Abstract

Native Americans suffer greater health disparities associated with risk factors such as diabetes, obesity, drug and alcohol abuse, suicide rates, cardiovascular disease, stroke, andhypertension compared to other ethnic groups. A main deterrent to healthcare for the Native American population is inadequate healthcare policies that stem from an illness-based care system that attempts to treat individuals rather than the population as a whole. Western medicinestandards are mainly used in the healthcare field when diagnosing and treating health problems and are often considered the medical standard. However, the Western framework creates a problematic superiority complex and leads to the invalidation of Native Americans' traditional views. Natives have described that a significant barrier for them seeking health services is the lack of trained providers with the knowledge, skills, or training to work with their community in a more traditional form. In addition, mental health has been a targeted area of concern, mainly in part due to historical trauma that has resulted in substance dependence, PTSD, youth behavioral problems, and a rise in suicide rates among the population. Native Americans are disproportionately represented in mental health statistics, experiencing higher rates of substance abuse, suicide, and psychological distress compared to the general population. However, despite this overrepresentation in mental health needs, they are severely underserved and underrepresented in the availability of mental health professionals. Although Indigenous healthcare faces a variety of barriers, multiple strategies can be pursued to combat these obstacles, starting with rebuilding the views and process of the health services offered to Native Americans as well as being more mindful to the Native wholistic approach to healing and optimal health as a way of life. Viable approaches and solutions to safeguard Native access to healthcare are presented and are crucial to overall Native welfare and quality of living.

1. Introduction

Native Americans suffer greater health disparities associated with risk factors such as diabetes, obesity, cardiovascular disease, stroke, and hypertension compared to other ethnic groups ^{1, 2, 3, 4, 5}. While Native health has improved, there still remains wellbeing differences including economic, social, physical, mental, and spiritual disparities ¹.

In modern healthcare, disparities persist as a sobering reality of the inequality of health opportunities across diverse populations. One of the most notable populations facing healthcare inequality is American Indian (AI)/ Alaska Native (AN) communities. Socioeconomic factors, limited funding and access to healthcare, and long-term systemic biases are among some of the challenges that disproportionately affect the Indigenous community. As of 2016, an estimated $23.2-$39.8 billion of direct and indirect costs was garnered due to Indigenous health disparities ⁶. The challenge presents itself as to what steps are necessary to ensure that all people have equal opportunities to lead healthy lives. The purpose of this research review is to examine Native American barriers to accessibility to healthcare, recognize the lack of support for sufficient and adequate Native healthcare, and to encourage a more mindful outlook to the Native wholistic approach to healing and optimal health as a way of life. Viable approaches and solutions to safeguard Native access to healthcare are presented and are crucial to overall Native welfare and quality of living

2. Indigenous Concepts of Health

Within the Native community, health is shaped by larger social constructs, including family, community, nature, and creator. The Indigenous community prefers a more traditional approach to health that emphasizes holism, balance, and interconnectedness ⁷. Traditional healing promotes harmony and unity with all-natural elements in relation to one another. The balance and interconnectedness of the four main areas of spirit, body, mind, and environment ultimately determine that person's overall health. All four areas must hold equal weight to achieve wellness; when all areas are in "harmony" with one another, that person is considered to be in good health ⁸. The difference in Indigenous healthcare practices from Western medicine stems from distinct cultural standpoints and traditional healing philosophies within the native community. Native traditional healing includes prayer, ceremonies, storytelling, and working with healers to sustain balance and wellness, much of which was suppressed during colonization and the introduction of Western Medicine ⁹. Despite the challenges of colonization and forced cultural integration, many Native Americans continue to utilize their traditional views as a source of healing and empowerment, highlighting the importance of the Indigenous concepts of health and wellness.

