------------------------------------------------------------------------------------------
BILL IN65 
BBiultlitnegs  $$14217


946 
923
Helena $68,
Great Falls $112,521
"iles City $37 558
446  $5, 147
"issoula $64,
791
501 
BakAeRErA--s----f---i----e----l----d--- ----$----5----3---,----------------------------------------------------------
CALFI FORNrI A esno $173,157 $12,
073  000 $17
0510 6$8546,  $14
 916 $44, 814 
807 $6 550 $32, 
Sacralento $t552  58$,565, 889
Los Angeles  228 
San Diego $281,319 $7 866 $141,557
800705  $$174306 $1,2, 
107 
SSaan nFr anJcioscso e$1 16S,9540 6$12,6,518 $414 698 $97, 589
Santa Barbara $22793 $6239, 627 $61, 818
207 
000 $1,
Dallas $169, 64001 $094 043 
OKLAHO"A AREA------------------------------- --------------------------------------------------------------------

Oklahola Cit) $9440 9$4795, $72278 2$1 ,872 
$634 
TWulisac $h18i6,t45a9  $$422,46877 $3,65,468 $3,990 $261,967 $5 368 $13, 316 
$523 $25, 620
PRheoennoix  $$7154, 9,500 $3,
AREA-.'---------------------------------------------------------- 624 
PHOENI X 
849 $9 
648 $136,000 $130, $941
Salt Lake City $39, 631
810 $185, 566 
PORTLAND AREA----------------------------------------------

SPortlanpd  oka06n9e $ 3$5 55,027707  $14
800 $2,
Seattle $251 779 $1, 186, 354 $281, 578 $227 193
Tucson $141,084 $203, 010 $21, 139 
TUCSONAREA-----------------------------------------------------------------------------------------------------
$107
Boston $138,
USET AREA .------------------------------------------------------------------------------------------------------

New Ycrk City $164,531 
138  $8, 150  $24 257 -------- -------__....__--------------;"-------------------;--:-------------------------------------------------------------------------------------------
Pregral  Other 3rd Party Pt. CelIE ctiens  State  Ceunty  City  Other  TOTAL 
ALL PROGRAPIS  $1, 071  184  $1, 155, 483  269, 125  $679, 289  $132, 594  $682, 510  $18, 991, 445 
Percent  100. OZ 
Average  $59  510  157, 774  $84, 608  $84 911  $44  1"/8  $31, 023  $542, 613 
POlin ilul  la$115h  a$300   $6, 583  $$5, 514  8$12, 607 6$296,  $34  580 
Plaxilul  $751, 585  $;:73, 211  $270, 576  $184, 823  $95, 599  $184, 826  $2, 631, 924 
' $199

722" 
ABERDEEN AREA---------------------

Pierre $4) 000 
Denver $4432,0 $29, 551
$192 $16,
ALBAUQUlEbRQUuE qAREuA-e---r-q---u--e-- ------ ----

365 $9,699 $202,868
738 $38,
012 $299 156 
BEPClIDJh I AiRcEA- -a---g---e-- --$---9--- -9--0- 4--- -i-i-1-.3.-,------------------------------------------------7-3--1- --$-1--9-0-- -8-1-7 

Green Bay $73,
Detroit 277 $6312 1$246,
525 $32, 886 $268,043 
Anaconda $1,
PPlililnManukeeea $p7o51l,is585  $:!76,1,  917 $2, 631, 924

Butte211 $ 9, 179 $1$84,823 $524 388 $
184 826 $1, 796, 832

Billings $127,
BILLINGS AREA--------------------- -------..----------------------------------------------------------------

634 $34 580
923
GPrleialte Fsa lCl3si8 t4$y 5 $5$1145 3$,3,073 $46,594 
HPellenai $2s, soula $62404 $121,
 312
761 $1 155 $90, 
Bakersfield 893
500 $43 
291 
501
000 $1,
CAL IFORN I A AREA------------------- --------------------------------------------------------$-8--1--2-- $--5--3-,- ---

885
264 $199,
FLroess nAon $g4e1les '13  2703 $340,6276  $$256, 94370, 707
314 $270,576 $72,  952 $1, 128, 342 
850 $426,
Sacralento $46,375 $l03,224 $130, 820
San Diego $13 744 H9 370 $92,221 $9, 284 
San Francisco $86 421 592,953 $117,0884 $7120,1057  $$415,5442 $71, 221, 221 
San Jose $11, 32, 224 $131, 827 $544 116
320 
Santa 8arbara $34 399 $l48,581 $54 000 $49, 132
OKDLAHaOPIAl ARlEA-a---s---- ---$---5----2--8- 8--- -5--3- 1--,--4------3------9-5-----2- ----$-5-----2 ------$-3-----5-,----6------3------
 ---
322 $47  198 $874 291 
OTkluahlolsa aCi ty$ $53,
 406 533 $991 $324 00000 $53, 728
188 533, 172 $941,050
WRicheita $n2, o $149,
Phoen88i7x 52 1,451 $27  387 $378,478 
PHOENI X AREA---------------------- ------- -----------------------------------------------------------------

