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American Health: Examining Our Commitment to Indian Health Services
Shelagh Roberts
acial and ethnic disparities are important national health care issues; so much so that goals to address these disparities are included among Healthy People 2010. However, it often seems that the focus of the disparity dialogue centers on inequities regarding access and health outcomes of America’s largest minority groups, African Americans and Latinos, as compared with those of Caucasians. In fact, it would seem as though other groups are sometimes treated as little more than footnotes regarding disparities. As the focus on eliminating discrepancies expands, and data collection and information increase, we have come to know more about the specific problems facing other American population groups. As such, the plight of Native Americans (American Indians and Alaska Natives) has increasingly pervaded the national health care consciousness.
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Examining Our Commitment to Indian Health Services
Health Care Policy As with all groups, the challenge in pinpointing both specific problems and potential solutions requires a detailed look into the history of health care delivery for that population, the core beliefs and values of the multitribal cultures that influence wellness, and the examination of behaviors and attitudes within the cultures that shape its promotion of physical, mental and spiritual well-being. In the case of Native Americans, public policy may be a more integral piece of the puzzle than for other populations, for there is no other group whose health care needs and delivery systems are so intricately intertwined with federal plans. Consequently, solutions for Indian Health Service’s (IHS) weaknesses must include a renewed commitment by the federal government to keep promises made to the first Americans.
The issue of government-sponsored health care remains a sensitive one for many Native Americans, who tend to bristle when the subject of “free” health care is raised. At the recent Department of Health and Human Services, Office of Minority Health meeting (July 2002) entitled, “Closing the Health Gap Together—The National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health,” Loren Sekayumptewa, MSW, chief executive officer and president of the National Council on Urban Indian Health and a member of the Hopi tribe, posed the rhetorical question: “Why should Native Americans get free health care?” When being asked that question, he said he simply and consistently answers: “Because we deserve it.” He reminded those in attendance that Native Americans sacrificed thousands of acres of land through treaties for a set of promises that included health care. Similarly, in a special series on Indian Health for the Arizona Republic newspaper, reporter Judy Nichols chronicled the dire state of Indian health care, calling it “separate, unequal.” Nichols quotes Sergio Maldonado, Sr., program coordinator in the American Indian Studies program at Arizona State University, on the subject of free health care: “When people say, ‘You get free health care,’ I say, ‘Bear sweat. There’s no ‘Free.’ Blood was spilled” (Nichols, 2002). Such responses recall the troubled history of the first Americans and reveal a lingering resentment over past treatment of Native Americans by the federal government—treatment that still resonates with many American Indians and treatment that must be considered carefully in determining how practitioners can improve relationships and build trust with clients, particularly when they are essentially government employees. Native Americans remember a time when the U.S. government systematically subverted traditional Indian healing practices. Author Brett Lee Shelton recounts that in 1882, then Secretary of the Interior H. M. Teller complained of the “great hindrance to the civilization of the Indians is the influence of the medicine men. . . . The medicine men resort to various artifices and devices to keep the people under their influence . . . using their conjurers’ arts to prevent the people from abandoning their heathenish rites and customs” (Shelton, 2001, p. 15). Early attempts at forced assimilation included banning tribal spiritual health care practices, including mechanisms to punish participation in Sun Dances by incarceration and/or withholding of rations for up to 30 days (Shelton, 2002). American Indians have not forgotten assimilation measures in the early 20th century forbidding children to speak their native languages, requiring them to attend government-run, Bureau
Shelagh Roberts is a policy analyst for AWHONN in Washington, D.C. DOI: 10.1177/1091592303255721
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of Indian Affairs boarding schools and imposing forced separation from relatives. Shelton writes of the “historical grief from this trauma” that is “commonly regarded as a contributing factor for high rates of alcoholism, depression, suicide, and domestic abuse” (Shelton, 2002, p. 17). The legacy of the long history between Native Americans and the U.S. federal government continues to influence perceptions and relations within the Indian Health Service.
Evolution of IHS Native Americans are the only group whose primary health care delivery systems are provided by the federal government as a totally separate entity, operating as the Indian Health Service within the Department of Health and Human Services. The establishment of IHS followed 100 years of piecemeal, decentralized approaches by the federal government to provide health services to Native Americans. The landmark Snyder Act of 1921 established the first formal authorization for federal provision of health care services to members of all federally recognized tribes. However, it languished under the Bureau of Indian Affairs until finally, in 1954, the responsibility for Indian Health care was transferred to the Public Health Service. The creation of IHS resulted in the first dramatic improvement in the status of Indian health care since the federal government agencies became involved (Shelton, 2001, p. 21). Great improvements in areas such as infant mortality and morbidity and overall mortality from infectious diseases have steadily occurred since 1954; however, progress has plateaued and new disease patterns have emerged demanding new strategies for care (Indian Health Service, 2002). Today, Indian Health Service is a comprehensive network composed of 12 regions that encompass 550 health care delivery facilities in 35 states and provides care for 1.5 million Indians among 558 federally recognized tribes (Indian Health Service, 2002; see Box 1 for additional demographics). With a 2001 budget of $2.6 billion, IHS provides comprehensive personal and public health services, including • • • • • •
dentistry nutrition community health sanitation injury prevention institutional environmental services
Within the current American population, more than 55 percent of Native Americans rely on IHS alone for their health care needs; only 28 percent have private health insurance (Indian Health Service, 2002). Indian Health Service has two primary components: direct care that is provided at an IHS facility or contract health services (CHS) that are provided by a non-IHS facility or provider. While the direct care, reservation-based system provides a
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comprehensive health care package that includes pharmacological, dental, mental health and vision care services, Native Americans must look outside the Indian Health Service facility and obtain a referral to obtain care through “contract health services.”
