Health Care for American Indians in the United States

Gerald Greenway, Ph.D. Analytical ChemistryMember, Rotary Club of Rolla, Missouri, USA

September 15, 2011

Who is Indigenous in the United States?

– Ancestry from any of the original peoples of North and South American

– Anyone who self identifies on the Census – Tribal membership – rules varyPreferred term is American Indian/Alaska

Native (AI/AN)

Map of USA in 1600

Map of Indian Reservations, 2011

United States Federal Recognition• Currently 565 tribes and 223 Alaska Native

villages have met the special requirements to be recognized by the US government

• These tribes are sovereign nations and deal with the federal agencies on a government to government basis

• After 1924, Congress granted American Citizenship to all Indians born in the Territorial limits of the US

American Indians are Important to the US Society and Economy

• There are currently over four million American Indians/Alaska Natives (Census 2000)

• The population is young and growing• Some tribes have lands with oil, lumber and

minerals • World Opinion: The US is judged by other

nations depending on how well it treats its least privileged groups

The AI/AN Population is Growing

American Indian and Alaska NativeIHS Service Population

1,500

1,600

1,700

1,800

1,900

2,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Calendar Year

Thousands

Casino Operations

• In 2001, 201 of 562 Federally Recognized tribes participated in gaming operations aka casinos resulting in Tribal revenue from 354 casinos in 2002 of $14.5 Billion

• It is a regulated industry in the US established under the Indian Gaming Regulatory Act of 1988

http://en.wikipedia.org/wiki/Gambling_in_the_United_States#Indian_gaming

Defense Contracting

• Cherokee Nation Businesses received more than $40 Million for a 2011-2013 contract to provide logistics, services and support for military hardware

• Cherokee Nation Industries was awarded a Gold Status rating by the Boeing corporation for its superior performance and on time delivery, operating a 120,000 plus sq ft of expandable manufacturing space in Stillwell, Oklahoma, employing 150 people, 70 of which worked under Boeing subcontracts

http://savethetribe.org/2011/08/14/cherokee-nation-businesses-gets-its-largest-federal-contract-ever/

AI/AN Socio-Economic Profile

Income Status in 1999American Indians and Alaska Natives (alone)

and U.S. All-Races, 2000 Census

$30,599

$41,994

10

20

30

40

50

Median Household Income

Dollars (Thous.)

25.7

12.4

0

10

20

30

Below Poverty Level (All Ages)

Percent

0

U.S. All Races

American Indians andAlaska Natives

Employment

Employment Status by SexAmerican Indians and Alaska Natives (alone)

and U.S. All-Races, 2000 Census

13.1

11.7

5.7 5.8

0

5

10

15

Civilian Unemployed Males Civilian Unemployed Females

Percent

U.S. All Races

American Indians andAlaska Natives

US Government Provides Health Care

• Historical Treaty obligations from 1793 have required the US government to provide free health care to every Federally recognized Tribal member in perpetuity, regardless of economic advantage or disadvantage

• Tribes are the First Americans; they are not viewed as mere occupants at contact with the Europeans but as unfortunate recipients of maltreatment to whom the US owes compensation

Providing Health Care to AI/AN

• The current Indian Health Service moved to the Department of Health and Human Services in 1955 following the passage of the Transfer Act – Open Door Policy: Provides direct care to any

AI/AN who belongs to a Federally recognized Tribe

The Indian Health Service Today

• Provides healthcare to approximately 2 million of the 3.4 million AI/AN in hospitals, clinics, and other settings throughout the US

• $ 4 Billion Nationwide Health Care Delivery Program with 16,159 employees of whom 70% are AI/AN– Dental: $152.6 million for a population with more tooth decay and gum

disease than the general population of the US– Mental Health/ Substance Abuse: $267 million– Contract Health: Reimburses for care from another facility when IHS

cannot provide that care itself. $779.3 million was budgeted for this in the last year.

