Overview

Fulfilling the Trust Responsibility

Why does the federal government contribute to health care for tribal people? Health care is part of the federal trust responsibility and is based on treaty agreements—in other words, it is something the U.S. agreed to provide in return for Indian land.

The Indian health care system is the way that the federal government fulfills this responsibility, which occurs through three major pathways, collectively called the "I/T/U":

1. Indian Health Service (IHS): A federal agency that operates clinics and other facilities to provide direct patient care, advocates for the health of AI/ANs within the federal government, and provides funding to tribal health services managed by tribes, including Urban Indian Health Programs.
2. Tribal health services: Health care programs managed by tribes with funding from IHS.
3. Urban Indian Health Programs: A total of 33 nonprofit urban Indian organizations that provide health care to Indian people who live in cities, with funding from IHS and other sources.

In addition, Purchased or Referred Care (PRC) provides limited funding to pay outside providers for services that are unavailable through the other three pathways.

This system only partially fulfills the trust responsibility. Like other Americans, tribal members are unable to count on free, comprehensive health care for a number of reasons:

• Funding levels are far too low to meet the need.
• Funding is unpredictable and sometimes not allocated where the need is greatest.
• Health care for tribal members might be provided only in limited locations such as on a specific tribe’s reservation, which individual tribal members might be unable to access.
• The system is based on the assumption that tribal members’ care is still often covered through individual insurance, such as through employers or Medicare/Medicaid.
• Coordinating these multiple health care and insurance systems places an administrative burden on individuals and providers that can stand in the way of access to care.