Policy Analysis: Issue of Health Disparities in Alaska Natives and American Indians
Health disparities among Alaska Natives and American Indians (AI/ANs) have been reported since the initial contact that occurred nearly 500 years in the past. Moreover, the disparities are common in every age and across a wide spectrum of various disease categories (Sarche & Spicer, 2008). Accordingly, AI/ANs endure persistent health disparities that include health status decline, barriers to essential health services, and high uninsured rates. The group also experiences a lower status of health in comparison to other Americans (Frizzell, 2016). The disproportionate burden of disease and reduced life expectancy in AI/ANs can be attributed to cultural differences, discrimination in health care delivery, disproportionate poverty, and few educational opportunities. Nonetheless, laws, executive orders, treaties, and the Constitution establish the responsibility of the federal government to offer AI/ANs certain health services, protections, and rights as a government to government form of relationship (Frizzell, 2016). As such, members of the nearly 560 federally recognized Alaska Native and American Indian Tribes are considered eligible for the services offered by IHS (Indian Health Service). Basically, IHS is one of the federal agencies within “the Department of Health and Human Services that provides a health service delivery system specifically for AI/ANs” (Frizzell, 2016, p.1). Currently, the services provided by IHS do not include health insurance. Also, the contemporary system of health care is often identified as “the IHS, tribes and tribal organizations, and urban Indian programs (ITUs)” (Frizzell, 2016, p.1). Typically, tribes receive direct health services from IHS or acquire the services through contracting agreements. However, the tribes may choose to combine the two alternatives based on each tribe’s preferences and needs. The ITU system receives funds through annual discretionary appropriations to IHS. Nevertheless, barriers such as persistent underfunding continue to minimize access to health services for the majority of AI/AN populations. Since its establishment in 1955, IHS has never received enough funds to ensure the delivery of adequate health services (Frizzell, 2016). Historically, levels of need financing fluctuate between forty percent and sixty percent, which may be attributed to continuous declines in the health statuses of AI/ANs. On a national scale, ITU delivers healthcare services through Tribal and IHS facilities in 36 states, particularly in isolated and rural areas. Frizzell (2016) noted that IHS “directly operates 31 hospitals (service units), 52 health centers (clinics), 2 school health centers (clinics), and 31 health stations (satellite clinics)” (p.1). On the other hand, tribal organizations and tribes operate nearly 50% of the health services associated with IHS. In particular, tribes are in charge of “15 hospitals, 256 health centers, 9 school health centers, and 282 health stations (including 166 Alaska Native village clinics)” (Frizzell, 2016, p.1). Furthermore, tribal organizations, tribes, and IHS operate eleven regional youth centers that deal with the treatment of substance abuse. IHS also provides funds for health centers located in thirty-four urban locations in the country.
Not every AI/AN is enrolled among the federally-recognized tribes. Some of the natives belong to state-recognized tribes whereas others remain unrecognized but classify themselves as AI/ANs. In many cases, tribal membership influences access to health benefits significantly. For instance, descendants and members of tribes that are federally recognized have relatively more access to various federal services and benefits. Specifically, federally recognized tribal members enjoy certain provisions “in the Patient Protection and Affordable Care Act (ACA)” (Frizzell, 2016, p.1). In previous decades, AI/ANs have made significant population shifts from rural areas to metropolitan locations. Between the 1990s and 2005, for example, almost 50% of AI/ANs identified their primary residential areas as rural, especially trust lands or reservations. However, the worsening of economic conditions compelled many AI/ANs to leave rural areas and establish their homes in urban areas in order to find jobs. Current data indicates that 22% of such populations reside on reservations whereas 60% reside in metropolitan locations (Frizzell, 2016). Still, access to Indian facilities in urban areas remains limited with IHS funding only 34 urban clinics throughout the US.
