Government Indian Hospital System is Sick, Watchdog Finds

Corroded Pipes Flood Operating Room with Sewage

Dilapidated homes on the Navajo Nation Indian reservation
On the Sprawling Navajo Nation Reservation. David McNew / Getty Images

In 1851, the U.S. federal government began forcing the American Indians it hadn't massacred in the preceding decades onto desolate reservations. Over a century later, in 1956, the government decided it owed something to the Indians and built them some hospitals. Unfortunately, it is not always the “thought that counts.”

Today, conditions in those aging, run-down hospitals, with their outdated equipment and inadequate medical staffs, are raising serious “concerns about patient safety,” according to a federal inspector general.


The principal federal government health care provider and health advocate for 2.2 million of the estimated 3.7 million American Indian and Alaskan Native people living in the United States is Indian Health Services (IHS), an agency within the cabinet-level U.S. Department of Health and Human Services (HHS).

As the main source of health care services, the IHS operates 28 acute-care hospitals providing free primary and preventive health care services on an inpatient and outpatient basis to people of the 567 federally recognized tribes. IHS also operates several out-patient only clinics and health centers.

As of 2016, about half or IHS’s $1.8 billion budget for Indian and Alaskan Native health care services is allocated to federal operations serving tribes directly. The other half of the budget goes to the individual Indian tribes or tribal organizations that have contracts and/or compacts with IHS.

During the fiscal year 2013, IHS-run and tribally run hospitals reported more than 13 million outpatient visits and a total of 44,677 inpatient admissions. Nearly half of these admissions (20,469 inpatients) were to the 28 IHS-operated hospitals.

But Problems Abound in Indian Hospitals

Sadly, over a century after the Wounded Knee Massacre, conditions at the U.S. government-run Indian hospitals are deplorable.

According to an October 2016 report from Department of Health and Human Services (HHS) Inspector General (IG) Daniel R. Levinson, the 28 acute-care IHS hospitals are located in only 8 states, and often in remote locations. An additional 18 hospitals operated by tribes or tribal organizations operate under contracts with IHS.

According to IG Levinson, all 46 of the hospitals face, “longstanding challenges” that “warrant focused attention to support quality care.”


Several of the hospitals are located more than 200 miles from the nearest city.

“One [hospital] administrator reported that patients must travel 100-200 miles to receive post-acute care, which may be particularly problematic for patients at the end-of-life stage,” the report said.

Lack of Resources

Another hospital administrator quoted in the report described how a lack of resources, such as nursing homes and rehabilitation clinics in the surrounding community and the “Third World” conditions, like no running water or electricity, “sometimes prevent the hospital from discharging patients, particularly during the winter months.”

While most of the hospitals admit relatively few inpatients, the number of patients requiring outpatient care increased by over 70% from 1986 to 2013, often exceeding the hospitals’ capabilities to treat them. As a result, patients face difficulty in getting appointments and long waiting times to receive care.

While IHS hospitals can refer patients to private hospitals or clinics, the agency’s budget rarely allows it. During 2013 alone over 147,000 requests for referral were denied, according to the report.

Despite the rapid increase in outpatient treatment recruitment and retention of doctors remains low. In 2014, the physician vacancy rate at IHS hospitals was 33%, compared to only 18% for hospitals nationwide.

“Hospitals attribute their staffing shortages to geographic isolation, limited incentives, non-competitive pay, and a lengthy hiring process,” noted the report.

Raw Sewage Has No Place in Operating Rooms

Administrators of 15 of the 28 hospitals interviewed by the inspector general’s office reported that old or inadequate physical environments in their facilities “challenged their ability to provide quality care.

For example, one of the IHS hospitals reported that aging plumbing in the equally aging structure caused raw sewage to leak into the operating room after its old pipes corroded.

According to the report, the average age (or length of time since a major renovation) of IHS hospitals is 37 years—nearly four times the nationwide average of 10 years. The two oldest IHS hospitals are both 77 years old.

“According to engineering staff at IHS, the oldest hospital structures were never designed to provide modern health care, and over time, health care practices and technology changed and outpaced many IHS hospitals,” stated the inspector general.

Indian Health Suffers

As statistics from the IHS show, conditions in its hospitals have, to some extent, contributed to the poor health of Native Americans, compared to general U.S. population.

  • The infant mortality rate among American Indians and Alaska Natives—at 7.6 deaths per 1,000 live births—is 26% higher than among the general population.
  • American Indian and Alaska Native babies are twice as likely as non-Hispanic white babies to die from sudden infant death syndrome (SIDS).
  • The overall death rate among Indians and Alaska Natives is 26% higher than among the white population.
  • American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the U.S. all races population—73.7 years to 78.1 years, respectively.

IHS Responds

In an agency statement to the IG’s report, the IHS claimed it “has been aggressive in its approach to address these challenges, working with tribal partners to implement a strategy that ensures a quality of care for its patients and instill a culture of accountability across the agency to improve health care delivery to its patients.”

In addition, IHS noted that HHS Secretary Sylvia Mathews Burwell had formed an “executive council” comprised of health care professionals and Native American representatives to work on the problem.

Inspector General Levinson recommended that the executive council “undertake a concerted effort to examine and address the longstanding challenges facing IHS hospitals.”

He further recommended that IHS should create a new, comprehensive strategic plan – with specific action items and completion dates – to address the agency’s worsening problems.

The IHS agreed, stating, “IHS concurs with the recommendations . . . and is committed to building on efforts currently underway to correct the service issues.”