The forces that produce these tensions include not only the decisions of key elite parties (often based on competing interests), but also broad social, political, and economic processes. For example, because IHS is a federal agency that works throughout the contiguous United States and Alaska, the boundaries of IHS are frequently permeated by the national organization of health care as well as the government’s relationship with Native nations. This is particularly relevant when considering reproductive health care, an often contentious area of political debate and one that is frequently used
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