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March 16, 2020

Investing in the Health of American Indians and Alaska Natives

Author Affiliations
  • 1Division of General Internal Medicine, The University of Utah, Salt Lake City
  • 2Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 3Division of General Internal Medicine, Department of Health Care Policy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. Published online March 16, 2020. doi:10.1001/jamainternmed.2020.0189

The US government’s duty to provide health care to Native Americans, including American Indians and Alaska Natives, dates from 1787, when the Constitution codified promises made in treaties, including those guaranteeing “proper care and protection” to indigenous tribes, as “the supreme law of the land.”1 In 1955, the Indian Health Service (IHS) was created to serve this mission. At present, the IHS operates 92 clinics and 24 medical centers in 36 states. It provides direct medical care to more than 2 million Native Americans representing more than 500 diverse tribes.2

The $5.8 billion budget of the IHS’s 2019 fiscal year notwithstanding, inadequate funding and systemic barriers to care have perpetuated striking health disparities among Native Americans. This is especially true in rural areas, where long distances between facilities, a lack of modern transportation and telecommunication infrastructure, and health care workforce shortages contribute to age-adjusted mortality rates that are 30% higher than those for other Americans. Native Americans born in 2020 can expect to live 5.5 years fewer on average than others in the US. Preventable causes of death such as chronic liver disease, diabetes, and substance use disorders are important contributors to this disparity.3

Of the many challenges facing rural tribal communities, the lack of reliable access to health care is among the most important. Underresourced local health systems and barriers to accessing care outside the IHS act synergistically to limit Native Americans’ ability to receive medical care. In 2018, 25% of positions for physicians and other clinicians within the IHS were unfilled, with some regions experiencing vacancy rates greater than 45%.4 In addition, persistent deficits in workforce training and education infrastructure have led to shortages in support staff (eg, radiology and laboratory technicians) that are integral to a functioning health system. Physicians and medical centers outside the IHS are often sparse and inaccessible to Native Americans without additional health insurance or tribal funding, leaving patients with nowhere to turn. Although more resources and financial support from the federal government are a necessary part of closing these care gaps, recent developments in rural health policy, technology, and medical education offer opportunities to improve health.

Leveraging Partnerships to Build Local Health Care Infrastructure

Alleviating the health crisis facing Native Americans requires strong tribal health systems and local environments that support healthy living. Regional universities and academic medical centers can partner with tribal leadership in fostering community-based programs that build and support the local health care workforce. Such partnerships can increase health care services as well as contribute to economic, educational, and civic development for tribal communities. Examples of successful collaborations include longitudinal health professions mentorship programs for Native American youth, embedded rural medicine training programs supported by academic medical centers, and community health worker initiatives that bring outside resources and job training to bolster the local health care workforce. Further initiatives might include expanding opportunities for residents and fellows to have clinical experiences within tribal communities; reforming the admissions process for medical schools, residency, and fellowship programs to increase the number of Native Americans in the workforce; and working with colleges in tribal communities to establish vocational training programs for medical staff. In the long term, initiatives that improve educational opportunities for Native Americans in primary and secondary education (prior to medical school application) are essential.

Developing partnerships that incorporate tribal beliefs, history, language, and current priorities requires expertise as well as long-term commitment. The IHS and the National Congress of American Indians have supported numerous partnerships between tribes and academic institutions, such as the Center for Native American Health (University of New Mexico), the Rural Health Leadership Fellowship (Rosebud Sioux with Massachusetts General Hospital), and Navajo Nation Community Outreach and Patient Empowerment (Navajo with Brigham and Women’s Hospital and Partners in Health). These partnerships are examples of how collaborations can be guided by tribal leadership to ensure that efforts are centered on each community’s self-identified needs. With appropriate investment and a commitment to ongoing tribal consultation, academic institutions can support the health of tribal communities and, at the same time, enrich the educational and personal experiences of their trainees.

