Indian Health Care Improvement Act
PL 94-437 (S.522), enacted 09/30/1976

90 STAT. 1400 
PUBLIC LAW 94-437—SEPT. 30, 1976 
Public Law 94-437 
94th Congress 
An Act 
Sept. 30, 1976 
[S. 522] 
Indian Health 
Care 
Improvement 
Act 
25 use 1601 
note. 
25 use 1601. 
To implement the Federal responsibility for the care and education of the Indian 
people by improving the services and facilities of Federal Indian health pro-
grams and encouraging maximum participation of Indians in such programs, 
and for other purposes. 
Be it enacted hy the Senate and House of Representatives of the 
United States of America in Congress assembled, That this Act may 
be cited as the "Indian Health Care Improvement Act". 
FINDINGS 
SEC. 2. The Congress finds that— 
(a) Federal health services to maintain and improve the health of 
the Indians are consonant with and required by the Federal Govern-
ment's historical and unique legal relationship with, and resulting 
responsibility to, the American Indian people. 
(b) A major national goal of the United States is to provide the 
quantity and quality of health services which will permit the health 
status of Indians to be raised to the highest possible level and to 
encourage the maximum participation of Indians in the planning and 
management of those services. 
(c) Federal health services to Indians have resulted in a reduction 
in the prevalence and incidence of preventable illnesses among, and 
unnecessary and premature deaths of, Indians. 
(d) Despite such services, the unmet health needs of the American 
Indian people are severe and the health status of the Indians is far 
below that of the general population of the United States. For example, 
for Indians compared to all Americans in 1971, the tuberculosis death 
rate was over four and one-half times greater, the influenza and pneu-
monia death rate over one and one-half times greater, and the infant 
death rate approximately 20 per centum greater. 
(e) All other Federal services and programs in fulfillment of the 
Federal responsibility to Indians are jeopardized by the low health 
status of the American Indian people. 
(f) Further improvement in Indian health is imperiled by— 
(1) inadequate, outdated, inefficient, and undermanned facil-
ities. For example, only twenty-four of fifty-one Indian Health 
Service hospitals are accredited by the Joint Commission on 
Accreditation of Hospitals; only thirty-one meet national fire and 
safety codes; and fifty-two locations with Indian populations have 
been identified as requiring either new or replacement health 
centers and stations, or clinics remodeled for improved or addi-
tional service; 
(2) shortage of personnel. For example, about one-half of the 
Service hospitals, four-fifths of the Service hospital outpatient 
clinics, and one-half of the Service health clinics meet only 80 per 
centum of staffing standards for their respective services; 
(3) insufficient services in such areas as laboratory, hospital 
inpatient and outpatient, eye care and mental health services, and 
services available through contracts with private physicians, clin-
ics, and agencies. For example, about 90 per centum of the surgical 
operations needed for otitis media have not been performed, over 
57 per centum of required dental services remain to be provided, 
and about 98 per centum of hearing aid requirements are unmet; 
(4) related support factors. For example, over seven hundred 
housing units are needed for staff at remote Service facilities; 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1401 
(5) lack of access of Indians to health services due to remote 
residences, undeveloped or underdeveloped communication and 
transportation systems, and difficult, sometimes severe, climate 
conditions; and 
(6) lack of safe water and sanitary waste disposal services. 
For example, over thirty-seven thousand four hundred existing 
and forty-eight thousand nine hundred and sixty planned replace- -
ment and renovated Indian housing units need new or upgraded 
water and sanitation facilities. 
(g) The Indian people's growth of confidence in Federal Indian 
health services is revealed by their increasingly heavy use of such 
services. Progress toward the goal of better Indian health is depend-
ent on this continued growth of confidence. Both such progress and 
such confidence are dependent on improved Federal Indian health 
services. 
DECLARATION OF POLICY 
SEC. 3. The Congress hereby declares that it is the policy of this 25 USC 1602. 
Nation, in fulfillment of its special responsibilities and legal obliga-
tion to the American Indian people, to meet the national goal of 
providing the highest possible health status to Indians and to provide 
existing Indian health services with all resources necessary to effect 
that policy. 
;; o 
DEFINITIONS 
SEC. 4. For purposes of this Act— 
25 USC 1603. 
(a) "Secretary", unless otherwise designated, means the Secretary 
of Health, Education, and Welfare. 
(b) "Service" means the Indian Health Service. 
(c) "Indians" or "Indian", unless otherwise designated, means any 
person who is a member of an Indian tribe, as defined in subsection 
(d) hereof, except that, for the purpose of sections 102, 103, and 
201 (c)(5), such terms shall mean any individual who (1), irrespective 
of whether he or she lives on or near a reservation, is a member of a 
tribe, band, or other organized group of Indians, including those 
tribes, bands, or groups terminated since 1940 and those recognized 
now or in the future by the State in which they reside, or 
who is a descendant, in the first or second degree, of any such mem-
ber, or (2) is an Eskimo or Aleut or other Alaska Native, or (3) 
is considered by the Secretary of the Interior to be an Indian for 
any purpose, or (4) is determined to be an Indian under regulations 
promulgated by the Secretary. 
(d) "Indian tribe" means any Indian tribe, band, nation, or other 
organized group or community, including any Alaska Native village 
or group or regional or village corporation as defined in or established 
pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688), 43 USC 1601 
which is recognized as eligible for the special programs and services °
o
*
®
-
provided by the United States to Indians because of their status as 
Indians. 
