examination survey provides national prevalence data for hepatitis c but excludes several high risk populations including federal prisoners, homeless individuals and over one million native americans residing on reservations. to address this concern, in 2012 ihs implemented a nationwide hepatitis c virus (hcv) antibody testing program for persons born between 1945 and 1965. this resulted in a fourfold increase in the number of patients screened. ihs facilities of the southwest reported the largest gains in number of patients tested and the percentage of eligible patients that received testing. currently, the incidence rate of acute hepatitis c in native americans is higher in comparison to any other racial/ethnic group (1.32 cases per 100,000). additionally, native americans have the highest rate of hepatitis c related deaths (12.95% in 2015) in comparison to any other racial/ethnic group. despite this prevalent need, ihs currently does not include any new direct acting anti-retroviral (daa) hepatitis c medications on its national core formulary. new daa drugs provide a cure to hepatitis c in most cases but are costly. due to their lack in funding and quality of care, the ihs has not been able to effectively combat the native american hcv issue, unlike the veterans affairs system, which was able to eradicate much of the disease through adequate resources from the federal government. scholarships the ihs offers three types of scholarships to native american students pursuing an education in healthcare: preparatory scholarship, pre-graduate scholarship, and health professions scholarship. the health professions scholarship commits undergraduate and graduate students to a full-time service commitment after their professional training. these scholarships help to staff indian health programs with native american professionals. in addition, the ihs's indians into medicine (inmed) program offers grants to universities to support native american students in their medical education through mentorship, tutoring, financial aid, and more. it has also been used to support and encourage students before college to take pre-medical courses. tribal self-determination notable self-determination legislation in 1954, the indian health transfer act included language that recognizing tribal sovereignty and the act additionally "afforded a degree of tribal self-determination in health policy decision-making." the indian self determination and education assistance act (isdeaa) allows for tribes to request self-determination contracts with the secretaries of interior and health and human services. the tribes take over ihs activities and services through an avenue called ‘638 contracts’ through which tribes receive the ihs funds that would have been used for ihs health services and instead manage and use this money for the administration of health services outside of the ihs. self-determination successes and concerns the benefits and drawbacks of tribal self determination have been widely debated. many tribes have successfully implemented elements of health-related self determination. an example is the cherokee indian hospital in north carolina. this community-based hospital, funded in part by the tribe's casino revenues, is guided by four core principles: "the one who helps you from the heart", "a state of peace and balance", "it belongs to you" and "like family to me" "he, she, they, are like my own family". the hospital is based on the adoption of an alaska native model of healthcare called the "nuka system of care", a framework that focuses on patient-centered, self-determined health service delivery that heavily relies on patient participation. the nuka system of care was developed by the southcentral foundation in 1982, a non-profit healthcare organization that is owned and composed of alaska natives. the nuka system's vision is "a native community that enjoys physical, mental, emotional and spiritual wellness". every alaska native in the health system is a "customer-owner" of the system and participates as a self-determined individual who has a say in the decision-making processes and access to an intimate, integrated, long-term care team. when a customer-owner seeks care, their primary care doctor's foremost responsibility is to build a strong and lasting relationship with the beneficiary, and customer-owners have various options through which they can give input and participate in decisions about their health. these options include surveys, focus groups, special events and committees. the board is made up entirely of alaska natives who helped design the system and actively participate in running it effectively. following the implementation of the nuka system of care in alaska native health, successes in improved standards of care have been achieved, such as increases in the number of alaska natives with a primary care provider, in childhood immunization rates, and customers satisfaction in regard to respect of culture and traditions. in addition, decreases in wait times for appointments, wait lists, emergency department and urgent care visits, and staff turnover have been reported. the north carolina cherokee indian hospital in 2012 as well as other tribes have implemented the nuka system approach when planning their new or revamped health centers and systems. some tribes are less optimistic about the role of self determination in indian healthcare or may face barriers to success. tribes have expressed concern that the 638 contracting and compacting could lead to "termination by appropriation", the fear that if tribes take over the responsibility of managing healthcare programs and leave the federal government with only the job of funding these programs, then the federal government could easily "deny any further responsibility for the tribes, and cut funding". the fear of potential termination has led some tribes to refuse to participate in self determination contracting without a clear resolution of this issue. some tribes also renounce self determination and contracting because of the chronic underfunding of ihs programs. they do not see any benefit in being handed the responsibility of a "sinking ship" due to the lack of a satisfactory budget for ihs services. other tribes face various barriers to successful self determination. small tribes lacking in administrative