The Story of Indian Health is - 麻省理工学院人工智能研究专业

The Story of Indian Health is
Complicated by History, Shortages &
Bouts of Excellence

Mark N. Trahant

抽象的: One of the primary goals of the U.S. government’s entry into health care was to protect soldiers
by isolating tribal populations and inoculating them against infectious disease. When tribes signed the le-
gally binding treaties, the United States promised them doctors, nurses, 设施, and basic health care.
Yet this promise has never been fully funded by Congress. The Indian Health Service, which includes trib-
al and nonprofit health agencies, is tasked with defying gravity, and this has led to a regular cycle of heart-
breaking stories about a system that fails American Indian and Alaska Native patients. 然而, at the same
时间, the Indian health system has achieved remarkable innovation and excellence.

Every so often, the “story” of Indian health is told

by a news organization. 例如, The Wall Street
Journal reported the death of several Native Ameri-
can patients in Pine Ridge and Sisseton, South Da-
kota, and Winnebago, Nebraska: “In some of the
nation’s poorest places, the government health ser-
vice charged with treating Native Americans failed
to meet minimum U.S. standards for medical facili-
领带, turned away gravely ill patients and caused un-
necessary deaths, according to federal regulators,
agency documents and interviews.” The report adds
that the Indian Health Service (ihs) “operates a net-
work of hospitals and clinics, much like the Veter-
ans Health Administration. Under U.S. treaties that
date back generations, the service is legally respon-
sible for providing medical care to about 2.2 百万
tribal members. But that system has collapsed in the
often-remote corners of Indian Country, where pa-
tients live hours from other medical providers, 经常
have no insurance and depend on the federal ser-
vice.”1 A few days later, at a budget hearing on Cap-

mark n. trahant, 研究员
自美国科学院院士
2017, is an independent journalist.
He is the former Editorial Page Edi-
tor of the Seattle Post-Intelligencer and
a Kaiser Family Foundation Media
Fellow. He is the author of The Last
Great Battle of the Indian Wars (2010)
and Pictures of our Nobler Selves: A His-
tory of Native American Contributions
to News Media (1996) and has con-
tributed to such collections as Lewis
and Clark through Indian Eyes: Nine
Indian Writers on the Legacy of Expedi-
的 (编辑. Alvin M. Josephy, 2006).