(e) "Tribal organization" means the elected governing body of 
any Indian tribe or any legally established organization of Indians 
which is controlled by one or more such bodies or by a board of 
directors elected or selected by one or more such bodies (or elected 
by the Indian population to be served by such organization) and 
which includes the maximum participation of Indians in all phases 
of its activities. 
(f) "Urban Indian" means any individual who resides in an urban 
center, as defined in subsection (g) hereof, and who meets one or more 
90 STAT. 1402 
PUBLIC LAW 94-437—SEPT. 30, 1976 
of the four criteria in subsection (c) (1) through (4) of this section. 
(g) "Urban center" means any community which has a sufficient 
urban Indian population with unmet health needs to warrant assist-
ance under title V, as determined by the Secretary. 
(h) "Urban Indian organization" means a nonprofit corporate body 
situated in an urban center, composed of urban Indians, and providing 
for the maximum participation of all interested Indian groups and 
individuals, which body is capable of legally cooperating with other 
public and private entities for the purpose of performing the activities 
described in section 503 (a). 
T I T L E I—INDIAN H E A L T H 
M A N P O W E R 
PURPOSE 
25 use 1611. 
SEC. 101. The purpose of this title is to augment the inadequate 
number of health professionals serving Indians and remove the mul-
tiple barriers to the entrance of health professionals into the Service 
and private practice among Indians. 
Grants. 
25 use 1612. 
Application, 
submittal and 
approval. 
Amount and 
payment. 
Appropriation 
authorization. 
HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS 
SEC. 102. (a) The Secretary, acting through the Service, shall make 
grants to public or nonprofit private health or educational entities or 
Indian tribes or tribal organizations to assist such entities in meeting 
the costs of— 
(1) identifying Indians with a potential for education or train-
ing in the health professions and encouraging and assisting them 
(A) to enroll in schools of medicine, osteopathy, dentistry, veteri-
nary medicine, optometry, podiatry, pharmacy, public health, 
nursing, or allied health professions; or (B), if they are not 
qualified to enroll in any such school, to undertake such post-
secondary education or training as may be required to qualify 
them for enrollment; 
(2) publicizing existing sources of financial aid available to 
Indians enrolled in any school referred to in clause (1) (A) of 
this subsection or who are undertaking training necessary to 
qualify them to enroll in any such school; or 
(3) establishing other programs which the Secretary determines 
will enhance and facilitate the enrollment of Indians, and the 
subsequent pursuit and completion by them of courses of study, 
in any school referred to in clause (1) (A) of this subsection. 
(b) (1) No grant may be made under this section unless an applica-
tion therefor has been submitted to, and approved by, the Secretary. 
Such application shall be in such form, submitted in such manner, and 
contain such information, as the Secretary shall by regulation pre-
scribe: Provided^ 
That the Secretary shall give a preference to 
applications submitted by Indian tribes or tribal organizations. 
(2) The amount of any grant under this section shall be determined 
by the Secretary. Payments pursuant to grants under this section may 
be made in advance or by way of reimbursement, and at such intervals 
and on such conditions as the Secretary finds necessary. 
(c) For the purpose of making payments pursuant to grants under 
this section, there are authorized to be appropriated $900,000 for fiscal 
year 1978, $1,500,000 for fiscal year 1979, and $1,800,000 for fiscal year 
1980. For fiscal years 1981, 1982, 1983, and 1984 there are authorized 
to be appropriated for such payments such sums as may be specifically 
authorized by an Act enacted after this Act. 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1403 
HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR INDIANS 
SEC. 103. (a) The Secretary, acting through the Service, shall make 
scholarship grants to Indians who— 
(1) have successfully completed their high school education 
or high school equivalency; and 
(2) have demonstrated the capability to successfully complete 
courses of study in schools of medicine, osteopathy, dentistry, 
veterinary medicine, optometry, podiatry, pharmacy, public 
health, nursing, or allied health professions. 
(b) Each scholarship grant made under this section shall be for a 
period not to exceed two academic years, which years shall be for 
compensatory preprofessional education of any grantee. 
(c) Scholarship grants made under this section may cover costs of 
tuition, books, transportation, board, and other necessary related 
expenses. 
(d) There are authorized to be appropriated for the purpose of this 
section: $800,000 for fiscal year 1978, $1,000,000 for fiscal year 1979, 
and $1,300,000 for fiscal year 1980. For fiscal years 1981,1982,1983, and 
1984 there are authorized to be appropriated for the purpose of this 
section such sums as may be specifically authorized by an Act enacted 
after this Act. 
Scholarship 
grants, eligibility 
requirements. 
25 use 1613. 
Two-year 
limitation. 
Appropriation 
authorization. 
HEALTH PROFESSIONS SCHOLARSHIP PROGRAM 
SEC. 104. Section 225(i) of the Public Health Service Act (42 
U.S.C. 234(i)) is amended (1) by inserting "(1)" after "(i)", and 
(2) by adding at the end the following: 
"(2) (A) In addition to the sums authorized to be appropriated 
under paragraph (1) to carry out the Program, there are authorized 
to be appropriated for the fiscal year ending September 30, 1978, 
$5,450,000; for the fiscal year ending September 30, 1979, $6,300,000; 
for the fiscal year ending September 30, 1980, $7,200,000; and for 
fiscal years 1981,1982, 1983, and 1984 such sums as may be specifically 
authorized by an Act enacted after the Indian Health Care Improve-
ment Act, to provide scholarships under the Program to pi'ovide 
physicians, osteopaths, dentists, veterinarians, nurses, optometrists, 
podiatrists, pharmacists, public health personnel, and allied health 
professionals to provide services to Indians. Such scholarships shall 
be designated Indian Health Scholarships and shall be made in 
accordance with this section except as provided in subparagraph (B). 
