indian health service indian health service the indian health service (ihs) is an operating division (opdiv) within the u.s. department of health and human services (hhs). ihs is responsible for providing direct medical and public health services to members of federally recognized native american tribes and alaska native people. ihs is the principal federal health care provider and health advocate for indian people. this article is about the native american agency in the united states. for the ministry in india, see ministry of health and family welfare. indian health serviceihs logooperating division overviewformed1955 (1955)preceding operating divisionbureau of indian affairsjurisdictionu.s. federal governmentheadquarters5600 fishers lane, north bethesda, maryland, u.s., 20857(rockville mailing address)annual budget$5.9 billion (2017)operating division executivesroselyn tso, director, indian health servicebenjamin smith, deputy director, indian health servicechild operating divisionhhs agencieswebsitewww.ihs.gov the ihs provides health care in 37 states to approximately 2.2 million out of 3.7 million american indians and alaska natives (ai/an). as of april 2017, the ihs consisted of 26 hospitals, 59 health centers, and 32 health stations. thirty-three urban indian health projects supplement these facilities with various health and referral services. several tribes are actively involved in ihs program implementation. many tribes also operate their health systems independent of ihs. it also provides support to students pursuing medical education to staff indian health programs. formation and mission the provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and indian tribes. this relationship, established in 1787, is based on article i, section 8 of the constitution, and has been given form and substance by numerous treaties, laws, supreme court decisions, and executive orders. health services for the needs of american indian and alaska natives in the united states were first provided through the department of war from the early 19th century until the office of indian affairs came into creation and took over the mission. after the mission again changed departmental authority to the department of health, education, and welfare's public health service in 1955, the ihs was established. the original priorities were stated to be assemble a competent health staff institute extensive curative treatment for the seriously ill develop a full-scale prevention program that would reduce the excessive amount of illness and early deaths, especially for preventable diseases employment ihs employs approximately 2,650 nurses, 700 physicians, 700 pharmacists, 100 physician assistants and 300 dentists, as well as a variety of other health professionals such as nutritionists, registered medical-record administrators, therapists, community health representative aides, child health specialists, and environmental engineers and sanitarians. it is one of two federal agencies mandated to use indian preference in hiring. this law requires the agency to give preference to qualified indian applicants before considering non-indian candidates for employment, although exceptions apply. ihs draws a large number of its professional employees from the u.s. public health service commissioned corps. this is a non-armed service branch of the uniformed services of the united states. professional categories of ihs commissioned corps officers include physicians, physician assistants, nurses, dentists, therapists, pharmacists, engineers, environmental health officers, and dietitians. many ihs positions are in remote areas as well as its headquarters outside of rockville, maryland, and at phoenix indian medical center in phoenix, arizona. in 2007, most ihs job openings were on the navajo reservation. 71% of ihs employees are american indian/alaska native. the ihs also hires native/non-native american interns, who are referred to as "externs". participants are paid based on industry standards, according to their experience levels and academic training, but are instead reimbursed for tuition and fees if the externship is used for an academic practical experience requirement. legislation the snyder act of 1921 (23 u.s.c. 13) was the first formal legislative authority allowing health services to be provided to native americans. in 1957, the indian facilities act authorized funding for community hospital construction. this authority was expanded in 1959 with the indian sanitation and facilities act, which also authorized construction and maintenance of sanitation facilities for native american homes, communities, and lands. indian self-determination act of 1975 (public law 93-638) expectmore.gov lists four rated areas of ihs: federally administered activities (moderately effective), healthcare-facilities construction (effective), resource- and patient-management systems (effective), and sanitation-facilities construction (moderately effective). all federally recognized native american and alaska natives are entitled to health care. this health care is provided by the indian health service, either through ihs-run hospitals and clinics or tribal contracts to provide healthcare services. indian health care improvement act of 1976 (public law 94-437) the passing of the indian health care improvement act of 1976 expanded the budget of the ihs to expand health services. the ihs was able to build and renovate medical facilities and focus on the construction of safe drinking water and sanitary disposal facilities. the law also developed programs designed to increase the number of native american professionals and improve urban natives' health care access. other legislation title v of the indian health care improvement act of 1976 and title v of the indian health care amendment of 1980 have increased the access to healthcare native americans living in urban areas receive. the ihs now contracts with urban indian health organizations in various us cities in order to expand outreach, referral services, and comprehensive healthcare services. administration ihs headquarters at 5600 fishers lane in rockville, maryland the indian health service is headed by a director; as of 27 september 2022, the current director is roselyn tso. reporting to the director are a chief medical officer (dr. loretta christensen, m.d. as of 2022), deputy directors (field operations, intergovernmental affairs, management operations, and quality health care), and offices for tribal self-governance, urban indian health programs, and direct service and contracting tribes. twelve regional area offices each coordinate infrastructure and programs in a section of the united states. a 2010 report by senate committee on indian affairs chairman byron dorgan, d-n.d., found that the aberdeen area of the ihs is in a "chronic state of crisis". "serious management problems