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Health Care Systems for American Indians

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  • Important Dates:Indian Health Office in Department of War- Indian health/infections seen as a threat to the future of an expanding nation.1934 American Indians granted citizenship1987 IHS moved to the Department of Health and Human Services
  • Snyder Act- authorized funds “for the relief of distress and conservation of health…[and] for the employment of…physicians..for Indian tribes throughout the United State.” (1921)Transfer Act (1955)placed Indian health programs in the Public Health System. (1955)Indian Sanitation Facilities Act- give the SFC (abbreviation?) program authority for providing essential water supply, sewage, and solid waste disposal facilities for American Indian and Alaska Native homes and communities.
  • Indian Health Services provides a comprehensive health service delivery system for approximately 1.8 million of the 3.3 million American Indian and Alaska natives
  • This slide provides a geographic distribution of the IHS service locations in 2005.
  • Expenditures in the general U.S are 2.5 times greater and the IHS appropriationsThis could contribute to the gap in health disparities
  • The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans.  Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences.  These are broad quality of life issues rooted in economic adversity and poor social conditions. Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the five leading causes of American Indian and Alaska Native deaths (2004-2006). American Indians and Alaska Natives born today have a life expectancy that is 5.2 years less than the U.S. all races population (72.6 years to 77.8 years, respectively; 2003-2005 rates American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). (Rates adjusted for misreporting of Indian race on state death certificates; 2004-2006 rates.) Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling.  In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system.
  • The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans.  Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences.  These are broad quality of life issues rooted in economic adversity and poor social conditions. Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling.  In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system.
  • Mention that disease burden shifting to chronic disease which require long-term care—large shift on needed health care resources
  • Native Americans have a very holistic approach to life and approach mental health in the same way.Can be in contradiction with Western medicine, which tends to compartmentalize the parts of a person in order to provide treatment.Within the IHS system, there is a shortage of mental health professionals to address the increasing needs in tribal communities.
  • American Indians and Alaska Natives (AI/AN) are ranked third in the nation in rate of new infections (incidence) of human immunodeficiency virus (HIV) compared with all other races and ethnicities. Health disparities and disproportionate co-risk factors (including sexually transmitted infections, substance use, and stigma) among AI/ANs contribute both directly and indirectly to the risk of HIV transmission. HIV/AIDS is communicable, affects a younger population, and has no cure or vaccine.
  • There are 565 tribes in the U.S. with their own distinct language, cultural and traditions. This can make it difficult to develop a universal method or approach for health care delivery.Tribal communities are also geographically diverse ranging from urban to rural and frontier or very isolated.

Transcript

  • 1. Health Care Systems for American Indians/Alaska Natives in the United States
    Rochelle Lacapa, MPH
    Johns Hopkins Center for American Indian Health
  • 2. Presentation Overview
    History- Federal Trust Agreement
    Historical Context of American Indian/Alaska Native Health Disparities
    The Indian Health Care System
    Health Disparities of American Indians and Alaska Natives
    Emerging Health Issues
    Challenges in Service Delivery
    Partnerships to Improve Service Delivery- Johns Hopkins Center for American Indian Health
  • 3. Our History
    3
  • 4. Social Influences: Wars, Conquest, Health and Governance
    1779: First U.S. Congress established Indian Health office in Dept. of War
    1890: Indian Wars – 471 treaties signed through 1890
    1849: Indian Health Office Moved to Department of Interior
    1890: End of Indian Wars
    World War I
    1928: Meriam Report
    1934: American Indians Granted Citizenship
    WW II - 1940’s
    1945-46: Nuremberg Trials
    1955: Transfer Act
    1987: IHS is a DHHS Agency
  • 5. Basis for Federal Health Benefits to American Indians
    Treaties exchanged indigenous lands for federal trust responsibilities and benefits.
    Snyder Act (P.L. 67-85): first legislation authorizing funds to manage health issues
    Transfer Act (1955): Shifted the IHS from the War Department to the Department of Health and Human Services
    Indian Sanitation Facilities Act (P.L. 86-121): provided water, sewage and solid waste services.
    Indian Self-Determination and Education Assistance Act (P.L. 93-638, as amended): Allows tribes to administer health services provides tribes (1975)
    Indian Health Care Improvement Act (P.L. 94-437): Expands of the self-determination act and includes planning and management of health services (1976) (2008)
  • 6. Our Present
  • 7. The Indian Health Services (IHS)
    MISSION: …to raise the physical and mental, social and spiritual health of American Indians and Alaska Natives to the highest possible level.
