Funding Indian Health Services

Double-clicking into Navajo Nation and COVID-19 impact

By Aneet Atwal, Leah Shin, Nikolas Berkobien, Tanya Kumar

Executive Summary:

Native Americans continue to experience disproportionately negative health

outcomes, an existing trend that has been exacerbated by the COVID-19 pandemic.
The pandemic’s disproportionate impact on the Native Americans is caused in large part
due to the weaknesses of the Indian Health Service (IHS), an operational division of the
Department of Health and Human Services (HHS). The disproportionate lack of funding
for the IHS is part of a steady historical trend which contributes to significant health
system weaknesses.

Therefore, to mitigate the damage wrought by the pandemic and to improve

Native American population health, funding for IHS should be increased and
focused on three specific target areas: Native American health professions, the
healthcare emergency management program, and emerging technology in
healthcare.

Background:

The Navajo Area Indian Health Service (NAIHS) is one of 12 regional

administrative units of the Indian Health Service (IHS), an operational division of the
Department of Health and Human Services (HHS). According to the IHS, native
American reservation communities fare worse in health outcomes and mortality rates
compared to their non-Native American counterparts 1.

While all native tribes are at high risk for contracting COVID-19 and lacking sufficient
access to healthcare, the Navajo Nation is at particular risk as a result of historical
inequalities producing severe poverty, lack of access to running water and electricity,
crowded living conditions in multigenerational homes, insufficient access to healthy
foods from forced removal from lands, and pre-existing health conditions. The particular
circumstances of the Navajo Nation compound the threat of spreading COVID-19 and
realizing the destructive health outcomes. According to the Navajo Department of
Health, there are more than 29,000 reported positive cases2.

1
IHS Profile | Fact Sheets
2
The Navajo Nation and Access to Health Care During COVID-19 | The Bill Lane Center for the American
West (stanford.edu)
The IHS, the Veteran’s Health Administration (VHA), Medicaid, and Medicare are
diverse programs through which the federal government is either a direct provider of
healthcare services or pays for services as a public insurer. Specifically, IHS and VHA
provide health care services directly to eligible beneficiaries3. In 2017, the Indian Health
Service spent $3,332 per patient, according to a report by the National Congress of
American Indians. By comparison, VHA spent $10,692 per patient, Medicare spent
$12,829 per patient that year, and Medicaid spent $7,789 per patient. Conventionally,
IHS has always been disproportionately funded and lacks to provide eligible individuals
with needed services, and with COVID-19, the need for healthcare funding has only
been exacerbated.

Unfortunately, not only is there a lack of funding and access to healthcare in the Navajo
Nation, but there is a lack of nurses, doctors, beds, and adequate medical facilities. The
vacancy rate in the health system for doctors in Navajo Nation is more than 25 percent;
for nurses, it is 40 percent4. Navajo Nation has 14 health care facilities on the
reservation. There are 222 hospital beds available to the reservation’s more than
170,000 residents. That ratio of hospital beds to population is about a third of the figure
for the general population in the United States.

Recommended Action

After examining IHS funding trends, budget allocation characteristics, and three
other federal health programs (Medicaid, Medicare, and the VHA), from 2017 to 2021,
policy change must begin by increasing funding for the IHS (see Figure 1). We
recommend providing the IHS with a two-fold increase to their 2017 per capita spending
amount, totaling $4,078 * 1,600,000 people = $6,524,800,00 * 2 = $13,049,600,0005 for
the FY22 fiscal year.

3
GAO-19-74R, Indian Health Service: Spending Levels and Characteristics of IHS and Three Other
Federal Healthcare Programs
4
Pandemic Highlights Deep-Rooted Problems in Indian Health Service - The New York Times
(nytimes.com)
5
Reclaiming Tribal Health: A National Budget Plan to Rise Above Failed Policies and Fulfill Trust
Obligations to Tribal Nations
Unlike urban areas that have trained local medical experts on demand, scalable
technology infrastructure, and medical resources to adapt to the increased precautions
of COVID-19, many rural regions like those in Navajo Nation need additional support
from IHS.

The IHS is the primary federal health care system and health services provider to the
566 federally recognized Tribes in the US. Compared to our Federal, State, local and
Tribal partners, the IHS has a relatively small and limited support role in emergency and
disaster preparedness, response and recovery in IHS supported locations6.

Implementation Plan

As IHS is a facet of the Executive Branch within our federal government,

immediate action can be taken if we advocate to the White House for an Executive
Order for initial funds through the current year. Coalescing with tribal territory focused
lobbying groups and associations to advocate for a higher budget proposal in the next
fiscal year’s legislative Appropriations bill.

While IHS is significantly smaller in terms of annual spending levels and the number of
individuals served, the sudden increase of COVID-19 cases has increased the number
of individuals needing medical assistance and total spending dollars needed in a
funding cycle.

6
Emergency Management | Division of Environmental Health Services (DEHS) (ihs.gov)
Therefore, stimulus funds should be allocated and funneled into IHS to make ongoing
distribution more equal across the increased needs for IHS serving regions like Navajo
Nation.

Proposal of Increased Funds & Their Allocation

With the allocated budget, we plan to increase the funding per beneficiary.
Highlighted below is a list of new proposed budgetary allocation projects for the
suggested IHS funds:

Priorities Cost Description

Indian Health Professions $103.39M Currently, Diné college within Navajo Nation
has created a 2/4 year degree program
partnership with ASU’s 7 Nursing Program. We
propose to fully fund this program, increase
cohort size, and fund recruiting/retention
strategies for the program.

Healthcare Emergency $100M We propose to create a dedicated governance

Management Program program, team, and pool of funds to address
disasters, emergencies, unprecedented
circumstances, etc. for IHS.

Emerging Technology in $90.6M Emerging healthcare technology hasn't been

Healthcare leveraged in tribal territories. Many reservations
lack access to electricity, sufficient broadband,
and appropriate technological infrastructure in
order to connect patients to physicians. We
propose funding to roll out tele-health services
and research initiatives.

Hospital & Clinics $569.6M

Purchased/Referred Care $460.3M

Mental Health $308.8M

Alcohol and Substance $255.0M

7
Arizona State University
Abuse

Dental Services $207.2M

Maintenance & improvement $152.8M

Health Care Facilities $152.3M

Construction

Indian Health Care $114.4M

Improvement Fund

Electronic Health Records $95.2M

System

Urban Indian Health $90.94M

Community Health $107.2M

Representatives

Public Health Nursing $57.26M

Equipment $44.33M

Health Education $32.9M

Facilities and Environmental $6.498M

Health Support

Direct Operations $352TH

Self-Governance $13TH

Tribal Management Grants $3.0TH

Alaska Immunization $2.0TH