Healthcare policy for American Indians cannot be understood apart from the US government’s Indian policy more generally, and neither Indian policy in general nor healthcare policy in particular has been consistent over the past century or more. Moreover, they have often appeared to be inconsistent in their aims. From the late 19th century to the 1930s, the emphasis of Indian policy was on the assimilation of Indians into the larger US society, and their abandonment of tribalism. With the coming of the New Deal in the 1930s, policy shifted to what would now be called self-determination. By the early 1950s, however, selfdetermination had been abandoned in favour of assimilation, manifested in the government’s attempt – successful in several instances – to terminate the special trust status of Indian tribes. By the late 1960s, that policy had been abandoned and self-determination was once again the stated policy. The consequences for health policy have been paradoxical. Despite the concern to create better health services responsive to the needs of Indians during the New Deal of the 1930s, for instance, quality and access did not improve noticeably. On the other hand, in the 1950s, when termination of Indians’ special status had become the goal, it became evident that, without a significant improvement in health status, they would be unable to assimilate adequately. Thus, services were improved significantly, with beneficial consequences for health. That improved system of health services became the target of criticism by many who believed that it was insufficiently responsive to community needs. Changes in federal legislation in the 1970s allowed tribal governments and other entities to assume responsibility for the management and provision of services without, however, providing a mechanism for financial support to grow as the costs of care increased. Thus there has been little increase in financial support for services over the past 20 years or so, and the result has been that both preventive and curative services have suffered, and the mortality rate of Indians has increased.
