Native Americans living in IHS areas have lower life expectancies than the U.S. population as a whole and face considerably higher mortality rates for some conditions. For Native Americans ages 15 to 44 living in those areas, mortality rates are more than twice those of the general population. Native Americans living in IHS areas have substantially higher rates for diseases such as diabetes. Fatal accidents, suicide, and homicide are also more common among them. Mortality rates for some leading causes of death— such as heart disease, cancer, and chronic lower respiratory diseases—are nearly the same for these Native Americans as for the general population. However, these Native Americans also have substantially lower rates of mortality for other conditions, such as Alzheimer’s disease (see fig. 1 for a summary of key differences in health status indicators between the two groups). In 2004, IHS estimated that its patient population was approximately 1.4 million Native Americans. Area offices oversee the delivery of services and provide guidance and technical support to the area’s facilities. The 12 IHS areas include all or part of 35 states (see fig. 2 for a map of the counties included in the 12 areas). Within the 12 areas, direct care services are generally delivered through IHS-funded hospitals, health centers, and health stations. As of October 2001, which is the most recent year of available data, there were 413 such facilities. These included 49 hospitals that ranged in size from 4 to 156 beds. Nineteen of these hospitals had operating rooms. There were 231 health centers and 133 health stations. These two types of facilities vary in the scope of their services and in their hours of operation. Health centers offer a range of care, including primary care services and at least some ancillary services, such as pharmacy, laboratory, and X-ray, at least 40 hours a week. Health stations offer primary care services and are open fewer than 40 hours a week. Services not available through direct care may be purchased through contracts with outside providers. In most cases, the facility that provides a patient’s direct care services also authorizes payment for contract care services. The use of contract care services varies considerably. For example, in two areas (California and Portland) all hospital-based services are purchased through contract care. In the other 10 areas, some hospital- based services are provided at IHS-funded facilities, while others are purchased through contract care. Tribes have the option of operating their own direct care facilities and contract care programs. As of October 2001, tribes were operating 27 percent of the 49 hospitals and 70 percent of the 364 health centers and health stations. The remaining facilities were federally operated. For fiscal year 2005, approximately 50 percent of the IHS budget was allocated to tribes to deliver services. IHS funds a range of health care services for Native Americans. These services can be organized into three broad categories: primary care, ancillary, and specialty services. Table 1 shows these three categories, as well as the subcategories of services (for example, laboratory and pathology services) within each. The table also provides examples of specific services, whose availability may vary among IHS-funded facilities. Primary care services constitute the first level of health care and are generally the entry point for all other services. Ancillary services can be ordered by either a primary care provider or a specialist. For example, a blood test can be ordered by a primary care provider for an initial health assessment or by an oncologist to test for recurrence of cancer. Specialty services constitute a second level of care and generally address conditions of higher acuity than those addressed by primary care. Eligibility requirements for direct care and contract care differ. In general, all persons of Native American descent who belong to the Native American community are eligible for direct care at IHS-funded facilities. To be eligible for contract care, a Native American generally must also reside within a federally established contract care area and either (1) reside on a reservation within the area or (2) belong to or maintain close economic and social ties with a tribe based on such a reservation. In most cases, a contract care area consists of the county or counties in which a reservation is located, as well as any counties it borders. Contract care pays for services only when patients are unable to obtain such services through other sources, including Medicare, Medicaid, or private insurance (fig. 3 provides an overview of the eligibility requirements for contract care). The services for which IHS provides contract care must also meet medical priority criteria. Each IHS area office is required to establish medical priorities consistent with guidance published by IHS headquarters (see table 2 for an overview of the guidance). Federally operated facilities must abide by the priorities set by their respective area offices, assign a priority level to each service requested, and fund services in order of priority, as funds permit. Although federally operated facilities are required to pay for all priority I services (emergent/acutely urgent care), facilities may otherwise pay for all or only some of the services in the lowest priority level they fund. Tribally operated facilities have discretion in setting medical