The establishment of the Indian Health Service (IHS) forms the basis of the federal government's health care obligations to American Indian / Alaska Natives (AI/AN).Treaty health care terms represented part of the government's payment to Indian tribes for giving up their ancestral homelands to the United States. These treaties are contracts between the federal government and sovereign tribal governments. During the 1950s, the Indian Health Service was established within the U.S. Public Health Service to deliver basic health services for Native Americans. During the 1960s and 1970s, IHS began transitioning toward the concept of "tribal self-determination," with tribal governments taking greater responsibility for the management of federal programs provided to them.
The Indian Self-Determination and Education Act was enacted in 1975. In the 1980s, there were further increases in funding for Indian health programs with special emphasis on professional excellence, construction of modern health facilities, and movement toward greater tribal involvement. The movement toward "self-determination" continued to grow through the 1990s, and Congress passed legislation extending tribal self-governance, allowing tribes to contract and compact for the programs, services, functions, and activities within IHS and the Bureau of Indian Affairs. A student loan repayment program (IHSLRP) for health care provider training was implemented under IHS supervision. This offers added incentive for health care providers to take employment at IHS, tribal self-governed and urban Indian health center facilities.
"The Indian Health Service Loan Repayment Program (IHSLRP) annually consults with Indian tribes, tribal organizations, Urban Indian Health Organizations, and the various health facilities operated by the IHS to determine their staffing needs. Beginning in fiscal year (FY) 2004 and continuing through FY 2010, chiropractic medicine was not identified as one of the needed professions for which priority would be given for the IHSLRP; thus, it was eliminated from the list of eligible professions."
According to the 2010 IHS Fact Sheet, the Indian Health Service administrates its services through a U.S. system of 12 area offices and 161 IHS and tribally managed service units. In 2009, IHS administered 29 hospitals, 59 health centers, 28 health stations and 34 urban Indian health centers for the American Indian / Alaska Native population. Self-governed tribes currently maintain 16 hospitals, 237 health centers, 166 Alaska village clinics and 93 health stations. Over 1.9 million American Indians and Alaska Natives residing on or near reservations are covered with these combined services.
Starting in 1994 with seven tribes transitioning to Title V self-governance, there are now more than 330 tribes that have made the shift from IHS managed health programs to tribal self-governance, more than half of the 564 federally recognized tribes. There are also approximately 234 tribes and tribal organizations that contract under Title I, with more than half of the entire IHS budget managed by sovereign tribes through self-determination contracts or self-governance (government-to-government) compacts.
The 34 Indian urban health centers in the United States serve to provide a safety net for AI/AN urban Indians who have moved off their enrolled reservation or are descendants of tribal members relocated in the 1950s as part of the federal relocation program by the Bureau of Indian Affairs. Over 600,000 American Indian / Alaska Natives reside in these urban center regions. A per-capita personal health care expenditure comparison of U.S. general population to IHS expenditures is $6,826 to $2,690. (IHS Fact Sheet)
Gathering current data on the numbers of graduating doctors of chiropractic who are American Indian or Alaska Native directly from the colleges has been difficult because of confidentiality issues. All chiropractic colleges that receive federal financial aid must provide the federal government with ethnicity/race information through the Integrated Postsecondary Education Data System (IPEDS). For the period covering 1996-2007, 119 American Indian / Alaska Natives graduated from U.S. chiropractic colleges (89 males, 30 females) with the DC degree. The total number of AI/AN doctors of chiropractic is unknown other than those found between 1996-2007.
While there are many native and non-native chiropractors working in the vicinity of tribal reservations, there are only six confirmed Native American DCs employed in tribal self-governed health facilities. One DC, Dr. F. Scott Powell, has been hired as health director of the Shoalwater Bay Tribal Clinic in Tokeland, Wash.
The Indian Health Care Improvement Act (IHCIA), the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives, expired in 2000 but was made permanent as part of H.R. 3590, the Patient Protection and Affordable Care Act, passed and signed on March 23, 2010 by President Obama. It includes many major changes and improvements to facilitate the delivery of health care services, such as increasing the proportion of all degrees in the allied health professions awarded to Indians so that the proportion of Indian health professionals is raised to at least the level of that of the general population. The term health profession means allopathic medicine, family medicine, pediatrics, nursing, public health, dentistry, psychology, social work, marriage and family therapy, naturopathic medicine, chiropractic medicine and all other allied health professions.
Although chiropractic services are included in the IHCIA, most Native Americans are being denied rightful access to chiropractic care. Native American DCs also are not afforded the same opportunities for employment as other designated health care occupations. The 119 Native American chiropractors who graduated from accredited chiropractic colleges between 1996 and 2007 have only one loan repayment program candidate award as a contracted health care provider. A discipline chief for chiropractic health care will be required to help meet the needs of the federally recognized tribes working under IHS, self-governed tribal health centers or urban Indian health centers to establish priorities and to help administer the IHSLRP.
Both Medicare and Medicaid recognize doctors of chiropractic as physicians. Within the past decade, chiropractors have been officially positioned in the Veterans Health Administration and Department of Defense facilities. Additionally, chiropractic care is available to members of Congress at the U.S. Capitol through the Office of the Attending Physician. At least 20 percent of Americans with back pain consult a chiropractor as a first provider choice, as back pain remains one of the most costly and common reasons for medical primary care visits.
The mission of IHS can be advanced through the selection of chiropractors trained to provide wellness services and to monitor and detect population-specific needs and chronic diseases, such as diabetes, obesity, alcoholism and tobacco addictions. While IHS has until now maintained a "no demand, no need" policy regarding chiropractic, the future of the chiropractic profession in Indian health care delivery will hopefully grow exponentially with the expansion of tribal self-determination and self-governance.
Dr. Gary Auerbach, founding president of the World Federation of Chiropractic, holds a graduate certificate in public health from the University of Arizona, Zuckerman College of Public Health. He is the administrator of the American Indian / Alaska Native Doctors of Chiropractic Ad-Hoc Committee. If you are an American Indian / Alaska Native DC in the U.S., visit www.aiandc.org to learn more.
Dr. Monica Smith is with the Palmer Center for Chiropractic Research.
Click here for previous articles by J. Michael Menke, MA, DC, PhD.