Native Americans have suffered extreme inequities in health care and health outcomes throughout the history of the United States. However, over the past fifty years, the health care needs of Native Americans have drastically changed as this population becomes increasingly urbanized. To address this new reality and provide legally obligated health care more efficiently and effectively, the federal government must develop new funding mechanisms that either supplement or ideally replace the current Indian National Health Service (IHS).

Treaties in the 1800s between the United States and tribal nations laid the legal foundation for the federal government’s obligation to provide health care services to American Indians and Native Alaskans. The Indian National Health Service, an agency within the Department of Health and Human Services, was established in 1955 to create a more uniform and centralized mode of providing services.  Despite this legal obligation to provide health care, the Native American population has faced significant and continued health disparities. Native Americans currently have a life expectancy that is five and a half years less than the national average and they continue to die at higher rates than all other Americans in many categories of causes of death, including chronic liver disease, diabetes, chronic lower respiratory diseases, assault/homicide, and intentional self-harm/suicide.

One major reason for these disparities is that the IHS has been chronically underfunded throughout its history. According to an analysis by the National Congress of American Indians, in order to match the level of care provided to federal prisoners, funding for the IHS would have to almost double.

Another major issue heightening the health care disparities Native Americans face is that IHS funding is not designed to provide care effectively for the mass migration of Native Americans who have moved from remote reservations into urban areas. Today, around seventy percent of Native Americans live in metropolitan areas, compared with thirty-eight percent in 1990. IHS funding has not reflected this major demographic shift, as there are 54,000 urban Native Americans who lack any access to IHS services or tribally operated facilities. As the New York Times reported, in recent years, on average only about one percent of the IHS budget has been allocated to urban programs.  Urban Indian Health Programs have been established to try and meet the needs of those who fall outside of IHS services, however there are approximately one million people living in the service areas of these nonprofit organizations, creating a demand for service that is far greater than can be met.

This large disparity in federal funding is problematic for many reasons as it clearly fails to meet the federal government’s duties to provide health care under the trust obligation. Given that the program designed to provide services is not reaching or providing care to those in inner cities, the funding system for IHS’s programs needs to be readjusted to reflect the new reality. In addition to readjusted and increased funding, more awareness needs to be created around the issues that urban Native Americans face. As Janeen Comenote, executive director of the National Urban Indian Family Coalition, noted , “[t]his is a population that is invisible…people assume they’re not there and don’t face some of the same issues that impact Native peoples who live on reservations”. Without more outreach programs, education programs, community network groups, and increased funding, Urban Indian Health Programs will continue to struggle to provide adequate health care to urban Native Americans, care that the federal government is legally obligated, yet failing, to provide.