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The IHS: A Blog Series, Part 3: Funding as a Barrier to Care

The poor health outcomes among American Indian and Alaskan Native (AI/AN) individuals are disproportionately higher in the United States for a multitude of reasons. AI/AN life expectancy is five and a half years shorter than the average and they continue to face higher rates of chronic diseases such as diabetes, liver disease, and lower respiratory disease (1). One of these reasons is attributed by many to the persistent and chronic underfunding of the IHS (2, 3


For FY 2022, the needs of the IHS is estimated to be $48 billion by the Tribal Budget Formulation Workgroup (TBFWG)(3). While the TBFWG requested, at a minimum, $12.759 billion for the year, the President’s Budget request was only $8.5 billion. This was, however, the highest administration IHS budget request ever (3,7). As a discretionary spending program (as opposed to Medicare funding, for example), the IHS has to compete with other agencies, such as the Department of Defense, for funding every year (2). In 2019, healthcare spending for the IHS per user was $4,078 compared to $11,582 per capita spent for the general population (5,6). This discrepancy is thought to contribute to worse health outcomes for AI/AN patients (3) 

The routine underinvestment of IHS manifests in numerous ways. In addition to limitations in funding for medical care, additional providers and services, the average age of IHS health care facilities is greater than 37 years. Due to increasing user population and insufficient space, many facilities are currently severely overcrowded, impeding the access of American Indians/Alaska Natives to health care and contributing to the limitations in increasing the number of health care providers. (8). IHS funding has also simply not kept up with the inflation of medical costs (4). Additional funds could significantly improve access to specialty providers, services, and technology which are crucial for the care of AI/AN patients. In addition to these direct care funding limitations, as mentioned in the prior blog, referral coverage for specialty providers, services, and technology are significantly limited as well. Without secondary insurance, these services often require significant and often out of reach personal funds. Clearly, such circumstances can greatly affect health outcomes (2).  

(Source: GAO

Funding limitations affect the IHS’s ability to recruit and retain quality healthcare practitioners. Vacancies and high provider turnover are a detriment to quality and continuity of care. The Government Accountability Office (GAO) found in 2018 an average of 25% vacancy rate for all providers, with physician vacancies at a 34% rate (9). The TBFWG suggests increasing the budget for the Indian Health Professions line by $3.4 million to help combat this issue (3).  

Medicaid and other third- party funding are crucial for the IHS’s operation. IHS received only about $1 billion from these sources in FY 2019. Despite this supplement, the IHS still requires significant additional monetary support to meet its needs (3). To fulfill its Trust responsibility and ensure the adequate provision of healthcare to AI/AN communities, additional funding support for the IHS and Tribal communities is required from the United States government. 

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