Role of Policies Over Time

It is important to highlight the role of assimilation policies that began in the late 1800s because these policies have had sustained effects on Native American communities and, ultimately, their health conditions. As the United States expanded westward, Native Americans were forced to move to reservations, and the federal government made efforts to assimilate Native Americans into mainstream society. As tribes resettled, they continued to suffer from the infectious diseases that plagued the population during the prior decades of warfare. Assimilation policies took on many forms, including the General Allotment Act of 1887,⁴ legislation that abolished the group title of a tribe to land and replaced it with individual plots. In addition, the Bureau of Indian Affairs implemented a boarding school system, which prohibited traditional Native American practices, including religion, medicine, language, and other traditional cultural expressions (e.g., dress, hairstyle, etc.) (Shelton, 2004). This boarding school system, coupled with the prohibition of traditional health care activities, exacerbated the already dismal health and living conditions of Native American communities at the time. The results included rampant infectious diseases, poor sanitation, malnutrition, poverty, overcrowding and inadequate ventilation in homes, poor education practices, and isolation. The harsh conditions that Native Americans had to endure on reservations were extensively documented in The Meriam Report, a study commissioned to assess the status of tribes across the country at the time (Meriam, 1928).

After the assimilation era, there was a series of policies and legislation that formed the periods of Native American policy known as reorganization and, subsequently, termination. In his report on the legal and historical roots of health care for Native Americans, Shelton detailed the chronology and impact of these policies, including the Indian Reorganization Act of 1934 (IRA).⁵ The IRA was designed to stimulate economic development and self-determination, while also promoting the adoption of modern business-like practices for governing tribes (Shelton, 2004). This positive shift in power was short-lived, as it was followed by termination policies in the 1950s, which had enduring effects on Native American communities regarding mental health, identity, and social and family networks (Walls and Whitbeck, 2012). Congress passed legislation discontinuing the special federal–tribe “trust” relationship with 109 tribes and bands (Shelton, 2004). The termination policies resulted in the removal of tribes' federal recognition, the elimination of their reservations, and the forced relocation of Native Americans from their tribal lands to major urban areas.

Following the termination-era policies, the federal government made the official transition to tribal self-determination and passed laws to restore tribal sovereignty. In 1975 Congress recognized the importance of tribal decision making in tribal affairs and the significance of the nation-to-nation relationship between the United States and tribes through the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA).⁶ The ISDEAA directs the Secretary of the U.S. Department of Interior and the Secretary of the U.S. Department of Health and Human Services to enter self-determination contracts or compacts with tribal organizations, upon the request of any Native American tribe (Bauman and Floyd, 1999). Subsequent amendments to the ISDEAA strengthened the federal policies supporting tribal self-determination and self-governance.

Health Care Services

Unlike other racial and ethnic minority groups in the United States, Native Americans have legal rights to federal health care services. Federal responsibility for Native American health care was codified in the Snyder Act of 1921⁷ and the Indian Health Care Improvement Act⁸ (IHCIA) of 1976, which together form the legislative authority for the federal agency known today as the Indian Health Service (IHS) (U.S. Commission on Civil Rights, 2004). The Snyder Act authorized funding for health care services to federally recognized tribes, and the IHCIA defined the structure for the delivery of health services and authorized the construction and maintenance of health care and sanitation facilities on reservations (U.S. Commission on Civil Rights, 2004). Although these pieces of legislation marked significant progress, the Snyder Act has been criticized for its use of broad and vague language, which does not facilitate long-term planning or provide resources based on need. This is considered to have influenced the piecemeal approach that has shaped the funding and distribution of health care resources for Native Americans (IOM, 2003).

