HCBS Waiver Services for Alaska Natives: Policy Analysis

Needs Statement: Health Disparities Among Alaska Natives

According to Goins and Spencer (2005), the provision of services to specific populations—particularly those groups who face barriers to equity in healthcare—has always been an important focus of public health. The public health perspective outlines a societal approach to protecting and promoting health, which emphasizes prevention, macro-level interventions, and the reshaping of public policy. A primary difference between public health and the more biomedical model is that the government often subsidizes care providers in public health, with a focus on preventing, rather than curing, disease (Goins & Spencer, 2005).

Older American Indians and Alaska Natives (AI/ANS) life expectancy has increased dramatically since the early 1970s. This increase, from 63.5 years in 1972 to 73.2 years in 1994, is largely attributed to the efforts of the Indian Health Service (IHS) to eliminate infectious disease and meet the acute-care needs of AI/ANS (Goins & Spencer, 2005). Despite these improvements, much remains to be done to bring the healthcare standards of these peoples up to the national standard. In this regard, Padgett (1999) emphasizes that "problems with health and mental health that face older American Indians and Alaska Natives are widespread and likely to intensify if current trends continue. Several publications have detailed their excess morbidity and mortality in comparison with whites and other ethnic minorities" (p. 139).

The IHS reports that the Alaska Area Indian Health Service works in conjunction with Alaska Native Tribes and Tribal Organizations (T/TO) to provide comprehensive health services to 139,107 Alaska Natives (Eskimos, Aleuts, and Indians). Approximately 99% of the Alaska Area budget is managed by T/TOs pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended. The Alaska Area negotiates and administers 14 Title I contracts and one Title V compact with 25 separate tribal funding agreements. The latter has resulted in the Alaska Tribal Health Compact, which sets forth terms and conditions for tribal management of a comprehensive system of healthcare that covers all 228 federally recognized tribes in Alaska.

IHS-funded, tribally managed hospitals are located in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome, and Sitka. There are 37 tribal health centers, 166 tribal community health aide clinics, and five residential substance abuse treatment centers. The Alaska Native Medical Center in Anchorage is the statewide referral center and gatekeeper for specialty care. Other health promotion and disease prevention programs that are statewide in scope are operated by the Alaska Native Tribal Health Consortium (ANTHC), which is managed by representatives of all Alaska tribes.

There are 37 residual positions in the Alaska Area IHS that perform inherently federal functions which cannot be contracted to T/TOs. The Alaska Area supports USPHS Commissioned Corps officers and civil service employees assigned to T/TOs to aid them in the provision of health services. Additionally, to address the critical shortage of medical providers in remote facilities, the Alaska Area IHS awards federal personal services contracts for itinerant and emergency providers to work in tribal facilities. During FY 2010, providers hired through Area Office personal services contracts numbered 44 dentists, 27 physicians, 3 nurses, 20 pharmacists, 3 optometrists, and 4 nurse practitioners. Other federal agencies, such as the Arctic Investigations Laboratory of the Centers for Disease Control (CDC), work closely with the Alaska Area IHS and the tribes to improve the health status of Alaska Natives. The Indian Health Service still holds title to six tribally operated hospitals and three tribally operated health centers in Alaska and is responsible for their maintenance (Alaska Area Indian Health Service, 2011).

Although the life expectancy of AI/ANS has improved, it remains below the national average. Certain demographic characteristics make older AI/ANS particularly vulnerable to experiencing health disparities compared to the general population. Poverty and low educational levels are common among AI/ANS: 27% of AI/ANS ages 65 to 74 live below the poverty level, compared to 10% of the general population and 8% of Caucasians, and one-third of AI/AN elders age 75 or older live in poverty, compared to 17% for the general population and 15% for Caucasians. Some 8.9% of AI/ANS have a bachelor's degree or higher, compared to 20.3% of the general population and 21.5% of Caucasians. Taken together, poverty and low educational levels are strongly associated with poor health and an increased likelihood of chronic and disabling conditions (Goins & Spencer, 2005).

