Patients suffer when Indian Health Service doesn't pay for outside care • South Dakota Searchlight (2024)

  • Health
  • Indigenous Affairs

When the Indian Health Service can’t provide medical care to Native Americans, the federal agency can refer them elsewhere. But each year, it rejects tens of thousands of requests to fund those appointments, forcing patients to go without treatment or pay daunting medical bills out of their own pockets.

In theory, Native Americans are entitled to free health care when the Indian Health Service foots the bill at its facilities or sites managed by tribes. In reality, the agency is chronically underfunded and understaffed, leading to limited medical services and leaving vast swaths of the country without easy access to care.

Its Purchased/Referred Care program aims to fill gaps by paying outside providers for services patients might be unable to get through an agency-funded clinic or hospital, such as cancer treatment or pregnancy care. But resource shortages, complex rules, and administrative fumbles severely impede access to the referral program, according to patients, elected officials, and people who work with the agency.

The Indian Health Service, part of the Department of Health and Human Services, serves about 2.6 million Native Americans and Alaska Natives.

Native American public health officials are stuck in data blind spot

Native Americans qualify for the referred-care program if they live on tribal land — only 13% do — or within their nation’s “delivery area,” which usually includes surrounding counties. Those who live in another tribe’s delivery area are eligible in limited cases, while Native Americans who live beyond such borders are excluded.

Eligible patients aren’t guaranteed funding or timely help, however. Some of the Indian Health Service’s 170 service units exhaust their annual pool of money or reserve it for the most serious medical concerns.

Referred-care programs denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients in fiscal year 2022.

As a result, Native Americans might forgo care, increasing the risk of death or serious illness for people with preventable or treatable medical conditions.

The problem isn’t new. Federal watchdog agencies have reported concerns with the program for decades.

Connie Brushbreaker, a member of the Rosebud Sioux Tribe, has been denied or waitlisted for funding at least 14 times since 2018. She said it doesn’t make sense that the agency sometimes refuses to pay for treatment that will later be approved once a health problem becomes more serious and expensive.

“We try to do this preventative stuff before something gets to the point where you need surgery,” said Brushbreaker, who lives on her tribe’s reservation in South Dakota.

Many Native Americans say the U.S. government is violating its treaties with tribal nations, which often promised to provide for the health and welfare of tribes in return for their land.

“I keep having my elders here saying, ‘There’s treaty rights that say they’re supposed to be able to provide these services to us,’” said Lyle Rutherford, a council member for the Blackfeet Nation in northwestern Montana who said he also worked at the Indian Health Service for 11 years.

Native Americans have high rates of diseases compared with the general population, and a median age of death that’s 14 years younger than that of white people. Researchers who have studied the issue say many problems stem from colonization and government policies such as forcing Indigenous people into boarding schools and isolated reservations and making them give up healthy traditions, including bison hunting and religious ceremonies. They also cite an ongoing lack of health funding.

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Congress budgeted nearly $7 billion for the Indian Health Service this year, of which roughly $1 billion is set aside for the referred-care program. A committee of tribal health and government leaders has long made funding recommendations that far exceed the agency’s budget. Its latest report says the Indian Health Service needs $63 billion to cover patients’ needs for fiscal year 2026, including $10 billion for referred care.

Brendan White, an agency spokesperson, said improving the referred-care program is a top goal of the Indian Health Service. He said about 83% of the health units it manages have been able to approve all eligible funding requests this year.

White said the agency recently improved how referred-care programs prioritize such requests and it is tackling staff shortages that can slow down the process. An estimated third of positions within the referred-care program were unfilled as of June, he said.

The Indian Health Service also recently expanded some delivery areas to include more people and is studying whether it can afford to create statewide eligibility in the Dakotas.

Jonni Kroll of the Little Shell Tribe of Chippewa Indians of Montana doesn’t qualify for the referred-care program because she lives in Deer Park, Washington, nearly 400 miles from her tribe’s headquarters.

She said tying eligibility to tribal lands echoes old government policies meant to keep Indigenous people in one place, even if it means less access to jobs, education, and health care.

Kroll, 58, said she sometimes worries about the medical costs of aging. Moving to qualify for the program is unrealistic.

“We have people that live all across the nation,” she said. “What do we do? Sell our homes, leave our families and our jobs?”

People applying for funding face a system so complicated that the Indian Health Service created flowcharts outlining the process.

Misty and Adam Heiden, of Mandan, North Dakota, experienced that firsthand. Their nearest Indian Health Service hospital no longer offers birthing services. So, late last year, Misty Heiden asked the referred-care program to pay for the delivery of their baby at an outside facility.

Heiden, 40, is a member of the Sisseton-Wahpeton Oyate, a South Dakota-based tribe, but lives within the Standing Rock Sioux Tribe’s delivery area. Native Americans who live in another tribe’s area, as she does, are eligible if they have close ties. Even though she is married to a Standing Rock tribal member, Heiden was deemed ineligible by hospital staff.

Now, the family has had to cut into its grocery budget to help pay off more than $1,000 in medical debt.

“It was kind of a slap in the face,” Adam Heiden said.

White, the Indian Health Service spokesperson, said many providers offer educational materials to help patients understand eligibility. But the Standing Rock rules, for example, aren’t fully explained in its brochure.

When patients are eligible, their needs are ranked using a medical priority list.

Connie Brushbreaker’s doctor at the Indian Health Service hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon. But hospital staffers said the unit covers only patients at imminent risk of dying.

She said that, at one point, a worker at the referred-care program told her she could handle her pain, which was so intense she had to limit work duties and rely on her husband to put her hair in a ponytail.

“I feel like I am being tossed aside, like I do not matter,” Brushbreaker wrote in an appeal letter. “I am begging you to reconsider.”

