New Directions in Federal Indian Policy a Review of the

Am J Public Health. 2014 June; 104(Suppl iii): S263–S267.

American Indian Health Policy: Historical Trends and Gimmicky Issues

Accepted September xiii, 2013.

Abstract

The United States has a trust responsibleness to provide services to American Indians and Alaska Native (AI/AN) persons. However, a long-standing history of underfunding of the Indian Health Service (IHS) has led to meaning challenges in providing services.

Twentieth century laws, including the Snyder Act, Transfer Human activity, Indian Self-Determination and Education Assistance Act, and Indian Wellness Care Comeback Act (IHCIA) take had an effect on the fashion health services are provided. IHCIA was reauthorized as part of the Patient Protection and Affordable Care Act (ACA). Several provisions in ACA allow for potential improvements in access to services for AI/AN populations and are described herein.

Although policy developments have been promising, IHS underfunding must be resolved to ensure improved AI/AN health.

American Indian and Alaska Native (AI/AN) tribes accept had a unique history with the United States that is mixed with disharmonize, warfare, cooperation, and partnership. This history has resulted in a circuitous web of federal Indian policy, treaties, and intergovernmental relationships. Services provided to AI/AN persons (east.g., housing, education, health care) accept been guaranteed through treaties, executive orders, and other legal bases. For case, betwixt 1778 and 1868, at least 367 treaties were ratified by the federal government.1 The Supremacy Clause of the U.s. Constitution establishes the Constitution, federal statutes, and treaties as "the supreme law of the state." Typical language in many of the treaties signed between the The states and tribal nations included phrases similar "promise of all proper care and protection" in exchange for tribal land and natural resources. The upshot is that there is a trust responsibility on behalf of the federal regime to provide services to AI/AN persons. The federal Indian trust responsibleness is a legal obligation under which the government "has charged itself with moral obligations of the highest responsibility and trust" toward Indian tribes.2 This obligation was initially described by Chief Justice John Marshall in 1831 in reference to the Supreme Court case Cherokee Nation 5 Georgia.3 Trust responsibility is also a legally administrated financial obligation on the part of the US regime to defend tribal treaty rights, lands, assets, and resources, as well every bit a duty to provide health services. Still, a long-standing history of underfunding of the Indian Health Service (IHS) and its predecessor agencies has led to meaning challenges in providing proper care and protection. This article provides a cursory overview, history, and evolution of AI/AN wellness policy as well as contempo trends and contemporary issues.

POLICY HISTORY

A deficiency of resources has plagued the provision of wellness services to AI/AN persons since the final treaties were signed in 1871. For example, according to the 1890 Annual Report of the Commissioner of Indian Affairs, physicians working with Indian populations were paid an boilerplate almanac salary of $1028 compared with $2823 and $2622 for Ground forces and Navy physicians, respectively.4 In 1914, Warren K. Moorehead, a commissioner for the Bureau of Indian Diplomacy, stated that "It is incomprehensible to me that appropriations for combating disease are then meager."five Unfortunately, underfunding of the IHS continues to this day (Figure one). However, numerous laws passed in the 20th century take had a significant impact on the mode wellness services are provided to AI/AN persons. Several of them, including the Snyder Deed, Transfer Act, Indian Self-Determination and Didactics Assistance Act, and the Indian Health Care Improvement Act, are described here. These four laws encompass only a minor portion of the exhaustive list of laws and policies affecting how AI/AN individuals receive health services.

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2009–2010 Indian health expenditures per capita compared with other federal wellness care expenditures per capita.

Note. FEHB = Federal Employee Health Benefits; IHS = Indian Health Service.

Source. National Tribal Budget Formulation Workgroup.6

Snyder Act

Earlier 1955, the Indian health program was operated by the Agency of Indian Affairs (BIA)—an agency within the Section of the Interior. The Snyder Act of 1921 states that

The Bureau of Indian Affairs, nether the supervision of the Secretary of the Interior, shall straight, supervise, and expend such moneys as Congress may from time to fourth dimension appropriate, for the benefit, care, and assistance of the Indians throughout the United States.

This was the first constabulary that allowed Congress to advisable funds to address AI/AN health on a recurring ground. Included in the list of adequate uses of Congressional appropriations was "for relief of distress and conservation of health," and "for the employment of … physicians."7 The funding authorisation for many of the electric current activities of the IHS is rooted in the Snyder Act.

