Access to health care for the indigenous population within the United States borders is different than the other health insurance systems available for the general population. The relationship and support of the native communities in the US by the then newly formed US government began as an agreement between sovereign nations. This relationship was written into the Constitution, but has had many problems over the course of time. Many provisions and offerings of medical and food assistance to native people was directly attached to the regulations that tribes remain within certain restricted land areas, typically referred to as reservations. Even when this was followed, this services regularly arrived months late. In fact, many attribute the start of poor health for natives to the relegation of indigenous communities on reservations, which has created problems in developing health care for them over time. An example of this is the focus on assimilation of native people into dominant white culture, especially around health practices. This directly influence the removal of medical care from these reservations and forced those who needed care to leave their community. After a Commission was lead in 1928 to evaluate the status of health in indigenous communities, it was determined that this standard of assimilation was in fact causing more harm than good. Native medicine healers were requested to participate in the federal health provisioning for their people. Once the Indian Health Service, as we know it today, was formed, it was held under the Public Health Service Office. The first priority of this office was to create facilities in the remote areas that most of the native people were being brought from. This would not only increase access to care, but also create jobs in the community. The Indian Health Services is now an agency within the Department of Health and Human Services. It's responsible for providing federal health services to American Indians and Alaskan native people. Anyone who is part of one of the 574 federally recognized tribes in the United States is eligible for services. To be clear, Indian Health Services is not health insurance, but a health service system. Only those who qualified may go through the proper registration to receive care through these services. It is the primary health care provider and health advocate for indigenous people. The Indian Health Service budget formulation process consists of annual forums for Indian tribes and organizations to interact with the Indian Health Service to establish program priorities and budget recommendations. Their involvement ensures that the Indian Health Service budget reflects the evolving health needs of indigenous communities. Access to care gaps persist with the Indian Health Service that should be noted. Although there are 574 federally recognized tribes to date, there are many more tribe still seeking federal recognition. Therefore, some American Indians and Alaskan natives are not eligible to seek care from the Indian Health Service. The Indian Health Service is divided into 12 physical areas of the United States, and they are primarily focused in rural areas in spite of the fact that 78 percent of indigenous people now live in cities and urban areas. The Indian Health Service is also chronically underfunded expenditures per patient are just 1/4 of the amount spent in the Veterans Health Care System and 1/6 of what is spent for Medicare. Indian Health Service facilities are on average under staffed by 25 percent. Remember, Indian Health Service delivers care. The purpose of health insurance is to protect individuals from paying the full cost of medical services when they are injured or sick. Even people who are eligible for Indian Health Service need health insurance in order to see specialists and seek health care when Indian Health Service is not an option. Medicaid provides health coverage to low income indigenous individuals who meet Medicaid eligibility standards, regardless of their eligibility to receive services from the Indian Health Service. In 2018, Medicaid covered 1.8 million indigenous people. The Affordable Care Act expanded Medicaid, but not all states expanded Medicaid, so not all indigenous people have access to expanded Medicaid as a result. The Indian Health Service has historically been a leader in health information technology. However, their current electronic health record systems are behind current technology capabilities and heading in a direction where the system will no longer be viable. The Indian Health Service is underfunded to address this issue. Lastly, due to underfunding and limited locations, wait times and travel times for patients seeking care have been challenging to address. In summary, the Indian Health Service provides critical infrastructure for health care for indigenous communities in the US. However, gaps in access and coverage of services persists that contribute to health inequities for these communities. Another special population that is important to highlight are veterans, people who served in active military, naval or air service, and who discharged or released from their duty under conditions other than dishonorable. There are around 19 million US veterans, representing less than 10 percent of the US adult population. It is allocated $68 billion annually and it is the largest health system in the nation. The Veterans Administration, commonly known as the VA, has been providing care since the Civil War. The post-World War II era saw the need to dramatically re-envision the role of VA and caring for nearly 16 million new veterans. For the first time the US military saw more casualties due to combat injuries than diseases, and improved battlefield medical care met more service members returned home with wounds that were not previously survivable. World War II saw a radical reorganization of the VA health care services. There was an undertaking of key initiatives, including establishing new veterans hospitals to accommodate care for veterans of all eras and conflicts and converting former military hospitals into veterans facilities. Locating VA hospitals alongside major medical schools to promote research and innovation. Responding both to US physicians shortages and providing training for veterans pursuing medical education after the war. Also incorporating mental health services and facilities into the design and operations of new VA hospitals for the first time, re-envisioning the concept of the modern General Hospital. Lastly, creating a pilot program known as the Michigan Plan to allow veterans to be treated by local physicians, expanding access to care where VA care was not available. While many were claiming benefits being provided by the VA, it was difficult to access newer forms of care for most veterans, such as care for post-traumatic stress disorder. The Veterans Health Care Amendment Act in 1979 expanded VA centers across the nation that focused on this type of counseling and was primarily used for Vietnam veterans. These centers eventually expanded to all veterans and now also provide services for those with other needs such as addiction disorders. It is important to note that historically, not all veterans were given access to VA care. For example, indigenous people volunteered and served in higher percentages in the military than any other ethnicity. Their special skills resulted in many benefits and victories for US Armed Forces. Indigenous people who served in the US military were not allowed to receive full benefits, including medical benefits, even though they were veterans until 1921. Pre-civil Rights era did not seek care for Black Americans until the first segregated hospital was opened in 1923 in Tuskegee, Alabama. Segregation based on race did not end in VA hospitals until 1954. While the injustice of previous lack of services to Black and indigenous veterans is still not widely recognized today. The VA did establish a center for minority veterans in 1994. Their focuses on caring for this population. Today, the VA healthcare system is the largest in the country. It focuses on all facets of health care from primary care to counseling and inpatient work. The VA surprisingly does not benefit all veterans. There are very specific guidelines about who qualifies and for what. For example, only those who have served in active duty qualify. That does not include the reserves or the National Guard. One cannot have been dishonorably discharged, but there is a petition process to receive benefits, even if this happened. If one is enlisting after September 7th,1980, they must serve 24 continuous months or full period of active duty unless they were discharged honorably for disability or hardship. Anyone before 1980 who served qualifies for general health care. Even if you do qualify, only specific groups get full benefits, such as dental, or are considered a priority group. A few of these specific groups are Vietnam and Gulf War vets, prisoners of war, recipients of the Purple Heart and Medal of Honor, and those with disability resulting from service.
