Indian Health Service
The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally recognized Native American Tribes and Alaska Native people. IHS is the principal federal health care provider and health advocate for American Indian people.[1]
This article is about the Native American agency in the United States. For the ministry in India, see Ministry of Health and Family Welfare.Operating Division overview
1955
5600 Fishers Lane, North Bethesda, Maryland, U.S., 20857
(Rockville mailing address)
$5.9 billion (2017)
- Roselyn Tso, Director, Indian Health Service
- Benjamin Smith, Deputy Director, Indian Health Service
The IHS provides health care in 37 states to approximately 2.2 million out of 3.7 million American Indians and Alaska Natives (AI/AN).[2] As of April 2017, the IHS consisted of 26 hospitals, 59 health centers, and 32 health stations. Thirty-three urban Indian health projects supplement these facilities with various health and referral services. Several tribes are actively involved in IHS program implementation.[3] Many tribes also operate their health systems independent of IHS.[1] It also provides support to students pursuing medical education to staff Indian health programs.[4]
Employment[edit]
IHS employs approximately 2,650 nurses, 700 physicians, 700 pharmacists, 100 physician assistants and 300 dentists, as well as a variety of other health professionals such as nutritionists, registered medical-record administrators, therapists, community health representative aides, child health specialists, and environmental engineers and sanitarians.[1][3] It is one of two federal agencies mandated to use Indian Preference in hiring. This law requires the agency to give preference to qualified Indian applicants before considering non-Indian candidates for employment, although exceptions apply.[5]
IHS draws a large number of its professional employees from the U.S. Public Health Service Commissioned Corps. This is a non-armed service branch of the uniformed services of the United States. Professional categories of IHS Commissioned corps officers include physicians, physician assistants, nurses, dentists, therapists, pharmacists, engineers, environmental health officers, and dietitians.[6]
Many IHS positions are in remote areas as well as its headquarters outside of Rockville, Maryland, and at Phoenix Indian Medical Center in Phoenix, Arizona. In 2007, most IHS job openings were on the Navajo reservation. 71% of IHS employees are American Indian/Alaska Native.[6]
The IHS also hires Native/non-Native American interns, who are referred to as "externs". Participants are paid based on industry standards, according to their experience levels and academic training, but are instead reimbursed for tuition and fees if the externship is used for an academic practical experience requirement.[7]
A network of twelve regional offices oversee clinical operations for individual facilities and funds. As of 2010, the federally operated sites included 28 hospitals and 89 outpatient facilities.[23]
Tribal self-determination[edit]
Notable self-determination legislation[edit]
In 1954, the Indian Health Transfer Act included language that recognizing tribal sovereignty and the Act additionally "afforded a degree of tribal self-determination in health policy decision-making."[50] The Indian Self Determination and Education Assistance Act (ISDEAA) allows for tribes to request self-determination contracts with the Secretaries of Interior and Health and Human Services. The tribes take over IHS activities and services through an avenue called ‘638 contracts’ through which tribes receive the IHS funds that would have been used for IHS health services and instead manage and use this money for the administration of health services outside of the IHS.[50]
Self-determination successes and concerns[edit]
The benefits and drawbacks of Tribal Self Determination have been widely debated. Many tribes have successfully implemented elements of health-related Self Determination. An example is the Cherokee Indian Hospital in North Carolina. This community-based hospital, funded in part by the tribe's casino revenues, is guided by four core principles: "The one who helps you from the heart", "A state of peace and balance", "it belongs to you" and "Like family to me" "He, she, they, are like my own family".[51] The hospital is based on the adoption of an Alaska Native model of healthcare called the "Nuka System of Care", a framework that focuses on patient-centered, self-determined health service delivery that heavily relies on Patient participation.
