The IHS, or Indian Health Service, is a federal agency responsible for providing health care to American Indians and Alaska Natives across the United States. It operates within the Department of Health and Human Services and serves approximately 2.8 million people who are members or descendants of 574 federally recognized tribes. Its stated mission is to raise the physical, mental, social, and spiritual health of these communities to the highest level.
Who the IHS Serves
Eligibility centers on being American Indian or Alaska Native with a connection to a federally recognized tribe. That connection can take several forms: formal tribal enrollment, residence on tribal land, active participation in tribal affairs, or other evidence of Native descent. The Bureau of Indian Affairs publishes an updated list of recognized tribes each year, and IHS uses that same list to determine which tribal communities qualify.
Some non-Native individuals can also receive care in limited situations. Children under 19 who are the natural, adopted, or foster children of an eligible Native person qualify. A non-Native spouse may be eligible if the local tribal governing body approves it. Non-Native women pregnant with an eligible Native person’s child can receive care through pregnancy and the postpartum period. And if someone in an eligible person’s household has an acute infectious disease or poses a public health risk, they can be treated regardless of their own eligibility status. When there’s any doubt about whether a person qualifies, IHS policy requires that urgent care be provided first while eligibility is sorted out.
How the System Is Organized
The IHS is divided into 12 regional areas, each with its own administrative office: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson. These offices oversee a network of hospitals, health centers, and clinics spread across 37 states.
Not all of these facilities are run directly by the federal government. Under the Indian Self-Determination and Education Assistance Act, tribes have the option to take over management of health programs that IHS would otherwise operate. Some tribes contract with IHS to administer specific services while keeping others under federal control. Others assume full authority over their health care programs through what’s called self-governance compacting. Many tribes use a combination of both approaches, tailoring the arrangement to their community’s needs. This means the IHS system is really a patchwork of federally run and tribally run facilities, all drawing on federal funding.
Funding and Spending Gaps
The IHS budget for fiscal year 2025 was proposed at $8.2 billion in total funding, including $260 million for a dedicated diabetes program. That sounds like a large number until you compare it to what other federal health programs spend per person. Based on 2017 figures from the Government Accountability Office, IHS spent roughly $4,078 per patient. Medicaid spent $8,109 per person, the Veterans Health Administration spent $10,692, and Medicare spent $13,185. IHS spending per capita was less than a third of Medicare’s.
That gap has real consequences. Facilities face maintenance backlogs, outdated medical equipment, and staffing challenges that limit the care available in many communities. Budget proposals have included plans to address a $2 billion backlog in essential building repairs, $1.3 billion per year to modernize electronic health records, and $454 million to replace outdated medical equipment. A proposal to shift IHS to mandatory funding beginning in fiscal year 2026, rather than relying on annual congressional appropriations, would grow the budget to approximately $42 billion by 2034.
Health Disparities in Native Communities
American Indians and Alaska Natives die at higher rates than the general U.S. population from a wide range of causes. Heart disease and cancer are the leading killers, with age-adjusted mortality rates of about 195 and 178 per 100,000 people respectively. Unintentional injuries rank third at nearly 94 per 100,000, and diabetes fourth at 66 per 100,000.
The disparities are especially stark for conditions tied to chronic disease, addiction, and mental health. Alcohol-related deaths occur at a rate of 50 per 100,000, chronic liver disease and cirrhosis at about 43 per 100,000, and suicide at roughly 20 per 100,000. These rates consistently exceed national averages, reflecting both the health challenges in these communities and the resource constraints of the system designed to serve them.
The Special Diabetes Program
Diabetes has been a particular focus of IHS efforts. The Special Diabetes Program for Indians, funded at $260 million in the 2025 budget with a proposed increase to $270 million the following year, supports prevention and treatment programs across tribal communities.
The program has shown measurable results. Before the program launched, average blood sugar control among Native patients with diabetes, measured by a marker called A1c, sat at 8.4%. After several years of program funding, that average dropped to 7.4%. A one-percentage-point drop in A1c has been shown to reduce the risk of diabetes complications like heart attack, stroke, amputation, and kidney damage by about 21%. Blood pressure readings also improved significantly during the same period. These intermediate improvements are meaningful because they slow the progression toward the most serious and costly complications of diabetes.
How IHS Differs From Insurance
IHS is not health insurance. It’s a direct care system, meaning it operates its own facilities and employs its own providers. If you’re eligible, you can walk into an IHS or tribal facility and receive care, but the system doesn’t function like a traditional insurance card you can use at any hospital or doctor’s office. When patients need specialty care that isn’t available at their local IHS facility, a program called Purchased/Referred Care can cover treatment from outside providers, but this is subject to funding limits and medical priority levels.
Many Native people also carry Medicaid, Medicare, or private insurance, and IHS facilities bill those programs when applicable. This third-party revenue supplements the agency’s direct congressional funding and helps stretch limited resources further. The combination of direct federal funding and insurance billing makes up the total per-capita spending figure, which still falls well below what other federal health programs spend per person.