The IHS is the federal agency responsible for fulfilling the trust obligation to provide health services to Native Americans. When the federal responsibility for health care services was transferred from the U.S. Department of the Interior to the U.S. Department of Health, Education, and Welfare in 1955, the IHS was established under the Public Health Service. This transfer resulted in the doubling of appropriations for the IHS. Currently, the IHS operates within the U.S. Department of Health and Human Services. IHS is only required to provide federal health care services to federally recognized tribes. Individual eligibility for services is determined by a number of criteria, including, but not limited to, the requirement that the individual is of Native American descent, is regarded as a tribal member, has some legal evidence of tribal enrollment or certificate of origin, and resides on or near a federal reservation (IOM, 2003). The IHS consists of a network of hospitals, clinics, field stations, and other programs that collectively serve approximately 2.2 million Native Americans (IHS, 2015). The IHS system is divided into three major branches: the federally operated direct health care services, tribally operated health care services, and urban Native American health care services and resource centers. For those who are eligible, health care services can be received at any IHS facility; however, there are complex rules that restrict the delivery of contract medical care that is not available in IHS facilities (Jim et al., 2014).

Since the passage and amendments of the ISDEAA, there has been an increasing trend toward tribal self-governance with respect to all domains of life, including health care. As a result, tribes have the option to receive direct services from the IHS, to assume responsibility for health care with the option to contract with IHS, or to fund the establishment of their own programs or supplementation of ISDEAA programs (IHS, 2016). The option of self-governance allows tribes to tailor health care services to the needs of their communities. The IHS operates from the understanding that tribal leaders are in the best position to assess and address the needs of their communities. More than half of the IHS appropriation is currently administered by tribes, through self-determination contracts or self-governance compacts (IHS, 2015).

There are a number of barriers that preclude the IHS from reaching its full potential of providing quality, efficient health care services to its target population to reduce disparities (U.S. Commission on Civil Rights, 2004). The persistent lack of adequate funding is often cited as a barrier to reducing the pervasive health disparities that affect Native Americans (Sequist et al., 2011; Warne and Frizzell, 2014). Every year, Congress appropriates funds to IHS to fulfill the trust responsibility to provide health care services. According to the National Congress of American Indians, in 2014 the IHS per capita expenditures for patient health services were only $3,107, compared to $8,097 per person for health care spending nationally, and when examining medical spending only, IHS per capita was approximately $1,904 (National Congress of American Indians, 2016).

A physician survey conducted in 2007 explored barriers to quality improvement within the IHS. The findings revealed that access to high-quality specialists within geographic proximity, nonemergency hospital admission, high-quality imaging services, and high-quality outpatient mental health services were high-priority barriers for physicians (Sequist et al., 2011). Furthermore, a majority of the physicians felt that a lack of IHS funding to support provision of care through subspecialists was a crucial barrier to quality improvement (Sequist et al., 2011).

Income and Wealth

Native Americans are one of the most economically impoverished populations in the United States. The median household income for this group is $37,227, as compared with $53,657 in the nation as a whole (U.S. Census Bureau, 2015). Given that income is a strong predictor of health outcomes and life expectancy (Chetty et al., 2016; Woolf et al., 2015), this disparity in income has severe consequences for the health and well-being of Native Americans. This particular population also has a higher proportion of people living in poverty than the rest of the country, with 28.3 percent of Native Americans living in poverty, compared with 15.5 percent of the total population (U.S. Census Bureau, 2015). Income and poverty are inextricably tied to employment opportunities, of which there are too few for Native Americans. Native Americans have the highest unemployment rate (9.9 percent in 2015) of any racial or ethnic group in the United States (U.S. Bureau of Labor Statistics, 2016).

In terms of recent trends in economic well-being, it is important to recognize the lasting effects of the economic recession of 2008. Native Americans saw declines in employment and income that were similar to other racial and ethnic groups; however, this population on average was in a more vulnerable financial condition than other groups at the beginning of the period. The unemployment rate for Native Americans spiked from 11 percent in 2008 to 18 percent in 2010 (Pettit et al., 2014). In that same time period, Native Americans also experienced almost double the percentage increase in the poverty rate as other racial and ethnic groups did, with the largest increase observed in the West (Pettit et al., 2014). By 2013 the overall Native American unemployment rate had dropped to 11.3 percent, but rates were still high in the Midwest (16.9 percent), Northern Plains (15 percent), and Southwest (15 percent) regions of the country (Austin, 2013).

