SPH report: Health status of American Indians/Alaska Natives continues to decline – Part 2

March 1, 2016

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

Yesterday we discussed the persistent health inequities American Indians and Alaska Natives (AI/AN) face today brought forth in a new report by Linda Frizzell, Ph.D., assistant professor in the University of Minnesota School of Public Health.

The Indian health system (IHS) is unlike any other. It serves some of the poorest, sickest and most remote populations in the United States. Each tribe’s culture guides their elected leadership to meet their respective needs in this complex environment.

Health services access

Barriers to access routine health services continue to plague AI/AN communities. Access to primary care services is limited and requires an ability to travel for access to basic professional health services. All reservations have an “automatic designation” of a Health Professional Shortage Area (HPSA), and the entire country, according to the Health Resources Service Administration (HRSA), is designated as a “Mental Health Professional Shortage Area,” with a few metropolitan exceptions. Given these factors, the ability for AI/ANs to access even minimum health services requires extra planning, support, reliable transportation and availability of a culturally appropriate health provider.

“Currently, the highest need is for behavioral health services, which are difficult to find in all rural areas,” said Frizzell. “Access to and the availability of behavioral health professionals, such as psychiatrists, psychologists, drug counselors, and social workers is seriously lacking. Poverty, geographic location and cultural differences further limit the amount and quality of services available.”

For those who do receive treatment, many find that the care provided is not intensive enough, not long enough and/or lacking in important follow-up health and social services.

Additionally, patients oftentimes forgo their health appointments with needed specialists because their out-of-pocket costs are too high. Other significant factors they must consider include: loss of work time, child/elder care, home heating maintenance (some only have wood as a heating source), livestock care and home security issues. Certainly telemedicine can have a role in reducing some of these disparities, but there remains a need for the development of technology for use in all rural areas.

Patient protection and the Affordable Care Act (ACA)

The implementation of the ACA creates opportunities to increase health services for AI/AN communities and reduce health disparities.

“Health reform implementation has been quite challenging. The federal requirement for meaningful consultation with tribal governments has often been in vain,” said Frizzell. “The definition of an ‘Indian’ remains the most critical.”

Frizzell’s report also said call centers have been inadequate at answering questions related to special benefits and protections available to AI/ANs, leading to application errors.

In addition, there are thousands of exemption applications that have not been processed for reasons that are unclear, and a large proportion of the applications have been processed incorrectly.

The cumulative effect of these problems have all contributed to low enrollment of health insurance plans due to process confusion and the perception that there is no real reason to sign up, since IHS (by law) must provide direct services to all AI/ANs without cost. A designated AI/AN call center may reduce some of these problems.

Health workforce

Access to a quality health workforce has been a longstanding barrier to care for AI/ANs. Remote and rural location, lower pay, limited staff and equipment at facilities dramatically affect the ability to recruit and retain a skilled workforce.

The health service needs of AI/ANs require unique provider qualifications. Consider the historical actions of colonization, genocide, wars, forced relocation, discrimination, broken treaties and promises and political injustices upon AI/ANs. These actions have resulted in an entire population that has been traumatized and forced to survive in a “learned dependency” environment. Often this practice environment overwhelms health service professionals and leads to early burnout or limited years of service.

For the third part of the series check back with Health Talk tomorrow.