Box 1.
Native Americans in the U.S. In 2000, roughly 4.1 million (1.5 percent) of census responders identified themselves as American Indian/ Alaska Native. There are American Indians living in every state of the union, but the majority—43 percent— reside in the West, with 31 percent in the South, 17 percent in the Midwest, and 9 percent in the Northeast. The 10 states with largest American Indian populations in order are • • • • • • • • • •
California Oklahoma Arizona Texas New Mexico New York Washington North Carolina Michigan Alaska
The largest tribal groups are the • • • • • • • • • •
Cherokee Navajo Latin American Indian Choctaw Sioux Chippewa Apache Blackfeet Iroquois Pueblo
Source: U.S. Census Bureau.
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CHS services are designed primarily as supplemental care for Native Americans residing on or near their tribes’ reservation within the contract health service delivery area. According to the IHS (2001), “most CHS provided is for urgent or emergency needs, as defined by the local service unit and requires prior approval for non-emergency care and notification within 72 hours for emergency care.” The CHS is considered by some to be the most burdensome and inadequate aspect of Indian Health Service. Current literature regarding Native American health reveals a systematic problem where IHS facilities provide basic care, while individuals with more serious problems are referred to CHS and face burdensome requirements, including a tedious process that requires patients to exhaust other federal mechanisms for health care assistance, including Medicaid and Medicare, before they are eligible for the contract health service. There is an impression that there is little recourse for Native Americans who need more than a flu shot but less than a heart transplant. The CHS system creates a significant coverage lapse for services that go beyond preventive care or mild injuries but are not immediately life threatening and cannot be considered emergencies. Another critical shortcoming of CHS is that it’s reliant on congressional funding that is largely inadequate for the population it serves. Essentially, once the allocated money is spent, nobody in CHS can access specialty care until the beginning of the next fiscal year (Dixon, 2001). Budget shortfalls necessitate a prioritizing system that usually means that only Priority I services, such as emergency medical services, are covered. These limitations prevent needed services such as routine screening mammograms or reconstructive surgery after mastectomy. In the Arizona Republic series, Nichols (2002) chronicles the experience of a desperate mother’s attempt to obtain care for her 14-year-old daughter through contract health services. When the girl hurt her foot in gym class, her mother took her to an Indian Health Service clinic where it was recommended that the girl have a magnetic resonance imaging, and possibly surgery—services not available through IHS. The daughter was referred out, but Indian Health Service would not pay for it. She was told to apply for Medicaid, which took more than 45 days to get a decision while her daughter “limped through school on crutches”(Nichols, 2002). Even after receiving approval from Medicaid, the private doctor refused to perform the MRI because the daughter had Medicaid coverage; he referred them back to the local hospital. Nichols quotes the mother, “It just seems like unless you’re on your deathbed, you can’t go for services” (Nichols, 2002).
Self-Determination A key facet of Indian Health Service is that federally recognized tribes enjoy sovereignty and self-governing status. The Indian Self-Determination and Education Assistance Act
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allows tribes to redesign their health care programs to incorporate traditional cultural values if they choose to do so. Almost 44 percent of IHS’s $2.6 billion budget is now transferred to tribes through tribal shares, and those tribes largely determine how to design health care systems to best serve their populations (Indian Health Service, 2002). While sovereignty is critical in designing health programs that reflect Native American values and priorities, differences among various tribes can cause many problems when allocating resources for care. Federal law allows that qualified Indians who are members of federally recognized tribes and who have established chart records in IHS are eligible for health care coverage on reservations. However, some tribes, particularly those with sovereign operations, do not want to extend care to Indians from other tribes, which can create barriers to access for Native Americans who may not live close to their own home reservations because they have relocated and now reside closer to an Indian health care facility administered by another tribe. Because resources are scarce, some health care advocates see this as another example of pitting Indian against Indian in the fight for limited resources.
