Is Health Care Entitlement a Solution to the Problem of Health Disparities for American Indians/Alaska Natives?

Transcription

1 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

2 Health Disparities Different meanings - general to specific Access to care might include Transportation Health insurance Health literacy Type and quality of health care received Many examples in the IOM report (Unequal Treatment) Discrimination or prejudice

3 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 system Few other data sources Special studies, SEER, etc. Two key annual IHS publications Regional Difference in Indian Health Trends in Indian Health

4 Health Disparities for AI/ANs Reflected in an array of mortality and morbidity statistics In , the causes for a number of ageadjusted death rates for AI/ANs far exceeded that for the US, all races 638% greater for alcoholism 400% greater for tuberculosis 291% greater for diabetes 215% greater for unintentional injuries, etc Source: Trend in Indian Health ( ). Page 7.

5 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

6 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 Source: I.H.S. Unpublished manuscript

7 Why Reference these Underlying Causes? To discuss health status or disparities requires a larger context including: History of white-indian relationship The trust relationship that many tribes have with the federal government Explains 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

8 AI/ANs Comprise a heterogeneous population 560 federally recognized tribes The number continues to increase Some have only state recognition and/or no recognition In the 2000 census there was a 26% increase in population 2.5 million identify as AI/AN 4.1 million identify 1 or more other race or ethnicity Demographic profile of the 2.5 million is similar to that of developing nations Less known about the new 4.1 million

9 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,

10 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,

11 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

12 The Federal Government Treaties specified the terms of the agreement Services of a physician or medical supplies Health services continued under annual appropriation The War Department, then Department of Interior Snyder 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?

13 Colonized Nations AI/ANs have long been crippled by poor health Dating 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 factor Forced removal and resettlement to unproductive lands (reservations, rancherias, villages) Health resources have never been adequate The 1955 Transfer Act

14 Access to Health Care Today Largely depends on where one resides Eligibility includes evidence of tribal enrollment Over half of the AI/AN population reside off the reservation Some are counted among the urban poor 36 urban Indian Health Programs 10 provide comprehensive outpatient services

15 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)

16 Health Status Today Considerable 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

17 Health Status Today The 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

18 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

19 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

20 Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Quality of Health Care Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems & the Legal and Regulatory Climate Discrimination: Biases & Prejudice, Stereotyping, & Uncertainty Disparity Populations with Equal Access to Health Care Source: IOM (2003): Unequal Treatment p.4.

21 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

22 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).

23 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).

24 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).

25 General Findings Inadequate funding was the most frequent barrier to eliminating health disparities Forced to ration health care Issues/debates over who is the payer of last resort Discrimination exists and has impact on quality of care but is rarely examined Discrimination is reported to happen more often in non-tribal or non-ihs facilities

26 Compacting/Contracting and Quality of Health Care Within the Indian Health system: Patients said they receive quality care Quality control more assured by tribal control Made more responsive to local needs Less waiting time and improved continuity of care Negative impact on quality of care Political instability New agenda and reallocation of health resources

27 What is Being Done to Address Health Disparities? Refer to the diabetes prevention model as one example Special 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

28 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* * IHS level of need at $15 billion, funded at $2.4 billion Source: FCLN, 2000

29 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 years Salt Lake City, August 1999 What is to be gained or lost under an entitlement program?

30 Some Positive Expectations Will take funding out of the annual political process Authority will serve in place of an annual request/justification Will not have to compete with other 13 appropriation bills Funded at the level of need Will define a benefit package

31 Some Anticipated Negative Outcomes May not be accepted by Congress Services will be heavily regulated Eligibility requirements will be regulated Income, blood quantum, geographic area

32 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

33 A Study is a Wise Move Will help tribes make an informed decision Will take into account multiple concerns so as not to erase gains made Self-determination Increased attention to health promotion/prevention Community based studies Investment tribes make in improving health care delivery system that is culturally appropriate

34 Will an Entitlement Program be the Answer? Can only predict Will most likely increase funds Will most likely help decrease the political process But: The cost to tribal sovereignty may not be acceptable May 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.