The Indian Health Service is technically responsible for providing healthcare to enrolled tribal members. In practice, it’s a underfunded, understaffed system delivering substandard care to populations with some of the worst health outcomes in the country. Let’s break down how the U.S. government continues to fail treaty obligations while Native people suffer and die from preventable causes.
The Treaty Obligation
Healthcare for Native Americans isn’t charity—it’s payment for land. Treaties promised healthcare in exchange for territory. The federal government took millions of acres and has consistently failed to uphold its end of the bargain. Current IHS funding is a fraction of what’s needed to meet healthcare needs.
The United States spends more per capita on healthcare for federal prisoners and military members than it does on IHS patients. Let that sink in—the government values imprisoned people over the original inhabitants whose land was stolen through broken promises.
Funding Shortfalls
IHS is chronically underfunded. The system serves over 2.6 million people across 574 tribes with a budget that works out to around $4,000 per person annually. For comparison, Medicare spending averages about $14,000 per person.
This funding gap means:
- Facilities with outdated equipment
- Insufficient staffing
- Limited specialty services
- Long wait times for appointments
- Inability to provide comprehensive care
- Forced rationing of services
When money runs out during the fiscal year, services get cut. Dental care stops. Elective procedures get cancelled. People wait months or longer for appointments.
Geographic Barriers
Many tribal communities are in remote locations, hours from the nearest IHS facility. Getting care means taking time off work (if you have work), finding transportation, possibly traveling overnight, and potentially missing multiple days for a single appointment.
Specialty care is often unavailable at local IHS facilities. Patients need referrals to off-reservation providers, which requires pre-authorization, adds travel costs, and creates bureaucratic nightmares. Emergency care might be accessible, but follow-up care isn’t.
Health Disparities
Native Americans face staggering health disparities:
- Higher rates of diabetes, with some communities experiencing rates 3-5 times the national average
- Infant mortality rates 60% higher than whites
- Life expectancy several years shorter than the general population
- Higher rates of substance abuse and mental health issues
- Greater prevalence of chronic diseases
- Elevated rates of suicide, particularly among youth
These disparities aren’t genetic or cultural deficiencies—they’re direct results of poverty, inadequate healthcare access, historical trauma, and ongoing oppression.
Behavioral Health Services
Mental health and substance abuse services through IHS are woefully inadequate. Many facilities lack psychiatric services. Substance abuse treatment programs are underfunded and overwhelmed. Culturally appropriate mental health care is rare.
Historical trauma—the compounding effects of genocide, forced relocation, boarding schools, and ongoing discrimination—affects mental health across generations. Addressing this requires culturally grounded treatment that IHS often can’t provide.
Suicide rates among Native youth are alarmingly high. Prevention programs exist but are chronically underfunded. When young people in crisis reach out for help, services often aren’t available.
The COVID-19 Impact
The pandemic devastated tribal communities. Initial government response was slow and inadequate. Native Americans had infection and death rates far exceeding their population percentage. Tribal nations had to organize their own responses, sometimes in conflict with state governments denying their sovereignty.
The pandemic exposed and exacerbated existing healthcare infrastructure weaknesses. It also demonstrated what’s possible—when additional funding flowed during the crisis, tribal health systems proved capable of organizing effective responses including vaccination campaigns that outpaced many states.
Maternal and Infant Health
Native women face maternal mortality rates twice that of white women. Prenatal care access is limited. Hospitals serving tribal areas may lack obstetric services, forcing pregnant women to travel long distances. Postpartum care is often inadequate.
Cultural practices around pregnancy and childbirth aren’t always respected in non-Native healthcare settings. Traditional birth workers face barriers to practicing. The medicalization of childbirth can conflict with cultural values around the sacred nature of bringing life into the world.
Elder Care
As the Native population ages, elder care needs increase. Long-term care facilities are limited on reservations. Cultural preferences for family caregiving are challenged by economic realities requiring working-age adults to be employed off-reservation. End-of-life care often doesn’t incorporate traditional spiritual practices.
Elders carry cultural knowledge that must be passed down. When they’re isolated in facilities far from family and community, this transmission is interrupted. Healthcare for elders should support their role as knowledge keepers while meeting medical needs.
What Needs to Change
IHS funding must be increased dramatically and guaranteed to meet actual healthcare needs, not what Congress decides is sufficient. Healthcare facilities need modernization. Staffing must increase with competitive salaries attracting and retaining qualified providers. Services must expand to include comprehensive specialty care.
Culturally competent care must be standard. Traditional healing practices should be integrated where appropriate. Native healthcare professionals should be recruited and supported. Tribes must have more control over their healthcare systems.
Tribal Self-Determination
Some tribes have opted for self-governance, taking control of their healthcare systems through contracts with IHS. Results have been mixed—tribes gain control but still face funding limitations. Successful programs demonstrate that tribal management can be more effective than federal control when adequate resources are provided.
Sovereignty means tribes should control their own healthcare. Federal government’s role should be fulfilling treaty obligations through funding, not micromanaging how care is delivered.
Medicaid and Insurance
Many Native people qualify for Medicaid, which can supplement IHS services. However, Medicaid expansion wasn’t adopted in all states, leaving some tribal members without access. Private insurance is unaffordable for many on reservations where employment is limited.
Complex interactions between IHS, Medicaid, and private insurance create confusion and barriers. Patients shouldn’t need to navigate bureaucratic mazes to get healthcare guaranteed by treaty.
The Path Forward
Healthcare is a treaty right, not a benefit. The federal government must fully fund healthcare for Native Americans. Period. This isn’t about charity—it’s about honoring agreements made in exchange for land.
Beyond funding, systemic changes are needed. Traditional healing must be respected. Cultural practices must be incorporated. Native healthcare professionals must be trained and supported. Communities must have voice in how healthcare is delivered.
What You Can Do
Advocate for full IHS funding. Contact representatives demanding treaty obligations be honored. Support organizations working to improve Native healthcare. Recognize that healthcare disparities killing Native people are policy choices, not inevitabilities.
If you work in healthcare, educate yourself on issues facing Native patients. Push your institution to provide culturally competent care. Support tribal partnerships. Advocate for Native students in healthcare education programs.
The healthcare crisis in Indian Country is genocide in slow motion—people dying from preventable causes because the government won’t honor promises made for the land you live on. That should make you angry. Turn that anger into action demanding change.
Native people deserve healthcare that works. They’ve paid for it many times over with land, with trust, with lives. The crisis continues because fixing it isn’t a priority for those in power. Make it a priority. Demand better. Native lives depend on it.
If you’re struggling, you don’t have to carry it alone. In the U.S., call or text 988 to reach the Suicide & Crisis Lifeline any time (press 2 for Spanish), text HOME to 741741 for the Crisis Text Line, or, for LGBTQ+ young people, contact The Trevor Project. If you’re in immediate danger, call 911.
