Opportunities for Change: Improving the Health of American Indians/Alaska Natives in Washington State docx

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OpportunitiesforChange:



Improving the Health of
American Indians/Alaska Natives
in Washington State


AmericanIndianHealthCareDelivery
Plan
2010‐2013






April2010

American Indian Health Commission for
Washington State

Acknowledgements
Publicationofthe2010–2013AmericanIndianHealthCareDeliveryPlanwouldnothave
beenpossiblewithoutthecontributionsandsupportofthefollowingorganizations:
TheAmericanIndianHealthCommissionofWashingtonState
TheWashingtonStateDepartmentofHealth
TheUrbanIndianHealthInstitute–SeattleIndianHealthBoard
Northwest
PortlandAreaIndianHealthBoard
Thefollowingservedaseditors,contributors,andprovideddraftingassistance:
AmericanIndianHealthCommissionOralHealthCareWorkgroup
AmericanIndianHealthCommissionMaternal‐InfantHealthWorkgroup
AmericanIndianHealthCommissionMentalHealthWorkgroup
AmericanIndianHealthCommissionLong‐TermCareWorkgroup
AmericanIndianHealthCommissionExecutiveCommittee
SherylLowe,executivedirector,
AmericanIndianHealthCommission
KrisLocke,ruralhealthconsultant,AmericanIndianHealthCommission
KrisSparks,DepartmentofHealth’sOfficeofCommunityHealth
Systems/RuralHealth
ZeynoShorter,PhD,ruralhealthepidemiologist,DepartmentofHealth
JenniferSabel,PhD,injuryepidemiologist,DepartmentofHealth
NancyAnderson,MD,MPHFaculty,EvergreenStateCollege
Laurie
Cawthon,MD,WashingtonStateDepartmentofSocialandHealth
Services
JoseliAlves‐Dunkerson,DDS,manager,DepartmentofHealthOralHealth
Program
JosephCampo,WashingtonStateOfficeofFinancialManagement
RalphForquera,executivedirector,SeattleIndianHealthBoard

RachelBrucker,epidemiologist,UrbanIndianHealthInstitute
AlicePark,epidemiologist,UrbanIndianHealthInstitute

JimRoberts,policyanalyst,NorthwestPortlandAreaIndianHealthBoard
JoshuaD.Jones,MD,epidemiologist,PortlandAreaIndianHealthServices
AMERICANINDIANHEALTHCOMMISSIONmembers:
ChehalisTribe ColvilleConfederatedTribes CowlitzIndianTribe
JamestownS’KlallamTribe KalispelTribe LowerElwhaKlallamTribe
LummiTribe MakahTribe MuckleshootTribe
N.A.T.I.V.E.Project NooksackTribe PortGambleS’KlallamTribe
PuyallupTribe QuinaultNation QuileuteTribe 
SamishNation Sauk‐SuiattleIndianTribe SeattleIndianHealth
Board
ShoalwaterBayTribe SkokomishTribe SnoqualmieNation
SpokaneTribe SquaxinIslandTribe StillaguamishTribe  
SuquamishTribe SwinomishTribe TulalipTribe
UpperSkagitTribe

AmericanIndianHealthCareDeliveryPlan2010‐2013

TableofContents

LetterfromChairwomanScottandSecretarySelecky
 Page

I. ExecutiveSummary 2

II. HealthDisparitiesandServiceDelivery 7
 A. TheAmericanIndianHealthCareDeliveryPlan 7
 B. TheAmericanIndianHealthCommission:ATribal‐stateModelof

Collaboration 8
 C. TheIndianHealthDeliverySystem……. 9
 D. UrbanIndian
HealthPrograms 15
 E. HealthDisparitiesandAmericanIndians/AlaskaNativesinWashington 20

III. OpportunitiesforChange 23
A. State‐Tribal‐UrbanIndianHealthCollaborative 23
B. IndianHealthDataCollaboration 25
C. National,Tribal,andstateHealthReform 26

IV. 2007–
2009IndianHealthAccomplishments 29

V. 2009–2011GoalsandObjectives 31
1 TribalForumforImprovingAI/ANHealth 31
2 ImprovedMaternalandInfantHealth 34
3 Long‐TermCareDeliverySystemsinIndianCountry 37
4 OralHealthCareAccess 39
5 AI/ANAccesstoMentalHealthServices 49

VI. TribalHealthProgramsinWashingtonState 56


Attachments
A:AcronymsReference


Opportunities for Change: Improving the Health of AI/ANs in WA State Page 1
2010-2013 American Indian Health Care Delivery Plan

OpportunitiesforChange:



“Formorethanfourteenyears,Congresshasfailedto
reauthorizetheIndianHealthCareImprovementActand
comprehensivelymodernizeNativeAmericanhealthcare
services.Thisisunfairandunacceptable.

Today’sNativeAmericansaredisproportionatelysuffering
fromdebilitatingillnesses,likediabetes,heartdiseaseand
stroke.Theinfantmortalityrateis
150percenthigherfor
NativeAmericaninfantsthanwhiteinfants,andthesuicide
rateforNativeAmericansistwoandahalftimesthenational
rate.Withthesealarmingstatistics,improvementstoNative
Americanhealthcarecouldnotcomeatamoreurgenttime.”

‐ThenSenatorBarackObama
January18,2008;U.S.SenateFloor









Opportunities for Change: Improving the Health of AI/ANs in WA State Page 2
2010-2013 American Indian Health Care Delivery Plan


I. ExecutiveSummary

TheAmericanIndianHealthCareDeliveryPlan(hereinafterreferredtoas“theplan”)is
acollaborativeeffortbetweenWashingtonStateDepartmentofHealth,theAmerican
IndianHealthCommissionforWashingtonState(AIHC),andWashingtonStateTribes.
Since1997theplananditssubsequentupdateshasservedasaframeworkfor
Tribes,
UrbanIndianHealthOrganizations(UIHO),thecommission,andWashingtonState
(hereinafterreferredtoas“thestate”)toaddressasharedgoalofimprovingthehealth
statusofAmericanIndian/AlaskaNativepeople(AI/AN).Overthepast12yearsmuch
hasbeenaccomplished,yetmoreworkremains.WhiletheoverallhealthofAI/ANs
slowlyimprovesovertime;thesignificantgapinhealthoutcomesbetweenAI/ANand
otherpopulationshasnotsignificantlychanged.