Transfer Act

The Indian health program became a responsibility of the Public Health Service under the Transfer Act of 1954. The act states

that all functions, responsibilities, authorities, and duties…relating to the maintenance and operation of hospital and health facilities for Indians, and the conservation of Indian health … shall be administered by the Surgeon General of the United states Public Health Service.

The act also states that

whenever the health needs of the Indians tin can be improve met thereby, the Secretary … is authorized in his discretion to enter into contracts with whatsoever … institution providing for the transfer of Indian hospitals or wellness facilities

with the status that such a transfer cannot exist made "unless such activity has been canonical by the governing torso of the tribe."8 This language recognized tribal sovereignty and afforded a degree of tribal self-conclusion in wellness policy decision-making. The authorities contained in the Snyder Act were likewise transferred to the Secretary of Health, Education, and Welfare (now Wellness and Human Services).

Indian Cocky-Determination and Education Assistance Act

The Indian Self-Determination and Teaching Assist Human activity (ISDEAA) was enacted in 1975, and it is possibly the most significant police force affecting how health services are provided to AI/AN tribes.9 This act is the basis for authorizing tribes to assume the management of BIA and IHS programs, and information technology directs the Secretaries of Interior and Health and Human Services to enter into self-determination contracts at the request of whatever tribe.10 In terms of health services, any programme, office, service, or activeness of the IHS tin can exist assumed by the tribe under a "638 contract." Under Championship I of the ISDEAA, a tribe may become a federal contractor to provide services as outlined in the IHS line detail upkeep for a given service unit (clinic or infirmary). Nether Championship V of ISDEAA, the funding agreement is a "638 compact" and is essentially a block grant for a total budget corporeality, and the tribes take greater flexibility in reprogramming resources to meet local health needs. Several financial and administrative advantages are available to the tribes via ISDEAA:

Carry-Over Funding. Unlike many federally funded programs that crave complete budget expenditures inside a given fiscal year, nether the ISDEAA, "whatever funds for any fiscal year which are non obligated or expended shall remain bachelor for obligation or expenditure during such succeeding financial yr for which they were originally appropriated, contract, or granted. No boosted justification need exist provided past the tribal organization."eleven
Third-Party Acquirement. Acquirement collected from private or public insurance is treated as supplemental revenue and does not affect the negotiated dollar amounts in 638 funding agreements.
Eligibility for Grants. Tribal 638 programs are eligible for numerous federal grants for which the IHS, as a federal agency, is not eligible. For example, a tribe is eligible for Community Health Center grants from the Health Resource and Services Administration under Department 330 of the Public Health Service Deed. These grants support health centers in health professions shortage areas, which include many Indian reservations. A tribe tin can combine contracted or compacted funds from ISDEAA with Section 330 grants in addition to collecting tertiary-political party revenue, resulting in significantly greater resources to address community wellness.
Contract Back up Costs. Contract Support Costs (CSCs) are authoritative funds used to manage a contract and are based on the tribes' indirect cost rates. For example, if a tribe has a 30% indirect cost rate, the ISDEAA contract would include all directly costs of contracted services plus 30% for CSCs. The IHS does not have similar line items for administrative costs. However, federal budgets in contempo years have not supported 100% of CSCs owed to the tribes, thus creating significant controversy.12

More than half of the IHS budget is now managed by the tribes under ISDEAA.thirteen Although there are numerous examples of successfully implemented tribal health programs, some tribal leaders have expressed concerns over contracting or compacting for services that are chronically and significantly underfunded.fourteen

Indian Wellness Care Comeback Act

The Indian Health Intendance Improvement Human activity (IHCIA) was enacted in 1976 and was instrumental in setting national policy to amend the health of Indian people. The language regarding the responsibility of the United States to maintain and meliorate the wellness of AI/AN persons was needed to enhance the intent of previous laws by expanding and describing modern health services.15 Title V of IHCIA established the Urban Indian Wellness Programs, of which there are 34 nationally.sixteen The act besides included the initial authorization that allowed IHS and tribal 638 wellness programs to nib Medicare and Medicaid. Since 1976, reimbursements from Medicare, Medicaid, and Children'southward Health Insurance Program (CHIP) have aided Indian wellness programs to expand access to services.

