1-3.1 HISTORICAL BACKGROUND

1800-1900 . Federal health services for Indians began under War Department auspices in the early 1800's. At this time the Federal Indian policy was primarily one of military containment. As early as 1802 or 1803 Army physicians took emergency measures to curb contagious diseases among Indian tribes in the vicinity of military posts. The first large scale smallpox vaccination of Indians was authorized by Congress in 1832. Transfer of the Indian program from the War Department to the Department of the Interior, newly created in 1849 to deal with the Nation's resources, stimulated the extension of physicians' services to Indians. Federal construction of hospitals and infirmaries began in the early 1880's, originally to serve Indian boarding school students almost exclusively. Nurses appeared on the staff for the first time in the 1890's. 1900-1955 . Professional medical supervision of Indian health activities began with the establishment of the position of Chief Medical Supervisor in 1908. Appropriations designated specifically for general health services to Indians first appeared in the budget in fiscal year 1911. Creation of the Health Division in 1924 raised the status of the program and allowed direct access to the Commissioner of Indian Affairs. Officers of the Public Health Service Commissioned Corps have been detailed to the Indian health program to meet the needs for qualified staff, especially in the supervisory posts, since 1926. Proposals for transfer of the program to the Public Health Service were made by the House Committee on Indian Affairs as early as 1919, but were rejected at that time by both the Public Health Service and the Bureau of Indian Affairs as undesirable and impracticable. A similar proposal was made in 1949 by the Hoover Commission's Task Force on Public Welfare, and was supported by the Association of State and Territorial Health Officers, the American Medical Association, the Association on American Indian Affairs, and others. The transfer was made on July 1, 1955, to the Public Health Service, Department of Health, Education, and Welfare as the agency responsible for the country's human resources.

1-3.2 SERVICE PUBLICATIONS

Additional background information is available in the following publications of the Service:

"The Indian Health Program 1800-1955."

"To the First Americans" yearly update.

"The Indian Health Program of the Public Health Service".

The best available general history of the Public Health Service is:

"The United States Public Health Service, 1798-1950" by Ralph Chester Williams, M.D., Commissioned Officers Association of the United States Public Health Service, Washington, D.C., 1951.

1-3.3 GENERAL AUTHORITY

The Indian Health program became a primary responsibility of the Public Health Service under Public Law 568, 83rd Congress, 2nd session (42 USC 2001), August 5,1954. (See Exhibit l-3.3(1)). This Act provides in part "that all functions, responsibilities, authorities, and duties . . . relating to the maintenance and operation of hospital and health facilities for Indians, and the conservation of Indian health... shall be administered by the Surgeon General 1/ of the United States Public Health Service." The Act further provides that "whenever the health needs of the Indians can be better met thereby" the Public Health Service might "enter into contracts with any State, Territory, or political subdivision thereof, or any private non-profit corporation, agency or institution providing for the transfer of Indian hospitals or health facilities" with the condition "that all facilities transferred shall be available to meet the health needs of the Indians and that such health needs shall be given priority over those of the non-Indian population." Where such a facility "has been constructed or maintained for a specific tribe of Indians" such a transfer cannot be made "unless such action has been approved by the governing body of the tribe", with a provision for recapture if a transferred facility is found "not thereafter serving the needs of the Indians." Those are the major provisions of the Act.

Among the authorities transferred to the Secretary of Health, Education, and Welfare from the Secretary of Interior, were those contained in the so-called Snyder Act, 25 U.S.C. 13. (See Exhibit 1-3.3(8)). That act provides authority to "expend such moneys as Congress may from time to time appropriate for the benefit, care and assistance of the Indians throughout the United States... for relief of distress and conservation of health." This is the basic appropriation authorization for the Indian Health Service. Consistent with this statutory language Congress has, in the legislative history of certain annual appropriations, directed the Indian Health Service to expend money on specific activities leading to changes in the scope of the program. In this connection, special health programs affecting Indians in California rural communities, Rapid City, South Dakota, and special urban health studies in metropolitan areas such as Minneapolis, Minnesota, have been authorized.

