Native Americans face significant health care disparities—in some categories the worst in the nation, even compared with other minorities. They have higher rates of uninsurance, a shorter life expectancy, decreased access to care, and disproportionate rates of mental illness and substance abuse, and are more likely to die of chronic diseases than are other Americans. The Indian Health Service (IHS) provides care to many who would otherwise go without, but it receives less money per person per year than any other federally funded health care service.
Coinciding with National American Indian and Alaskan Native Heritage Month, the Harvard University Native American Health Program presented a symposium on Nov. 8 to address these issues and share stories of working in Indian country. Speakers from across the United States participated in five panels moderated by HMS faculty. One of the biggest hurdles is simply geography. Typically, American Indians live in the Western states, often in rural areas far from major medical centers and even from IHS facilities.
But natives in urban settings face their own access problems, argued Ralph Forquera, the executive director of the Seattle Indian Health Board and director of the Urban Indian Health Institute. Only one percent of the IHS budget goes to urban health care programs, and this population tends to be overlooked because the people are not concentrated on reservations.
“The biggest struggle we have as urban Indians is invisibility,” he said.
Staff shortages and high turnover make managing chronic conditions difficult. Darren Vincenti, clinical director at the Hopi Health Care Center in Arizona, said that in many IHS facilities, clinicians must devote half their time to acute care, reducing their availability for primary care appointments. Charles North, chief medical officer at the IHS, described a cycle in which patients cannot get appointments so they seek urgent care, which increases the pressure on emergency departments and takes funding and staff away from primary care, making appointments even harder to come by.
The picture painted at the symposium was not entirely bleak. Many of the participants noted that limited funding spurred creativity and innovation. “Lack of resources is the mother of invention,” said North.
Thomas Sequist, HMS assistant professor of medicine at Brigham and Women’s Hospital, noted that the IHS is a leader in the use of health technology. Theresa Cullen, IHS chief information officer, explained the importance of tailoring each electronic medical record to include data on more than just that patient. “The Indian Health Service recognizes that the delivery of health care does not occur in a vacuum,” she said. “It does not occur for individual patients independent of the context of their family, their community, and the population.”
Many participants cited the Chronic Care Model—a system that uses six different elements, including community resources, to promote interaction between an informed patient and a health care team—as a means to integrate the community, culture, behavioral health, and other non-traditional elements into disease management. Home visits and mobile clinics improve compliance and reduce the number of no-shows. Telemedicine is being used to improve the screening rates for certain conditions and train support staff.
Despite the lack of resources, the IHS is a free, functional health care system for the uninsured, a resource that other impoverished people in the United States do not have. Donald Berwick, HMS clinical professor of pediatrics at Children’s Hospital Boston and of health care policy at HMS and president of the Institute for Healthcare Improvement, said that the IHS shows promise for the American health care system as a whole.
“Most of American health care cannot accomplish what we just heard,” he said. “Here’s an under-resourced, deeply stressed, highly troubled system with an unjust distribution of wealth, and they are doing very well.”