I/T/U Wellness Care Delivery and Funding Authorities

With the legislative initiatives of the 20th century, the provision of services for AI/AN persons has evolved significantly. The wellness care delivery system is now described equally the "I/T/U" system, in which "I" represents IHS, "T" represents tribal 638 programs, and "U" represents the urban health centers. The funding authority for IHS is rooted in both the Snyder Act and the Transfer Act. ISDEAA allows tribes to have over the management of wellness programs from the IHS via contracts or compacts, and Championship V of the IHCIA established the Urban Indian Health Centers.

Level of Demand Funded

A long-standing issue in the provision of health services to AI/AN persons is underfunding of the IHS.17 For example, between 1993 and 1998, IHS appropriations increased by viii%, while medical inflation increased by xx.6%. Every bit a result, when both the rate of medical aggrandizement and increases in the AI/AN population were considered, there was, in reality, a subtract of 18% in the per capita appropriation for IHS during this period.eighteen In 1998, Congress requested that the IHS develop a written report on wellness status and resource shortages. A Level of Need Funded (LNF) Workgroup was established to develop a methodology for determining appropriate funding levels for Indian wellness.19 Considering both federal employees and AI/AN persons have a legal correct to health services, the LNF Workgroup compared IHS per capita expenditures with the Federal Employee Wellness Benefits (FEHB) program. The LNF study in 1998 showed a 46% shortfall in funding for AI/AN persons receiving care through the IHS compared with FEHB.20

RECENT TRENDS AND Time to come DIRECTIONS

Since the passage of the IHCIA in 1976, the role of the Centers for Medicare and Medicaid Services (CMS) in Indian health has expanded. In our experience, some tribes and AI/AN persons have been reluctant to enroll in CMS programs for various reasons, including trust problems related to sharing personal information with a non-Indian regime bureau and the fact that many tribes have treaties that ensure access to health care. Notwithstanding, these treaties are with the federal authorities, not the IHS, and CMS is a component of the federal government. CMS has a much larger upkeep than IHS, and its programs should exist considered an of import component of the federal trust responsibleness to provide health services. For many IHS and tribal service units, the funds generated from tertiary-party revenue exceeds the funding from directly Congressional appropriations, and in most cases, Medicaid is the primary payer because of high rates of poverty. The percentage of AI/AN adults living at or beneath the federal poverty level in 2009 (20.4%) was about 2.5 times greater than the percentage of Whites living in poverty (8.4%).21 Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) should increase the number of AI/AN individuals eligible for and enrolled in Medicaid. This should consequence in increased access to wellness services; however, some states take elected non to expand Medicaid. Information technology is unclear what the impact will exist on AI/AN persons in states that choose not to expand Medicaid.

A divide and parallel Medicaid system exists for the IHS and tribal 638 programs. States are reimbursed with 100% Federal Medical Assistance Percent for payments fabricated to these programs, and therefore, land funds are non used to pay for Medicaid-covered services in IHS or 638 facilities. However, the urban Indian health centers are not eligible for 100% Federal Medical Help Percentage, and the states must pay their percentage of Medicaid costs to these facilities.

Potential Impact of the ACA

Although the ACA is often referred to equally "health care reform," in truth, it is wellness insurance reform. In addition to Medicaid expansion, some other key provision includes the requirement of wellness insurance companies to pay for preventive services and cancer screening. For AI/AN persons, when specialty and other services are non directly available at an IHS or tribal facility, services are purchased in the public and private sectors through the Contract Health Services (CHS) program of the IHS. With high rates of diseases similar colorectal cancer among AI/AN populations in sure regions of the The states, access to screening or diagnostic colonoscopy could outcome in earlier detection and potentially life-saving interventions. Yet, the IHS is non health insurance, and the guidelines for referrals under the CHS are non affected by the ACA. Therefore, a procedure like colonoscopy, which is not considered to be a high priority referral by a CHS program, could be denied. As a result, disparities in colorectal cancer mortality could worsen unless AI/AN persons have admission to health insurance—Medicaid or otherwise.

