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Is Health Care Entitlement a Solution to the Problem of Health Disparities for American Indians/Alaska Natives?
Jennie R. Joe, PhD, MPH
Professor, Family and Community Medicine
Director, Native American Research and Training Center
University of Arizona
Health Disparities
Different meanings - general to specific
Access to care might includeTransportationHealth insuranceHealth literacy
Type and quality of health care receivedMany examples in the IOM report (Unequal Treatment)
Discrimination or prejudice
What is Known About Health Disparities
American Indians/Alaska Natives (AI/ANs)
Based primarily on data collected from IHS or the IHS-funded health care systemFew other data sourcesSpecial studies, SEER, etc.
Two key annual IHS publicationsRegional Difference in Indian HealthTrends in Indian Health
Health Disparities for AI/ANs
Reflected in an array of mortality and morbidity statistics
In 1996-98, the causes for a number of age-adjusted death rates for AI/ANs far exceeded that for the US, all races638% greater for alcoholism400% greater for tuberculosis291% greater for diabetes215% greater for unintentional injuries, etc
Source: Trend in Indian Health (2000-2001). Page 7.
Michael Trujillo, M.D.
Former director of the federal Indian Health Service (IHS)
Attributed some of the following underlying causes of health disparities among AI/ANs in 2000:
Social and cultural disruptions
Poor education
Poverty
Michael Trujillo, M.D.*Underlying causes of health disparities among
AI/ANs in 2000 cont.:
Lack of political presence
Limited access
Widening gap in healthcare spending
Recommends “legislation”
*“One Prescription for Eliminating Health Disparity: Legislation.”
Source: I.H.S. Unpublished manuscript. 2000.
Why Reference these Underlying Causes?
To discuss health status or disparities requires a larger context including:History of white-Indian relationshipThe trust relationship that many tribes have with the
federal governmentExplains why there is a federal Indian Health Service
The definition of who is an American Indian or an Alaska Native and how this affects their eligibility for the health services
AI/ANsComprise a heterogeneous population
560 federally recognized tribesThe number continues to increaseSome have only state recognition and/or no recognition
In the 2000 census there was a 26% increase in population2.5 million identify as AI/AN4.1 million identify 1 or more other race or ethnicity
Demographic profile of the 2.5 million is similar to that of developing nationsLess known about the “new” 4.1 million
Census Data
2000: Median age is 29.8 compared to 35.5 for U.S., all races
1990: 65% high school graduates compared to 75% for U.S., all races
1990: 8.9 % bachelor’s degree or higher compared to 20.3% U.S., all races
Source: Trends in Indian Health, 2000-2001
Census Data
1990: $19,897 median household income compared to $30,056 U.S., all races
1990: 31.6% below poverty level compared to 13.1% U.S., all races
No question that poverty and inadequate schooling are key factors
Source: Trends in Indian Health, 2000-2001
The Federal Government
Historically has had a central role in the delivery of health care services to AI/ANs
Rooted in treaties negotiated with some tribes prior to the late 1800s
A form of prepaid health plan for lands ceded to the government
The Federal Government
Treaties specified the terms of the agreementServices of a physician or medical suppliesHealth services continued under annual appropriation
The War Department, then Department of InteriorSnyder Act in 1921
Today federal health dollars continue through federal appropriation“if they receive free health care, why is the health
situation not any better?”
Colonized Nations
AI/ANs have long been crippled by poor healthDating back to the arrival of the Europeans
Wave after wave of communicable diseases completely decimated or drastically depopulated many of the tribes
Warfare added another factorForced removal and resettlement to unproductive
lands (reservations, rancherias, villages)Health resources have never been adequate
The 1955 Transfer Act
Access to Health Care Today
Largely depends on where one residesEligibility includes evidence of tribal enrollment
Over half of the AI/AN population reside off the reservationSome are counted among the urban poor36 urban Indian Health Programs
10 provide comprehensive outpatient services
Access to Health Care Today
Reservation-based health care delivered by:
IHS
Tribe through Self Determination contract
Tribe through self-governance compact
Combination and/or other (missions)
Health Status TodayConsiderable improvement since 1955 (post
transfer to PHS)
Some regional differences
Increase in life expectancy (women more than men)
Mortality reflects a young population taking risks -unintentional injuries/substance abuse
Despite young population, there is heart disease and cancer
Increase in chronic diseases
Health Status TodayThe health disparity picture involves a number of
preventable health problems
Tribal programs in health promotion
Diabetes prevention, Strong Heart, community based programs
Increased interest in health-related research: NARCH
Some positive impact noted in IOM study
Inclusion of AI/ANs in the IOM Study
IOM study included AI/ANs
The congressional charge to the IOM committee:Assess the extent of racial/ethnic differences in
health care not attributable to known factors (e.g., access to care, ability to pay, insurance coverage, etc.)
