Improving health care for Native Americans

One of the most underserved populations in America with respect to health care is Native Americans. This community has a higher burden of illness, injury and premature death, and the health care needs of this population are seldom part of policy discussions because of its relatively small population (Katz, 2004). More are uninsured than most other groups as well, which creates problems with respect to access to care. Katz (2004) notes that almost half of low-income Native Americans are uninsured (prior to the ACA), and that over half of this group has incomes more than 200% below the poverty line, the impact of lack of access is widespread.

From a structure level, the US government has responsibility for providing health care to members of federally recognized tribes, and this is carried out by the Indian Health Service (IHS). The IHS is known to be chronically underfunded – in 2004 to the amount of $1.8 billion.Moreover, the Indian Health Service has limited reach (Katz, 2004). It only cares for around 1.5 million out of the 4.1 million people who are identified as Native American. The remainder are ineligible for care from the IHS because they are not members of federally recognized tribes. Many of the others are distant from IHS sites, as those sites are in areas with high concentrations of Native Americans, but those same services are unavailable outside of those areas. Katz (2004) notes that when the IHS was created, the majority of Native Americans lived on reservations but that today, a large percentage of the Native American population lives in urban areas.

With 60% of Native Americans living in urban areas, they are either ineligible for health care from IHS or do not have access to IHS facilities (ACOG, 2012). The outcomes for this community in urban areas tend to be poor – higher rates of teenaged pregnancy, late or no prenatal care, alcohol and tobacco use during pregnancy, higher infant mortality, higher SIDS and higher preterm birth. These outcomes are the result of a lack of access to care for urban Native American women (ACOG, 2012).
One of the issues facing underserved communities in general is that there are a lack of trained physicians for such communities. This means that majority ethnicity physicians ultimately end up playing an important role in care delivery, but also points to a potential solution for improving care to underserved populations (Komaromy et al, 1996). Training more Native Americans to become doctors is a pathway to providing better service to these communities, especially in rural areas (Marcinko, 2016).
Funding is another potential solution, at Katz (2004) notes. The IHS system is chronically underfunded, which creates tremendous pressure on the existing facilities, but also makes it more difficult for an extension of reach into urban areas with higher concentrations. Further, the quality of care invariably suffers as the result of this poor funding level. This is not a big number in terms of the federal budget, so it seems reasonable that steady increases in funding, coupled with a plan to invest that money in building better facilities, moving more into urban areas, perhaps with mobile clinics, will help to alleviate some of the crisis.

Access to insurance is also a barrier. Some tribes have decided to take control over their public health care delivery systems by contracting the functions of IHS, which has allowed some larger tribes to develop their own public health departments, becoming more mobile and able to meet the needs of their constituents more readily (Allison, Rivers & Fottler, 2007).

A final recommendation is to focus more attention on preventative services. There are high costs associated with services to cure illness and injury – taking steps to improve health outcomes earlier in life, and reduce the incidence of things like substance abuse, will go a long way to helping reduce costs later on. This calls back the ACOG's point about women's health; focusing on mothers is one way to improve outcomes for the children, especially where proper prenatal care and education about substance use is concerned. When mothers have proper access to health care, no matter whether in a rural or urban environment, that will lay the groundwork for a healthier community down the road.