Improving Access and Choice Through Health Insurance and Federal Subsidies

In rural areas with a paucity of medical resources, unrestricted access of Native Americans to regional health care systems outside the IHS should be assured. Expanding insurance coverage and increasing federal funding to fully subsidize all care received at non-IHS facilities for uninsured or underinsured Native Americans are synergistic approaches to improving access and creating opportunities for local health system development. Since the Affordable Care Act (ACA) was signed into law in 2010, the number of Native Americans reporting insurance coverage has increased from 64% to 78% nationally, with most relying on public insurance for coverage.5 Although the IHS provides care to all Native Americans regardless of insurance status, having insurance coverage enables Native Americans to receive care at more regional non-IHS facilities, thus enhancing access and choice. Nonetheless, there are regional disparities in insurance coverage. For example, gains in Medicaid coverage under the ACA averaged 17% in states that have expanded Medicaid, compared with 8% in states that have not.5 In nonexpansion states, such as Oklahoma and South Dakota, with large rural populations of Native Americans, Medicaid expansion under the ACA would offer opportunities to address care gaps.

In addition to improving access to care, health insurance plays a central role in strengthening the IHS. The reason is that a patient’s insurance can be billed for care provided at an IHS facility. Because the IHS has fixed discretionary funding to pay for care received at outside health systems, perennial budget shortfalls can restrict referrals, leading to unmet medical needs and the rationing of care. In some tribal communities, during certain periods of the year, there is no funding for nonemergent referrals. However, in 2018, the IHS billed Medicaid $729 million for medical services.5 Such revenue can be used to improve local facilities as well as to subsidize referrals for uninsured or underinsured individuals.

Infrastructure to Support Expanded Telehealth Services

Even if Native Americans had no insurance-related barriers to health care, geography limits access to regional facilities. For example, within the Navajo Nation (located in parts of Arizona, Utah, and New Mexico), 9000 of the 11 600 miles of road are dirt and often impassable in rain or snow. Telehealth services can connect specialty care and other distant health care resources to geographically isolated tribes; the IHS and the Federal Communication Commission are supporting its expansion.6 Telehealth services can also serve as a resource for primary care clinicians within the IHS, who often manage patients with complex medical conditions. Large telehealth organizations, such as Avera eCare, based in Sioux Falls, South Dakota, provide remote guidance to patients and clinicians, and can coordinate care between different health systems. For example, they can arrange for emergency transfer from rural facilities in cases where local resources are inadequate to provide necessary care, such as for women with obstetrical emergencies.7

As the health disparities facing Native Americans result from a historically diverse set of challenges, the solutions must be multifaceted. The path forward includes building local environments that support healthy living as well as the adoption of innovative ideas in health care delivery that encompass the traditions, culture, and priorities of tribes. It also includes increased funding for the IHS, improved insurance coverage for Native Americans outside the IHS, and reliable access to needed health care.

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Article Information

Corresponding Author: Michael A. Incze, MD, MSEd, Division of General Internal Medicine, The University of Utah, 30 N 1900 E, Room 5R218, Salt Lake City, UT 84132 (michael.incze@hsc.utah.edu).

Published Online: March 16, 2020. doi:10.1001/jamainternmed.2020.0189

Conflict of Interest Disclosures: Dr Sequist reported personal fees from RAND and Regenstrief Institute. No other disclosures were reported.

Additional Contributions: The authors thank Dr Nicole Lurie for her invaluable contributions to the article. Dr Lurie was not compensated.

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Indian Health Service. Disparities. Accessed September 21, 2019. https://www.ihs.gov/newsroom/factsheets/disparities/
United States. Congress, “INDIAN HEALTH SERVICE: Agency Faces Ongoing Challenges Filling Provider Vacancies.” GAO-18-580, August 2018. https://www.gao.gov/products/GAO-18-580
United States. Congress, INDIAN HEALTH SERVICE Facilities Reported Expanding Services Following Increases in Health Insurance Coverage and Collections” GAO-19-612, September 2019.https://ww.gao.gov/products/GAO-19-612
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