'(B) (i) The Secretary, acting through the Indian Health Service, 
shall determine the individuals who receive the Indian Health Schol-
arships, shall accord priority to applicants who are Indians, and shall 
determine the distribution of the scholarships on the basis of the 
relative needs of Indians for additional service in specific health 
professions. 
"(ii) The active duty service obligation prescribed by subsection 
(e) shall be met by the recipient of an Indian Health Scholarship 
by service in the Indian Health Service, in a program assisted under 
title V of the Indian Health Care Improvement Act, or in the private 
practice of his profession if, as determined by the Secretary in accord-
ance with guidelines promulgated by him, such practice is situated in 
a physician or other health professional shortage area and addresses 
the health care needs of a substantial number of Indians. 
"(C) For purposes of this paragraph, the term 'Indians' has the 
same meaning given that term by subsection (c) of section 4 of the 
Appropriation 
authorization. 
Distribution. 
Active duty 
service 
obligation. 
Post, p. 1410. 
"Indians.' 
90 STAT. 1404 
PUBLIC LAW 94-437—SEPT. 30, 1976 
Ante, p. 1401. 
Indian Health Care Improvement Act and includes individuals 
described in clauses (1) through (4) of that subsection.". 
25 use 1614. 
Appropriation 
authorization. 
INDIAN HEALTH SERVICE EXTERN PROGRAMS 
SEC. 105. (a) Ajiy individual who receives a scholarship grant pur-
suant to section 104 shall be entitled to employment in the Service 
during any nonacademic period of the year. Periods of employment 
pursuant to this subsection shall not be counted in determining the 
fulfillment of the service obligation incurred as a condition of the 
scholarship grant. 
(b) Any individual enrolled in a school of medicine, osteopathy, 
dentistry, veterinary medicine, optometry, podiatry, pharmacy, public 
health, nursing, or allied health professions may be employed by the 
Service during any nonacademic period of the year. Any such employ-
ment shall not exceed one hundred and twenty days during any 
calendar year. 
(c) Any employment pursuant to this section shall be made with-
out regard to any competitive personnel system or agency personnel 
limitation and to a position which will enable the individual so 
employed to receive practical experience in the health profession in 
which he or she is engaged in study. Any individual so employed 
shall receive payment for his or her services comparable to the salary 
he or she would receive if he or she were employed in the competitive 
system. Any individual so employed shall not be counted against any 
employment ceiling affecting the Service or the Department of Health, 
Education, and Welfare. 
(d) There are authorized to be appropriated for the purpose of 
this section: $600,000 for fiscal year 1978, $800,000 for fiscal year 1979, 
and $1,000,000 for fiscal year 1980. For fiscal years 1981, 1982, 1983, 
and 1984 there are authorized to be appropriated for the purpose 
of this section such sums as may be specifically authorized by an Act 
enacted after this Act. 
25 use 1615. 
Appropriation 
authorization. 
CONTINUING EDUCATION ALLOWANCES 
SEC. 106. (a) In order to encourage physicians, dentists, and other 
health professionals to join or continue in the Service and to provide 
their services in the rural and remote areas where a significant portion 
of the Indian people resides, the Secretary, acting through the Service, 
may provide allowances to health professionals employed in the Serv-
ice to enable them for a period of time each year prescribed by regula-
tion of the Secretary to take leave of their duty stations for profes-
sional consultation and refresher training courses. 
(b) There are authorized to be appropriated for the purpose of this 
section: $100,000 for fiscal year 1978, $200,000 for fiscal year 1979, 
and $250,000 for fiscal year 1980. For fiscal years 1981, 1982, 1983, 
and 1984 there are authorized to be appropriated for the purpose of 
this section such sums as may be specifically authorized by an Act 
enacted after this Act. 
TITLE II—HEALTH SERVICES 
HEALTH SERVICES 
25 use 1621. 
SEC. 201. (a) For the purpose of eliminating backlogs in Indian 
health care services and to supply known, unmet medical, surgical, 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1405 
dental, optometrical, and other Indian health needs, the Secretary is 
authorized to expend, through the Service, over the seven-fiscal-year 
period beginning after the date of the enactment of this Act the 
amounts authorized to be appropriated by subsection (c). Funds 
appropriated pursuant to this section for each fiscal year shall not be 
used to offset or limit the appropriations required by the Service 
under other Federal laAVs to continue to serve the health needs of 
Indians during and subsequent to such seven-fiscal-year period, but 
shall be in addition to the level of appropriations provided to the 
Service under this Act and such other Federal laws in the preceding 
fiscal year plus an amount equal to the amount required to cover pay 
increases and employee benefits for personnel employed under this 
Act and such laws and increases in the costs of serving the health needs 
of Indians under this Act and such laws, which increases are caused 
by inflation. 
(b) The Secretary, acting through the Service, is authorized to 
employ persons to implement the provisions of this section during the 
seven-fiscal-year period in accordance with the schedule provided in 
subsection (c). Such positions authorized each fiscal year pursuant 
to this section shall not be considered as offsetting or limiting the per-
sonnel required by the Service to serve the health needs of Indians 
during and subsequent to such seven-fiscal-year period but shall be in 
addition to the positions authorized in the previous fiscal year. 
(c) The following amounts and positions are authorized, in accord-
ance with the provisions of subsections (a) and (b), for the specific 
purposes noted: 
(1) Patient care (direct and indirect) : sums and positions as 
provided in subsection (e) for fiscal year 1978, $8,500,000 and two 
hundred and twenty-five positions for fiscal year 1979, and 
$16,200,000 and three hundred positions for fiscal year 1980. 