    GOAL: …to assure that comprehensive, culturally personal and public health services are available and accessible to American Indian and Alaska Native people.
    Dr. Yvette Roubideaux, Director
  • 8. The Indian Health Care System
    Indian Health Service (IHS) Direct Health Care Services
    12 Area Offices
    163 Tribally Managed Service Units
    Service Units Represent: 33 hospitals, 53 health centers, 38 health stations
    Tribally Managed Health Care Services
    78 Self-Determination Contracts
    232 Self-Governance Compacts
    Contracts and Compacts Represent: 15 hospitals, 221 health centers, 97 health stations, 176 Alaska village clinics
    Urban Indian Health Care Services and Resource Centers
    34 Urban Programs
    600,000 American Indians/Alaska Natives served by urban programs
  • 9. IHS Service Population and Annual Patient Services
    IHS Service Population
    565 federally recognized tribes in the United States- mostly in the Western United States
    2 million American Indian and Alaska Natives residing on or near reservations
    Annual Patient Services
    Inpatient Admission: 50,349
    Outpatient Visits: 11,778,527
    Dental Services: 3,568,201
  • 10. IHS User Population by Area (2005)
    10
    Alaska
    128,095
    TOTAL IHS USER POPULATION
    FOR 2005: 1,438,196
    Portland
    99,139
    Billings
    70,473
    Bemidji
    96,222
    Aberdeen
    118,114
    Phoenix
    147,299
    IHS Headquarters
    Rockville, MD
    California
    73,648
    Navajo
    238,515
    Oklahoma
    306,727
    Albuquerque
    86,674
    Tucson
    24,412
    Nashville
    48,878
  • 11. IHS Appropriations and Third Party Collections
    Appropriations
    FY 2010: IHS Federal Budget Appropriation $4.05 billion
    FY 2009: IHS Federal Budget Appropriation $3.58 billion
    Third-Party Collection (Private Insurance)
    FY 2010 $702 million
    FY 2011 (estimated) $829 million
  • 12. 2010 IHS Funding Distribution
  • 13. IHS Per Capita Health Care Expenditures and Human Resources
    Per Capita Personal Health Care Expenditures
    IHS Service Population: $2,741
    Total U.S. Population: $6,909
    Human Resources
    Total IHS Employees: 16,159
    70% are American Indian/ Alaska Native
    900 Physicians
    2,700 Nurses
    35 Physician Assistants/Nurse Practitioners
    300 Dentists
    650 Pharmacists
    605 Engineers/Sanitarians
  • 14. Indian Health Service Population
    14
    1.4m
    AI/ANs
    Unserved
    1.8m
    AI/ANs
    Served
    3.3m AI/ANs
    IHS Service Population Growth
    • Population growth rate of 1.6% per year
    • 15. 71% high school graduates (80% U.S.) & 12% college graduates (24% U.S.)
    • 16. 26% of AI/ANs fall below poverty standard
    • 17. Unemployment is 3.0 times the US rate
  • Top 10 Mortality Disparities Among American Indians and Alaska Natives
    IHS Service Area2004-2006 and U.S. All Races 2005(Age-adjusted mortality rates per 100,000 population)
  • 18. Health Disparities Cont.
    Leading Causes of Death
    Heart Disease
    Malignant Neoplasm
    Unintentional Injuries
    Mortality Rates Relative to the General U.S. Population
    Tuberculosis (500% higher)
    Alcoholism (514% higher)
    Diabetes (177% higher)
    Average Life Expectancy: 72.6 years (5.2 years less than the average)
    Confounding Factors:
    Inadequate education
    High poverty
    Discrimination in health care delivery
    Cultural differences
    Inadequacy of funding for health care systems
  • 19. Changes in Morbidity and Mortality Over the PastThree Decades
    Shift from Infectious to Chronic Illness
    Diabetes
    Liver Disease
    Cancers
    Mental Health and Behavioral Health Disorders
    Emerging Health Issues
    Obesity
    Suicide
    HIV and STIs
  • 20. 1956 IHS Hospital in Shiprock, New Mexico
    Inadequate space for all sick children so dresser drawers were utilized as beds.
    18
  • 21. Changes in Mortality Among American Indians and Alaska Natives
    Top 10 Diseases Over Two Time Periods
    Rates are per 100,000
  • 22. Emerging Health Issues and Potential Impacts on Service Delivery
    Obesity
    Suicide
    HIV/Sexually Transmitted Infections
  • 23. Emerging Health Issue: Obesity
    Historically, obesity was not a concern among Native Americans.
