You learn something new every day. Today I learned something about the Indian Health Service.

I've been a healthcare wonk for nearly a decade (in fact, the 10th anniversary of this website is coming up exactly one month from today), and I've learned a lot about how the U.S. healthcare system works (or, oftentimes, doesn't). Yet, even after all that time, I still occasionally stumble upon information about it which seems like it should have been something I knew all along, yet somehow never knew until now.

The Indian Health Service falls into this category. Don't get me wrong; I knew the IHS existed, and I knew that it serves roughly 2.2 million eligible Native Americans and Alaska Natives nationally. I've referenced it many times before, usually when discussing the types of healthcare coverage people have or funding included in various Congressional bills.

However, in all that time, I somehow was under the impression that the IHS was similar to either the Veterans Administration or Medicaid in terms of how it works, how it's paid for...and how comprehensive it is. I offer no excuses as to why I thought that was the case; I just did.

It turns out I was quite wrong. While digging into the just-released 2023 Current Population Survey Annual Social & Economic Supplement report from the U.S. Census Bureau, I was a bit perplexed by this bit at the beginning:

...Additionally, people are considered uninsured if they only had coverage through the Indian Health Service (IHS), as IHS coverage is not considered comprehensive.

* Comprehensive health insurance covers basic health care needs. This definition excludes single service plans such as accident, disability, dental, vision, or prescription medicine plans.

Huh.

This is even more confusing given the the description of IHS on the official government website:

Members of 567 federally recognized American Indian and Alaska Native Tribes and their descendants are eligible for services provided by the Indian Health Service. IHS provides a comprehensive health service delivery system for approximately 2.2 million American Indians and Alaska Natives.

The Indian Health Service (IHS) is the health care system for federally recognized American Indian and Alaska Natives in the United States. It’s important to clarify that the IHS is not a health insurance provider and that the IHS can provide healthcare to only eligible Alaska Native and American Indians at its federal hospitals and clinics.

When you read the FAQ, however...

...The Indian Health Service is funded each year through appropriations by the U.S. Congress. The Indian Health Service is not an entitlement program, such as Medicare or Medicaid. The Indian Health Service is not an insurance program. The Indian Health Service is not an established benefits package.

Direct health care services are services provided at an IHS/Tribal/ Urban facilities/ Purchased/ Referred Care (PRC) are services that the IHS is unable to provide in its own facilities. PRC are provided by non-IHS health care providers and facilities. PRC payments are authorized based on clearly defined guidelines and are subject to availability of funds. The Indian Health Service cannot always guarantee that funds are always available. Funds appropriated by the U.S. Congress currently cover an estimated 60% of health care needs of the eligible American Indian and Alaska Native people.

Unfortunately, that means that services obtained under PRC must be prioritized, with life-threatening illnesses or injuries being given highest priority. The patient medical referral is reviewed by PRC to determine if the medical need is within the available funding at that time. It also means that the IHS formulary (the list of drugs and medicines available from IHS pharmacies) may not include all drugs and medicines, but will include most of the ones that have proven to be beneficial and cost-effective.

This certainly explains why the ACA has special provisions allowing eligible Native Americans and Alaska Natives to enroll in extremely low-cost ACA exchange plans even if they're also enrolled in IHS coverage:

The Affordable Care Act (ACA), also known as the health care law, was created to expand access to coverage, control health care costs, and improve health care quality and coordination. The ACA also includes permanent reauthorization of the Indian Health Care Improvement Act, which extends current law and authorizes new programs and services within the Indian Health Service.

For American Indians and Alaska Natives, the ACA will help address health disparities by investing in prevention and wellness and increasing access to affordable health coverage.

The ACA provides American Indians and Alaska Natives with more choices; depending on your eligibility and the coverage available in your state, you can:

• Continue to use IHS, tribal, and/or urban Indian health programs
• Enroll in a qualified health plan (QHP) through the Marketplace
• Access coverage through Medicare, Medicaid, and the Children's Health Insurance Program

If you choose to enroll in a QHP through the Health Insurance Marketplace plan, you may qualify for special benefits and protections offered to American Indians and Alaska Natives.

I even found this brochure PDF explaining why eligible NA/ANs should consider enrolling in ACA exchange plans, Medicaid, CHIP etc. It has 10 bullet points,, but I'm only listing the first two and the last one here:

Fact #1: IHS is not health insurance

The Indian Health Service (IHS) is a part of the federal government that delivers health care to American Indians and Alaska Natives (AI/ANs) and provides funds for tribal and urban Indian health programs. Health insurance, on the other hand, pays for health care covered by your plan. It protects you from paying the full costs of medical services when you are injured or sick and pays for services to prevent you from becoming ill.

Fact #2: Even people eligible for IHS need insurance

Health insurance covers many things Indian health care programs do not provide. With health insurance. you can:

• Get in to see specialists
• Get health care for covered services without IHS Purchase Referred Care authorization
• Get health care when you are away from home

And, most depressingly:

Even though health care 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 Indians and Alaska Natives. That is why IHS does not offer certain services and why some services aren’t available at certain times of year. In fact, the IHS budget only meets about half of the need, so enrollment in health insurance helps expand needed care. And with insurance, health care is available when you need it.

I'm not entirely sure whether the only reason IHS coverage isn't comprehensive is due to it being horribly underfunded or if it's also inherent in the way the program itself is structured. It may be a combination of both.

In any event, this would certainly explain why President Biden's proposed 2023 fiscal year budget includes a 37% increase in funding for the IHS vs. what it received last year:

The President's Fiscal Year 2023 Budget proposes the first-ever fully mandatory budget for the IHS. This proposal is a historic step forward towards securing adequate, stable, and predictable funding to improve the overall health status of American Indians and Alaska Natives. It also ensures we never repeat the disproportionate impacts experienced during the pandemic.

The budget proposes to authorize and appropriate funding for IHS for ten years, from FY 2023 to FY 2032. The budget significantly increases IHS' funding over ten years, makes all funding mandatory, and exempts all proposed law mandatory funding from sequestration. This historic step is in response to the longstanding recommendations of tribal leaders shared in consultation with the Department of Health and Human Services and IHS.

In FY 2023, the budget includes a total of $9.3 billion in mandatory funding for IHS, which is $2.5 billion above FY 2022 enacted. In FY 2032, the budget culminates in a total funding level of $36.7 billion. When compared with the FY 2022 enacted level of $6.8 billion, the FY 2032 proposed funding level represents an increase of close to $30 billion, or 442 percent over ten years.

Over a five-year period, the budget provides an increase of more than $11 billion to expand direct health care services. It also includes an additional $6 billion to finalize modernization of the IHS electronic health record system. The budget would also fully fund the remaining projects on the 1993 Health Care Facilities Construction Priority List.

The bold action in the FY 2023 President's Budget demonstrates the Administration's continued commitment to work to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level and strengthen the Nation-to-Nation relationship. Today's announcement also acknowledges the need to implement long-term solutions to address IHS funding challenges, which contribute to the stark health disparities faced by American Indian and Alaska Native people.

Obviously just because President Biden is proposing it hardly means that the GOP-controlled House of Representatives (or even the Democratically-controlled Senate) is going to approve it...but it's good to see that the Biden Administration is at least aware of and attempting to address the issue.