(2) Field health, excluding dental care (direct and indirect) : 
sums and positions as provided in subsection (e) for fiscal year 
1978, $3,350,000 and eighty-five positions for fiscal year 1979, and 
$5,550,000 and one hundred and thirteen positions for fiscal year 
1980. 
(3) Dental care (direct and indirect) : sums and positions as 
provided in subsection (e) for fiscal year 1978, $1,500,000 and 
eighty positions for fiscal year 1979, and $1,500,000 and fifty posi-
tions for fiscal year 1980. 
(4) Mental health: (A) Community mental health services: 
sums and positions as provided in subsection (e) for fiscal year 
1978, $1,300,000 and thirty positions for fiscal year 1979,'and 
$2,000,000 and thirty positions for fiscal year 1980. 
(B) Inpatient mental health services: sums and positions as 
provided in subsection (e) for fiscal year 1978, $400,000 and fifteen 
positions for fiscal year 1979, and ^600,000 and fifteen positions 
for fiscal year 1980. 
(C) Model dormitory mental health services: sums and posi-
tions as provided in subsection (e) for fiscal year 1978, $1,250,000 
and fifty positions for fiscal year 1979, and $1,875,000 and fifty 
positions for fiscal year 1980. 
(D) Therapeutic and residential treatment centers: sums and 
positions as provided in subsection (e) for fiscal year 1978, 
$300,000 and ten positions for fiscal year 1979, and $400,000 and 
five positions for fiscal year 1980. 
(E) Training of traditional Indian practitioners in mental 
health: sums as provided in subsection (e) for fiscal year 1978, 
$150,000 for fiscal year 1979, and $200,000 for fiscal year 1980. 
Employment 
during seven-
fiscal-year period. 
Appropriation 
autnorization. 
90 STAT. 1406 
PUBLIC LAW 94-437—SEPT. 30, 1976 
Research funds. 
Appropriation 
authorization. 
(5) Treatment and control of alcoholism among Indians: 
$4,000,000 for fiscal year 1978, $9,000,000 for fiscal year 1979, and 
$9,200,000_for fiscal year 1980. 
(6) Maintenance and repair (direct and indirect) : sums and 
positions as provided in subsection (e) for fiscal year 1978, 
$3,000,000 and twenty positions for fiscal year 1979, and $4,000,000 
and thirty positions for fiscal year 1980. 
(7) For fiscal years 1981, 1982, 1983, and 1984 there are 
authorized to be appropriated for the items referred to in the 
preceding paragraphs such sums as may be specifically authorized 
by an Act enacted after this Act. For such fiscal years, positions 
are authorized for such items (other than the items referred to 
in paragraphs (4) (E) and (5)) as may be specified in an Act 
enacted after the date of the enactment of this Act. 
(d) The Secretary, acting through the Service, shall expend directly 
or by contract not less than 1 per centum of the funds appropriated 
under the authorizations in each of the clauses (1) through (5) of 
subsection (c) for research in each of the areas of Indian health care 
for which such funds are authorized to be appropriated. 
(e) For fiscal year 1978, the Secretary is authorized to apportion 
not to exceed a total of $10,025,000 and 425 positions for the programs 
enumerated in clauses (c) (1) through (4) and (c)(6) of this section. 
TITLE III—HEALTH FACILITIES 
25 use 1631. 
Appropriation 
authorization. 
Consultation. 
CONSTRUCTION AND RENOVATION OF SERVICE FACILITIES 
' 
SEC. 301. (a) The Secretary, acting through the Service, is author-
ized to expend over the seven-fiscal-year period beginning after the 
date of the enactment of this Act the sums authorized by subsection 
(b) for the construction and renovation of hospitals, health centers, 
health stations, and other facilities of the Service. 
(b) The following amounts are authorized to be appropriated for 
purposesof subsection (a) : 
(1) Hospitals: $67,180,000 for fiscal year 1978, $73,256,000 for 
fiscal year 1979, and $49,742,000 for fiscal year 1980. For fiscal 
years 1981,1982,1983, and 1984, there are authorized to be appro-
priated for hospitals such sums as may be specifically authorized 
by an Act enacted after this Act. 
(2) Health centers and health stations: $6,960,000 for fiscal 
year 1978, $6,226,000 for fiscal year 1979, and $3,720,000 for fiscal 
year 1980. For fiscal years 1981, 1982, 1983, and 1984, there are 
authorized to be appropriated for health centers and health sta-
tions such sums as may be specifically authorized by an Act 
pTiJir*i'Pfi j-iTI'^^T* i"ni^ Ar*i" 
(3) Staff housing:'$1,242,000 for fiscal year 1978, $21,725,000 
for fiscal year 1979, and $4,116,000 for fiscal year 1980. For fiscal 
years 1981,1982, 1983, and 1984, there are authorized to be appro-
priated for staff housing such sums as may be specifically author-
ized by an Act enacted after this Act. 
(c) Prior to the expenditure of, or the making of any firm commit-
ment to expend, any funds authorized in subsection (a), the Secretary, 
acting through the Service shall— 
(1) consult with any Indian tribe to be significantly affected 
by any such expenditure for the purpose of determining and, 
wherever practicable, honoring tribal preferences concerning the 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1407 
size, location, type, and other characteristics of any facility on 
which such expenditure is to be made; and 
(2) be assured that, wherever practicable, slich facility, not 
later than one year after its construction or renovation, shall meet 
the standards of the Joint Committee on Accreditation of 
Hospitals. 
