First World Healthcare, Third World Resources: Indian Health Service (IHS)

The Veteran’s Administration (VA) healthcare system was in dire straights a few decades ago. The Vietnam war was pushed to the rear-view mirror, as were its brave warriors. But, increased scrutiny by the press has helped the VA transform itself in the past 20 years. Can IHS do the same?

The VA needed a few wars to get the attention and resources it needed for reform. I don’t think Natives can handle another genocide to get IHS what it needs! But, slowly, our people are being decimated by poor healthcare and misappropriated/scarce resources. Out-of-sight is out-of-mind and out-of-budget. Is the reason IHS cannot function like the VA basically come down to public relations?


The recent hearing on the poor state of IHS funding opened up a few old wounds…for me, and for anyone who cares about the health of Native People. In its best days, IHS is funded at only 50% of its estimated needs, and, thanks to OMB oversight and reckless politics, the sequester randomly cut essential funding from IHS, the only health system targeted for sequester cuts. Death rates have doubled on some reservations since the sequester and Tribes have had to cannibalize other essential services just to create a minimal amount of support for important health services. It is disturbingly, familiarly, sad.

But, sequester aside, IHS has never been the most efficient or effective healthcare system. It is steeped in poor funding, aging infrastructure, inferior resources, and uneven staffing. To be fair, IHS employs some of the most dedicated providers in healthcare, people who are providing first world medical care with third world resources. It is the system itself, moreso than the providers, that seems antiquated, constipated, and, at times corrupt with apathy. Unlike the VA healthcare system, a system that I think predominantly demonstrates a positive model of what national healthcare systems can be, IHS is a sad testament to what could happen in a national healthcare system if it is allowed to languish.

Put Me in Coach

When I first came to DC, I wanted to work in Native Healthcare Advocacy. I wanted to work for IHS. I studied healthcare systems and issues in college, after watching my family and Tribal members receiving what I would consider sub-optimal care on the reservations. My grandfather has been Tribal Health Director for years and I had seen him have to hustle to meet the health needs of the Tribe at a variety of levels, from rides to appointments to negotiating for IHS contract resources. There was so much need and so much room for improvement. In my naive head, I told people that I someday hoped to be the director of IHS!

I applied to IHS many times, but never received a positive reply (too qualified or not enough). I ended up at the National Indian Health Board (NIHB), a wonderfully dedicated non-profit focusing on Native healthcare, including working on a number of IHS projects. Even at NIHB, trying to help IHS at every turn, IHS seemed to be getting in its own way. There often seemed to be a great concern for bureaucracy over results. But, I thought, if I could just get in there I could make a difference. I kept applying, even for receptionist positions…nothing.

The facts espoused at the hearing a few weeks ago (pushed for by Senator Thune—I was quite surprised, yet very pleased!) were sadly familiar. There was the usual litany of travesties of neglect, many congressional. There were the oft repeated accusations highlighting misguided priorities within HHS, the government agency that houses IHS. And, there was the reflexive and complacent acquiescence of their challenges by IHS representatives. The stories, the reactions, the words themselves were so familiar. Yet, each time I hear them, a new part of my heart breaks.

What if The Scapegoat Believes She is Guilty?

What was different at the hearings this time? There seemed to be more emotion and outrage from congressional members. They seemed to be tired of the script. Frustrated politicians. That is good. I have not sensed such frustration from that side of the table at previous hearings. The frustration, the emotion, usually comes from the Tribal representatives who have to live these issues. Maybe we might be getting close to starting something? Maybe. But until IHS representatives risk offering meaningful answers and principled advocacy at the policy level, the results will not trickle down to where they need to land: the people.

Yet, at some level, I persist in my desire to work in IHS, despite my friends teasing me. My friends made fun of me again after I lamented about the state of Indian Healthcare and the apparent apathy of IHS representative. Who would want to jump on a sinking ship that even the captain seems to have all but abandoned? To be fair, this apathy can be born of learned helplessness in a system that routinely and almost purposely neglects the health needs of its poorest people, despite the codified mandate of treaty obligations and court rulings.

But, absent passion and strategy, one merely manages. And, management alone can’t fix an under-resourced program. I told my friends that I still wanted to be part of the solution. They see IHS as a place to work if you want job security. I see it as a place to work for your people. But, when young people who are willing to commit to a very difficult fight, willing to storm the windmills of bureaucracy with sensible passion, are routinely turned away by aging IHS functionaries, I have to wonder about the future of Indian Healthcare.

I have friends doing great work on Indian Healthcare from outside of the HHS/IHS system at places like NIHB and NCAI. Maybe that is where the voice of the people will find a way to rally action. To be fair, I also have friends who have gone to work for IHS. Friends with strong ideals and commitment. I have seen a few acquiesce to the culture there. But, most are quietly trying to figure out how to make positive change in such an unwieldy system. Until those people reach critical mass, however, the IHS culture of bureaucracy will continue to be a scapegoat at these hearings, rather than more important issues of service and resource allocation.

Step It Up, IHS!

Watch the hearing for yourself. Hear the statistics. Listen for the passion in the presentations from tribal members. Be surprised by the disgust and almost derisive tone of the congressional members. Then listen to the IHS response. Flat and apologetic. Maybe they are working more effectively behind the scenes. But, allowing people to focus on the inadequacies of IHS process (all be they real), rather than the abusive inequities and broken promises at the root of the larger issues does not move these important issues forward. As we have seen time and time again, we need to make our voices heard and throw light where it can have the most positive effect…especially if there is a camera and congressional members in the room! Step it up, IHS. And, if you need help, my e-mail address is


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