on Medicare beneficiaries has grown eightfold. This inequity has a large impact on service rationing, health disparities and life expectancy, and can lead to preventive services being neglected. 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. Data from the 2014 National Emergency Department Inventory survey showed that only 85% of the 34 IHS respondents had continuous physician coverage. Of these 34 sites, only 4 sites utilized telemedicine while a median of just 13% of physicians were board certified in emergency medicine. The majority of IHS emergency department from the survey reported operating at or over capacity. Tribal reservations are often sequestered in unfavorable and isolated locations. According to a study of provider vacancies in the IHS, conducted by the Department of Health and Human Services (2016), about half of the clinics studied identified their remote location as a large obstacle for hiring and retaining staff. Issues surrounding isolation, lack of shopping centers, schools, and entertainment also dissuades providers from moving to these areas. Such vacancies lead to cutting of patient services, delays in treatment, and negative effects on employee morale. Studies show that such problems surrounding Native Americans and reservation inequality may be addressed by growing a Native American healthcare workforce. Since its beginnings in 1955, the IHS has been criticized by those it serves in medical deserts and by public officials. 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. See also Title 25 of the Code of Federal Regulations Health insurance Health insurance in the United States Luana Reyes Native American health Suicide among Native Americans in the United States References External links Indian Health Service in the Federal Register Indian Health Services account on USAspending.gov Indian Health Facilities account on USAspending.gov Indian Health Care Improvement Act (PDF/details) as amended in the GPO Statute Compilations collection Biography of Dr. Yvette Roubideaux United States Department of Health and Human Services Emery A. Johnson Papers - National Library of Medicine finding aid Agencies of the United States Public Health Service Government agencies established in 1955 Native American organizations Native American health Hospital networks in the United States Medical and health organizations based in Maryland 1955 establishments in the United States