A common misconception about Native American communities is that their health care needs are covered in full by the federal government. A trust agreement was created between the United States and Tribal communities that have been sourced through various treaties, laws, executive orders and court decisions, which provide federally recognized Tribal members a legal right to health services. Indian Health Services (IHS), an agency of the Department of Health and Human Services, was created to provide comprehensive health services to Tribal communities, serving approximately 2.6 million American Indian and Alaska Native people who belong to 574 federally recognized tribes in 37 states. IHS may provide service directly through IHS-operated facilities and their Urban Indian Program clinics or provide financial support to Tribally-run health care centers. However, IHS has been chronically underfunded and understaffed for decades. In 2017, the Government Accountability Office (GAO) found that IHS per capita spending was $4,078 compared to $8,109 for Medicaid, $10,692 for VHA, $13,1285 for Medicare, and $8,600 for federal prisoners.  

Since IHS operates on annual appropriations, community members are often forced to postpone services for the next fiscal year when funding has been depleted, and the amount of IHS funding is subject to change on an annual basis with discretion from Congress. Tribal leaders and allies have rightly criticized the federal government for clearly violating their promises and not honoring treaties to provide health care. Additionally, a long history of insufficient care, exploitation and discrimination have caused Native Americans to suffer worsened health outcomes such as higher rates of chronic health conditions. Many Tribes have taken initiative to develop their own public health programs to address these health disparities. 

Community Story shared by New Mexico Together for Healthcare

Cecelia Fred became a paraplegic as a result of a gun accident when she was a child. At that time, specialists from Craig Hospital, a rehabilitation hospital in Denver that helps people with spinal injuries came to New Mexico to care for her. Over the years, the specialists stopped coming and doctors at the Gallup Indian Medical Center didn’t know how to care for her. She received a new plan through Medicaid and struggled to understand how it worked and what was covered. Indian Health Services doesn’t provide all the supplies she needs and unfortunately Cecelia has to pay for catheters out-of-pocket. Read Cecelia’s full story here.

Many families have moved away from reservations, which has presented unique challenges to accessing care. However, access to care has been difficult within reservations as well. Although the Urban Indian Program offers some care points, it still does not provide sufficient access. Native American members who have no choice but to receive care outside of IHS system have to petition for reimbursement from IHS, but severely limited funding cannot cover the cost of care to all who need it. The New York Times found that since 2016 – 2019, IHS has declined to pay medical bills for more than 500,000 patients, resulting in more than $2 billion in medical debt. The COVID-19 pandemic exacerbated the weaknesses of IHS, and Native American communities that were already at high risk with underlying health issues suffered devastating losses and likely accumulated disproportionate levels of new medical debt. The Affordable Care Act helped expand Medicaid coverage to over 300,000 Native Americans, but more support is needed in helping patients understand their coverage and navigate systems. However, many Tribal leaders have argued that the promise of health care did not include burdensome demands that arise from Medicare and Medicaid registration and enrollment.  

The community story shared from New Mexico Together for Healthcare shines a light on how the lack of funding at IHS can pass on out-of-pocket health care expenses to patients. However, data on Native American communities is very limited. The true impact of medical debt in Native American communities is still unclear. The quality of data collected may be limited due to the lack of administrative capacity at IHS facilities and data collected from Tribally-operated health systems may go unreported. In April 2022, the Biden administration’s FY2023 budget request included a historic $9.1 billion in mandatory funding to IHS, which is subject to growth along with health care costs. Mandatory funding for IHS would allow for long-term planning of health programming, improve access to quality care, address health inequities, and finally rectify historical underfunding that drives medical debt in the community. However, Biden’s announcement is subject to approval from Congress. We must encourage our lawmakers to work in collaboration with Tribal leaders to approve mandatory funding and invest in adequate data collection to deliver on a long-overdue commitment to the health of our Tribal nations.