3. Areas of Concern

Indigenous communities grapple with a variety of pressing concerns when discussing health disparities, from inadequate access to care, historical injustices and discrimination, inefficient mental health services, and high rates of health issues. These concerns urge us to examine our healthcare system for more effective solutions

A main area of concern is the high rates of obesity, chronic diseases, social pathologies, and drug and alcohol abuse that have the most significant negative impact on the Native community. Research shows that the Indigenous population's life expectancy is over five years lower than the general population, mainly due to the increase in heart disease, diabetes, and cancer among the population ¹⁰. A main deterrent to healthcare for the Native American population is inadequate healthcare policies that stem from an "illness-based care system" that attempts to treat individuals rather than the population as a whole ⁷. There are shortfalls in preventive care and health education, along with challenges in accessing healthcare services and consultations due to limited availability and accessibility. In addition, the Native American population has notably less access to healthcare than the general U.S. population, with programs that are severely underfunded.

Another main area of concern among the Native community is the need for culturally sensitive services. Western medicine standards are mainly used in the healthcare field when diagnosing and treating health problems and are often considered the medical standard. However, the Western framework creates a problematic superiority complex and leads to the invalidation of Native Americans' traditional views. AI/ANs have described that a significant barrier for them seeking health services is the lack of trained providers with the knowledge, skills, or training to work with their community in a more traditional form ⁸. Mental health has been a targeted area of concern among this group, mainly in part due to historical trauma that has resulted in substance dependence, PTSD, youth behavioral problems, and a rise in suicide rates among the population. Statistically, mental health morbidities are 1.7 to 7 times higher among Native Americans for substance abuse and mental health challenges ¹¹. Native Americans are disproportionately represented in mental health statistics, experiencing higher rates of substance abuse, suicide, and psychological distress compared to the general population. However, despite this overrepresentation in mental health needs, they are severely underserved and underrepresented in the availability of mental health professionals.

4. Rural Health

Additionally, lack of availability due to geographical location is cited as a major deterrent to the Indigenous community seeking care. Access to healthcare in rural communities presents a multifaceted challenge characterized by geographic isolation, limited healthcare infrastructure, and socioeconomic barriers. According to recent statistics, 54% of the nation's 5.2 million Native Americans live in rural locations, and 68% of all indigenous populations live near their homelands, located primarily in rural America ¹⁰. Rurality poses challenges when considering access to care, transportation, technological advancement, providers, and financial investments. These issues result in high rates of uninsured individuals and a lack of healthcare providers. To put this into perspective, only 9% of U.S. Physicians practice in rural areas compared to 20% of the population living in these areas ¹⁰. The remote location of Native American Health services leads to increased recruitment problems and a higher turnover rate for providers working in these locations.

The land's difficult terrain and sacred values also make technological advances harder, limiting access to telehealth and other virtual health programs these communities could benefit from. Access to the Internet and technology is shown to provide people with digital news, education, and health and increase economic and social opportunities for communities ¹². Native American Tribes located in rural America are at a disadvantage due to the lack of funding from the federal government and exclusion from digital society. Limited internet access and understanding on how to use specific technology complicates the process of applying for grant awards. It hinders tribes from accessing crucial health information, such as deadlines for healthcare programs and services, which are not being addressed by government policies ¹². Limited access to technological advancements and funding in rural areas is also related to the problem of outdated equipment and facilities, deepening disparities in healthcare access and quality.

Communities in rural areas face many challenges, among which transportation and housing problems stand out prominently. In rural areas, limited housing availability and poor-quality housing directly impact health outcomes. Housing directly affects health, with substandard housing being linked to an increased risk of chronic disease ¹⁰. Inadequate heating, plumbing, leaks, overcrowding, and pests can all contribute to significant health issues. Furthermore, transportation difficulties pose barriers to accessing healthcare services. Most high-quality centers specializing in care are in major cities, meaning the Native American population living in rural areas must travel considerable amounts for care. Rurality also poses challenges for accessing post-procedure checkups and rehabilitation services that may require multiple visits per week or month. According to the American Heart and Stroke Association, "39% of American Indians faced difficulty with transportation when accessing care compared with 18.2% of non-Hispanic Whites." These disparities highlight the urgent need for targeted interventions to ensure reasonable access to healthcare in rural communities.

