NATIVE AMERICAN HEALTH CARE DISPARITIES 

BRIEFING 

EXECUTIVE SUMMARY

February 2004 

Office of the General Counsel 

U.S. Commission on Civil Rights
Contents 

The Tribal-Federal Government Relationship................................................................................ 2 

Federal Government Oversight and Responsibility.................................................................... 3 

Legislation .................................................................................................................................. 4 

Current Native American Health Disparities.................................................................................. 5 

Diabetes ...................................................................................................................................... 6 

Tuberculosis................................................................................................................................ 8 

Mental Health ............................................................................................................................. 8 

Unintentional Injuries ............................................................................................................... 10 

Major Cardiovascular Diseases ................................................................................................ 11

Pneumonia and Influenza.......................................................................................................... 12 

Cancer ....................................................................................................................................... 12 

Infant Mortality and Maternal Health....................................................................................... 14 

Causes of Health Disparities......................................................................................................... 14 

1. Limited Access to IHS Health Facilities............................................................................... 16 

IHS Health Care Services Eligibility Requirements......................................................... 17 

IHS Direct/Tribal/Urban Programs................................................................................... 18 

Direct Delivery System..................................................................................................... 20 

Tribal Health Programs..................................................................................................... 22 

Urban Indian Health Programs ......................................................................................... 24 

Contract Health Services Program.................................................................................... 26 

2. Poor Access to Health Insurance .......................................................................................... 27 

Social and Cultural Factors............................................................................................... 29 

Procedural Factors ............................................................................................................ 30 

Collection Factors ............................................................................................................. 31 

3. Insufficient Federal Funding................................................................................................. 33 

4. Quality of Care Issues........................................................................................................... 38 

Ability to Recruit and Retain Health Providers ................................................................ 38 

Accreditation Status.......................................................................................................... 40 

Importance of “Culturally Competent” Health Services .................................................. 42 

Problem of Aging Facilities.............................................................................................. 45 

5. Disproportionate Poverty and Poor Education ..................................................................... 46 

Reauthorization of the Indian Health Care Improvement Act ...................................................... 49 

Summary....................................................................................................................................... 51 
1

 Native American Health Care Disparities Briefing 

Executive Summary

Four years ago, the U.S. Commission on Civil Rights examined the efforts of the 

Department of Health and Human Services and concluded that, even after 35 years of periodic 

monitoring and reporting by the Commission, equal access to health care was not accorded the 

same federal protection as equal opportunity in housing, education, and employment.1

 The 

Commission reported that discrimination against minority populations manifests itself in a 

variety of ways, including: 

 Differential delivery of health services. 

 Inability to access health services because of lack of financial resources, culturally 

incompetent providers, language barriers, and the unavailability of services. 

 Exclusion from health-related research.2 

Revisiting the specific issue of disparities in Native American health care, the Commission held 

a briefing on October 17, 2003, in Albuquerque, New Mexico.3

In preparation for the briefing, the Commission examined compelling evidence that 

disparities in the health status of Native Americans persist. While some disparities result from 

intentional discrimination based on race or ethnicity, more frequently discrimination must be 

inferred from the continued existence of a chronically underfunded, understaffed, and inadequate 

health care delivery system. For Native Americans, the existence of glaring disparities across a 

wide range of health status, outcome, and service indicators, combined with the manner in which 

the disparities mirror patterns of historical discrimination, makes a convincing argument that the 

current situation is in fact discriminatory. 

The purpose of the briefing was to examine the role of discrimination and bias in the 

existence of ongoing health disparities for Native Americans by consulting with tribal leaders, 

key government officials, leading experts, health care advocates, and concerned citizens. By 

necessity, the disparities were explored and the causes documented. In evaluating the various 

 

1

 U.S. Commission on Civil Rights, The Health Care Challenge: Acknowledging Disparity, Confronting 

Discrimination, and Ensuring Equality September 1999, p. vii (hereafter cited as USCCR, The Health Care 

Challenge). 

2

 Ibid., p. iii. 

3

 Throughout this report, the term “Native American” is used in lieu of “American Indian” or other terminology 

when not specifically citing or paraphrasing other work. It should be understood to include Alaska Natives unless 

otherwise noted. Native Hawaiians are not included in the Native American category because they are not 

recognized as having the same government-to-government relationship, and are thus not eligible for the federal 

programs available to other Native groups. The term “Indian Country” refers to geographic regions encompassing 

reservations and trust lands within which Indian laws and customs and federal laws relating to Indians govern. See 

Theodore H. Haas, chief counsel, United States Indian Service, The Indian and the Law (Lawrence, KS: Haskell 

Institute, June 1949), p. 15 <http://thorpe.ou.edu/cohen/tribalgovtpam2ptl&2.htm> (last accessed Nov. 21, 2003). It 

is also important to recognize that Native Americans are not simply another minority or ethnic group. They enjoy a 

unique political status that carries unique privileges discussed in more detail in this executive summary. 
2

causes, the Commission focused its attention on the structure and operation of the Native 

American health care delivery programs, the availability and adequacy of funding, as well as 

legislative, structural, and managerial changes that affect the delivery of health services to Native 

Americans. 

This executive summary presents the issues and concerns raised during the October 

briefing by panelists and the public. The first section will briefly review the basis for the federal 

government’s obligation to provide health care to Native Americans, an obligation both 

substantive and indisputable. Next follows a depiction of the current health status and then an 

accounting of the government’s efforts to meet its obligation to Native Americans. Despite 

encouraging efforts by the Indian Health Service and recent reductions in the prevalence and 

incidence of some illnesses and deaths, health status disparities remain troubling. In fact, the 

health status of Native Americans remains unquestionably far below that of the general 

population. 

The largest portion of the executive summary will focus on the various causes for the 

existing disparities in the health status of Native Americans, including the many barriers that 

inhibit access and perhaps the most critical underlying fact, that promised health care services for 

Native Americans have never been fully funded. 

Finally, this summary will explain current legislative efforts to address present 

disparities. In the end, this discussion will begin to address the critical question of whether the 

current framework for providing health care to Native Americans perpetuates an indirect, yet 

insidious, discriminatory effect on the Native Americans it is committed to serve. 

Information acquired during the briefing will be supplemented with additional research in 

preparation of a full report on health care disparities, expected to be submitted to the 

Commissioners for approval later in 2004. The report will include findings and 

recommendations. 

THE TRIBAL-FEDERAL GOVERNMENT RELATIONSHIP 

Native Americans are dying of diabetes, alcoholism, tuberculosis, suicide, unintentional 

injuries, and other health conditions at shocking rates. Beyond the mortality rates, Native 

Americans also suffer significantly lower health status and disproportionate rates of diseases 

compared with all other Americans. During the briefing, Michael Bird, executive director of the 

National Native American AIDS Prevention Center, made evident how long these devastating 

realities have afflicted the Native American peoples as he quoted from an address to Congress by 

President Nixon in 1970: 

The First Americans—the Indians—are the most deprived and most isolated 

minority group in our nation. On virtually every scale of measurement: 

employment, income, education, and health, the condition of the Indian people 

ranks at the bottom. This condition is the heritage of centuries of injustice. From 

the time of their first contact with European settlers, the American Indians have 
3

been oppressed and brutalized, deprived of their ancestral lands, and denied the 

opportunity to control their own destiny.4

The conditions described by President Nixon, which still exist today, are the result of the 

federal government’s failure to respect promises made to Native Americans over the past 300 

years in exchange for 400 million acres of tribal land and the unfulfilled “trust” relationship that 

requires the government to protect tribal lands, assets, resources, treaty rights, and health care, 

among other obligations. The legal source of this trust obligation, however, is imprecise as the 

boundaries and duties of the trust relationship have evolved over the past two centuries. Pursuant 

to the power “[t]o regulate Commerce . . . with the Indian tribes”5

 a series of treaties, judicial 

decisions, and statutes has shaped federal trust responsibility. Accordingly, the federal 

government has accepted many obligations, including education, construction, law enforcement, 

and medical services. This health care obligation requires the government to provide medical 

treatment to all Native Americans living in the United States. 

Federal Government Oversight and Responsibility 

Very early in the life of this country, the federal government promised health care 

services to Native Americans in exchange for land.6

 The motive for providing health care was 

not solely altruistic. The government was also attempting to gather information on the numbers 

of Native Americans, to control the Native American population, and to protect white citizens 

from the spread of infectious diseases.7 The federal government initially assigned the 

responsibility for Native American health care to the Office of Indian Affairs in the War 

Department. Health care duties were subsequently transferred to the newly formed Department 

of the Interior, where the responsible office was eventually renamed the Bureau of Indian Affairs 

(BIA).8 Starting in the 1920s, concerns developed regarding the administration of government 

programs by BIA. Specifically, there were complaints that BIA was poorly equipped to combat 

 

4

 Michael Bird, statement before the U.S. Commission on Civil Rights, briefing, Albuquerque, NM, Oct. 17, 2003, 

transcript, pp. 82–83 (hereafter cited as Briefing Transcript). 

5

 U.S. CONST. art. I, § 8, cl. 3. 6

 Over the past 300 years, Native American nations have traded hundreds of millions of acres to the federal 

government in exchange for benefits to guarantee the survival and integrity of their tribes, including health care. See 

Indian Health Care Improvement Act Reauthorization of 2003, S. 556, 108th Cong. § 2 (2003). See also Holly T. 

Kuschell-Haworth, Jumping Through Hoops: Traditional Healers and the Indian Health Care Improvement Act, 2 

DEPAUL J. HEALTH CARE L. 843, 844 (1999) (hereafter cited as Kuschell-Haworth, Traditional Healers and the 

Indian Health Care Improvement Act), citing American Indian Policy Review Commission, Report on Indian 

Health: Task Force Six, 1976, p. 33. 

7

 National Library of Medicine, “Early United States Government Interest in Native American Health,” 

<www.nlm.nih.gov/exhibition/if_you_knew/if_you_knew_03.html> (last accessed July 15, 2003). 

Although U.S. Army surgeons treated Native American victims of smallpox near the opening of 

the 19th-century, government concern for Native American health at this time was manifest more 

in counting the numbers of people who died from this and other diseases, and estimating how 

many were left, than in providing institutional remedies. 

Ibid. 

8

 Kuschell-Haworth, Traditional Healers and the Indian Health Care Improvement Act, citing American Indian 

Policy Review Commission, Report on Indian Health: Task Force Six, 1976, p. 29. 
4

public health emergencies.9 Because of these concerns, a commission was formed to inspect 

reservations, schools, and hospital settings. This commission issued the Meriam Report, 

documenting substandard health conditions resulting from government inefficiency and 

inadequate funding.10 To develop an effective system of preventive medicine and public health, 

the commission recommended adequately funding Native American health care,11 spurring a 

short-lived movement to improve health conditions for Native Americans.12 In 1955, the division 

responsible for Native American health care was transferred to the Department of Health and 

Human Services (HHS). Today, the Indian Health Service (IHS), an agency within HHS, is the 

principal federal health care provider. 

Legislation 

Perhaps the most significant achievement for Native American health care has been the 

codification of the federal responsibility in the Snyder Act of 1921.13 Together, the Snyder Act 

and the Indian Health Care Improvement Act of 197614 form the basic legislative authority for 

today’s Indian Health Service. The Snyder Act charged BIA to “direct, supervise, and expend 

such moneys as Congress may from time to time appropriate, for the benefit, care, and assistance 

of the Indians . . . for relief of distress and conservation of health.”15 Congress subsequently 

enacted the Indian Health Care Improvement Act (IHCIA), establishing the basic programmatic 

structure for delivery of health services to Native Americans and authorizing the construction 

and maintenance of health care and sanitation facilities on reservations. The wording and effect 

of IHCIA clearly acknowledge the legal and moral responsibility for “providing the highest 

possible health status to Indians . . . with all the resources necessary to effect that policy.”16 

Like the Snyder Act, the IHCIA provides appropriations authority for the delivery of 

health services to Native American people. In fact, the IHCIA provides comprehensive directives 

to the federal government for the delivery of health care services. Although the most recent 

 

9

 National Library of Medicine, “Reservation and Hospital Health Care Under the Office of Indian Affairs (c.1890–

1925),” <www.nlm.nih.gov/exhibition/if_you_knew/if_you_knew_06.html> (last accessed July 15, 2003). 10 National Library of Medicine, “The Meriam Commission and Health Care Reform (1926–1945),” <www.nlm.nih. 

gov/exhibition/if_you_knew/if_you_knew_07.html> (last accessed July 15, 2003). 

11 Lewis Meriam et al., The Problem of Indian Administration, Chapter 1: General Summary of Findings and 

Recommendations, Report of a Survey made at the request of Honorable Hubert Work, Secretary of the Interior, 

Feb. 21, 1928, <www.alaskool.org/native_ed/research_reports/IndianAdmin/Chapter1.html#chap1> (last accessed 

July 15, 2003). 

12 National Library of Medicine, “Transfer to Department of Health, Education, and Welfare (1946–1969),” 

<www.nlm.nih.gov/exhibition/if_you_knew/if_you_knew_08.html> (last accessed July 15, 2003). 

13 Ch. 115, 42 Stat. 208 (1921) (codified as amended at 25 U.S.C. § 13 (1994)). 

14 Pub. L. No. 94-437, 90 Stat. 1400 (codified as amended in scattered sections of 25 U.S.C.). 

15 The Snyder Act, 25 U.S.C. § 13 (1994). 

16 The Indian Health Care Amendments of 1980, Pub. L. No. 96-537, 94 Stat. 3193 (codified as amended in 

scattered sections of 25 U.S.C. (1994)). In reauthorizing the IHCIA in 1990, Congress passed three major health 

bills amending the IHCIA and providing statutory authorization for a comprehensive and community-based mental 

health program, the authorization for self-governance demonstration projects, and the expansion of the urban Indian 

health programs. 
5

IHCIA has expired and not been reauthorized, Congress has nevertheless continued to 

appropriate funds for IHCIA programs under the authority of the Snyder Act.17 

CURRENT NATIVE AMERICAN HEALTH DISPARITIES 

Despite the funds appropriated by Congress to deliver health care services for Native 

Americans, a wide range of public health status indicators demonstrate that Native Americans 

continue to suffer disproportionately from a variety of illnesses and diseases.18 Dr. Jon Perez, 

director of behavioral health for IHS, described these health disparities as “real and highly 

visible” to Native Americans.19 He explained that while the incidence and prevalence of many 

infectious diseases have been dramatically reduced through increased clinical care and public 

health efforts such as vaccination for infectious diseases and the construction of sanitation 

facilities, Native Americans continue to experience health disparities and higher death rates than 

the rest of the U.S. population.20 IHS has been given primary responsibility for eliminating this 

disproportionate health status and has been largely successful in reducing mortality rates, while 

making significant improvements in other areas.21

Today, Native Americans continue to experience significant rates of diabetes, mental 

health disorders, cardiovascular disease, pneumonia, influenza, and injuries. Native Americans 

are 770 percent more likely to die from alcoholism, 650 percent more likely to die from 

tuberculosis, 420 percent more likely to die from diabetes, 280 percent more likely to die from 

accidents, and 52 percent more likely to die from pneumonia or influenza than other Americans, 

including white and minority populations.22 As a result of these increased mortality rates, the life 

expectancy for Native Americans is 71 years of age, nearly five years less than the rest of the 

U.S. population.23 Dr. Perez pointed out some of these health disparities as well as some of the 

 

17 The IHCIA has been introduced in the last three sessions of Congress, however, it has not reached the floor of 

Congress. At the time of this writing, two separate versions awaited action in House and Senate committees. The 

chances of reauthorization and the subsequent impact will be discussed in greater detail in a later section. See Myra 

Munson, Esq., partner, Sonosky, Chambers, Sachse, Miller & Munson, interview, Aug. 11, 2003. 

18 See generally Office of Management and Budget, Statistical Policy Directive No. 15, “Race and Ethnic Standards 

for Federal Statistics and Administrative Reporting,” 1977; Office of Management and Budget, “Recommendations 

from the Interagency Committee for the Review of the Racial and Ethnic Standards to the Office of Management 

and Budget Concerning Changes to the Standards for the Classification of Federal Data on Race and Ethnicity,” July 

9, 1997, <www.whitehouse.gov/omb/fedreg/print/directive_15.html> (last accessed July 15, 2003). 

19 Perez Statement, Briefing Transcript, p. 14. 

20 Ibid., p. 15. 

21 Since 1973 mortality rates have been reduced for the following: tuberculosis (82 percent); maternal deaths (78 

percent); infant deaths (66 percent); accidents (57 percent); injury and poisoning (53 percent); and pneumonia and 

influenza (50 percent). Indian Health Service, Trends in Indian Health 1998–99, <www.ihs.gov/publicinfo/ 

publications/trends98/part2.pdf> (last accessed Aug. 21, 2003) (hereafter cited as IHS, Trends in Indian Health 

1998–99). See also Perez Statement, Briefing Transcript, pp. 14, 15. 

22 A Bill to Reauthorize the Indian Health Care Improvement Act and H.R. 2440, Indian Health Care Improvement 

Act Amendments of 2003: Joint Hearing Before the Senate Committee on Indian Affairs and the House Resources 

Committee, Office of Native American and Insular Affairs, 108th Cong. (2003) (statement of Dr. Charles W. Grim, 

director, Indian Health Service). See also H.R. 2440, Indian Health Care Improvement Act Amendments of 2003. 

23 U.S. Department of Health and Human Services, Assistant Secretary for Legislation, “Testimony of David 

Satcher, Assistant Secretary for Health and Surgeon General of the U.S. Public Health Service, U.S. Department of 
6

mortality rates during the briefing. Additionally, he explained that fully seven of the top 10 

causes of the high morbidity and mortality rates are “directly related to, or significantly affected 

by individual behavior and lifestyle choices.”24 

The following is a discussion of the specific health disparities suffered by Native 

Americans in contrast to whites and minority populations.25 Information on the health status and 

outcomes of individual tribes is presented when it is illustrative of the existence of similar 

disparities throughout the Native American community. Incidence, prevalence, morbidity, or 

mortality rates of diseases and health conditions are used to examine and measure those public 

health issues disproportionately affecting Native Americans.26

Diabetes 

Diabetes is one of the most serious health challenges facing Native Americans, resulting 

in significant morbidity and mortality rates.27 In fact, Native Americans have the highest 

 Health and Social [sic] Services, Before the House Commerce Committee, Subcommittee on Health and 

Environment,” May 11, 2000, <www.hhs.gov/asl/testify/t000511a.html> (last accessed July 15, 2003) (hereafter 

cited as HHS, “Satcher Testimony”). 

24 Perez Statement, Briefing Transcript, p. 19. 

25 The Department of Health and Human Services defines a health disparity as “a population-specific difference in 

the presence of disease, health outcomes, or access to care.” U.S. Department of Health and Human Services, Health 

Resources and Services Administration, Bureau of Primary Health Care, “Current Needs and Current Issues in 

Minority Health Research,” UNC 7th Annual Summer Public Health Research Institute on Minority Health, June 18, 

2001, <www.cmh.pitt.edu/PPT/H20010614.ppt> (last accessed July 15, 2003) (hereafter cited as HHS, “Current 

Needs”). Federal, state, and local health agencies measure existing health disparities for specific populations by a 

variety of “health status indicators.” Indicators include incidence, prevalence, morbidity, and mortality rates for a 

number of illnesses that relate to a particular segment of the population, as well as maternal and infant mortality 

rates. Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000—

Statistical Notes: Trends in Racial and Ethnic-Specific Rates for the Health Status Indicators: United States, 1990–

98, no. 23, January 2002, p. 1 (hereafter cited as CDC, Trends in Racial and Ethnic-Specific Rates). 

