A Federal Indian Health Insurance Plan: Fulfilling a solemn obligation to American Indians and Alaska Natives in the United States

The Indian Health Service (IHS) is but the latest effort to honor the constitutional and treaty commitment made to deliver health care to American Indians and Alaska Natives in the United States. The agency currently serves over 2.5 million American Indians and Alaska Natives through IHS-operated health facilities, as well provides funding support for contractual delivery of health services by Tribes to their constituents. Not unlike its predecessors, however, the IHS is struggling to fulfill its stated mission. Access to specialty care remains limited through the agency, particularly for Urban Indians, due to limited fiscal support of the Purchase-Referred Care Program. As a result of chronic underfunding stemming from Congressional inaction, the agency faces perennial understaffing and leadership turnover. In addition, the IHS is structurally unprepared to address the progressive urbanization of Alaska Natives and American Indians, more of whom now live in New York City than in North Dakota. Given these challenges, a renewed approach is warranted. In this essay, we review the history of the IHS, examine its current fiscal challenges, outline the ongoing demographic shift of AI/AN toward urban centers, and call for the creation of a Federal Indian Health Insurance Plan. Offered as a benefit to all American Indians and Alaska Natives without cost-sharing, the plan would be applicable both on and off tribal lands. Funded through mandatory appropriations, the plan would significantly increase fiscal support for AI/AN health programs and work to reduce health disparities affecting AI/ANs in the United States.