CONSTRUCTION OF SAFE WATER AND SANITARY WASTE 
DISPOSAL FACILITIES 
SEC. 302. (a) During the seven-fiscal-year period beginning after the 
date of the enactment of this Act, the Secretary is authorized to expend 
under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), the 
sums a.uthorized under subsection (b) to supply unmet needs for safe 
water and sanitary waste disposal facilities in existing and new Indian 
homes and communities. 
(b) For expenditures of the Secretary authorized by subsection (a) 
for facilities in existing Indian homes and communities there are 
authorized to be appropriated $43,000,000 for fiscal year 1978, 
$30,000,000 for fiscal year 1979, and $30,000,000 for fiscal year 1980. 
For expenditures of the Secretary authorized by subsection (a) for 
facilities in new Indian homes and communities there are authorized 
to be appropriated such sums as may be necessary for fiscal years 
1978, 1979, and 1980.-For fiscal years 1981, 1982, 1983, and 1984 for 
expenditures authorized by subsection (a) there are authorized to be 
appropriated such sums as may be specifically authorized in an Act 
enacted after this Act. 
(c) Former and currently federally recognized Indian tribes in the 
State of New York shall be eligible for assistance under this section. 
P R E F E R E N C E TO INDIANS AND INDIAN FIRMS 
SEC. 303, (a) The Secretary, acting through the Service, may utilize 
the negotiating authority of the Act of June 25, 1910 (25 U.S.C. 47), 
to give preference to any Indian or any enterprise, partnership, cor-
poration, or other tvpe of business organization owned and controlled 
by an Indian or Indians including former or currently federally 
recognized Indian tribes in the State of New York (hereinafter 
referred to as an "Indian firm") in the construction and renovation of 
Service facilities pursuant to section 301 and in the construction of 
safe water and sanitary waste disposal facilities pursuant to section 
302. Such preference may be accorded by the Secretary unless he finds, 
pursuant to rules and regulations promulgated bv him, that the project 
or function to be contracted for will not be satisfactory or such project 
or function cannot be properly completed or maintained under the pro-
posed contract. The Secretary, in arriving at his finding, shall consider 
whether the Indian or Indian firm will be deficient with respect to 
(1) ownership and control by Indians, (2) equipment, (3) bookkeep-
ing and accounting procedures, (4) substantive knowledge of the 
project or function to be contracted for, (5) adequately trained person-
nel, or (6) other necessary components of contract performance. 
(b) For the purpose of implementing the provisions of this title, 
the Secretary shall assure that the rates of pay for personnel engaged 
in the construction or renovation of facilities constructed Or renovated 
in whole or in part by funds made available pursuant to this title are 
not less than the prevailing local wage rates for similar work as 
determined in accordance with the Act of March 3, 1931 (40 U.S.C. 
276a-276a-5, known as the Davis-Bacon Act). 
25 use 1632. 
Appropriation 
authorization. 
New York Indian 
tribes, eligibility 
for assistance. 
25 use 1633. 
eonstruction 
personnel, pay 
rates. 
40 use 276a 
note. 
90 STAT. 1408 
PUBLIC LAW 94-437—SEPT. 30, 1976 
42 u s e 2004a. 
SOBOBA SANITATION FACILITIES 
SEC. 304. The Act of December 17, 1970 (84 Stat. 1465), is hereby 
amended by adding the following new section 9 at the end thereof: 
"SEC. 9. Nothing in this Act shall preclude the Soboba Band of 
Mission Indians and the Soboba Indian Reservation from being pro-
vided with sanitation facilities and services under the authority of 
section 7 of the Act of August 5, 1954 (68 Stat. 674), as amended 
by the Act of July 31,1959 (73 Stat. 267).". 
TITLE IV-ACCESS TO HEALTH SERVICES 
42 
use 
1395f, 
1395n. 
42 
use 
1395x. 
ELIGIBILITY OF INDIAN HEALTH SERVICE FACILITIES 
UNDER MEDICARE PROGRAM 
SEC. 401. (a) Sections 1814(c) and 1835(d) of the Social Security 
Act are each amended by striking out "No payment" and inserting 
in lieu thereof "Subject to section 1880, no payment". 
(b) Part C of title XVIII of such Act is amended by adding at the 
end thereof the following new section: 
Hospital or 
skilled nursing 
facility, eligibility 
for payments. 
42 use 1395qq. 
Ineligible 
hospital or skilled 
nursing facility, 
submittal of plan 
for compliance. 
Fund for 
improvements. 
Post, p. 1413. 
Post, p. 1410. 
"INDIAN HEALTH SERVICE FACILITIES 
"SEC. 1880, (a) A hospital or skilled nursing facility of the Indian 
Health Service, whether operated by such Service or by an Indian 
tribe or tribal organization (as those terms are defined in section 4 
of the Indian Health Care Improvement Act), shall be eligible for 
payments under this title, notwithstanding sections 1814(c) and 
1835 (d), if and for so long as it meets all of the conditions and require-
ments for such payments which are applicable generally to hospitals 
or skilled nursing facilities (as the case may be) under this title. 
"(b) Notwithstanding subsection (a), a hospital or skilled nursing 
facility of the Indian Health Service which does not meet all of the 
conditions and requirements of this title which are applicable gen-
erally to hospitals or skilled nursing facilities (as the case may be), 
but which submits to the Secretary within six months after the date of 
the enactment of this section an acceptable plan for achieving com-
pliance with such conditions and requirements, shall be deemed to meet 
such conditions and requirements (and to be eligible for payments 
under this title), without regard to the extent of its actual compliance 
with such conditions and requirements, during the first 12 months 
after the month in which such plan is submitted. 
