The Government Shutdown Aggravates an Already Strained Indian Health Services
The partial government shutdown enters its 27th day and no end is in sight. Although major health care programs like Medicaid and Medicare are funded, this is not true for the Indian Health Services (IHS). The IHS is a health care agency run by the Department of Health and Human Services but funded by the Department of the Interior (DOI). The agency serves 2.2 million American Indians and Alaska Natives (“AI/AN”s) from 537 federally recognized tribes in 37 states, providing direct care through 45 hospitals and 300 clinics. The agency also contracts with Tribes and tribal organizations to provide health services and funds 41 Urban Indian Health Programs (UIHPs) in 59 locations across the country. The federal government fulfills its trust obligation to provide health care to AI/ANs through the IHS. The DOI is caught up in the shutdown, meaning that the IHS is the only agency responsible for providing health care to millions that is experiencing a lapse in funding, despite being bound by centuries-old treaties to provide care. Already, people with medical problems are losing access to care: organizations providing critical health care services have shuttered, physicians and nurses are being forced to shift their time to providers who can pay them, and providers are choosing which medical issues do or do not get treated. All of these problems are going to get much worse if the shutdown continues.
Contextualizing the Government Shutdown among American Indian and Alaska Native Communities
The government shutdown seriously jeopardizes the health and health care of millions of people receiving care through IHS. AI/AN communities already shoulder health problems and social determinants of poor health at disproportionate levels. Compared to Whites, AI/ANs are 2.5 times as likely to live below poverty and more likely to report fair or poor health. AI/AN adults are twice as likely to have diabetes, 30 percent more likely to have hypertension, and 27 percent more likely to be obese. Compared to the overall population, AI/ANs experience serious psychological distress and post-traumatic stress disorder at higher levels, but they have limited access to mental health care.
Furthermore, even in the absence of the shutdown, IHS and tribal providers are profoundly underfunded to meet the health care needs of the communities they serve. Every year—particularly in states that have not implemented Medicaid expansion—there is a morally shocking triaging of medically necessary care in which some people with significant health care needs are turned away due to capped federal funds in many tribal providers.
Given this context, the shutdown amplifies an already aggravated health landscape for AI/ANs and a financially challenged health care system responsible for providing care to millions of people, with consequences already being felt throughout the country.
Health Care Services and Health of Millions Threatened
During the federal appropriations stalemate, IHS in principle continues to provide direct clinical health services and “other functions necessary to meet the immediate needs of patients, medical staff, and medical facilities.” In practice, this protection leaves major gaps that are rapidly getting worse. About 9,000 IHS employees, or 60 percent, continue to work because they provide “essential” services but are unpaid, including doctors and nurses. One of the key ways the shutdown is destabilizing tribal health care is that clinics are starting to lose staff to payable work.
Additionally, IHS is unable to provide any funding to Urban Indian Health Programs during the shutdown. UIHPs offer an array of services including primary and oral care, HIV treatment, substance use disorder treatment, behavioral health, and other preventive services. Among UIHPs, according to the National Council on Urban Indian Health, two facilities have closed and four are within 30 days of closing in the absence of funding.
Below we detail the impact--both realized and threatened—of the shutdown on the health and health care of AI/ANs on specific communities. The threat is imminent across urban and rural areas and geographic regions.
Baltimore, MD and Boston, MA
A nonprofit contracted by IHS operating in both cities started scaling back services at the beginning of the shutdown and then shuttered on Saturday. The nonprofit provides direct oral and behavioral health care services, and conducts outreach and provides referrals to other services. In the past weeks, the nonprofit had experienced four opioid overdoses, two of them fatal, demonstrating the need for continued services and the danger of halting care. The nonprofit was owed two months’ worth of reimbursements from IHS before the shutdown and before closing its doors. In addition to employing a staff composed of 90 percent AI/ANs, it also serves tribal citizens who work for the federal government as IHS headquarters are in Baltimore.
The Sault Tribe Health Division is losing about $100,000 daily of federal funds used to staff clinics and maintain a food pantry. It is considering furloughing employees and scaling back services. The tribe has resorted to redirecting its own funds to try to delay service gaps and ultimately closure, but that approach cannot last much longer.
The small and rural Yomba Shoshone Tribe does not have a clinic on the reservation. It does not generate its own income and depends on the federal government for funding for all its services, including public transportation. Members seeking clinical attention rely on public transportation to commute to an IHS clinic where clinical staff are working without pay for now, but because of the shutdown, they lack access to Department of the Interior-funded transportation services.
An organization providing community health services targeting urban AI/ANs is considering halting a variety of services if the impasse holds. Those services include an in-patient treatment center for substance dependency and a traditional medicine outpatient program that helps people with recovery. The organization receives a quarter of its funding from IHS.
Not Aid but Responsibility
The U.S. government is under treaty obligation to provide health care and other services, like public safety and education, to AI/AN tribes and nations. The funding these communities receive is not aid, it is a legal obligation between governments. The impasse is “destabilizing Native health delivery and health care provider access” and by doing so also “destabilizing Tribal Governments, families, children, and individuals.”
Beyond the critical short-term need to resolve the shutdown, the impact of the stalemate on the health and health care of AI/ANs demonstrates the grave need to allocate funding for these services on a mandatory basis, as other federal health care programs are funded. AI/ANs have a long history of unfair treatment by the federal government: they should never again have their medical care disrupted by a partisan appropriations fight. The government shutdown is imposing terrible risks on a disproportionately high-risk and underserved group of Americans. It is also exposing a fundamental structural injustice in our health care system.