Prior to the 1950s, most American Indian/Alaska Natives (A.I./A.N.) resided on reservations, in nearby rural towns, or in tribal jurisdictional areas such as Oklahoma. In the era of the 1950s and 1960s, the federal government passed legislation to terminate its legal obligations to Indian tribes, resulting in policies/programs to assimilate Indian people into the mainstream of American society. This philosophy produced the Bureau of Indian Affairs (B.I.A.) Relocation/Employment Assistance Programs which enticed Indian families living on impoverished Indian Reservations to "relocate" to various cities across the country, i.e., San Francisco, Los Angeles, Chicago, Salt Lake, Phoenix, etc. B.I.A. Relocation offered job training and placement, and was viewed by Indians as a way to escape poverty on the reservation. Health care was usually provided for six months through the private sector, unless the family was relocated to a city near a reservation with an Indian Health Service (I.H.S.) facility service area, such as Rapid City, Phoenix, and Albuquerque. Eligibility for I.H.S. was not forfeited due to Federal Government relocation.
The American Indian and Policy Review Commission found that in the 1950s and 1960s, the B.I.A. relocated over 160,000 A.I./A.N.s to selected urban centers across the country. Today, 62.3% of all AI/ANs identified in the 1990 census reside off-reservation. This percentage represents 1.39 million of the 2.24 million A.I./A.N.s identified in the 1990 census updated by I.H.S.. The updated 1994 census identifies 1.3 million (58%) A.I./A.N.s residing in urban areas. For comparison purposes, the IHS total service population is approximately 2.1 million with about 1.6 million active users. This figure includes 427,100 eligible urban Indian active users who reside in geographic locations with access to an I.H.S. or Tribal facility.
In the late 1960s, urban Indian community leaders began advocating at the local, state and federal levels for culturally appropriate health programs addressing the unique social, cultural and health needs of A.I./A.N.s residing in urban settings. These community-based grassroots efforts resulted in programs targeting health and outreach services to the Indian community. Programs that were developed at that time were in many cases staffed by volunteers, offering outreach and referral-type services, limited primary care and maintaining programs in storefront settings with limited budgets.
In response to the efforts of the urban Indian community leaders in the 1960s, Congress appropriated funds in 1966, through the I.H.S. for a pilot urban Indian clinic in Rapid City. In 1973, Congress appropriated funds to study unmet urban Indian health needs in Minneapolis. The findings of this study documented cultural, economic, and access barriers to health care and led to congressional appropriations under the Snyder Act to support emerging Urban Indian clinics in several B.I.A. relocation cities, i.e. Seattle, San Francisco, Tulsa, and Dallas.
The awareness of poor health status of all Indian people continued to grow, and in 1976, Congress passed the Indian Health Care Improvement Act (IHCIA), PL. 94-437. This law is considered health care reform legislation to improve the health and well being of all A.I./A.N.s. Title V targets specific funding for the development of programs for A.I./A.N.s residing in urban areas. Since passage of this landmark legislation, amendments to Title V have strengthened Urban Indian Health programs to expand to direct medical services, alcohol services, mental health services, HIV services, health promotion, and disease prevention services. (PL 100-713, PL 101-630, PL 102-573)