" (c) Notwithstanding any otlier provision of this title, payments to 
which any hospital or skilled nursing facility of the Indian Health 
Service is entitled by reason of this section shall be placed in a special 
fund to be held by the Secretary and used by him (to such extent or 
in such amounts as are provided in appropriation Acts) exclusively 
for the purpose of making any improvements in the hospitals and 
skilled nursing facilities of such Service which may be necessary to 
achieve compliance with the applicable conditions and requirements 
of this title. The preceding sentence shall cease to apply when the 
Secretary determines and certifies that substantially all of the hospitals 
and skilled nursing facilities of such Service in the United States are 
in compliance with such conditions and requirements. 
"(d) The annual report of the Secretary which is required by sec-
tion 701 of the Indian Health Care Improvement Act shall include 
(along with the matters specified in section 403 of such Act) a detailed 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1409 
statement of the status of the hospitals and skilled nursing facilities 
of the Service in terms of their compliance with the applicable condi-
tions and requirements of this title and of the progress being made by-
such hospitals and facilities (under plans submitted under subsection 
(b) and otherwise) toward the achievement of such compliance.". 
(c) Any payments received for services provided to beneficiaries 
hereunder shall not be considered in determining appropriations for 
health care and services to Indians. 
(d) Nothing herein authorizes the Secretary to provide services to 
an Indian beneficiary with coverage under title XVIII of the Social 
Security Act, as amended, in preference to an Indian beneficiary 
without such coverage. 
SERVICES PROVIDED TO MEDICAID ELIGIBLE INDIANS 
SEC. 402. (a) Title XIX of the Social Security Act is amended by 
adding at the end thereof the following new section: 
42 use 1395qq 
note. 
Services to an 
Indian 
beneficiary. 
42 use 1395qq 
note. 
42 use 1395. 
"INDIAN HEALTH SERVICE FACILITIES 
"SEC. 1911. (a) A facility of the Indian Health Service (including 
a hospital, intermediate care facility, or skilled nursing facility), 
whether operated by such Service or by an Indian tribe or tribal orga-
nization (as those terms are defined in section 4 of the Indian Health 
Care Improvement Act), shall be eligible for reimbursement for 
medical assistance provided under a State plan if and for so long as 
it meets all of the conditions and requirements which are applicable 
generally to such facilities under this title. 
"(b) Notwithstanding subsection (a), a facility of the Indian 
Health Service (including a hospital, intermediate care facility, or 
skilled nursing facility) which does not meet all of the conditions and 
requirements of this title wliich are applicable generally to such facil-
ity, but which submits to the Secretary within six months after the 
date of the enactment of this section an acceptable plan for acliieving 
compliance with such conditions and requirements, shall be deemed 
to meet such conditions and requirements (and to be eligible for reim-
bursement under this title), without regard to the extent of its actual 
compliance with such conditions and requirements, during the first 
twelve months after the month in which such plan is submitted.". 
(b) The Secretary is authorized to enter into agreements with the 
appropriate State agency for the purpose of reimbursing such agency 
for health care and services provided in Service facilities to Indians 
who are eligible for medical assistance under title XIX of the Social 
Security Act, as amended. 
(c) Notwithstanding anj^ other provision of law, payments to which 
any facility of the Indian Health Service (including a hospital, inter-
mediate care facility, or skilled nursing facility) is entitled under a 
State plan approved under title XIX of the Social Security Act by 
reason of section 1911 of such Act shall be placed in a special fund to 
be held by the Secretary and used by him (to such extent or in such 
amounts as are provided in appropriation Acts) exclusively for the 
purpose of making any improvements in the facilities of such Service 
which may be necessary to achieve compliance with the applicable 
conditions and requirements of such title. The preceding sentence shall 
cease to apply when the Secretary determines and certifies that sub-
stantially all of the health facilities of such Service in the United 
States are in compliance with such conditions and requirements. 
Eligibility for 
reimbursement. 
42 u s e 1396J. 
Ante, p. 1401. 
Facilities, 
submittal of plan 
for compliance. 
42 u s e 1396J 
note. 
42 u s e 1396] 
note. 
42 u s e 1396. 
Supra. 
90 STAT. 1410 
PUBLIC LAW 94-437—SEPT. 30, 1976 
42 use 1396J 
note. 
Federal medical 
assistance 
percentage. 
42 use 1396d. 
Ante, p. 1401. 
(d) Ajiy payments received for services provided recipients here-
under shall not be considered in determining appropriations for the 
provision of health care and services to Indians. 
(e) Section 1905(b) of the Social Security Act is amended by 
inserting at the end thereof the following: "Notwithstanding the first 
sentence of this section, the Federal medical assistance percentage shall 
be 100 per centum with respect to amounts expended as medical assist-
ance for services which are received through an Indian Health Service 
facility whether operated by the Indian Health Service or by an Indian 
tribe or tribal organization (as defined in section 4 of the Indian 
Health Care Improvement Act).". 
, 
25 use 1671 
note. 
42 use 1395, 
1396. 
REPORT 
SEC. 403. The Secretary shall include in his annual report required 
by section 701 an accounting on the amount and use of funds made 
available to the Service pursuant to this title as a result of reimburse-
ments through titles XVIII and X I X of the Social Security Act, as 
amended. 
TITLE V—HEALTH SERVICES FOR URBAN INDIANS 
PURPOSE 
25 use 1651. 
