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Why the Indian Health Care Improvement Act Has Failed to Effectively Fund Workforce Development for the Indian Health Service
The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.
American Indian, Alaska Native, United States Indian Health Service, health policy, health workforce
Health systems in the United States face significant current and future shortages of health care professionals.1–4 Systems that operate in rural and remote settings are among the most challenged in recruiting a workforce capable of meeting the health needs of local communities, and merit national attention to policies aimed at capacity building.5–8 Among such health systems is the Indian Health Service (IHS), a [End Page 375] United States federal agency formed in 1955. It is the primary system providing direct health care to members of 574 federally-recognized tribes and an estimated 2.6 million American Indian/Alaska Native (AI/AN) people.9
In 2018, a report from the U.S. Government Accountability Office noted health care provider vacancy rates in multiple disciplines within IHS administrative regions averaging at 25% (with a range of 13 to 31%).10 When considering physician vacancies alone, the rate rises to an average of 29% (with a range of 21 to 46%). These vacancies were reported to challenge patient access to care, the quality of care delivered, and the morale of IHS employees.10 Moreover, resultant poorer access to care may contribute to the ongoing and stark health disparities noted in many AI/AN communities compared with other U.S. populations, including a 6.4 year drop in life expectancy for Native Americans over the first two years of the COVID-19 pandemic (2019–2021).11–13
While geography, competitive salaries, and overall agency funding have affected vacancies, a particularly longstanding and modifiable disconnect exists between the IHS and clinical training programs. Indeed, the IHS is an exception among direct care federal health systems for having no formalized process for working with academic medical centers (AMC).14 Most AMCs that do have collaborative agreements with the IHS have them for sporadic rotations. An exception to this is the Uniformed Services University for the Health Sciences, which holds an agreement with the IHS for nationwide IHS rotations for health trainees.15 Most typically, an AMC must assume major associated educational costs for a rotation (for example, the loss of federal funding streams for a medical resident's salary while a resident rotates outside of the AMC).
By comparison, the value of dedicated formalized partnerships with AMCs focused on clinical training programs has been recognized, legislated, funded, and established within the Veterans Health Administration (VHA) for more than 75 years.16 Within the IHS, several initiatives focused on workforce development are authorized and funded through the U.S. Indian Health Care Improvement Act (IHCIA). However, a key portion of the act (U.S. Code 1616p) that would allow the agency to work with AMCs to develop robust clinical training remains unfunded. Indeed, a 2015 National Indian Health Board (NIHB) analysis concluded that health professional chronic shortage demonstration project(s) authorized in 1616p of the IHCIA remain unimplemented due to a lack of appropriated funds.17
Clinical training programs, centered within both government and academic medical institutions, have shown trends toward increased interest in developing a health workforce to better serve populations facing health inequities. Such interest aims to enhance diversity in clinical training environments in which trainees learn. As an example, equity-focused training initiatives have grown within graduate medical education (GME) programs for physicians, with goals of focusing training on system and community collaborations.18 Tangible outcomes have included the development of a small number of residency and fellowship clinical training programs focused on providing care within the IHS and to AI/AN communities. However, both existing and aspiring health training programs of this kind often face financial challenges in the initiation and the expansion phases. New funds to the IHCIA applied to U.S. Code 1616p could support the growth and longevity of such clinical training programs within the IHS, and thereby support overall workforce efforts. [End Page 376]
Funding Challenges for the Indian Health Care Improvement Act
The IHCIA was initially passed in 1976 and along with the Snyder Act of 1921 forms the primary legislation for provision of health care to AI/AN people; it is the legal means by which the U.S. federal government honors the Constitution (Article 1, Section 8 gives the federal government jurisdiction to interact in trade and services with tribal governments, as they are considered sovereign nations), as well as treaties and trust obligations with tribal governments in exchange for ceded territories.19–20 The overarching goal of the IHCIA is to authorize the U.S. Department of Health and Human Services (HHS), most typically through the IHS, to carry out health activities and pursue health goals focused on AI/AN people.21 However, it should be noted that the passing of the IHCIA was politically and financially contentious. Indeed, in a strategic memorandum to President Gerald Ford in September of 1976 recommending his signature on the bill, its overall popularity and the potential political backlash of an executive veto were major considerations. It was also frankly discussed that approval of the IHCIA did not make a financial commitment requisite:
"The bill is only an authorization measure. While it is true that the Indian community and the Indian Health Service will be encouraged by your signature to recommend appropriations for the full amounts, you and OMB can handle any unjustified requests through the budget machinery, and in that discriminating way—next December—rather than through the sledgehammer of a veto—in October, protect the budget from excesses. The draft statement (Tab A) makes it clear that your signing the bill does not constitute overpromising or making a commitment to budget the amounts authorized."22[p.2]