Inadequate Funding Insufficient funding for IHS is probably the primary concern for most Indian health care advocates. Indian Health Service derives its funding from congressional appropriations that historically have been inadequate to meet the needs of a growing population that still faces major challenges in integrating mainstream medicine practice and delivery systems with traditional tribal healing practices and cultural norms. Public policy has not kept pace with the dynamic Native American population that is increasing and changing, and many would argue that the government is not keeping its promise to provide health care for Native Americans. Indian Health Service publications cite a recently developed model to estimate the costs of providing a package of personal health care services for Native Americans that would be equivalent to the standard most major health plans provide. According to the cost model, IHS funding is only sufficient to cover 59 percent of the necessary funding to provide services similar to those offered by mainstream health plans (Indian Health Service, 2001). Congressional funding has remained flat during the last several years. Congress does not regard Indian health as an entitlement program, which means that once appropriated funds are exhausted, services cease. Dixon, Mather, Shelton, and Roubideaux (2001) reported that for the five-year period from fiscal year 1994 to 1998, congressional appropriations grew by 8 percent while medical inflation increased by more than 20 percent. Concurrently, the Indian population increased by 12.8 percent, resulting in an adjusted per capita decline of 18 percent during that time period (Dixon et al.,
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2001). This inequity results in the rationing of health care services for Native Americans and Alaskan Natives—hardly the total coverage to which most Native Americans believe they are entitled. Funding levels such as these or even levels that see moderate improvements will not reverse a trend of rationing services or decrease disparities. More aggressive changes will need to occur if real progress is to be made.
Cultural Disparities The current state of Indian health care and health status is a cause for great concern among tribal leaders and health care advocates. Specific intervention strategies are needed to address the significant differences between the health of the American Indian and Alaska Native population and the general U.S. population. American Indians and Alaska Natives born today have a life expectancy of five fewer years than the average in the U.S. (Indian Health Service, 2001). Major areas of concern are centered around chronic diseases such as diabetes, accidental injuries, and diseases with behavioral components, such as obesity and substance abuse—primarily alcoholism (see Box 2 regarding disparities). American Indians and Alaska Natives also suffer from disparities in the perinatal period, particularly accounting for a disproportionate share of fetal alcohol syndrome deaths. Alaska Natives have a rate of 5.2 per 1,000 live births as compared with 0.4 per 1,000 among the population as a whole. In 1999, the death rate among infants born to American Indian or Alaska Native mothers was 9.3 per 1,000 live births as compared to the national rate of 7.0 per live births. The SIDS death rate among infants born to American Indian or Alaskan Native mothers was twice the national rate (U.S. Department of Health and Human Services, 2002, p. 43). More research is needed into the cultural and genetic implications of the wide variation among Indian groups and the danger of treating all Native Americans or Alaska Natives as one. Intervention strategies to improve disparities must
Box 2.
Indian Mortality Compared to Other Americans Indians experience disproportionately high mortality compared with other Americans from (IHS, 2001) • • • • • •
Alcoholism: 740 percent higher Tuberculosis: 500 percent higher Diabetes: 390 percent higher Injuries: 340 percent higher Suicide: 190 percent higher Homicide: 180 percent higher
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include not only a focus on Native American behavior and cultural beliefs but also recognition of the differences among all American Indian/Alaska Native populations. There is often a wide degree of variation in disease prevalence among tribes. For example, approximately half of Pima Indians between ages 30 and 64 have type 2 diabetes. Other variations within the Alaska Native subgroups demonstrate that Eskimo groups have a diabetes prevalence of 12.1 per 1,000 and Aleut groups are at 32.6 per 1,000 (U.S. Department of Health and Human Services, 2002, p. 41). The recognition of the alarming rates of disease for particular disorders, such as diabetes, alcoholism and unintentional injuries, has spurred a call for action among tribal leaders and policymakers, who have taken some steps to respond to the need for substance abuse prevention and treatment programs, but more needs to be done. The IHS system created in 1954 could not be expected to project and account for these well-documented and recognized disparities that are so evident in 2003, but now that they have been identified, well-funded, culturally competent strategies to attack them must emerge.
Economic Disparities The economic disadvantages of the American Indian and Alaska Native population is, of course, a critical component that contributes to the prevalence of disease. The American Indian/Alaskan Native population can be described, “as the poorest, least educated, and most neglected ethnic minority in the U.S. . . . this population is more likely to be unemployed, drop out of school, have a low income, and be predisposed to numerous health and social risks” (Cesario, 2001, p. 13). Poverty and geographic-related barriers such as unemployment, lack of available transportation for rural Indians, limited access to specialty care, displacement of Urban Indians, self-alienation among Indians who no longer retain their cultural heritage, and both intertribal and majority population language barriers are each serious roadblocks in efforts to eliminate disparities in the health for Native Americans. None
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of these problems can be fully addressed without intense collaboration between tribal leaders, policymakers, health care providers and native populations (see Box 3 for additional resources).