Some other provision in the ACA that could bear upon AI/AN health is expansion of Federally Qualified Health Centers (FQHCs). FQHCs are funded by grants from the Health Resources and Services Administration that are authorized by Department 330 of the Public Health Service Human activity.22 Although the ACA authorizes FQHC expansion, information technology will be upwards to Congress to advisable the funds needed to implement this expansion. Tribal 638 programs and urban Indian health centers are eligible for these grants; still, as a federal agency, IHS is not eligible. Nationally, several tribal 638 programs and urban Indian health facilities receive "330 grants" and are within the network of community health centers funded by the Health Resources and Services Administration.

Permanent Reauthorization of the IHCIA

Although it was due for reauthorization in 2000, the IHCIA was permanently reauthorized as role of the ACA in March 2010.23 The Announcement of National Indian Health Policy in the IHCIA states that

Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and urban Indians and to provide all resource necessary to result that policy.

This version of the IHCIA differs in multiple ways from the original IHCIA. It includes several modifications designed to improve the provision of health services to AI/ANs, such as:

Augmented authorities of the IHS director;
Dominance for hospice, assisted living, long-term care;
Modernization of current law apropos collecting reimbursements from Medicare, Medicaid, and Fleck;
Permission for tribes and tribal organizations to purchase health benefits for their community members;
Allowing IHS to enter into agreements with the Departments of Veterans Affairs and Defense to share health facilities and services;
Allowing a tribe or tribal system that operates programs nether ISDEAA and an urban Indian organization to buy health insurance coverage for its employees from FEHB;
Authorization for the establishment of a Community Wellness Representative (unremarkably called community health workers in other sectors) program for urban Indian organizations; and
Directing the IHS to establish comprehensive behavioral health, prevention, and treatment programs.24

Although the provisions in the new version of the IHCIA are promising, this deed authorizes Congress to appropriate resources to run into these goals. However, there is no guarantee that Congress will appropriate adequate resources.

Policy Innovations

Although significant numbers of AI/AN persons are impoverished,25 many tribal communities are successful financially. With economic development comes the opportunity to aggrandize wellness programs. In our experience, many tribes are successfully implementing health policy innovations, including tribal self-insurance programs. The process of combining tribal 638 programs with cocky-insurance essentially increases admission to services by coordinating multiple funding streams and by overcoming the limitations of CHS. In addition, some tribal communities are inbound into individual sector partnerships with hospital systems, insurance companies, the pharmaceutical industry, academic institutions, and other sectors to develop novel solutions to health services needs. Too, integration of Traditional Indian Medicine is occurring at many I/T/U programs. Creative policies that allow for coordination of care across medical disciplines and Traditional Indian Medicine allow for improved cultural competence and patient satisfaction.

CONCLUSIONS

AI/AN wellness policy has a complex history, and it is a collection of sometimes conflicting federal Indian law, health policy, and intergovernmental relationships. U.s. history has borne out a unique human relationship between AI/AN tribes and the federal regime, including forced acculturation, warfare, and severely underfunded wellness services, leading to astringent AI/AN health disparities. The Indian health organization is diverse and vulnerable, and the need exists to closely monitor laws and regulations that challenge the ability of tribes to receive and to provide wellness services. Policy and program development needs to avoid unnecessary barriers and to improve tribal relationships with all levels of regime.

Key elements of federal Indian health police force and policy include treaties, federal trust responsibility, tribal sovereignty, and the regime-to-government relationship. Citizens who are eligible for I/T/U services generally consider admission to wellness services as "pre-paid" past the vast amounts of AI/AN state and natural resources that were taken by the U.s. authorities. Congress appropriates funds annually for the IHS. Even so, unlike Medicaid and Medicare, the IHS is not an entitlement program in the federal budget. Rather, it is a discretionary program, its means of support is susceptible to unrelated political agendas, and it is dependent on the will of Congress. The IHS budget has non kept step with medical aggrandizement and the increases in AI/AN population. Long-term underfunding of the IHS is a contributing gene to AI/AN health disparities, and Congress needs to abide by its trust responsibilities and its treaty obligations to provide proper intendance to AI/AN persons.

