Indian Health Care 101

What is the federal government’s trust responsibility for Indian health care?

Under law, tribal governments are treated as “domestic dependent nations”—similar to states in terms of sovereignty but with a trust obligation from the federal government.  The federal government is considered to be the trustee with responsibility for the 567 federally-recognized tribes.

The trust responsibility means that the government has a fiduciary duty to act in the best interest of Tribes and American Indians / Native Alaskans (AI/AN). That responsibility is not restricted to the borders of reservations, and it includes issues related to health care.

Who are urban Indians?

More than 70% of AI/AN now live in urban areas, as compared with 45% in 1970 and 8% in 1940.  This migration has occurred for several reasons, but mainly because of federal government coercion during the Relocation Era (1945-1968) and later because of lack of economic opportunities on reservations. 

27% of AI/AN live in poverty, proportionately more than any other group, and double the rate of 14% of Americans generally.   In fact, AI/AN in many large cities experience poverty at levels comparable to and in excess of the poorest reservations. 

How do urban Indians receive health care?

Urban Indians receive health care from a variety of sources, including private insurance, the exchanges established under the Affordable Care Act (ACA), Medicare, Medicaid, and the Department of Veterans Affairs (DVA).

The most important source is the Indian Health Service (IHS), which uses a three-prong (I/T/U) system to provide health care: Indian Health Service/Tribal/ Urban Indian health system.

How well does the Indian Health Service work?

IHS is consistently and drastically under-resourced, usually funded at just 50% of need; sometimes, the agency runs out of money in the middle of the fiscal year, which often forces patients to forego serious care and delay basic care. 

Despite more than two-thirds of Indians living off reservations, more than half (56.4%) of the AI/AN patients who used UIHPs in 2010 lacked any form of health insurance. IHS spends only 1% of its budget on the provision of care to urban Indians. 

What are the health care challenges experienced by urban Indians?

Urban Indians are confronted with an array of dire threats to their physical and mental health and well-being—alcoholism, suicide, high unemployment, behavioral health issues, and racial prejudice.  Nevertheless, as noted above, IHS spends only a tiny fraction of its budget on urban programs. 

Financially hard-pressed cities are almost unable to offset that whopping deficit.  From Medicaid to DVA, federal agencies short-change AI/AN who live in urban areas, paying the entire bill for AI/AN when they receive health care services on reservations but not when those same AI/AN receive those same health care services from UIHPs. 

What are UIHPs?

UIHPs, were created in 1972 following the Termination Era by Congress to fulfill the federal government’s health care-related trust responsibility for Indians who live off the reservations, and they are managed by an Executive Director and a Board of Directors.  

UIHPs are represented by the National Council of Urban Indian Health (NCUIH), which is a 501(c)(3), membership-based organization devoted to the development of quality, accessible, and culturally sensitive health care programs for AI/AN living in urban communities. 

What are the authorities for urban Indian health care? 

The authorization for Indian health care programs is the Indian Health Care Improvement Act, which was permanently authorized in 2010 pursuant to a provision included in the ACA, and the IHS is part of the Department of Health and Human Services.

The Congressional authorizers for AI/AN health care specifically are the Senate Indian Affairs Committee and the House Natural Resources Subcommittee on Indian, Insular and Alaska Native Affairs; and the Congressional appropriators are the Senate and House Interior Appropriations Subcommittees.

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