5. Healthcare Policy Barriers

Health policies in the United States have historically failed to adequately address the needs of the Native American population, resulting in barriers to healthcare accessibility. The U.S. Department of Health and Human Resources created The Indian Health Service (IHS) as a primary health provider for Native Americans. According to recent statistics, about 60% of the Nation, or 4 million Native Americans, rely on IHS as their primary provider ¹⁰. However, this program, designed to provide adequate healthcare to indigenous communities, faces its own set of challenging barriers.

Among the challenges confronting the IHS is the issue of inadequate funding. The Indian Health Service is a non-entitlement program requiring annual U.S. Congress appropriations ¹³. This dependence on discretionary funding from the federal government makes it difficult for the program to account for budget allocations. In addition, the IHS is severely underfunded, which creates significant gaps between the resources available and the overall healthcare needs of the Indigenous community. Research supports that per Capita healthcare expenditure was $8,092 for the general U.S. population and only $3,107 for IHS as of 2014 ¹⁴. This level of funding grossly underscores the needs of the Native American community and expresses the limited support state and government institutions allot to the Indigenous community. Mental health, which is cited as a significant concern among the Native American population, lacks the funding necessary to improve the services available to the community. Funding for mental health services is recorded as receiving the lowest amount of grants from the IHS; only 10% of the funds allotted to the IHS are allocated to mental health services ⁹. Needed diagnostic and treatment services may also be delayed or denied due to the lack of funding available. Without the resources necessary to receive care, the IHS fails to address the critical needs of the Indigenous community.

The Indian Health Service resources are only given to tribes recognized by the Federal government, creating yet another barrier to receiving this service. The groups not recognized by the federal government are not eligible for aid and, therefore, more likely to be uninsured. Research findings demonstrate that 400 non-federally recognized tribes have limited access or cannot receive or apply for federal grants ¹². Lack of availability explains why Native Americans are more likely to delay or go without needed care, further substantiating their distrust for the IHS. Lack of trust in the Federal government and IHS leads to the Indigenous community not wanting to participate in government funding, along with cultural insensitivity, burdensome enrollment, and fluctuating eligibility requirements ¹⁴. Evidence suggests that these shortfalls in resources further deepen the challenges the Indigenous community faces.

The Indian Health Service, although used as a primary healthcare policy for most Native Americans, lacks many resources and benefits that other federally supported policies have. These include not paying premiums, deductibles, and copays under IHS coverage regardless of personal income ¹³. The type of coverage provided is a significant deterrent when finding a provider who will take this type of insurance. Due to low reimbursement rates, many healthcare providers are unwilling to accept IHS plans ¹⁴. Consequently, access to care for Native American individuals covered by these plans is severely limited. Applications for receiving IHS care are another area for concern since strict deadlines, technical language, and low health literacy rates among the Indigenous community make it more difficult for tribes to apply for coverage or grants.

Despite efforts to address health disparities, significant healthcare policy barriers exist within the IHS. These challenges highlight the need for policy reform as well as increasing the allocation of funds given to the IHS annually. Addressing these barriers is critical to ensure that the Native American communities receive the quality of care they deserve.

6. Solutions

Indigenous healthcare faces a variety of barriers; however, multiple strategies can be pursued to combat these obstacles, starting with rebuilding the views and process of the health services offered to Native Americans.

1. From a community and policy level, revamp mental health services in Native American communities by drawing upon Indigenous knowledge systems and traditional and cultural practices.

2. AIE (American Indian Elders) Navigators are another way to inform the community about health care policies and coverage. AIE Navigators can use group presentations or one-on-one consultations to share accurate information on coverage plans ¹⁴. Support within the community is critical to overcoming many healthcare disparities.