The Displacement of the Urban Indian One of these specific problems, the plight of the urban Indian, merits special attention as it’s a problem of immense magnitude that has yet to be comprehensively addressed. As mentioned earlier, the National Leadership Summit on Eliminating Racial and Ethnic disparities in Health featured several breakout sessions devoted to the specific nature of challenges facing the Native American population. One of the breakout sessions in the Minority Health summit was entitled, “Where Do Native Americans Who Are Not Covered by IHS Go for Healthcare?” The title alone reveals a frustration with a bureaucratic system that may be well meaning and successful in some areas but contains lapses in coverage and access that must be addressed. Sekayumptewa explains that fewer than half of Native Americans live on reservations, yet the Indian Health Service’s programs are designed around that model, and services are overwhelmingly geared toward serving those Indians on reservations. Mervin Savoy, chairwoman of the Piscataway Conoy Tribe in Indian Head, Maryland, described a situation where she has attempted over many years to lobby her state government to eliminate what she calls “a penalty for moving,” or the loss of health care for Indians who leave the reservations. Savoy states that she “cannot get anywhere” with the state’s government. She claims that there is nowhere for the 15,000 Native Americans residing in the Washington, D.C./Rockville, MD, area to go for care. “They want us to go to Tennessee,” she lamented. While she expressed some hope that with new gubernatorial leadership, the status may change, there is nothing to suggest that it will. She concluded her presentation with a simple question: “Where do we go? I ask you, where do we go?” Answers are complicated. Sekayumptewa emphasized that particularly in the eastern states that have low Native
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American populations and few reservations, access is by far the most important health care concern. While Title V of the Indian Health Care Improvement Act of 1976 (P.L. 93-437) provided some funding for urban health care centers, Sekayumptewa commented that there are few Urban Indian Health clinics nationwide. Of the Urban Indian Health Programs represented by the National Council of Urban Indian Health, 22 provide medical services, 12 are access programs, and 10 are alcohol/substance abuse treatment facilities. To put it in perspective, according to Sekayumptewa, even though 60 percent of American Indians live off the reservation, only 1 percent of the budget for Indian Health Service goes to care for urban Indians. The challenge of providing care for urban Indians is compounded by the fact that unless overall funding increases dramatically, providing more resources for the care of urban Indians would siphon resources for reservation-based medical services and contract health services, and those programs are already suffering from inadequate funding.
Renewing the Commitment The mission of IHS is to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level (Indian Health Service, 2002). What is needed is a renewed commitment and acknowledgment from policymakers and tribal leaders of what it will take to provide care for Native Americans and Alaska Natives that is on par with the level of service mainstream Americans enjoy in private coverage. Without this, the disparities in populations will be difficult to eradicate. If the national goal, per Healthy People 2010, is to eliminate racial and ethnic disparities in health, then honest commitment and action to provide a full range of services are imperative. These include increasing
Box 3.
Getting All the Facts • Office of Minority Health: http://www.omhrc.gov/omhhome.htm • U.S. D.H.H.S. Indian Health Service: www.ihs.gov • National Council on Urban Indian Health: http://www.ihs.gov/NonMedicalPrograms/Urban/ncuih/ • U.S. Census Bureau; Native Americans and Alaskan Natives: http://www.census.gov/prod/2002pubs/ c2kbr01-15.pdf • IHS regarding maternal/child health information: http://www.IHS.gov/MedicalPrograms/MaternalChild Health/WomensHealth.asp
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access for urban Indians, improving the delivery of specialty services and referral procedures for non-life-threatening emergencies, and the continuation of programs and models that will improve the economic and social conditions of Native Americans. Right now, it seems that obtaining parity is a visionary goal without the commitment and resources to achieve it. References Cesario, S. (2001). Care of the Native American woman: Strategies for practice, education, and research. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30, 1319. Dixon, M. (2001). Access to care for American Indians and Alaskan Natives. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 61-89). Washington, DC: American Public Health Association. Dixon, M., Mather D., Shelton, B., & Roubideaux, Y. (2001). Economic and organizational changes in health care systems. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 89122). Washington, DC: American Public Health Association. Indian Health Service. (2001a). Fact sheet: Health care away from home reservation. Washington, DC: Author. Retrieved from www.IHS.gov/GeneralWeb/HelpCenter/ CustomerServices/CHSDA.asp Indian Health Service. (2001b). Facts on Indian Health Disparities, Indian Health Serive/Office of the Director, Public Affairs Staff. Washington, DC: Author. Retrieved from www.ihs.gov Indian Health Service. (2001c). Issue page: Health disparities trends. Washington, DC: Author. Retrieved from http://info.IHS.gov Indian Health Service. (2002). Fact sheet: Indian Health Service, An agency profile. Washington, DC: Author. Retrieved from www.ihs.gov Nichols, J. (2002, April 14). Indian health care: Separate, unequal. The Arizona Republic. Shelton, B. L. (2001). Legal and historical basis of Indian health care. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 1-31). Washington, DC: American Public Health Association. U.S. Department of Health and Human Services, Office of Minority Health. (2002). Good health for all, Eliminating racial and ethnic disparities in health. Washington, DC: Author.