559 $25$4296 $,353,658
631 
311 521,
Sal t Lake City $4  746 
PORTLAND AREA--------------------- ------------------------------------------------------------------------

Portland 
SSepaotktalnee  $$4101,,272976 5 $566,,4853073  $$6667,  955780 . 3$17 9, $7419$ 2$9,5 5569097  $$3,72,  859123  $$23,2 4769,, 061315  
Tucson 
Boston $138,
TUCSON AREA-------------------$--1--1 -5--- --$--6-- -----------------------------------------------2-4--6- -$--1-5--3-,--3-4-8
 
USENT AREeA----M----- -----Y-----o-----r- ---k----- -----C-----i------ -----t-----y----- -----$-----1-----9-----6-----,--------

531
545  APPENDIX B

MEDICAL RECORD REVIEW

A total of 186 medical records were reviewed in 7 of the 9

study. 
sites visited for this  Records were selected in such 
a way as to represent a random sample of both active and
inactive cases. 
There is no uniformity, however, in the 
records. 
kind of information maintained in the  Some UIHP 
sites keep records according to the JCAHO standards while other 
sites keep records in an informal manner more suitable for 
drop-in clinics. All of the sites maintained intake data 
showing age, status as Indian or non-Indian and employment and 
insurance coverage. All records showed each visit made 
symptoms presented, treatment given and follow-up or 
referral recommended.

The following summaries highlight the results of this

review. 
Race 
Number of 
Individuals  Percent 
Ethnici t 
Indian  135  72. 
Non- Indian  27. 
Asian 
Black 
Greek 
Hispanic
White 
Information 
not available 
Total  186  100. 
Residence 
Of the 140 individuals in the sample who had information 
regarding their residence, 127 or 90. 7 percent lived in 
urban areas. Thirteen, or 9. 3 percent, were from rural or
reservation areas. 
The remaining 46 individuals did not 
information. 
provide this 
B-1
 Employment 
Only 32 of the 186 records clearly showed that the patient

was employed. For most, the information was not included.

Age 
The following table shows a breakdown of the ages of the

population sampled.

Number of
Individuals  Percent 
11.5 
3-5 
12. 
19-55  105  60. 
56+ 
Total 
174 
100. a 
The date of birth for 12 individuals was missing. 
Total Visits and Utilization

The following tables describe the number of visits each person

made to the UIHP and the number of years they had used the

facili ty.

The total number of visits per individual ranged from

1 to 75 visits.

Number of  Number of

Visi ts  Indi vidual s  Percent 
36.
2-3  24. 
32. 
21+ 
Total 
179 
100. a 
The information for seven individuals was not available.  Number of  Number of

Years  Individuals  Percent 
135  78.
2-3 
10. 
11+ 
Total 
173  100. a 
The information for 13 individuals was not available. 
Insurance 
The following is the breakdown of the insurance
, or lack
thereof 
, that these individuals possess. 
Number of

Insurance  Individuals  Percent 
Welfare 
SSI
IHS/reservation
Medicaid 
14. a
Medicare 
Other/private
None  28. 
No information
 40. 
available 
Total 
186  99. 
B-3
 COMMUN ITY HEALTH  CENTERS 
APPENDIX C

UIHP  UIHP  UnIP  CHCs  CHCs 
Pro  ects  Direct Services  Title V  # Clinics  Section  330 
Phoenix  Limi ted  136, 000 576, 421 
Tucson  141, 020  154, 052 
Bakersfield  & R  53, 073  651, 328 
Fresno  Full  173, 510  508, 000 
Los Angeles
 Limi ted  565, 157  294, 024 
Sacramento  Full  258, 066  -0
San Diego
 Full  281, 807  491, 683 
San Francisco  Full  414, 319  687, 838 
San Jose  Full  239, 800  $ 1, 415, 904 
Santa Barbara
 I &  Dental  236, 075  -0
Denver  Limited  217, 406  455, 742 
Chicago  Li mi ted  151, 125  $ 7, 131, 337 
Wichi ta
 Full  247, 610  221, 977 
Boston  Limi ted  138, 531  308, 340 
Detroit  $ 1, 557, 012 
Minneapolis  Full  751, 395  255, 694 
Anaconda  32, 946  -0
Billings Limited  127, 923  256, 200 
Butte  I & R  41 , 521  175, 450 
Great Falls  112, 558  -0
Helena  Limi ted  68, 446  -0
Miles City 37, 791  -0
Missoula  I &  64, 501  -0
Omaha  Full  86, 000  328, 719 
Al::uquerque  Limi ted  132, 000  293, 194 
Re!1o  149, 631  -a
New York Ci ty  164, 138  $16, 750, 000 
Oklahoma Ci ty Full  499, 000  $ 1, 038, 898 
Tulsa  Full  365, 468  768, 838 
Por-:land  Limi ted  697, 000 
Pie::re  Full  185, 000  100, 000 
Dallas  Full  475, 400  031, 879 
Salt  Lake Ci ty  Limi tea  185, 500  $ 1, 030, 000 
Seattle  Full  $1, 186, 354  100, 000 
Spokane  Full  55, 084  65, 000 
Green Bay
 135, 000  -0
Mi hlaukee  Full  465, 865  468, 143 
* Data unavailable.  APPENDIX D

