Think Out Loud

New Indian Health Service funding provides stability, but long-standing issues remain

By Gemma DiCarlo (OPB)
Jan. 20, 2023 8:12 p.m.

Broadcast: Monday, Jan. 23

For the first time ever, the Indian Health Service will receive just over $5 billion in advance appropriations. That means the agency will still be able to provide services to its roughly 2.6 million patients in the event of a funding lapse, such as a government shutdown.


While the stopgap funding will provide crucial stability for the agency, experts and advocates say IHS is still chronically underfunded. A federal report found that its 2022 budget — close to $7 billion — funded less than half of what patients needed. And a report from the Tribal Budget Formulation Workgroup, which advises the federal government, estimated the agency would need a $51 billion budget to provide adequate health services and address health disparities in Native American communities.

Melanie Henshaw is the Indigenous affairs reporter for Street Roots. She dug into these issues and joins us to explain what the new funding will and won’t do.

The following transcript was created by a computer and edited by a volunteer:

Dave Miller: This is Think Out Loud on OPB, I’m Dave Miller. For the first time ever, the Indian Health Service will receive just over $5 billion in advance appropriations. It means that even in the case of a government shutdown, the agency will still be able to provide services to its roughly 2.6 million patients. But experts and advocates say that this newfound stability does not change the larger picture – that of a chronically underfunded agency. Melanie Henshaw wrote about this recently for Street Roots, where she is the Indigenous affairs reporter, and she joins us now. Welcome to Think Out Loud.

Melanie Henshaw: Hi Dave, thank you so much for having me on.

Miller: Thanks for joining us once again. The Indian Health Service was created in 1955. What is the US government required to provide in terms of Native healthcare?

Henshaw: The U. S. Federal government is required to provide critical health care services to Native Americans and Alaska Natives who are the citizens of the 574 federally-recognized Tribes that are on Turtle Island, otherwise known as the United States of America. The IHS was created in 1955 to fulfill those obligations. So the US Federal government is required to not only provide these health services to Native folks, but to not bill them, individually. Citizens of federally recognized Tribes are able to receive services through IHS for everything from regular physical health care to mental health care, dental and vision.

Miller: What does the Indian Health Service look like in the Northwest?

Henshaw: The Indian Health Service is broken up into 12 service areas. Our local service area is called the Portland Service Area, and that services the 43 federally recognized Tribes located in Oregon, Washington and Idaho. And that’s going to look like a network of Tribally operated clinics. So individual Tribes that are operating their own health clinics, funded through IHS dollars as well as five IHS Clinics in Tribal communities and one at Chemawa Indian School down in Salem. So for the roughly 300,000 Native Americans and Alaskan Natives who receive IHS Services, they would go to one of those clinics or one of the IHS-funded Urban Indian Health Clinics like NARA Northwest, which is located in Portland.

Miller: What are the shortcomings within this large Portland branch of the Indian Health Service?

Henshaw: The issues that we see in the Portland service area are issues that are prevalent throughout other IHS service areas as well. Some of the issues that IHS clinics in this branch face are issues with staff recruitment, staff retention, inability to offer a full suite of services year round or potentially even the inability to operate the clinic year round. Now, in fiscal year 2021, which is the latest year for which data is available, 100% of dentist positions in the Portland service branch were vacant as well as 50% of medical officer positions, which is a senior physician position, and 50% of nursing positions were vacant in the Portland service area.

Miller: As you noted earlier, these are treaty rights, this is health care, guaranteed by rights. But if 100%, say, of the dental staff are not hired in this area, does that mean that if you’re a Native person in Portland or in Vancouver or other parts of Northwest, you simply cannot get dental care through this service?

Henshaw: Essentially when there is no staff or not enough staff to provide the service through one of the IHS clinics themselves, IHS has the capability to make referrals to outside medical service providers. So what would happen is if you were unable to get a service from IHS directly, they would be able to provide a referral for you to see a third party specialist to fulfill that service. Now, people I spoke with said that that can be really problematic in terms of access. It’s difficult for people who are expecting to receive all of their services through IHS to then have to find a third party provider or find a way to reach the third party provider to receive that service.

Miller: So let’s turn to the recent news from Congress. What’s the difference between annual funding, which has been the norm for many years now, and the advance appropriation for the next two years that IHS finally got, thanks largely to the work of Oregon’s Democratic Junior Senator, Jeff Merkley.

Henshaw: It’s essentially a difference in funding structure. Up until December of last year, IHS received all of its funding through what’s called annual appropriations. Annual appropriations are discretionary spending that takes place through appropriations legislation and essentially provides funding only through that fiscal year. That put IHS In a really difficult position. Whenever there was a budgetary lapse or government shutdown, IHS very quickly ran out of money and that seriously impacted IHS’s ability to offer services or even affected its ability to have clinics stay open.


Miller: You actually wrote about what happened in a shutdown, something like four years ago. What did you see nationwide?