Map of IHS facilities and services

Primary Care Model

• Population based Needs Assessment• Planning process that is community based• Provision of staffing, equipment and space for

comprehensive primary care including dental for all patients

Use of Community Health Representatives

Distribution of CHR Client Contacts by SettingOctober 1, 2003 to September 30, 2006

Total Number: 1,887,881

Community 49%

Home 29%

CHR Office 12%

Hospital/Clinic 7%Radio/Telephone 2%School 1%

Community Public Health Principles

• Community Health staff included with all facilities

• Health education staff• Sanitation and other engineering services

available

Health Inequalities or Disparities

• IHS develops many measures of how different health conditions are for AI/AN than for the general population

• These differences also called inequalities or disparities are used by the agency to go before Congress to justify receiving more money for health care

• Without this information, the budget of IHS could not be justified, but with this information, the agency regularly receives funding under a bill called the Indian Health Care Improvement Act

Selected Disparities

0 40 80 120 160

Tucson

Aberdeen

Bemidji

Nashville

Phoenix

Albuquerque

Oklahoma

Billings

Navajo

Portland

California

Alaska

Rate per 100,000 Population

Age-Adjusted Diabetes Mellitus Death RatesCalendar Years 1999-2001

IHS Adjusted Total - All Areas = 77.7

U.S. All Races (2000) = 25.2

Unadjusted

Adjusted for Race Misreporting

Selected Disparities

0 25 50 75 100

Aberdeen

Alaska

Albuquerque

Tucson

Billings

Phoenix

Navajo

Portland

Bemidji

California

Oklahoma

Nashville

Rate per 100,000 Population

Age-Adjusted Alcohol-Related Death RatesCalendar Years 1999-2001

IHS Adjusted Total - All Areas = 43.2

U.S. All Races (2000) = 6.9

Unadjusted

Adjusted for Race Misreporting

Since IHS came into being, there has been a steady increase in the number of years an AI/AN can expect to

live

1940 1950 1960 1970 1980 1990 1997 2000 20040

10

20

30

40

50

60

70

80

Life Expectancy At Birth, AI/AN (US), 1940-2004

Impacts of New IHS Facilities

• Increased access• More services and staff• More equipment and space• Increased resources• Individual health status• Increased patient satisfaction• Increased in community infrastructure

Changes in Health Status

American Indian and Alaska NativeYPLL

YEAR POPLT 65 YPLL YPLL Rate

2000-2002 4730536 333021 70.41997-1999 4423015 313711 70.91994-1996 4058227 307731 75.81992-1994 3786490 301014 79.5

NOTE: YPLL for Total Indian Health SerivceBased on Populations Projections Developed December, 2005

These vary significantly by Tribe and Region

0 40 80 120

Aberdeen

Billings

Alaska

Tucson

Bemidji

Phoenix

Navajo

Oklahoma

Portland

Albuquerque

Nashville

California

Rate per 1,000 Population Under 65 Years of Age

Years of Potential Life Lost (YPLL) RatesCalendar Years 1999-2001

IHS Adjusted Total - All Areas = 81.8

U.S. All Races (2000) = 45.7

Unadjusted

Adjusted for Race Misreporting

Dental Improvements

• Increases in the number of 5-19 year old children with no decay

• Increase in the number of dental sealants placed on children’s molar teeth

• And increase in the number of older patients with 20 or more teeth

New Models

• Wellness – to address issues of obesity,• Telehealth – to provide needed services and

consultation not available locally• Traditional Healing – to augment services and

respond to patient needs• Improving Patient Care – to realign services to

focus on individual patient needs

New organizational Models

• Self Governance– Tribes manage their own systems with funds from

the government• Joint Ventures

– IHS and Tribes share resources to build and staff new facilities

Future Challenges

• Providing opportunities to provides new types of care – Nursing Home, Dialysis, Inpatient Psychiatric

• Future increases in funding may be limited because of US economic issues

• New lifestyle and other disease challenges which require new types of care such as Obesity

Lessons Learned for Planning

• Work closely with local leaders and community

• Communicate and outreach through indigenous representatives, mobile units

• Employ Tribal members• Incorporate indigenous culture and knowledge• Focus on primary care and conserve resources