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acial and ethnic disparities are important national health care issues; so much so that goals to address these disparities are included among Healthy People 2010. However, it often seems that the focus of the disparity dialogue centers on inequities regarding access and health outcomes of America’s largest minority groups, African Americans and Latinos, as compared with those of Caucasians. In fact, it would seem as though other groups are sometimes treated as little more than footnotes regarding disparities. As the focus on eliminating discrepancies expands, and data collection and information increase, we have come to know more about the specific problems facing other American population groups. As such, the plight of Native Americans (American Indians and Alaska Natives) has increasingly pervaded the national health care consciousness.
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Examining Our Commitment to Indian Health Services
Health Care Policy As with all groups, the challenge in pinpointing both specific problems and potential solutions requires a detailed look into the history of health care delivery for that population, the core beliefs and values of the multitribal cultures that influence wellness, and the examination of behaviors and attitudes within the cultures that shape its promotion of physical, mental and spiritual well-being. In the case of Native Americans, public policy may be a more integral piece of the puzzle than for other populations, for there is no other group whose health care needs and delivery systems are so intricately intertwined with federal plans. Consequently, solutions for Indian Health Service’s (IHS) weaknesses must include a renewed commitment by the federal government to keep promises made to the first Americans.
The issue of government-sponsored health care remains a sensitive one for many Native Americans, who tend to bristle when the subject of “free” health care is raised. At the recent Department of Health and Human Services, Office of Minority Health meeting (July 2002) entitled, “Closing the Health Gap Together—The National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health,” Loren Sekayumptewa, MSW, chief executive officer and president of the National Council on Urban Indian Health and a member of the Hopi tribe, posed the rhetorical question: “Why should Native Americans get free health care?” When being asked that question, he said he simply and consistently answers: “Because we deserve it.” He reminded those in attendance that Native Americans sacrificed thousands of acres of land through treaties for a set of promises that included health care. Similarly, in a special series on Indian Health for the Arizona Republic newspaper, reporter Judy Nichols chronicled the dire state of Indian health care, calling it “separate, unequal.” Nichols quotes Sergio Maldonado, Sr., program coordinator in the American Indian Studies program at Arizona State University, on the subject of free health care: “When people say, ‘You get free health care,’ I say, ‘Bear sweat. There’s no ‘Free.’ Blood was spilled” (Nichols, 2002). Such responses recall the troubled history of the first Americans and reveal a lingering resentment over past treatment of Native Americans by the federal government—treatment that still resonates with many American Indians and treatment that must be considered carefully in determining how practitioners can improve relationships and build trust with clients, particularly when they are essentially government employees. Native Americans remember a time when the U.S. government systematically subverted traditional Indian healing practices. Author Brett Lee Shelton recounts that in 1882, then Secretary of the Interior H. M. Teller complained of the “great hindrance to the civilization of the Indians is the influence of the medicine men. . . . The medicine men resort to various artifices and devices to keep the people under their influence . . . using their conjurers’ arts to prevent the people from abandoning their heathenish rites and customs” (Shelton, 2001, p. 15). Early attempts at forced assimilation included banning tribal spiritual health care practices, including mechanisms to punish participation in Sun Dances by incarceration and/or withholding of rations for up to 30 days (Shelton, 2002). American Indians have not forgotten assimilation measures in the early 20th century forbidding children to speak their native languages, requiring them to attend government-run, Bureau
Shelagh Roberts is a policy analyst for AWHONN in Washington, D.C. DOI: 10.1177/1091592303255721
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of Indian Affairs boarding schools and imposing forced separation from relatives. Shelton writes of the “historical grief from this trauma” that is “commonly regarded as a contributing factor for high rates of alcoholism, depression, suicide, and domestic abuse” (Shelton, 2002, p. 17). The legacy of the long history between Native Americans and the U.S. federal government continues to influence perceptions and relations within the Indian Health Service.
Evolution of IHS Native Americans are the only group whose primary health care delivery systems are provided by the federal government as a totally separate entity, operating as the Indian Health Service within the Department of Health and Human Services. The establishment of IHS followed 100 years of piecemeal, decentralized approaches by the federal government to provide health services to Native Americans. The landmark Snyder Act of 1921 established the first formal authorization for federal provision of health care services to members of all federally recognized tribes. However, it languished under the Bureau of Indian Affairs until finally, in 1954, the responsibility for Indian Health care was transferred to the Public Health Service. The creation of IHS resulted in the first dramatic improvement in the status of Indian health care since the federal government agencies became involved (Shelton, 2001, p. 21). Great improvements in areas such as infant mortality and morbidity and overall mortality from infectious diseases have steadily occurred since 1954; however, progress has plateaued and new disease patterns have emerged demanding new strategies for care (Indian Health Service, 2002). Today, Indian Health Service is a comprehensive network composed of 12 regions that encompass 550 health care delivery facilities in 35 states and provides care for 1.5 million Indians among 558 federally recognized tribes (Indian Health Service, 2002; see Box 1 for additional demographics). With a 2001 budget of $2.6 billion, IHS provides comprehensive personal and public health services, including • • • • • •
dentistry nutrition community health sanitation injury prevention institutional environmental services
Within the current American population, more than 55 percent of Native Americans rely on IHS alone for their health care needs; only 28 percent have private health insurance (Indian Health Service, 2002). Indian Health Service has two primary components: direct care that is provided at an IHS facility or contract health services (CHS) that are provided by a non-IHS facility or provider. While the direct care, reservation-based system provides a
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comprehensive health care package that includes pharmacological, dental, mental health and vision care services, Native Americans must look outside the Indian Health Service facility and obtain a referral to obtain care through “contract health services.”
