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EDITORIAL |
Marsha Lillie-Blanton is with the Henry J. Kaiser Family Foundation, Washington, DC. Yvette Roubideaux is with the Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson.
Correspondence: Reprint requests should be sent to Marsha Lillie-Blanton, DrPH, Kaiser Family Foundation, 1330 G St NW, Washington, DC 20005 (e-mail: mlillie-blanton{at}kff.org)
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INTRODUCTION |
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 TOP INTRODUCTION WHY A FOCUS ON...UNDERSTANDING AND ADDRESSING THE...CONCLUSIONReferences |
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With the September 2004 opening of the Smithsonian Institution’s National Museum of the American Indian, many of us have taken time to celebrate the history and culture of Native Americans and their contributions to America. The museum provides an opportunity to inform Americans about chapters in the nation’s history that are often misrepresented. It also provides an opportunity to reflect upon and assess how well the United States has lived up to its trust responsibility to provide for the health of American Indians and Alaska Natives.
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WHY A FOCUS ON AIAN HEALTH POLICY CHALLENGES? |
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TOPINTRODUCTIONWHY A FOCUS ON...UNDERSTANDING AND ADDRESSING THE...CONCLUSIONReferences |
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The federal government has a unique relationship with American Indians and Alaska Natives that is defined by the US Constitution, treaties, Supreme Court cases, and legislation.5 In exchange for tribal lands, the US government agreed to provide health care to members of federally recognized tribes. The Indian Health Service (IHS), an agency of the US Department of Health and Human Services, has fulfilled that responsibility since 1955. The AIAN health system has evolved greatly since then and now consists of IHS hospitals and health centers managed by the federal government, tribally managed services, and urban Indian health programs.
While IHS is the hub of the AIAN health system, AIAN people also qualify for private and other public sources of health financing and services. In fact, about half (49%) of American Indian and Alaska Natives younger than 65 years have job-based or private coverage.6 An estimated 17% of the AIAN population has coverage through Medicaid or other public programs. Medicaid is playing an increasing role in financing AIAN care and as a revenue source for IHS providers.7 However, large disparities exist in the funding and availability of health services for AIAN people relative to other Americans.
In fiscal year 2003, IHS had an operating budget of $2.9 billion to provide or pay for care for a service population of approximately 1.5 million of the 4.1 million people who identify themselves as AIAN. This amounts to $1914 per patient per year,8 which was less than the nation spent per capita in 2002 on public sector health care financing programs serving the nonelderly population ($3545) (unpublished data from the Kaiser Family Foundation analysis of the 2002 Medical Expenditure Panel Survey, available from the authors). According to one study that used the Federal Employees Health Benefits Plan (FEHP) as the primary benchmark, an additional $1.8 billion would be needed to provide active IHS users with services at the same level as those provided in a mainstream health plan such as the FEHP.9
Despite limited financial resources, IHS has made great progress in improving the health of American Indians and Alaska Natives over the past several decades.2 A recent study also shows that low-income American Indians and Alaska Natives reporting IHS as their only source of coverage fare better than uninsured American Indians and Alaska Natives and approximately as well as low-income insured Whites on several measures of access and utilization.6
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UNDERSTANDING AND ADDRESSING THE CHALLENGES |
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TOPINTRODUCTIONWHY A FOCUS ON...UNDERSTANDING AND ADDRESSING THE...CONCLUSIONReferences |
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Several of the studies highlight the health care challenges faced by the Indian health system. Denny and coauthors10 confirm other studies that reveal a higher prevalence of risk factors for chronic diseases in AIAN elders, including obesity, physical inactivity, and smoking. Nez Henderson and coauthors11 also highlight, in the case of cigarette smoking, how these risk factors for chronic disease vary by region, often resulting in a need to tailor intervention efforts to the local tribe or culture. Puukka et al.12 demonstrate how using more advanced and appropriate statistical methods reveals that the burden of cancer is actually greater than previously documented in American Indians and Alaska Natives.
Despite advances and improvements in health care for American Indians and Alaska Natives, some conditions, such as tuberculosis, continue to be a significant health challenge for this population, as shown by E. Schneider.13 Mansberger and coauthors14 illustrate how research can help identify the causes of visual impairment in American Indians and Alaska Natives, which may lead to better diagnosis and treatment in the future. All of these studies help highlight persistent and growing disparities in risk factors and health conditions that will continue to challenge the already underfunded Indian health system.
The article by Manson et al.15 is especially noteworthy for examining social determinants of health and health disparities. The finding that American Indian tribal members, both male and female, witnessed traumatic events, experienced traumas to loved ones, and were victims of physical attacks more often than their counterparts in the general US population is startling. However, the research team does not assume that alcohol use is the main cause (as is often portrayed in the media) but commits to undertake further analysis to assess the nature of the association between these events and alcohol use, since it is conceivable that traumatic life events can increase the likelihood of alcohol use and abuse, just as heavy drinking can increase risk of aggressive acts. Moreover, the authors raise the broader issue of the potential link between trauma and physical health problems and disparities in care.