Today,thestate,Tribes,andUrbanIndianHealthOrganizationsfaceextraordinary
challengesinproactivelyaddressinghealthissuesastheygrapplewiththeimpactsofa
nationalrecessionunlikeanyseeninmanyyears.Whilethesechallengesaredaunting,
theyalsopresentuniqueopportunitiestoredefinetheapproachesusedtoaddress
Indianhealthdisparitiesandtoimprovecollaborationacrossmultiplesystems,
governments,organizations,infrastructures,andpolicies.Leadershipandpartnerships
aremoreimportantthanever,notonlytosurvivethecurrentcrisis,buttocontinue
movingforwardwiththecomplexworkinaddressinghealthdisparitiesandwisely
leveraginglimitedresourcesavailabletodoso.

Overthenextfouryears,Tribes,theAmericanIndianHealthCommission,Department
ofHealth,theGovernor’sOffice,theWashingtonStateHealthCareAuthority(HCA),and

WashingtonDepartmentofSocialandHealthServices(DSHS)willworktoaddress
tribally‐identifiedpriorityhealthissuesincollaborationwithotherstateagenciesand
stakeholdersthatsharesimilargoals.Atthesametime,amoretargetedeffortwillbe
launchedtodeterminethetrueextentofhealthdisparitiesfortheoverallstateAI/AN
populationinthe21
st
century.Throughamoresystematicassessmentofthecurrent
healthstatusofAI/ANandtheenvironmentsandsystemsinwhichTribalhealth
programsfunctiontoday,wecanbegindevelopingastronger,strategicframeworkfor
addressingfuturepriorityareas.Theultimategoaloftheseeffortsistoclosethegap
between
goodhealthoutcomesandincreasedmortalityforWashington’sAI/AN
populationanddevelopmorecomprehensiveservicesinTribalcommunities.



Opportunities for Change: Improving the Health of AI/ANs in WA State Page 3
2010-2013 American Indian Health Care Delivery Plan
InSectionI,HealthDisparitiesandServiceDelivery,amoredetailedlookattheplan
anditshistoryisprovidedinordertoemphasizeitsimportanceinon‐goingtribal‐state
workonIndianhealthissues.Theplan,mandatedbytheWashingtonLegislaturein
1995,isanimportantblueprintforaddressingthepoorhealthstatusofAmerican
IndianandAlaskanNativesinacollaborativeandstrategicmanner.

Theplanisdevelopedthroughaunique,Tribally‐drivenprocess.Everyotheryear,
AmericanIndianHealthCommissionhostsaTribalLeadersHealthSummittoshape
strategiesforaddressingidentifiedpriorityhealthissuesonwhichthecommissionwill
workoveratwo‐tofour‐yearperiodoftime.Triballeadersandcommissiondelegates
definethosepriorityareaspriortothesummit,andAIHCcreatesworkgroupsaround
eachtopic,workgroupsthatincludeTriballeaders,Tribalhealthproviders,Tribalhealth

policyexperts,AIHCdelegates,stateleadersandstatehealthexperts.Workgroups
developdraftpositionpapersonthepriorityissuesidentifiedwithrecommended
strategiesonhowtoresolvetheissuescollaboratively.Thepapersarepresentedand
discussedatthesummits,revisedandapprovedbytheAIHCdelegates.Thesepapers
serveastheframeworkforsubsequentplans.

AIHCismorethoroughlydiscussedinSectionIforitsuniquenessasastate‐Tribal
modelforhealthcollaboration.AIHC’smissionistoimprovethehealthofAI/ANpeople
throughtribal‐statecollaborationonhealthpoliciesandprogramsthatwillhelp
decreasedisparities.Thecommissioncontinuestoserveasaneffectiveforumfor
achievingunityandguidingthecollectiveneedsofTribalgovernmentsandurban
Indianhealthprogramsinprovidinghigh‐quality,comprehensivehealthcaretoAI/ANs
inWashington.

SectionIalsodescribestheexistingIndianhealthcaredeliverysystem.Thefederal
government’sobligationtoprovidehealthcareservicestoAI/AN,explicitinsome
treaties,hasbeensetforthinaseriesoffederallaws,executiveordersandcourt
decisions.ThelandmarkSnyderActof1921,wasthefirsttimeCongressenacted
legislationpermanentlyauthorizingappropriationsforAmericanIndianhealthcare.In
presentday,theIndianSelf‐DeterminationandEducationAssistanceActof
1975(P.L.
93‐638)–authorizingthefederalIndianHealthService(IHS)toturnoverfull
administrativeresponsibilityforIHSprograms,throughcontracts,totribesupontheir
request‐andtheIndianHealthCareImprovementActof1976(P.L.94‐437)–
authorizingaseriesofhealthprogramsbasedona“community
healthmodel”
approachanddirectingincreasedappropriationsforsuchprograms–andtheir
subsequentamendments,nowguidethedeliveryofhealthservicestoIndianpeople.
TribescanoperatehealthprogramsthroughTitleIofP.L.93‐638andcontractwithIHS,

Opportunities for Change: Improving the Health of AI/ANs in WA State Page 4
2010-2013 American Indian Health Care Delivery Plan
orunderTitleIII,andentercompactswiththefederalgovernmenttoassumefull
responsibilityforhealthprograms.Indianhealthprogramsprovideprimary,
environmental,community,andcontracthealthservicesthroughprogramseither
operatedbythefederalgovernmentthroughtheIHS,bylocaltribalgovernment,orby
urbanIndianhealthorganizations.The
systemiscomplexyetimportanttounderstand
inthecontextofIndianhealthstatustoday.

SectionIalsodescribesingreaterdetailtheUrbanIndianProgramanditsdelivery
system.ManyAI/ANliveinurbanareasandarenoteligibleforhealthservicesinthe
samewayinwhichreservation‐
basedAI/ANare.UrbanIndianProgramswarrant
attentionastheseservicesareseverelyunderfundedandtheneedsareasgreatas
thoseforreservation‐basedIndianpeople.

IndianhealthdisparitiesarealsoexploredinSectionI.AlthoughAmericanIndians
compriseonlyabouttwopercentofWashington’spopulation,theirsignificanthealth
careneedsanduniquelegalstatuswarrantpublicattention.AmericanIndianand
AlaskanNativesinWashingtonexperiencedisproportionatelyhighmortalityand
morbiditycomparedtothegeneralpopulation.Datafrom2003‐2007indicatethat
AI/ANshavethehighestmortalityratesforallcausesthananyotherpopulationinthe
state,
1
withspecificcausesincludingbutnotlimitedtosuicide,injury,chronicliver
disease,ChronicObstructivePulmonaryDisease,andheartdisease.

