Going Native: Healthcare Access and Disparities in American Indian Populations

In recent history, terms like holocaust, oppression and apartheid have been reserved in popular media for African-Americans, Jews, women, the LGBT community and other marginalized populations. Their struggles, of course, are very real. However, there are groups in the United States that do not have the privilege of being brought to the forefront of public attention. American Indians and Alaska Natives experience some of the highest rates of child abuse, suicide, homicide, accidental deaths, domestic violence and alcoholism in the country. The difference between them and other minorities, though, is that their plight often goes undiscussed and quite frankly, is swept under the rug.

We live in the age of Trump: our future is uncertain with respect to foreign policy, the stock market (à la Bitcoin), and most of all, healthcare (I’ll explain later on why my Trump reference is relevant). Among public health practitioners, it is widely accepted that the health of a population correlates with the social order: environment is key. American Indian and Alaska Native populations experience some of the highest rates of mortality due to obesity, cancer, respiratory disease and alcoholism, to name a few. Take, for instance, obesity. Obesity rates in Native American children and adults exceed those of all other races in the United states combined. Though this group is not homogeneous by any means (in fact, Pima Indians comprise most of the obese Native American population), the disparity is staggering. Obesity, across all races, is a contributing factor to long-term health issues.

In socially-privileged communities, which happen to be predominantly white, there is greater access to education and resources. Why does this matter? Undoubtedly, there is a positive correlation between education & community conditions, and access to decent healthcare systems. A study in Washington showed that there is limited access to healthy food on reservations; there are almost no supermarkets, and foods abundant with sugar prevail on shelves of convenience stores in these regions. Natives living on the reservation are not ‘powerful purchasers’ in a consumer sense. Energy-dense foods are less expensive on a per-calorie basis; the financially-constrained consumer tends to purchase these items in order to maximize their spending power.

Obesity and type 2 diabetes are not just ‘problems’ in the American Indian and Alaska Native communities — these are epidemics. Natives who reside on the reservation, essentially, are living in food deserts. The same Washington study showed that the nearest on-reservation supermarket from tribal headquarters was on average 5.3 miles away, while the average distance to an off-reservation supermarket (for those without a supermarket on the reservation) was 11.1 miles. Many individuals living on the reservation lack reliable transportation; instead of making the trek to a supermarket where there are healthier food items available, Natives living on the reservation often choose to shop at local stores with less nutritious options.

Let’s bring this back to healthcare, though. This post is not intended to serve as a diatribe on white privilege, marginalization of Natives, or the general trainwreck of a healthcare system that we have in the United States. Many of these facts are well-known (if you are hearing these messages for the first time, you may want to crawl out from the rock you’ve been hiding under). The point of this article is to highlight access to care. Previously, I wrote a post regarding how the current healthcare system in the United States actually facilitates the racial divide. It should be no surprise that racism is institutional. We have taken tremendous strides as a nation to repair the relationship between once-divided and segregated groups of people. However, it is clear that remnants of institutional racism still exist. Healthcare access happens to be a bastion for these aforementioned remnants.

When it comes to access to care, disparities among the races is not unique to the United States. The United Nations published a pamphlet called, “The State of the World’s Indigenous Peoples.” According to the U.N., indigenous people suffer from high rates of poor health and live shorter lives than their non-indigenous counterparts. Contrary to the viewpoint of Trump’s base of supporters, indigenous populations do not choose to live in conditions that adversely affect the health of themselves and their families. Health status is affected by living conditions, income levels, employment rates, sanitation, access to clean water, and food availability. Interestingly, the notion of a food desert and barriers to accessing healthcare are widespread; across the world, there is a theme of boxing out natives and making it increasingly difficult for them to lead healthier lifestyles.

American Indians and Alaska Natives do not have the same access to healthcare throughout the United States. Black and Hispanic populations face the same challenges, however there is a fundamental difference between the two discussions. Policy seems to address the issues of Black and Hispanic communities; policy ignores the needs of American Indians and Alaska Natives. There are a few reasons that this occurs: 1) There is a common misconception that the Indian Health Service is adequate and addresses the health needs of Native communities; 2) Public health practitioners do not collect enough data to support new policy implementation that support the fact that American Indians and Alaska Natives lack access to care; and 3) people simply do not recognize that different minority populations have different needs.

Almost half — yes, half — of the low-income American Indian/Alaska Native community is uninsured. This statistic is even more staggering when you consider the prevalence of poverty across the Native populations: 55% of all American Indians and Alaska Natives have incomes below 200% of the federal poverty level. Only 25% of Whites in the United States live under these conditions. The perceptions is this: American Indians and Alaska Natives are under the care of the IHS, so they do not face the same challenges that other impoverished communities face with respect to access to care. This could not be further from the truth. By mandate, the U.S. government must provide care to members of federally recognized tribes. The government has fulfilled this through services provided by the IHS. In 2003, the IHS received $2.5 billion in federal appropriations for its services. Unfortunately, this was about $1.8 billion short of what it would need to adequately deliver care. Here’s another important note about the IHS that highlights that this system is just not as effective as many may think: the majority of American Indians and Alaska Natives live in cities. When the IHS was established in the 1950s, most American Indians and Alaska Natives were living on reservations. IHS hubs remain on reservations today; I don’t think I need to hit you over the head and highlight that this is a fundamental disconnect.

So, Donald Trump (did you think I forgot?) If Trump’s bill had been passed, the following ten changes would have been made:

1) Reduction of Medicaid federal payments for Medicaid expansion beginning in 2021. The end of expansion by 2023.

2) Discontinuation of Medicaid spending starting in 2024.

3) Reduction of Obamacare tax credits.

4) Removal of the ACA mandate to provide 10 essential health benefits.

5) Premium increases for senior citizens.

6) Stripping of federal funds for Planned Parenthood.

7) Elimination of the tax for those who don’t buy insurance.

8) Removal of tax on companies that don’t provide health insurance.

9) Expansion of HSAs to everyone.

10) Three million adults up to 26 years old would have stayed on their parents’ insurance plans.

Now, these changes don’t all seem that bad. However, let’s bring this all back to what really matters to the American people and the United States government: cost. Your costs would have increased if you fit one of these molds:

1) You have a chronic illness.

2) You are older.

3) You become pregnant.

4) You need an abortion.

5) Your company only provided coverage because the ACA forced them to.

6) You are one of the 22 million people who received subsidies or the Medicaid expansion.

7) You use mental and behavioral health services, including drug rehabilitation.

8) You decide to reapply for health insurance, after a lapse of 61 days.

Okay, say you didn’t check any of these boxes. Trumpcare would be great, right? Not exactly. Under the skinny bill, healthcare costs would have risen at a faster rate than under Obamacare. The Congressional Joint Committee on Taxation estimated that tax cuts from Trumpcare would add $460 billion to the debt over 10 years. That’s right, $460 billion.

But, I digress. This article has nothing to do with cost. This articles, does, however, have everything to do with a population that may suffer from long-term consequences of Obamacare “reform.” See, numbers get people’s attention. The sob stories don’t always garner as much recognition. Trump’s healthcare plan would have left over 23 million more individuals uninsured. Not to mention, this same plan would cut $53 million from the overall IHS budget, when there is already a massive deficit. Obamacare might not be perfect, but Trumpcare would have devastated a community that already lacks a voice when it comes to healthcare policy making. I’d urge the Trump administration to focus on the impact of its decisions on communities that don’t have the same voting power as Mr. President’s base of supporters.

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