Box 1.
Native Americans in the U.S. In 2000, roughly 4.1 million (1.5 percent) of census responders identified themselves as American Indian/ Alaska Native. There are American Indians living in every state of the union, but the majority—43 percent— reside in the West, with 31 percent in the South, 17 percent in the Midwest, and 9 percent in the Northeast. The 10 states with largest American Indian populations in order are • • • • • • • • • •
California Oklahoma Arizona Texas New Mexico New York Washington North Carolina Michigan Alaska
The largest tribal groups are the • • • • • • • • • •
Cherokee Navajo Latin American Indian Choctaw Sioux Chippewa Apache Blackfeet Iroquois Pueblo
Source: U.S. Census Bureau.
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CHS services are designed primarily as supplemental care for Native Americans residing on or near their tribes’ reservation within the contract health service delivery area. According to the IHS (2001), “most CHS provided is for urgent or emergency needs, as defined by the local service unit and requires prior approval for non-emergency care and notification within 72 hours for emergency care.” The CHS is considered by some to be the most burdensome and inadequate aspect of Indian Health Service. Current literature regarding Native American health reveals a systematic problem where IHS facilities provide basic care, while individuals with more serious problems are referred to CHS and face burdensome requirements, including a tedious process that requires patients to exhaust other federal mechanisms for health care assistance, including Medicaid and Medicare, before they are eligible for the contract health service. There is an impression that there is little recourse for Native Americans who need more than a flu shot but less than a heart transplant. The CHS system creates a significant coverage lapse for services that go beyond preventive care or mild injuries but are not immediately life threatening and cannot be considered emergencies. Another critical shortcoming of CHS is that it’s reliant on congressional funding that is largely inadequate for the population it serves. Essentially, once the allocated money is spent, nobody in CHS can access specialty care until the beginning of the next fiscal year (Dixon, 2001). Budget shortfalls necessitate a prioritizing system that usually means that only Priority I services, such as emergency medical services, are covered. These limitations prevent needed services such as routine screening mammograms or reconstructive surgery after mastectomy. In the Arizona Republic series, Nichols (2002) chronicles the experience of a desperate mother’s attempt to obtain care for her 14-year-old daughter through contract health services. When the girl hurt her foot in gym class, her mother took her to an Indian Health Service clinic where it was recommended that the girl have a magnetic resonance imaging, and possibly surgery—services not available through IHS. The daughter was referred out, but Indian Health Service would not pay for it. She was told to apply for Medicaid, which took more than 45 days to get a decision while her daughter “limped through school on crutches”(Nichols, 2002). Even after receiving approval from Medicaid, the private doctor refused to perform the MRI because the daughter had Medicaid coverage; he referred them back to the local hospital. Nichols quotes the mother, “It just seems like unless you’re on your deathbed, you can’t go for services” (Nichols, 2002).
Self-Determination A key facet of Indian Health Service is that federally recognized tribes enjoy sovereignty and self-governing status. The Indian Self-Determination and Education Assistance Act
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allows tribes to redesign their health care programs to incorporate traditional cultural values if they choose to do so. Almost 44 percent of IHS’s $2.6 billion budget is now transferred to tribes through tribal shares, and those tribes largely determine how to design health care systems to best serve their populations (Indian Health Service, 2002). While sovereignty is critical in designing health programs that reflect Native American values and priorities, differences among various tribes can cause many problems when allocating resources for care. Federal law allows that qualified Indians who are members of federally recognized tribes and who have established chart records in IHS are eligible for health care coverage on reservations. However, some tribes, particularly those with sovereign operations, do not want to extend care to Indians from other tribes, which can create barriers to access for Native Americans who may not live close to their own home reservations because they have relocated and now reside closer to an Indian health care facility administered by another tribe. Because resources are scarce, some health care advocates see this as another example of pitting Indian against Indian in the fight for limited resources.
