Is Health Care Entitlement a Solution to the Problem of Health Disparities for American Indians/Alaska Natives? Jennie R. Joe, PhD, MPH Professor, Family.

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Source: I.H.S. Unpublished manuscript. 2000.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

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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.