    21
  • 24. Emerging Health Issue: Suicide
    22
    THE WHOLE BEING
    Inter-active circles represent a metaphor for the thought-life process
  • 25. Suicide Rates by Ethnicity and Age
  • 26. Emerging Health Issue: HIV/Sexually TransmittedInfections
    Number of HIV & AIDS Diagnoses Among AI/AN, 1993-2001
  • 27. HIV/Sexually Transmitted Infections Cont.
    Rates
    Through 2008, approximately 3500 cases of HIV/AIDS with a rate of 12.8 per 100,000
    HIV screening rates have more than tripled
    Incidence rate is 14.7 per 100,0009
    Risk Factors
    Disproportionate rates of STI
    Second highest rates of gonorrhea, Chlamydia and syphilis combined in the nation
    Alcohol and Substance Abuse
    Depression
    Domestic Violence
    Low Socioeconomic Status
    Young Population (relative to other groups)
    Social and Cultural Norms
    Implications for Health Care Delivery
    Short timeline from diagnosis to death- emphasis on early diagnosis, treatment and surveillance
    AI/AN half as likely to use contraceptives as non-Native peers- emphasis on “safe sex” practices
  • 28. Challenges In Service Delivery
    Diversity Among Tribes and Cultural Appropriateness
    Continuity of Care
    Access to Care
    Funding for Prevention Programming
  • 29. Diversity and Cultural Appropriateness
    Diverse Tribes, Cultures, Languages, Lifestyles, and Locations
  • 30. Continuity of Care
    IHS facilities experience high turn-over rates in medical staff
    Slow shift towards a primary care physician model
    Relationship building is essential to promote medical compliance
    Physician/patient interaction time limits this
  • 31. Access to Care
    Vast geography to cover
    Travel time and expense may be too large for patients to receive care
    Shortage of specialized services providers
    Mental Health Professionals
    Surgeons
  • 32. Funding for Prevention Programming
    Appropriations focus primarily on direct care
    No distinct line-item for prevention
    Prevention efforts can take a long period of time until results are seen
  • 33. Collaborations to Meet Health Care Needs:The Johns Hopkins Center For American Indian Health (CAIH)
    MISSION
    To work in partnership with the American Indian and Alaska Native communities to raise health status, self-sufficiency and health leadership to the highest possible level.
    VISION
    To support American Indian and Alaska Native communities in achieving:
    1. optimum physical, mental and social well-being,
    2. autonomy over community-based research and health services, and
    3. worldwide leadership to overcome health inequalities.
    VALUES
    A commitment to integrity, professional excellence, compassion, and mutual respect for individuals, cultures and nations.
  • 34. CAIH Role in the Health System
    Formal Memorandum of Understanding (1991)
    Assist to fill prevention gaps
    Conduct research to provide information on health disparities
    Address emerging health issues
    Help fill the training gap for American Indian health professionals
    Operates 7 field sites in
  • 35. CAIH Milestones in American Indian Health
    33
  • 36. CAIH Milestones Cont.
    Prevention of Infant Deaths from Diarrhea: Introduction of Oral Rehydration Therapy (ORT) among White Mountain Apache and Navajo
    Eradication of Hib Disease and Bacterial Meningitis: Clinical trial proving efficacy of vaccine to eliminate HaemophilusInfluenzae type b (Hib)
    Wiping Out Pneumococcal Disease: A large-scale vaccine trial marking the advent of efficacious vaccine to prevent pneumonia, meningitis and middle ear infections.
    Promoting Youth Development: Native Vision promotes healthy lifestyles, fitness, education, leadership and community service
    Family Spirit- Child Care Education and Outreach for Teen Parents: Home-based outreach program for vulnerable families to promote a lifetime of health.
    Training American Indian Health Professionals and Scholars: Graduate training for American Indian/Alaska Native health professionals at Johns Hopkins.
    Stopping Youth Suicide: Utilizing a para-professional model to screen and refer suicidal youth for crisis care and the development of and innovative community-based intervention
    Preventing RSV Disease: Clinical trial to show the effectiveness of an antibody to reduce RSV hospitalizations among Navajo and Apache babies.
    34
  • 37. Keys to High Quality Health Care for American Indians and Alaska Natives
    Culturally appropriate health care delivery
    Partnerships and Collaborations with services providers and tribes
    Inclusion of American Indian and Alaska Native tribes in the development and implementation of services
    Utilization of diverse resources to fund prevention efforts
    Continued development of indigenous health care professionals
  • 38. Our Future
    36
  • 39. Acknowledgements
    The Johns Hopkins Center for American Indian Health
    Dr. Phil Smith, Native American Research Centers for Health
    The Indian Health Services
    The Centers for Disease Control