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

15. 71% high school graduates (80% U.S.) & 12% college graduates (24% U.S.)

16. 26% of AI/ANs fall below poverty standard

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