26 “Incidence is the number of cases of disease having their onset during a prescribed period of time. It is often 

expressed as a rate (for example, the incidence of measles per 1,000 children 5–15 years of age during a specified 

year). Incidence is a measure of morbidity or other events that occur within a specified period of time.” Centers for 

Disease Control and Prevention, National Center for Health Statistics, “Incidence,” NCHS Definitions, Aug. 21, 

2002, <www.cdc.gov/nchs/datawh/nchsdefs/incidence.htm> (last accessed Sept. 20, 2003). 

“Prevalence is the number of cases of a disease, infected persons, or persons with some other attribute during a 

particular interval of time. It is often expressed as a rate (for example, the prevalence of diabetes per 1,000 persons 

during a year).” Centers for Disease Control and Prevention, National Center for Health Statistics, “Prevalence,” 

NCHS Definitions, Aug. 23, 2002, <www.cdc.gov/nchs/datawh/nchsdefs/prevalence.htm> (last accessed Sept. 20, 

2003). 

The mortality rate is defined as the total or crude death rate from all causes, usually expressed as deaths per 1,000. A 

disease-specific mortality rate includes those deaths due to one disease and is usually reported per 100,000 persons. 

The population can be defined by sex, age, or other factors. University of Kansas Medical Center, “Mortality Rate,” 

<www.kumc.edu/instruction/medicine/pathology/ed/keywords/kw_mortalit.html> (last accessed Sept. 20, 2003). 

The morbidity rate is defined as “[a]n incidence rate used to include all persons in the population under consideration 

who become clinically ill during the period of time stated. The population may be limited to a specific sex, age 

group or those with certain other characteristics.” University of Kansas Medical Center, “Morbidity Rate,” 

<www.kumc.edu/instruction/medicine/pathology/ed/keywords/kw_morbidit.html> (last accessed Sept. 20, 2003). 

27 National Institute of Diabetes & Digestive & Kidney Diseases of the National Institutes of Health, “Diabetes in 

American Indians and Alaskan Natives,” NIDDK National Diabetes Information Clearinghouse, <www.niddk.nih. 
7

prevalence of Type 2 diabetes in the world, and rates are increasing at “almost epidemic 

proportions.”28 The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) 

defines diabetes mellitus as a group of diseases characterized by high blood levels of glucose 

stemming from defective insulin secretion and/or action.29 Most Native Americans with diabetes 

have Type 2 diabetes, also known as adult onset diabetes, which is caused by the body’s 

resistance to the action of insulin and impaired insulin secretion. Type 2 diabetes can be 

managed with healthy eating, physical activity, oral medication, and/or injected insulin.30 In fact, 

Dr. Jon Perez stated that one of the most distressing aspects of Type 2 diabetes is that with 

lifestyle changes it is largely preventable.31 

Despite the fact that the rates of diabetes in the Indian community are “staggering,” the 

rates do not paint a true picture of how devastating the disease can really be, according to Dr. 

Dee Ann DeRoin, board member of the Association of American Indian Affairs.32 This is 

because the leading cause of mortality in the Indian community is heart disease, and hidden in 

that statistic is the fact that the largest percentage of deaths from heart disease are caused by 

diabetes. Thus, diabetes is both devastating the community in terms of quality of life and 

“maiming and killing” Native Americans.33

Another startling fact regarding the prevalence of Type 2 diabetes is that it has recently 

become a significant threat to Native American children.34 Its incidence is rising faster among 

Native American children and young adults than any other ethnic population.35 IHS has 

documented a 54 percent increase in the prevalence of diagnosed diabetes among Native 

American youth 15 to 19 years of age since 1996.36 Historically, Type 2 diabetes has been 

restricted to adults, at least partially as a result of declining insulin sensitivity with age.37 Its 

presence among children foreshadows the early arrival of more serious complications.38

Another national health care authority expressed concern about the challenges that 

diabetes presents for Native Americans of all ages. In 2000, Dr. David Satcher, the Surgeon 

General of the United States, testified that “the diabetes rate for American Indians and Alaska 

Natives is more than twice that for whites. The Pima [American Indians] of Arizona have one of 

 gov/health/diabetes/pubs/amindian/amindian.htm> (last accessed July 15, 2003) (hereafter cited as NIDDK, 

“Diabetes in American Indians”). See also Jack Trope, president, and Dee Ann DeRoin, M.D., board member, 

Association of American Indian Affairs, telephone interview, July 15, 2003. 28 Perez Statement, Briefing Transcript, p. 18. 

29 NIDDK, “Diabetes in American Indians.” See also Trope and DeRoin interview. 30 NIDDK, “Diabetes in American Indians.” See also Trope and DeRoin interview. 31 Perez Statement, Briefing Transcript, p. 18. 

32 Trope and DeRoin interview. 

33 Ibid. 

34 American Academy of Pediatrics, “Significant Health Disparities Threaten American Indian Children and Youth,” 

press release, Aug. 1, 2002, <www.aap.org/advocacy/washing/american_indian.htm> (last accessed Sept. 24, 2003) 

(hereafter cited as American Academy of Pediatrics, “Significant Health Disparities”). 

35 Perez Statement, Briefing Transcript, p. 18. 

36 American Academy of Pediatrics, “Significant Health Disparities.” 37 Mayo Clinic, “Mayo Clinic Study Finds People Over 40 Need Frequent Exercise to Prevent or Treat Type 2 

Diabetes,” news release, Aug. 15, 2003, <www.mayoclinic.org/news2003-rst/1911.html> (last accessed Aug. 22, 

2003). 

38 Perez Statement, Briefing Transcript, p. 18. 
8

the highest rates of diabetes in the world.”39 Furthermore, NIDDK estimates that approximately 

15 percent of Native Americans who receive health care from IHS have diabetes.40 Native 

Americans are 2.6 times more likely to be diagnosed with diabetes than non-Hispanic whites of a 

similar age.41 As troubling as these numbers are, they may understate the number of Native 

Americans with diabetes. In a screening study conducted in three geographic areas, NIDDK 

found that 40 to 70 percent of Native American adults between the ages 45 and 74 have diabetes, 

many previously undiagnosed. Data from the Navajo Health and Nutrition Survey showed that 

22.9 percent of Navajo adults 20 and older had diabetes. At least 14 percent had a history of 

diabetes, but another 7 percent were found to have undiagnosed diabetes during the survey.42 

Although measures can be taken to reduce the likelihood of disability and death from 

diabetes, the disease is still associated with serious health complications and premature death.43

From 1994 through 1996, the IHS age-adjusted death rates for diabetes mellitus were 350 

percent greater than the rates for the rest of the American population.44 Dr. Perez emphasized the 

prevention of diabetes as a way of eliminating costly treatment options, in addition to reducing 

the disease burden from the suffering population.45

Tuberculosis 

Although the tuberculosis rate among Native Americans is declining, it continues to 

disproportionately affect this population in the number of cases and severity of disease.46 The 

American Lung Association reported that in 1998, the incidence rate of tuberculosis among 

Native Americans was 12.6 cases per 100,000 persons, which is more than five times the rate for 

non-Hispanic whites (2.3).47 Similarly, in 2001, it was reported that the annual incidence of 

tuberculosis for Native Americans was twice that of the overall U.S. population; mortality rates 

were six times higher.48 

Mental Health 

Native Americans are at a higher risk for mental health disorders than other racial and 

ethnic groups in the United States,49 and are consistently overrepresented among high-need 

 

39 HHS, “Satcher Testimony.” 

40 NIDDK, “Diabetes in American Indians.” 

41 Ibid. See also Perez Statement, Briefing Transcript, p. 18. 42 Ibid. 

43 American Academy of Pediatrics, “Significant Health Disparities.” 44 IHS, Trends in Indian Health 1998–99. 45 Perez Statement, Briefing Transcript, p. 19. 

46 Jay C. Butler et al., “Emerging Infectious Diseases Among Indigenous Peoples,” Emerging Infectious Diseases, 

vol. 7, no. 3 supplement, June 2001, p. 554 (hereafter cited as Butler et al., “Emerging Infectious Diseases”). 

47 American Lung Association, “American Indians/Alaskan Natives and Lung Disease,” fact sheet, September 2000, 

<www.lungusa.org/diseases/nativelung_factsheet.html> (last accessed Sept. 20, 2003). 48 Butler et al., “Emerging Infectious Diseases,” p. 554. 

49 See S. Nelson, G. McCoy, M. Stetter, and W.C. Vanderwagen, “An Overview of Mental Health Services for 

American Indians and Alaska Natives in the 1990s,” Hospital and Community Psychiatry, vol. 43, 1992, pp. 257–

61. See also USCCR, The Health Care Challenge, p. 46. 
9

populations for mental health services.50 The Surgeon General reported that this 

overrepresentation might be attributed to the high rates of homelessness, incarceration, alcohol 

and drug abuse, and stress and trauma in Native American populations.51 The Surgeon General’s 

report further indicated that the U.S. mental health system is not well equipped to meet these 

needs; specifically that IHS, due to both budget constraints and personnel problems, is mostly 

limited to basic psychiatric emergency care.52 According to Dr. Perez, IHS does not provide 

quality, ongoing psychiatric care.53 Instead, IHS’ approach is one of responding to immediate 

mental health crises and stabilizing patients until their next episodes.54

The most significant mental health concerns today are substance abuse, depression, 

anxiety, violence, and suicide.55 Of these, substance abuse, notably alcoholism, has been the 

most visible health disorder crisis,56 while depression is emerging as a dominant concern.57

These two illnesses are often a consequence of isolation on distant reservations, pervasive 

poverty, hopelessness, and intergenerational trauma, including the historic attempts by the 

federal government to forcibly assimilate tribes.58 

Alcohol abuse is widespread in Native American communities. Native Americans use 

and abuse alcohol and other drugs at younger ages, and at higher rates, than all other ethnic 

groups.59 Consequently, their age-adjusted alcohol-related mortality rate is 5.3 times greater than 

that of the general population.60 The Department of Health and Human Services, Substance 

Abuse and Mental Health Services Administration’s National Household Survey on Drug Abuse

reported the following for 1997: (1) 19.8 percent of Native Americans ages 12 and older reported 

using illegal drugs that year, compared with 11.9 percent for the total U.S. population; and (2) 

 

50 High-need populations include the following: people who are homeless, people who are incarcerated, people 

exposed to trauma, and people with drug and alcohol problems. See U.S. Department of Health and Human 

Services, Office of the Surgeon General, “Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report 

of the Surgeon General,” fact sheet, <http://www.surgeongeneral.gov/library/mentalhealth/cre/fact4.asp> (last 

accessed Dec. 19, 2003). 

51 Ibid. 

52 Judy Nichols, “Special Report—Part 2, Indian Health Care: Critical Condition,” Arizona Republic, July 21, 2002 

<www.azcentral.com/news/specials/indianhealth/0721hospital21.html> (last accessed Sept. 24, 2003). 

53 Jon Perez, director of behavioral health, Indian Health Service, interview in Rockville, MD, July 21, 2003. 54 Ibid. 

55 See U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services 

Administration, Center for Mental Health Services, “Cultural Competence Standards in Managed Care Mental 

Health Services: Four Underserved/Underrepresented Racial/Ethnic Groups,” Introduction, <www.mentalhealth.org/ 

publications/allpubs/SMA00-3457/intro.asp> (last accessed Sept. 15, 2003). 

56 See, e.g., Kay Culbertson, executive director, Denver Indian Health and Family Services, telephone interview, 

Sept. 3, 2003; Emery Johnson, interview in Silver Spring, MD, Aug. 18, 2003; Ralph Forquera, executive director, 

Seattle Health Board, telephone interview, Aug. 27, 2003; Perez interview. 

57 Perez interview. 

58 Ibid. 

59 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 

Center for Substance Abuse Treatment, “Cultural Issues in Substance Abuse Treatment,” 1999. 60 Ibid. 
10

Native Americans had the highest prevalence rates of marijuana and cocaine use, in addition to 

the need for drug abuse treatment.61

One of the more troubling indicators of the toll depression takes on Native Americans is 

reflected in the suicide rates. The suicide rate for Native Americans continues to escalate and is 

190 percent of the rate of the general population. In fact, suicide is the second leading cause of 

death for Native Americans 15 to 24 years old and the third leading cause of death for Native 

American children 5 to 14 years old.62 Recent data from the American Academy of Pediatrics 

indicate that in 2002 the youth suicide rate for Native Americans was twice as great among 14- 

to 24-year-olds, and three times as great among 5- to 10-year-olds, as it was in the general 

population.63

Despite a significant demand for mental health services, there are approximately 101 

mental health professionals available per 100,000 Native Americans, compared with 173 mental 

health personnel per 100,000 whites.64 With a greater need for mental health specialists, but 

fewer available for treatment, Native Americans frequently do not receive the necessary care for 

substance abuse, depression, anxiety, suicide ideations, and other mental health conditions. 

Unintentional Injuries 

Public health authorities consider death and disabilities from unintentional injuries as a 

safety issue affecting the health of entire populations.65 During the October briefing, Dr. Jon 

Perez identified unintentional injuries as an issue of particular concern for Native Americans.66

In fact, unintentional injuries are the leading cause of death for Native Americans under the age 

of 44 and the third leading cause of death overall.67 The age-adjusted injury death rate for Native 

Americans is approximately 250 percent higher than that for the total U.S. population.68

Moreover, Native Americans suffer injuries at rates 1.5 to five times the rate for other 

 

61 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 

National Clearinghouse for Alcohol & Drug Information, “Drug Use Among Native Americans Is Higher than Other 

Racial/Ethnic Groups,” The NCADI Reporter, Oct. 29, 1998, <www.health.org/newsroom/rep/95.aspx> (last 

accessed July 15, 2003). See also Centers for Disease Control and Prevention, Trends in Racial and Ethnic-Specific 

Rates, p. 11 (between 1990 and 1998, the lung cancer death rate for American Indians or Alaska Natives increased 

by 28 percent). 

62 IHS, Trends in Indian Health 1998–99, p. 66. 

63 American Academy of Pediatrics, “Significant Health Disparities.” 

64 U.S. Department of Health and Human Services, Office of the Surgeon General, Substance Abuse and Mental Health 

Services Administration, “Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon 

General,” fact sheet, <www.surgeongeneral.gov/library/mentalhealth/cre/fact4.asp> (last accessed Dec. 19, 2003). 65 Association of Schools of Public Health, “The Population Approach to Public Health,” Apr. 7, 2003, <www.asph. 

org/print.cfm?page=724> (last accessed Sept. 20, 2003). 

66 Perez Statement, Briefing Transcript, p. 17. 

67 Indian Health Service, “Injuries,” IHS Health and Heritage Brochure—Health Disparities, <www.info.ihs.gov> 

(last accessed Sept. 26, 2003) (hereafter cited as IHS, “Injuries”). The causes of death include unintentional motor 

vehicle crashes, unintentional pedestrian events, firearm use, unintentional drowning, and unintentional fire. See

Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, vol. 52, no. 30, Aug. 1, 2003, 

p. 698. 

68 U.S. Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health, 2d 

ed., ch. 15, November 2000 (hereafter cited as HHS, Healthy People 2010). 
11

Americans.69 In real terms this translates to more than 1,300 deaths and more than 10,000 

hospitalizations each year for more than 50,000 days of medical care.70 Outpatient clinics treat an 

additional 330,000 for injuries.71 The financial cost of treating these injuries is correspondingly 

high. Each year IHS spends more than $150 million to treat those suffering from unintentional 

injuries.72 Injuries result in 46 percent of all Years of Potential Life Lost (YPLL) for Native 

Americans.73 This is five times greater than the YPLL due to the next highest cause, heart 

disease (8 percent).74 

Major Cardiovascular Diseases 

In the past, heart disease and strokes were rare among Native Americans, but recently 

heart disease has become the number one cause of death; stroke is now the fifth leading cause of 

death.75 This dramatic increase appears as the general population has experienced a 50 percent 

decrease in heart disease; thus, Native Americans now have cardiovascular disease rates twice 

that of the general population.76 These soaring rates can be traced to the high rates of diabetes, 

high blood pressure, and the presence of other risk factors, including poor eating habits and 

sedentary lifestyles.77

The Centers for Disease Control and Prevention conducted a national telephone survey to 

determine the extent that risk factors for heart disease and stroke (i.e., high blood pressure, 

current cigarette smoking, high cholesterol, obesity, and diabetes) were present in this 

population. According to the survey, 63.7 percent of Native American men and 61.4 percent of 

Native American women reported having one or more of these risk factors. The following 

specific risk factors were reported in significantly high percentages: 

 21 percent of men and 23 percent of women said they had been told by a health 

professional that they had high blood pressure. 

 

69 IHS, “Injuries.” 

70 HHS, Healthy People 2010. 71 Ibid. 

72 IHS, “Injuries.” 

73 HHS, Healthy People 2010, ch. 15. Years of Potential Life Lost is a measure of premature mortality. It is 

calculated using the numbers of deaths in each age group and the difference between the midpoint of the age group 

and the average life expectancy. See Centers for Disease Control and Prevention, National Center for Health 

Statistics, NCHS Definitions, <http://www.cdc.gov/nchs/datawh/nchsdefs/yearsofpotentiallifelost.htm> (last 

accessed Dec. 19, 2003). 

74 HHS, Healthy People 2010, ch. 15. 75 Indian Health Service, “Heart Disease & Strokes,” IHS Health and Heritage Brochure—Health Disparities, 

<www.info.ihs.gov> (last accessed Sept. 26, 2003). This jump in heart disease and stroke is attributed to the gradual 

improvement of health care for Native Americans. In the past, Native Americans were dying of other diseases before 

they reached the age where heart disease becomes more prominent. See Dr. Charles W. Grim, “Eliminating 

Disparities Is More Than an Access Issue,” Remarks before the Association of American Indian Physicians, Aug. 4, 

2003, <http://www.ihs.gov/PublicInfo/PublicAffairs/Director/2003_Statements/FINAL-AAIP_August_2003.pdf> 

(last accessed Dec. 19, 2003) “The health of Indian Country has changed from one of disease and illness to one of 

primarily chronic conditions influenced strongly by behavioral and lifestyle issues.” 

76 Ibid. 

77 Trope and DeRoin interview. 
12

 32.8 percent of men and 28.8 percent of women reported that they were current smokers. 

 Almost 16 percent of respondents had been told by a health care professional that they 

had high cholesterol and more than 7 percent were told that they had diabetes. 

 Almost a fourth of the male respondents (23.6 percent) and nearly one-fifth of the 

females (19.1 percent) were obese (21.5 percent of all Native Americans).78

The CDC also observed that having more than one risk factor for heart disease and stroke 

was more common among older Native American men and women, the unemployed, those with 

less education, and those reporting their health status as fair or poor.79 

Pneumonia and Influenza 

From 1994 through 1996, the Indian Health Service estimated that the age-adjusted death 

rate from pneumonia and influenza for Native Americans was 71 percent greater than the rate for 

the entire U.S. population.80 In 1998, Native American patients hospitalized for pneumonia 

accounted for the greatest number of hospital discharges for elderly Medicare beneficiaries (49.3 

per 1,000 discharges) in the entire U.S. population.81

Cancer 

Cancer among Native Americans is a growing concern.82 While some statistics indicate 

lower cancer mortality rates for Native Americans in some regions of the United States than for 

whites, African Americans, Asians, and other races, it has become the leading cause of death for 

Alaska Native women and is the second leading cause of death among Native American 

women.83 Among health care professionals there is concern that lower mortality rates obscure 

 

78 Centers for Disease Control and Prevention, Office of Communication, “Facts About Heart Disease and Stroke 

Among Native Indians and Alaska Natives,” Media Relations, June 2, 2000, <www.cdc.gov/od/oc/media/ 

pressrel/r2k0602.htm> (last accessed July 15, 2003) (hereafter cited as CDC, “Facts About Heart Disease and 

Stroke”). See also Georgetown University Center for Child and Human Development, University Center for 

Excellence in Developmental Disabilities, National Center for Cultural Competence, “Rationale for Cultural 

Competence in Primary Health Care,” Policy Brief 1, <www.georgetown.edu/research/gucdc/nccc/nccc6.html> (last 

accessed July 15, 2003) (hereafter cited as Georgetown University, “Rationale for Cultural Competence”) (only 50 

percent of Native Americans, 44 percent of Asian Americans, and 38 percent of Mexican Americans have had their 

cholesterol checked within the past two years). 