WhileprogresshasbeenmadeinimprovingthehealthofAI/ANoverthelast30years,

thegapinhealthoutcomesremains.Atargetedcommitmentandeffortisneededin
ordertoensurethisgapiseliminated.ThestateandTribeswillworktogetherto
implementeffectivepublichealthprograms,diseasepreventionandtreatment
strategies,andpursueadequatelevelsofresources,bothfinancialandprofessional.
Theongoinggovernment‐to‐governmentrelationshipcontinuestoraisetheissueof
improvingthestatusofAmericanIndianandAlaskanNativesasamutualpriority.

SectionII,OpportunitiesforChangedescribesthreeinitiativesthatprovidethe
potentialforfurtherreducingAI/ANhealthdisparitiesanddevelopingpoliciesthat
improvetheabilityofTribestoprovideneededservicesintheircommunities.Withthe
economicchallenges
wefacealsocomeopportunitytorethinkourapproachesto
overallimprovedhealth,andinparticular,Indianhealth.Duringthistime,thereare
opportunitiesforclearlyformulatingasharedvisionandmissionandtoimplement
strategiesthatlookbeyondthecrisisoftoday.



1
WashingtonStateVitalStatistics2006.AnnualReport.CenterforHealthStatistics,Olympia,WA.
January2009


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2010-2013 American Indian Health Care Delivery Plan
First,aState‐Tribal‐UrbanIndianHealthCollaborativehasbeenre‐institutedata
state/triballeaderpolicylevelforaddressingappropriatesystemschangeandpolicy
decisionsthatneedtobemadetochangehealthoutcomesforIndianpeople.This
group—comprisedoftribalgovernments,healthstaff,andstateleadersacross
multiplesystemsanddepartments—willbestrategicallyaligningstatewideIndian

healthdisparitiesworkwithGovernorGregoire’s5‐PointHealthCareInitiative.Thiswill
allowthegrouptoleverageexistingresources,maximizethelimitedfundscurrently
available,andcreatetheinfrastructurenecessarytofurtherreduceIndianhealth
disparitiesinthefuture.

Second,severalagencies,organizations,andinstitutionshaveexpressedarenewed
interestincomingtogethertodevelopamorecompletesetofAmericanIndianhealth
statusdata.Accuratedataisnecessarytosupportcommunityhealthassessmentsand
policydevelopmenttoimproveservicedeliveryandhealthstatusofIndianpeople.
WithoutpaintingamorethoroughpictureofIndianhealthinWashingtontoday,the
abilitytoplanorimproveservices,monitorquality,andanalyzecostsisseverely
impaired.Tribalgovernmentsmustbeintricatelyinvolvedinsucheffortstoassurethe
useofthedataisculturally‐appropriate,acceptable,andmeaningfulinimprovingthe
healthoftheirpeople.Byreinstitutingeffortsthatbeganin1997betweenthe
AmericanIndianHealthCommissionandWashingtonStateDepartmentofHealth
throughanAmericanIndianDataCommittee,anupdatedframeworkcanbedeveloped
foraddressingpriorityhealthissuesforAI/AN.

Third,sweepingnationalhealthreformandthecurrentadministrationofferaunique
opportunityforchangeinhowhealthcareisprovidedtoAI/ANs.AsIndianhealth
leadershipsuchastheU.S.IndianHealthServices,theNationalIndianHealthBoard,
andmoreregionally,theNorthwestPortlandAreaIndianHealthBoard,strongly
advocatesfortheinclusionofIndianhealthreforminnationalreformstrategies,the
stateisalsorethinkinghowitprovidesquality,affordable,andcost‐effectivehealth
caretoitscitizens.Thestate,Tribes,andthecommissionwillactivelypartnerinthese
effortstoaddresstheneedforAI/ANincreasedaccesstoexistingservices,increased
Tribalproviderreimbursementopportunitiesso
culturally‐appropriateservicescanbe
providedinTribalcommunities,anddevelopmechanismsforevaluatingprogressfor
improvedIndianhealthstatus.


SectionIII,2007‐2009Accomplishments,highlightssomeofthemajorachievements
madeforIndianhealthinthestatesincethelastplanwaspublishedin2007.Additional
partnershipshavebeendeveloped,keypolicyissueshavebeenaddressed,andthere


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2010-2013 American Indian Health Care Delivery Plan
areanincreasednumberofTribalrepresentativesservingonrelevantstate
committeesandtaskforces.

SectionVI,GoalsandObjectives,identifiesthepriorityissueareastargetedtobe
addressedoverthenextfouryears.ThegoalsarethosethatAIHC,Tribes,UrbanIndian
HealthOrganizations(UIHO),andthestatewillworktogetherontofurtherthemission
ofeliminatingIndianhealthdisparities.Thefirstcomponent,TribalForumfor
ImprovingAI/ANHealth,focusesonstrategiestostrengthenthecollectivevoicefor
TribesandUrbanIndianHealthProgramstogreaterinfluencehealthpolicyandassure
fullaccessbyAI/ANstohealthservicesandprogramsinthestate.Thisgoalalso
includeseffortstodevelopandimplementstrongerstrategiesforaddressingIndian
healthdisparitiesandthedevelopmentofmoreeffectivecommunicationavenues
betweenTribesandthestatesoTribesareawareofemergenthealthnews,
information,andopportunities.Whileplansinthepasthaveservedwellininforming
individuals,Tribes,andorganizationsonthepoorstatusofIndianhealthand
identifyingpolicyworkbeingaccomplished,furthercollaborativeconversationsand
effortsacrosstribes,systems,organizations,andresearchinstitutionsmustbepursued
tostrategicallyaddressthesedisparities.Thiscomponentoutlineshowthatmight
begintobeaccomplishedoverthenextfouryears.

Thefourhealthpriorityareas—Maternal‐InfantHealth,Long‐TermCare,OralHealth,
andMentalHealthservices—wereidentifiedatthe2008TribalLeadersHealth

Summitandserveastheareasofdisparitiesfromwhichthebroaderworkdescribed
abovecouldbeshaped.Eachpriorityareaincludes:(a)Goalstatement;(b)Problem
statement;(c)Anysupportingdata;and(d)Strategies(objectives)foraddressingthe
problem.ThestrategiesarerecommendationsdevelopedinAmericanIndianHealth
CommissionpositionpapersattheTribalLeadersHealthSummitinNovember2008
andsubsequentlyapprovedbycommissiondelegatesin2009.Atargetedfocusinthese
fourpriorityTribalhealthareaswillallowustonotonlydevelopsolutionstothese
specificproblems;itwillalsoserveasawaytofurtherdefinetheprocessbywhich
additionalIndianhealthdisparitiescanbeaddressedinthefuture.Thestrategies
identifiedin
thissectionwillbepursuedbasedonresourceavailabilityineacharea.

