Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.
Skip Navigation U.S. Department of Health and Human Services
Agency for Healthcare Research Quality
Archive print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

Where Are the Gaps?


Yvette D. Roubideaux, M.D., M.P.H. (Rosebud Sioux), President, Association of American Indian Physicians, Clinical Assistant Professor, College of Public Health, University of Arizona, Tucson, AZ.

A number of health status trends among American Indians/Alaska Natives (AI/AN) shape the healthcare systems serving them:

  • Increased life expectancy and a growing population of elders increases the need for long-term care.
  • The growing impact of chronic disease results in the need for healthcare systems to alter their foci (from infectious to chronic disease) and develop more strategies for community- and prevention-based care.
  • Despite improvements, disparities still exist in both health status and quality of care. This calls for more data to better understand the health needs of AI/AN, access issues, quality of care delivered compared with accepted standards, best practices/what works within Indian communities, customer satisfaction, and cost effectiveness.

Healthcare systems serving AI/AN are also going through significant changes:

  • One of the most important has been the shift from Indian Health Service (IHS) to tribal management of healthcare systems. Nationwide, nearly one-half of healthcare systems serving AI/AN are tribally controlled due to compacting and contracting (through Public Law 93-638); this continues to increase.
  • With approximately one-half of AI/AN living in urban areas, there is growing awareness of the challenges faced by urban Indian programs.
  • Underfunding of Indian healthcare, as well as increasing costs of services, has led to growing reliance on third-party reimbursement.
  • Efforts to meet the needs of their clients have led many healthcare systems to increasingly interact with other systems, such as the Health Care Financing Administration, State agencies, private insurers and managed care organizations, and academic centers and universities. Working with these outside systems adds complexity to healthcare delivery.

These trends mean that leaders in tribal healthcare face multiple challenges in raising health status to the highest level and in building the highest quality healthcare systems. These challenges include the areas of:

  • Health workforce, especially in recruiting and retaining AI/AN clinicians and workers and in implementing strategies to improve the cultural competency of non-Native clinicians and workers.
  • Administrative capacity.
  • Technology.
  • More and better data to improve access and quality and to advocate for funds.
  • Both maximizing existing resources and discovering new resources (while upholding the Federal trust responsibility).
  • Investing in long-term planning rather than solely short-term survival and crisis management.


1997 trends in Indian health. Washington (DC): Indian Health Service, U.S. Department of Health and Human Services; 1998 Dec.

Roubideaux YD. Current issues in Indian health policy: a background paper. Conference on Native American Health and Welfare Policy in an Age of New Federalism; 1999 Jan; Tucson (AZ): Udall Center for Studies in Public Policy.

Previous Section Previous Section         Contents         Next Section Next Section

The information on this page is archived and provided for reference purposes only.

AHRQ Advancing Excellence in Health Care