79 CDC, “Facts About Heart Disease and Stroke.” 

80 IHS, Trends in Indian Health 1998–99. This rate of influenza is significant since influenza can be particularly 

severe among diabetic patients. Agency for Healthcare Research and Quality, “National Healthcare Disparities 

Report: 4. Management of Chronic Diseases Presents Unique Challenges,” <www.ahcpr.gov/qual/nhdr03/ 

nhdrsum03.htm> (last accessed Dec. 31, 2003). 

81 Paul W. Eggers, Ph.D., and Linda G. Greenberg, Ph.D., “Racial and Ethnic Differences in Hospitalization Rates 

Among Aged Medicare Beneficiaries, 1998,” Health Care Financing Review, Summer 2000, <www.cms.hhs.gov/ 

review/00summer/eggers.pdf> (last accessed July 15, 2003). In comparison, the number of hospital discharges per 

1,000 for other racial/ethnic groups, due to pneumonia, included: whites, 22.1; blacks, 22.4; Hispanics, 25.3; and 

Asians, 17.1. 

82 Native American Cancer Research Corporation, “Native Americans and Cancer,” <http://members.aol.com/ 

natamcan/nativeca.htm> (last accessed Dec. 31, 2003). 

83 Centers for Disease Control and Prevention, “Cancer Mortality Among American Indians and Alaska Natives—

United States, 1994–1998,” Morbidity and Mortality Weekly Report, Aug. 1, 2003, <www.cdc.gov/mmwr/preview/ 
13

important regional and cancer-specific differences in mortality, knowledge of which could assist 

local cancer prevention and treatment strategies.84 Specifically, higher rates of cancer mortality 

appeared in Alaska and the Northern Plains region of the United States, with 217.9 deaths (per 

100,000 population) and 238.6, respectively, from 1994 through 1998.85 The overall cancer 

mortality rate for the rest of the United States for this period was 164.2 deaths per 100,000.86

These Native American cancer mortality rates in Alaska and the Northern Plains region are 

attributed to colorectal, gallbladder, kidney, liver, lung, and stomach cancers.87 Similarly, 

cervical cancer mortality rates were higher among Native Americans than among all racial and 

ethnic populations (3.7 versus 2.6, respectively), especially in the East and Northern Plains 

regions of the United States.88

A startling fact about cancer in Indian Country is that Native Americans have the lowest 

cancer survival rates among any racial group in the United States.89 Though some data are 

available, there is insufficient research on cancer among Native Americans.90 Nevertheless, 

experts have suggested that Native American cancer patients experience the disease differently 

from non-Native populations.91 Reasons for the difference include genetic risk factors, late 

detection of cancer, poor compliance with recommended treatment, presence of concomitant 

disease, and lack of timely access to diagnostic or treatment methods.92 Lyle Jack, a 

representative of the Lakota Sioux, testified that misdiagnosis and late diagnosis were especially 

 mmwrhtml/mm5230a4.htm> (last accessed Sept. 23, 2003) (hereafter cited as CDC, “Cancer Mortality Among 

American Indians and Alaska Natives”); Native American Cancer Research Corporation, “Native Americans and 

Cancer,” <http://members.aol.com/natamcan/nativeca.htm> (last accessed Dec. 31, 2003). The cancer mortality rate 

for Native Americans was lower during 1989 through 1993, as compared with the rate for the overall U.S. 

population. Similarly, from 1996 through 2000, Native Americans also experienced one of the lowest mortality rates 

from invasive cancers (138 deaths per 100,000 persons), compared with other racial and ethnic groups: blacks 

(257.1), whites (199.1), Hispanics (137.9), and Asian/Pacific Islanders (124.5). CDC, “Cancer Mortality Among 

American Indians and Alaska Natives.” 

84 American Public Health Association, “Abstract #55992: Regional Patterns of Cancer Mortality in American 

Indians and Alaska Natives in the U.S., 1994–1998,” <http://apha.confex.com/apha/131am/techprogram/paper_ 

55992.htm> (last accessed Sept. 23, 2003) (hereafter cited as American Public Health Association, “Regional 

Patterns of Cancer Mortality”) (David King Espey, M.D., an IHS cancer epidemiologist in Albuquerque, New 

Mexico, was scheduled to present his study on regional cancer mortality rates in American Indians and Alaska 

Natives before the annual meeting of the American Public Health Association in November 2003). 

85 American Public Health Association, “Regional Patterns of Cancer Mortality.” See also Associated Press State & 

Local Wire, “CDC: Indians in Upper Midwest Have Higher Rates of Cancer Deaths,” Aug. 1, 2003, BC Cycle (the 

Northern Plains region includes Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North and South Dakota, 

and Wyoming). 

86 American Public Health Association, “Regional Patterns of Cancer Mortality.” 

87 Ibid. 

88 CDC, “Cancer Mortality Among American Indians and Alaska Natives.” See also ibid. (the East consists of 

Alabama, Connecticut, Florida, Kansas, Louisiana, Maine, Massachusetts, Mississippi, New York, North Carolina, 

Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, and Texas). 

89 Native American Cancer Initiative, Inc., “Native American Cancer Research, Chapter 1: Introduction and 

Background,” <http://members.aol.com/natamcan2/cha01.htm> (last accessed Dec. 31, 2003). 

90 Ibid. 

91 Ibid. 

92 Ibid. 
14

prevalent on his reservation.93 Accordingly, additional research must be conducted to more fully 

explore the magnitude and causes of cancer disparities among Native Americans. 

Infant Mortality and Maternal Health 

Infant mortality and maternal health rates are also considered to be indicators of health 

status for a particular community.94 Historically, Native Americans have suffered inordinately 

high infant mortality rates.95 Despite recent improvement, disparity persists. Native American 

infants continue to die at a rate two to three times higher than the rate for white infants.96

Moreover, Georgetown University’s Center for Child and Human Development, National Center 

for Cultural Competence, reported that for Native Americans, the incidence of sudden infant 

death syndrome (SIDS) is more than three to four times the rate for white infants.97

Not surprisingly, maternal health factors also indicate lower health status. Pregnant 

Native American women consistently hold the lowest percentage of women receiving early 

prenatal care when compared with women of other races and ethnicities. For example, the 

percentage of Native American women receiving early prenatal care was 66.7 percent in 1995, 

compared with 83.6 percent of white non-Hispanic women.98

In sum, the health indicators discussed above document the reality that Native Americans 

have significantly higher mortality rates and markedly lower health status than the general 

population. To understand why these health disparities persist, despite the federal government’s 

promise to provide quality health care, we examine the health care programs, services, and 

facilities available to Native Americans. 

CAUSES OF HEALTH DISPARITIES 

The causes of the disparities in the health status of Native Americans are many and 

varied. Among the causes identified by the director of IHS is racial discrimination.99 Analyzing 

the effects of that discrimination proves difficult as the unique racial or ethnic status and political 

history of Native Americans introduce unique emotional variables. According to Michael Bird, 

“when you dispossess people of their land or labor, their culture, their language, their tradition, 

and their religion you set into force powerful forces that impact in a very negative and adverse 

way.”100 These comments on discrimination echoed the findings of the Commission’s 1999 

report on health care disparities,101 as well as those of several other government agencies. The 

 

93 Jack Statement, Briefing Transcript, p. 54. 

94 HHS, “Current Needs.” 

95 CDC, Trends in Racial and Ethnic-Specific Rates (between 1990 and 1998 the infant mortality rate for infants of 

American Indian or Alaska Native women declined by 29 percent). 96 Georgetown University, “Rationale for Cultural Competence”; CDC, Trends in Racial and Ethnic-Specific Rates. 97 Georgetown University, “Rationale for Cultural Competence.” 

98 Food Research and Action Center, “WIC in Native American Communities: Building a Healthier America,” 

Report Summary, 2000, <www.frac.org/html/publications/wic01summary.pdf> (last accessed July 15, 2003). 

99 Grim Statement, Briefing Transcript, p. 60. 

100 Bird Statement, Briefing Transcript, p. 82. 

101 USCCR, The Health Care Challenge, p. 73. 
15

National Institutes of Health recognized that racial bias contributed significantly to differences in 

health care among people of color in its Strategic Plan for Health Disparities Research,102 while the 

Institute of Medicine established that “whites are more likely to receive more, and more thorough, 

diagnostic work and better treatment and care than people of color—even when controlling for 

income, education, and insurance.”103 Few studies, however, have addressed how racial bias 

systematically affects the health of Native Americans. Though the categorization of discrimination 

in general terms is possible, the nature of that discrimination has changed to become subtle and 

more difficult to address.104 Consequently, identifying all areas in which racial bias and 

discrimination influence or contribute to existing health disparities proves difficult. 

Current research indicates that there are five primary contributors to disparities in health 

status and outcomes for Native Americans. It must be observed that these factors are not beyond 

the influence of racial bias and discrimination, either systemic or individual. The five factors 

include: 

 Limited access to appropriate health facilities. 

 Poor access to health insurance, including Medicaid, Medicare, and private insurance. 

 Insufficient federal funding. 

 Quality of care issues. 

 Disproportionate poverty and poor education.105

These five factors are not mutually exclusive; in fact, there is substantial overlap. As 

heard throughout the briefing, this is particularly true when funding considerations are 

implicated. For example, a person may arrive at a health facility only to find that lack of funding 

has prevented the facility from providing the necessary services or that there is an extended 

waiting period before services will be available. Lyle Jack, councilman of the Oglala Sioux, 

stated that although his tribe has what is considered to be one of the best rehabilitation centers, it 

does not have sufficient funding to staff the facility properly.106 Regardless of the reason, health 

care access remains limited. Thus, we turn to a discussion of the five factors that sustain the 

disparities in health status. 

 

102 National Institutes of Health, Office of the Director, Office of Behavioral and Social Sciences Research, 

“Strategic Plan for Health Disparities Research, FY 2002–2006,” Mar. 28, 2001, <www.obssr.od.nih.gov/ 

Activities/HealthDisp.htm> (last accessed July 14, 2003). See generally Institute of Medicine of the National 

Academies, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, DC: 

National Academies Press, 2002) (hereafter cited as Institute of Medicine, Unequal Treatment). 103 Vernellia Randall, Racial Discrimination in Health Care in the United States as a Violation of the International 

Convention on the Elimination of All Forms of Racial Discrimination, 14 J. LAW & PUB. POL’Y 45, 57–8 (2002). 

See also Institute of Medicine, Unequal Treatment, pp. 1–5. 104 Institute of Medicine, Unequal Treatment, p. 630. 

105 The extent to which health disparities for a specific Native American are affected by each of these causes is 

largely dependent on geography and tribal affiliation. See also Grim Statement, Briefing Transcript, pp. 60–61. 106 Jack Statement, Briefing Transcript, p. 24. 
16

1. Limited Access to IHS Health Facilities 

Access to health care is determined by four major factors of health care coverage: 

affordability, availability, accessibility, and acceptability.107 Affordability is the ability to 

purchase insurance or care.108 Availability of care is determined by availability of staff and 

facilities and measured by the ratio of providers to population.109 Accessibility is indicated by the 

eligibility for and/or entitlement to receive care, and by the ease of service access and 

utilization.110 Acceptability is determined by whether the service provided and received is 

perceived to be acceptable to the health care recipients.111 

These four factors are of major concern for Native Americans. To a limited degree, IHS 

services have made health care affordable for eligible Native Americans. A later section of this 

summary will examine funding issues and the degree to which federal funding makes adequate 

health care affordable. Additionally, IHS initiatives and a greater number of tribes getting 

involved in the management and operation of health care services are making IHS services more 

culturally acceptable for Native Americans. These and other issues associated with quality and 

acceptability of care will also be discussed later. The remaining factors, availability and 

accessibility of health care, are influenced by IHS organization and its service delivery system. 

How IHS services are structured and provided significantly influence the degree to which Native 

Americans have access to health care. Each will be discussed below. 

 Unfortunately, for the more than 538,000 Native Americans living on reservations or 

other trust lands where the climate is inhospitable, the roads are often impassable,112 and where 

transportation is scarce, health care facilities are far from accessible. Anslem Roanhorse, director 

of the Division of Health for the Navajo Nation, stated that on the Navajo reservation 78 percent 

of the public roads are unpaved and 60 percent of the homes lack telephone service.113 Even 

worse, for those who can get to the facilities, the equipment, medicine, and services are often not 

available for their needed treatment. Traveling to more distant facilities or delaying treatment are 

the only options. 

For example, in Eagle Butte, South Dakota, the Cheyenne River Sioux tribe does not 

have an obstetrics unit in its hospital and is worried that the new proposed hospital will not have 

one. “Obstetrics services for the tribe’s approximately 210 births a year are contracted out, ‘and 

last year there were five births in the ambulance on the way to Pierre,’ 90 miles away.”114 For the 

Kalispel tribe in Usk, Washington, the problem extends beyond specialty services. The tribe has 

no on-site primary care facility, so tribal members must travel 75 miles to receive care at the 

 

107 Gwendolyn Roberts Majette, Access to Health Care: What a Difference Shades of Color Make, 12 ANN. HEALTH 

L. 121, 121 (2003); Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 246. 108 Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 246. 

109 Ibid. 

110 Ibid. 

111 Ibid. 

112 “Native Americans in the Census,” Anchorage Daily News, Nov. 1, 2002, <www.adn.com/alaska/vprinter/story/2059310p-2157469c.html> (last accessed July 15, 2003); Restructuring Initiative Workgroup, 

Transitions 2002: A 5-Year Initiative to Restructure Indian Health, Final Report to the Indian Health Service, 

October 2002 (hereafter cited as Restructuring Initiative Workgroup, Transitions 2002). 

113 Roanhorse Statement, Briefing Transcript, p. 139. 

114 Peter Harriman, “Indian Health Worries Shared,” Argus Leader, Aug. 25, 2003, p. 1A. 
17

Wellpinit Service Unit IHS clinic or use an IHS contract facility, if available.115 Geographical 

access problems are not limited to remote, rural facilities. For the 25,000 urban Indians living in 

Denver, Colorado, the closest IHS hospitals are in Albuquerque, New Mexico (450 miles away) 

and Rapid City, South Dakota (400 miles away).116

Beyond location and inadequate transportation, understanding the availability and 

accessibility factors requires an understanding of how the eligibility requirements, and structure 

and operation of IHS influence access. After discussing eligibility requirements, this section will 

explore the three delivery mechanisms for health services (IHS direct delivery, tribally operated 

facilities, and urban Indian health facilities), including their respective advantages and 

disadvantages. 

IHS Health Care Services Eligibility Requirements 

Native Americans must meet specific eligibility criteria before they can access IHS health 

care services.117 They do not need to establish economic need to receive services. However, the 

very eligibility requirement that is the basis for providing health care has become contentious. 

This eligibility concern mainly lies with the determination of who is “Indian” and which 

“Indians” should receive services.118 Some argue that the eligibility requirements are established 

to exclude and not to extend health care services to Native Americans.119 From an IHS 

perspective, however, establishing a firm eligibility requirement is necessary to meet the demand 

for services in light of limited resources.120 

 

115 American Indian Health Commission of Washington State, “2003 American Indian Health Care Delivery Plan,” 

July 2003, p. 103, <www.aihc-wa.org/Issues/AIHCDP.htm> (last accessed Aug. 28, 2003). 116 The Reauthorization of the Indian Health Care Improvement Act: Hearing Before the Senate Indian Affairs Comm., 

107th Cong. (2001) (statement of Kay Culbertson, executive director, Denver Indian Health and Family Services). 

117 IHS services are provided to (1) an individual of Indian or Alaska Native descent; (2) an Indian of Canadian or 

Mexican origin, recognized by an Indian tribe or group as a member of an Indian community served by the Indian 

Health program; (3) a non-Indian woman pregnant with an eligible Indian’s child for the duration of her pregnancy 

through post-partum (usually six weeks); or (4) a non-Indian member of an eligible Indian’s household when the 

medical officer in charge determines that services are necessary to control a public health hazard or an acute 

infectious disease which constitutes a public health hazard. 

A person is of Indian or Alaska Native descent as evidenced by one or more of the following factors: (1) is regarded 

by the community in which he lives as an Indian or Alaska Native; (2) is a member, enrolled or otherwise, of an 

Indian or Alaska Native Tribe or Group under federal supervision; (3) resides on tax-exempt land or owns restricted 

property; (4) actively participates in tribal affairs; (5) any other reasonable factor indicative of Indian descent. 

Indian Health Service, “Indian Health Manual,” pt. 2, ch. 1 <http://www.ihs.gov/publicinfo/publications/ 

ihsmanual/Part2/pt2chapt1/pt2chpt1.htm#212> (last accessed July 15, 2003). 

118 Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 248. 

119 Ibid. See also Ralph Forquera, Urban Indian Health (the Henry J. Kaiser Family Foundation, November 2001), p. 8 

(hereafter cited as Forquera, Urban Indian Health); Delight Satter, M.P.H., research scientist, UCLA Center for Health 

Policy Research, and director, American Indian and Alaska Native Research Program, interview, July 1, 2003. 120 See Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 248. 
18

IHS Direct/Tribal/Urban Programs 

IHS provides health care services to approximately 1.5 million of the 2.6 million Native 

Americans in the United States.121 Recipients include members of more than 560 federally 

recognized tribes in 35 states.122 IHS provides services primarily to the Native Americans living 

on or near reservations, in rural areas. 

IHS is not a health insurance program; rather, it is a federally funded service providing 

health care services to eligible Native Americans. According to Dr. Charles Grim, director of the 

Indian Health Service, it is a program of “universal eligibility but limited availability.”123 Funds 

for IHS health care are discretionary, not a personal entitlement.124 Consequently, IHS provides 

health care services only to the extent appropriated funding allows. In addition to its health 

services role, IHS is the principal health advocate for Indian people.125 Accordingly, it 

collaborates with federal entitlement programs, state or local health care programs, and private 

insurance providers to ensure that adequate care is funded and provided. 

IHS is made up of 12 regional administrative units called area offices, as shown in Figure 

1, and these area offices oversee the operation of IHS programs. 

 

121 Indian Health Service, “Indian Health Service Introduction,” <www.ihs.gov/publicinfo/publicaffairs/welcome% 

5Finfo/ihsintro.asp> (last accessed Oct. 3, 2003) (hereafter cited as IHS, “Introduction”). 122 Ibid. See also Indian Entities Recognized and Eligible to Receive Services from the United States Bureau of 

Indian Affairs, Notice, 67 Fed. Reg. 46,328 (July 12, 2002). 123 Grim Statement, Briefing Transcript, p. 104. 

124 As will be discussed in the sections on barriers to health insurance, there is a widely held perception among 

Native Americans that they are entitled to health care based on their unique relationship and history with the federal 

government. Related, in part, to this historical view is a vigorous debate as to whether Native American health care 

should become a formal government “entitlement program.” Those in favor see entitlement status as a means of 

enforcing sufficient funding to fully meet federal health care obligations. Those opposed see entitlement as a 

potential ceiling for individual services and a potential loss of bargaining position as the federal obligation becomes 

enforceable only by individuals rather than the tribes. See Munson interview; Ed Fox, executive director, Northwest 

Portland Area Indian Health Board, interview, Aug. 14, 2003. 

125 IHS, “Introduction.” 
19

Figure 1: Indian Health Service—Service Population by Area 

Source: Indian Health Service, Trends in Indian Health 1998–99, <http://www.ihs.gov/publicinfo/ 

publications/trends98/part2.pdf> (last accessed Aug. 21, 2003). 