The 55-year-old was eventually approved for funding and had surgery this July, two years after injuring her shoulder and four months after her referral.

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Patients said they sometimes have trouble reaching referred-care departments due to staffing problems.

Patti Conica, a member of the Standing Rock Sioux Tribe, needed emergency care after developing a serious infection in June 2023. She said she applied for funding to cover the cost but has yet to receive a decision on her case despite repeated phone calls to referred-care staffers and in-person visits.

“I’ve been given the runaround,” said Conica, 58, who lives in Fort Yates, North Dakota, her tribe’s headquarters.

She now faces more than $1,500 in medical bills, some of which have been turned over to a collection agency.

Tyler Tordsen, a Republican state lawmaker and member of the Sisseton-Wahpeton Oyate in South Dakota, says the referred-care program needs more funding but officials could also do a “better job managing their finances.”

Some service units have large amounts of leftover funding. But it’s unclear how much of this money is unspent dollars versus earmarked for approved cases going through billing.

Meanwhile, more tribes are managing their health care facilities — an arrangement that still uses agency money — to try new ways to improve services.

Many also try to help patients receive outside care in other ways. That can include offering free transportation to appointments, arranging for specialists to visit reservations, or creating tribal health insurance programs.

For Brushbreaker, begging for funding “felt like I had to sell my soul to the IHS gods.”

“I’m just tired of fighting the system,” she said.

Have you had an experience navigating the Indian Health Service’s Purchased/Referred Care program that you’d like to share with KFF Health News for our reporting? Tell us here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Patients suffer when Indian Health Service doesn't pay for outside care • South Dakota Searchlight (2024)

FAQs

Patients suffer when Indian Health Service doesn't pay for outside care • South Dakota Searchlight? ›

Some of the Indian Health Service's 170 service units exhaust their annual pool of money or reserve it for the most serious medical concerns. Referred-care programs denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients in fiscal year 2022.

Who pays for Indian health services? ›

A: The Indian Health Service is funded each year through appropriations by the U.S. Congress.

Is the Indian Health Service part of the public health service? ›

The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally recognized Native American Tribes and Alaska Native people.

How does Indian Health Services coordinate with Medicare? ›

Indian Health Services provides coverage for care at IHS facilities. However, IHS is not insurance. Thus, Medicare can supplement IHS by providing coverage at a larger range of facilities. Your provides who accept IHS will also accept Medicare.

Which government is responsible for Native American health care provided by the Indian health services? ›

Delivery of Indian Health Care

To accomplish this goal, the Federal Government created Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), whose sole mission is to deliver health care to AI/ANs.

Are Native Americans entitled to free healthcare? ›

American Indians: Currently have access to free (or significantly reduced cost) health care through Tribal and Urban Indian health programs. Are not required to maintain minimal coverage (exempt from the individual mandate).

What benefits are Indians entitled to? ›

Financial Assistance and Social Services (FASS)

It gives financial aid to tribal members who cannot get Temporary Assistance for Needy Families (TANF), also known as welfare. Qualified members may receive money for: General needs such as food, clothing, shelter, and utilities. Child care.

Can a non-native go to IHS? ›

A person may be regarded as eligible and within the scope of the IHS health care program if he or she is not-otherwise excluded by provision of law, and is: American Indian and/or Alaska Native.

What is the Indian Health Care Improvement Act? ›

The Indian Health Care Improvement Act (IHCIA), the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives, was made permanent when President Obama signed the bill on March 23, as part of the Patient Protection and Affordable Care Act.

Are IHS employees federal employees? ›

We are staffed by approximately 15,000 dedicated and hardworking employees made up of a mixture of Civil Service, federal employees, and United States Public Health Services (USPHS) Commissioned Officers.

How much Native American blood do you need to get benefits? ›

The Bureau of Indian Affairs uses a blood quantum definition—generally one-fourth Native American blood—and/or tribal membership to recognize an individual as Native American. However, each tribe has its own set of requirements—generally including a blood quantum—for membership (enrollment) of individuals.

How much does it cost to live on an Indian reservation? ›

Average one-bedroom apartments go for about $500/month. The reservation's peripheries were defined by small, detached sprawl housing, which sells for around $145,000.

Which program most directly helps Native Americans obtain health care? ›

The Indian Health Service (IHS) is a part of the federal government that delivers health care to American Indians and Alaska Natives (AI/ANs) and provides funds for tribal and urban Indian health programs. Health insurance, on the other hand, pays for health care covered by your plan.

Who is paying for India's healthcare? ›

India has a multi-payer universal health care model that is paid for by a combination of public and government regulated (through the Insurance Regulatory and Development Authority) private health insurances along with the element of almost entirely tax-funded public hospitals.

What states have Indian clinics? ›

The Indian Health Service is divided into twelve physical areas of the United States: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson. Each area has a unique group of Tribes that they work with on a day-to-day basis.

Is the Indian Health Service good? ›

The Indian Health Service's goal is to improve the health of American Indians and Alaska Natives by providing quality and accessible health care services. However, many IHS facilities are not in good condition and IHS's medical equipment is aging—which can negatively affect patient care.

Who pays for health insurance in India? ›

Individuals or families buy health insurance policies from various public and private insurers. The insured pays a regular premium to the insurance company in exchange for coverage.

Are Indian Health Service employees federal employees? ›

We are staffed by approximately 15,000 dedicated and hardworking employees made up of a mixture of Civil Service, federal employees, and United States Public Health Services (USPHS) Commissioned Officers.

How underfunded is the Indian Health Service? ›

Henshaw: Per capita funding for IHS is significantly lower than that of other federally operated health service providers. So for Medicare, per capita spending is about three times more than IHS.

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