Thefinalsection,TribalHealthProgramsinWashingtonState,providesspecific
informationaboutexistingTribalandUrbanIndianhealthprogramsandclinics.Italso
providesinformationaboutthetypesofservicethatareprovidedbyeachsitein
order
tocompletetheprofileoftheIndianhealthdeliverysysteminourstate.



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2010-2013 American Indian Health Care Delivery Plan
Manyopportunitiesforchangeexistinthecurrentenvironment.Overthenextfour
years,Tribes,AIHC,andpartnershavetheopportunitytoidentifyandimplementnew,
moreimpactfulwaysofaddressingthehealthofIndianpeople.The2010‐2013
AmericanIndianHealthCareDeliveryPlanisaguideforfurtheringthateffortandfor
achievinghealthyoutcomesandcomprehensive,culturallyappropriatehealthservices
forAmericanIndians/AlaskaNativesinWashington.


II. HealthDisparitiesandServiceDelivery

A. AmericanIndianHealthCareDeliveryPlan

TheWashingtonStateHealthServicesActof1993originallyauthorizedtheAmerican
IndianHealthCareDeliveryPlan.In1995,responsibilityfortheplanwastransferred
fromtheHealthCareAuthoritytotheDepartmentofHealth,whichallocatedfundsto
developtheplan.

ThepurposeoftheplanasstatedinRCW43.70.590wasto:
 (make)recommendationstoprovidersandfacilities’methodsforcoordinatingand
jointventuringwiththeIndianhealthservicesforservicedelivery
 (find)methodstoimproveAmericanIndianspecifichealthprogramming,and;
 (create)co‐fundingrecommendationsandopportunitiesfortheunmethealth
servicesprogrammingneedsofAmericanIndians

Aseparatelaw,RCW43.70.052(4)alsodirectedtheDepartmentofHealth“in
consultationandcollaborationwiththefederallyrecognizedtribes,urbanorother
Indianhealthserviceorganizations,andthefederalareaIndianhealthservice,(to)
design,develop,andmaintainanAmericanIndian‐specifichealthdata,statistics
informationsystem.Thedepartmentrulesregardingconfidentialityshallapplyto
safeguardtheinformationfrominappropriateuseorrelease.”

ThefirstplanwaspublishedinJuly1997,markingthebeginningofasignificant
partnershipbetweenWashington’sTribesandDepartmentofHealthtoidentifyand
addresshealthdisparitiesaffectingAmericanIndiansandAlaska
Natives.Anadvisory
groupwascreatedtodevelopthefirstplan,comprisedofAmericanIndianandnon‐
Indianhealthcareprovidersandrepresentativesoftribal,state,andlocal
organizations.Thethreeprimaryplanobjectivessetforthbythisgroupaptlydescribe

thepremiseoftheplantoday:



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2010-2013 American Indian Health Care Delivery Plan
1. UnderstandthehealthstatusofAmericanIndiansinthestate
2. Developstrategiestoimprovetheirhealthstatus
3. Closegapsintheprovisionofhealthcareservices

Theplanhasbeentheresultofactivecollaborationbetweentribes,tribal
organizations,andthedepartment.Ithasalsohelpedtosparkadditionalcollaboration
withotherstateagenciesandvariouspublicandnon‐profitentitiesinWashington.
Whiletheplanseekstoprovideacomprehensiveoverviewoftheprogress,
opportunitiesandchallengesthattribesandthestatefaceineliminatinghealth
disparitiesaffectingWashington’sAI/ANpopulation,itbynomeansisasubstitutefor
thegovernment‐to‐governmentrelationshipthatexistsbetweenfederallyrecognized
Tribesandstategovernment.Throughtheauspicesofthecommission,tribescontinue
tobethedrivingforceintheplan’scontentandscope.

B. TheAmericanIndian HealthCommissionforWashingtonState

AmericanIndianHealthCommissionwascreatedin1994byfederallyrecognizedtribes,
UrbanIndianhealthorganizations,andotherIndianorganizationstoprovideaforum
foraddressingTribal‐statehealthissues.Thecommission’smissionistoimprovethe
healthofAI/ANpeoplethroughtribal‐statecollaborationonhealthpoliciesand
programsthatwillhelpdecreasedisparities.Thecommissionworksonbehalfofthe29
federally‐recognizedTribesand2UrbanIndianHealthOrganizationsinthestate.
DelegatesareofficiallyappointedbyTribalCouncilstorepresenteachindividualTribe,
andUrbanIndianHealthOrganizationrepresentativesserveasmembers‐at‐large.This

modelhasbeenpresentedinstate,regional,andnationalsettingsasaframework,or
tool,forothersintheirworkinformingstrongtribal‐statepartnershipsonhealthcare
issues.Thecommissioncontinuestoserveasaneffectiveforumforachievingunityand
guidingthecollectiveneedsofTribalgovernmentsandurbanIndianhealthprogramsin
providinghigh‐quality,comprehensivehealthcaretoAI/ANsinWashington.The
ultimategoalinpromotingincreasedTribal‐statecollaborationistoimprovethehealth
statusofAmericanIndiansandAlaskaNativesbyinfluencingstateandTribalhealth
policyandresourceallocation.Keyactivitiesinclude:

• Identifyinghealth
policyissuesandadvocatingstrategiestoaddressTribalconcerns
• Coordinatingpolicyanalysis
• SolicitingandcollectinginformationfromthestateforTribalreviewandresponse
• DisseminatinginformationtoTribalhealthprogramsandleaders
• Promotingthegovernment‐to‐governmentrelationshipbetweenTribesandstate
healthagencies


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PleaseseeSectionV.A.forfurtherdetailsaboutthecommission.

C. TheIndianHealthServiceDeliverySystem

FederalgovernmentalresponsibilityforprovidinghealthservicestoAmericanIndians
datesbackmorethan200yearstotheassumptionofresponsibilityforIndian
educationand‘civilization.’LegalresponsibilityforAmericanIndianhealthtracesback
tomanyofthetreatiesenactedbetween1776and1858andtheirinclusionofmedical
careaspartialcompensationforthecedingoflandandotherresources.About30
treatiesspecifiedaccesstoaphysicianormedicalfacility,whileanequalnumber

merelycontainedgeneralclausespromisingassistancetothepoorandinfirm.Every
treatysignedbytribesinWashingtonincludedareferencetomedicalattendancetobe
defrayedbytheUnitedStates.Inmostcases,littlewasdonetomeettheseobligations.
2
TreatiesnegotiatedbytheUnitedStates,whichexchanged400millionacresofIndian
lands,createdatrustobligationfortheprovisionofhealthcareservicestoAI/ANs.This
solemnresponsibilityhasbeenaffirmedinnumeroustreaties,statutes,U.S.Supreme
Courtdecisions,andExecutiveOrders.