As of October 1, 2001, the area offices consisted of 155 basic administrative units called 

service units.126 Within these 12 areas are 545 health care delivery facilities, including 49 

hospitals, 231 health centers, 133 health stations, five school health centers, and 176 Alaska 

village clinics operated by IHS or the tribes.127 IHS-funded services are delivered in three ways: 

direct IHS services, tribal services, and Urban Indian Health Programs. For those Native 

Americans who qualify, IHS health services are delivered directly, through tribally contracted 

and operated health programs, or at IHS contract facilities.128 Additionally, 34 Urban Indian 

Health Programs provide limited health and referral services to approximately 150,000 Native 

Americans living in cities throughout the country.129 Each of the three delivery programs is 

discussed in turn, followed by a discussion of the Contract Health Services program. 

 

126 Indian Health Service, Office of Public Health, Regional Differences in Indian Health 2000–2001, p. 4 (hereafter 

cited as IHS, Regional Differences). 

127 Ibid., p. 17. 

128 Indian Health Service, “Fact Sheet,” <www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp> (last 

accessed Sept. 4, 2003) (hereafter cited as IHS, “Fact Sheet”). 

129 Ibid. Jennie R. Joe, “The Rationing of Healthcare and Health Disparity for the American Indians/Alaska 

Natives,” in Institute of Medicine of the National Academies, Unequal Treatment: Confronting Racial and Ethnic 

Disparities in Health Care (Washington, DC: National Academies Press, 2002), p. 534 (hereafter cited as Joe, “The 

Rationing of Healthcare”). Currently, only about 38 percent of Native Americans live on federal trust lands; the 

remainder reside in off-reservation or urban communities. See also ibid., p. 529. 
20

Direct Delivery System 

The IHS direct care delivery system consists of hospitals, health centers, health stations, 

and residential treatment centers.130 Federal employees in the Indian Health Service provide 

health care services in 63 IHS-operated service units, administering 36 hospitals and 59 health 

centers, 49 health stations, and two school health centers.131 Most IHS hospitals also have active 

outpatient departments that provide dental, mental health, and other services.132 IHS-operated 

facilities will expend $674 million or 46 percent of the FY 2004 budget appropriated for noncontract services. 

Health centers are physically separate from hospitals and offer a complete range of 

ambulatory services (including primary care physicians, nursing, pharmacy, laboratory, and 

radiology services) for a minimum of 40 hours per week.133 By comparison, health stations are 

often smaller mobile units, which offer fewer outpatient services for fewer than 40 hours per 

week. Mid-level practitioners usually provide primary care, with physician care available on a 

regularly scheduled basis.134 

In general, IHS direct services are limited in scope compared with services in non-IHS 

facilities. IHS hospitals are smaller and have fewer beds than other U.S. community hospitals. In 

addition, IHS hospitals provide limited inpatient services and fewer high-technology services. 

Aside from the three large IHS hospitals (the Alaska Native Medical Center in Anchorage, 

Alaska; the Gallup Indian Medical Center in Gallup, New Mexico; and the Phoenix Indian 

Medical Center in Phoenix, Arizona), IHS hospitals have fewer than 50 beds and most are 

without surgical or obstetrics services.135 Following the national trend, IHS services are shifting 

from inpatient care to an emphasis on ambulatory care services.136

Despite IHS efforts to provide for the health care needs of Native Americans, limited 

funding has led to the rationing of services.137 Rationing of health services limits patients’ access 

to only medically necessary services.138 Medically necessary services are defined by an attending 

physician who determines the health care treatment that is necessary to “preserve life, limb, and 

sensory organs or to prevent clear deterioration of health status.”139 Limited funding also forces 

 

130 IHS, “Fact Sheet.” 

131 IHS, Regional Differences, p. 4. 

132 Pfefferbaum, Providing for the Health Care Needs of Native Americans, pp. 211, 233. 133 IHS, Regional Differences, p. 13. 134 Indian Health Service, “IHS Glossary of Terms,” <www.ihs.gov/aboutihs/thisglossary.asp> (last accessed Dec. 

30, 2003). 

135 Joe, “The Rationing of Healthcare,” p. 534. 

136 Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 234. See generally South Carolina 

Hospital Association, “Glossary,” <http://www.bluecrossca.com/bus_units/lgrp/50plus_Glossary.htm> (last 

accessed Sept. 30, 2003). Ambulatory care services are defined as “[s]ervices rendered to persons not confined 

overnight, including emergency, clinical, laboratory, radiology and home health services. Often referred to as 

‘outpatient’ services.” Ibid. 

137 Craig Vanderwagen, M.D., acting chief medical officer, Indian Health Service, interview, July 21, 2003; see also 

Roanhorse Statement, Briefing Transcript, p. 169. 

138 Vanderwagen interview. 

139 Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 253. 
21

IHS officials to restrict patient access to specialty care services.140 Dr. Craig Vanderwagen, 

acting chief medical officer for IHS, acknowledged that rationing health care is not the optimal 

method of treating patients: 

We don’t feel good about the number of patients who need care who are rejected 

because their problem is not life-threatening. . . . It’s rationing. We hold them off 

until they’re sick enough to meet our criteria. That’s not a good way to practice 

medicine. It’s not the way providers like to practice. And if I were an Indian tribal 

leader, I’d be frustrated.141

In addition, where services are not available through IHS direct or tribal providers, IHS 

purchases those services from non-IHS providers under the Contract Health Services program.142

IHS has increasingly relied on contract services, as it is difficult to provide complicated services 

to many widespread and remote areas with small populations.143 As IHS uses more of its 

resources for contract services, fewer resources are available for IHS direct services. As a result, 

it becomes more difficult to develop and improve IHS services.144

Despite these problems with IHS-provided health care, there are advantages to using a 

federally operated system. First, the direct delivery system does bring services to remote Indian 

reservations where market conditions would otherwise prevent the delivery of health services.145

Even though service is limited, eligible Native Americans do receive health care. In many 

situations, tribes have neither the resources nor the expertise to provide or manage care. IHS 

brings both resources and expertise.146 Second, several sources familiar with Native American 

health care issues agree that IHS has done a remarkably good job providing for the health needs 

of Native Americans, considering formidable obstacles and limited funding.147 Third, while 

disparities still exist, the health status of Native Americans has improved over the past few 

decades.148 

 

140 Vanderwagen interview. 

141 Ibid. 

142 IHS, “Fact Sheet.” See the section in this summary on Contract Health Services for a detailed discussion on this 

program. 

143 Pfefferbaum, Providing for the Health Care Needs of Native Americans, p. 235. 

144 Ibid. 

145 Lyle Jack, tribal councilman, Oglala Sioux, interview, Oct. 23, 2003. 

146 Ibid. The ability of the federal government to provide federal benefits (of greater value than the tribes can afford 

to pay) and therefore recruit more and higher quality individuals is one reason some tribes choose not to enter into 

compacting agreements. See Taylor McKenzie, former vice president, Navajo Nation, interview, Sept. 11, 2003. 

Additionally, as long as the government is providing care there is less fear that all money will be withdrawn. As the 

tribes take over, some tribes fear that the federal government will use that as motivation to back out of their 

obligation to pay. See Joe, “The Rationing of Healthcare,” p. 544. 

147 Jennifer Giroux, M.D., Indian Health Board of Minneapolis, health care policy research and administrative 

fellow, Center for American Indian and Minority Health, University of Minnesota, interview, July 23, 2002; Jennie 

Joe, Ph.D., M.P.H., R.N., professor, Family and Community Medicine, University of Arizona School of Medicine, 

interview, June 24, 2003; J.T. Petherick, Esq., M.P.H., executive director, National Indian Health Board, interview, 

July 2, 2003; Delight E. Satter, M.P.H., research scientist, UCLA Center for Health Policy Research, director, 

American Indian and Alaska Native Research Program, interview, July 1, 2003. 

148 See Perez Statement, Briefing Transcript, p. 15. Since 1973 mortality rates have been reduced for the following: 

tuberculosis (82 percent); maternal deaths (78 percent); infant deaths (66 percent); accidents (57 percent); injury and 

poisoning (53 percent); and pneumonia and influenza (50 percent). Indian Health Service, Trends in Indian Health 
22

Tribal Health Programs 

In addition to IHS direct services, the Indian Self-Determination and Education 

Assistance Act (the Self-Determination Act) allows tribes to contract or compact to provide 

health care services to their tribal members.149 Where tribes choose not to contract for health 

programs, IHS continues to provide health services to the tribes.150 While some tribes have 

chosen to receive health care services directly from IHS, more tribes are taking on the 

management and delivery of health care services.151

Congress first enacted the Self-Determination Act in 1975 to further the goal of Native 

American self-determination by ensuring maximum Native American participation in the 

management of federal programs and services for Native Americans.152 The act authorizes tribes 

to take over the management and administration of programs through contractual arrangements 

with the agencies that previously administered them.153 Under the act, tribes receive funding for 

the programs they contract to manage. IHS and the Bureau of Indian Affairs are two federal 

agencies that enter into “self-determination contracts” with tribes. 

In 1992, the Self-Determination Act was reauthorized through amendments to the Indian 

Health Care Improvement Act.154 The self-governance programs created pursuant to the SelfDetermination Act were designed to provide tribal governments with more control and decisionmaking authority over the day-to-day operation of programs providing services to Native 

Americans. The Self-Determination Act also promotes the government-to-government 

relationships referenced in the Constitution.155

Currently, there are 61 self-governance tribal compacts and 81 funding agreements 

representing 285 tribes and providing health services to more than 51 percent of the tribes.156

 1998–99, <www.ihs.gov/publicinfo/publications/trends98/part2.pdf> (last accessed Aug. 21, 2003) (hereafter cited 

as IHS, Trends in Indian Health 1998–99). See also Perez Statement, Briefing Transcript, pp. 14, 15. 

149 25 U.S.C. §§ 450–458hh (1994 & Supp. VI 1998). Under this law, tribes can contract with the federal 

government to take over the management of all or part of their health care programs; subsequent amendments 

allowed tribes to compact with the federal government to obtain more power and independence in the management 

of their health programs. 

150 It is important to recognize that the decision to continue to rely on IHS for health services “is as legitimate a selfgovernance decision as that of a tribe that chooses to operate the program themselves.” Munson Statement, Briefing 

Transcript, p. 252. 

151 Joe, “The Rationing of Healthcare,” p. 534. 

152 Pub. L. No. 93-638, 88 Stat. 2203 (1992) (codified as amended in 25 U.S.C. §§ 450–457 (1994)). 

153 U.S. General Accounting Office, Federal Tort Claims Act: Coverage and Claims for Tribal Self-Determination 

Contracts at the Indian Health Service, July 31, 2001, GAO-01-1001T. 

154 Pub. L. No. 102-573, Title VII, § 814, 106 Stat. 4590 (1992) (codified as amended in 25 U.S.C. § 450f (1994)). 

See also Pub. L. No. 102-573, 106 Stat. 4526 (1992) (codified as amended in scattered sections of 25 U.S.C.). 

155 The tribal self-governance demonstration project mandated that the Secretary of the Department of the Interior 

(DOI) select 20 tribes, for the period of five years, to plan, conduct, consolidate, and administer programs, services, 

and functions previously administered by DOI. See Pub. L. No. 102-573, Title VII, § 814, 106 Stat. 4590 (1992) 

(codified as amended in 25 U.S.C. § 450f (1994)). The project required DOI to negotiate and to enter into an annual 

written funding agreement with the participating tribes. This funding agreement allowed the participating tribal 

governments to “redesign programs, activities, functions or services and to reallocate funds for such programs, 

activities, functions or services.” Id. 

156 Indian Health Service, Office of Tribal Self-Governance, “Purpose and Method of Operation,” <www.ihs.gov/ 

NonMedicalPrograms/SelfGovernance/index.asp> (last accessed Sept. 22, 2003). 
23

During FY 2003, $796 million of the $1.47 billion appropriated to IHS for non-contract services 

was transferred to the tribes under these programs.157 In terms of available hospital care, tribally 

operated hospitals are generally small; 80 percent have 50 or fewer beds.158 Native American 

tribes manage 13 hospitals, 172 outpatient health centers, 176 village clinics in Alaska, 84 health 

stations, and three school health programs.159 Although these tribally operated facilities are 

intended to promote tribal self-governance, IHS considers these tribal programs as extensions of 

IHS.160 IHS provides technical assistance, helps prospective tribal contractors develop 

applications, and assumes responsibility, oversight, and control of these tribally operated health 

care services.161 

While contracts allow the tribes to take over and manage existing health programs 

without making substantial programmatic changes, compacts allow tribes more flexibility in reprioritizing or changing the health programs to meet what they perceive to be the most urgent 

health care needs in their communities.162 Compacting, created in response to criticisms that IHS 

oversight of tribal programs was excessive, promotes and supports tribal initiative.163

Compacting also gives more authority to the tribes and reduces IHS bureaucracy.164 

Generally, the shift toward tribal autonomy in health care matters has been a dramatic 

success.165 Virtually every tribe that has taken control of health facilities has expanded the 

services provided.166 Additionally, tribal authority has brought an increase in the number of 

Native American employees. Consequently, the knowledge gained regarding specific techniques 

and the general importance of health remains in the community, building a foundation or 

“corporate knowledge” that might otherwise have rotated to other communities with the transfer 

of Public Health Service employees.167 Employees’ earnings, as well, usually remain in the 

community, providing economic stimulus.168 More importantly, as tribes take over the 

management and operation of their health programs, the overall quality of care provided has 

improved by being more responsive to local needs.169 Finally, tribal control creates two financial 

 

157 Ibid. See also U.S. Department of Health and Human Services, “FY 2004 Budget in Brief,” <www.hhs.gov/ 

budget/04budget/fy2004bib.pdf> (last accessed July 14, 2003) (hereafter cited as HHS, “FY 2004 Budget in Brief”). 158 U.S. General Accounting Office, Report to the Ranking Minority Member, Human Resources and 

Intergovernmental Relations Subcommittee, House Committee on Government Reform and Oversight, Indian 

Health Service—Improvements Needed in Credentialing Temporary Physicians, April 1995, p. 10 (hereafter cited as 

GAO, IHS—Improvements) (the three largest IHS hospitals are in Phoenix, Arizona; Gallup, New Mexico; and 

Anchorage, Alaska). 

159 IHS, Regional Differences, p. 17. 160 Pfefferbaum, Providing for the Health Care Needs of Native Americans, pp. 211, 237. 

161 Ibid., p. 237. 

162 Ibid. 

163 Ibid. 

164 Ibid. 

165 Paula Williams, Indian Health Service, interview, Sept. 8, 2003; Dorothy Dupree, Centers for Medicare & 

Medicaid Services, interview, June 30, 2003; Don Kashevaroff, Alaska Native Tribal Health Consortium, interview, 

Sept. 3, 2003. 

166 Munson interview. 

167 Ibid. 

168 Ibid. 

169 Joe, “The Rationing of Healthcare,” pp. 539–40. 
24

gains for health care. First, the tribes become more efficient at third-party recovery because they 

recognize the direct increase in the amount of money available for the purchase of additional 

health services. Second, the tribes have become willing to seek out private and public grants, 

knowing that their share of IHS funding will not be reduced as a result.170 

While tribal autonomy has its advantages, potential drawbacks exist. The most significant 

of these potential drawbacks is the inability to take advantage of “economy of scale” or the fall 

in average costs resulting from an increase in the scale of production.171 Economies of scale in 

health care delivery reduce health care costs by improving efficiency. Improved efficiency 

enables larger health care facilities to provide services at a reduced cost in the same manner that 

large corporate retail stores provide reduced prices to consumers of retail goods. A second 

drawback stems from the discretion granted a sovereign authority. Tribes now control their own 

data. Consequently, not all tribes contribute all data to IHS. This affects available data on actual 

health status, administration, and funding. Dave Baldridge, formerly with the National Indian 

Council on Aging, was especially critical of the impact these data problems would have on the 

ability to address health concerns on a national level.172 In the context of behavioral health, he 

saw the potential for “500 tribes operating in 500 different directions.”173 The absence of 

consistent, reliable data would make it impossible to compare and contrast. He referred to the 

shift, or “devolution,” of the established, integrated system of Indian health care in the direction 

of tribally operated programs as the “balkanization” of a previously effective health care 

system.174

Overall, the increase in tribal operation of health care services has brought more 

autonomy for the tribes and in turn has established care that fits the needs of each individual 

tribe. However, tribal services generally lack the technology and the knowledge gained in a 

larger health care delivery system.175 Additionally, while tribal services have found some success 

in third-party collection and in utilizing non-IHS funding to support their health care service 

needs, like IHS, tribal services are faced with limited resources in meeting the health care needs 

of their tribal members. Accordingly, tribal services face significant obstacles in providing full 

access to health care for Native Americans. 

Urban Indian Health Programs 

In addition to IHS direct services and tribal services, Urban Indian Health Programs 

provide health care services to urban Native Americans. According to 2000 census data, 61 

percent of the Native American population lives in urban areas. The Indian Health Care 

Improvement Act (IHCIA) allows for federal funding to sponsor operation of Urban Indian 

Health Programs to provide limited services to this community.176 In FY 2004, $31.5 million has 

 

170 Munson interview. 

171 Pfefferbaum, Providing for the Health Care Needs of Native Americans, pp. 211, 237. See also Collins English 

Dictionary, “Economy of Scale,” <http://www.wordreference.com/english/definition.asp?en=economy+of+scale> 

(last accessed Dec. 17, 2003). 

172 Baldridge Statement, Briefing Transcript, p. 346. 

173 Dave Baldridge, interview, Nov. 4, 2003. 

174 Baldridge Statement, Briefing Transcript, p. 346. 

175 Baldridge interview. 

176 Joe, “The Rationing of Healthcare,” p. 535. 
25

been requested for the Urban Indian Health Program, an increase of $245,000 from FY 2003. 

This represents less than 1 percent of annual IHS appropriations for programs serving 24 percent 

of the Native American population. In addition to the severe underfunding of urban Indian 

programs, Norman Ration of the Nation Indian Youth Council described problems associated 

with the lack of representation for urban Indians. He noted that the inability to voice urban 

Indian concerns has resulted in funding mechanisms that allow funds designated for urban 

Indians to be spent elsewhere.177 Consequently, with only 24 percent receiving limited service 

from these urban programs, 37 percent of all Native Americans (almost 1 million Native 

Americans) remain with no access to IHS facilities.178

These urban-based Indian programs, which began as not-for-profit clinics and survived 

on donated equipment, supplies, and volunteer services, became slightly more reliable sources of 

care with the funding made available through IHCIA.179 Currently, approximately 34 Urban 

Indian Health Programs in more than 41 locations are partially supported by IHS.180 The balance 

of their funding is obtained through tribal support, as well as public and private grants. 

Urban Indian Health Programs serve approximately 100,000 Native Americans who 

either do not meet IHS eligibility criteria or who reside outside IHS and tribal service areas.181

Another 49,000 Native Americans use urban programs in cities located in IHS direct or tribal 

service delivery areas.182 Far more (the 37 percent identified above) are forced to seek their own 

care, even if that means returning to tribal lands to obtain health care services.183 

The services provided vary among the 34 programs. Several provide comprehensive 

medical services as well as substance abuse and community preventive care programs. A greater 

percentage provide only limited service, with 26 percent providing only diagnostic and referral 

services.184 Urban Indians who are on public assistance, unemployed, or employed in jobs 

without health benefits most often use these facilities.185 

Unlike IHS and tribal health services that are provided without charge to eligible Native 

Americans, Urban Indian Health Programs provide services on a sliding-fee basis.186 In addition, 

 

177 Ration Statement, Briefing Transcript, p. 78. 

178 Urban Indian Health Institute, “National Aggregate Urban Indian Data,” <www.uihi.org/data.asp> (last accessed 

Aug. 23, 2003). See also Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis and 

Recommendations” (14th Annual), Mar. 19, 2003, pp. 7, 25 (hereafter cited as Northwest Portland Area Indian 

Health Board, “FY 2004 IHS Budget Analysis”). 

