Archived APHA Policy Statement

Noting that the 1990 US Census Bureau reports that reservation-based Indian populations have fewer economic and educational opportunities than the rest of US society, partly due to the remoteness and isolation of many of their communities;¹ and

Finding that American Indians and Alaska Natives health status is lower than the general US population due to poor nutrition compounded by unsafe water supplies, and inadequate waste disposal facilities and that they experience a higher incidence of otitis media, heart disease, alcohol and drug problems, chronic liver disease, mental health problems, diabetes, oral disease,^13,14obesity,^15,16 and injuries;² and

Recognizing that American Indians and Alaska Natives are citizens of their Tribes, their states and the United States of America and that the Tribes are governments with the inherent right to govern themselves; and

Affirming that the Federal responsibility for American Indian/Alaska Native health care is grounded in treaty obligations, case laws, the Snyder Act of 1921 (PL 83-568), the Indian Health Care Improvement Act (PL 94-437), as well as historical obligations;³ and

Confirming that the Federal government has a special "trust responsibility" that entitles federally recognized Tribes to participate in federal financial programs and other services, such as education and health care; and

Observing that approximately 1.34 million American Indians and Alaska Natives belong to the more than 545 federally recognized tribes and qualify for Indian Health Services and Bureau of Indian Affairs services; and

Acknowledging that in keeping with the concept of tribal sovereignty, the Indian Self-Determination and Educational Assistance Act (PL 93-638) of 1975, as amended, gives Tribes the option of staffing and managing Indian Health Service programs in their communities, and provides for funding for improvement of tribal capability to contract or compact under the Act; and

Noting that the relationship between the Indian Health Service and the Tribes has been defined through an extensive and exhaustive process conducted by the Indian Health Design Team;⁵ and

Realizing that the public health responsibilities for American Indians and Alaska Natives must be addressed at both the National and Tribal level and that the entire public health apparatus, including federal, state, county, municipal, and Tribal health organizations, is jointly responsible;⁶ and

Understanding that the Tribe has ultimate responsibility for the majority of public health activities and will decide whether to accomplish alone, by contract or compact, by agreement with another agency, or by other collaborative arrangement; and

Maintaining that Tribes are and must be the central force in public health programs for American Indian and Alaska Natives and that each sovereign Tribe has the independent authority to determine their own standards and measures, set public health priorities, and carry out public health functions;⁷ and

Knowing that the provision of health care to American Indians and Alaska Natives in Indian country and urban areas has become increasingly complex and even with increased flexibility in use of health care dollars these dollars are becoming less available;⁸ and

Recognizing that Congress has encouraged the Indian Health Service to carry out their responsibility using three distinct delivery systems, the Indian Health Service direct hospitals and clinics (I), the tribally operated health programs, services and facilities (T), and the urban Indian health programs(U); and

Finding that the President's Budget for Fiscal Year 1999 amounts to only a one percent increase ($19.7 million) in the Indian Health Service's budget well below the projected 3.5 percent medical inflation rate and that the current level of Indian Health Service funding is only meeting 36 percent of the health need;⁹ and

Observing that the inflation adjusted per capita Congressional appropriation for the Indian Health Service has declined from $1,442 in Fiscal Year 1993 to $1,183 in Fiscal Year 1998, an 18 percent decline in real spending,¹⁰ and that the Indian Health Service appropriation in Fiscal Year 1997 was less than 34 percent of the per capita expenditure for the civilian US population for medical care;¹¹and

Acknowledging that the National Indian Health Board, the National Congress of American Indians, the Tribal Self-Governance Advisory Committee and the National Urban Indian Health Council are advocating for a $419 million increase, including at least a $110 million increase in Contract Support Costs, in the Fiscal Year 1999 Indian Health Service budget based upon a comprehensive tribal formulated budget process; and

Believing that no American Indian or Alaska Native from any Tribe, no matter how small or remote, should be without identifiable and realistic access to the benefits of health care and public health protection.

Therefore based on culturally appropriate considerations:

1. Reaffirms that the federal government of the United States of America has a trust responsibility for American Indian/Alaska Native health care grounded in treaty obligations, case law, the Snyder Act of 1921 (PL 83-568), and the Indian Health Care Improvement Act (PL 94-437), as well as historical obligations;
2. Recommends that the Indian Health Service retain capacity for assessing changing health needs of Indian people, determining the amount of resources that are needed to address those needs, and assisting the Indian Health Service direct hospitals and clinics, the tribally operated hospitals and clinics, and the urban Indian health programs, as requested, to develop effective strategies to meet those needs;¹²
3. Urges the public health community, including state and local agencies, and Tribes to build mutually collaborative working relationships to improve and promote public health for all American Indians and Alaska Natives;
4. Urges the public health community to recognize, honor, and respect Tribal beliefs and practices to promote public health education and training with Tribes to improve access to information, practice, and standards;
5. Encourages Tribes to improve their public health capabilities through staff development and training, high prioritization of funding for public health programs/services, and appropriate technical assistance arrangements;
6. Supports efforts to assure that American Indians and Alaska Natives from all Tribes should have identifiable and realistic access to the benefits of public health protection;
7. Endorses significant increases in Indian Health Service funding levels to continue support for health care improvement, self-determination and the technical assistance needed to support both efforts in the true spirit of Tribal sovereignty, consistent with the recommendations of the Indian Health Design Team;
8. Urges States to develop relationships with Tribal health entities to improve capacity and capabilities and to support these improvements with additional funding support; and
9. Supports and encourages the continued development of the I/T/U concept as a means of implementing the federal government's obligation for health care for American Indians and Alaska Natives.

References

1. Indian Health Service, Comprehensive Health Care Program for American Indians & Alaska Natives, Public Health Service, US Department of Health and Human Services: Washington, DC.
2. Ibid.
3. Bush JK. Legal, Historical and Political Context in which Tribes Make Health Care Decisions. Denver, CO: National Indian Health Board, 1996.
4. Ibid.
5. Indian Design Team. Design for a New IHS: Final Recommendations of the Indian Design Team, Report Number II, January 1997.
6. Baseline Measures Workgroup Final Report. Prepared for the American Indian and Alaska Native People and the Indian Health Service, September 1996.
7. Ibid.
8. Ibid.
9. Bauman D. Tribal Perspectives on Indian Health, Self-Determination and Self-Governance. National Indian Health Board, February 3, 1998.
10. Mather D. IHS financial trends during self-governance (Title III) compacting FY 93 to FY 97. Tribal Perspectives on Indian Self-Determination and Tribal Self-Governance in Health Care Management, Vol 2, National Indian Health Board (in press).
11. Health Care Financing Administration: Health Care Financing Review cited by the Indian Health Service FY 99 submission to the US Department of Health and Human Services.
12. Indian Design Team. Design for a New IHS: Final Recommendations of the Indian Design Team, Report Number II, January 1997.USDHHS, Indian Health Service, Office of Public Health, Division of Community and Environmental Health, Program Statistics Team. Trends in Indian Health, 1997 ISSN# 1095-2896
13. Indian Health Service, Oral Health of Native Americans: A Summary of Recent Findings, Trends and Regional Differences, August 1994.
14. Will JC, Strauss KF, Mendlein JM, Ballew C, White LL, Peter DG. Diabetes Mellitus among Navajo Indians: Findings from the Navajo Health and Nutrition Survey. J Nutr. 1997;127:2106S-2113S, 1997.
15. Scanlon KS, Dalenius K, Parvanta I, Grummer-Strawn L. Pediatric Nutrition Surveillance, 1997 Annual Summary. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, 1998 (in press).