Indian Population Below Poverty Level

The Census Bureau publishes data on Indian population by
metropoli tan and " 
urbanized" areas. These data are broken 
down to show Indian population in 1979 for all income levels 
level. 
as well as for Indians below the poverty 
The IHS 
uses the figures for all income levels as the base for its 
projections of current year Indian population in UIHP
ci ties. 
These data , in turn, are used to calculate
utilization rates. 
The following table shows the Indian population for 1979 for

all income levels and for those below the poverty level for

several California cities: 
ALl1l 9I7en9 vIcnodeimaln sPeo pulation
Income Below 
City 
Poverty Level 
San Francisco 
946  225 
San Jose 
728  080 
Los Angeles 581  101 
Sacramento 
407  797 
Santa Barbara  065  359 
SOURCE:	 Bureau of the Census, 1980 General Social and 
Economic Characteristics, California, p. 543.
The 1980 Census asked about 1979 income. 
Indian population below the poverty line might provide a 
more realistic basis for proj ecting current Indian target
population. 
D-1  Penetration 
Communi ty 
Communi ty penetration examines to what extent the Indian 
community, based on IHS population projections
, is utilizing
the proj ect. The IHS population proj 
ections are based upon
county Indian population census data
, except in the case of
Anaconda , Butte, Pierre, Missoula, Miles City, Fresno and
Helena 
, where they are based upon a smaller subdivision. 
The
IHS population projections for the urban areas 
may, in some
cases 
, include reservation populations. 
The following table presents the Indian census compared to 
Indian users by program for FY 1986. 
The Indian census data was provided by the Indian Health

Service.  -------- -------------
Indian Census Compared to Indian Users by Program, FY 1986

Program  Indian Users/Census 
ALL PROGRAMS  17. 
Average  61. 
Minimum 
1. 8% 
Maximum  717 . 
Omaha 83.

ABERDEEN AREA----------------------

Pierre 717.

DAlebunqvueerrq u1e0 7..


ALBUQUERQUE AREA-------------------

Chicago 
AREA-----------------------
BEM I DJ I 
11 . 6% 
GMDetrroie it
lewn aBuaky e3e7 .

Minneapolis 21.

38 . 2%
Anaconda 136.

BILL I NGS AREA----------------------
Billings 46.

Butte 62.

HGreealte nFaal l1s 6354..


Miles City 271.

Missoula 95.

Bakersfield 
FreAsREnA--o---- --2----5-----.--
 -
CAL I FORN I A 
Los Angeles 7 . 1%
Sacramento 5.

7 .
SSSaan anDi engFo r anJcoisscoe 2 3.2 .
 9%
Santa Barbara 54.

7 . 1%
DTaulllassa  282..


OKLAHOMA AREA----------------------

Oklahoma City 18.

Wichi ta 30.

Phoenix 29.

Reno 42.

AREA-----------------------
PHOEN I X 
Lake City 
Sal t  27 . 4% 
PORTLAND AREA----------------------

PSoretlanad ttle 32.

Spokane 48.

Tucson 
TUCSON AREA------------------------

Boston 19.

5. 1% 
USET AREA--------------------------

New York City 1.

0- 3
 APPENDIX E

I & R VERSUS DIRECT HEALTH COSTS

Dollars Expended

Direct Care  I & R  % I & R

Boston
111  373  61.

Seattle 
560  437  168  348

Lake City
Sal t  165  965  975  14.

Helena 
112  140  22.

Tucson 
111  562  881  34.

Phoenix 
122  234  230  148  65.

Los Angeles 935  480  232  460  20.

San Francisco 
356  505  103  511

Missoula 
332  526  82. 
Total--Nine Sites
379  738  963  362  15.
Total--All Sites 
356  987  570  759  25. 
Includes all expenditures other than I & R

Includes all community and health education costs

Excludes direct care from Phoenix IHS Hospital

SOURCE: Urban Indian Health Program, FY 1986 Charts and
Graphs , American Indian Health Care Association
Minneapolis 
, 1987