SEC. 501. The purpose of this title is to encourage the establishment 
of programs in urban areas to make health services more accessible 
to the urban Indian population. 
, 
CONTRACTS WITH URBAN INDIAN ORGANIZATIONS 
25 use 1652. 
SEC. 502. The Secretary, acting through the Service, shall enter into 
contracts with urban Indian organizations to assist such organizations 
to establish and administer, in the urban centers in which such organi-
zations are situated, programs which meet the requirements set forth 
in sections 503 and 504. 
CONTRACT ELIGIBILITY 
25 use 1653. 
SEC. 503. (a) The Secretary, acting through the Service, shall place 
such conditions as he deems necessary to ejffect the purpose of this 
title in any contract which.he makes with any urban Indian organi-
' 
zation pursuant to this title. Such conditions shall include, but are 
not limited to, requirements that the organization successfully under-
take the following activities: 
(1) determine the population of urban Indians which are or 
could be recipients of health referral or care services; 
(2) identify all public and private health service resources 
within the urban center in which the organization is situated 
which are or may be available to urban Indians; 
(3) assist such resources in providing service to such urban 
n 
Indians; 
(4) assist such urban Indians in becoming familiar with and 
utilizing such resources; 
(5) provide basic health education to such urban Indians; 
(6) establish and implement manpower training programs to 
accomplish the referral and education tasks set forth in clauses 
(3) through (5) of this subsection; 
(7) identify gaps between unmet health needs of urban Indians 
and the resources available to meet such needs; 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1411 
(8) make recommendations to the Secretary and Federal, State, 
local, and other resource agencies on methods of improving health 
service programs to meet the needs of urban Indians; and 
(9) where necessary, provide or contract for health care services 
to urban Indians. 
(b) The Secretary, acting through the Service, shall by regulation 
prescribe the criteria for selecting urban Indian organizations with 
which to contract pursuant to this title. Such criteria shall, among 
other factors, take into consideration: 
(1) the extent of the unmet health care needs of urban Indians 
in the urban center involved; 
(2) the size of the urban Indian population which is to receive 
assistance; 
(3) the relative accessibility which such population has to 
health care services in such urban center'; 
(4) the extent, if any, to which the activities set forth in sub-
section (a) would duplicate any previous or current public or 
private health services project funded by another source in such 
urban center; 
(5) the appropriateness and likely effectiveness of the activities 
set forth in subsection (a) in such urban center; 
(6) the existence of an urban Indian organization capable of 
performing the activities set forth in subsection (a) and of enter-
ing into a contract with the Secretary pursuant to this title; and 
(7) the extent of existing or likely future participation in the 
activities set forth in subsection (a) by appropriate health and 
health-related Federal, State, local, and other resource agencies. 
Urban Indian 
organizations, 
selection criteria. 
OTHER CONTRACT REQUIREMENTS 
SEC. 504. (a) Contracts with urban Indian organizations pursuant 
to this title shall be in accordance with all Federal contracting laws 
and regulations except that, in the discretion of the Secretary, such 
contracts may be negotiated without advertising and need not conform 
to the provisions of the Act of August 24, 1935 (48 Stat. 793), as 
amended. 
(b) Payments under any contracts pursuant to this title may be 
made in advance or by way of reimbursement and in such installments 
and on such conditions as the Secretary deems necessary to carry out 
the purposes of this title. 
(c) Notwithstanding any provision of law to the contrary, the 
Secretary may, at the request or consent of an urban Indian orga-
nization, revise or amend any contract made by him with such organi-
zation pursuant to this title as necessary to carry out the purposes of 
this title: Provided^ however, That whenever an urban Indian orga-
nization requests retrocession of the Secretary for any contract entered 
into pursuant to this title, such retrocession shall become effective 
upon a date specified by the Secretary not more than one hundred and 
twenty days from the date of the request by the organization or at 
such later date as may be mutually agreed to by the Secretary and 
the organization. 
(d) In connection with any contract made pursuant to this title, 
the Secretary may permit an urban Indian organization to utilize, 
in carrying out such contract, existing facilities owned by the Federal 
Government within his jurisdiction under such terms and conditions 
as may be agreed upon for their use and maintenance. 
25 use 1654. 
49 Stat. 793. 
40 use 270a-
270d. 
Contract revision 
or amendment. 
Government 
facilities, use. 
90 STAT. 1412 
PUBLIC LAW 94-437—SEPT. 30, 1976 
(e) Contracts with urban Indian organizations and regulations 
adopted pursuant to this title shall include provisions to assure the 
fair and uniform provision to urban Indians of services and assistance 
under such contracts by such organizations. 
Report to 
Secretary of the 
Interior. 
25 use 1655. 
Audit. 
, 
: : , 
REPORTS AND RECORDS 
SEC. 505. For each fiscal year during which an urban Indian orga-
nization receives or expends funds pursuant to a contract under this 
title, such organization shall submit to the Secretary a report including 
information gathered pursuant to section 503(a) (7) and (8), infor-
mation on activities conducted by the organization pursuant to the 
contract, an accounting of the amounts and purposes for which Federal 
funds were expended, and such other information as the Secretary may 
request. The reports and records of the urban Indian organization 
with respect to such contract shall be subject to audit by the Secretary 
and the Comptroller General of the United States. 
AUTHORIZATIONS 
25 use 1656. 
SEC. 506, There are authorized to be appropriated for the purpose 
of this title: $5,000,000 for fiscal year 1978, $10,000,000 for fiscal year 
1979, and $15,000,000 for fiscal year 1980. 