priorities. While these facilities must have a priority setting system, they may develop a system that differs from the guidance established by IHS. In addition to meeting eligibility and medical priority requirements, Native Americans must meet certain procedural requirements for services to be paid for through contract care. In particular, individuals who obtain emergency services generally must notify IHS within 72 hours of obtaining the services. IHS headquarters data on denials of payment for contract care are incomplete. However, in fiscal year 2003, patients’ or providers’ failure to comply with two procedural requirements (72-hour notification of emergency services and prior approval of nonemergency services) accounted for at least 16 percent of all reported denials of payment for contract care nationwide. The $2.6 billion that the Congress appropriated for fiscal year 2005 for IHS included funds for direct care, as well as $505 million for contract care services. From the $2.6 billion, IHS also funds public health nursing, scholarships to health professionals, and other functions. In addition to IHS’s federal appropriation, facilities are reimbursed for the services they provide on site by private health insurance and federal health programs, such as Medicare and Medicaid. IHS-funded facilities are allowed to retain reimbursements from private and federal health programs, without an offsetting reduction in their IHS funding, in order to fund health services. In fiscal year 2004, IHS-funded facilities obtained approximately $628 million in reimbursements, with 92 percent collected from Medicare and Medicaid and 8 percent from private insurance. The availability of primary care—medical, dental, and vision—services largely depended on the extent to which Native Americans were able to gain access to the services offered at IHS-funded facilities. The 13 facilities we visited generally offered primary care—medical, dental, and vision— services; however, Native Americans’ access to these services was not always assured. Although primary care services were offered, facility and tribal officials identified several factors that affected access to these services, such as wait times between scheduling an appointment and receiving services, travel distances to facilities, and a lack of transportation. All 13 facilities we visited offered medical services, such as initial physical examinations for pregnant women and well-baby checkups, while 12 facilities offered dental services, such as oral examinations, cleanings, and sealants. Twelve of 13 facilities offered vision care. Four facilities offered certain primary care services by making arrangements for patients to obtain these services at other locations, including other IHS-funded facilities. The arrangements facilities made for care differed, depending on their relationships with other IHS-funded facilities, the nature of the service, and proximity to other facilities. For example, one clinic routinely referred patients needing eye examinations to an IHS-funded hospital located about 50 miles away with which it had an ongoing relationship. Another facility provided dental services on site to children, pregnant women, and adults with diabetes, while referring all others seeking dental care to other IHS-funded facilities. For vision services, this facility directed patients to a different facility that offered eye examinations for children and adults. Another facility purchased primary care services from private providers for Native Americans who lived 75 miles from that facility. At over half of the facilities we visited, facility officials indicated that patients were able to obtain certain primary care services—such as physical examinations and well-baby checkups—often within 3 weeks of calling for an appointment. However, the waiting times between calling for an appointment and receiving services were considerably longer for other primary care services. For example, four facilities reported that patients routinely had to wait more than a month for some types of primary care, which was in excess of standards or goals identified in other federally operated health care service delivery systems. The wait times at the four facilities ranged from 2 to 6 months, with the services cited as requiring lengthy waits being women’s health care, general physicals, and dental care. In some cases, facility officials reported that the demand for services exceeded available appointment slots. For example, facility or tribal officials at 7 of the 13 facilities cited a need to increase dental services in order to keep up with their populations’ demand. Additionally, three facilities indicated that medical care slots made available for same-day appointments were usually filled within 45 minutes of the phone lines being opened. At one of these facilities, 20 to 30 slots were usually filled within 15 to 30 minutes. An official at this facility estimated that it was turning away 25 to 30 patients a day. Officials at 6 of the 13 facilities we visited cited a need to increase the amount of primary care services to meet demand in the service population. Some tribal officials remarked on the demoralizing effect on patients who had difficulty getting appointments. For example, one tribal official noted that rather than remain at the facility all day to see a provider, patients would wait to seek care until their condition became an emergency that required a higher level of treatment.