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The Indian Health Service Is Insufficient. It’s Time for Medicare for All.

Native people are among those who have the most to gain from a transition to a universal health care system.

Members of National Nurses United union members wave "Medicare for All" signs during a rally in front of the Pharmaceutical Research and Manufacturers of America in Washington on April 29, 2019.

Native Americans and Indigenous people in Alaska live 5.5 years less on average than other racial groups — and 20 years shorter than the national average in some states. It’s no wonder that health care access is a top concern for Native Americans.

The Indian Health Service (IHS) historically has played a critical role for Native American patients to obtain health care. The federal government funds and provides treatment for people who can prove they are members of a Native American tribe. Most IHS centers are located in remote areas and serve reservation populations. For those living near an IHS provider, care is limited. The program is chronically underfunded.

However, many Native Americans don’t live near a reservation today. Like many low-income patients, they struggle to access affordable health care. This lack of access to quality health care results in complex avoidable medical conditions, shorter life spans and medical debt.

As medical bills grow and government and private health plans remain inadequate, Native people have among the most to gain from the prospect of the U.S. transitioning to a Medicare for All universal health care system.

Lack of health care access for Native people is, of course, not new. Ever since European settlers stripped Native people of their land, pillaged their resources and brought infections to their elderly and children, their health has been endangered by the powers that be. There are many reasons for Native Americans’ shorter lifespans. Poverty contributes significantly to death and disease. Native people disproportionately live below the federal poverty line and suffer from food insecurity and chronic disease.

Dr. Annie Belcourt (Otter Woman), an associate professor at the University of Montana’s Pharmacy Practice and School of Public and Community Health Sciences Department and former resident of the BlackFeet reservation, told Truthout, “A vicious combination of factors explains health disparities punishing people that grew up on reservations like I did. We have similar challenges of rural low-income patients, but it goes further. The trauma of genocide and family separation still impact us and the people I study. We have the IHS, but its resources are never enough. Plus, a majority of American Indian patients moved off their land to cities and struggle to get health care like other vulnerable and uninsured populations.”

There are many reasons why Native people suffer from poor health outcomes. Poor access is a critical factor. Native Americans and Alaska Natives are more likely to report having diabetes, cardiovascular disease and frequent stress. The suicide rate for Native American and Alaska Native adolescents and young adults is two and half times higher than the national average. This drives researchers and community members like Dr. Belcourt.

“Mental health challenges accompanying the onset of chronic disease go hand in hand,” Dr. Belcourt explained. “These chronic conditions compound themselves and often go untreated, crushing one’s ability to get on their feet and lead independent lives, launching a spiral of poverty and despair.”

Jeff Axtell, the Chief Executive Officer of Native Americans for Community Action — an Urban Indian Health Institute clinic in Flagstaff, Arizona — cited that health access and lack of insurance are the most significant barriers for patients to obtain necessary treatment.

“The patients we see are prone to late stage cancer, Type 2 Diabetes and mental illness,” Axtell said. “It’s no coincidence that this is because of poor health access. Most of our patients are uninsured. Some can get Medicaid but many are either not enrolled or have too many assets in one form or another. It’s hard to witness our patients experience psychological distress and deter the care they need to live.”

To note, Arizona has expanded eligibility for Medicaid, a state-federal safety-net insurance program, for working low-income patients – a move which the Affordable Care Act encourages. Challenges remain.

Nationwide, half of uninsured adult Native Americans and Alaska Natives live in states that did not expand eligibility to Medicaid. The Affordable Care Act has been of some assistance, but Medicaid and affordable Obamacare health plans remain elusive. Most Native people don’t obtain health care on the job, and it’s not easy to access public insurance — or even get appointments at IHS medical centers.

Axtell told me that health insurance enrollment is challenging. “Every day we try to get navigators and our staff to enroll uninsured patients to get covered. However, opting in, like most things, is a barrier that many people don’t look to cross.” He continued, “Of course many uninsured patients seek care in the emergency room, the most expensive form of treatment that makes everyone pay up more in the end in the form of higher premiums, copays and deductibles.”

One in three Native Americans remains uninsured and experiences financial stress due to medical bills.

Leonard Smith, the Executive Director of the Native American Development Corporation (NADC) and member of the Assiniboine Sioux Tribe, said his organization’s patients often complain of skyrocketing medical bills in the Montana, Wyoming, and South Dakota regions. Smith oversees a Native American health clinic that has patients from over 72 tribes. He also runs a community development-oriented financial institution focusing on lifting Native people out of poverty.

“The specter of medical debt hovers over the patients we see,” Smith said. “Many only get care as a last resort, not getting the check-ups and preventative care they need to detect serious illnesses. Along the way lives are cut short, driving families into debt and poor credit. Nonprofits and community groups we serve find client exposure to medical bills as a real source of pain.”

Smith is no stranger to IHS care. Despite improvements and funding increases, IHS is not meeting the needs of its patients. It receives a set amount to care for its 2.56 million patients. Services are often limited. Treatment is inconvenient. Centers are not close.

IHS spending per patient is inadequate and begs for more federal resources. In 2013, Indian Health Service spending for patient health services was $2,849 a person compared to $7,717 for health care spending per patient nationally, according to the National Congress of American Indians.

Tommy Rock, a Monument Valley Utah-based researcher and member of the Navajo Nation, lives on the reservation where he grew up and studies the intersection of the environment, poverty and health. He told Truthout, “Life on the reservation is hard. Patients often struggle to get the care they need. With issues related to poverty and exposure to air pollution and dirty water, patients need access to better treatment and services. IHS may guarantee health care but it’s not playing out in reality.” Rock echoed Belcourt, Axtell and Smith on how care at IHS is often helpful – if you can get it. Funding shortfalls, quality staff retention and recruitment continue to burden IHS facilities.

The dangerous dearth of health access for Native people means we must implement a new agenda. Medicare for All can play a critical role in preserving IHS and truly expanding health coverage for all Indigenous people in the U.S.

Medicare for All would preserve the IHS. Patients can stick with the national health plan or continue to use the IHS to get care. Under Medicare for All, enrollment is automatic upon birth; and there would be no more out-of-pocket commitments that deter people from getting screened, delaying detection of infections and life-threatening diseases.

Medicare for All remains the optimal universal health plan that expands coverage for all, and reduces overall health care expenditures. Many of these savings can be redirected to other social welfare priorities, like stabilizing the IHS and boosting programs to get more rural health care workers to places that need them.

The United States remains the only industrialized nation that permits its people to lose their home, job and the shirt off their back in the event they are born with a disability, break a limb or contract late-stage cancer.

To boost public health, America must further invest in its people — including the Indigenous residents of this nation.

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