Submittal to 
Congress. 
Legislative 
recommenda-
tions. 
25 use 1657. 
25 use 1658. 
REVIEW o r PROGRAM 
SEC. 507. Within six months after the end of fiscal year 1979, the 
Secretary, acting through the Service and with the assistance of the 
urban Indian organizations which have entered into contracts pursuant 
to this title, shall review the program established under this title and 
submit to the Congress his assessment thereof and recommendations 
for any further legislative efforts he deems necessary to meet the pur-
pose of this title. 
RURAL HEALTH PROJECTS 
SEC. 508. Not to exceed 1 per centum of the amounts authorized by 
section 506 shall be available for not to exceed two pilot projects pro-
viding outreach services to eligible Indians residing in rural com-
munities near Indian reservations. 
TITLE VI—AMERICAN INDIAN SCHOOL OF MEDICINE; 
FEASIBILITY STUDY 
FEASIBILITY STUDY 
25 use 1661. 
Report to 
Congress. 
SEC. 601. The Secretary, in consultation with Indian tribes and 
appropriate Indian organizations, shall conduct a study to determine 
the need for, and the feasibility of, establishing a school of medicine 
to train Indians to provide health services for Indians. Within one 
year of the date of the enactment of this Act the Secretary shall com-
plete such study and shall report to the Congress findings and recom-
mendations based on such study. 
PUBLIC LAW 94-437—SEPT. 30, 1976 
90 STAT. 1413 
TITLE VII—MISCELLANEOUS 
REPORTS 
SEC. 701. The Secretary shall report annually to the President and 
the Congress on progress made in effecting the purposes of this Act. 
Within three months after the end of fiscal year 1979, the Secretary 
shall review expenditures and progress made under this Act and make 
recommendations to the Congress concerning any additional authoriza-
tions for fiscal years 1981 through 1984 for programs authorized under 
this Act which he deems appropriate. In the event the Congress enacts 
legislation authorizing appropriations for programs under this Act 
for fiscal years 1981 through 1984, within three months after the end 
of fiscal year 1983, the Secretary shall review programs established or 
assisted pursuant to this Act and shall submit to the Congress his 
assessment and recommendations of additional programs or additional 
assistance necessary to, at a minimum, provide health services to 
Indians, and insure a health status for Indians, which are at a parity 
with the health services available to, and the health status, of the 
general population. 
REGULATIONS 
SEC. 702. (a) (1) Within six months from the date of enactment of 
this Act, the Secretary shall, to the extent practicable, consult with 
national and regional Indian organizations to consider and formulate 
appropriate rules and regulations to implement the provisions of this 
Act. 
(2) Within eight months from the date of enactment of this Act, 
the Secretary shall publish proposed rules and regulations in the Fed-
eral Register for the purpose of receiving comments from interested 
parties. 
(3) Within ten months from the date of enactment of this Act, the 
Secretary shall promulgate rules and regulations to implement the 
provisions of this Act. 
(b) The Secretary is authorized to revise and amend any rules or 
regulations promulgated pursuant to this Act: Provided^ That, prior 
to any revision of or amendment to such rules or regulations, the 
Secretary shall, to the extent practicable, consult with appropriate 
national or regional Indian organizations and shall publish any pro-
posed revision or amendment in the Federal Register not less than 
sixty days prior to the effective date of such revision or amendment 
in order to provide adequate notice to, and receive comments from, 
other interested parties. 
Report to the 
President and 
Congress. 
25 use 1671. 
Program review, 
submittal to 
Congress. 
Consultation. 
25 use 1672. 
Publication in 
Federal Register. 
Rules or 
regulations, 
proposed revision 
or amendment; 
publication in 
Federal Register. 
PLAN OF IMPLEMENTATION 
SEC. 703. Within two hundred and forty days after enactment of 
this Act, a plan will be prepared by the Secretary and will be sub-
mitted to the Congress. The plan will explain the manner and schedule 
(including a schedule of appropriation requests), by title and section, 
by which the Secretary will implement the provisions of this Act. 
Submittal to 
Congress. 
25 use 1673. 
90 STAT. 1414 
PUBLIC LAW 94-437—SEPT. 30, 1976 
LEASES WITH INDIAN TRIBES 
25 use 1674. 
SEC. 704. Notwithstanding any other provision of law, the Secretary 
is authorized, in carrying out the purposes of this Act, to enter into 
leases with Indian tribes for periods not in excess of twenty years. 
AVAILABILITY OF FUNDS 
25 use 1675. 
SEC. 705. The funds appropriated pursuant to this Act shall remain 
available until expended. 
Approved September 30, 1976. 
LEGISLATIVE HISTORY: 
HOUSE REPORTS: No. 94-1026 pt. I and 94-1026 part IV (Comm. on Interior and 
Insular Affairs), No. 94-1026 pt. II (Comm. on Ways and 
Means), and No. 94-1026 pt. Ill (Comm. on Interstate and 
Foreign Commerce) all accompanying H.R. 2525. 
SENATE REPORT No. 94-133 (Comm. on Interior and Insular Affairs). 
CONGRESSIONAL RECORD: 
Vol. 121 (1975): May 16, considered and passed Senate. 
Vol. 122 (1976): July 30, considered and passed House, amended, in lieu of 
H.R. 2525. 
Sept. 9, Senate concurred in House amendment with an 
amendment. 
Sept. 16, House concurred in Senate amendment. 
WEEKLY COMPILATION OF PRESIDENTIAL DOCUMENTS: 
Vol. 12, No. 40: Oct. 1, Presidential statement.