LegalbasisforAmericanIndianHealthCare
Overthepast85+years,thefederalgovernment’sobligationtoprovidehealthcare
servicestoAmericanIndiansandAlaskaNatives,explicitinsometreaties,hasbeen
explicitlysetforthinaseriesoffederallaws,executiveordersandcourtdecisions.
Amongthemostimportant:



SnyderActof1921–Congress,forthefirsttime,enactedlegislationpermanently
authorizingappropriationsforAmericanIndianhealthcare.Theactauthorizedthe
BureauofIndianAffairstoexpendfederalfundsandemployphysicians“forthe
reliefofdistressandconservationofhealth.”


JohnsonO’MalleyActof1934
–affirmedthefederalgovernment’sfinancial
responsibilityforIndianhealthservices,authorizingtheSecretaryoftheInteriorto
contactwithstateandlocalgovernmentsandprivateorganizationstoprovide
educational,medical,andotherassistancetoAmericanIndianswhonolongerlived
onthereservation.


TransferActof1954
–healthservicesforAI/ANwastransferredfromtheInterior
DepartmenttoanewlycreatedDivisionofIndianhealth(re‐titledtheIndianHealth
Service[IHS]in1955)undertheU.S.PublicHealthServiceintheDepartmentof
Health,EducationandWelfare.Primarymotivationforthetransferwastoimprove


2
AmericanIndianPolicyReviewCommission;ReportonIndianHealth:TaskForceSix‐IndianHealth.
WashingtonDC:USGovernmentPrintingOffice.1976


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qualityofmedicalservicestoAmericanIndiansthroughsupervisionbyanagency
withmoreadministrativeexpertiseandfundinginhealthcare.


IndianHealthFacilitiesActof1957–authorizedIHStocontributetothe
constructioncostsofcommunityhospitalsincaseswheresuchfacilitiescould
providebetteraccessandcarethanwouldthedirectconstructionofIndian
facilities.


IndianSanitationFacilitiesandServicesActof1959–expandedthescopeofIHS
programsbyauthorizingtheagencytoprovidesanitationfacilitiesincludingwater
supplies,drainageandwastedisposalforAmericanIndianhomes,communitiesand
lands.


IndianSelf‐DeterminationandEducationAssistanceActof1975
(P.L.93‐638)–
authorizedtheIHStoturnoverfulladministrativeresponsibilityforIHSprograms,
throughcontracts,toTribesupontheirrequest.


IndianHealthCareImprovementActof1976(P.L.94‐437,IHCIA)–authorizeda
seriesofhealthprogramsbasedon“communityhealthmodel”approachand
directedincreasedappropriationsforsuchprograms;includedfirstspecific
legislativeacknowledgementofthespecialfederalresponsibilityforAmerican
Indianhealthservices,establishedurbanIndianhealthprograms,andremoved
prohibitionofMedicaidandMedicarereimbursementstoIHSandTribally‐operated
facilities.


IndianHealthCareImprovementActAmendmentsof1992(P.L.102‐573)–
extendedTribalself‐governancetotheIHS;self‐governanceallowstribestoassume
responsibilityforresourcemanagementandservicedelivery,providinggreater
flexibilitytodesignanddevelopprogramsthatbettermeettheneedsofits
members,withnoabrogationofthefederalgovernment’strustresponsibility.

TheFederalIndianHealthService(IHS)
ThefoundationoftheIndianHealthServiceistoupholdthefederalgovernment’s
obligationtopromotehealthyAI/ANpeople,communitiesandculturesandtohonor
andprotecttheinherentsovereignrightsofTribes.Itsmissionis“toraisethephysical,
mental,socialandspiritual
healthofAI/ANstothehighestlevel”anditsgoalisto
“assurethatcomprehensive,culturallyacceptablepersonalandpublichealthservices
areavailableandaccessibletoAI/ANpeople.”

3
TheIndianHealthServicedelivery
systemwasdesignedtobeanintegrated,community‐basedsystemthatemphasizes
preventionandpublichealth,deliversandpurchaseshealthcareservicesandprovides
theinfrastructureforhealthimprovementsbybuildinghealthfacilitiesandsanitation


3
IndianHealthServices,IndianHealthServicesIntroduction,
/>



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systems,aswellasguaranteeinglong‐termimprovementthroughtraining,recruitment
andretentionofhealthpersonnel.Inadequateresources,however,createbarriersfor
theIndianhealthsystemtofullyachieveitsmission.

Thefollowingisexcerptedfromanarticle,“HealthDisparitiesChallengePublicHealth
AmongNativeAmericans”byJimRobertsandDr.JoshuaJones,publishedinthe2004
Fall/WintereditionoftheNorthwestPublicHealthJournalthatmorefullydescribesthe
Indianhealthdeliverysystemasitexiststoday
4
:

“TheAI/ANhealthcaredeliverysystemconsistsofapproximately594health
carefacilitiesacrossthecountry,including49hospitals,545ambulatory
facilities(231healthcenters,fiveschool‐basedhealthcenters,133health
stations,and176AlaskaNativevillageclinics).Thesehealthcarefacilitiescan

begroupedintothreecategories:
thoseoperateddirectlybyIHS,thoseoperated
bythetribesthroughaTribalHealthAuthority(THA)bycontractorcompact
withIHS,andthoseprovidingservicestourbanAI/ANs(individualsnotresiding
onornearanIndianreservation).

Alongwithambulatoryprimarycareservices,facilitiesmayofferinpatientcare,
medicalspecialties,traditionalhealingpractices,dentalcare,mentalhealth
care,eyecare,andsubstanceabusetreatmentprograms.Manytribesarealso
servedbycommunityhealth(e.g.,childhoodimmunizations,homevisits)and
environmentalhealth(e.g.,sanitation,injuryprevention)programs,whichmay
beadministeredbyIHSorTribes.Specialtyservicesandtypesofmedicalcare
thatarenotavailableatagivenfacilityareoftenpurchasedfromprovidersin
theprivatesectorthroughacontracthealthservice(CHS)program.TheIHSand
THAsapplystringenteligibilitycriteriatodeterminewhichpatientsqualifyfor
CHSfunding.TheseverelylimitedpoolofCHSdollarsalsomeansthatmostCHS
programslimitreimbursementtothosediagnosticortherapeuticservicesthat
areneededtopreventtheimmediatedeathorseriousimpairmentofthehealth
ofthepatient.Amongotherproblems,thisresultsinreducedaccesstoscreening
servicesandcontributestoincreasedcancermortality;forexample,accessto
breastcancerscreeningisaparticularproblemforNativewomen,withonly52
percentin2000reportingamammograminthepasttwoyears.

