The federal trust responsibility: congressional policy on American Indian and Alaska Native health and recommendations to improve health outcomes

For over 500 years, American Indians and Alaska Natives (AI/ANs) have been afflicted with higher rates of morbidity and mortality than that of the general population. These marked disparities in health status persist today, with the Indian Health Service (IHS) reporting higher AI/AN mortality rates from chronic liver disease and cirrhosis (368% higher), diabetes mellitus (177% higher), unintentional injuries (138% higher), and chronic lower respiratory diseases (59% higher). Ironically, AI/ANs are the only ethnic groups in the United States who are born legally entitled to healthcare. Through treaties with Indian tribes, Congress has promised to provide education, housing, and healthcare to the AI/AN population. Today, the federally-funded IHS delivers services to 2.2 million AI/ANs through direct health care services and tribally operated health care programs. So why do American Indians and Alaska Natives have some of the worst health outcomes? Congress is not unfamiliar with providing healthcare to special populations; it also manages programs such as Medicare, the Veterans Administration, Tricare, and the Bureau of Prisons. However, a closer comparison amongst federal health programs reveals a stark inequality in Congressional appropriations. Congress spends less per head on the American Indian or Alaska Native than any other federal healthcare program; the average Medicare patient is budgeted over four times as much funding. An awareness of how differences in funding can impact health disparities is of great public health importance. Understanding where Congress is channeling its funds gives direct insight to those programs and populations it prioritizes most, and accordingly, questions regarding health equity manifest. Equally significant is a realization of how federal health policy, more so than the advancement of medical innovations, can improve the outcomes of AI/ANs. The federal government has not fulfilled its promise to secure AI/AN health and must provide more funding support to tribes to in order to do so. The Patient Protection and Affordable Care Act provides opportunities for tribes to apply for supplementary funding through grants in Comparative Effectiveness Research. These grants will allow tribes to better enable best practices for alternative avenues of healthcare delivery, and provide a greater understanding towards healthcare disparities.