When the Indian Health Service fails to 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 forgo care or pay exorbitant medical bills out of pocket.
In theory, Native Americans are right to free health care when the Indian Health Service pays the bill at its facilities or tribally operated sites. In reality, the agency is chronically underfunded and understaffed, resulting in limited medical services and large areas of the country without easy access to care.
Its Purchased/Referred Care program aims to fill gaps by paying outside providers for services that patients might not be able to get through an agency-funded clinic or hospital, such as cancer treatment or pregnancy care. But resource shortages, complex rules and administrative snafus 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, provides care to approximately 2.6 million Native Americans and Alaska Natives.
Native Americans qualify for the directed assistance program if they live on tribal lands — only 13% do so — or within their nation “delivery area,” which usually includes surrounding counties. Those who live within another tribe’s surrender area are eligible in limited circumstances, while Native Americans who live beyond those boundaries are excluded.
However, eligible patients are not guaranteed funding or timely care. Some of the Indian Health Service’s 170 service units exhaust their annual fund of money or reserve it for the most serious medical problems.
Directed care programs denied or deferred nearly $552 million in spending on approximately 120,000 eligible patient claims in fiscal year 2022.
As a result, Native Americans may forgo care, increasing the risk of death or serious illness for people with preventable or treatable conditions.
The problem is not new. Federal control agencies have concerns reported with the program for decades.
Connie Brushbreaker, a member of the Rosebud Sioux Tribe, has been turned down or put on a waiting list for funding at least 14 times since 2018. She said it makes no sense that the agency sometimes refuses to pay for treatment that will only be approved when a health problem becomes more serious and expensive.
“We try to do these things preemptively before it gets to the point where it requires surgery,” said Brushbreaker, who lives on his tribe’s reservation in South Dakota.
Many Native Americans argue that the U.S. government is violating treaties with tribal nations, which often promised to guarantee the health and well-being of tribes in exchange for their lands.
“They keep having my elders here say, ‘There are treaty rights that state they should be able to provide these services to us,’” said Lyle Rutherford, a council member of the Blackfeet Nation in northwestern Montana, who said he also worked at the Indian Health Service for 11 years.
Native Americans have high disease rates compared to the general population and an average age of death that is 14 years younger compared to that of whites. The researchers who have studied the issue They say many problems stem from colonization and government policies, such as forcing indigenous people to go to boarding schools and remote reservations and giving up healthy traditions, including buffalo hunting and religious ceremonies. They also cite a continuing lack of funding for health care.
Congress has allocated about $7 billion to the Indian Health Service this year, with about $1 billion for the referral program. A committee of tribal health and government leaders has long made funding recommendations that far exceed the agency’s budget. His latest report says the Indian Health Service needs $63 billion to cover patient needs in fiscal year 2026, including $10 billion for directed care.
Brendan White, a spokesman for the agency, said improving the referral program is a major focus of the Indian Health Service. He said about 83 percent of the health units it manages were able to approve all eligible funding requests this year.
White said the agency has recently improved as a reference health care programs are prioritizing such requests and addressing staffing shortages that can slow the process. An estimated one-third of positions within the referral assistance program remained vacant as of June, she said.
The Indian Health Service too recently expanded some delivery areas to include more people and is studying if it can afford to create statewide eligibility in the Dakotas.
Jonni Kroll of the Little Shell Tribe of Chippewa Indians in Montana is not eligible for the referral health care program because he lives in Deer Park, Washington, about 400 miles from his tribe’s headquarters.
He said tying eligibility to tribal lands echoes old government policies aimed at keeping Indigenous peoples in the same 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. Relocating to qualify for the program is unrealistic.
“We have people living all over the country,” he said. “What do we do? Sell our homes, leave our families and our jobs?”
People applying for funding are faced with a system so complicated that the Indian Health Service created flowcharts outlining the process.
Misty and Adam Heiden, of Mandan, North Dakota, have experienced this firsthand. The nearest Indian Health Service hospital no longer offers birthing services. So late last year, Misty Heiden asked her referral program to pay for their baby to be delivered at an off-site facility.
Heiden, 40, is a member of the Sisseton-Wahpeton Oyate tribe, based in South Dakota, but lives on the Standing Rock Sioux tribe’s calving grounds. Native Americans who live on another tribe’s land, like her, are eligible if they have close ties. Although she is married to a Standing Rock tribe member, Heiden was deemed ineligible by hospital staff.
The family has now had to cut their grocery budget to pay off more than $1,000 in medical debt.
“It was a bit of a slap in the face,” Adam Heiden said.
White, the Indian Health Service spokeswoman, said many providers offer teaching materials to help patients understand eligibility. But the Standing Rock Rulesfor example, they are not explained exhaustively in the relevant brochure.
When patients are eligible, their needs are classified using a list of medical priorities.
Connie Brushbreaker’s doctor at Indian Health Service Hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon. But hospital staff He said the unit only covers patients at imminent risk of death.
She said that, at one point, a health care worker told her she could handle the pain, which was so severe that she was forced to limit her job duties and rely on her husband to tie her hair in a ponytail.
“I feel like I’m left out, like I don’t matter,” Brushbreaker written in an appeal letter“Please reconsider.”
Funding was ultimately approved for the 55-year-old woman, who underwent surgery in July, two years after her shoulder injury and four months after she reported it.
Patients said they sometimes have difficulty reaching the care departments they are referred to due to staffing issues.
Patti Conica, a member of the Standing Rock Sioux Tribe, needed emergency care after contracting a serious infection in June 2023. She said she applied for funding to cover the costs, but has yet to receive a decision on her case despite repeated calls to health care providers and in-person visits.
“They made fun of me,” said Conica, 58, who lives in Fort Yates, North Dakota, her tribe’s headquarters.
He now owes more than $1,500 in medical bills, some of which were turned over to a debt collection agency.
Tyler Tordsen, a Republican state legislator and member of the Sisseton-Wahpeton Oyate in South Dakota, says the directed assistance program needs more funding, but officials could also do a “better job of managing their finances.”
Some service units have large amounts of remaining fundingBut it’s unclear how much of that money is unspent dollars and how much is funds earmarked for approved and billed cases.
In the meantime, more tribes are running their own health facilities, an arrangement that still uses agency money, to try new ways to improve services.
Many also try to help patients get outside care in other ways. This may include offering free transportation to appointments, arranging appointments with specialists, or creating tribals. health insurance programs.
For Brushbreaker, asking for funding “was like selling your soul to the gods at IHS.”
“I’m just tired of fighting the system,” she said.
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