179 Joe, “The Rationing of Healthcare,” p. 535. 

180 Indian Health Service, “Urban Indian Health Programs,” <www.ihs.gov/NonMedicalPrograms/Urban/UIHP.asp> 

(last accessed Oct. 4, 2003); Forquera, Urban Indian Health, pp. 9–10. 181 Ibid. 

182 Ibid. IHS, Office of Urban Programs, telephone interview, Sept. 30, 2003 (while these urban Native Americans 

may live within IHS or tribal service delivery areas, even if a facility is in close proximity, they may not meet the 

eligibility requirements to receive services). 

183 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” p. 25. 

184 ITU Budget Workgroup, “FY 2003 Needs Based Budget Presentation,” p. 44, <www.npaihb.org/index.html> 

(last accessed Aug. 19, 2003). See also Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget 

Analysis.” 

185 Joe, “The Rationing of Healthcare,” p. 535. 

186 Forquera, Urban Indian Health, p. 12. 
26

many of the services are restricted to primary care.187 Urban Indians must also pay when referred 

for such services as inpatient hospital care, specialty services, and diagnostics.188

Panelists at the Commission briefing agreed that despite the fact that a large majority of 

Native Americans are living in urban settings, the Urban Indian Health Programs leave those 

without private insurance, Medicaid, or Medicare with virtually no access to health care.189

Norman Ration emphasized that although Native Americans are moving to urban areas in 

alarming numbers, “IHS does not ‘get it’ when it comes to addressing the health care needs of 

urban Indians.”190 Kay Culbertson, executive director of the Denver Indian Health and Family 

Services, also stated that urban Native Americans have become invisible to federal policies, with 

services being geared toward tribal members living on reservations.191 She added that the health 

care needs of Native Americans living off reservation are as great or even worse than the needs 

of Native Americans who live on their homelands.192

Contract Health Services Program 

Through its Contract Health Services (CHS) program, IHS purchases primary and 

specialty health care services for eligible Native Americans when services are not available 

through IHS direct or tribal services.193 For FY 2004, $493 million has been requested for CHS, 

amounting to 25 percent of funds allocated for clinical services.194 

To receive contract health services, in addition to meeting IHS eligibility requirements, 

Native Americans must live within designated contract health service delivery areas.195 Because 

of severe funding restrictions, IHS limits contract health care to those services determined to 

have medical priority.196 According to Ed Fox, executive director of the Northwest Area Indian 

Health Board, these priorities are established locally and vary depending on the level of funding 

and the relative nature of the need.197 In FY 2001, IHS deferred payment authorization for 

111,620 recommended cases and denied care for 22,030 cases,198 a 75 percent increase in denials 

 

187 Ibid. 

188 Ibid. 

189 Ration Statement, Briefing Transcript, p. 77; Culbertson Statement, Briefing Transcript, p. 277. Despite the 

apparent opposition of tribal and urban leaders in the quest for additional funding, there was general agreement that 

the question is not whether to provide health care to urban Indians or to the tribes, but whether additional funding is 

needed for all Native Americans. There seems to be a consensus that the battle for funding should not become a 

mechanism for division. 

190 Ration Statement, Briefing Transcript, p. 78. 

191 Culbertson Statement, Briefing Transcript, p. 268. 

192 Ibid., p. 276. 

193 This includes patients of IHS and tribally operated facilities. See Indian Health Service, “Glossary,” 

<http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisGlossary.asp> (last accessed Dec. 18, 2003). 

194 HHS, “FY 2004 Budget in Brief.” 

195 Forquera, Urban Indian Health, p. 8. 

196 Kuschell-Haworth, Traditional Healers and the Indian Health Care Improvement Act. 

197 Fox interview. 

198 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” pp. 3, 41. Furthermore, these 

numbers are certainly low, as tribes frequently fail to report after denial is certain. 
27

from 1998.199 The denial rate has reached the point that the existence of a “loss of life or limb” 

rule is commonly recognized.200 Mr. Fox observed that by August, with several weeks remaining 

in the fiscal year, most facilities either defer or deny gallbladder surgeries and eyeglass 

prescriptions, as well as other services of equivalent urgency.201 As an illustration, IHS officials 

identified one facility where only 14 of 45 cases needing referral for necessary services were 

even forwarded for CHS review.202 Even fewer of those reviewed actually received contracted 

care.203 As a further impediment to accessing quality health care, IHS requires that other nonIHS sources be exhausted for payment before contract services are sought.204 In other words, the 

patient still receives a referral, but instead of IHS paying the bill, the referral lists the alternate 

health care provider as the payer, subject to any applicable restrictions. If the alternate provider 

requires any deductible or co-payment IHS may pay it, if funding is available.205 

As discussed earlier, Contract Health Services programs require that patients live in 

certain contract health service delivery areas identified for their respective tribes. Accessibility to 

IHS contract health care services is effectively ended when individuals move from their home 

reservations to urban or rural locations, which are often outside contract health service delivery 

areas.206 Consequently, IHS-funded services are generally not accessible to the estimated 61 

percent of Native Americans who live off reservations in urban areas. The exceptions are the 

estimated 150,000 with limited access to the 34 Urban Indian Health Programs. 

As explained earlier, not all IHS and tribal hospitals provide a full range of specialty 

services such as cardiology, ophthalmology, and orthopedics. For these services, patients must 

use the Contract Health Services program, subject to the severe budgetary constraints discussed 

above. Contract services are usually restricted because most of CHS funding is consumed by 

emergency care.207 Those awaiting more routine care experience lengthy delays and unnecessary 

complications.208 Accordingly, while contract services provide health care otherwise unavailable 

through IHS direct or tribal providers, due to restricted funding, limited services, and lengthy 

delays in receiving services, Native Americans do not have full access to health care through the 

Contract Health Services program. 

2. Poor Access to Health Insurance 

Of the four major factors affecting access to health care, affordability is often considered 

the most formidable. Because the government has a trust responsibility to provide health care to 

 

199 ITU Budget Workgroup, “FY 2003 Needs Based Budget Presentation,” <www.npaihb.org/index.html> (last 

accessed Aug. 19, 2003). 

200 Ibid. See also Jack Statement, Briefing Transcript, p. 26. 

201 Fox interview. 

202 Vanderwagen interview. 

203 Ibid. 

204 Kuschell-Haworth, Traditional Healers and the Indian Health Care Improvement Act. 

205 Ibid. 

206 Indian Health Service, “Health Care Away From Home Reservation,” <www.ihs.gov/GeneralWeb/HelpCenter/ 

CustomerServices/CHSDA.asp> (last accessed Oct. 8, 2003). 

207 Joe, “The Rationing of Healthcare,” pp. 539–42. See also Vanderwagen interview. 208 Joe, “The Rationing of Healthcare,” pp. 539–42. See also Vanderwagen interview. 
28

Native Americans, the adequacy of federal funding becomes one measure of affordability, one 

measure of access to health care. Federal funding will be addressed in a later section of this 

summary. This section will address the individual Native American’s contribution to funding 

health care as represented by enrollment in health insurance programs. Because Native American 

enrollment figures for job-based insurance and public insurance programs fall well below those 

for white Americans, the barriers to health insurance are the focal point for this discussion. 

Data from the Kaiser Commission on Medicaid and the Uninsured indicate that 43 

percent of Native Americans have access to employer-sponsored health insurance, compared 

with 72 percent of white Americans.209 This low figure may be partly attributed to high 

unemployment among Native Americans, 7.6 percent as opposed to 3.0 percent for white 

Americans,210 and to the fact that many jobs available to Native Americans do not offer health 

insurance.211 In addition to those with job-based insurance, 27 percent rely on public health 

insurance, such as Medicaid, Medicare, the State Children’s Health Insurance Program (SCHIP), 

and the Veterans Administration services.212 This leaves the remainder, nearly one-quarter of the 

Native American population, with no insurance at all.213 For those individuals, IHS is the only 

obligated provider. If IHS is unable to provide services, the uninsured Native American must 

seek charity, or more frequently, go without health care until the situation requires emergency 

attention. 

Of those who are uninsured some percentage are eligible for coverage but are not 

enrolled because they either lack access or they choose not to enroll. Many choose not to enroll 

based on the belief that the federal government is required to provide health care, without 

regulation or limitation, as a result of treaties and obligations created in court decisions and 

legislation.214 The barriers to insurance that Native Americans face are numerous and substantial. 

They can be explained using three overlapping categories: social and cultural factors that limit 

enrollment, procedural factors that discourage enrollment, and factors that limit the collection of 

third-party funds to which Native American patients and/or IHS are entitled. The specific factors 

within each category are discussed in sequence below. 

 

209 Kaiser Commission on Medicaid and the Uninsured, “Key Facts,” June 2003, p. 12, <www.kff.org/minority 

health/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14366> (last accessed Dec. 30, 2003) (hereafter 

cited as Kaiser, “Key Facts”). Duane Jeanotte, director of headquarters operations, Office of the Director, IHS, 

explained that “the availability of insurance in the total Indian population is not known, but anecdotal information 

suggests that it’s less than other groups.” Jeanotte Statement, Briefing Transcript, p. 199. For the IHS and the tribal 

user population, Mr. Jeanotte estimates that 60 percent have some type of third-party coverage. Ibid., p. 202. 

210 U.S. Census Bureau, “Employment Status 2000,” Census 2000 Brief, p. 5, <www.census.gov/prod/2003pubs/ 

c2kbr-18.pdf> (last accessed Sept. 22, 2003). 211 Kaiser, “Key Facts.” 

212 By some estimates as many as 40 percent of Native Americans are eligible for Medicaid, with more eligible for 

Medicare and SCHIP, and as many as 50 percent have private insurance (IHS estimates that 60 percent have some 

form of third-party insurance). Yet IHS estimates that only 25 percent of the money spent on Native American 

health care comes from non-IHS sources. See Kaiser, “Key Facts.” The Veterans Administration’s programs serve 

more than 165,000 Native Americans. See “VA and HHS to Improve Health Care for Indian Veterans,” Seminole 

Tribune, Mar. 21, 2003, p. 4. Additional sources include the TriCare program with the Department of Defense, 

serving 12,800 Native Americans and their families (see “Hopi Mom Among Missing,” Newsday, Mar. 30, 2003, p. 

W18); and state and federal correctional institutions, serving almost 29,000 inmates (see Bureau of Justice Statistics, 

“American Indians and Crime,” 1997, <www.ojp.usdoj.gov/bjs/pub/pdf/aic.pdf> (last accessed July 11, 2003)). 

213 Kaiser, “Key Facts.” 

214 Dupree interview. 
29

Social and Cultural Factors 

Many agree that the major factor preventing Native Americans from enrolling in public 

insurance programs is their belief that they are entitled to health care as a result of their unique 

relationship with the federal government.215 From the perspective of many Native Americans, 

they purchased a service at heavy cost, on the order of 400 million acres of land, and full 

recovery should be neither costly nor burdensome for the individual patient. Therefore, these 

Native Americans see Medicare and Medicaid registration and enrollment procedures, as well as 

the accompanying rules and regulations, as burdens for which they did not bargain and with 

which they should not be required to comply.216 Even the strong community interest in full 

collection from these programs is sometimes not enough to overcome this view. 

The perception of burden derives from several factors, including requests for private 

information and the necessity for documentation to support the paperwork.217 Additionally, 

Native Americans fear that participating in public programs will lead to the elimination of 

IHS.218 This fear has been reinforced by budget proposals that have, in essence, deducted from 

appropriated funds the amount increased by collections from public insurance programs.219 In 

fact, that dynamic has probably guided budgetary policy over the past seven to 10 years.220

Significantly, tribally operated facilities have proved to be more effective at increasing 

enrollment in and collections from public insurance programs than federal IHS facilities.221

Native Americans are typically more comfortable releasing private information to other Native 

Americans; the tribal facilities are motivated to seek additional funds available to them; the tribal 

facilities use a different, more flexible billing system, which is capable of adapting to changing 

reimbursement requirements; and the tribal facilities experience less turnover, enabling the 

facility to build relationships with state government officials.222

Not completely separate from the view that Native Americans are entitled to health care 

is the stigma sometimes associated with public programs. Historically, stigma has centered on 

the perception others have of welfare recipients. Many beneficiaries of public programs feel that 

they are perceived as lazy and that they fail to get respect as a result of accepting public 

assistance.223 A study by George Washington University researchers has found that the actual 

 

215 Dupree Statement, Briefing Transcript, p. 216. 216 Dupree interview. 

217 A study by the California Policy Research Center found that the requirement for the production of any documents 

or records to determine eligibility was problematic. Delight E. Satter, Steve Wallace, Trang Lee, and Andrea 

Zubiate, “Improving Health Insurance Coverage for American Indian Children and Families Under Healthy 

Families,” SCHIP Final Report, June 2002, p. 15, <www.healthpolicy.ucla.edu/pubs/files/AIAN_report_ 

062002.pdf> (last accessed July 14, 2003) (hereafter cited as Satter et al., “Improving Health Insurance Coverage”). 

See also Dupree interview. 

218 Satter et al., “Improving Health Insurance Coverage.” 

219 Lovell Hopper, director, Division of Financial Management, Indian Health Service, interview, July 21, 2003. 

220 Ibid. 

221 Dupree interview. 

222 Ibid. 

223 Sara Rosenbaum, Karen C. Jones, Kathleen A. Maloy, and Jennifer P. Stuber, “Beyond Stigma: What Barriers 

Actually Affect the Decisions of Low-Income Families to Enroll in Medicaid?” July 2000, <www.gwu.edu/~chsrp/ 

pdf/stig.pdf> (last accessed July 11, 2003). 
30

stigma is even broader.224 Stigma is related as much to how recipients will be treated in the 

application process and how health care providers will treat those recipients once they are 

enrolled as it is to the mere perception of others.225 This stigma factor is amplified by several of 

the procedural factors discussed below. 

Procedural Factors 

Native Americans’ perception that they are burdened by the requirement to enroll in 

public insurance programs is magnified by the confusing and difficult enrollment process.226

Very few Native Americans understand the Medicaid, Medicare, and SCHIP eligibility 

requirements; in fact, many IHS employees are equally confounded.227 One frequent 

misunderstanding involves Native Americans being asked for co-payments for programs such as 

SCHIP, when they are specifically exempt from the co-payment requirement.228 Any costsharing requirement impedes enrollment in public programs.229

Inconsistent guidance from the Centers for Medicare & Medicaid Services (CMS) 

compounds the problem. Policy is frequently promulgated by telephone from CMS headquarters, 

because CMS regulations on Native American health care are incomplete.230 The answer to a 

specific question, and consequently policy at the local level, may depend on who answers the 

telephone.231

In other situations problems arise in the presence of very specific regulations and 

policies. One problem stems from the association of the 100 percent Federal Medical Assistance 

Percentage (FMAP) with the IHS facility, rather than the individual. In general terms, FMAP is 

the statutory percentage of Medicaid funds paid by the states but reimbursed by the federal 

government.232 Under the current arrangement, full federal reimbursement for state expenditures 

is dependent on performance of services in an approved IHS facility. Contracted health care, 

long-term care, and home care do not qualify for the 100 percent FMAP.233 Essentially, the states 

 

224 Ibid. 

225 Ibid. 

226 Dupree interview. 

227 Ibid. 

228 See Dupree Statement, Briefing Transcript, p. 212, and Dupree interview. 

229 Dupree Statement, Briefing Transcript, p. 212 230 Dupree interview. 

231 Ibid. Fox interview. 

232 U.S. Department of Health and Human Services, Office of Health Policy, “Federal Medical Assistance 

Percentages,” <http://aspe.os.dhhs.gov/health/fmap.htm> (last accessed Dec. 18, 2003). 

233 Indian Health Service, “Speaking with One Voice IHS, Tribes, Urban,” Draft Report on the Indian Health 

Service Regional I/T/U Consultation Meeting held February 1, 2, 1999, in Reno, Nevada, <www.ihs.gov/Admin 

MngrResources/reauthor/files/ihs-5ren.doc> (last accessed July 14, 2003) (hereafter cited as IHS, “Speaking with 

One Voice”). See Christian Richardson, “Federal Decision on Indian Health Care Reversed,” Aberdeen American 

News, Oct. 4, 2003, p. A4. This may be expanding to include coverage of contracted services. On September 30, 

2003, a federal judge in South Dakota (in an unpublished decision) ruled that the Centers for Medicare & Medicaid 

Services must reimburse the South Dakota Department of Social Services 100 percent of the costs of medical 

services provided under the CHS program for “essential” treatment. Ibid. See also Dupree Statement, Briefing 

Transcript, p. 211. 
31

must contribute a portion if services are provided outside an IHS facility. Consequently, states 

are disinclined to provide assistance in enrolling Native Americans in public programs when 

increasing enrollment results in fewer services from the conventional tax base. By extending the 

100 percent FMAP to all facilities, the disincentive is removed and states will be more likely to 

encourage Native American enrollment in public programs. One manifestation of this issue was 

addressed during the briefing. Because tribal nursing homes are not eligible for 100 percent 

FMAP, the state is less inclined to certify them.234 Uncertified facilities are ineligible for 

Medicare, making them unprofitable, particularly on or near reservations.235 Other procedural 

barriers include the coverage available under Medicare Part B and various technical issues 

associated with those eligible for Medicaid and Medicare, also referred to as “dual eligibles.”236

The shift to managed care in the past decade has also brought change to reimbursement 

from third parties. As the individual states have required citizens to work within a managed care 

system to receive Medicaid benefits they have chosen different methods for dealing with Native 

Americans, whose facilities frequently do not meet managed care requirements. Exemptions to 

mandatory enrollment come in the form of opt-in or opt-out programs, among other voluntary 

and mandatory programs.237 The response of Native Americans has not been uniform, as some 

tribes have sought further exemptions, while others are seeking ways to increase facility 

participation in the managed care provider networks.238

In addition to the system and facility requirements, individual eligibility requirements can 

also impose barriers. In the context of Medicare, the requirement for 40 quarters of Social 

Security-covered employment excludes many elderly applicants who would otherwise qualify for 

Medicare. With high unemployment rates on reservations and the disproportionately high 

number of persons failing to meet the 40-quarter requirement, tribes have sought a Native 

American exemption.239 Such an exemption would markedly increase Medicare eligibility. 

Furthermore, confusion and insufficient information about the availability of Medicaid to 

purchase Medicare Part B coverage have excluded an additional undefined number of elderly 

Native Americans.240 

Collection Factors 

Whether a Native American patient has health insurance is irrelevant to his or her 

eligibility to receive IHS health care. The existence of health insurance only affects the ability of 

IHS to seek reimbursement. To the extent that IHS is reimbursed for the care it provides, every 

dollar gained is one additional dollar available for health care for Native Americans. For many 

 

234 Dupree Statement, Briefing Transcript, p. 224. 

235 Ibid. 

236 Ibid., pp. 213–14. 

237 Centers for Medicare & Medicaid Services, “American Indian and Alaska Native Beneficiaries: Current Issues 

and News: June 22, 2000 Centers for Medicare & Medicaid Services Consultation Issues,” <www.cms.hhs.gov/ 

aian/summiss.asp> (last accessed July 14, 2003) (hereafter cited as Centers for Medicare & Medicaid Services, 

“Current Issues”). 

238 Ibid. 

239 Ibid. 

240 Dupree interview. 
32

reasons, IHS collection from third parties has increased dramatically in the past 10 years.241 This 

remarkable improvement in collections was achieved with a programmatic effort including 

“higher negotiated Medicare and Medicaid rates, new authority to bill under CHIP [Child Health 

Insurance Program] and more efficient business management practices, involving patient 

eligibility determination, documentation of services and processing of claims.”242 Despite this 

significant improvement, barriers to full reimbursement remain. 