Education

Education is a significant determinant of health for Native Americans, as the U.S. educational system has historically been a source of discrimination and, in many cases, trauma for this population. One of the most overt examples of this is the implementation of the boarding school system, which was designed with the purpose of eliminating students' tribal identity and facilitating assimilation into mainstream American culture (Executive Office of the President, 2014; Shelton, 2004). Today, educational progress for Native Americans is far behind that of other racial and ethnic groups. A report from the National Center for Education Statistics reveals that Native Americans have the highest high school dropout rate in the country, which was at 14.6 percent in 2012, compared with a low of 3.3 percent among Asians/Pacific Islanders (Stark and Noel, 2015). In addition, Native Americans had the lowest high school completion rate in 2012, which was at 79.0 percent compared with a high of 94.9 percent among Asians/Pacific Islanders (Stark and Noel, 2015). This disparity has serious implications for health inequities among Native Americans because the evidence demonstrates that there is a strong link between high school completion and health (Cutler and Lleras-Muney, 2006).

Since the civil rights movement in the 1960s, there has been an emergence of grassroots educational institutions that seek to support tribal identity, address academic deficiencies, and resolve the lack of quality education experiences and sense of displacement among tribal students (Crazy Bull, 2015). Research suggests that culturally relevant education increases the likelihood that a young Native American stays in school. Currently, approximately 20,000 students attend tribal colleges and universities full time in the United States (Crazy Bull, 2015).

Housing

Housing conditions for Native Americans are a major consideration for health disparities, on and off of reservations. Housing affordability is a community-level factor that affects Native Americans' access to shelter. According to a recent U.S. Department of Housing and Urban Development report, from 2006 to 2010 roughly 4 out of 10 Native American households had excessive cost burdens, paying more than 30 percent of their income on housing (Pettit et al., 2014). This was comparable to households among other racial and ethnic groups; however, Native American households were more likely to be severely cost-burdened (i.e., paying more than 50 percent of their income on housing) than households of other racial and ethnic groups (Pettit et al., 2014). While home ownership rates in tribal areas were relatively high (67 percent) in 2010, the overall homeownership rate for Native Americans lagged behind that of other racial and ethnic groups, at 54 percent and 65 percent, respectively (Pettit et al., 2014).

Safe and healthy housing is a determinant of health to which many Native Americans do not have access. For example, the U.S. Environmental Protection Agency reports that as of 2011, there were more than 120,000 tribal homes lacking access to basic water sanitation (EPA, 2012), and the IHS reports that almost 1 in 10 Native American homes are without safe and reliable water (Indian Health Service, 2011). It should also be noted that there are certain Native American communities that are particularly affected by the lack of quality housing (i.e., not having complete plumbing and kitchen facilities) in the Alaska, Arizona, and New Mexico regions (Pettit et al., 2014). Those living in extreme climate conditions, such as Alaska, are especially vulnerable to potential damages to their poor-quality housing caused by extreme weather.

Overcrowding in homes is an issue for Native Americans that research suggests is linked to the onset or exacerbation of many health problems. These health issues include respiratory conditions, the transmission of infectious diseases, child well-being (i.e., academic achievement, behavior problems, physical health), depression, and sleep deprivation (Angel and Bittschi, 2014; Solari and Mare, 2012; Webster, 2015). From 2006 to 2010, Native American households were much more likely to be overcrowded than all households in general, with 8.1 percent of Native American households being overcrowded and about one-third of these being severely overcrowded (Pettit et al., 2014). The highest incidence of overcrowding in Native American homes was in larger tribal areas, where 11 percent of households were overcrowded, compared with 3.1 percent of all U.S. households (Pettit et al., 2014). When examining overcrowding and its effects, it is important to recognize the cultural values and customs that shape household traditions in Native American communities.