Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act

Medicolegal death investigations on tribal lands-underrepresented or underserved?

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands.

How Funding Policy Maintains Structural Inequity Within Indigenous Community-Based Organizations

Despite efforts to increase investment in Indigenous health and well-being in the United States, disparities remain. The way in which health-promoting organizations are funded is one key mechanism driving the systemic, long-term health disparities experienced by Indigenous people in the US. Using Indigenous-led community-based organizations (ICBOs) that provide psychosocial care as a case study, we highlight multiple ways in which policies that regulate the external funding that ICBOs depend on must change to promote equity and allow the organizations to flourish and address unmet psychosocial needs for Indigenous community members. We use a system dynamics approach to discuss how "capability traps" arise from a misfit between external funding regulations and organizations' needs for sustainability and effective care provision. We provide suggestions for reforming funding policies that focus on improving ICBO sustainability.

Medicaid expansions and differences in guideline-adherent cervical cancer screening between American Indian and White women

BACKGROUND

Although preventable through screening, cervical cancer incidence and mortality are higher among American Indian and Alaska Native women (AIAN) than White women. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansions may uniquely impact access and use of cervical cancer screening among AIAN women and ultimately alleviate this disparity.

METHODS

Using Medicaid eligible AIAN (N = 4681) and White (N = 57,661) women aged 18-64 years from the 2010-2020 Behavioral Risk Factor Surveillance System, we implemented difference-in-differences regression to estimate the association between the Medicaid expansions and guideline-adherent cervical cancer screening and health care coverage.

RESULTS

The Medicaid expansions were not associated with guideline-adherent cervical cancer screening (AIAN: -1 percentage point [ppt] [95% confidence interval, CI: -4, 2 ppts]; White: 3 ppts [95% CI: -0, 6 ppts]), but were associated with a 2 ppt increase (95% CI: 0, 4 ppt) in having had a pap test in the last 5 years among White women. The Medicaid expansions were also associated with increases in having a health plan (AIAN: 5 ppts [95% CI: 1, 9]; White: 11 ppts [95% CI: 7, 15]) and decreases in avoiding medical care due to costs (AIAN: -8 ppts [95% CI: -13, -2]; White: -6 ppts [95% CI: -9, -4]).

CONCLUSIONS

While we observed improvements in health care coverage, we did not observe changes to guideline-adherent cervical cancer screening following the ACA's Medicaid expansions. Given the disproportionate burden of cervical cancer among AIAN women, identifying ways to improve cervical cancer screening uptake and delivery should be prioritized to reduce preventable deaths.

The maternal health of American Indian and Alaska Native people: A scoping review

Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.

Experiences of Health Insurance among American Indian Elders and Their Health Care Providers

CONTEXT

American Indian elders have a lower life expectancy than other aging populations in the United States because of inequities in health and in access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. Although the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers.

METHODS

From June 2016 to March 2017, we conducted qualitative interviews with 96 American Indian elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two southwestern states. Interviews focused on elders' experiences with health care and health insurance. We analyzed transcripts iteratively using open and focused coding techniques.

FINDINGS

Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian elders and communities.

CONCLUSIONS

Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian elders. Policy makers must not neglect their responsibility to directly fund health care for American Indians.

Assessing County-Level Vulnerability for Opioid Overdose and Rapid Spread of Human Immunodeficiency Virus and Hepatitis C Infection in South Dakota

BACKGROUND

Key indicators of vulnerability for the syndemic of opioid overdose, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) due to injection drug use (IDU) in rural reservation and frontier counties are unknown. We examined county-level vulnerability for this syndemic in South Dakota.

METHODS

Informed by prior methodology from the Centers for Disease Control and Prevention, we used acute and chronic HCV infections among persons aged ≤40 years as a proxy measure of IDU. Twenty-nine county-level indicators potentially associated with HCV infection rates were identified. Using these indicators, we examined relationships through bivariate and multivariate analysis and calculated a composite index score to identify the most vulnerable counties (top 20%) to this syndemic.

RESULTS

Of the most vulnerable counties, 69% are reservation counties and 62% are rural. The county-level HCV infection rate is 4 times higher in minority counties than nonminority counties, and almost all significant indicators of opioid-related vulnerability in our analysis are structural and potentially modifiable through public health interventions and policies.

CONCLUSIONS

Our assessment gives context to the magnitude of this syndemic in rural reservation and frontier counties and should inform the strategic allocation of prevention and intervention services.

Producing insecurity: Healthcare access, health insurance, and wellbeing among American Indian elders

Although health care is a treaty-guaranteed right for members of federally recognized tribes, decades of research describe persistent disparities in health and access to health services for American Indians. Despite gains in insurance enrollment after the passage of the 2010 Affordable Care Act, underfunding of the Indian Health Service and national debate over the new health law contributes to insecurity, especially among the majority of American Indians aged 55 and older who rely on public insurance. We consider the production of insecurity surrounding health care for American Indian elders, analyzing its pragmatic and affective consequences. Between June 2016 and March 2017, we conducted 96 quantitative surveys and in-depth qualitive interviews with American Indian elders aged 55 and older in two states in the U.S. Southwest. Interviews were recorded, professionally transcribed, and analyzed iteratively using open and focused coding. We found that elders consistently shared discourses of doubt, fear, and uncertainty that centered on: 1) interactions with healthcare providers and facilities, especially the IHS; 2) calculations regarding health insurance and the potential costs of healthcare services; and 3) dynamics at the national level around health policy, particularly for American Indians. We argue that persistent perceptions of healthcare insecurity present a major barrier to wellbeing that remains unaddressed by existing health policy interventions for this population, which focus predominately on individual-level knowledge and behavior.

Health Promotion Programs and Policies in the Workplace: An Exploratory Study With Alaska Businesses

Introduction

We examined health insurance benefits, workplace policies, and health promotion programs in small to midsize businesses in Alaska whose workforces were at least 20% Alaska Native. Participating businesses were enrolled in a randomized trial to improve health promotion efforts.

Methods

Twenty-six Alaska businesses completed from January 2009 through October 2010 a 30-item survey on health benefits, policies, and programs in the workplace. We generated frequency statistics to describe overall insurance coverage, and to detail insurance coverage, company policies, and workplace programs in 3 domains: tobacco use, physical activity and nutrition, and disease screening and management.

Results

Businesses varied in the number of employees (mean, 250; median, 121; range, 41–1,200). Most businesses offered at least partial health insurance for full-time employees and their dependents. Businesses completely banned tobacco in the workplace, and insurance coverage for tobacco cessation was limited. Eighteen had onsite food vendors, yet fewer than 6 businesses offered healthy food options, and even fewer offered them at competitive prices. Cancer screening and treatment were the health benefits most commonly covered by insurance.

Conclusion

Although insurance coverage and workplace policies for chronic disease screening and management were widely available, significant opportunities remain for Alaska businesses to collaborate with federal, state, and community organizations on health promotion efforts to reduce the risk of chronic illness among their employees.