Why the Federal Government Provides Health Care
The United States provides health services to members of federally recognized tribes. This often surprises readers, who may assume it is a form of welfare. In legal and historical terms, it is generally understood differently. Many treaties between tribes and the United States included promises about medical care, and in exchange tribes gave up land and other rights. Courts and Congress have also described a federal trust responsibility toward tribes, a principle that grew out of early nineteenth century Supreme Court decisions. Congress has repeatedly cited this relationship when it has passed health laws for Native people. For that reason, this article refers to federal health care obligations, not charity.
The extent and legal force of these obligations are matters of debate in law and policy, and a short article cannot settle them. What is clear is that, historically, health services were part of the arrangement under which Apache peoples came to live on reservations.
Health Care on Early Reservations
When Apache groups were placed on reservations in the later nineteenth century, health care was minimal and often came from army surgeons or agency physicians, when it existed at all. Crowded camps, new diseases, poor rations and the stress of forced relocation produced serious health problems, a theme covered in the material on epidemic disease and in discussion of Apache health after reservations. Traditional healers continued to serve their communities, a subject taken up in the material on traditional Apache medicine, and many families used both traditional and outside care when it was available.
In 1921, the Snyder Act gave general congressional authority for the Bureau of Indian Affairs to spend money on Native health, education and other needs. Services remained thin for decades. Hospitals were few and under-resourced, and tuberculosis and other infectious diseases were widespread concerns in Native communities in the first half of the twentieth century.
The Creation of the Indian Health Service
In 1954, Congress passed the Transfer Act, moving responsibility for Native health care from the Bureau of Indian Affairs to the Public Health Service. The Indian Health Service began operating in 1955. The change placed care under medical professionals within a health agency, and it was followed by new hospitals and clinics, sanitation work, and programs to train staff. The agency’s work is often credited with reducing some infectious disease burdens, although health outcomes for Native people have continued to lag behind national averages in many areas. Figures vary by region and year, so this article gives none.
The agency organizes its work through regional service areas. Apache nations in Arizona and New Mexico are served through the facilities and programs of areas located there, and the Apache Tribe of Oklahoma through the area covering Oklahoma. Facilities, clinics and programs change over time, so the Indian Health Service website and each nation’s health department are the places to confirm what exists now.
Later Laws: Funding and Tribal Operation
Two later laws are especially important:
- The Indian Health Care Improvement Act of 1976 aimed to raise standards, support recruitment of health professionals and expand services. It has been amended and reauthorized several times, and it was made permanent in 2010.
- The Indian Self-Determination and Education Assistance Act of 1975, together with its amendments, allowed tribes to take over the running of health programs previously managed by the federal agency. Amendments in 1988 and 2000 expanded the options, including self-governance agreements.
As a result, many Native nations, including a number of Apache nations, now operate their own clinics and health departments, sometimes alongside federally run facilities. The funding often still comes in large part from federal appropriations, but a tribal board or council makes decisions about the day-to-day program. Some nations also bill insurance programs for services, a source of revenue that supplements federal funding. Which arrangements a nation chooses is an internal decision and differs from one to another.
Persistent Challenges
Commonly discussed concerns include:
- funding that is often described as lower than the need;
- distance to specialty care, especially for people in remote parts of reservations;
- staffing shortages, which are widespread in rural health care;
- chronic conditions such as diabetes, which affect many Native communities;
- gaps between what the federal system covers and what patients need, including referrals outside the system.
Health officials and tribal leaders discuss these at length, and policies change from year to year. Readers interested in specific programs, eligibility or services should rely on official sources, not on this summary.
Health, Culture and Community
Many Apache communities see health as connected to community, land and family, and some tribal programs bring together clinical care and traditional practice, a relationship discussed in the material on traditional and clinical medicine. Some knowledge held by healers is not shared publicly, and this site does not describe it. Tribal control over health programs is often described as a way to make services more responsive to local needs and values.
This article is general history and not medical or legal advice. For information on eligibility, services and current programs, consult the Indian Health Service and the health department of the relevant Apache nation. This site is independent and speaks for no Apache nation.