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Learn from the Tribes to Reform the Indian Health Service

When it comes to Indian Health Service too much effort is spent on complicated financial reporting requirements rather than quality of care.
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The Indian Health Service (IHS) has long been a source of frustration and anger for American Indians and Alaska Natives (AI/AN). Chronically under-funded, short-staffed and sometimes badly-staffed, it has often felt more like a broken promise than a source of quality, culturally appropriate care. I am not AI/AN but I did spend more than seven years in the Obama Administration working on IHS issues and heard time after time from tribal leaders about the difficulties their people faced with IHS.

We tried to make things better at IHS, including significant funding increases plus the benefits for AI/AN from the Affordable Care Act, such as expanded access to Medicaid. But serious problems remain, particularly at some of the hospitals and clinics in the High Plains, such as Winnebago, Rosebud, and Pine Ridge. Members of Congress are right to demand improvement, such as Restoring Accountability in the Indian Health Service Act, introduced by Senators Barrasso, Thune, and Hoeven. It will make it easier for IHS to get rid of doctors and nurses who should not be practicing. It also takes steps to improve pay. It contains a number of useful provisions. But I fear it will be insufficient, in part because funding remains short but also because it does not tap into other sources of Native experience – the tribes that already run their own hospitals and clinics.


Today, more than half of IHS funds go to tribes to manage and to see facilities are entirely tribally-operated. They do not need to follow current federal rules that govern “direct service” IHS facilities. They are free to innovate and experiment. As Mark Trahant recently wrote:

IHS is no longer only a government-run system. Much of the agency is now a funding mechanism for tribal, nonprofit, and urban operations. And that’s where so much of the innovation and excellence in Indian health exists. We need to know more about what’s working and why. Yet Congress (and the public narrative) continue to think of an IHS that no longer exits. At least entirely.

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The federal part of IHS has relatively little knowledge of which tribally-operated facilities are the best – most of the interaction involves the complicated financial reporting requirements related to federal auditing, not around the quality of the medical care provided. So a more extensive effort is required to learn the best practices in Indian health that have been developed.

So far there has been little effort to seek out this wisdom. Understandably, the tribes that have been directly impacted by poor care were invited to the Congressional hearings to describe their experiences and give their recommendations. Those are vital but we should learn from the places doing Indian health right as well as from those tribes that have suffered from where it has been done badly.

Congress should establish a commission with leading experts on Indian health care from the self-governance tribes and task it with providing advice from their experience. How do they recruit and retain providers? How do they infuse their care with tribal culture and practices? How do they deal with doctors who are not doing quality work? How do they use technology to bring care to rural communities? What are the best ways to incorporate an understanding of historical trauma into the provision of health care? The list of key questions is long and requires an in-depth exploration to address.

The tribes running their own facilities have extensive experience facing up to the same challenges that the direct service hospitals and clinics have – it’s time to learn from them how to remake IHS so that it provides more of the quality care its patients deserve.

Doug Steiger is a public policy consultant, focused on social services such as child welfare, early childhood development, and other anti-poverty programs. He was the Counselor to the Secretary for Human Services at the Department of Health and Human Services from November 2012 until January 2017.