and a lack of oversight of this region have adversely affected the access and quality of health care provided to native americans in the aberdeen area, which serves 18 tribes in the states of north dakota, south dakota, nebraska and iowa," according to the report. between 2015 and 2017, the agency saw five different directors. rear admiral chris buchanan, a seminole, served as acting director from january–june 2017. prior to buchanan, the office was headed by attorney mary l. smith (cherokee). yvette roubideaux (rosebud sioux), was appointed director of ihs by president obama in 2009; she was re-nominated for a second four-year term in 2013 but was not re-confirmed by the senate. after she stepped down in 2015, she was briefly replaced by robert mcswain (mono). roubideaux was also preceded by mcswain, who had served as director for eight months. trump's nominee for the post, robert m. weaver of the quapaw tribe, withdrew from consideration after questions arose about his resume. in june 2017, hhs secretary alex azar appointed rear admiral michael d. weahkee, a zuni, to be acting director. in july 2017, weahkee was severely chastised during the united states senate appropriations subcommittee on interior, environment, and related agencies budget hearings by senator jon tester. weahkee refused to answer repeated direct questions about whether the 2018 ihs budget proposal was adequate to fulfill the service's remit. in the december 11, 2019 senate committee on indian affairs hearing on the nomination of weahkee as director of the indian health service, sen. tester, a former chairman and former vice chairman of the committee, told weahkee, "i think you're going to get confirmed ... and you should get confirmed." weahkee was finally confirmed to the post on april 21, 2020, by a voice vote in the senate. in a letter dated january 11, 2021, weahkee informed tribal and urban indian leaders that he had been asked to tender his resignation by january 20, "to allow the incoming administration to appoint new leadership". in 2009, indian health service pediatrician stanley patrick weber was accused of sexually abusing boys under his care at ihs facilities across a two-decade span. weber resigned in 2016 and in 2020 was sentenced to five life terms in prison for the crimes. a 2019 report commissioned by ihs found that ihs officials did not properly investigate or follow up on the accusations against weber, promoting him to medical director of the ihs hospital in pine ridge, south dakota after the accusations were made. in january 2021, elizabeth fowler of the comanche nation, was named as acting director. ms fowler had been executive director of the ihs oklahoma city area since 2019. the current director, roselyn tso, was nominated to the position by president joe biden in may 2022, and was confirmed by the united states senate in september 2022. areas a network of twelve regional offices oversee clinical operations for individual facilities and funds. as of 2010, the federally operated sites included 28 hospitals and 89 outpatient facilities. graphic from the government accountability office showing the patient populations per service area for the year 2014 alaska area: director, christopher mandregan, jr., m.p.h. (aleut community of st. paul, alaska) albuquerque area: director, leonard thomas, m.d. (navajo) bemidji area: director, daniel frye, m.h.a. sault ste. marie tribe of chippewa indians (chippewa) billings area: director, bryce redgrave california area: director, beverly miller, c.p.a. (cherokee) great plains area: director, james driving hawk (rosebud sioux). the name of this area was changed in 2014 from the aberdeen area. nashville area: director, dr. beverly cotton (mississippi choctaw) navajo area: director, roselyn tso oklahoma area: director, rear adm. travis watts phoenix area: director, (ret.) rear adm. charles ty reidhead, m.d., m.p.h. (three affiliated sioux tribes) portland area: director, dean seyler, b.s. (confederated tribes of warm springs) tucson area: director, dixie gaikowski (three affiliated sioux tribes) services and benefits the ihs provides a variety of health services in outpatient and inpatient settings, with benefits including pharmacy, dental, behavioral health, immunizations, pediatrics, physical rehabilitation, and optometry. a more extensive list can be found at the official ihs website, and it is recommended for patients to contact their particular ihs facility to confirm services provided since benefits may differ by location. eligibility to qualify for health benefits from the ihs, individuals must be of american indian and/or alaska native descent and be a part of an indian community serviced by ihs. individuals must be able to provide evidence such as membership in a federally recognized tribe, residence on tax-exempt land, or active participation in tribal affairs. federally recognized tribes are annually defined by the bureau of indian affairs (bia). non-indians can also receive care if they are the child of an eligible indian, the spouse (including same-sex spouses) of an eligible indian, or a non-indian woman pregnant with an eligible indian's child. the exact policy can be found in the ihs indian health manual (ihm). to apply for benefits through the ihs, individuals can enroll through the patient registration office of their local ihs facility. individuals should be prepared to show proof of enrollment in a federally recognized tribe. direct care versus purchased/referred care (prc) "direct care" refers to medical and dental care that american indians and alaska natives receive at an ihs or tribal medical facility. if patients are referred to a non-ihs/tribal medical facility, there is the option to request for coverage via the ihs "purchased/referred care (prc) program". due to limited funds from u.s. congress, referrals through prc are not guaranteed coverage. authorization of these payments are determined through several factors, including confirmation of ai/an tribal affiliation, medical priority, and funding availability. ihs national core formulary the ihs national pharmacy and therapeutics committee (nptc) is composed of administrative leaders and clinical professionals, including pharmacists and physicians, who regulate the ihs national core formulary (ncf) to reflect current clinical practices and literature. the ncf is reviewed every quarter and revised as needed based on arising health needs within the native american communities, pharmacoeconomic analyses, recent guidelines, national contracts, and clinician advice. fibric acid derivatives and niacin extended release were removed from the formulary in february 2017, but there were no changes made to the ncf during the may 2017 meeting. the complete national core formulary can be found on the ihs website. necessity for hepatitis c coverage the national health and nutrition