Analysis of Data and Policy
Data Misclassification
One common issue affecting AI/ANs involves the misclassification of the group in terms of mortality data. Since most AI/ANs live in metropolitan locations, the misclassification gap continues to widen. Consequently, many Native Americans do not identify themselves as AI/ANs due to the ongoing problem of discrimination. In addition, the ability of funeral coroners or directors to accurately indicate race on death certificates using a person’s physical features often leads to gross misclassification. As a result, misclassification impedes the development of effective federal policies due to the collection of inaccurate AI/ANs’ mortality data. Recently, nonetheless, efforts have been made to enhance the accuracy of data by matching the Social Security numbers of patients that receive services at IHS facilities with the individuals that choose the services of other health care providers. Although the process has been tedious, it has yielded misclassification results that range from 40% to 80% (Frizzell, 2016). Such significant results should be considered during policy development. However, alternative approaches often include the matching of “all-cause death rate in IHS Contract Health Service Delivery Areas (CHSDA), now referred to as Purchased and Referred Care (PRC), for AI/ANs that do not use ITUs” (Frizzell, 2016, p.2).
Disparities in Healthcare
IHS data suggests that the mortality rates of AI/ANs are higher compared to the rates of other Americans. In particular, deaths related to suicide, injuries, diabetes, alcoholism, vehicle crashes, and tuberculosis are 62, 152, 189, 510, 229, and 600 percent higher than in other groups, respectively. A study carried out in 2014 to identify the leading cause of mortality reported that Native Americans failed to show a significant decrease in all-cause death rates whereas Whites showed significant improvements (Frizzell, 2016). Many other studies have shown that disparities in mortality rates between Whites and AI/ANs in the US remain large for many causes of mortality (Williams & Sternthal, 2010; Espey et al., 2014). However, the gap may be narrowed through robust and concerted public health efforts by local, state, tribal, and federal healthcare agencies, which also give particular attention to economic and social disparities.
Legal Justifications
The federal promises to offer Indian healthcare services predate the US Constitution. After the US had become independent, every federal branch acknowledged the country’s obligations to native tribes, as well as the unique trust relationships that exist between the AI/ANs and the government. The trust responsibilities of the federal government to AI/ANs are described in the Constitution, in addition to Acts such as “Snyder Act, Indian Self-Determination and Education Assistance Act, Indian Health Care Improvement Act, and Patient Protection and Affordable Care Act[ACA]” (Frizzell, 2016, p.2). Despite the various federal promises, however, the contemporary Indian healthcare system is still in despair. Most AI/ANs lead unhealthy lifestyles and die at younger ages than other American groups (Frizzell, 2016). Tribal communities are also affected by health risks resulting from inadequate treatment resources, poverty, and historical trauma.
IHS Funding
While the “National Indian Health Board (NIHB) Testimony to the Senate Indian Affairs Committee” was presenting a discussion about the 2013’s “Mandatory Appropriations for the Indian Health Service,” the board reported that the IHS’ healthcare expenditures, per capita, were only “$2,849, compared to $7,717 per person for health care spending nationally” (Frizzell, 2016, p.3). NIHB noted that Congress had increased the budget of over the years, but funding discrepancies were still evident. For instance, the budgets failed to keep up with sequestration cuts and medical inflation.
Access to Health Services
The rural and reservation AI/AN viewpoint argues that access to routine healthcare is hindered by multiple barriers. As a result, the AI/ANs’ ability to access healthcare requires the availability of culturally suitable health provider, reliable transportation, financial support, and extra planning. Often, Native Americans forego appointments with healthcare specialists due to prohibitive costs associated with home security problems, livestock care, residential heating maintenance, work time loss, and child or elder care (Frizzell, 2016). Such costs create extra hardships for AI/ANs, which force them to postpone important medical appointments. Although telemedicine can reduce some of the disparities, there is still a requirement for the development of more effective policies and technological arrangements to promote healthcare delivery in rural areas. Currently, ACA provides opportunities for increasing insurance coverage and health services for every AI/AN in order to minimize longstanding disparities. As such, the provision possesses the potential for terminating “rationed Purchased and Referred Care services (previously called Contract Health Services program)” (Frizzell, 2016, p.4). Presently, a member of AI/ANs who needs health procedures that are not offered at ITU centers is required to request for a referral from private or public service providers. Fortunately, ACA offers timely opportunities for members of AI/AN to register for a health insurance cover and sets low costs of obtaining the previously rationed healthcare services (Frizzell, 2016). Nevertheless, the Act continues to confront issues that discourage AI/ANs from participating. One of the main caveats involves the definition of AI/ANs, which identifies a Native American as “an enrolled member of a federally recognized tribe” (Frizzell, 2016, p.4). Accordingly, unregistered natives are not identified as AI/ANs but allowed to apply for hardship exemptions that are offered to all Americans under the act. The unregistered AI/ANs include the “beneficiaries of Indian Health Service/Tribal/Urban (I/T/Us) health services” who are often identified by the IHS as Indians.
