Self-Determination in American Indian/Alaska Native health care



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.



6 Responses to “Self-Determination in American Indian/Alaska Native health care”

  1. harveyksite Says:

    Interesting post! The lack of funds spent per individual in communities dealing with the morbidity and mortality associated with chronic medical and psychiatric disease is unacceptable and I agree with the senator from Wyoming who referred to it as “malpractice”. I would like to see a comparison of the clinical care indicators and utilization data for the health centers in the Alaska area vs. the Great Plains to support the transition to tribal control (especially if there is some controversy regarding this issue. I agree that Congress needs to fund these facilities appropriately in order to allow them to effectively treat these communities. Thanks again for posting!

    • anatheaee Says:

      Areas with greater tribal control do tend to do better, but, of course, the confounders are many. For example, currently their is approx a 37% vacancy rate in physician positions in the Great Plains Area. Most tribes that choose to take over providing their own healthcare services, though they stumble a lot along the way, end up providing higher quality services. Tribal facilities on average increase funding in their operating budget by 28% over IHS facilities. See

  2. aguzmangva Says:

    Thank you so much for this excellent post and writing about this under-reported problem. I had the opportunity to research maternal mortality in Canadian Aboriginals, and there are similar parallels with the American Indian/Alaskan Native population that you bring to our attention.

    The Aboriginal population in Canada is rapidly growing compared to the non-Aboriginal population, and faces significant barriers to health, including poor socioeconomic status and access to health care.

    Healthcare in Canada is government funded, thus allocation of resources and access falls under government responsibility. Despite a rapidly growing Aboriginal population, resources have been capped, and therefore cannot meet the needs of the population . Compounding these issues, the majority of political players driving health policy and making health care decision in Canada are non-Aboriginal. Over centuries of assimilation, non-Aboriginal health authorities have rejected traditional Aboriginal knowledge of health and healing .

    I was shocked to read the 2014 statistic you presented – it’s incredible that the entitlements to federal prisoners are higher user than the AI/AN people.

    I hope worldwide, indigenous and aboriginal peoples will one day have an equal healthcare.

    • anatheaee Says:

      Thank you for your comment. The issues of aboriginal peoples around the world are similar. In many cases, nations have historically ghettoized their native people to remote places and so the average citizen can’t easily see their concerns. For example, I doubt many Americans are aware that 40% of Navajo nation residents don’t have running water or plumbing and probably even more are not on the power grid. We have enough Navajo people suffering the consequences of exposure to uranium mining to have a regular uranium clinic. Similar to Canada, the AI/AN population is small but growing and $3000 per person doesn’t buy much health care.

  3. elizabethwetzler Says:

    Thank you for writing on this topic! I’ll be honest and say that before I read your blog, I did not know much (if anything at all) about healthcare for the AI and AN populations! I do know, however, that it seems unjust that anyone’s healthcare would depend on appropriations that may or may not be approved in a timely manner. I think that, as you indicated, and Warne and Frizzel (2014) also suggested, this is a matter of social justice and civil rights. Addressing these inequities should be a national priority. Thanks again, for bringing this matter to my attention! Link for Warne & Frizzell is:

    • anatheaee Says:

      Thank you for your comment. There is a strong feeling in the Northern Plains that the federal government is responsible for doing a better job in funding and providing health care. Like the Politico article references, 37% of physician positions are vacant in the Great Plains and CMS shut down multiple emergency rooms in that area; it’s a crisis situation. Tribes in other areas have selected to take the federal dollars, find ways to supplement them, and provide high-quality care for themselves. For complex reasons, the Great Plains Area tribes are unable or unwilling to do so, leaving the federal government to have to do a better job.

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