The IHCIA was renewed four times prior to its 2010 permanent reauthorization as part of the Patient Protection and Affordable Care Act (ACA).20 With permanent reauthorization as part of the ACA, new components included updates to reimbursement policies to IHS facilities, new insurance coverage options to tribes and tribal organization, and new options for working with AMCs to develop clinical training programs.23 Permanent reauthorization was viewed, as stated by President Barack Obama at that time, as "a critical step in fulfilling that responsibility [to provide health services to AI/AN people] by modernizing the Indian health care system and improving access to health care for American Indians and Alaska Natives."24 However, further supporting the IHCIA by fully funding all of its provisions remains a priority for tribal governments through the NIHB.25
Existing Workforce Initiatives through the IHCIA
In multiple references to "the Service" throughout the IHCIA, the legislation is referring to the IHS. Indeed, among the agencies under HHS, the IHS agency mission is most distinctly tied to direct health services and health workforce for AI/AN people. As such, policies for workforce development within the IHCIA target the IHS, and importantly often focus on career development of individuals from AI/AN communities. Most notable of these are IHS programs to fund training for AI/AN students entering health [End Page 377] care professions, as well as loan repayment programs. Such programs are derived from U.S. Codes 1613a, 1616a, 1616e, 1616g, and 1621p and include:
• The IHS Scholarship Program: The IHS scholarship program has been legislated in the IHCIA since 1988 under 25 U.S. Code 1613a. In fiscal year 2021, it funded 134 new and 121 extension scholarships with approximately $13.7 million.26 Scholars incur a service obligation that must begin within 90 days of completion of training in a federal IHS or tribal facility; similarly, they may incur relocation costs and changes to cost of living once accepting a position. In fiscal year 2021, the IHS reported a 36% success rate for placement within that time, with challenges in placement related to completion of licensing examinations and finding positions. Notably, unlike the National Health Service Corps scholarships, IHS scholarships for tuition, fees, and related costs have not been tax exempt. An attempt to modify exemption status for IHS scholarships was introduced in the 2021–22 U.S. Congress.27
• The Indians into Medicine, American Indians into Nursing, and Indians into Psychology Programs: The IHCIA authorizes funding for three grant programs to training institutions to provide support to AI/AN students while they complete their health career training (U.S. Codes 1616e, 1616g, and 1621p). In fiscal year 2021, there were three to five awardee institutions for each of these grant programs, with an average annual funding of $240,000–$340,000.26
• The IHS Loan Repayment Program (LRP): The IHCIA also legislates an IHS-specific loan repayment program (U.S. Code 1616a); such programs are a known lever in both recruitment and retention of health professionals.28 The IHS LRP offers up to $20,000 per year in exchange for a two-year service obligation within the IHS, plus $5,000 per year to offset tax liability. In comparison, counterpart LRP awards offered by the program of the National Health Service Corps are tax exempt.29 Granting tax exemption for these much-needed IHS programs would allow the IHS to make at least 25% more awards with the same level of funding. A 2012 analysis by the Friends of Indian Health, a coalition of 26 professional organizations, determined that making the IHS loan repayments tax-free would save $7.21 million, which in turn would fund an additional 232 awards.30 This finding was reinforced in 2017 by the IHS Tribal Self Governance Advisory Committee in a letter to the Acting IHS Director requesting action on making the IHS LRP tax-exempt.31 Over the past decade, bills have been introduced to Congress to provide tax exemption for the IHS LRP, as well as allowances for meeting obligations on a half-time basis to strengthen agency efforts at recruitment and retention; none has advanced beyond committee reviews. As an example of the reach of the program, in the fiscal year 2021, there were 1,626 health care professionals receiving support for loan repayments across the system. Yet, there remained 38 "matched unfunded" and 314 "unmatched unfunded" positions that diminish the agency's ability to recruit to need (with "matched" indicating employment in an Indian health program; those who were unmatched decided against an offered position because they did not receive loans or could not find a position meeting their personal or professional interests).26 [End Page 378]
Further Application of the IHCIA for Persistent Workforce Needs
The previously noted vacancies exist despite the successfully funded—although arguably underfunded—workforce development components of the IHCIA. Notably, a critical amendment to the first of eight titles within the IHCIA was added with its permanent reauthorization under the ACA in 2010, in the section focused on supporting workforce development. With the 2010 permanent reauthorization of the IHCIA, the addition of 25 U.S. Code 1616p provided the federal government the opportunity to fund "demonstration programs'' through the IHS [see Box 1 for more information].32 Essentially, the law could be used by the IHS as a mechanism to fund clinical training programs acting within, or in partnership with the agency, with the intention of building the health care workforce needed for AI/AN communities. Specifically, 1616p authorizes a mechanism for use of new funding for clinical training programs that place health professions trainees into IHS settings, with the express purpose of increasing access to care in the near and long term. It also contains language to encourage the funding of IHS partnerships with AMCs for scholarly and professional growth of the IHS workforce.
With the addition of 1616p in 2010, the IHS gained the authority to pilot mechanisms for partnership with health professions clinical training programs that resemble those of the Veterans Health Administration (VHA) or the Military Health System (MHS).
. U.S. CODE 1616P.32 HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS
(a) Demonstration programs
The Secretary, acting through the Service, may fund demonstration programs for Indian health programs to address the chronic shortages of health professionals.
