In 1975, the Indian Self Determination and Education Assistance Act (PL-93-638) was passed to allow for tribes to contract with federal agencies to govern their own services. Tribes, considered “dependent domestic nations”, have varied in how much they have taken advantage of self-determination opportunities in health care. For example, 99% of the Indian Health Service (IHS) funding in the Alaska Area is under tribal control, while very little of the Great Plains Area has been transferred to tribal control. Under treaty rights, the federal government is responsible for the “proper care and treatment” of members of recognized tribes in perpetuity. There exists some sentiment that self-determination is a way of letting the federal government out of its treaty responsibilities to Native people. Others, like Donald Warne, MD, MPH, see so-called “638” tribally-managed health care as offering increased opportunities for third party revenue and grant funding, and increased local control versus IHS facilities, resulting in more services and better access.
AI/AN health care funds are not considered an entitlement like Medicare, Medicaid, or VA benefits, meaning that Congress must appropriate funding annually. In 2014, this was $3099 per user, which is less than that spent on federal prisoners. In comparison to the general US population, AI/AN people suffer higher age-adjusted death rates (from diabetes, chronic liver disease and cirrhosis, accidents, tuberculosis, pneumonia and influenza, suicide, homicide, and heart disease), as well as infant mortality twice the general population. IHS is a severely underfunded and understaffed agency, which, at least in the Great Plains Area, is providing care which Senator John Barrasso (R-Wy) recently called “malpractice”.
I am calling upon the IHS to provide technical assistance, capacity development, and transfer planning for tribal control. I am also calling upon Congress to fund these efforts for the improvement of AI/AN health.