Why the Indian Health Care Improvement Act Has Failed to Effectively Fund Workforce Development for the Indian Health Service.

The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.

Recruiting Indigenous Patients Into Clinical Trials: A Circle of Trust.

The Circle of Trust is a new conceptual model that can help investigators and the American Indian/Alaska Natives (AI/AN) community work together to promote inclusion of AI/AN populations in clinical trials to improve health outcomes. Racial/ethnic minority groups remain underrepresented in clinical trials and this creates the need and opportunity for novel approaches. Indigenous populations are particularly underrepresented in clinical trials. Studies show that AI/AN have the lowest representation of race/ethnic groups in the United States. American Indian/Alaska Natives suffer from significant health disparities with higher rates of morbidity and mortality and lower rates for preventative measures and access to health services. A variety of barriers to recruitment of minority patients exist at several levels including the system/institutional, interpersonal, and the individual. The authors, experts in AI/AN health and recruitment of minorities into research, collaborated to modify the currently existing and published "trust triangle" model that focuses on minority recruitment to include participants, researcher, and trusted entity. We advocate for expanding the trust triangle into a circle of trust inclusive of community. The "circle of trust" is a new conceptual model that can help investigators and the AI/AN community work together to promote inclusion of AI/AN populations in clinical trials to improve health outcomes.