SPH report: Health status of American Indians/Alaska Natives continues to decline – Part 1

February 29, 2016

Editor’s note: This is the first post in a three part series. The second and third posts can be found here and here. The complete report can be found here.

A new report recently released by Linda Frizzell, Ph.D., assistant professor in the University of Minnesota School of Public Health further highlights the persistent health inequities American Indians and Alaska Natives (AI/AN) face today.

AI/AN tribes have a fraught relationship with the federal government due to a history of attempted genocide, forced acculturation, severely underfunded health services and a health status that continues to decline. Frizzell says there remains a complex quagmire of federal Indian law, policy and intergovernmental relationships.

AI/ANs have long experienced lower health status compared to other Americans, including lower life expectancy, disproportionate disease burden perhaps due to problems with access to care, including primary health care and behavioral health services, specialty medical care, long-term care, emergency services, disproportionate poverty, discrimination in the delivery of health services, limited educational opportunities and cultural differences.

Members of 567 federally recognized AI/AN tribes and their descendants are eligible for services provided by the Indian Health Service (IHS), a federal agency within the Department of Health and Human Services that provides a health service delivery system specifically for AI/ANs. However, it is not a type of health insurance.

The IHS continues to be severely under-funded, receiving only about 40 to 60 percent of the level of funding required to provide services equivalent to the federal employee health benefit plan. Average expenditures for IHS health services per capita, were $2,849 compared to $7,717 per person nationally.

“Congress appropriates funds annually for the IHS. Unlike Medicaid and Medicare, the IHS is not considered an entitlement program in the federal budgetary process,” said Frizzell. “The IHS budget has not kept pace with medical inflation and the increasing eligible population, resulting in a reduction of inflation-adjusted per capita spending.”

Frizzell says full funding to meet 100 percent of projected need would be $28.7 billion and is practically achievable in a twelve year phase-in plan.

AI/AN health disparities

Since 1955, the IHS was the first “managed care” system in the country, starting in its current home within the Department of Health and Human Service, Public Health Services. Services to AI/ANs have always been “rationed” using an IHS priority system that historically exhausts funds to meet only the “life and death” medical needs of patients. Procedures such as cataract surgery, joint replacements and other non-life threatening procedures may be delayed until appropriated funds are available.

Some startling statistics from IHS data finds AI/ANs die at higher rates than other Americans:

  • Tuberculosis (TB) – 600 percent higher
  • Alcoholism – 510 percent higher
  • Vehicle crashes – 229 percent higher
  • Diabetes – 189 percent higher
  • Injuries – 152 percent higher
  • Suicide – 62 percent higher

Fortunately, the IHS services are based on a public health model. This has helped Indian health programs reach and serve AI/ANs through practical and effective community-based services with limited funds. This model, which offers numerous prevention services, has slowed the decline in health status.

Frizzell says a concerted, robust public health effort by federal, tribal, state and local public health agencies, along with attention to social and economic disparities, may help narrow the gap.

Current Indian health system

The IHS is multifarious and fragile. There is an intense need to monitor laws and regulations that challenge the ability of tribes to provide health services. Additionally, these laws and regulations are often confusing to federal and state agencies, which have limited knowledge or no experience with Indian health law and policy. Much more needs to be done to avoid superfluous barriers and improve meaningful consultation relationships with all levels of government.

Despite all federal promises, the current IHS remains in despair. As previously stated, AI/ANs continue to live less healthy lives and die younger than other Americans. AI/ANs experience significantly higher:

  • Mortality rates for alcoholism, TB, suicide, cancer, and influenza
  • Infant and maternal mortality rates
  • Rates of intimate partner violence
  • Levels of dental caries of AI/AN children
  • Incidence of drug use disorders

Frizzell says devastating health risks persist from historical trauma, poverty and a lack of adequate treatment resources.