One noteworthy barrier to full collection is a lack of data.243 As noted earlier, enrollment 

and eligibility data for public insurance programs are inaccurate and incomplete. With accurate 

data on eligibility and enrollment, IHS, CMS, and the tribes themselves would be able to redirect 

resources to where the need is greatest. 

A second barrier is erected by the Medicaid reimbursement mechanism. For IHS 

facilities, reimbursement is calculated using an “all-inclusive rate” per encounter.244 This allinclusive rate is a coarsely developed average, which may vary significantly from actual costs. 

This variance is problematic on its own, but the definition of “encounter” can magnify the 

problem. Depending on the nature of the encounter and the specific variance, the reimbursement 

amount may be significantly more or less than the amount anticipated or due.245 

Many of the remaining barriers to increased collection overlap with barriers to 

enrollment. In attempting to simplify collection efforts, the resulting mechanism may reduce the 

amount collected.246 The lack of training that leads to a failure to enroll those eligible also leads 

to billing errors and inefficiencies.247 An administrator who does not know and is unable to 

determine which services are billable will inevitably neglect to bill for all covered procedures.248

Additionally, collecting improper or incomplete documents leads to a denial of benefits and 

necessarily fewer collections.249 During the briefing, Dorothy Dupree of the Centers for 

Medicare & Medicaid Services identified additional barriers, including high turnover in billing 

staff, high submission of incomplete claims or improper billing, failure to submit claims, little to 

no follow-up on pending claims, and difficulty in getting the right people through training 

workshops.250 

 

241 Indian Health Service, “Indian Health Service FY 2004 Performance Plan, FY 2003 Revised Final Performance 

Plan and FY 2002 Performance Report,” Sept. 13, 2002, p. 13, <www.ihs.gov/AdminMngrResources/Budget/ 

downloads/FY_2004/GPRA%20Perf-Plan%20Report.doc> (last accessed July 14, 2003). 

242 Ibid. 

243 Jeanotte Statement, Briefing Transcript, p. 199. The use of the all-inclusive rate, described below, also leads to 

data problems. One reason to use the all-inclusive rate is the minimal data-keeping requirement. See Dupree 

Statement, Briefing Transcript, pp. 211–14. 

244 For a partial explanation of the all-inclusive rate calculation, see Jeanotte Statement, Briefing Transcript, p. 201, 

and Dupree Statement, Briefing Transcript, p. 214. 245 Centers for Medicare & Medicaid Services, “Current Issues.” See also IHS, “Speaking with One Voice,” and 

Dupree Statement, Briefing Transcript, pp. 215–16. 

246 Dupree interview. 

247 Ibid. 

248 Ibid. 

249 Ibid. 

250 Dupree Statement, Briefing Transcript, p. 213. 
33

Any barrier to enrollment, regardless of the reason, is necessarily a barrier to collection. 

Taken collectively, these barriers to collection affect an already overburdened IHS budget and 

magnify the inadequacy of current funding levels. 

3. Insufficient Federal Funding 

Inadequate federal funding has been consistently identified as a significant obstacle to 

providing adequate health care and eliminating disparities in health status for Native Americans. 

The need for additional funding is well supported, as advocates for Native American health care 

have developed a variety of measurements to verify the inadequacy of present funding levels. 

The following arguments have been made when requesting additional funding: 

 Annual increases in IHS funding have failed to account for medical inflation rates and 

increases in population. 

 Annual increases in IHS funding are less than those for other HHS components. 

 Annual increases have effectively been reduced to reflect increased collection efforts 

despite express congressional intent that they not be reduced. 

 Annual per capita expenditures rise to only 60 percent of the federal benchmark level for 

health care expenditures. 

 Annual per capita expenditures fall below the level for every other federal medical 

program and standard. 

Below are an overview of these individual measurements and specific identifiable needs, 

an explanation of what can be done with increased funding, and a look at the ramifications of not 

immediately providing appropriate funds. 

As the primary health care provider for Native Americans, IHS receives the vast majority 

of funds appropriated for that purpose. For FY 2004, the President’s budget request included 

$2.9 billion for IHS, just 4.5 percent of a $64 billion HHS discretionary budget and an even 

smaller 0.5 percent of the overall HHS budget of $538 billion.251 While other HHS components 

and programs do provide limited health-related services for Native Americans, their Native 

American expenditures are equal to 0.5 percent of IHS spending on Native Americans, less than 

$20 million.252 

Another HHS program, the Centers for Medicare & Medicaid Services (CMS), 

contributes significantly to the support of Native American health services, though indirectly, as 

all funding is distributed to IHS via individual state Medicaid and Medicare programs. The 

President’s FY 2004 budget request estimated Medicaid and Medicare expenditures of $439 

 

251 Indian Health Service, “President’s Fiscal Year 2004 Budget Request Proposes 2.6 Percent Increase for Indian 

Health Service,” press release, Feb. 3, 2003, <www.ihs.gov/PublicInfo/PublicAffairs/PressReleases/Press_Release_ 

2003/Release_04_IHS_2004_Budget_Request.asp> (last accessed July 14, 2003) (hereafter cited as IHS, 

“President’s Fiscal Year 2004 Budget Request”). See also U.S. Commission on Civil Rights, A Quiet Crisis: 

Federal Funding and Unmet Needs in Indian Country, 2003, Tables 2 and 3 of Chapter 3 (citing the Budget of the 

United States Government, Fiscal Year 2004, Historical Tables, Table 5.4, pp. 103–04). 

252 See U.S. Commission on Civil Rights, A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country, 

2003, Tables 2 and 3 of Chapter 3 (citing the Budget of the United States Government, Fiscal Year 2004, Historical 

Tables, Table 5.4, pp. 103–04). 
34

billion.253 IHS estimated public third-party collections of $517 million, or 0.1 percent of the 

combined annual Medicaid and Medicare budget.254 Because of the distribution mechanism used, 

CMS funds spent on Native Americans are seen as IHS collections or reimbursements, rather 

than budgeted appropriations. When IHS budget appropriations are combined with collections 

from CMS and private, third-party insurers, the total composes the program-level funding for 

IHS and provides a better picture of the overall federal government spending on Native 

American health care. For FY 2004, the President’s budget estimates reimbursement in excess of 

$560 million, for a total IHS program-level funding of almost $3.6 billion.255 

The overall IHS budget has grown at a rate slightly below the rate of inflation over the 

past several years. The $2.9 billion budgeted for FY 2004 appropriations represents an increase 

of 2.6 percent from FY 2003,256 an amount far below that needed to maintain the current level of 

services.257 With only this limited increase, the actual spending power will decline due to the 

high specific medical inflation rate, the moderate health services and facilities inflation rates, and 

significant population growth in the Native American community.258 The Northwest Portland 

Area Indian Health Board estimates that $360 million, a full 12.4 percent increase, would be 

needed simply to cover current services and mandatory costs.259 

Comparing the current rate of increase with other HHS programs, IHS also falls short. 

The 2.6 percent increase for FY 2004 compares to a 5.5 percent increase for Medicaid and a 10.9 

percent increase for Medicare.260 Over a longer period IHS fares no differently; it has the 

smallest rate of increase within HHS over the past five years.261 When the annual IHS budget 

figures are adjusted for inflation it becomes apparent that the per capita spending power for IHS 

appropriations, in 1996 dollars, is roughly the same today as it was in 1991; IHS appropriations 

dropped from a high of $1,439 in 1991 to a low of $1,197 in 1998.262 

Only enhanced collection efforts have made up the difference and prevented a continuous 

decline from 1991 until today, despite the intent that collections supplement rather than replace 

 

253 HHS, “FY 2004 Budget in Brief.” 

254 IHS, “President’s Fiscal Year 2004 Budget Request.” 

255 Ibid. This figure does not include reimbursement to tribal programs, as no nationwide data are collected. See 

Jeanotte Statement, Briefing Transcript, p. 201. 256 IHS, “President’s Fiscal Year 2004 Budget Request.” 

257 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” p. 2. 

258 For FY 2004, the Northwest Portland Area Indian Health Board estimates the medical inflation rate for CHS at 12.5 

percent, the health services inflation rate at 7.5 percent, the facilities inflation rate at 4.0 percent, and the population 

growth at 2.1 percent of the health services account. See Northwest Portland Area Indian Health Board, “FY 2004 IHS 

Budget Analysis,” p. 13. See also The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate 

Comm. on Indian Affairs, 108th Cong. (2003) (statement of Dr. Charles W. Grim, director, Indian Health Service). 

259 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” pp. 9, 15. Mandatory costs 

include $19.6 million for federal pay increases, $16 million for tribal pay increases, and $25.5 million to fund 

staffing and operating costs for new facilities. See also The President’s FY 2004 Budget for Indian Programs 

Before: Hearing Before the Senate Comm. on Indian Affairs, 108th Cong. (2003) (statement of Dr. Charles W. 

Grim, director, Indian Health Service). 260 HHS, “FY 2004 Budget in Brief.” 

261 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” p. 39. 

262 Indian Health Service, “Ten Year Funding Trends,” <www.ihs.gov/nonmedicalprograms/ihdt2/Oldindex.asp> 

(last accessed July 3, 2003). 
35

annual appropriations.263 IHS has raising collections as one of its long-term goals, and 

collections from alternate programs have risen considerably in the past decade. IHS officials 

estimate that collections could be increased by 25 percent; however, the current IHS 

infrastructure may not support an immediate 25 percent increase in services.264 

From the CMS perspective, it is impossible to determine precisely current CMS 

expenditures with current data collection systems.265 Two factors contribute to problems tracking 

expenditures: tribal health programs are not required to report collection information to IHS, and 

collection figures for CMS services provided outside IHS facilities are dependent on selfreporting by patients. For reasons already discussed, many Native Americans are reluctant to 

report their status. 

Even with a verified and complete third-party collection effort, it is unlikely that current 

program-level funding for Native American health care would be adequate. This adequacy was 

central to recent hearings before the Senate Committee on Indian Affairs. On February 26, 2003, 

and March 5, 2003, the committee conducted hearings on the President’s FY 2004 budget 

request for Indian programs. Hearing participants addressed a wide array of Native American 

programs, including the Indian Health Service. Dr. Charles W. Grim, director of the Indian 

Health Service, described an increasing budget, demonstrative of government commitment to 

high-quality health care for Native Americans.266 In contrast, advocates described marginal 

budget increases woefully inadequate for bridging the divide between current funding and that 

necessary for Native Americans to receive the same medical care as other Americans.267

 

263 See 25 U.S.C. § 1641(a) (1994). 

Determination of appropriations. Any payments received by a hospital or skilled nursing facility 

of the Service (whether operated by the Service or by an Indian tribe or tribal organization 

pursuant to a contract under the Indian Self-Determination Act (25 U.S.C. §§ 450f et seq.)) for 

services provided to Indians eligible for benefits under title XVIII of the Social Security Act (42 

U.S.C. §§ 1395 et seq.) shall not be considered in determining appropriations for health care and 

services to Indians. 

Id.

264 IHS executive staff, interview, July 21, 2003. IHS executive staff members who were present at this interview 

included Michel Lincoln, deputy director, Office of the Director; Duane Jeanotte, director of headquarters 

operations, Office of the Director; Robert McSwain, director, Office of Management Support; Gary Hartz, acting 

director, Office of Public Health; Paula K. Williams, director, Office of Tribal Self-Governance; Craig 

Vanderwagen, M.D., acting chief medical officer, Office of the Director; Michael Mahsetky, director of legislative 

affairs, Office of the Director; Lovell Hopper, director, Division of Financial Management, Office of Management 

Support; Cliff Wiggins, senior operations research analyst, Office of the Director; Jon Perez, Ph.D., director, 

Division of Behavioral Health, Office of Clinical and Preventive Services, Office of Public Health; Ron Demaray, 

division director, Self-Determination, Office of Tribal Programs, Office of the Director; and Kitty Marx, senior 

policy analyst/legislative affairs, Division of Regulatory & Legal Affairs, Office of Management. 265 Dupree interview. 

266 See generally The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on

Indian Affairs, 108th Cong. (2003) (statement of Dr. Charles W. Grim, director, Indian Health Service). 267 See generally The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on

Indian Affairs, 108th Cong. (2003) (statements of Tex Hall, president, National Congress of American Indians; Julia 

Davis-Wheeler, chair, National Indian Health Board; and Kay Culbertson, executive director, Denver Indian Health 

and Family Services). 
36

Additionally, those testifying described an IHS budget shortfall of $18 billion, money needed to 

extend IHS services to all Native Americans.268 

Continued underfunding of IHS reflects the importance of the Native American program 

relative to all other federal medical programs. HHS estimates the annual per capita health care 

spending for the general population at $5,065. In contrast, IHS spends $1,914 per eligible user, 

or 38 percent of that spent by the general population.269

Figure 2 demonstrates that IHS expenditures are significantly less than every other federal 

benchmark and illustrates the inadequacy of federal funding for Native American health care. 

Figure 2: Per Capita Health Care Expenditures 

$5,915

$5,214 $5,065

$3,879 $3,803

$619

$1,914

$3,725

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Medicare

expenditures 

VA users US per

capita 

Medicaid

acute care

Federal

prisoners

FEHB

benchmark

per IHS user

IHS medical

care

IHS nonmedical

Source: U.S. Department of Health and Human Services, Indian Health Service, Office of 

Management Support, Division of Financial Management, “IHS Appropriations Per Capita 

Compared to Other Federal Health Expenditure Benchmarks,” March 2003. 

In addition to the funding disparities, specific funding deficiencies in the FY 2004 budget 

exist. The FY 2004 budget request includes $493 million for Contract Health Services (CHS), a 

5 percent increase over FY 2003. This represents a shortfall of more than $500 million, and is 

 

268 The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on Indian Affairs, 

108th Cong. (2003) (statements of Tex Hall, president, National Congress of American Indians, p. 7, and Julia 

Davis-Wheeler, chair, National Indian Health Board, p. 5). This number includes $9–10 billion in annual 

expenditures and $9 billion one-time facilities construction expenses. See also Northwest Portland Area Indian 

Health Board, “FY 2004 IHS Budget Analysis,” p. 2. 

269 Indian Health Service, Office of Management Support, Division of Financial Management, “IHS Appropriations 

Per Capita Compared to Other Federal Health Expenditure Benchmarks,” March 2003. 
37

well below that necessary to even maintain the current level of services.270 Among all IHS 

programs, CHS is the most vulnerable to inflationary pressures.271 It is estimated that between 

FY 1992 and FY 2003, CHS lost more than $250 million to inflation alone.272 At current 

deteriorating levels, only treatment for life-threatening conditions can be funded, particularly 

toward the end of the fiscal year. Failure to increase funding for CHS will lead to continued 

delays in delivering necessary, though not life-threatening, medical services. The budget request 

also includes no increase in contract support costs for the administrative infrastructure necessary 

for the tribal programs to function properly.273 An additional $150 million would be necessary to 

enable scheduled expansion of these tribal programs.274 Urban health care has current unmet 

needs of more than $1.5 billion. Nevertheless, advocates for urban health care request only an 

additional $6 million for two compelling reasons.275 First, and perhaps most importantly, the 

current political and fiscal climate is unlikely to support substantial increases in funding. Second, 

the current IHS structure, including facilities and employees, cannot accommodate immediate 

full funding.276 Any attempt to fully fund urban Indian health care would require extensive 

structural change and sustained, gradual increases in funding.277 

Tribal leaders and health care advocates have noted that more funding is needed to 

expand and improve health care for Native Americans. Tribal leaders have calculated the gains 

that they would realize for incremental changes in funding. For every $100 million in purchasing 

power, IHS, tribal, and urban health programs could provide: 

 365,000 outpatient visits 

 13,000 inpatient days 

 115,000 dental services 

 10,000 mental health contacts 

 28,000 alcohol treatment visits 

 23,000 Contract Health Services outpatient visits 

 

270 The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on Indian Affairs, 

108th Cong. (2003), p. 6 (statement of Julia Davis-Wheeler, chair, National Indian Health Board). 

271 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis,” p. 22. 272 Ibid. 

273 The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on Indian Affairs, 

108th Cong. (2003), pp. 6–7 (statement of Julia Davis-Wheeler, chair, National Indian Health Board). 

274 Ibid. 

275 The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on Indian Affairs, 

108th Cong. (2003), p. 9 (statement of Kay Culbertson, executive director, Denver Indian Health and Family 

Services). 

276 Ibid. See also Duane Jeanotte, director of headquarters operations, Indian Health Service, interview, July 21, 2003. 277 The President’s FY 2004 Budget for Indian Programs: Hearing Before the Senate Comm. on Indian Affairs, 

108th Cong. (2003), p. 9 (statement of Kay Culbertson, executive director, Denver Indian Health and Family 

Services); ITU Budget Workgroup, “FY 2003 Needs Based Budget Presentation,” p. 18, <www.npaihb.org/index. 

html> (last accessed Aug. 19, 2003). 
38

 16,000 public health nursing visits 

 29,000 health education services278

With a $100 million increase in appropriated funding, an increase of approximately 3.1 

percent, the Native American health care system could offer substantially more services. 

However, an increase in funding may well not be realized anytime soon. During the 

Commission’s briefing, Myra Munson, an attorney and advocate for Native American health care 

issues, noted that “the ultimate policy document is always the budget document.”279 With limited 

funds, IHS and other agencies are challenged to find creative ways to halt declining 

acceptability, availability, affordability, and accessibility of health services for Native 

Americans. Health care issues for Native Americans, however, are not only about IHS 

underfunding. In the words of Ms. Munson, they are also about “education underfunding, about 

housing underfunding, about roads underfunding, about justice underfunding, about the 

conditions in which Indian people live. If you take away all the things that allow people to be 

responsible for themselves and have a sense of hope, to have an opportunity, then health will 

suffer as well.”280

4. Quality of Care Issues 

Several factors, in addition to funding, affect a facility’s ability to provide quality health 

services. Other factors include the ability to recruit and retain qualified health providers, 

accreditation status, the age of the facility’s physical structures, and its capacity to deliver health 

care services in a culturally appropriate manner. 

Ability to Recruit and Retain Health Providers 

The ability to recruit and retain competent health care providers is one indicator of the 

quality of care at a health facility. In some cases, poor quality creates high turnover. Not 

surprisingly, highly trained medical personnel get frustrated at the inability to provide care at the 

level they were trained to provide. Additionally, overworked staffs quickly develop burnout.281

In other situations, high turnover results in a poor quality of service. High turnover leaves gaps 

where facilities are undermanned and disrupts continuity of care. Historically, IHS has 

experienced shortages in doctors, dentists, pharmacists, and nurses.282 IHS director Dr. Charles 

Grim stated that vacancy rates range anywhere from 8 to 23 percent.283 In 2001, his staff reported 

that the physician vacancy rate for IHS facilities was 10 percent, and the average length of 

service for IHS physicians was 8.1 years.284 Consequently, Dr. Grim stated the agency must hire 

 

278 Northwest Portland Area Indian Health Board, “FY 2004 IHS Budget Analysis.” 

279 Munson Statement, Briefing Transcript, p. 214. 

280 Ibid., p. 250. 

281 Open Session before the U.S. Commission on Civil Rights, Gallup Medical Facility, Gallup, NM, Oct. 16, 2003. 

Remarks of Dr. Jana Gunnell, New Mexico Department of Public Health. 

282 Restructuring Initiative Workgroup, Transitions 2002.

283 Grim Statement, Briefing Transcript, p. 61. 

284 Indian Health Service, “Workforce,” Issue Summary, February 2001, <http://info.ihs.gov/infrastructure/ 

infrastructure4.pdf> (last accessed Sept. 25, 2003) (hereafter cited as IHS, “Workforce”). More recent figures list 
39

almost 1,200 doctors to fill 900 vacant physician positions each year.285 IHS has had difficulty 

achieving this goal in some locations, which it primarily attributes to the remoteness of some 

sites.286 The vacancy rate for other health care professionals at IHS facilities also causes concern. 