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itol Hill, a number of senators weighed in
on The Wall Street Journal report. “The sto-
ries are heartbreaking,” said Senator Lisa
Murkowski, R-Alaska, chair of the Appro-
priations subcommittee that funds Indian
health programs. She added that though the
then-Acting Director of ihs, Mary Smith,
had indicated that “the agency was com-
mitted to doing ‘whatever it takes’ to de-
liver quality care,” Murkowski still found
that serious problems continued, 包括-
ing hospitals operating without having re-
ceived recertification from the Center for
Medicare and Medicaid Services despite
额外的 $29 million approved to ad- dress these problems.2 Murkowski stat- ed that she was “very concerned” that the Trump budget request does not adequately meet the needs for health care in Indian Country. The disparities be- tween health outcomes for American Indi- an and Alaska Native people compared to the population at large are staggering. 考试用- 普莱, American Indians and Alaska Natives are three times more likely to die from diabetes. The drug-related death rate for Native Amer- icans has increased 454 percent since 1979 to almost twice the rate for all other ethnicities. 和, the suicide rate among our First Peoples is roughly twice that for the rest of the pop- 计算. In order to improve health care de- livery, the ihs must do a better job at hiring and retaining an adequate number of qual- ified doctors and nurses. The ihs must also do a better job of maintaining a large facilities infrastructure that serves 2.2 million Ameri- can Indians and Alaska Natives. This requires significant resources. 现在, the vacancy rate for Indian Health Service doctors, 这- 奶嘴, and physician assistants is roughly 30 百分. The backlog of facilities mainte- nance at ihs hospitals is over half a billion dollars, and according to the agency’s own budget documents, the average age of its fa- cilities is roughly four times that of its private sector counterparts. Additional resources are not the only answer–the agency must also do more to improve the quality of its exist- ing work force.3 Another member of the subcommittee, Jon Tester, D-Montana, was frustrated by the administration’s budget request and the refusal of the agency’s current acting head, Michael Weahkee, to admit wheth- er there would be an increase or a de- crease in the agency’s ability to hire staff. When questioned directly about the bud- get, Weakhee replied only that the ihs was prioritizing “maintaining direct care ser- vices.”4 But this was not an isolated inci- 凹痕; there has been a long history of Indi- an Health Service directors who were un- able or unwilling to answer that question. If we consider the Senate exchanges as a story, it becomes one that tells of incompe- 张力, poor management, too few doctors, 和, most certainly, not enough money. Because we only have sparse evidence about Indian health problems prior to Eu- ropean contact, this story of Indian health begins with European colonization, when serious health challenges such as smallpox reached catastrophic proportions. As his- tory of medicine scholar and physician David S. Jones has written, “Estimates of pre-contact American populations vary between 8 和 112 百万 (2 到 12 million for North America), and estimates of to- tal mortality range from 7 到 100 百万. Whatever the exact numbers, the mortali- ty was unprecedented and overwhelming.” Europeans introduced several diseases, 在- cluding smallpox, measles, influenza, and malaria, to Native populations from the sixteenth to nineteenth centuries. “Popu- lations often decreased by more than 90% during the first century after contact. As recently as the 1940s and 1960s, new high- ways and new missionaries brought patho- gens to previously isolated tribes in Alaska and Amazonia.”5 It’s impossible to over- l 从http下载 : / / 直接的 . 米特 . / 教育论文 – 压力 / 的f / / / / 1 4 7 2 1 1 6 1 8 3 1 4 5 5 d a e d _ a _ 0 0 4 9 5 压力 / . 来宾来访 0 7 九月 2 0 2 3 117 147 (2) Spring 2018Mark N. Trahant state the consequences of a 90 percent mortality rate. This is the root of histor- ical trauma: the collective memory of a people nearly wiped off of their homeland. Greg Bourland, then-chairman of the Cheyenne River Tribe in South Dakota, shared in The New York Times Magazine a personal familial history of epidemic. He wrote about his great-great-grandmother Blue Earnings: She was a powerful Lakota medicine woman. They say that she drank water all the time. She got sick from smallpox, and when she was getting ready to die, she asked for a bowl of water. She said, “I’m going to show you part of my powers, and why I’m sick.” They put the bowl in front of her, and she spit into it, and out of her mouth flew four little wa- ter creatures. Here in the Dakotas, around the edge of lakes, there are these insects. They look as if they can walk on the water. They skitter. Three of them were jumping around in the bowl, and the other was dead. She pointed and said: “See, that one got sick from this white man’s disease, from small- pox. If that one can’t live, I can’t live, either.” And she died.6 Indeed, it was the epidemics that de- fined the early public health initiatives of the United States. The Army sent doctors to military posts in order to protect soldiers from infectious diseases, leading Army doc- tors to care for tribal communities, at least on an irregular basis. 在 1832, the War De- partment negotiated a treaty with the Win- nebago Tribe in Wisconsin that promised two physicians as partial payment for ced- ed acres. The cost was budgeted at $200 每
年. (As a comparison: an Indian agent’s
salary in that region was $800 per year and that was considered low. Missouri River agent John Sanford wrote to Superinten- dent of Indian Affairs William Clark and asked for a $400-a-year salary increase be-
cause he deserved a job with less risk and

better pay.) Not every treaty was as specific,
but most of the nearly four hundred treaties
that Congress ratified included the promise
of doctors. Some spelled out the construc-
tion and operation of hospitals as a part of
the deal. But treaties only made the prom-
ise. Congress still had to appropriate the
钱, and that has never happened.