As they have for other ethnic groups, the most notable population health problems experienced by AI/ANS have shifted from infectious diseases to chronic diseases. Two of the most prevalent chronic diseases among older adults in this group are diabetes and arthritis. AI/AN elders experience some of the highest rates of diabetes in the world. In general, diabetes is four to eight times more common among AI/ANS than among the overall U.S. population. The prevalence of arthritis is also greater among AI/ANS than among non-AI/ANS, a difference most likely genetic in origin. Furthermore, the age of disease onset may be earlier. For example, half of one reservation population with rheumatoid arthritis was diagnosed before age 35, much earlier than is commonly found among non-AI/ANS. Mounting evidence suggests that such chronic and disabling diseases among AI/ANS are increasing and represent substantial healthcare costs (Goins & Spencer, 2005).

One of the strongest determinants of use of long-term care, either institutionalized or non-institutionalized, is health and functional status. Estimates suggest that AI/AN elders experience some of the highest physical disability rates of any U.S. ethnic group. While African Americans are more likely than Caucasians to experience the disadvantages of shorter life and longer periods of health impairment, for AI/ANS the levels of impairment and length of inactive life are the highest among all ethnic groups, with approximately 50% to 60% of later years spent with disabilities (Goins & Spencer, 2005). It is therefore not surprising that long-term care provision is especially important in Indian Country, given the socioeconomic disadvantages to which AI/ANS are subject and the growing rates of chronic disease and physical disability they experience. While one of the core functions of public health is to ensure that all populations have access to appropriate care, a number of issues present particular problems in the delivery of services—especially the provision of long-term care. Distinctive factors related to culture, AI/ANS political status, and related implications for health policy compound the problems of low socioeconomic status and poor health for AI/ANS (Goins & Spencer, 2005).

Federally recognized tribes have a unique political status that has influenced the provision of public health services. This status is based on the sovereignty of federally recognized tribal governments, the treaty-making process under which the U.S. assumed certain responsibilities to tribal governments, and the resulting federal-Indian relationship. A breakdown of the native peoples of Alaska is provided in the table below.

Table: Breakdown of Native Peoples of Alaska

Eskimos: More than half of all Alaska Natives are Eskimo. The two main Eskimo groups, Inupiat and Yupik, differ in their language and geography. The former live in the north and northwest parts of Alaska and speak Inupiaq; the latter live in southwest Alaska and speak Yupik. Few Eskimos can still speak their traditional Inupiaq or Yupik language as well as English. Along the northern coast of Alaska, Eskimos are hunters of the bowhead and beluga whales, walrus, and seal. In northwest Alaska, Eskimos live along the rivers that flow into the area of Kotzebue Sound, where they rely less on sea mammals and more on land animals and river fishing. Most southern Eskimos live along the rivers flowing into the Bering Sea and along the Bering Sea Coast from Norton Sound to the Bristol Bay region.

Aleuts: Most Aleuts originally lived in coastal villages from Kodiak to the farthest Aleutian Island of Attu. They spoke three distinct dialects, which were remotely related to the Eskimo language. When the Russians came to the Aleutian Islands in the 1740s, Aleuts inhabited almost every island in the chain. Now, only a few islands have permanent Aleut villages. Severe and unpredictable weather conditions in the Aleutian Islands make transportation both expensive and time-consuming. The region is dependent on the fishing industry, which is variable from year to year.

Interior Indians (Athabascans): The Athabascans inhabit a large area of Central and Southcentral Alaska. They may have been the first wave of Natives to cross the land bridge over 15,000 years ago. Although their language is distinct, they may be linguistically related to the Navajo and Apaches of the Southwest U.S. There are eight Athabascan groups in Alaska, and all eight share similar language, customs, and beliefs.

