Composed of over three hundred tribes, the American Indian population now numbers more than 1.5 million and consistently has had a birthrate twice that of the United States population. In their attempts to obtain adequate and equitable health care and alcohol and substance abuse services, whether on reservations or in urban areas, American Indians tend to rely upon the American institution called the Indian Health Service (IHS), which is a branch of the Public Health Service located within the United States Department of Health and Human Services. Based on the 1980 census, ”59 percent were included in IHS’s estimated service population” and were located in the thirty-two reservation states. In 1970, over half (54 percent) lived in rural areas and only one-fourth resided in urban areas but by 1980 ”almost two-thirds of [those] identifying themselves as [American] Indians lived off reservations, tribal trust lands, or other Indian lands,” over half (54 percent) lived in metropolitan areas, and nearly “10 percent were on or near reservations that were in or contiguous to metropolitan areas and were served by IHS urban or tribal facilities." In addition, the estimated IHS service population for fiscal year (FY) 1990 of 1,103,608 American Indians represents a 33 percent increase from 1980 and a 140 percent increase since 1970. Not only service population increases, but also issues of poor planning, mismanagement, escalating and “catastrophic” health costs, federal budget constraints, and other problems have resulted in smaller delivery, and consequent increased pressures for possible IHS program elimination and change.