Corefundingofmostofthehealthservices(includingCHS)derivesfromIHS;
however,manyprogramsarealsodependentongrantfunding,tribalrevenue,

4
Roberts,JimandJones,Joshua.HealthDisparitiesChallengePublicHealthAmongNativeAmericans.Northwest
PublicHealthJournal:UniversityofWashingtonSchoolofPublicHealth&CommunityMedicine,Winter2004.

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2010-2013 American Indian Health Care Delivery Plan
andcollectionsfromthird‐partypayers(includingstateMedicaidprograms)to
remainfinanciallyviable.Morethan36percentofAI/ANfamiliesintheUnited
Statesmakinglessthan200percentofthefederalpovertylevelhadnohealth
insurance,apercentagesecondonlytoLatinos.

Alongwiththecommunityhealthprogramsassociatedwiththehealthcare
facilitiesineachcommunity,anincreasingnumberoftribesaretakinganactive
roleinpublichealthpracticeandresearchintheircommunity.Theseactivities
includegrant‐fundedcollaborationswithacademicresearchersandfederal
agencies(suchasapopulation‐basedBehavioralRiskFactorSurveillanceSurvey
specifictotribalcommunities)andactivecollaborationswithstateandcounty
healthdepartmentsinsuchareasasincreasingaccesstochildhood
immunizations.

Inaddition,thelastdecadehasseenamovetowardincreasingepidemiologic
capacitywithintriballyrunorganizations.IntheNorthwest,threetribally
operatedepidemiologycentershavebeenfoundedwithfundingfromIHSand
sustainedbygrant‐fundedactivities:theNorthwestTribalEpidemiologyCenter
attheNorthwestPortlandAreaIndianHealthBoard,servingthe43federally‐
recognizedtribesinIdaho,Oregon,andWashington(www.npaihb.org);the
AlaskaNativeEpidemiologyCenterattheAlaskaNativeHealthBoard
(www.anhb.org);andtheUrbanIndianHealthInstituteattheSeattleIndian
HealthBoard,whichfocusesonurbanIndiansnationally(www.uihi.org).The
workofthesetribalorganizationshasmadeprogressindocumentingthe
dramatichealthproblemsthatfaceNativecommunitiesintheNorthwest.
AlthoughthehealthcaresystemservingtheAI/ANpopulationmayseem
comprehensive,theprovisionofadequatehealthcaretoAI/ANsishamperedby

chronicunderfundingofIHSbytheUSCongress.

ThelackofadequatefundingtobothCHSprogramsandthedirectservices
providedbyIHSandtribalfacilitiesmeansthatuniversalaccesstocarefor
AI/ANsisfarfromareality.ItisestimatedthattheIHSisfundedatonly50
percentofitslevelofneed;someprograms,suchasmentalhealth,arefunded
ataslowas30percent.Therelationshipbetweenchronicunderfundingand
increasinghealthdisparitieshasbeenoutlinedintworecentreportsfromthe
U.S.CommissiononCivilRights.Thereportsconcludethatthestateofhealth
caredeliverytotheAI/ANpopulationisinastateofcrisis.Itseemslikelythatas
accesstocarebecomesevenmorelimitedduetoinadequatefunding,health
statusdisparitiesbetweenNativepeopleandthegeneralUSpopulationwill


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continuetowiden,andAI/ANswillcontinuetobedeniedopportunitiesfor
buildinghealthiercommunities.”

ThePortlandAreaIndianHealthService
ThePortlandAreaIndianHealthService(PAO)providesaccesstohealthcareforan
estimated150,000Indianresidentsofthe43federallyrecognizedTribeslocatedin
Idaho,Oregon,andWashington.Healthdeliveryservicesareprovidedbyamixof
healthcenters,healthstations,preventativehealthprograms,andurbanprograms.
Healthcentersprovideawiderangeofclinicalservicesandareopen40hourseach
week.Healthstationsprovidealimitedrangeofclinicalservicesandusuallyoperate
lessthan40
hoursperweek.Preventiveprogramsoffercounselorandreferralservices.
ThePortlandAreaIndianHealthServiceoperatessixfederalhealthfacilitiesinfive
TribalcommunitiesandoneatChemawaIndianSchool.Tribe’soperatehealthfacilities

undertheauthorityoftheIndianSelf‐DeterminationandEducationAssistanceAct
(PublicLaw93
‐638,asamended),TitlesIandV.

Twenty‐threeTribe’shaveTitleVcompactsandtherearetwenty‐fourTribe’sorTribal
organizationsthatcontractunderTitleI.Overall,Tribesadministermorethan74
percentofthePortland‐areabudgetauthorityappropriationthroughSelf‐
DeterminationcontractsorSelf‐Governancecompacts.Therearealsothreeurban
programswithservicesrangingfromcommunityhealthtocomprehensiveprimary
healthcareservices.Currentareasofemphasisare:

• InfantHealth
• HighRiskMaternalandChildHealth
• TobaccoUseIntervention
• DomesticViolence
• Diabetes
• Women'sHealthCare
• CancerScreening

NorthwestPortlandAreaIndianHealthBoard
TheNorthwestPortlandAreaIndianHealthBoard(NPAIHB)workscloselywiththe
PortlandAreaIndianHealthService.Establishedin1972,theboardisanon‐profittribal
advisoryorganizationservingthe43federallyrecognizedtribesofOregon,Washington,
andIdaho.Eachmembertribeappointsadelegateviatribalresolution,andmeets
quarterlytodirectandoverseeallactivitiesofNPAIHB.Theboarddelegatescreateand
updateastrategicplan,whichcontainsfourmainfunctionalareas:healthpromotion
anddiseaseprevention,legislativeandpolicyanalysis,trainingandtechnical


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assistance,andsurveillanceandresearch.Theboardhousesatribalepidemiology
center(Epicenter),severalhealthpromotiondiseasepreventionprojects,andisactive
inIndianhealthpolicy.