Health Workforce
Limited access to quality healthcare workforce is among the most common barriers to the achievement of high-quality care services at ITU centers. Typically, limited medical equipment, lengthy hiring process, lower pay, and the remoteness of various locations have been shown to affect the capacity of ITU systems to retain and recruit healthcare providers (Frizzell, 2016). A recent study of Indian healthcare facilities reported that about 45% of administrators had identified the existence of urgent needs for primary care physicians (Frizzell, 2016). Usually, AI/ANs’ healthcare needs require unique service provider qualifications because various historical actions have traumatized the entire population. The actions include political injustices, adverse economic conditions, broken promises and treaties, forced relocation, wars, genocide, colonization, and discrimination of AI/ANs (Frizzell, 2016). Such historical actions have forced AI/ANs to live in learned dependency environments. In turn, the dependency environments overwhelm healthcare professionals and cause early burnouts. Nevertheless, IHS and the different Tribes have proposed that the problem can be solved by exempting “IHS scholarships and student loan repayments for health service professionals” from taxation (Frizzell, 2016, p.5). The approach can establish parity between the IHS and federal healthcare providers like the National Health Service Corps.
Mental Health
Available data indicate that AI/ANs confront more problems of mental illness than other Americans. Particularly, researchers have reported clear disparities for AI/ANs’ suicide, violence, posttraumatic stress, and substance abuse (Gone &Trimble, 2012). Studies have also shown that the success of behavioral healthcare services often depends on the recognition of traditional views of mental illness and healing practices (Frizzell, 2016). Usually, AI/ANs do not distinguish psychological concerns from physical complaints and may express their feelings of distress in a way that is inconsistent with the standard diagnostic category. Although ACA creates opportunities for improving outcomes in AI/ANs confronting the problems of drug abuse and mental illness, the issues of behavioral health remain culturally undefined and underestimated in AI/AN populations. Large-scale studies have also demonstrated elevated risks for indicators of alcohol and substance abuse among AI/ANs in comparison to other groups in the US (Chen et al., 2012). However, the societal and personal challenge of behavioral ill health can be minimized by ensuring that at-risk individuals can access culturally appropriate treatment and prevention measures easily (Frizzell, 2016). ACA’s provisions for behavioral health include “specific language for government to government relations for tribes and tribal organizations, urban Indian programs, and the Indian Health Service” (Frizzell, 2016, p.6). Furthermore, certain sections of the public sector work with states or federal departments to accelerate the delivery of behavioral health care to AI/ANs.
Adoption of Public Health Models
In most cases, public healthcare support for Native Americans is nearly non-existent (Artiga & Arguello, 2013; Friedman, 2016). Although the majority of Americans can access mental health facilities, accredited healthcare departments, government-sponsored health centers, or facilities for treating substance abuse, such services are often unavailable in the Indian Country (Frizzell, 2016). The problems are exacerbated by issues such as adverse childhood experience, historical trauma, and high poverty rates. As such, there is a need for the country to develop an effective healthcare policy and adopt practical public health models.