Inadequate Funding Insufficient funding for IHS is probably the primary concern for most Indian health care advocates. Indian Health Service derives its funding from congressional appropriations that historically have been inadequate to meet the needs of a growing population that still faces major challenges in integrating mainstream medicine practice and delivery systems with traditional tribal healing practices and cultural norms. Public policy has not kept pace with the dynamic Native American population that is increasing and changing, and many would argue that the government is not keeping its promise to provide health care for Native Americans. Indian Health Service publications cite a recently developed model to estimate the costs of providing a package of personal health care services for Native Americans that would be equivalent to the standard most major health plans provide. According to the cost model, IHS funding is only sufficient to cover 59 percent of the necessary funding to provide services similar to those offered by mainstream health plans (Indian Health Service, 2001). Congressional funding has remained flat during the last several years. Congress does not regard Indian health as an entitlement program, which means that once appropriated funds are exhausted, services cease. Dixon, Mather, Shelton, and Roubideaux (2001) reported that for the five-year period from fiscal year 1994 to 1998, congressional appropriations grew by 8 percent while medical inflation increased by more than 20 percent. Concurrently, the Indian population increased by 12.8 percent, resulting in an adjusted per capita decline of 18 percent during that time period (Dixon et al.,
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2001). This inequity results in the rationing of health care services for Native Americans and Alaskan Natives—hardly the total coverage to which most Native Americans believe they are entitled. Funding levels such as these or even levels that see moderate improvements will not reverse a trend of rationing services or decrease disparities. More aggressive changes will need to occur if real progress is to be made.
Cultural Disparities The current state of Indian health care and health status is a cause for great concern among tribal leaders and health care advocates. Specific intervention strategies are needed to address the significant differences between the health of the American Indian and Alaska Native population and the general U.S. population. American Indians and Alaska Natives born today have a life expectancy of five fewer years than the average in the U.S. (Indian Health Service, 2001). Major areas of concern are centered around chronic diseases such as diabetes, accidental injuries, and diseases with behavioral components, such as obesity and substance abuse—primarily alcoholism (see Box 2 regarding disparities). American Indians and Alaska Natives also suffer from disparities in the perinatal period, particularly accounting for a disproportionate share of fetal alcohol syndrome deaths. Alaska Natives have a rate of 5.2 per 1,000 live births as compared with 0.4 per 1,000 among the population as a whole. In 1999, the death rate among infants born to American Indian or Alaska Native mothers was 9.3 per 1,000 live births as compared to the national rate of 7.0 per live births. The SIDS death rate among infants born to American Indian or Alaskan Native mothers was twice the national rate (U.S. Department of Health and Human Services, 2002, p. 43). More research is needed into the cultural and genetic implications of the wide variation among Indian groups and the danger of treating all Native Americans or Alaska Natives as one. Intervention strategies to improve disparities must
Box 2.
Indian Mortality Compared to Other Americans Indians experience disproportionately high mortality compared with other Americans from (IHS, 2001) • • • • • •
Alcoholism: 740 percent higher Tuberculosis: 500 percent higher Diabetes: 390 percent higher Injuries: 340 percent higher Suicide: 190 percent higher Homicide: 180 percent higher
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include not only a focus on Native American behavior and cultural beliefs but also recognition of the differences among all American Indian/Alaska Native populations. There is often a wide degree of variation in disease prevalence among tribes. For example, approximately half of Pima Indians between ages 30 and 64 have type 2 diabetes. Other variations within the Alaska Native subgroups demonstrate that Eskimo groups have a diabetes prevalence of 12.1 per 1,000 and Aleut groups are at 32.6 per 1,000 (U.S. Department of Health and Human Services, 2002, p. 41). The recognition of the alarming rates of disease for particular disorders, such as diabetes, alcoholism and unintentional injuries, has spurred a call for action among tribal leaders and policymakers, who have taken some steps to respond to the need for substance abuse prevention and treatment programs, but more needs to be done. The IHS system created in 1954 could not be expected to project and account for these well-documented and recognized disparities that are so evident in 2003, but now that they have been identified, well-funded, culturally competent strategies to attack them must emerge.
Economic Disparities The economic disadvantages of the American Indian and Alaska Native population is, of course, a critical component that contributes to the prevalence of disease. The American Indian/Alaskan Native population can be described, “as the poorest, least educated, and most neglected ethnic minority in the U.S. . . . this population is more likely to be unemployed, drop out of school, have a low income, and be predisposed to numerous health and social risks” (Cesario, 2001, p. 13). Poverty and geographic-related barriers such as unemployment, lack of available transportation for rural Indians, limited access to specialty care, displacement of Urban Indians, self-alienation among Indians who no longer retain their cultural heritage, and both intertribal and majority population language barriers are each serious roadblocks in efforts to eliminate disparities in the health for Native Americans. None
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of these problems can be fully addressed without intense collaboration between tribal leaders, policymakers, health care providers and native populations (see Box 3 for additional resources).