经过 1880, there were seventy-seven phy-
sicians serving the entire American Indi-
an population in the United States and its
territories. Commissioner of Indian Af-
fairs Thomas J. Morgan urged Congress
shortly before the turn of the century, “in
the name of humanity,” to fund hospitals
and every agency because their absence
was a “great evil that in my view amounts
to a national disgrace.” Morgan calculat-
ed the disparity in resources, finding that
the Army spent $21.91 per soldier and the Navy $48.10 per sailor, while the govern-
ment only appropriated $1.25 per Indian patient.7 The first direct appropriation for Indian health programs was made in 1911 for the “relief of distress and prevention of dis- eases” among the Indians. President Wil- liam Howard Taft said it was not enough: the conditions were “very unsatisfactory” and the Indian death rate was more than twice that of the general population. He asked Congress to increase wages because the “smallness of the salaries” affected the qualifications and ability of the physicians in the Indian Service. The average salary was $1,186 每年, less than half of the
average salary for a government employee.
“As guardians of the welfare of the Indi-
答案,” the president told Congress, “it is our
duty to give the race a fair chance for an
unmaimed birth, healthy childhood, 和
a physically efficient maturity.”8

The Bureau of Indian Affairs (bia) 创造-
ed a health division in 1921. But poor fund-
英, low salaries, inadequate supplies, 和
deficient facilities contributed to an unsat-
isfactory health care system. “All we re-

118

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代达罗斯, 美国艺术学院学报 & SciencesThe Story of Indian Health is Complicated by History, Shortages & Bouts of Excellence

ally need,” Michael J. Pijoan, a doctor at
the Navajo Medical Center, wrote in 1951,
“are good doctors, facilities and pharma-
ceuticals. I am weary.” A month later, 他
resigned, 说, “the system is no longer
medical. It is only bureaucratic. No more
ceremonies are allowed in hospitals. Indi-
ans are now numbers, not people. 我们是
machines. This is intolerable. We leave.”9
在 1955, Congress recognized at least part
of the problem and transferred health pro-
grams away from the bia to the new In-
dian Health Service. Ray Shaw, the ihs’s
director at the time, promised Congress
that he would make improvements. 尽管
working at the bia, he noted that Congress
had appropriated $30 million to treat tu- berculosis, but the money was never used for that purpose. According to Shaw, the director of the bia said he needed the money for other things. “I never forgot that,” Shaw said. As a new agency, the In- dian Health Service budget increased from $10 million per year to $17.7 百万. This is where the story gets complicated. The new Indian Health Service was ambitious and innovative despite being underfunded. 在 1976, Congress proposed a sweeping new authorization for Indian health programs. The Indian Health Care Improvement Act “declares that it is the policy of this Nation, in fulfillment of its special responsibilities and legal obligation to the American Indian people, to meet the national goal of provid- ing the highest possible health status to In- dians and to provide existing Indian health services with all resources necessary to ef- fect that policy.”10 The legislation called on Congress to appropriate at least $1.6 十亿
in new funding for Indian health, spending
resources on improving staffing, 设施,
access to care for urban Indian populations,
和, 首次, opened up Medicare
and Medicaid revenue. “While there have
been improvements in health status of In-
dians in the past 15 年, a loss of momen-

tum can further slow the already sluggish
rate of approach to parity. Increased mo-
mentum in health delivery and sanitation
as insured by this bill speed the rate of clos-
ing the existing gap in age at death,” White
House advisor Ted Marrs wrote in support
of the legislation. “在 1974 the average age
at death of Indians and Alaska Natives was
48.3. For White U.S. citizens the average
age of death was 72.3. 为他人, the av-
erage age was 62.7.”11 For Marrs, the “bot-
tom line” was an unavoidable connection
between “equity and morality” when there
is a more than twenty-year differential in
age at death between Indians and non-Indi-
答案. Yet this idea–the improvement of In-
dian health programs–divided the Nixon
and later the Ford administrations.