(b) Purposes of programs
The purposes of demonstration programs under subsection (a) shall be—
(1). to provide direct clinical and practical experience within an Indian health program to health profession students and residents from medical schools;
(2). to improve the quality of health care for Indians by ensuring access to qualified health professionals;
(3). to provide academic and scholarly opportunities for health professionals serving Indians by identifying all academic and scholarly resources of the region; and
(4). to provide training and support for alternative provider types, such as community health representatives, and community health aides.
(c) Advisory board
The demonstration programs established pursuant to subsection (a) shall incorporate a program advisory board, which may be composed of representatives of tribal governments, Indian health programs, and Indian communities in the areas to be served by the demonstration programs. [End Page 379]
The VHA maintains an Office of Academic Affiliations and, as of 2014, budgets over $1 billion annually to support 120,000 annual trainees and 11,000 graduate medical education (GME) positions.14 The MHS funds and operates the Uniformed Services University; the system's largest GME sponsor, known as the National Capital Consortium, operates 66 GME programs with approximately 700 trainees.33 While the VHA primarily uses academic health center-affiliated programs, the MHS maintains mostly internal GME programs.34
While all the noted federal direct health care programs face workforce needs, increasing the ability of the IHS to develop clinical training programs and partnerships through additional, new funds authorized under 1616p of the IHCIA could enhance the overall equity of federal health workforce development. Several potential scenarios for how such funding could be used are important to consider. New demonstration programs could include the development and accreditation of internal clinical training programs for physicians, nurses, or other health care professionals in IHS facilities with large enough patient volumes to meet training exposure requirements. The benefits of internally administered programs include the ability to engineer clinical training to meet specific areas of professional shortages in the workforce, as well as more extensive training (and proficiency development) with the nuances of the IHS environment and with a focus on health issues for AI/AN communities. However, if administered directly by the IHS, such programs would require a rigorous administrative component not previously developed within the agency and would lack activities or partnerships with AMCs, potentially limiting career development opportunities.
Formation of educational partnerships with academic institutions provides another opportunity to seek funding for a demonstration program. Indeed, an array of clinical training programs can be found in tribal colleges, community colleges, universities, and AMCs. Often, such programs need new or additional clinical learning environments to those the program already uses. Sharing the funding for clinical training positions with existing training programs would still allow the IHS to determine the types of professions being trained within its facilities. It additionally creates an immediate opportunity for an increased workforce through shared clinician educators. Of note, partnerships with universities and institutions of higher learning are included in the IHS 2019–2023 Strategic Plan.35
Recruitment and retention of health professionals in rural IHS locations is challenged by several factors that cannot be easily addressed by workforce development programs, including geographic isolation, opportunities for families, and available housing.10,35 Additionally, as the IHS strengthens its continuum of health professions development programs, it is likely to be challenged by a lack of academic administrative resources at IHS headquarters and its area offices. For comparison, the success of the VHA in academic partnership development has been attributed in part to the creation of the VHA Office of Academic Affiliations.16 Academic administration resources would likely facilitate the success of demonstration programs developed under the authority of IHCIA 1616p. The optimal distribution between national, area, and local levels of such resources is an important consideration. In many domains, IHS resources are largely distributed to the agency's area offices, rather than centralized at its headquarters. Placement at area offices helps, for instance, tribal self-management programs more readily [End Page 380] access important administrative resources. However, in the case of academic programs, a centralized academic office would be necessary (parallel to the many nationally organized academic health programs). Taking GME as an example, the nation's models are largely organized and financed through the Centers for Medicare and Medicaid Services, the VHA, and the Health Resources and Services Administration, all headquartered in or near Washington, D.C.36 In addition to a headquarters-level office, each IHS area office would likely benefit from at least one academic administrator linked to the new headquarters office.
Moving Forward with a Focus on Equitable Federal Health Care Systems
Past generations have recognized and legislated health workforce demonstration projects as central to the success of the IHS, as enshrined in the IHCIA. In an era of increased investment in health care workforce development across federal programs, the IHS is poised to synergize with its peer agencies and academic clinical training programs to address its chronic workforce shortages. An investment of new finances to unfunded components of the IHCIA, including U.S. Code 1616p demonstration projects, could happen at no better time than the present.
MICHAEL A. SUNDBERG is affiliated with the University of Minnesota Medical School–Twin Cities. LORETTA CHRISTENSEN is affiliated with the Indian Health Service. ALLISON KELLIHER is affiliated with Johns Hopkins University. MATTHEW L. TOBEY is affiliated with Massachusetts General Hospital and Harvard Medical School. MICHAEL TOEDT is affiliated with Toedt Health Solutions, LLC. MARY J. OWEN is affiliated with the University of Minnesota Medical School–Duluth.
Acknowledgments
The views expressed in this commentary are solely those of the individual authors and do not necessarily reflect the official views of any governments or organizations, including the Indian Health Service, or the policies of the U.S. Department of Health and Human Services. The mention of trade names, commercial practices, and organizations does not imply endorsement by Tribal Nation governments or the U.S. government.