The Displacement of the Urban Indian One of these specific problems, the plight of the urban Indian, merits special attention as it’s a problem of immense magnitude that has yet to be comprehensively addressed. As mentioned earlier, the National Leadership Summit on Eliminating Racial and Ethnic disparities in Health featured several breakout sessions devoted to the specific nature of challenges facing the Native American population. One of the breakout sessions in the Minority Health summit was entitled, “Where Do Native Americans Who Are Not Covered by IHS Go for Healthcare?” The title alone reveals a frustration with a bureaucratic system that may be well meaning and successful in some areas but contains lapses in coverage and access that must be addressed. Sekayumptewa explains that fewer than half of Native Americans live on reservations, yet the Indian Health Service’s programs are designed around that model, and services are overwhelmingly geared toward serving those Indians on reservations. Mervin Savoy, chairwoman of the Piscataway Conoy Tribe in Indian Head, Maryland, described a situation where she has attempted over many years to lobby her state government to eliminate what she calls “a penalty for moving,” or the loss of health care for Indians who leave the reservations. Savoy states that she “cannot get anywhere” with the state’s government. She claims that there is nowhere for the 15,000 Native Americans residing in the Washington, D.C./Rockville, MD, area to go for care. “They want us to go to Tennessee,” she lamented. While she expressed some hope that with new gubernatorial leadership, the status may change, there is nothing to suggest that it will. She concluded her presentation with a simple question: “Where do we go? I ask you, where do we go?” Answers are complicated. Sekayumptewa emphasized that particularly in the eastern states that have low Native
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American populations and few reservations, access is by far the most important health care concern. While Title V of the Indian Health Care Improvement Act of 1976 (P.L. 93-437) provided some funding for urban health care centers, Sekayumptewa commented that there are few Urban Indian Health clinics nationwide. Of the Urban Indian Health Programs represented by the National Council of Urban Indian Health, 22 provide medical services, 12 are access programs, and 10 are alcohol/substance abuse treatment facilities. To put it in perspective, according to Sekayumptewa, even though 60 percent of American Indians live off the reservation, only 1 percent of the budget for Indian Health Service goes to care for urban Indians. The challenge of providing care for urban Indians is compounded by the fact that unless overall funding increases dramatically, providing more resources for the care of urban Indians would siphon resources for reservation-based medical services and contract health services, and those programs are already suffering from inadequate funding.
Renewing the Commitment The mission of IHS is to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level (Indian Health Service, 2002). What is needed is a renewed commitment and acknowledgment from policymakers and tribal leaders of what it will take to provide care for Native Americans and Alaska Natives that is on par with the level of service mainstream Americans enjoy in private coverage. Without this, the disparities in populations will be difficult to eradicate. If the national goal, per Healthy People 2010, is to eliminate racial and ethnic disparities in health, then honest commitment and action to provide a full range of services are imperative. These include increasing
Box 3.
Getting All the Facts • Office of Minority Health: http://www.omhrc.gov/omhhome.htm • U.S. D.H.H.S. Indian Health Service: www.ihs.gov • National Council on Urban Indian Health: http://www.ihs.gov/NonMedicalPrograms/Urban/ncuih/ • U.S. Census Bureau; Native Americans and Alaskan Natives: http://www.census.gov/prod/2002pubs/ c2kbr01-15.pdf • IHS regarding maternal/child health information: http://www.IHS.gov/MedicalPrograms/MaternalChild Health/WomensHealth.asp
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access for urban Indians, improving the delivery of specialty services and referral procedures for non-life-threatening emergencies, and the continuation of programs and models that will improve the economic and social conditions of Native Americans. Right now, it seems that obtaining parity is a visionary goal without the commitment and resources to achieve it. References Cesario, S. (2001). Care of the Native American woman: Strategies for practice, education, and research. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30, 1319. Dixon, M. (2001). Access to care for American Indians and Alaskan Natives. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 61-89). Washington, DC: American Public Health Association. Dixon, M., Mather D., Shelton, B., & Roubideaux, Y. (2001). Economic and organizational changes in health care systems. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 89122). Washington, DC: American Public Health Association. Indian Health Service. (2001a). Fact sheet: Health care away from home reservation. Washington, DC: Author. Retrieved from www.IHS.gov/GeneralWeb/HelpCenter/ CustomerServices/CHSDA.asp Indian Health Service. (2001b). Facts on Indian Health Disparities, Indian Health Serive/Office of the Director, Public Affairs Staff. Washington, DC: Author. Retrieved from www.ihs.gov Indian Health Service. (2001c). Issue page: Health disparities trends. Washington, DC: Author. Retrieved from http://info.IHS.gov Indian Health Service. (2002). Fact sheet: Indian Health Service, An agency profile. Washington, DC: Author. Retrieved from www.ihs.gov Nichols, J. (2002, April 14). Indian health care: Separate, unequal. The Arizona Republic. Shelton, B. L. (2001). Legal and historical basis of Indian health care. In M. Dixon & Y. Roubideaux (Eds.), Promises to keep, public health policy for American Indians & Alaska Natives in the 21st century (pp. 1-31). Washington, DC: American Public Health Association. U.S. Department of Health and Human Services, Office of Minority Health. (2002). Good health for all, Eliminating racial and ethnic disparities in health. Washington, DC: Author.
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