The Nuka System of Care was developed by the Southcentral Foundation in 1982, a non-profit healthcare organization that is owned and composed of Alaska Natives.[52] The Nuka System's vision is "A Native community that enjoys physical, mental, emotional and spiritual wellness".[52] Every Alaska Native in the health system is a "customer-owner" of the system and participates as a self-determined individual who has a say in the decision-making processes and access to an intimate, integrated, long-term care team. When a customer-owner seeks care, their primary care doctor's foremost responsibility is to build a strong and lasting relationship with the beneficiary, and customer-owners have various options through which they can give input and participate in decisions about their health. These options include surveys, focus groups, special events and committees.[52] The board is made up entirely of Alaska Natives who helped design the system and actively participate in running it effectively.[52] Following the implementation of the Nuka System of Care in Alaska Native health, successes in improved standards of care have been achieved, such as increases in the number of Alaska Natives with a primary care provider, in childhood immunization rates, and customers satisfaction in regard to respect of culture and traditions. In addition, decreases in wait times for appointments, wait lists, emergency department and urgent care visits, and staff turnover have been reported.[52] The North Carolina Cherokee Indian Hospital in 2012 as well as other tribes have implemented the Nuka System approach when planning their new or revamped health centers and systems.
Some tribes are less optimistic about the role of Self Determination in Indian healthcare or may face barriers to success. Tribes have expressed concern that the 638 contracting and compacting could lead to "termination by appropriation", the fear that if tribes take over the responsibility of managing healthcare programs and leave the federal government with only the job of funding these programs, then the federal government could easily "deny any further responsibility for the tribes, and cut funding".[53] The fear of potential termination has led some tribes to refuse to participate in Self Determination contracting without a clear resolution of this issue.[54] Some tribes also renounce Self Determination and contracting because of the chronic underfunding of IHS programs. They do not see any benefit in being handed the responsibility of a "sinking ship"[53] due to the lack of a satisfactory budget for IHS services. Other tribes face various barriers to successful Self Determination. Small tribes lacking in administrative capabilities, geographically isolated tribes with transportation and recruitment issues, and tribes with funding issues may find it much harder to contract with the IHS and begin self-determination.[54] Poverty and a lack of resources can thus make Self Determination difficult.[55]
Current issues[edit]
Life expectancy for Native Americans is approximately 4.5 years less than the general population of the United States (73.7 years versus 78.1 years).[1] Native communities face higher rates of chronic diseases like cancer, diabetes, and kidney disease.[64] This is contributed to by the lack of public health infrastructure as well as the considerable distance to healthcare facilities for rural residents.[65]
In 2013, the IHS experienced funding cuts of $800 million, representing a substantial percentage of its budget.[66][67] Over the past twenty years, the gap between spending on federally recognized American Indian/Alaska Natives and spending on Medicare beneficiaries has grown eightfold.[68] This inequity has a large impact on service rationing, health disparities and life expectancy, and can lead to preventive services being neglected. Other issues that have been highlighted as challenges to improving health outcomes are social inequities such as poverty and unemployment, cross-cultural communication barriers, and limited access to care.[69]
Data from the 2014 National Emergency Department Inventory survey showed that only 85% of the 34 IHS respondents had continuous physician coverage.[70] Of these 34 sites, only 4 sites utilized telemedicine[70] while a median of just 13% of physicians were board certified in emergency medicine.[70] The majority of IHS emergency department from the survey reported operating at or over capacity.[70] Tribal reservations are often sequestered in unfavorable and isolated locations.[71] According to a study of provider vacancies in the IHS, conducted by the Department of Health and Human Services (2016), about half of the clinics studied identified their remote location as a large obstacle for hiring and retaining staff.[71] Issues surrounding isolation, lack of shopping centers, schools, and entertainment also dissuades providers from moving to these areas. Such vacancies lead to cutting of patient services, delays in treatment, and negative effects on employee morale.[72] Studies show that such problems surrounding Native Americans and reservation inequality may be addressed by growing a Native American healthcare workforce.[73]
Since its beginnings in 1955, the IHS has been criticized by those it serves in medical deserts and by public officials.[74][75][76][77]
Individuals who are not of citizens of federally recognized tribe or who live in urban areas may have trouble accessing the services of the IHS.[3]