Policy Recommendations
Frizzell (2016) argued that policymakers should avoid interfering with AI/ANs’ health programs. In addition, the protection of Indian healthcare programs requires various provisions to be included in new or current regulations and legislation. First, specific words such as ‘tribal,’ ‘tribal organizations,’ and ‘tribes’ should be included in the listing of government entities. The absence of such specific words may prevent the Centers for Medicare and Medicaid Services (CMS) from giving tribes adequate consideration. Thus, appropriate terms should be employed to ameliorate the relationship between governments. Moreover, there is a need to utilize other suitable terms such as local, tribal, state, and federal governments during policy development. Secondly, specific wording should be employed to ensure proper acknowledgement of ITU system as a unique healthcare provider that improves the access of AI/ANs to SCHIP programs, Medicare, and Medicaid (Frizzell, 2016). Such acknowledgment is essential and should be founded on the legal identification of an AI/AN as a dual citizen. Thirdly, it should be stated that an AI/AN is entitled to healthcare services after being enrolled in a federally recognized tribe or as a descendant of an enrolled tribal member. Moreover, there should be explicit recognition of AI/ANs’ special relationship with the current government. Such recognition can help in establishing effective policies that acknowledge government-to-government relationships. The approach can also strengthen the identification of AI/ANs as sovereign nations instead of being categorized as a racial or minority group. Fourthly, new legislation should include AI/ANs in the list of target groups during the creation of special programs that address inequities, health disparities, and access to healthcare. Funds should also be offered to ITU facilities to ensure the implementation of government regulations and new programs. In addition, new provisions should make explicit requirement for states and CMS to evaluate the impact of regulations on tribes, as well as carry out meaningful tribal consultations before issuing Medicaid plans, policies, or regulations that affect Native Americans. Although “Executive Orders from four administrations have supported” the approach, there are still “state waiver requests” approved by the CMS in the absence of meaningful tribal consultations (Frizzell, 2016, p.7). The fifth recommendation requires policymakers to respect the various customs and traditional healing practices of AI/ANs (Fortney et al., 2012). Respecting cultural beliefs involves the blending of AI/ANs’ traditions with modern medical approaches that emphasize community outreach and quality healthcare delivery. Accordingly, CMS should ensure that AI/ANs can access traditional treatment methods easily. It should also recognize traditional healthcare practices as a key aspect of Indian healthcare system. Lastly, effort should be made to promote the utilization of tele-health technology to reduce the health disparities observed in AI/ANs. In particular, “new collaborations with the Veterans Affairs for tele-health and reimbursement” should be built (Frizzell, 2016, p.7).
Consensus Building
The system of health delivery in the US is challenging for every rural American. Since the challenges are basic, there is a need to implement policies that ensure the delivery of at least basic medical services to Americans living in remote areas. Failure to implement such critical measures may exacerbate the unavailability of basic healthcare services to rural residents and AI/ANs, which may cost lives. Moreover, it may compel many rural residents to feel the urge to relocate to towns where healthcare services are relatively more accessible. However, individuals that cannot afford to move to cities end up going without services. In some cases, limited provision of health care services to AI/ANs living in small towns negates even the option for accessing essential medical services. As a result, the affected persons are forced to drive extra distances to access quality healthcare. If the trend is allowed to continue, AI/ANs will continue to suffer the adverse consequences of the lack of access to basic healthcare services. Hence, there is a need to build consensus around policy recommendations. The consensus can be built by advocating for increased access to quality healthcare services in the country’s rural areas. Moreover, groups that push for the recognition of AI/ANs and seek to relieve health care disparities should be strengthened to encourage policy makers to adopt various policy recommendations. Frizzell (2016) noted that current and past health statistics remain particularly alarming for the AI/AN group. As such, federally recognized AI/ANs continue to confront the complex problem of health inequity. Moreover, addressing the issue is hampered by barriers such as complex tribal jurisdictions and structures, as well as unintentional injuries, alcohol use, and poverty. Fortunately, while Congress was passing the ACA, it permanently reauthorized IHCIA (Indian Health Care Improvement Act), which creates new authorities for the health services of AI/ANs (Frizzell, 2016). Despite the reauthorization of IHCIA, there is a need for additional action to ensure the full implementation of the ACA. In particular, more effort is required on behalf of Congress and IHS in order to capitalize on the emergence of new authorities and reduce health disparities among AI/ANs.
Conclusion
Health care inequities among AI/ANs have been reported for hundreds of years. In particular, AI/ANs endure persistent health disparities that include health status decline, barriers to essential health services, and high uninsured rates. However, policymakers can minimize the healthcare inequities by not interfering with AI/ANs’ health programs. Moreover, various provisions should be included in federal regulations in order to protect Indian healthcare programs. For example, specific words like ‘tribal organizations’ should be included in the list of government entities to ensure that CMS offers adequate consideration to native tribes. Nonetheless, policy development and implementation continue to face various obstacles. Hence, there is a need to for consensus building, which can be achieved by advocating for increased access to quality healthcare services throughout the country and taking more action to ensure the full implementation of the ACA.
References
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