Native American Healthcare, Bureaucracy, and Poverty: Institutional Problems and Solutions

For decades Native Americans have experienced higher rates of mortality and chronic health problems than have other Americans. In “Native American Healthcare, Bureaucracy, and Poverty: Institutional Problems and Solutions,” Jordan K. Lofthouse and Kelcie McKinley find that both problems are the result of institutional barriers that keep Native Americans in poverty and of a healthcare system mired in bureaucracy. Immediate, small-scale policy changes and long-term institutional reforms are necessary for long-lasting improvements in outcomes.


The primary provider of healthcare for millions of Native Americans is the Indian Health Service (IHS), which is funded and managed by the federal government. However, the IHS has long struggled with underfunding and bureaucratic shortcomings, which are two important sources of health disparities.


Congress and IHS decision makers could implement the following policy changes to help improve the provision of healthcare in the IHS system.

  • Allocate more federal funding to the IHS as a practical, short-term solution for delivering more healthcare to more individuals.

  • Align the incentives of IHS workers to improve their performance and increase accountability for IHS decision makers.

  • Increase the supply of healthcare through the IHS by allowing innovators to find new and imaginative ways to improve people’s health (such as through telemedicine) and by removing barriers to willing healthcare providers.


Institutional reform at the level of the IHS is an important step. However, poor health outcomes can also be attributed to the pervasive poverty that many Native Americans experience. The underlying causes of Native American poverty often are rooted in the formal institutions of reservations.


Federal and tribal policymakers could implement the following institutional reforms to help address the underlying causes of Native American poverty:

  • Federal and tribal policymakers should focus on removing barriers to entrepreneurship and innovation that could contribute to faster economic growth and could lead to better health outcomes in the long run.

  • Reforms should include streamlining property rights, thereby cutting unnecessary red tape for businesses and property owners and reducing legal-political uncertainty. Although many tribes have started to make necessary reforms, such efforts must go further.

  • Native Americans who live in rural areas near reservations face economic hardships that contribute to poverty and poorer health outcomes. Removing barriers to rural economic development (such as access to reliable, high-speed internet) would likely help alleviate poverty for those individuals.


Allocating more funding to the IHS can provide a practical, short-term way to deliver more healthcare to Native Americans. This allocation of funding should not provide an excuse to avoid tackling institutional reforms to the IHS or, even more important, to avoid addressing the roots of Native American poverty. Without deeper, long-term institutional reforms like those mentioned earlier, health outcomes and economic opportunities are not likely to significantly improve.

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