The Indian health care system for American Indians and Alaska Natives is comprised of three elements: the Indian Health Service (IHS) programs, tribally operated health care facilities, and urban health care services. The Indian health system faces a future of increased demand for urban programs and services, increased tribal administration and operation of health care programs, and increased reliance on information systems and technology, such as telemedicine. I foresee a substantial increase in the direct delivery of health services to American Indians and Alaska Natives by tribal health programs, and a reciprocal decrease in the direct delivery of direct health services by the Indian Health Service. I expect the level of environmental, community, and public health programs to increase; however, the Indian Health Service may very well evolve into a model system of support to tribes and programs directed toward providing health services to American Indian and Alaska Native people. It is possible that the Indian Health Service will move into providing direct health services from regional specialty referral hospitals and referral centers. A specialty center for cardiac care currently exists; there is a cardiac program in Tucson with the University of Arizona Medical School for American Indians and Alaska Natives that serves Indian people of the Southwest. Similar specialty centers for neurology, orthopaedic, pediatric, and rehabilitation may become established Indian Health Service referral centers in conjunction with other specialty centers. I also anticipate further expansion of Indian urban programs and services, and their increased collaboration with other health care systems in metropolitan areas.

Management of Health Programs by Indian Tribes
I expect tribes to use a variety of programs to care for their people. It is certainly possible that a number of Tribal Health Maintenance Organization programs will evolve. Health promotion and disease prevention activities and personal accountability will take on increased importance in whatever health care system and organization comes to be.

Direct Health Care Services
Indian Health Service facilities will remain in those areas where tribes elect to have direct federal health care services. These facilities will, however, increase their technological ability to conduct consultation, patient diagnosis, and specialty medical procedures through various forms of telemedicine. These health specialty centers could provide culturally relevant health services for all American Indians and Alaska Native patients without regard to reservation or tribal affiliation. Reservation based health services can be assumed by the tribes, urban based services will continue, and Indian Health Service specialty medical centers will support both. The method of delivery of health care will change in the future Indian Health Service, but the U.S. government's commitment to providing health care for eligible American Indians and Alaska Natives will remain constant.