Dear Reader,

It’s a common misconception that Native Americans get “free” health care. Yet the responsibility to provide health care — among other core tenets — to Native Americans throughout the country is deeply rooted in United States history. The stories in this year’s edition of the Native News Honors Project show the steep, continuing cost of that care, as well as the enduring efforts to improve it.

The phrase “for the benefit, care and assistance…” is written into the United States’ agreements with sovereign Indian tribes. These words might seem cynical in 2017, nearly 100 years after they were written in the Snyder Act of 1921, the piece of legislation that eventually led to the creation of the Indian Health Service in 1955. It was a promise made law that to this day faces hurdles in funding, staffing and infrastructure.

This spring, Native News teams waded into the murky details of health care policy and pushed the notoriously tight-lipped Indian Health Service for answers. Teams traveled to all seven of the tribal reservations in Montana to find out how well the IHS is meeting the promise made so long ago.

We found that IHS is budgeted to spend about $4,000 per patient, half of the national average. The amount is touted as part of an efficient system, but overwhelmingly, patients feel underserved. IHS sites see high staff turnover, long wait times, geographic isolation, cultural misunderstandings and significant health disparities among Native Americans compared to national averages.

Although the IHS system is run by passionate, community-driven people, the system itself falters and succeeds inconsistently throughout the state. On Fort Peck, veterans promised health care by both IHS and the VA find access harder to secure, not easier. On the Rocky Boy’s reservation, an infrastructure crisis puts reliable access to water out of reach.

Elsewhere, communities are asking new questions about how to solve old problems. Northern Cheyenne leaders clash over whether to focus on diabetes prevention or treat its severest symptoms. On the Blackfeet reservation, prescriptions meant to ease the opiate crisis may be spawning a different problem.

Native Americans across Montana confront the systems that let them down and take matters into their own hands. On the Flathead reservation, a tribally run program aims to temper the challenges of mental health care in a place where nobody’s anonymous. In Crow Agency, an intrepid administrator works to revitalize long-term care close to home.

Systemic changes have brought hope to others. Increased insurance enrollment due to Medicaid expansion has let urban Native Americans get access to previously inaccessible health care, while on Fort Belknap, it has led to increased resources for the community, not just enrollees.

The price of health care in Indian Country can be measured on several scales. The cost is historic, it’s deep, and for most, it is under performing.

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