Source: Indian Health Service Alaska Area Services (2011)

The Indian Health Service is a federal agency in the U.S. Department of Health and Human Services that provides free healthcare to tribally enrolled AI/ANS—more than 1.6 million individuals—principally through the operation of sixty-one health centers and thirty-six hospitals (Goins & Spencer, 2005). It should be noted, however, that the provision of these healthcare services is constrained by the vast geographic distances involved in Alaska. The majority of communities in Alaska are separated by vast distances, and the distance from many communities to the nearest medical facility is equivalent to the distance from New York to Chicago (Indian Health Service Alaska Area Services, 2011).

A study funded by the Administration on Aging (AOA) examined issues affecting access to home- and community-based long-term care services among AI/ANS. Study results indicated that home healthcare was one of the most frequently needed services among AI/ANS. Further, 88% of services sometimes, rarely, or never met the need, and 36% of services were rarely to never available (Jervis, Jackson & Manson, 2002). Only twelve tribally operated nursing homes exist in the U.S., and these rely predominantly on funding from Medicaid and tribal subsidies. Many tribes would like to have nursing homes but are blocked by state certificate-of-need requirements, Medicaid licensing requirements, and lack of commercial financing. The lack of alternate medical resources, whether private insurance or public programs, may limit AI/ANS access to specialty medical care and long-term care not included as part of IHS benefits. This situation makes older AI/ANS particularly likely to experience disruption in continuity of care. Tribes have started to express a growing interest in providing options for home- and community-based long-term care to keep elders in their homes as long as possible. Some important services funded through Title VI of the Older Americans Act include congregate and home-delivered meals, information and referral, home assistance services, and the Family Caregiver Support program (Goins & Spencer, 2005).

Goals and Objectives of the HCBWS Program

There are three main goals for this policy initiative:

1. The main goal is to increase accessibility for individuals who will need these services. This will help reduce institutionalization of this group and enable them to remain in their own homes.

2. Create an environment where individuals who receive services will have their rights protected and will not have services denied unjustifiably.

3. The quality of these services should be maintained or increased when possible.

In support of the three overarching goals stated above, the policy initiative will also be guided by the following objectives:

1. Educate the community to increase participation in this program. Most eligible people do not even know that programs like these exist.

2. Work with area hospitals to ensure that individuals being discharged are recommended for waiver services, which will enable them to return to their own homes or communities.

3. The State of Alaska will ensure that enhanced services are available to qualified individuals in the most effective manner.

4. Ensure that the state has an efficient appeals system for those who do not qualify.

5. Address the shortage of staff at the state level to ensure that people needing HCBWS are located and assessed quickly.

Overall Policy Strategy

The unique political relationship between the federal government and AI/AN tribes adds another layer that must be considered in determining how to best serve this population (Goins & Spencer, 2005). The overall policy strategy that will be used to achieve the above-stated goals and objectives is as follows:

1. Since there could be a waiting period for recipients to get screened for HCBWS, early application should be encouraged.

2. Grants should be readily available as a stopgap measure for those on waiting lists.

3. As noted above, Alaskan communities are far-flung and geographically remote. Agencies located in remote areas should meet the same certification requirements as those in larger cities. With no one to care for their elderly family members, the cost to society in hospital care begins to strain the system. One viable approach will therefore be to have HCBWS services in place to help reduce costs in the long run.

References

Alaska Area Indian Health Service. (2011). Indian Health Service. Retrieved from

Goins, R.T. & Spencer, S.M. (2005). Public health issues among older American Indians and Alaska Natives. Generations, 29(2), 30–33.

Indian Health Service Alaska Area Services. (2011). Indian Health Service. Retrieved from

Jervis, L.L., Jackson, Y. & Manson, S.M. (2002). Need for, availability of, and barriers to the provision of long-term care for older American Indians. Journal of Cross-Cultural Gerontology, 17, 295–311.

Padgett, D.K. (1999). Handbook on ethnicity, aging and mental health. Westport, CT: Greenwood Press.