A 2009 report by the Seattle Indian Health Board's Urban Indian Health Institute notes the absence of a comprehensive national policy on urban Indian health. This, at a time in Indian Country when rates of diabetes, depression, and heart disease have soared.

The UIHI report states, "Aside from the valiant, heroic efforts of our nation's urban Indian health care programs, American health care and America's leaders largely ignore these people."

Today, the lack of a cohesive strategy finds expression in the Affordable Care Act. ACA benefits, intended for all Indians, may be curtailed for urbanites forced to prove their tribal bona fides. It's the irony of a law intended to bridge disparities that the ACA could penalize urban Indians who can't adequately document membership in a federally recognized tribe. (And no health insurance spells a $695 IRS fine.) What of the scores of tribes only recognized by states?