Marjorie Lynch, Undersecretary of Health
and Human Services, sent a letter to Repub-
licans in the House saying the administra-
tion “strongly opposed” the legislation be-
cause of the costs: “scarce Federal health
dollars are directed to the areas of greatest
need, and that the Congress will agree that
existing authorities are sufficient to contin-
ue addressing the health needs of American
Indians and Alaska natives.” She added that
having Medicaid fund Indian health pro-
grams would be unfair both in terms of cost
and equity. States’ reimbursement rates
range from 50 到 83 百分. “To provide a
100 percent match for services to Indians
would be inequitable to other poor recipi-
ent groups, and to those States with many
families and individuals at poverty levels,
who happen not to be Indians.”12

Marrs pressed President Gerald R. Ford
to sign the bill into law. “Admittedly, I am
biased as a physician in favor of equity in
length of life so you will have to excuse
my considering the humanitarian aspect
along with the budgetary, pragmatic and
政治的,” he wrote. “Failure to adjust the
present course is in my opinion a flagrant
deprivation of human rights in a measur-
able as well as dramatic way.” Marrs’s pitch

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147 (2) Spring 2018Mark N. Trahant

worked. On October 1, 1976, President Ford
指出:

I am signing S. 522, the Indian Health Care
Improvement Act. . . . This bill is not without
its faults, but after personal review I have de-
cided that the well-documented needs for
improvement in Indian health manpower,
服务, and facilities outweigh the defects
in the bill. While spending for Indian Health
Service activities has grown from $128 米尔- lion in FY 1970 到 $425 million in FY 1977, Indi-
an people still lag behind the American peo-
ple as a whole in achieving and maintaining
good health. I am signing this bill because of
my own conviction that our first Americans
should not be last in opportunity.13

While the federal government has, 从
时不时地, recognized that the system is
underfunded and it cannot improve with-
out adequate revenue, professional staff,
and facilities, serious money always lags
behind health care spending for the gen-
eral population. ihs is expected to defy
重力.

So what happened after the Indian Health

Care Improvement Act became law? 乙酰胆碱-
cording to pediatrician Abraham Bergman
and colleagues:

Few bright spots exist in the shared history of
the American Indian and the federal govern-
蒙特. . . . A notable exception is the sustained
campaign by a little-known agency, the Indian
Health Service, to improve the health of this
人口. Except for the intractable prob-
lems associated with the abuse of alcohol,
the health status of Indians has been raised
to approximately the level attained by the rest
美国的. 人口. This achievement is
amazing when one considers the appalling
poverty and harsh physical environment in
which many Indians live.

But there remain huge challenges related
to diabetes, obesity, and mental health.
“We do not mean to present a rosy pic-

真实. . . . We wish to emphasize, 然而,
that given their isolation and harsh living
状况, many health status measures
are better than might be expected, in large
measure owing to the efforts of the ihs.”14
The story needs to account for the ihs
successes as well as the challenges. 骗局-
sider infant mortality rates. 在 1955, 在-
fant deaths were nearly three times higher
than that of the general population and ac-
counted for one-quarter of all early deaths
among infants under one year of age. 但
over the next twenty-five years, infant mor-
tality rates dropped by 82 百分, outpac-
ing the health gains of other disadvantaged
人口.

The Centers for Disease Control and Pre-
vention reported that, 在美国,
从 2004 到 2008, 84 percent of American
Indians and Alaska Natives have a “usual
place for health care.” That compares with
86 percent for White Americans, 85 百分
for African Americans, 和 72 percent for
Hispanics. And Native Americans are living
更长. “The aian population has a life ex-
pectancy at birth that is 2.4 years less than
that of all U.S. populations combined.”15
There is not a health care parity with the
general population, not by a long shot,
partly because of the chronic nature of so
many diseases that afflict Indian Country.
But efforts to close the existing gap in age
at death have certainly been improving
over the last four decades.

