American Indian and Alaska Native (AI/AN) refer to people who identify with one or more Tribes of the continental US or Alaska. Native Hawaiians are not AI/AN. 

Native American generally refers to members of groups Native to the US or its territories or people who are Native to any part of the Americas (Canada, Mexico, South America) that are also US residents. 

AI/AN can refer to a race – such as in Census or public health data – but also to a political status because some people, but not all, who identify as AI/AN are also members of federally recognized Tribes. 

AI/AN “race” is often used to identify Tribal members in public health data, but the two groups are not identical. Tribal members can be of any race or ethnicity and be AI/ANs in terms of political status

Due to the government-to-government relationship between them, the federal government and Tribes have what is called a “trust” relationship or the “trust responsibility”.  

This relationship is based on treaties that the US entered into with Tribes. The treaties guaranteed that the federal government would, among other things, “provide for the well-being of the tribes” in exchange for Tribal lands. 

The relationship is also considered to be nation-to-nation, differing from state-to-federal government or state-to-state relationships. 

Federal, State, or local public health agencies partnering with Tribal public health agencies should, therefore, treat these relationships as government-to-government interactions. Tribes are not non-profit organizations or other private entities; they are Nations. 

• Tribal governments have the same rights, authorities, and responsibilities of other nations to protect and promote the health of their citizens or members. 

• They can monitor public health threats and provide public health services. 

• They should be treated as Nations in interactions with other governments. Both state and federal agencies should interact with Tribes on a government-to-government basis. 

The US government has provided American Indians and, later, Alaska Natives, health care for over 200 years. Initially care was provided by military surgeons and Indian affairs were housed in the War Department until 1849. With the establishment of reservations, the US government provided services to American Indians, including food and healthcare. 

Many treaties commit the US government to providing healthcare for American Indians and Alaska Natives. Through its trust responsibility to Tribal nations, the federal government is required to provide, among other things, healthcare to AI/ANs in a way that it is not obligated to other Americans. This unique obligation also impacts the legal relationship between Tribes and the federal government. 

After different ways of providing care, the US created the Indian Health Service (IHS) in 1955 within the Public Health Service. 

The Indian Health Service (IHS) provides direct health services to 2.6 million American Indians and Alaska Natives in 37 states. It is not health insurance, it is a system of direct care providers, similar to the Veterans Affairs system. 

IHS can provide care through federally run facilities or Tribes can opt to operate their own facilities by contracting for those services. Most of these services are reservation-based and in rural areas. Tribes operate over half of all IHS facilities, including clinics, hospitals, and treatment centers.  

There is also a system of 45 Urban Indian Organizations (UIOs) serving urban AI/AN throughout the country. The majority of AI/ANs live in urban areas and not on reservations. A quarter (25%) of AI/ANs living in urban areas live in a county served by an urban Indian Health program.  

Tribal Epidemiology Centers (TECs) are part of the federal government’s efforts to provide health services to AI/AN communities. 

In 1992, Congress authorized the creation of TECs under the Indian Health Care Improvement Act to help provide public health services and support to Tribes. TECs fulfill seven core functions: 

1. Collect data relating to, and monitor progress made toward meeting, each of the health status objectives of the Service, the Indian Tribes, Tribal organizations, and urban Indian organizations in the Service area;                                 
2. Evaluate existing delivery systems, data systems, and other systems that impact the improvement of Indian health;                                                                                                                                                                                                                 
3. Assist Indian Tribes, Tribal organizations, and urban Indian organizations in identifying highest-priority health status objectives and the services needed to achieve those objectives, based on epidemiological data;                       
4. Make recommendations for the targeting of services needed by the populations served;                                                
5. Make recommendations to improve health care delivery systems for Indians and urban Indians;                                 
6. Provide requested technical assistance to Indian Tribes, Tribal organizations, and urban Indian organizations in the development of local health service priorities and incidence and prevalence rates of disease and other illness in the community;                                                                                                                                                                                           
7. Provide disease surveillance and assist Indian Tribes, Tribal organizations, and urban Indian communities to promote public health. 

Twelve TECs came to be established throughout the country, with eleven TECs serving the IHS Areas and one Urban Indian TEC. 

In 2010, TECs were designated as public health authorities for the purposes of HIPAA, allowing them to receive protected health information for public health purposes. More information about public health authority can be found in the Public Health Authority section of this toolkit.