capabilities, geographically isolated tribes with transportation and recruitment issues, and tribes with funding issues may find it much harder to contract with the ihs and begin self-determination. poverty and a lack of resources can thus make self determination difficult. budget the ihs receives funding as allocated by the united states congress and is not an entitlement program, insurance program, or established benefit program. the 2017 united states federal budget includes $5.1 billion for the ihs to support and expand the provision of health care services and public health programs for american indians and alaska natives. the proposed 2018 budget proposes to reduce ihs spending by more than $300 million. this covers the provision of health benefits to 2.5 million native americans and alaskan natives for a recent average cost per patient of less than $3,000, far less than the average cost of health care nationally ($7,700), or for the other major federal health programs medicaid ($6,200) or medicare ($12,000). affordable care act an integral focus of economic and health policy for native american healthcare is medicaid. under the affordable care act (aca) of 2010, states could choose to expand medicaid benefits. many native americans stood to benefit from this expansion of healthcare coverage. ihs and tribal facilities rely on beneficiaries like medicaid to help cover the congressional underfunding of the ihs itself. during the formation of the aca, tribal leaders pushed for the reauthorization of the indian health care improvement act and further provisions for ai/na recipients, which facilitated ihs medicaid funding. the aca also authorized funding to support residency training programs in tribal or ihs facilities through teaching health centers (thcs). such initiatives support provider retention as a greater percentage of graduates from these thcs chose to work in rural and underserved settings compared to the national average. expansion of medicaid under the aca is dependent on whether or not the state authorizes it. if states do not approve expansion, fewer people receive comprehensive coverage and ihs and tribal facilities do not receive the extra sources of funding. the ihs and tribal clinics can direct money toward provider recruitment with better reimbursement for patient services. opponents of using medicaid to alleviate health inequalities argue that it takes responsibility away from the government to provide comprehensive health services. they argue that underfunding of the ihs would still be persistent and possibly intensify under medicaid expansion as patients go to private providers. some tribal members assert that provisions under medicaid are not what was promised to the native american people as they are based on expanding affordability via insurance and not on providing comprehensive health services that are fully covered. by relying on services reimbursed by medicaid, this increases participation in private health services instead of public. due to the rural nature of reservations and lack of communication about the system, the enrollment and logistical processes involved in having medicaid can also pose a barrier to native americans signing up, and disrupt members' eligibility status. some proposed that to avoid these disruptions, the federal money from medicaid directed to tribe members could be directed straight to the ihs budget, allowing funding to go directly to tribes and giving them say over eligibility. in 2011, the center for medicare and medicaid services developed a mandate for tribal consultation regarding policy action in an effort to improve the quality of care for tribes. another economic proposition to improve healthcare is to surpass consultation status for tribes when it comes to medicaid policy and make them integral to the final decision making. this would help ensure that medicaid programs are culturally aware and can treat behavioral medical issues better. current issues life expectancy for native americans is approximately 4.5 years less than the general population of the united states (73.7 years versus 78.1 years). native communities face higher rates of chronic diseases like cancer, diabetes, and kidney disease. this is contributed to by the lack of public health infrastructure as well as the considerable distance to healthcare facilities for rural residents. in 2013, the ihs experienced funding cuts of $800 million, representing a substantial percentage of its budget. over the past twenty years, the gap between spending on federally recognized american indian/alaska natives and spending on medicare beneficiaries has grown eightfold. this inequity has a large impact on service rationing, health disparities and life expectancy, and can lead to preventive services being neglected. other issues that have been highlighted as challenges to improving health outcomes are social inequities such as poverty and unemployment, cross-cultural communication barriers, and limited access to care. data from the 2014 national emergency department inventory survey showed that only 85% of the 34 ihs respondents had continuous physician coverage. of these 34 sites, only 4 sites utilized telemedicine while a median of just 13% of physicians were board certified in emergency medicine. the majority of ihs emergency department from the survey reported operating at or over capacity. tribal reservations are often sequestered in unfavorable and isolated locations. according to a study of provider vacancies in the ihs, conducted by the department of health and human services (2016), about half of the clinics studied identified their remote location as a large obstacle for hiring and retaining staff. issues surrounding isolation, lack of shopping centers, schools, and entertainment also dissuades providers from moving to these areas. such vacancies lead to cutting of patient services, delays in treatment, and negative effects on employee morale. studies show that such problems surrounding native americans and reservation inequality may be addressed by growing a native american healthcare workforce. since its beginnings in 1955, the ihs has been criticized by those it serves in medical deserts and by public officials. individuals who are not of citizens of federally recognized tribe or who live in urban areas may have trouble accessing the services of the ihs.