Finally, in our experiences in providing health services and in administering health programs in AI/AN communities, the amount of needless suffering and loss of life related to preventable and treatable disease make IHS funding a affair of social justice and civil rights, and this issue needs to be a national priority for all public health advocates, non just for the AI/AN population. Resource and services available to AI/AN persons from across the Department of Health and Human Services and other agencies need to be expanded to meet the public health, clinical, research, and workforce needs of this population. To bring the IHS budget to an equitable level similar to the FEHB benchmark would crave approximately an additional $iii billion per year. With a Section of Health and Human Services budget of more $800 billion per year, this increment represents only a few tenths of 1%, and this increase would accept a significant return on investment in terms of saving lives and reducing human suffering. Possibly with strong partnerships in advocacy, in the 21st century, we tin overcome the scourge of Indian health underfunding that has plagued this population for the previous ii centuries.

Human being Participant Protection

Man participant protection was not needed because no human being participants were involved.

References

1. Prucha FP. American Indian Treaties: The History of a Political Anomaly. Berkeley, CA: University of California Press; 1994. p. 1. [Google Scholar]

ii. Seminole Nation five United States, 316 US 286 (1942).

iii. Cherokee Nation five Georgia, 30 US (five Peters) 1 (1831).

iv. DeJong DH. If Yous Knew the Conditions: A Chronicle of the Indian Medical Service and American Indian Health Care, 1908-1955. Lanham, Physician: Lexington Books; 2008. p. eight. [Google Scholar]

5. Moorehead WK. The American Indian in the United States: 1850-1914. Whitefish, MT: Kessinger Publishing; 2007. p. 85. Reprint of 1914 original. [Google Scholar]

6. National Tribal Budget Conception Workgroup. National tribal budget recommendation for the Indian Health Service: fiscal year 2013 budget. US Department of Wellness and Human Services: Washington, DC; 2011.

seven. The Snyder Act, Pub Fifty No. 67-85 (1921).

8. The Transfer Human action, Pub L No. 83-568 (1954).

nine. Warne D. Policy issues in American Indian health governance. J Law Med Ethics. 2011;(suppl 1):42–45. [PubMed] [Google Scholar]

x. Bauman D, Floyd J. Indian Tribal Health Systems Governance and Development: Bug and Approaches. Menlo Park, CA: Kaiser Family unit Foundation; 1999. [Google Scholar]

11. Amendment to ISDEAA, 102 Stat. 2285. Pub L No. 100-472 (1988).

thirteen. Rife JP. Caring and Curing: A History of the Indian Health Service. Terra Alta, WV: Public Health Service Commissioned Officers Foundation; 2009. p. 120. [Google Scholar]

15. The Indian Wellness Intendance Improvement Act, Pub Fifty No. 94-437 (1976).

16. Indian Health Service. Role of Urban Indian Health Programme. Available at: http://www.ihs.gov/urban. Accessed May 2, 3013.

17. Usa Commission of Ceremonious Rights. A Quiet Crisis: Federal Funding and Unmet Needs in Indian Country. Washington, DC: US Committee on Civil Rights; 2003. pp. 35–49. [Google Scholar]

18. Dixon M, Mather DT, Shelton BL . Organizational and economic changes in Indian Health Care Systems. In: Roubideaux Y, Dixon M, editors. Promises to Keep: Public Wellness Policy for American Indians and Alaska Natives in the 21st Century. Washington, DC: American Public Health Association; 2001. p. 105. [Google Scholar]

19. Frias H. Should Indian wellness intendance exist an entitlement. IHS Provider. 2003;lx:60–64. [Google Scholar]

xx. LNF Work Group Written report. Level of need funded: a written report to measure out the costs of a mainstream parcel of health services for Indian people. Rockville, MD: Indian Wellness Service; 1999:2.

21. Centers for Disease Control and Prevention. Health disparities and inequalities report 2011. MMWR Surveill Summ. 2011;60(01):13–17. [Google Scholar]

22. Public Wellness Service Human activity (42 USCS § 254b), Section 330.

23. Patient Protection and Affordable Intendance Act, Role III—Indian Health Care Comeback, Pub Fifty No. 111–148 (2010).

24. Congressional Research Service. Indian Wellness Care Improvement Act Provisions in the Patient Protection and Affordable Care Act (Pub L No. 111-148). 2010. Available at: http://www.ncsl.org/documents/health/IndHlthCare.pdf. Accessed February 26, 2014.

25. Beckles GL, Truman BI. Education and income — U.s., 2005 and 2009. MMWR Morb Mortal Wkly Rep. 2011;60(suppl):xiii–17. [Google Scholar]

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