Two of the articles describe both the severity of health problems facing American Indians and Alaska Natives and the efforts underway to address the problems. For example, May and coauthors16 show disturbingly high rates of suicide and suicide attempts in one American Indian tribal nation. However, they also describe a community-based intervention that helped to reduce suicide attempts, if not deaths, over a 15-year period. Sekiguchi et al.17 highlight the high prevalence and severity of oral disease among Alaska Natives and describe a new program designed to reduce barriers in access to dental care by employing dental health aides. Studies that document the outcome of specific interventions in Indian health settings are sorely needed, since most published Indian health research focuses on observational and descriptive data, and studies evaluating actual health system or clinical interventions are rare.4 For this type of research to occur in the future, efforts to improve health care for American Indians and Alaska Natives need to be more culturally appropriate and community based and must help build community capacity,18 like the collaborative approach described by Andersen et al.19
The problem of inadequate funding for the Indian health system is addressed by one of the commentaries in this issue. A. Schneider argues that the chronic underfunding of Indian health by the federal government has undercut the capacity of IHS to meet AIAN health care needs.20 He describes the current role of Medicaid in financing AIAN health care services and makes several recommendations for improving Medicaid as a source of financing for Indian health.
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CONCLUSION |
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TOPINTRODUCTIONWHY A FOCUS ON...UNDERSTANDING AND ADDRESSING THE...CONCLUSIONReferences |
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References |
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TOPINTRODUCTIONWHY A FOCUS ON...UNDERSTANDING AND ADDRESSING THE...CONCLUSIONReferences |
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2. Trends in Indian Health 1998–1999. Available at: http://www.ihs.gov/PublicInfo/Publications/index.asp. Accessed February 22, 2005.
3. Dixon M, Roubideaux Y, eds. Promises to Keep: Public Health Policy for American Indians and Alaska Natives in the 21st Century. Washington, DC: American Public Health Association; 2001.
4. Roubideaux Y. A Review of the Quality of Health Care for American Indians and Alaska Natives. New York, NY: The Commonwealth Fund; 2004.
5. Shelton BL. Legal and historical basis of Indian health care. In: Dixon M, Roubideaux Y, eds. Promises to Keep: Public Health Policy for American Indians and Alaska Natives in the 21st Century. Washington, DC: American Public Health Association; 2001:1–30.
6. Zuckerman, S, Haley J, Roubideaux Y, Lillie-Blanton, M. Health service access, use and insurance coverage among American Indians/Alaska Natives and Whites: what role does the Indian Health Service play? Am J Public Health. 2004;94:53–59.
7. Schneider A, Martinez J. Native Americans and Medicaid: Coverage and Financing Issues. Washington, DC: Kaiser Commission on the Future of Medicaid; December 1997.
8. Year 2003 Profile. Rockville, Md: Indian Health Service; 2003.
9. Indian Health Service. FEHP Disparity Index. Available at: http://www.ihs.gov/NonMedicalPrograms/Lnf/index.htm. Accessed January 14, 2005.
10. Denny CH, Holtzman D, Goins RT, Croft JB. Disparities in chronic disease risk factors and health status between American Indian/Alaska Native and White elders: findings from a telephone survey, 2001 and 2002. Am J Public Health. 2005;95:825–827.
11. Nez Henderson P, Jacobsen C, Beals J, et al. Correlates of cigarette smoking among selected Southwest and Northern Plains tribal groups: the AI-SUPERPFP Study. Am J Public Health. 2005;95:867–872.
12. Puukka EJ, Stehr-Green P, Becker TM. Measuring the health status gap for American Indians/Alaskan Natives: getting closer to the truth. Am J Public Health. 2005;95:838–843.
13. Schneider E. Tuberculosis among American Indians and Alaska Natives in the United States, 1993–2002. Am J Public Health. 2005;95:873–880.
14. Mansberger SL, Romero FC, Smith NH, et al. Causes of visual impairment and common eye problems in Northwest American Indians and Alaska Natives. Am J Public Health. 2005;95:881–886.
15. Manson SM, Beals J, Klein SA, et al. Social epidemiology of trauma among 2 American Indian reservation populations. Am J Public Health. 2005; 95:851–859.
16. May PA, Serna P, Hurt L, DeBruyn LM. Outcome evaluation of a public health approach to suicide prevention in an American Indian Tribal Nation, 1988–2002. Am J Public Health. In press.
17. Sekiguchi E, Guay AH, Brown LJ, Spangler TJ Jr. Improving the oral health of Alaska Natives. Am J Public Health. 2005;95:769–773.
18. Roubideaux Y. Perspectives on American Indian Health. Am J Public Health. 2002;92:1401–1403.
19. Andersen SR, Belcourt GM, Langwell KM. Building healthy tribal nations in Montana and Wyoming through collaborative research and development. Am J Public Health. 2005; 95:784–789.
20. Schneider A. Reforming American Indian/Alaska Native health care financing: the role of Medicaid. Am J Public Health. 2005;95:766–768.
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