For example, in 2001, IHS experienced a vacancy rate of 22 percent for dentists and 14 percent 

for optometrists.287 IHS also recognized that it is experiencing a shortage of registered nurses in 

inpatient and ambulatory care facilities, as well as pharmacists.288 On a local level, conditions 

can be even worse. The director of the Division of Health for the Navajo Nation reported nursing 

vacancy rates exceeding 25 percent.289

As an example of the impact of the lack of sufficient medical staff on the quality of care, 

Gregg Bourland and Harold Frazier, former chairman and vice chairman, respectively, of the 

Cheyenne River Sioux tribe in South Dakota, described the following situation at an IHS facility: 

In January and February 2002, the Eagle Butte Service Unit [in South Dakota] on 

the Cheyenne River Sioux reservation has been swamped with children with 

Influenza A, RSV [Respiratory Syntactical Virus], and one fatal case of 

meningitis. There are only three doctors on duty, one Physician Assistant, and one 

Nurse Practitioner. The only pediatrician is the Clinical Director who will not see 

any patients, even though there is a serious need for the services of a pediatrician. 

Several of these children have presented with breathing problems, high fever, and 

severe vomiting. The average waiting time at the clinic has been [between] four 

and six hours. The average time at the emergency room is similar. Most babies 

have been sent home without any testing to determine what they have and with 

nothing but cough syrup and Tylenol. In at least three cases, the baby was sent 

home after these long waits two or more times with cough syrup, only to be lifeflighted soon thereafter because the child could not breathe. The children were all 

diagnosed by the non-IHS hospital with RSV. . . . No babies have died yet, but the 

Tribe sees no justification for waiting until this happens when these viruses are 

completely diagnosable and treatable.290 

Improvements in recruiting, training, and compensation are needed to reduce staff 

shortages. IHS has instituted a student loan repayment program to attract and retain Native 

American health professionals.291 As a result of the program, the number of Native American 

federally employed health professionals has increased 195 percent and the proportion of the 

 average physician longevity at nine years. These numbers compare to an average of two to two and a half years in 

the 70s. See also Olson Statement, Briefing Transcript, p. 126. 285 Dr. Charles W. Grim, director, Indian Health Service, interview, July 21, 2003. 

286 IHS, “Workforce.” 

287 Ibid. 

288 Ibid. 

289 Roanhorse Statement, Briefing Transcript, p. 143. 

290 149 CONG. REC. S. 4109, 4147 (daily ed. Mar. 20, 2003) (statement of Sen. Daschle). As part of his statement, 

Senator Daschle referred to a letter from the Cheyenne River Sioux tribe to IHS describing the situation at the Eagle 

Butte Service Unit. See also id. at 4147. Senator Daschle noted the following quality of care issues at the Eagle 

Butte Service Unit: The facility does not have an obstetrician; it is funded at 44 percent of the need calculated by the 

IHS; and although Eagle Rock has a birthing room and 22 obstetrical beds, only two to three doctors are available to 

staff the clinic, hospital, and emergency room. Id.

291 IHS, “Workforce.” 
40

Native American professional staff has increased 104 percent since 1981.292 Typically, many 

recipients of IHS scholarships work in tribal facilities and Urban Indian Health Programs. 

Despite these signs of improvement, a need for qualified medical and nursing staff remains at a 

number of IHS facilities, particularly those in remote locations. 

Accreditation Status 

As an important indicator of their ability to provide quality health services, health care 

facilities in the United States seek accreditation by nationally recognized organizations. All the 

large IHS facilities and some of the tribal health centers are accredited either by the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO) or by the Accreditation 

Association for Ambulatory Health Care.293 

A certificate of accreditation from a recognized health care evaluating authority serves 

several functions. Most importantly, it instills public confidence in the quality of the services, 

satisfies safety standards and state licensure requirements, and supports recruitment and retention 

efforts.294 Accordingly, accreditation from JCAHO fulfills these requirements.295 Moreover, the 

Centers for Medicare & Medicaid Services (CMS) grants JCAHO “deeming” authority to 

consider each health care organization it accredits as meeting Medicare and Medicaid 

reimbursement certification requirements.296 As a result, JCAHO-accredited health care 

organizations are not subject to the CMS survey and certification process. Accreditation for 

Medicaid and Medicare reimbursement eligibility through this method is voluntary and seeking 

“deemed” status through accreditation is optional.297 

Although other health care accrediting associations exist, JCAHO is considered the 

primary accrediting body responsible for establishing national health care standards on patient 

safety and quality of health issues and evaluating various types of health facilities for their 

 

292 Ibid. 

293 Olson Statement, Briefing Transcript, pp. 129–30. 

294 See Joint Commission on Accreditation of Healthcare Organizations, “How to Become Accredited,” 

<www.jcaho.org/htba/index.htm> (last accessed Sept. 25, 2003). 

295 Joint Commission on Accreditation of Healthcare Organizations, “Facts About the Joint Commission on 

Accreditation of Healthcare Organizations,” About Us, <www.jcaho.org/about+us/jcaho/jcaho_facts.htm> (last 

accessed Sept. 5, 2003) (hereafter cited as JCAHO, “About Us”). 

296 Joint Commission on Accreditation of Healthcare Organizations, “Federal Deemed Status and State 

Recognition,” <www.jcaho.org/about+us/government+relations/fed_st_rec.htm> (last accessed Sept. 25, 2003) 

(hereafter cited as JCAHO, “Federal Deemed Status and State Recognition”). In order for a health care organization 

to participate in and receive payment from Medicare or Medicaid programs, it must be certified as complying with 

the Conditions of Participation, or standards, set forth in federal regulations. This certification is based on a survey 

conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services (CMS). However, if a 

national accrediting organization, such as the Joint Commission on Accreditation of Healthcare Organizations, has 

and enforces standards that meet the federal Conditions of Participation, CMS may grant the accrediting 

organization “deeming” authority and deem each accredited health care organization as meeting Medicare and 

Medicaid certification requirements. Ibid. See also Munson interview (stating that tribal facilities are now seeking 

JCAHO accreditation, in order to become eligible for funds from Medicaid and Medicare reimbursement). 

297 JCAHO, “Federal Deemed Status and State Recognition.” 
41

compliance with those standards.298 Since 1951, JCAHO has provided accreditation services for 

a variety of health care organizations, including hospitals (general, psychiatric, pediatric, 

rehabilitation, and critical care facilities), health care networks, assisted living facilities, 

ambulatory care centers, home care organizations, nursing homes, behavioral health facilities 

(including those that offer mental health and addiction services), and clinical laboratories.299 

In 2002, JCAHO conducted accreditation surveys of 35 to 40 IHS facilities and found the 

overall quality of care in IHS facilities to be adequate. The survey included IHS ambulatory care 

and behavioral health facilities, laboratories, and critical access hospitals in Arizona, California, 

Minnesota, Oklahoma, North and South Dakota, and Utah.300 On a scale from 1 to 100 (with 100 

considered full compliance), the scores for IHS facilities ranked from 97 to 100, compared with 

scores of 80s and 90s for comparable non-IHS facilities.301 As an example, comparable non-IHS 

facilities scored worse in complying with the JCAHO standard “Accessing Competence,” which 

requires facilities to assess each staff member’s ability to meet the performance expectations 

stated in his or her job description. Here, 25.1 percent of non-IHS facilities did not satisfy this 

standard, as compared with a 14.29 percent noncompliance score in IHS facilities.302

Despite these rankings, JCAHO also identified standard problem areas for IHS 

facilities.303 A few examples include: 

 “Environment of Care” (safety) Standard—14.29 percent of IHS facilities were not in 

compliance with hospital smoking policies, compared with a 2.7 percent noncompliance 

rate in comparable non-IHS facilities. 

 “Initial Assessment” Standard—28.57 percent of IHS facilities did not assess patients’ 

functional status when warranted by their needs or conditions, compared with a 3.8 

percent noncompliance rate for non-IHS facilities for this standard. 

 “Anesthesia Care” Standard—14.29 percent of IHS facilities did not comply with the 

requirement to follow medical staff criteria for discharging patients from post-sedation or 

post-anesthesia recovery areas or provide a qualified licensed independent contractor to 

approve the discharge, compared with a 0.8 percent noncompliance rate for non-IHS 

facilities. 

 

298 Mowll Statement, Briefing Transcript, p. 132; JCAHO, “About Us”; Charles A. Mowll, FACHE, executive vice 

president of business development, Government and External Relations, Joint Commission on Accreditation of 

Healthcare Organizations, interview, July 3, 2003. 

299 Mowll Statement, Briefing Transcript, pp. 132–33; Joint Commission on Accreditation of Healthcare 

Organizations, 2002 Hospital Accreditation Standards (Oakbrook Terrace: Joint Commission Resources, 2002), p. 

13 (hereafter cited as JCAHO, 2002 Hospital Accreditation Standards). See also ibid., pp. 12–13 (JCAHO uses 

standards from several accreditation manuals associated with these areas). 

300 See Mowll Statement, Briefing Transcript, p. 142; Mowll interview (These are smaller facilities that have referral 

agreements with larger hospitals. Critical access hospitals provide ancillary and support services to stabilize patients 

for a limited time before patients are transferred to a tertiary care facility for additional care). 

301 See Mowll Statement, Briefing Transcript, p. 142; Mowll interview (A few IHS facilities had survey scores that 

were considered as outliers on this scale. For example, a hospital in Oklahoma scored an 82, which indicated that the 

facility had more standards that were out of compliance than others). 

302 Joint Commission on Accreditation of Healthcare Organizations, “Indian Health Service Hospital Program—Top 

Standard Problem Areas, 1/1/2002 to 12/31/2002” (run date), June 19, 2003 (data provided in aggregate form). 

303 Ibid. 
42

 “Medication Use” Standard—14.29 percent of IHS facilities did not consistently have 

emergency medications available, controlled, and secured in the pharmacy and patient 

care areas, compared with a 2.8 percent noncompliance rate in comparable non-IHS 

facilities.304

Although these documented problem areas did not lower JCAHO’s overall rating of the 

IHS facilities, they affect the quality of care provided to Native Americans. The accreditation 

procedure that assesses the quality of a health facility must include all factors that affect quality. 

Panelists at the Commission briefing indicated that despite the JCAHO accreditation, the quality 

of health care provided by IHS does not always meet the standard of care acceptable to the 

Native American patients.305 As Dr. Richard Olson, director of Office of Clinical and Preventive 

Services at IHS noted, cultural competence is one measure of quality that JCAHO surveys do not 

evaluate. They also do not assess some of the major problems IHS is facing with high vacancy 

rates, aging and remote facilities, and rationing of services. 

Importance of “Culturally Competent” Health Services 

Ensuring that health care facilities satisfy national accrediting standards, recruiting and 

retaining qualified health care providers, updating and improving physical plants, reducing 

medical malpractice lawsuits, and eliminating the rationing of health services are essential 

ingredients in the delivery of quality health services. However, if health services are not offered 

to the targeted patient population in a culturally and linguistically appropriate manner, patient 

treatment will still be ineffective in eliminating racial and ethnic health care disparities.306 

Public health authorities view providing culturally and linguistically appropriate 

treatment as “culturally competent” treatment. Cultural competence is defined as: 

the demonstrated awareness and integration of three population-specific issues: 

health-related beliefs and cultural values, disease incidence and prevalence, and 

treatment efficacy. . . . [P]erhaps the most significant aspect of this concept is the 

inclusion of and integration of the three areas that are usually considered 

separately when they are considered at all.307 

The importance of culturally competent health services to the overall quality of health 

care is generally acknowledged.308 Dr. Grim noted that cultural and language barriers contribute 

to health disparities and limit access to health care.309 He added that IHS is working to make its 

programs more culturally relevant.310 Authorities realize the necessity of offering health care that 

 

304 Ibid. 

305 See generally Jack Statement, Briefing Transcript, p. 24; Kathy Janis Statement, Briefing Transcript, pp. 293–94; 

Dan Jaco Statement, Briefing Transcript, pp. 301–04; Margaret E. Garcia Statement, Briefing Transcript, p. 306. 

306 See generally Institute of Medicine, Unequal Treatment. 

307 The Henry J. Kaiser Family Foundation, “Compendium of Cultural Competence Initiatives in Health Care,” 

January 2003, p. 6, <www.kff.org/content/2003/6067/6067v6.pdf> (last accessed Sept. 17, 2003). 

308 See, e.g., Olson Statement, Briefing Transcript, p. 128. 

309 Grim Statement, Briefing Transcript, p. 62. 

310 Ibid., pp. 62, 65. 
43

recognizes the patient’s values, beliefs, and traditions, in order to provide quality services for 

specific populations.311 According to the Department of Health and Human Services: 

Health care providers typically presume they are color blind in their delivery of 

services. Few providers have thought about the biases they bring to patient 

encounters or about their own cultural/ethnic backgrounds, health beliefs, and 

health practices. These biases often result in both the system and its providers 

attempting to get the patient to conform to the mainstream instead of meeting a 

patient on her or his own cultural ground. Yet patient attitudes about health, 

religious views, and concepts of death often influence compliance, affect disease 

management, and alter health outcomes.312

The Office of Minority Health in the Department of Health and Human Services 

published final national standards on culturally and linguistically appropriate services (CLAS) in 

health care in December 2000.313 The CLAS standards are intended to address inequities in the 

provision of health services and to ensure that these services are more responsive to the needs of 

all patients and consumers.314 The standards are specifically designed to address the concerns of 

racial, ethnic, and linguistic population groups that experience unequal access to health services, 

to eventually eliminate racial and ethnic health disparities, and to improve the health of all 

Americans.315

The CLAS standards provide 14 principles and related activities to ensure culturally and 

linguistically appropriate services are integrated throughout a health care organization, in 

 

311 U.S. Department of Health and Human Services, Public Health Reports, “Culturally Competent Health Care,” 

Public Health Report 2000, by Jean Lau Chin, Ed.D., vol. 115, January–February 2000 (hereafter cited as HHS,

Public Health Report 2000). See also Johnson interview. Dr. Emory Johnson, former director of the Indian Health 

Service, discussed what happens when cultural competency is not considered. He provided the following examples 

of the need to understand patients collectively, as a community or tribe, in order to build relationships and create 

acceptance: 

Native Americans from a given tribe were opposed to the installation of sanitation lines. They had 

been living in homes, where every few years it was necessary to move the “privy.” When offered 

permanent piping into their homes, their assumption was that they would need to build a new 

home when the “privy” at the end of the pipe was full. They had no intention of accepting a 

system that forced them to build a new home every few years. Consequently, it was necessary to 

understand the local sensibilities and educate them, first to understand and then to accept the 

sanitation program. 

As further evidence, Dr. Johnson mentioned a Cornell University study, where a high-tech medical facility was 

placed in an impoverished rural setting. The study found that the high-tech program resulted in little improvement in 

health status, which was eventually attributed to a lack of understanding and acceptance in the rural community. 

Johnson interview. 

See also “MPH Student Blends Native American and Modern Medicine to Address Health Disparities,” Harvard 

Public Health Now, May 31, 2002, <www.hsph.harvard.edu/now/may31/student.html> (last accessed July 15, 

2003); J. Patterson, “Meeting the Needs of Native American Families and Their Children with Chronic Conditions, 

Families, Systems & Health, vol. 15, no. 3, 1997, pp. 237–41. See generally USCCR, Health Care Challenge, pp. 

44–45. 

312 HHS, Public Health Report 2000. 313 National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, Notice, 65 

Fed. Reg. 80,865 (Dec. 22, 2000). 

314 Id. at 80,873. 315 Id. 
44

partnership with the communities served by the facility.316 The standards are organized into three 

categories: culturally competent care, language access services, and organizational support for 

cultural competence. The standards are required for all recipients of federal funds, recommended 

for adoption as requirements by federal, state, and national accrediting agencies, and suggested 

for voluntary adoption by health care organizations.317 

If culturally and linguistically appropriate health services are desirable to Native 

Americans based on their unique cultures and the unique relationship with the federal 

government, distinctive approaches to health care should also be included in the delivery of 

health services to this population. Many Native Americans continue to employ traditional 

medicines and practices either as their sole form of health care or as a component of their overall 

health care.318 Accordingly, in March 2002, the Association of American Indian Physicians 

unanimously approved a resolution supporting Native American traditional healing and 

medicines as part of the spectrum of health care appropriate for Native Americans.319 As part of 

this resolution, the association intends to work with traditional healers for the benefit of Native 

patients and community health. 

In a study designed to identify what urban Indian family caregivers should inform health 

providers who work with Native American children with chronic health conditions about Indian 

culture, the caregivers concluded that providers should be aware of the role and importance of 

extended family members in a child’s overall care, any traditional health beliefs and healing 

practices, and any cultural communication patterns.320 Specifically, health facilities should avoid 

excluding extended family members who might visit a child, since they also assist in serving as 

primary caregivers to Native American children.321 Some Native American families may resist 

Western treatment recommendations and may want to use herbal remedies, healing ceremonies, 

and traditional healers as a primary or supplemental form of treatment.322 Furthermore, the study 

indicated that health providers should be aware of the significance of nonverbal communication 

for some Native American patients, such as indirect eye contact and silence.323 These nonverbal 

signs often indicate respect for the “healer,” which may cause some patients to refrain from 

asking questions or requesting health care services.324 Cultural competence, therefore, 

acknowledges the patient’s perspective and inevitably improves the quality and delivery of care. 

Reaching that level of competence requires insight, extensive training, and a programmatic 

commitment to cultural sensitivity. 

 

316 Id. 317 Id. 318 Joe, “The Rationing of Healthcare,” p. 537. 

319 Association of American Indian Physicians, “Resolution,” Mar. 13, 2002, <www.aaip.com/about/AAIP_trad_ 

med_resol_02.html> (last accessed July 15, 2003). 

320 Ann Garwick and Sally Auger, “What Do Providers Need to Know About American Indian Culture? 

Recommendations from Urban Indian Family Caregivers,” Families, Systems & Health, vol. 18, no. 2, 2000, p. 177. 

The study included a small sample of 30 Native American families from three tribes: 27 Ojibwe, two Lakota, and 

one Dakota in a large Midwestern city. The authors note that the results of this study may not be the same for 

families of other urban Indian tribes. 

321 Ibid. 

322 Ibid. 

323 Ibid. 

324 Ibid. 
45

To explore whether IHS facilities were delivering culturally competent health services, a 

focus group of Native Americans was formed in Albuquerque, New Mexico, and revealed that 

participants were generally satisfied with IHS providers’ awareness of Native American 

culture.325 However, despite that IHS provides training for non-IHS providers at contracted 

facilities,326 focus group participants cited biased behavior and cultural insensitivity toward the 

importance of traditional medicine by private sector health care providers.327 Findings from this 

focus group suggest that when IHS refers Native American patients to contracted health 

providers, these providers should be extensively apprised of and trained on the cultural and 

linguistic needs of all patients who seek their health services.328 

Problem of Aging Facilities 

IHS also faces the challenge of dealing with aging facilities. The average age of current 

IHS facilities is 32 years, compared with nine years for private sector facilities,329 indicating that 

a massive modernization program is urgently needed.330 New and properly designed facilities are 

needed to provide efficient space to deliver services.331 Some older IHS facilities, however, tend 

to be “inefficient and haphazard in their arrangement of space,” causing crowded waiting rooms, 

low productivity rates by providers, and ultimately patient dissatisfaction.332 In addition, the 

oldest facilities may not comply with Occupational Safety and Health Administration or 

Americans with Disabilities Act standards.333 Unfortunately, because of financial constraints, 

IHS has been unable to renovate its older facilities. An IHS survey in November 2002 estimated 

a backlog of $506 million in needed facilities repairs alone.334 

 

325 Joe, “The Rationing of Healthcare,” p. 538. 

326 Grim Statement, Briefing Transcript, p. 66. 

327 Joe, “The Rationing of Healthcare,” p. 538. 

IHS facilities and its leadership in many communities have always allowed patients and their 

families either time or a place (in a clinical setting) to consult with tribal healers or practitioners. 