Henshaw: In the 2018-2019 government shutdown, which lasted 35 days, IHS had to furlough approximately 25% of its staff. A whole host of IHS clinics were forced to close and Native people who received their health services through IHS actually died according to advocacy organizations that keep track of data from urban Indian organizations. Their data showed that five people who received services from urban Indian health clinics died during the shutdown and seven suffered drug overdoses.

So within a matter of weeks, IHS’s ability to function is dramatically impacted, which is why providing these advance appropriations - essentially a stopgap in the case of a government shutdown that will allow IHS to maintain its current level of service - is so important for the agency, according to all of the Tribal officials and Native health experts that I’ve spoken with.

Miller: Let’s turn from this issue of more surety in terms of funding to the actual level itself. I was really struck by the language put out by the federal government, by the Indian Health Service itself, in a brochure. It reads in part:

‘Even though healthcare is a treaty right, you should still get insurance. IHS has to work within yearly budgets approved by Congress and does not receive enough funds to meet all the health needs of American Indian and Alaska Natives.’

I read this as one federal agency throwing another part of the federal government just under the bus, saying ‘we’re not providing everything that you need. Sorry, get help on your own.’ What’s the estimate for the gulf between the needs in Indian country, in terms of health care, and the level of funding that has historically and even currently been available?

Henshaw: Both the federal government and Tribal health experts agree that the IHS is significantly underfunded, but it’s really a matter of debate just how underfunded IHS is. In July of last year, the Biden administration commissioned a report from the Department of Health and Human Services that essentially puts IHS’s funding at around 50% of where it needs to be. Now, if you contrast that with the estimate that comes from what’s called the Tribal Budget Formulation Work Group - a group of Native health experts that provides guidance to the federal government - they ask that the IHS receive $51.4 billion in funding, which is almost a 700% increase above its current budget.

So there’s a huge discrepancy between what Tribal health experts and the federal government essentially which holds the purse strings for funding, say in terms of how much IHS actually needs to provide all of the services that Native folks are promised through Trust and Treaties.

Miller: How does per person funding for the Indian Health Service compared to other federally-funded healthcare programs? I’m thinking about, say, Medicare or the VA.

Henshaw: Per capita funding for IHS is significantly lower than that of other federally operated health service providers. So for Medicare, per capita spending is about three times more than IHS. The VHA and Medicaid, as well as federal spending on federal prisoners, is more than double that per capita than IHS spending. So the government is putting double or even triple the amount of funding into these other health health services. And Tribal government officials that I spoke with said that points to essentially putting a lesser value on Native life than other lives.

Miller: What’s the connection between this level of funding – we could say this lack of funding for IHS - and the health statuses of Native Americans in the US?

Henshaw: Unfortunately, Native Americans and Alaska Natives have significantly worse health outcomes than other racial groups. And the average in the United States, Native Americans have a life expectancy that is approximately seven years shorter than the average life expectancy, as well as facing far worse outcomes with regards to COVID-19, diabetes, heart disease, obesity and other preventable diseases. And IHS says the reason for that is disproportionate levels of poverty, economic adversity, poor social conditions, as well as pointing to the delivery of health services and the ability to access health services. Now, even though Native Americans have such higher rates of these preventable deaths and disease at the same time, they’re also reporting significantly lower rates of having their own personal doctor or health care provider compared to the average population. So higher rates of disease and death, while simultaneously having less access to a doctor.

Miller: So what did you hear from experts or advocates about this overall funding situation? On the one hand, more stability because of this different kind of appropriation, this advance appropriation, but on the other, the long standing and continuing gap in the necessary level of funding.

Henshaw: Tribal officials that I spoke with see this as a significant step in the right direction. This advance appropriations is something that Native health advocates, Tribal government officials have been calling for, for more than a decade. So it’s a long time coming and there’s a lot of excitement in Indian country surrounding this decision.

At the same time, everybody is fully aware that IHS needs more money.  Everybody agrees. When I say everybody, I mean the federal government, patients, and Native health experts all agree that the IHS needs more funding. [They] say that this is a critical time to continue the push for additional funding and a switch towards what’s called mandatory funding, meaning that even with advance appropriations, the next fiscal budget that comes around, Congress could decide not to provide those appropriations. Mandatory funding would essentially mean the government no longer debates the funding on a yearly basis, and it’s a given that it would be funded like programs like Medicaid or Social Security.

Miller: Melanie Henshaw, thanks very much for joining us.

Henshaw: Dave, thank you so much for having me. Take care.

Miller: Likewise. Melony Henshaw is the Indigenous affairs reporter for Street Routes. She joined us to talk about the new found budget stability but ongoing lack of adequate funding for the Indian Health Service.

Contact “Think Out Loud®”

If you’d like to comment on any of the topics in this show, or suggest a topic of your own, please get in touch with us on Facebook or Twitter, send an email to, or you can leave a voicemail for us at 503-293-1983. The call-in phone number during the noon hour is 888-665-5865.