Additional authority was given under Public Law 151, 85th Congress (42 USC 2005), August 16, 1957, (see Exhibit 1-3.3(2)) which provides "that whenever the Surgeon General 1/... determines... that the provision of financial assistance... for the construction of a community hospital constitutes a method of making needed hospital facilities available for... Indians which is more desirable and effective than direct Federal construction he may provide such financial assistance." Two qualifications are placed on this authority: (1) The Surgeon General may make his determination only "after consultation with such Indians" and, (2) "shall take into account only those categories of Indians for which hospital and medical care, including outpatient care and field health services, is being 'provided by or at the expense of the Public Health Service on the date of enactment of this Act."

Public Law 121, 86th Congress, July 31, 1959, (see Exhibit 1-3.3(3)) amends the original transfer act to authorize the Surgeon General to "construct... or otherwise provide and maintain... essential sanitation facilities... for Indian homes, communities, and lands." It includes the authority to "acquire lands,... including sites, rights of way, and easements," to "make... arrangements and agreements with appropriate public authorities... and with the Indians to be served... regarding contributions toward the construction... and responsibilities for maintenance," and to "transfer any facilities provided... to any... public authority... or to any Indian tribe." The Act directs the Surgeon General to "consult with, and encourage the participation of, the Indians concerned, states, and political subdivisions thereof." It also provides that transfer of Indian owned land is subject to (1) "consent of such beneficial owner.. . in any case where a beneficial interest in such land is in any Indian," and (2) "reversion of title... if it ceases to be used for the purpose for which it is transferred."

Public Law 174, 90th Congress, December 5, 1967, "Partnership for Health Amendments of 1967," (see Exhibit 1-3.3(4)) amends Section 324 of the Public Health Service Act to authorize the Secretary to provide medical, surgical and dental treatment and hospitalization and optometric care for Federal employees and their dependents at remote medical facilities of the Public Health Service where such care and treatment are not otherwise available.

Public Law 702, 89th Congress, November 2, 1966 (Title II - Administration of the Pribilof Islands, Section 205, (see Exhibit l-3.3(5)) authorizes the Secretary to provide medical and dental care to the natives of the Pribilof Islands with or without reimbursement as provided by other law. Also authorizes the provision of such care to Federal employees and their dependents and tourists and other persons in the Pribilof Islands at reasonable rates as determined by him.

Public Law 93-197, 93rd Congress, December 22, 1973, the Menominee Restoration Act repealed the Act of June 17, 1954 (68 Stat. 250; USC 891-902, as amended) which had terminated Federal supervision over the rights and privileges of members of the Menominee Indian Tribe as a federally recognized sovereign Indian tribe; and restored those Federal services, including health services, furnished to American Indians because of their status as American Indians.

Public Law 93-222, the Health Maintenance Organization Act of 1973, December 29, 1973, section 6, amends the first section of the Act of August 5, 1954 (42 USC 2001), the Indian Health Transfer Act. (See Exhibit 1-3.3(1)) The amendment contained in Public Law 93-222, authorizes the Secretary, with the consent of the Indian people served, to contract with private or other non-Federal health agencies or organizations for the provision of health services on a fee-for-service basis or on a prepayment or other similar basis. Although included in the HMO Act, the authority is not limited to contracts with HMO's.

1-3.4 GOAL AND OBJECTIVES OF THE INDIAN HEALTH PROGRAM

Service Goal . Elevation of the health status of the Indian and Alaska Native to the highest possible level. Service Objectives . Institution of health programs which assure achievement of the Service goal through self-help activities conducted by and with the Indians and Alaska Natives to the ultimate realization of assumption of fuller responsibilities in meeting their health needs. Management of Service resources, (manpower, money, and materials) in a manner that provides a coordinated and balanced preventive curative and rehabilitative health program through a constantly updated Area-wide operations plan, initiated at the service unit level and consolidated in a comprehensive Service plan with Indian cooperation and consultation. Institution of continuing appraisal of health status to insure efficient application of effort in those areas to that will have the greatest impact on achieving the Service's goal, coupled with continued development of additional tools for measurement, evaluation, and application.

1/ Reorganization Plan No. 3 of 1966 transferred all statutory powers and functions of the Surgeon General to the Secretary of Health, Education, and Welfare.