这 1976 Indian Health Care Improve-
ment Act created a new statutory author-
ity for the Indian Health Service to direct
funds to urban populations in which most
American Indians and Alaska Natives live.
A 2007 report by the Urban Indian Health
Commission called this “a population in
crisis”: “Reliable health statistics on ur-
ban Indians are scarce because this de-
mographic has been studied so little and
its members are often misclassified on vi-
tal records as belonging to other races or
ethnicities. But what we do know about

120

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代达罗斯, 美国艺术学院学报 & SciencesThe Story of Indian Health is Complicated by History, Shortages & Bouts of Excellence

urban Indians’ health is enough to war-
rant immediate action.” The report cit-
ed dismal statistics: the infant mortality
rate among urban American Indians and
Alaska Natives was 33 percent higher than
that of the general population; the death
rate due to accidents was 38 percent high-
是; the death rate due to diabetes was 54
百分比高出; the rate of alcohol-related
deaths was 178 百分比高出; 最多 30
percent of all American Indian and Alaska
Native adults suffer from depression, 和
there is strong reason to believe the pro-
portion is even greater among those liv-
ing in cities; and cardiovascular disease,
now a leading cause of death, was virtually
unheard of among American Indians and
Alaska Natives as recently as forty years
前. The report concluded: “Urban In-
dians have less access to health care than
other Americans. 经常, their living condi-
tions are literally sickening. Persistent bias
against them and their mistrust of govern-
ment keep many from getting the health
care they need.”16

Only about 1 percent of the Indian Health
Service budget is spent on urban Indian
健康. There is another underappreciated
impact from the growth of Indian health
programs following the Indian Health Care
Improvement Act. 大约 1996, the Indian
Health Service became Indian Country’s
largest employer. Indian health was once a
small slice of the Bureau of Indian Affairs.
But by 1996, the agency’s budget was larg-
er than the bia’s and there were likely more
workers as well. 在 2017, 例如, 这
bia employed approximately 6,770 满的-
time workers compared with the 15,119 在
the Indian Health Service (包括 1,928
uniformed Public Health Service officers).
This makes sense and reflects what is hap-
pening with health care generally: clinics,
hospital systems, and university medical
centers are often a region’s largest employ-
是. But there is another story that has largely
been missed by both policy-makers and the

民众: the shift of the Indian Health Ser-
vice from a federal, government-operated
health care system to one that’s more than
60 percent operated by tribes, intertribal
组织, and nonprofits.

This is where the story gets lost in trans-
关系. Both the government-operated sys-
tem–which includes the facilities profiled
by The Wall Street Journal at Pine Ridge, Sis-
seton, and Winnebago–as well as the trib-
ally operated health care initiatives do not
have enough resources. The system as a
whole spent $3,688 per capita on its user population compared with $9,523 为了
我们. 人口.

Don Berwick, who ran the Centers for
Medicaid and Medicare, has called the In-
dian Health Service a model of efficiency:
“The Indian Health Service can and will
be one of the leading prototypes for health
care in America. The Indian Health Service
is trying to deliver the same or better care
with half the funding of other systems in
the United States.” Berwick added that the
very nature of the agency’s underfunding
has resulted in a discipline that’s “an ex-
ample for us all.”17

That discipline goes hand in hand with
创新. The Southcentral Foundation
in Anchorage set out to reinvent its program
by surveying its patients. “Are you sure you
want to do that?” ceo Katherine Gottlieb
was asked. “I was, 喜欢, delighted because I
knew what the answers were going to be. 我
was not surprised at all when the answers
came back. Long waits. Everybody hated
waiting.” Most of the primary care back
then was in the hospital’s emergency room
where they handled everything from “heart
attacks, broken arms, strep throat, 给你
name it, and here we were coming in with
our baby for just an appointment,” Gottlieb
说. “I personally waited up to seven hours,
waiting for an appointment, just to get in
the door.”