The services provided by most of these tribal healers or practitioners are seen as complementing 

modern medicine and provide a source of spiritual help for many patients. 

Ibid. 

328 See, e.g., Anslem Roanhorse, Jr., division director, Navajo Division of Health, interview, Sept. 24, 2003 (For 

contracted services, Navajo-speaking staff are on call to provide translation services, if needed, on a 24-hour basis. 

Orientation and training about the Navajo culture are done for contracted providers). 

329 See Indian Health Service, “Strategic Plan: Improving the Health of American Indian and Alaska Native People 

Through Collaboration and Innovation,” p. 5, and Perez Statement, Briefing Transcript, p. 16. 

330 Restructuring Initiative Workgroup, Transitions 2002. 331 Indian Health Service, Office of Public Health, Division of Facilities and Environmental Engineering Health 

Care Facilities Engineering, Millennium Report and Accomplishments Since 1954, January 2000, p. 32. 332 Ibid. 

333 Roanhorse interview. 

334 Results from Backlog of Essential Maintenance and Repair (Survey) as reported in Northwest Portland Area 

Indian Health Board, “FY 2004 IHS Budget Analysis,” p. 30. 
46

5. Disproportionate Poverty and Poor Education 

Not every disparity in health status for Native Americans can be attributed to care 

provided by a health care system. It is widely recognized that poverty and education can each 

contribute to the health disparities Native Americans experience.335 This fact is not lost on the 

tribes. During the Commission’s briefing, Lyle Jack, a tribal representative, criticized current 

funding distribution formulas for failing to consider the role of poverty on Native American 

health status.336 The reasons for the causal connection, while seemingly common sense, are not 

well documented. Scholars, however, generally recognize that income relates to health status 

because it increases access to care, provides access to better housing with fewer environmental 

hazards, and generally increases the opportunities to engage in healthy lifestyles.337 Similarly, 

education relates to health in that it increases exposure to health-related information, equips 

individuals with the skills necessary to apply health-promoting behavior, and is typically 

associated with higher incomes.338 

Unfortunately, Native Americans, like other people of color, are often poor and have 

lower levels of educational attainment. This section first details the link between socioeconomic 

status and health status; then follows with the link between educational attainment and health 

status. Because Native Americans have the highest poverty rate of any ethnic group and their 

educational attainment levels are significantly lower than the national average,339 it becomes 

apparent that their health status is compromised by these factors. On individual reservations, 

poverty levels are often significantly worse. Anslem Roanhorse, director of the Division of 

Health for the Navajo Nation, testified to the dire economic conditions the Navajo people face. 

Fifty-six percent live below the poverty level and 43 percent are unemployed. Additionally, more 

than 50 percent of homes rely on wood burning for heating, 32 percent lack adequate plumbing, 

and 60 percent lack telephone service.340

 

335 USCCR, The Health Care Challenge, p. 17. See also Health Disparities: Bridging the Gap: Hearing Before the 

Subcomm. on Public Health of Senate Comm. on Health, Education, Labor and Pensions, 106th Cong. (2000) 

(testimony of Ruth L. Kirchstein, acting director, National Institutes of Health); and E. Pamuk, D. Makuc, K. Heck, 

C. Reuben, and K. Lochner, Socioeconomic Status and Health Chartbook. Health, United States 1998, p. 25 

(Hyattsville, MD: National Center for Health Statistics, 1998) (hereafter cited as Pamuk et al., Socioeconomic Status 

and Health Chartbook). 

336 Jack Statement, Briefing Transcript, p. 24. 

337 Pamuk et al., Socioeconomic Status and Health Chartbook, p. 29. 

338 Ibid., p. 30. 

339 Native Americans have a poverty rate of 25.9 percent, compared with the national poverty rate of 11.3 percent. 

Among the other ethnic groups, the rates are 22.1 percent, 7.5 percent, 10.8 percent, and 21.2 percent, respectively, 

for blacks, white/non-Hispanics, Asians and Pacific Islanders, and Hispanics. See U.S. Census Bureau, Public 

Information Office, “Nation’s Household Income Stable in 2000, Poverty Rate Virtually Equals Record Low,” 

Census Bureau Reports, Sept. 25, 2001, CB01-158. 

In 1990, 65.5 percent of Native Americans 25 and older had graduated from high school, compared with 75.2 

percent for the total population. Furthermore, 9.3 percent of Native Americans 25 and older hold a bachelor’s 

degree, compared with 20.3 percent of the total population. See National Center for Education Statistics, “American 

Indians and Alaska Natives in Post-Secondary Education,” October 1998, p. 1-14. Other statistics demonstrate that 

Native Americans are twice as likely to drop out of high school as the national average. See U.S. Department of 

Education, Indian Nations at Risk Task Force, “Plans for Dropout Prevention and Special School Support Services 

for American Indian and Alaska Native Students,” 1992. 

340 Roanhorse Statement, Briefing Transcript, p. 139. 
47

An array of figures are used to establish poverty level or socioeconomic status. Income 

level is most frequently used, but unemployment rates, enrollment rates for public benefits, and 

asset holdings can also illustrate relative ability to pay for health services. Regardless of which 

basis is used, statistics consistently support the proportional relationship between health and 

socioeconomic status. More specifically, Americans living near or below the poverty level suffer 

from worse health than their wealthier counterparts and at age 45 have a life expectancy three to 

seven years shorter than those with higher incomes.341 While 27 to 37 percent of men living 

below the poverty line report being in fair or poor health, only 4 to 5 percent of high-income men 

report this. The results for women are similar.342

Mortality rates illustrate similar results. Low-income women are three times more likely 

to die from diabetes than their high-income counterparts, and the gradient is only slightly less 

steep for men.343 In addition, heart disease mortality rates for the poorest women are 3.4 times 

those for women with the highest incomes. Similarly, men earning less than $10,000 are 2.5 

times more likely to die from heart disease than men earning $25,000 or more.344

One possible explanation for the higher mortality rate is that risk factors known to 

contribute to the identified health conditions are more prevalent among poor adults. For example, 

31 percent of poor women suffer from hypertension, a risk factor for heart disease and stroke, 

compared with 19 percent of high-income women. Notably, hypertension in low-income women 

is almost twice as likely to be unmonitored and thus uncontrolled.345 Furthermore, poor men and 

women are about twice as likely to smoke as their high-income counterparts.346 

Inadequate access to medical care is another factor contributing to poor health for those 

living in poverty. Men and women living below the poverty line are almost five times more 

likely to have an unmet need for health care than adults with high family income.347

Furthermore, poor women are three times as likely as high-income women to have gone without 

seeing a doctor in the past year; poor men are twice as likely as high-income men.348 This could 

account for the fact that rates of avoidable hospitalizations are 2.4 times higher for those living 

below the poverty level and for the fact that 33 percent of those living below the poverty level 

have some activity limitation due to injury or chronic condition, compared with 11 percent of 

those living in the middle- and high-income brackets.349

As alluded to earlier, income and education are closely linked. On a national level, 

accounting for all workers in 1999, high school graduates earned $25,900 and college graduates 

earned $45,400, while high school dropouts earned an average of $18,900.350 Furthermore, high 

 

341 Pamuk et al., Socioeconomic Status and Health Chartbook, p. 88. 342 Ibid., p. 29. 

343 Ibid. 

344 Ibid. 

345 Ibid. 

346 Ibid. 

347 Ibid. 

348 Ibid. 

349 Ibid. 

350 U.S. Census Bureau, “The Big Payoff: Educational Attainment and Synthetic Estimates of Work-Life Earnings,” 

July 2002, <http://landview.census.gov/prod/2002pubs/p23-210.pdf> (last accessed July 17, 2003). 
48

school dropouts account for 12.9 percent of the working poor, more than double the rate of 

workers with a high school diploma.351 For many, dire financial situations make finding 

employment, rather than seeking an education, a priority. 

Conversely, wealthier, more educated people are more likely to have better access to 

medical care and safer home and work environments.352 In addition, they may have more 

opportunities to engage in healthy activities and lifestyles, more awareness of health issues, and 

more time to pursue healthy behaviors.353 It stands to reason that there is also an emotional cost 

associated with being poor and uneducated that may lead to worse health or poor health 

practices. 

Lack of education, considered alone, has historically been a very strong indicator of poor 

health. Among all racial and ethnic groups, men with less than 12 years of education are 2.5 

times more likely to die from a chronic disease than men with more than 12 years of 

education.354 The ratio for women is 2.1, and similar rates are passed from generation to 

generation.355 Infant mortality rates almost double for infants whose mothers have less than a 

high school education.356

Death due to injuries and suicide is also more prevalent among less educated individuals. 

For example, the least educated men are over three times more likely to die of injuries than the 

most educated men, and the least educated women are more than twice as likely to die of injuries 

than their well-educated counterparts.357 Likewise, suicide rates are higher for those with less 

education, up to 3.7 times higher, depending on race and gender.358

Adults with less education are also more likely to exhibit risk factors known to contribute 

to chronic health problems and have more difficulties gaining access to medical care. For 

example, mothers with more education are 40 percent more likely to have received early prenatal 

care than mothers with less than 12 years of education.359 Less educated mothers are almost 10 

times as likely to smoke during pregnancy as more educated mothers.360 Furthermore, heavy 

alcohol use, which can lead to cirrhosis, increased accident rates, and fetal alcohol syndrome, 

among other health problems, is 30 percent higher among adults with less than a high school 

education than it is among college graduates.361

While health disparities between the educated and uneducated exist among all racial and 

ethnic groups, the disproportionate lack of educational attainment among Native Americans 

obviously results in more health disparities for that population. As explained above, the pattern 

 

351 U.S. Department of Labor, Bureau of Labor Statistics, “Profile of the Working Poor, 2000,” March 2002, 

<www.bls.gov/cps/cpswp2000.htm> (last accessed July 17, 2003). 352 Pamuk et al., Socioeconomic Status and Health Chartbook, p. 29. 353 Ibid., pp. 29–30. 

354 Ibid., p. 90. 

355 Ibid. 

356 Ibid., p. 52. 

357 Ibid., p. 29. 

358 Ibid., p. 100. 

359 Ibid., p. 46. 

360 Ibid. 

361 Ibid. 
49

holds true for disproportionate poverty levels in the Native American communities. Without a 

doubt, increasing the general educational level of Native Americans and raising their general 

standard of living will result in improved health status. 

Consequently, any effort to improve the health status of Native Americans must 

necessarily address the high poverty rates and the disparate lack of education that afflict Native 

American communities, in addition to the access, funding, and quality of care issues described 

earlier. A significant portion of that effort involves the appropriations process, discussed in part 

earlier. A perhaps more achievable portion of that effort involves discrete statutory 

improvements as proposed in the Indian Health Care Improvement Act discussed in the 

following section. 

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT 

Among the pending changes identified thus far, including the Medicare Prescription 

Drug, Improvement, and Modernization Act of 2003, the reauthorization of the Indian Health 

Care Improvement Act appears to hold the most promise.362 The changes it proposes are 

expected to aid IHS and tribal leaders in making significant improvements to the health care 

provided to Native Americans. 

The most recent version of the Indian Health Care Improvement Act (IHCIA) was passed 

in 1992 and authorized through FY 2000; Congress extended it through FY 2001. Anticipating 

the expiration of the IHCIA, IHS initiated regional consultation meetings with tribal leaders in 

1998 to solicit input on changes to the act when the bill is introduced for reauthorization.363 The 

tribes formed a National Steering Committee (NSC) of tribal leaders to draft a comprehensive 

proposal to address concerns and unmet needs.364 The NSC sought to update the IHCIA to make 

it more responsive to current real-world needs, to increase opportunities for attracting more 

revenue into the health system, and to facilitate greater exercise of self-determination in health 

care program decision-making and regulations.365 

In October 1999, NSC delivered a proposal to revise the existing law to the President and 

Congress.366 Reauthorization legislation was introduced during the 106th and 107th sessions of 

Congress that substantially reflected the NSC proposal; however, the bill never reached the floor 

of either the House or the Senate. Subsequently, in September 2002, the Bush administration 

 

362 According to Dr. Charles W. Grim, director, Indian Health Service, several items in the Medicare Prescription 

Drug, Improvement, and Modernization Act of 2003 will be particularly important to Native Americans, including a 

provision to increase rural ambulance reimbursement rates; a provision to compensate IHS for providing emergency 

assistance to undocumented aliens; a provision to require Medicare hospitals to accept Medicare rates as payment in 

full from IHS users; an expansion of Medicare part B services in IHS facilities; and changes to Critical Access 

Hospital reimbursement rates. See Indian Health Service, “IHS Director Grim Congratulates Bipartisan Passage of 

Medicare Bill; ‘Bill Benefits All Americans and Has Specific Benefits for Indian Country,’ Director Says,” press 

release, Dec. 9, 2003, p. 1. 

363 Indian Health Service, “Overview of Consultation Process,” <http://www.ihs.gov/AdminMngrResources/ 

reauthor/Our_Initiative.cfm> (last accessed Dec. 19, 2003). 364 Ibid. 

365 Carol Barbero, Esq., partner, Hobbs, Straus, Dean & Walker, interview, Aug. 11, 2003; Munson interview. 

366 The structure of the IHCIA has been retained in the various reauthorization bills introduced to Congress with new 

and revised language inserted in all eight titles. 
50

voiced reservations about the costs associated with several sections of the bill.367 To address 

these budgetary concerns, NSC and Congress began negotiations to revise the draft bill. During 

these negotiations, in March 2003, Senator Ben Nighthorse Campbell reintroduced the bill as 

Senate bill 556.368 This bill is identical to earlier bills but does not include any revisions made 

pursuant to the NSC negotiations. The Senate Indian Affairs Committee conducted hearings in 

early 2003 to consider the bill. 

In June 2003, Representative Don Young introduced reauthorization bill H.R. 2440, 

which includes revisions made by NSC to address the administration’s earlier cost concerns.369

There are now numerous differences between the House and Senate bills. 

There is no single change in the reauthorization of the IHCIA that will close the health 

status gap for Native Americans. Instead, the bills attempt to address the problems contributing 

to the gap, more specifically, access to appropriate health facilities, access to health insurance, 

inadequate federal funding, quality of care, and poverty and education. They accomplish this task 

through a series of procedural changes to the established system. Additionally, the 

reauthorization bills reflect changes in the landscape of Native American health care programs 

and the fundamental shift in the delivery of health care to Native Americans. Specifically, the 

bills recognize that many tribes have assumed responsibility for administrating their own health 

programs under contracts and compacts.370 While tribes rely on government funding, the reliance 

is to varying degrees. Many tribes have found it necessary to access tribal money, charitable 

grants, and other funding sources. The reauthorization bills will allow for more flexible funding 

options. 

Recognizing that tribes and tribal organizations now operate over half of IHS programs, 

there are six principal objectives of reauthorization. The first of these are health promotion 

objectives. The reauthorization will affirm the principle that the health status objectives for 

Native Americans must be the same as for all other Americans.371 Previously, the only objective 

was to generally improve the health status of Native Americans. 

The second objective of reauthorization is to ensure a continuum of care by providing a 

full range of health programs instead of relying on demonstration projects that isolate ideas in 

individual programs.372 A flexible continuum allows the individual IHS, tribal, and urban Indian 

programs to use their own initiative in creating solutions that respond specifically to local needs. 

Third, the reauthorization updates the act to focus on programs instead of facilities, 

responding to the evolution of health services from an inpatient model with lengthy hospital 

 

367 In March 2001, the Congressional Budget Office (CBO) “scored” or estimated the federal budget impact of the 

mandatory spending parts of the Senate bill, S. 212. CBO estimated these would cost $6.9 billion over 10 years. 

Munson interview. 

368 Indian Health Care Improvement Act Reauthorization of 2003, S. 556, 108th Cong. (1st Sess. 2003). 

369 Indian Health Care Improvement Act Amendments of 2003, H.R. 2440, 108th Cong. (1st Sess. 2003). 

370 Today, tribes administer more than half of IHS funding through self-determination contracts or self-governance 

compacts There are 265 tribes and tribal organizations that have contracts, and another 56 compacts representing 

279 tribes. 

371 National Indian Health Board, “Reasons to Support the Reauthorization of the Indian Health Care Improvement 

Act H.R. 2440 and S. 556,” <http://www.nihb.org/docs/ihcia_reasons_to_support.pdf> (last accessed Dec. 19, 2003) 

(hereafter cited as National Indian Health Board, “Reasons to Support the Indian Health Care Improvement Act”). 372 Ibid. 
51

stays to a more ambulatory care model, where the physical location of services is less 

prominent.373 Frequently, third-party funding is not recovered because services do not fall within 

the specified categories of covered services, derived from inpatient care models. 

Fourth, the reauthorization permits more flexible funding alternatives and interagency 

partnerships to address maintenance and construction delays.374 This is particularly true for new 

homes being built by the Department of Housing and Urban Development. For example, IHS and 

HUD would be allowed to enter into an interagency agreement to provide financial assistance for 

sanitation facilities and services.375 

The fifth objective addresses behavioral health by authorizing the integration of mental 

health, substance abuse, and violence-prevention programs into a comprehensive behavioral 

health program. Combining programs will result in greater efficiency and a higher quality of 

care.376 Specifically, IHS, tribal, and urban Indian programs would be allowed to develop 

comprehensive behavioral health prevention and treatment programs that emphasize 

collaboration among alcohol, substance abuse, social services, and mental health programs.377

The development of tribal and local initiatives, instead of requiring the development of a single 

national plan, is encouraged. 

Finally, the sixth objective is to maximize recovery from Medicare and Medicaid 

through, among other means, amending the Social Security Act.378

Viewed in its entirety, IHCIA reauthorization would be a dramatic step forward in the 

effort to erase current disparities. If passed, the IHCIA would enable significant improvement in 

the health care provided to Native Americans. 

SUMMARY

As discussed throughout the briefing, many factors contribute to health care disparities 

among Native Americans. The examination of the structure and operation of the Native 

American health care delivery programs revealed that the location of health care facilities and the 

administrative framework of the delivery programs affect access to health care services for many 

Native Americans. The review of quality of services indicated that while IHS facilities have 

received adequate ratings in accreditation surveys, IHS faces significant problems with the 

retention and recruiting of qualified health care providers, and the maintenance of aging 

facilities. Furthermore, severely inadequate funding of IHS creates the majority of the access and 

quality issues. While not all access and quality issues may be resolved with additional funding, 

raising IHS funding levels to be comparable with mainstream health care organizations would 

eliminate many of the basic problems, while providing access to quality health care for Native 

Americans. 

 

373 Ibid. 

374 Ibid. 

375 Indian Health Care Improvement Act Amendments of 2003, H.R. 2440, 108th Cong. § 302 (2003). 

376 National Indian Health Board, “Reasons to Support the Indian Health Care Improvement Act.” 377 Indian Health Care Improvement Act Amendments of 2003, H.R. 2440, 108th Cong. § 703 (2003). 

378 National Indian Health Board, “Reasons to Support the Indian Health Care Improvement Act.” 
52

In addition, raising the health status of Native Americans to the level of the rest of the 

nation requires modification of the Indian Health Care Improvement Act of 1976. These 

modifications must reflect the current health status of the Indian population. But more 

importantly, they must recognize that health care for Native Americans is more than simply 

medical treatment; it involves a holistic approach, including lifestyle and behavioral 

considerations, education, housing, economic opportunity, as well as empowerment through selfdetermination and self-governance. The several objectives of the reauthorization listed above 

hold the promise for an approach that is more holistic. 

In sum, the briefing revealed that it is through ongoing legislative efforts, a dramatic 

increase in funding, consulting with and involving Native Americans in health care decisionmaking, and developing creative ways to provide services in the absence of considerable funding 

increases will significant strides be made in erasing today’s health care disparities experienced 

by Native Americans.