An open access publication of the American Academy of Arts & Sciences
Spring 2018

The Story of Indian Health is Complicated by History, Shortages & Bouts of Excellence

Mark Neil Trahant
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One of the primary goals of the U.S. government’s entry into health care was to protect soldiers by isolating tribal populations and inoculating them against infectious disease. When tribes signed the legally binding treaties, the United States promised them doctors, nurses, facilities, and basic health care. Yet this promise has never been fully funded by Congress. The Indian Health Service, which includes tribal and nonprofit health agencies, is tasked with defying gravity, and this has led to a regular cycle of heartbreaking stories about a system that fails American Indian and Alaska Native patients. Yet, at the same time, the Indian health system has achieved remarkable innovation and excellence.

MARK N. TRAHANT, a Fellow of the American Academy since 2017, is an independent journalist. He is the former Editorial Page Editor of the Seattle Post-Intelligencer and a Kaiser Family Foundation Media Fellow. He is the author of The Last Great Battle of the Indian Wars (2010) and Pictures of our Nobler Selves: A History of Native American Contributions to News Media (1996) and has contributed to such collections as Lewis and Clark through Indian Eyes: Nine Indian Writers on the Legacy of Expedition (ed. Alvin M. Josephy, 2006).

Every so often, the “story” of Indian health is told by a news organization. For example, The Wall Street Journal reported the death of several Native American patients in Pine Ridge and Sisseton, South Dakota, and Winnebago, Nebraska: “In some of the nation’s poorest places, the government health service charged with treating Native Americans failed to meet minimum U.S. standards for medical facilities, turned away gravely ill patients and caused unnecessary deaths, according to federal regulators, agency documents and interviews.” The report adds that the Indian Health Service (IHS) “operates a network of hospitals and clinics, much like the Veterans Health Administration. Under U.S. treaties that date back generations, the service is legally responsible for providing medical care to about 2.2 million tribal members. But that system has collapsed in the often-remote corners of Indian Country, where patients live hours from other medical providers, often have no insurance and depend on the federal service.”1  A few days later, at a budget hearing on Capitol Hill, a number of senators weighed in on The Wall Street Journal report. “The stories are heartbreaking,” said Senator Lisa Murkowski, R-Alaska, chair of the Appropriations subcommittee that funds Indian health programs. She added that though the then-Acting Director of IHS, Mary Smith, had indicated that “the agency was committed to doing ‘whatever it takes’ to deliver quality care,” Murkowski still found that serious problems continued, including hospitals operating without having received recertification from the Center for Medicare and Medicaid Services despite an additional $29 million approved to address these problems.2  Murkowski stated that she was “very concerned” that the Trump budget request

does not adequately meet the needs for health care in Indian Country. The disparities between health outcomes for American Indian and Alaska Native people compared to the population at large are staggering. For example, American Indians and Alaska Natives are three times more likely to die from diabetes. The drug-related death rate for Native Americans has increased 454 percent since 1979 to almost twice the rate for all other ethnicities. And, the suicide rate among our First Peoples is roughly twice that for the rest of the population. In order to improve health care delivery, the IHS must do a better job at hiring and retaining an adequate number of qualified doctors and nurses. The IHS must also do a better job of maintaining a large facilities infrastructure that serves 2.2 million American Indians and Alaska Natives. This requires significant resources. Currently, the vacancy rate for Indian Health Service doctors, dentists, and physician assistants is roughly 30 percent. The backlog of facilities maintenance at IHS hospitals is over half a billion dollars, and according to the agency’s own budget documents, the average age of its facilities is roughly four times that of its private sector counterparts. Additional resources are not the only answer–the agency must also do more to improve the quality of its existing work force.3

Another member of the subcommittee, Jon Tester, D-Montana, was frustrated by the administration’s budget request and the refusal of the agency’s current acting head, Michael Weahkee, to admit whether there would be an increase or a decrease in the agency’s ability to hire staff. When questioned directly about the budget, Weakhee replied only that the IHS was prioritizing “maintaining direct care services.”4 But this was not an isolated incident; there has been a long history of Indian Health Service directors who were unable or unwilling to answer that question. If we consider the Senate exchanges as a story, it becomes one that tells of incompetence, poor management, too few doctors, and, most certainly, not enough money.

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  • 1Dan Frosch and Christopher Weaver, “‘People Are Dying Here’: Federal Hospitals Fail Tribes,” The Wall Street Journal, July 7, 2017.
  • 2Subcommittee on the Department of the Interior, Environment, and Related Agencies, Chairman Lisa Murkowski Opening Statement, “Review of the FY2018 Budget Request for the Indian Health Service,” July 12, 2017, doc/071217-Chairman-Murkowski-Opening-Statement.pdf.
  • 3Ibid.
  • 4Subcommittee on the Department of the Interior, Environment, and Related Agencies, “Review of the FY2018 Budget Request for the Indian Health Service,” July 12, 2017, https://www -health-service.