Source: IOM (2003): Unequal Treatment
…and Evaluate
Potential source of disparities, including the role of bias, discrimination, and stereotyping at the individual (providers and patients), institutional, and health system levels
Provide recommendations regarding interventions to eliminate healthcare disparities
Non
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Disparity
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eFigure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care
Populations with Equal Access to Health Care
Clinical Appropriateness and Need
Patient Preferences
The Operation of Healthcare Systems & the Legal and
Regulatory Climate
Discrimination: Biases &Prejudice, Stereotyping, &
Uncertainty
Source: IOM (2003): Unequal Treatment p.4.
Considerable Data Limitation for AI/ANs
Undertake a quick study: phone interviews with 22 key tribal health leaders, providers, and consumer (focus group)
Explore questions on:Quality of care
Impact of contracting or compacting on quality of care
Issues of discrimination
Are Tribal Members Getting Quality Care?
[provider]: I have two part answers for this question. The first part is yes, I believe overall that tribal members in our area are receiving quality care given our limited resources. The second part is I do not believe tribal members are getting good preventive services, and the limited CHS (Contract Health Service) dollars prevent many from getting needed care (JY 6/22/01).
Has Contracting or Compacting Improved Quality of Care?
[provider]: My sense is that on balance, contracting and compacting has improved health care services. In Alaska, where healthcare has been compacted for the last 4-5 years, there are improvements in clinical care. If you walk into the Alaska Native Medical Center today, you get treated today, whereas under the old system, sometimes it was a couple of weeks before you could get an appointment (N 6/12/01).
Does Discrimination Affect Quality of Care?
[Consumer/tribal leader]: Private hospitals tend to place Indian patients in charity rooms or cubicles in hospitals, rarely in a room with a window, with a private bath or nice surroundings. I have accused the hospitals of placing our tribal members in these ‘Indian beds,’ but they denied it. I know because my husband was always placed in one of these ‘Indian beds’ (JR 6/25/01).
General Findings
Inadequate funding was the most frequent barrier to eliminating health disparitiesForced to ration health careIssues/debates over who is the payer of last resort
Discrimination exists and has impact on quality of care but is rarely examinedDiscrimination is reported to happen more often in
non-tribal or non-IHS facilities
Compacting/Contracting and Quality of Health Care
Within the Indian Health system:Patients said they receive quality careQuality control more assured by tribal controlMade more responsive to local needs
Less waiting time and improved continuity of care
Negative impact on quality of carePolitical instability
New agenda and reallocation of health resources
What is Being Done to Address Health Disparities?
Refer to the diabetes prevention model as one exampleSpecial congressional initiative Required separate funding to implement prevention
Barriers to addressing health disparities Lack of adequate funding Widening gap in health care spending
Appropriation not based on need Leads to rationing of health care
Gap in Annual Per Capita Healthcare Allocation
General U.S. population $3,766
Medicare $3,369
Bureau of Prisons $3,489
Veteran’s Administration $5,458
IHS $2,336*
Source: FCLN, 2000
* IHS level of need at $15 billion, funded at $2.4 billion
The Call for Entitlement
In the reauthorization of the Indian Health Care Improvement Act
A commission to initiate a study
An idea under discussion for a number of yearsSalt Lake City, August 1999What is to be gained or lost under an entitlement program?
Some Positive Expectations
Will take funding out of the annual political process Authority will serve in place of an annual
request/justificationWill not have to compete with other 13 appropriation bills
Funded at the level of need
Will define a benefit package
Some Anticipated Negative Outcomes
May not be accepted by Congress
Services will be heavily regulated
Eligibility requirements will be regulatedIncome, blood quantum, geographic area
Some Anticipated Negative Outcomes
Benefit package may not be comprehensive
Will IHS continue to be part of the delivery system?
Will it erode tribal sovereignty?
Entitlement programs get budget cuts
A Study is a Wise MoveWill help tribes make an informed decision
Will take into account multiple concerns so as not to erase gains madeSelf-determination
Increased attention to health promotion/prevention
Community based studies
Investment tribes make in improving health care delivery system that is culturally appropriate
Will an Entitlement Program be the Answer?
Can only predictWill most likely increase fundsWill most likely help decrease the political process
But:The cost to tribal sovereignty may not be acceptableMay find that an entitlement program with more
health care dollars may not readily address health disparity problems which are attributable to lifestyle behaviors, genetics, environment, etc.