TribalHealthProgramsandClinicsinWashingtonState
Thereare29federallyrecognizedTribesinthestatewith34clinics,threeofwhichare
operatedbytheIndianHealthServices,31ofwhichareoperatedbyTribes.Thevast
majorityofspecialtycarethatcannotbeprovidedwithinTribalclinicsispurchased
fromprivatehealthcareprovidersinnearbycommunities.EachTribereceivesafixed
amountofContractHealthServices(CHS)funding,whichisbasedonthenumberof
eligibleusers,theavailabilityofdirectcareservices,andotherhistoricalcircumstances.
Asdescribedunder“TheFederalIndianHealthService”sectionintheplan,fundingfor
CHSisnotadequatetoprovideallneededservices,andaprioritysystemisusedto
determinewhatcareispurchasedandwhatisdeferreduntilfundingisavailableor
untilthemedicalconditionisseriousenoughfortreatment.Federalpolicydictatesthat
IndianHealthServiceisa‘payoroflastresort.’IfanAI/ANrequirescareoutsidethe
IndianhealthcarefacilityandiseligibleforMedicaid,Medicare,hasprivateinsurance,
orifthereisanyotherpayor,allofthesemustpaybeforetheIndianhealthprogramis
obligatedtouseContractHealthServicesfunds.

EachTribalhealthprogramandeachclinicisunique.ThethreeIndianHealthService
clinicsarestaffedandoperatedbytheIndianHealthServicewiththeirownhealth
professionalswithintheirhealthcaredeliverystructure.Tribeswhoarecontracted
withIndianHealthServicehaveassumedadministrativeresponsibilityforexisting
healthprogramsthatwereformerlyrunbyIHS.Self‐governance,orcompacted,Tribes
entercompactsdirectlywiththefederalgovernmentandnegotiateannualfunding
agreementsthatcanprovidegreaterflexibilityinprovisionofservicesthatmeet
uniquecommunityneeds.


EveryTribehasitsownculture,infrastructure,traditions,governance,financing,and
healthprioritiesthatshapehowhealthcareisprovidedineachcommunity.To
understandtheTribalhealthcare‘system’inWashington,onemusthaveabroad

understandingofthefactorsthatplayintotheuniquenessofeachTribalcommunity
andtheholisticapproachmostTribeshaveinaddressinghealthpriorities.

WhilethefoundationforthehealthservicedeliverysysteminTribalcommunitiesisthe
federalIndianhealthcaresystemdescribedabove,adequatefundingwithinthis
systemhasneverbeenachieved.WashingtonStateTribeshavebecomeextremely


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successfulingeneratingrevenuethroughthird‐partycollections,whichhasbecomeas
muchapartofanIndianhealthclinic’sbasebudgetasfederallyappropriatedfunds.

Oneofthelargestsourcesofthird‐partyreimbursementhasbeenthroughthestate‐
federalMedicaidprogram.Thestabilityofthisrevenue‐generatingsource
isabsolutely
vital.AnyreductioninthissourceoffundingnowresultsinbasicTribalhealthservices
beingcut,ratherthanimprovementinitiativesbeingcurtailedordelayed.Tribesand
theAmericanIndianHealthCommissionworkwiththestateMedicaidoffice(Health
andRecoveryServicesAdministration)withintheDepartmentofSocialand
Health
ServicestoidentifyandimplementimprovementstotheMedicaidsystemforAI/AN
accessandTribalproviderreimbursement.Somesystemandservicedeliveryissues
haveimprovedthroughthisprocess;however,themoresubstantivechallengesTribes
haveinaccessingMedicaidreimbursementsarewiththefederalCentersforMedicaid
andMedicare(CMS).WashingtonStateTribesturntotheNorthwestPortlandArea

IndianHealthBoard,theNationalIndianHealthBoard(NIHB),andtheCMSTribal
TechnicalAdvisoryGroup(TTAG)asawaytoinfluencechangesatthenationallevel.

DetailedprofilesoftheIndianhealthprogramsinthestatecanbefoundinSectionVI
ofthisplan.

D. UrbanIndianHealthPrograms

TheAIHChasidentifiedUrbanIndianhealthasanareathatwarrantsadditional
attentionandheightenedawareness.ManyAI/ANpeopleliveinurbanareasinthe
state,andtheseAI/ANindividualsfacesignificantandoftenuniquechallengesin
accessingcareandremaininghealthy.Manyoftheseindividualsaremembersof
WashingtonStateTribes,othersaremembersofTribesfromotherstates,someare
membersoffederallyrecognizedTribes,othersarenot.Inordertoeffectivelyaddress
healthdisparitiesofallAI/ANinWashington,theremustbeamoreconcertedeffortto
linkurbanIndianhealthprogramstohealthreformeffortstakingplace.Thiswillallow
forimprovedcoordinationinprovidingacomprehensivehealthcaredeliverysystem
forIndianpeopleinWashington.InSectionIIIA,oneoftheprioritiesidentifiedforthe
State‐Tribal‐UrbanIndianHealthCollaborativeistobeginthisworkbyraising
awarenessofurbanIndianhealthissues.

ThefollowingisfromanissuebriefdevelopedbyRalphForquera,executivedirector,
SeattleIndianHealthBoard
5
.Thisbriefprovidesacomprehensivesummaryofurban


5
Forquera,Ralph.UrbanIndianHealthIssueBrief.SeattleIndianHealthBoard,forKaiserFamily
Foundation.2001

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Indianhistory,healthissues,andchallengesexperiencedbythispopulationandthe
UrbanIndianHealthOrganizationthatservethem.

“FewpeoplerealizethatthemajorityofAmericanIndiansandAlaskaNativesin
theUnitedStatesarenowlivinginAmericancities,notonreservations.Yet,
FederalhealthcarepolicytowardAmericanIndiansandAlaskaNatives
continuestofocuslargelyontheneedsofthoselivingonreservationsinrural
areas—needsthat,despitedemonstrableprogresssincethecreationofthe
IndianHealthService(I.H.S.)in1955,remainsubstantial(Kauffmanetal.,1997).
ThepurposeofthisIssueBriefistodescribethelargeandgrowingurbanIndian
population,theirhealthstatus,andthemajorfederalhealthprograms(i.e.,
I.H.S.andMedicare)andfederal‐stateprograms(i.e.,MedicaidandChildHealth
InsuranceProgram)thatareavailabletoimproveNativeAmericans’accessto
neededhealthservices.InsettingforththecircumstancesofurbanIndians,this
IssueBriefdoesnotintendtosuggestthatthehealthcareneedsofIndian
peoplelivinginruralareasareinanywaylesscompelling.