3. Expanding technological advancements in these communities, such as telehealth options, is another viable way to bridge the divide. Internet connectivity is a necessity, not a luxury; in this day and age, without access, tribal communities have unequal access to healthcare, education, and economic resources, further demonstrating the need for the incorporation of technological advancements ¹². While implementing such initiatives will require financial support, it is a necessary step to ensuring equal access to health resources.

4. Provide more financial resources through local, state, and federal support to build and cultivate Native American heritage, health, and cultural centers to bring more attention to Native preferences towards physical activity, nutrition, and wholistic spiritual, emotional, and social health. These types of facilities can foster greater awareness of Indigenous health needs while building more support from state and federal governmental officials as well as key stakeholders who are a part of policy making decisions through legislation. In addition, mutual understanding between the Native population and the general public can be greatly enhanced through educational Native health and wellness talks, panel discussions, seminars, and workshops that can benefit all populations.

5. The Native American contributions to society are numerous and priceless. Prioritizing celebrating Native American history, archives, artifacts, health and wellness progressive practices rooted in their history, and cultural traditions will help keep the well-being of Native people foremost in the minds of local, state, regional, and national policy decision-makers.

6. Supporting schools with the policy making mission to train and support rural and urban physicians in order to ensure enough physicians are available to the Native American community. Research suggests that incorporating Native American-based scholarship training programs and loan forgiveness is an excellent way to encourage and support staffing in rural areas ¹⁰.

7. Incorporating Native American community healthcare workers who know the history, culture, and community will build rapport among the Indigenous groups and create a sense of comfort and trust, encouraging more people to seek care. Community workers can also help educate and help with outreach and health literacy to bridge the divide. In addition, the importance of Native American health has been overlooked for far too long. Training Natives to represent for example the Indian Health Service (IHS) will create a more trusting and caring environment for Natives in the community to seek much needed medical help and attention. In addition, focusing on health information technology strategies will help to overcome transportation and distance barriers to medical facilities. Digital and software programs aimed at providing health information to Indigenous communities can help to serve Native Americans in both urban and more remote areas who might otherwise not be as tuned in to their health needs ^{15, 16, 17, 18}.

8. Finally, the lack of priority and emphasis on Native health in the United States is alarming. Approximately 75% of Natives ²³ live in urban areas ²⁴ yet only 1% of IHS funds which is severely underfunded, is apportioned towards the Native population ^{20, 21, 22}. To compound an already complicated situation, almost 33% of all Native Americans do not carry health insurance ^{19, 21}. Between lack of funding, inaccessibility to health care, and a limited focus on Native health in general, the physical, and health and well-being needs of Indigenous people in America must take precedence to eradicate unsettling health disparities.

7. Conclusion

Addressing the various healthcare disparities and systemic issues within the healthcare systems is a necessary step in revising and reforming Indigenous healthcare policies. By recognizing the historical injustices and respecting cultural differences, policymakers and tribes can work hand in hand, creating a more effective system. First and foremost, solutions grounded in Indigenous knowledge and traditional practices are crucial to fostering trust and encouraging more community members to seek care. Furthermore, adequate funding is necessary to move forward with implementing solutions. IHS, which is the primary health provider for the Indigenous community, should receive sufficient funding and resources necessary to deliver the type of care that is desperately needed by a large population. Prioritizing these healthcare initiatives is the next step in ensuring that individuals, regardless of their background, receive equal opportunities to access the healthcare services they need and deserve.

ACKNOWLEDGEMENTS

We would like to extend our sincere gratitude to Dr. David J. Dyck from the University of Guelph, Ontario, Canada for his comments, edits, and feedback in the preparation of this research.

Conflict of Interest

The authors have no conflicts of interest to declare.

Funding

Sisters of Charity Foundation, Columbia, South Carolina.

References