The Southcentral Foundation set out
on a new course, starting with a change in

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121

147 (2) Spring 2018Mark N. Trahant

the language. The phrase “patients” was
swapped for “customer-owner”: “We are
literally customer-owners, Alaska Natives.
Our board of directors are all Alaska Na-
tives.”18 When people are hired, 他们是
told this system is customer-owned. That’s
part of the deal: every patient is one of those
拥有者.

The Alaska Native Medical Center was
designed with a team-based approach to
health care that uses smaller waiting rooms,
so many people can be seen without long
waits. The medical team approach is differ-
耳鼻喉科, 也. The team sits together without hi-
erarchy. Members include doctors, medical
assistants, nurses, care coordinators, 和
often a behaviorist. Customer-owners can
choose their own team and make changes if
they are unhappy. The ideal is an integrated
system and a relationship with the patients,
resulting in less return visits.

在多数情况下, expenses increase at the
end of a person’s life in terms of health care
dollars spent. What if that were reversed?
What if dollars instead were invested early
on prevention, focusing on early root caus-
es of diseases to prevent the development
of heart disease, 糖尿病, depression, 或者
domestic violence? And the treatment of
root causes can reduce the health dispar-
ities that are so much a part of the Native
American experience. Gottlieb described
this model as especially necessary because,
as the baby boom generation ages, 那些
costs will be unaffordable.

The Southcentral Foundation calls this
the “Nuka” model, and the data back up
their experience. There has been a 40 每-
cent reduction in emergency room and ur-
gent care visits; A 50 percent decrease in
specialty care visits; A 20 percent decrease
in primary care visits; and more than a 35
percent decrease in admissions. Staff turn-
over has dropped dramatically and the over-
all rating by customers of their care stands
with a score of 91.7 百分. The Nuka mod-
el is not about money. “We still have a poor-

ly funded ihs system. We are not fully fund-
编辑,” claimed Gottlieb. 实际上, 她说, 这
government has not fulfilled its treaty-trust
obligations to American Indians and Alas-
ka Natives. Southcentral’s system is about
45 percent funded by the Indian Health Ser-
副, 50 percent from “aggressive” billing
of third-party insurers or Medicaid, 和
其余 5 percent from foundation
or other government grants.

“You won’t find anything in Indian Coun-
try like this campus,” said Douglas Eby, 这
Alaska Native Medical Center’s vice pres-
ident for medical services. There is less di-
rect funding from ihs, and this is by far the
biggest, most sophisticated campus in the
Indian health system. It’s also far better off
than most for a variety of reasons ranging
from leadership to the structure and re-
sources of Alaska Native corporations. “我们
were smart enough to say we need to op-
timize revenue, and we’ve done very well
at doing that,” Eby said. But the growth in
人口, people moving in from the vil-
lages, flat funding from ihs, and health care
being such a “wasteful” business drove a re-
thinking of the business model. “Our real
hope lies in controlling costs, doing things
smarter, better and avoiding high care cost
as much as possible.”19
When you consider historical trauma,

coupled with persistent underfunding by
the federal government, it’s remarkable
to think of any health facility accomplish-
ing innovation. The Indian Health Service,
tribal health centers, nonprofits, and urban
centers are tasked with delivering health
care at a fraction of the cost spent anywhere
else in America. And yes, sometimes that
falls short, sometimes dramatically so, 作为
in the case at the Winnebago Hospital. 但
that story has been told so often we forget
there is another one: the narrative of excel-
伦斯, 创新, and creativity in a sys-
tem that remains critically underfunded.

122

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代达罗斯, 美国艺术学院学报 & SciencesThe Story of Indian Health is Complicated by History, Shortages & Bouts of Excellence

尾注
1 Dan Frosch and Christopher Weaver, “‘People Are Dying Here’: Federal Hospitals Fail Tribes,”

The Wall Street Journal, 七月 7, 2017.