AGrowingPopulationofUrbanIndians
In1990,overhalfofthe2millionAmericanIndiansandAlaskaNativesinthe
UnitedStateslivedinurbanareas...Incontrast,anestimated430,000Indians
livedon279federalandstatereservationsthatyear,andanother40,000lived
inAlaskaNativevillages(Snipp,1996).

WhoareUrbanIndians?
UrbanIndiansaremembersof,ordescendantsofmembersof,oneofthemany
Indiantribes

orotherorganizedgroupsofaboriginalinhabitantsoftheAmericas
wholiveincities.TheIndianHealthCareImprovementActdefinestheterm
“UrbanIndian”tomeananyindividualwho“residesinanurbancenter”…and
“meetsoneormoreofthefourcriteria”forqualifyingasan“Indian”underthe
Act.

ThemigrationofIndiansfromthereservationstoAmericancitiesoccurred
throughoutthepastcenturyandisexpectedtocontinue.Theproportionof
IndianslivinginwhattheCensusBureaudefinesas“urbanizedareas”grewfrom
45percentin1970to56percentin1990(U.S.CensusBureau,2001,personal
communication).Historically,thismigrationreflectedfederalgovernment
“relocation”policiesineffectduringthe1950’s.Over160,000AmericanIndians
andAlaskaNativeswereforciblymovedfromtheirreservationsintocitiesto
promoteassimilationintothedominantU.S.society(Kauffmanetal.,2000;Hall,


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2010-2013 American Indian Health Care Delivery Plan
2001).Afailedsocialexperiment,thismandatory“relocation”policywas
discontinued30yearsago.

Migrationfromreservationstocitiescontinues,eventhough,astheymakethis
transition,Indiansfrequentlyloseaccesstohealthcareandotherbenefits
grantedthemwhenlivingonreservations.

Contemporarymigrationreflectsthesearchforemployment,
education,and
housingopportunitiesinlightofthehighunemploymentrates,limited
educationalsystems,andhousingshortagesonsomereservations.


UrbanIndiansareahighlydiversepopulation.Inanygivencity,theurbanIndian
populationislikelytoincludemembers(ordescendantsofmembers)ofmany
differenttribes,includingtribes
recognizedbythefederalgovernmentandtribes
thatarenot.Theseindividualsmayormaynothavecultural,religious,or
historicalties.Theytendtobedispersedthroughoutmetropolitanareasrather
thanresidingin“urbanIndianneighborhoods.”Asaresult,urbanIndiansmay
sharelessofasenseofcommunitythanIndianslivingonreservations,which
frequentlyaredominatedbyoneorperhapsafewmajortribalgroups.Itisalso
commonforurbanIndianstotravelbacktotheirhomereservationsforperiodic
visitstofamilyorfriendsasawayofmaintainingtheirculturalconnections.

TheHealthStatusofUrbanIndians
ThepoorerhealthstatusofAmericanIndiansandAlaskaNatives,comparedto
otherAmericans,hasbeenwelldocumented(Young,1996).Muchlessisknown
aboutthehealthofurbanIndians.Thefewempiricalandpopulation‐based
studiesthatexistsuggestthathealthindicesaresimilarforIndianpeoplewho
resideonornearreservationsandthoseinurbanareas.Onestudy,publishedin
theJournaloftheAmericanMedicalAssociation,analyzedbirths,deaths,and
communicablediseasesin1metropolitanand7ruralcountiesinWashington
Statebetween1981and1990andfoundthat,comparedwithurbanwhites,
urbanIndians
hadhigherratesoflow‐birthweightinfants,higherratesofinfant
mortality,higherratesofinjury‐andalcohol‐relateddeaths,andhigherratesof
tuberculosisandsexuallytransmitteddiseases(Grossmanetal.,1994).Another
article,publishedinCancer,suggeststhaturbanIndiansexperiencehealthrisks
laterinliferelatedto
earlieryearsoflivingonthereservation(Burhansstipanov,
2000)...


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2010-2013 American Indian Health Care Delivery Plan
SeveralfactorsconfoundthestudyofUrbanIndiansandtheirhealthstatus.The
principalproblemisthelackofaclear,uniformdefinitionofurbanIndiansthat
localandstatehealthofficialscanuseinidentifyingthepopulation.Another
factorthatcomplicatesmonitoringofhealthindicesisthedispersionofurban
Indiansthroughoutmetropolitanareas.Afurtherdifficultyisthatresidential
mobilityamongurbanIndiansisextremelyhigh,especiallyamonglow‐income
individualsandfamilies.Thesefactorscombinetomakeidentifyingthe
populationandcollectingaccuratehealthstatusdatadifficult.

TheUrbanIndianHealthProgram
...theurbanIndianprogram
wasfirstauthorizedin1976,morethan20years
aftertheestablishmentoftheI.H.S.,inTitleVoftheIndianHealthCare
ImprovementAct(P.L.94‐437).AsKauffman(1999)notes,TitleV“representeda
significantdeparturefortheIndianHealthService,whichhadpreviouslynot
includedIndiansliving
outsideI.H.S.serviceareaswithinthescopeofthe
program.”TheCongressionalrationalefortheprogram(HouseReport94‐1026)
wasinparttoaddresstheproblemsresultingfrommisguidedFederalpolicies
towardsAmericanIndiansandAlaskaNatives:“Itis,inpart,becauseofthe
failureofformerFederalIndianpoliciesandprogramsonthereservationsthat
thousandsofIndianshavesoughtabetterwayoflifeinthecities.
Unfortunately,thesamepoliciesandprogramsthatfailedtoprovideIndians
withanimprovedlifestyleonthereservationhavealsofailedtoprovide[them]
withthevitalskillsnecessarytosucceedinthecities”


ThepurposeoftheTitleVprogramistomakeoutpatienthealthservices
accessibletourbanIndians,eitherdirectlyorbyreferral.Theseservicesare
providedthroughnon‐profitorganizations,controlledbyurbanIndiansthat
receivefundsundercontractwiththeI.H.S.UrbanIndianorganizations
commonlysupplement
theseI.H.S.dollarswithrevenuesfromothersources,
suchasMedicaidandMedicarepayments,privateinsurancereimbursements,
andsupportfromlocalitiesandprivatefoundations.AsofFY2001,theIHSspent
$29.9millionappropriatedunderTitleVtohelpfund34Indianhealth
contractorsin20statesandtwoI.H.S.urbanservicesitesinOklahoma.The
majorityoftheseprogramsprovidemedicalservices;theremainderofferonly
referralservicesorotherservices,suchasalcoholandsubstanceabuse
treatment.Theseprogramsserveanestimated130,000urbanIndians(author’s
reviewofI.H.S.UrbanIndianProgramStatistics,1999)...
