When the Indian Health Service can’t provide care to Native Americans, the federal agency can refer them to other providers, but each year the agency denies tens of thousands of requests to subsidize such care, leaving patients without treatment or forced to pay high medical bills out of pocket.
In theory, Native Americans You have the right to free medical care When the Indian Health Service pays for facilities or tribal-controlled facilities. In practice, the agency Chronically underfunded In addition, medical services are limited due to a shortage of personnel, and access to medical care remains limited in vast areas of the country.
Purchased and referred care programs are intended to fill that gap by paying outside providers for services that patients might not be able to get at agency-funded clinics or hospitals, such as cancer treatment or pregnancy care. But patients, elected officials and people who work with government agencies say a lack of resources, complex rules and administrative inefficiencies have severely hindered access to the referral programs.
The Indian Health Service, part of the Department of Health and Human Services, serves approximately 2.6 million Native Americans and Alaska Natives.
Native American Qualify for the Referral Care Program If you live on tribal land Only 13% — or the country’s “Delivery AreaThey are typically designated “delivery areas” that include surrounding counties, and in limited cases, people who live within the delivery areas of other tribes are also covered, but Native Americans who live beyond those boundaries are not.
But eligible patients are not guaranteed financial or timely assistance, with some of the Indian Health Service’s 170 service units running out of annual funding or reserving funds for their most serious medical problems.
The referral care program denied or deferred about $552 million in spending on about 120,000 requests from eligible patients in fiscal year 2022.
As a result, Native Americans may have less access to health care and may be at increased risk of death or serious illness for those with preventable or treatable medical conditions.
This problem is not new. Federal watchdogs Reported Concerns In the program For decades.
Connie Brushbraker, a member of the Rosebud Sioux Tribe, has been denied funding or put on a waiting list at least 14 times since 2018. She said it doesn’t make sense for officials to refuse to pay for treatment that is approved after her health problems become more severe and expensive.
“We try to take precautions before it gets to the point where we need surgery,” said Brushbraker, who lives on a tribal reservation in South Dakota.
Many Native Americans claim the U.S. government is violating treaties with tribal nations under which it promises to provide for tribal health and welfare services in exchange for land.
“Elders here keep saying, ‘By treaty right, they should be able to provide us with these services,'” said Lyle Rutherford, a council member for the Blackfoot tribe in northwestern Montana who also worked for the Indian Health Service for 11 years.
Native Americans have a higher incidence of disease than the general population, and the median age at death is 14 years younger higher than whites. I researched the problem They say many of the problems stem from colonization and government policies that forced Native Americans into boarding schools and segregated reservations and forced them to abandon healthy traditions like bison hunts and religious ceremonies. They also point to continuing underfunding of health care.
Congress has appropriated about $7 billion for the Indian Health Service this year, with about $1 billion set aside for referral health programs. A committee of tribal health and government leaders has long proposed funding far beyond the agency’s budget. Latest Report The Indian Health Service says it needs $63 billion to meet patient needs in fiscal year 2026, including $10 billion for referral care.
Improving referral care programs is a top goal for the Indian Health Service, said agency spokesman Brendan White, who said about 83 percent of the health stations the agency manages were able to approve all of their eligible funding requests this year.
White said the department has made improvements recently. How to Refer Care The program is prioritizing such requests and is grappling with staffing shortages that could slow the process: As of June, an estimated one-third of the positions in the referral care program were vacant, he said.
The Indian Health Service also Recently expanded Expanding delivery areas I’m studying Whether the Dakotas can afford to create statewide eligibility.
Johnny Kroll, of the Little Shell Tribe of Montana Chippewa Indians, is not eligible for the referral care program because he lives in Deer Park, Washington, about 400 miles from his tribe’s headquarters.
She said tying eligibility to tribal lands reflects old government policies intended to keep Native people in one place, even if it meant limiting their access to jobs, education and health care.
Kroll, 58, said she sometimes worries about the medical costs of aging, and that moving to qualify for the program seems unrealistic.
“There are people all over the country,” she said. “What do we do? Do we sell our homes, leave our families, our jobs?”
People applying for financial assistance are informed that the Indian Health Service Created a flowchart Here’s an overview of the process:
Misty and Adam Heiden of Mandan, North Dakota, experienced this firsthand: Their local Indian Health Service hospital no longer offers birthing services, so late last year Misty Heiden asked a referral care program to pay for her to give birth at an outside facility.
Hyden, 40, is a member of the Sisseton Wahpeton Oyate Tribe, based in South Dakota, but lives within the delivery area of the Standing Rock Sioux Tribe. Native Americans who live in other tribes’ territories, like hers, are eligible if they have close ties. Hyden is married to a Standing Rock tribal member, but decided that hospital staff were not eligible.
Now the family has had to cut back on their grocery budget to pay off more than $1,000 in medical debt.
“It was like a slap in the face,” Adam Heiden said.
White, the Indian Health Service spokesman, said many health care organizations Educational Resources To help patients understand eligibility. However, Standing Rock RulesFor example, the brochure does not explain it well enough.
If the patient is eligible, their needs are Medical Priority List.
Dr. Connie Brushbraker of the Indian Health Service Hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon. Hospital staff He said the unit only caters to patients who are at imminent risk of death.
At one point, a staff member at the referral care program told her that the pain was tolerable, even though it was so severe that it limited her work load and forced her to rely on her husband to put her hair in a ponytail.
“I feel abandoned and unimportant” – Brushbreaker Written in the appeal“I urge you to reconsider.”
The 55-year-old was eventually approved for funding and underwent surgery in July this year, two years after injuring her shoulder and four months after being referred.
Patients said they sometimes struggle to reach referred medical departments due to staffing shortages.
Patty Konica, a member of the Standing Rock Sioux Tribe, developed a serious infection in June 2023 and required emergency treatment. She applied for financial assistance to cover the costs of her treatment, but says she has yet to receive a decision, despite multiple calls and in-person visits with referred care staff.
“We’ve been passed around from one place to another,” said Konica, 58, who lives in the tribe’s home base in Fort Yates, North Dakota.
She now owes more than $1,500 in medical bills, some of which have been turned over to debt collection agencies.
Rep. Tyler Tordsen, a Republican who represents Sisseton-Wahpeton, South Dakota, said the referral care program needs more funding, but that officials could do “better manage their finances.”
Some service units have a large amount of Remaining fundsBut it’s unclear how much of this money is unspent and how much is being used to fund approved claims that are in the claims process.
meanwhile, More Tribes The government is managing health facilities (still a mechanism for using government funding) and is looking for new ways to improve services.
Many health care organizations are trying to help patients get outside care in other ways, including providing free transportation to appointments, arranging for specialists to visit reservations, and building tribal communities. Health Insurance System.
For Brushbreaker, begging for financial assistance “felt like having to sell my soul to the IHS gods.”
“I just got tired of fighting the system,” she said.
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