Why the government provides health care at all
The Indian Health Service, or IHS, is often mistaken for a form of public insurance or a benefit. In law and in the view of Native nations, it is better understood as part of a federal obligation connected to the trust relationship between the United States and tribal nations. That obligation is generally described as resting on treaties, on federal statutes and on the exchange of land and peace for promises of services. Which legal source applies most directly differs from nation to nation: several Apache reservations were established by executive order rather than by ratified treaty, and nations tend to point to the wider trust relationship and to later statutes.
Whatever its precise legal basis, the idea is that Native nations gave up land and the federal government took on lasting responsibilities, including for health. Courts and Congress have treated parts of this as binding, though not as an entitlement that guarantees any specific level of care. The topic is discussed more broadly under federal health care obligations.
From the Army and the BIA to the IHS
In the early reservation years, health care for Apache people, if it existed, came from Army surgeons and agency physicians with very limited resources, a story told in the cluster on Apache health after reservations. Responsibility later passed to the Bureau of Indian Affairs, which ran small hospitals and field services. Studies in the 1920s, including the Meriam Report of 1928, found those services inadequate.
In 1954 Congress moved the federal Indian health program from the BIA to the Public Health Service, and the Indian Health Service began operating in 1955. The Snyder Act of 1921 had long been the main authority for federal Indian health spending, and the Indian Health Care Improvement Act of 1976 set out further goals for staffing, facilities and tribal participation. Congress made that law permanent in 2010.
How care is delivered on Apache reservations
IHS care reaches Apache communities in three general ways, and any one nation may use all of them:
- Direct services, in which IHS operates the hospital or clinic and employs the staff.
- Tribally managed services, in which the nation contracts or compacts to take over some or all of the work, a possibility opened by the Indian Self-Determination Act of 1975. Many Apache nations now manage some or all of their health programs.
- Urban Indian health programs, which serve Native people who live in cities and are not tied to a specific reservation.
When a service is not available locally, IHS and tribal programs may pay for referrals to outside providers through what is today called the Purchased/Referred Care program, which has limited funds and eligibility rules. Services at any reservation vary. A small clinic may handle basic care while patients travel to a larger hospital, sometimes hundreds of miles, for specialty treatment.
Eligibility generally depends on being a member of a federally recognized tribe or a descendant meeting federal criteria, and on where a person lives. These rules change, so the IHS website and the nation’s own health department are the places to check.
Traditional and clinical care
Some tribally managed programs include space for traditional healing or work with traditional healers alongside clinical care, a practice sometimes summarized as traditional and clinical medicine working together. How much of this happens, and how it is handled, depends on the nation and on what healers and families want. Information about traditional practice is shared at the community’s discretion, and this article does not describe it.
Documented gaps
Federal oversight bodies, congressional committees and civil rights reviews have repeatedly documented problems with the IHS system. The common themes are described here only in general terms:
- Funding that has fallen short of estimated needs. IHS is funded through annual appropriations rather than as an entitlement, so budgets can shift from year to year.
- Difficulty recruiting and keeping doctors, nurses and specialists, especially in remote places.
- Aging buildings and equipment.
- Long travel distances and limited transportation for patients.
- Gaps in behavioral health and substance use services.
Federal public health agencies report that American Indian and Alaska Native people, taken as a group, have lower life expectancy and higher rates of some conditions, such as diabetes, than the US population overall. These are national figures covering many nations, and they do not describe any single Apache community. Causes include history, poverty, access to care and environment, among others, and researchers do not attribute them to any one factor.
Local expertise and the next generation
Many Apache people work in health care, as nurses, community health representatives, physicians and administrators, in both IHS and tribal settings. Their role in building and running services is described in the article on Apache health professionals. Nations also run wellness and prevention programs of their own design. Because services and funding change, the best sources for what is available are the websites of the Indian Health Service and of the Apache nations’ health departments. This article is general information and not medical or legal advice.