Proposed budget for Indian Health Services won’t treat Native American patients equally

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Early treaties with the federal government were generally done in good faith by both tribal nations and the emerging United States. But by the mid 1800s, treaties more often than not were Bad Acts and Bad Paper, explicitly designed to deceive tribal nations and remove their lands, reflected in the boundaries of present day Indian Country.

This shift in policy was one of the first in the complex history of relationships between the various tribal nations and the United States government, documented by periods of autonomy and self-determination, assimilation and termination. As result of these of interactions between the United States government and tribal nations, a unique federal trust responsibility was established.

{mosads}In many treaties, the U.S. Government identified health services as part of its ongoing debt to tribal nations as part of the payment for their lands. The fulfillment of this obligation is enshrined by acts of Congress, and clearly mandate that health care disparities between Native Americans and the general U.S. population are to be eliminated. This duty is entrusted largely to the Indian Health Service (IHS).


A small federal agency, IHS serves 2.2 million Native Americans  across 36 states, mostly in small rural clinics and hospitals. The IHS has been in chronic crisis with ongoing high vacancy rates and turnover for doctors, as well as horrific lapses in quality of care. In these deeply rural settings, IHS is often the only health-care provider present, and can fall short in the service it should provide.

However, it is arguable that the IHS has been set up to fail. Federal Congressional leaders who correctly lambast IHS for performance lapses also support severe underfunding for the Agency. The IHS budget faces severe staffing challenges and spends on average only $3,332 per capita on each patient, compared to a national average of $9,207.

Congress should not be surprised that their funding shortfalls have had predictable results. While the executive and legislative branches debate the chicken-and-egg aspect of IHS budget and performance, these are but different federal silos passing the buck back and forth rather than being accountable to uphold federal treaty trust obligations.

The IHS National Tribal Budget Formulation Workgroup is tasked with making recommendations to the Indian Health Service on Tribal budget priorities every year. Since fiscal year 2010, the work group has made requests to fully fund the IHS over a 10-12 year time period — based on documented need.

There is no defensible reason as to why patients within the IHS still have less than half the per capita health spending of the general U.S. population to address the health inequities that have been repeatedly documented by data and presented to Congress. “Tribal self-governance is a model that must be supported and expanded. We cannot as a country fulfill a federal trust relationship based on failed economic policies, stifled by bureaucratic regulation and broken promises…” Senator Lisa Murkowski, May 25, 2015.

As a benchmark, compare another agency that provides direct medical care with a population that has a special relationship with the federal government. The 2018 Veterans Administration (VA) has a medical budget of about $86 billion, more than 14 times that of IHS (The VA serves a population about four times greater than IHS). The VA budget for information technology alone ($4.1 billion) is two-thirds the total budget of IHS ($6.1 billion).

There are reasons for optimism. IHS has long been shifting its stance from “for Native Americans” to “by Native Americans,” as an increasing proportion of health care facilities move from federally operated programs to tribal self-governance. Indeed, large tribally-run health systems in Alaska and Oklahoma could provide lessons learned to many private sector peers.

The president’s fiscal 2019 federal budget proposes an overall increase to the IHS budget of 8 percent over fiscal 2018 continuing resolution but eliminates key public health programs.

The proposed budget is not one that brings Native American patients to equality; not even close.  Congress must commit to the National Tribal Budget Formulation’s recommendation to get IHS up to full funding over a 12-year period and not wait another year to move IHS to equitable funding, which should be a national goal driven not by guilt, but by honor.

Jessica Leston, MPH works for Northwest Portland Area Indian Health Board (NPAIHB) as the HCV/HIV clinical programs manager. She has worked for tribal health services for 14 years.

Tags Health care indian Health Services Lisa Murkowski Native American health

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