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.

This law requires the agency to give preference to qualified Indian applicants before considering non-Indian candidates for employment, although exceptions apply.

[9] 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".

[13] 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.

[16] 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.

[17] Weahkee refused to answer repeated direct questions about whether the 2018 IHS budget proposal was adequate to fulfill the Service's remit.

[20] 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.

[22] 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.

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.

[39][40][41] Authorization of these payments are determined through several factors, including confirmation of AI/AN tribal affiliation, medical priority, and funding availability.

[42] Fibric acid derivatives and niacin extended release were removed from the formulary in February 2017,[42] but there were no changes made to the NCF during the May 2017 meeting.

[44] To address this concern, in 2012 IHS implemented a nationwide hepatitis C virus (HCV) antibody testing program for persons born between 1945 and 1965.

[47] Despite this prevalent need, IHS currently does not include any new direct acting anti-retroviral (DAA) hepatitis C medications on its National Core Formulary.

[49] Due to their lack in funding and quality of care, the IHS has not been able to effectively combat the Native American HCV issue, unlike the Veterans Affairs system, which was able to eradicate much of the disease through adequate resources from the federal government.

[4] The IHS's Indians Into Medicine (INMED) program offers grants to universities to support Native American students in their medical education through mentorship, tutoring, financial aid, and more.

"[51] The Indian Self Determination and Education Assistance Act (ISDEAA) allows for tribes to request self-determination contracts with the Secretaries of Interior and Health and Human Services.

[52] The hospital is based on the adoption of an Alaska Native model of healthcare called the "Nuka System of Care", a framework that focuses on patient-centered, self-determined health service delivery that heavily relies on Patient participation.

The Nuka System of Care was developed by the Southcentral Foundation in 1982, a non-profit healthcare organization that is owned and composed of Alaska Natives.

[54] The fear of potential termination has led some tribes to refuse to participate in Self Determination contracting without a clear resolution of this issue.

[60] During the formation of the ACA, tribal leaders pushed for the reauthorization of the Indian Health Care Improvement Act and further provisions for AI/NA recipients, which facilitated IHS Medicaid funding.

[61] The ACA also authorized funding to support residency training programs in tribal or IHS facilities through teaching health centers (THCs).

[62] Such initiatives support provider retention as a greater percentage of graduates from these THCs chose to work in rural and underserved settings compared to the national average.

[61] Some tribal members assert that provisions under Medicaid are not what was promised to the Native American people as they are based on expanding affordability via insurance and not on providing comprehensive health services that are fully covered.

[61] Due to the rural nature of reservations and lack of communication about the system, the enrollment and logistical processes involved in having Medicaid can also pose a barrier to Native Americans signing up, and disrupt members' eligibility status.

[60] In 2011, the Center for Medicare and Medicaid Services developed a mandate for tribal consultation regarding policy action in an effort to improve the quality of care for tribes.

[65] This is contributed to by the lack of public health infrastructure as well as the considerable distance to healthcare facilities for rural residents.

Other issues that have been highlighted as challenges to improving health outcomes are social inequities such as poverty and unemployment, cross-cultural communication barriers, and limited access to care.

[72] Issues surrounding isolation, lack of shopping centers, schools, and entertainment also dissuades providers from moving to these areas.

[75][76][77][78] Individuals who are not of citizens of federally recognized tribe or who live in urban areas may have trouble accessing the services of the IHS.