2 Subcommittee on the Department of the Interior, 环境, and Related Agencies, Chair-
man Lisa Murkowski Opening Statement, “Review of the FY2018 Budget Request for the In-
dian Health Service,” July 12, 2017, https://www.appropriations.senate.gov/imo/media/
doc/071217-Chairman-Murkowski-Opening-Statement.pdf.

3 同上.
4 Subcommittee on the Department of the Interior, 环境, and Related Agencies, “Re-
view of the FY2018 Budget Request for the Indian Health Service,” July 12, 2017, https://万维网
.appropriations.senate.gov/hearings/review-of-the-fy2018-budget-request-for-the-indian
-health-service.

5 大卫·S。. 琼斯, “The Persistence of American Indian Health Disparities,” American Journal of Public

健康 96 (12) (2006): 2122–2134.

6 Gregg Bourland, “A Pox on Our House,” The New York Times Magazine, 九月 9, 2002.
7 Michelle Sarche and Paul Spicer, “Poverty and Health Disparities for American Indian and Alaska
Native Children: Current Knowledge and Future Prospects,” Annals of the New York Academy of
科学 1136 (2008): 126–136.

8 William Howard Taft, “Diseases Among the Indians: Message from the President of the United
States in Relation to the Present Conditions of Health on Indian Reservations and Schools,”
八月 10, 1912, Senate Document no. 907, 62nd Congress, 2nd Session (华盛顿, 华盛顿特区:
Government Publishing Office, 1912), 1–3.

9 James P. Rife and Alan J. Dellapenna, Caring & Curing: A History of the Indian Health Service (Lando-
版本, 马里兰州。: phs Commissioned Officers Foundation for the Advancement of Public Health,
2009).

10 Declaration of National Indian Health Policy, 25 U.S.C. 1602 (1976).
11 Ted Marrs, Memo to the Secretary of the Interior, 行进 12, 1975, Box 2, Folder “Health Care
Legislation–S. 522 (2),” Bradley H. Patterson Files at the Gerald R. Ford Presidential Library.
12 Letter from Under Secretary of the Department of Health, Education and Welfare Marjorie
Lynch to H.R. Minority Leader John J. Rhodes, 六月 30, 1976, Folder “Health Care Legislation
–S. 522 (3),” Bradley H. Patterson Files at the Gerald R. Ford Presidential Library.

13 Gerald R. Ford, “Statement on Signing the Indian Health Care Improvement Act,” October 1, 1976,
hosted at “The American Presidency Project,” http://www.presidency.ucsb.edu/ws/?pid=6399.
14 Abraham B. 伯格曼, 大卫·C. Grossman, 安吉拉中号. Erdrich, 等人。, “A Political History of

the Indian Health Service,” The Milbank Quarterly 77 (4) (1999): 571–604.

15 Patricia M. 巴恩斯, Patricia F. Adams, and Eve Powell-Griner, “Health Characteristics of the
American Indian or Alaska Native Adult Population: 美国, 2004–2008,” National
Health Statistics Reports 20 (2010), https://permanent.access.gpo.gov/gpo26027/nhsr020.pdf.
16 Urban Indian Health Commission, Invisible Tribes: Urban Indians and Their Health in a Changing World
(Seattle: Urban Indian Health Institute, 2007), https://www.uihi.org/download/invisible-tribes
-urban-indians-health-changing-world/.

17 Mark Trahant, “The Double Standard of Government-Run Health Care: Indian Health Service,”
Indian Country Today, 七月 7, 2009, https://indiancountrymedianetwork.com/news/trahant
-the-double-standard-of-government-run-health-care-indian-health-service/.

18 Mark Trahant, “Customer/Owners are Key to the Nuka Model of Health Care in Anchorage,”
Indian Country Today, 二月 16, 2010, https://indiancountrymedianetwork.com/news/trahant
-customerowners-are-key-to-the-nuka-model-of-health-care-in-anchorage/.

19 同上.

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147 (2) Spring 2018Mark N. Trahant
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