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merica has broken several centuries worth of promises to its indigenous people. And we’re poised to do it again.

The consequences of this broken promise will affect Native Americans like Mr. W, who lives on the Navajo reservation in Arizona. At only 64 years of age, the complications he has already suffered from his poorly controlled diabetes read like a list from a medical textbook: loss of sensation in his feet and damage to his kidneys and vision. He recently needed to have a toe amputated because of a diabetes-related foot infection. Sadly, Mr. W’s story is all too common.

Native Americans are twice as likely to develop diabetes — and suffer from its complications — as whites. Their life expectancy is more than four years shorter and infant mortality is 60 percent higher. The list goes on. As doctors working on the Navajo reservation, we see these disparities every day.

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The Affordable Care Act provided a way to improve the health of thousands of Native Americans through Medicaid expansion. It provided a much-needed injection of funding to the long-neglected Indian Health Service and tribal health facilities by raising the income level needed for eligibility. With the poverty rate at 28 percent among Native Americans, this group disproportionately benefited from Medicaid expansion. According to the Kaiser Family Foundation, Medicaid expansion meant that 440,000 more Native Americans were eligible for Medicaid in 2015. That is a huge number when you consider the population of Native Americans nationally is 5.4 million.

Getting more eligible Native Americans covered by Medicaid provides some desperately needed relief for the overextended and underfunded Indian Health Service and tribal health systems. Previously, when an uninsured individuals like Mr. W needed care, they would go to any Indian Health Service or tribally run facility and receive care, regardless of their ability to pay.

Having Medicaid cover more Native Americans provides a double benefit. It lets newly covered patients seek care outside of Indian Health Service or tribal facilities if they prefer to do that. This takes some pressure off these organizations and improves overall access to health care. Those who choose to seek care at the often more culturally focused and community-based Indian Health Service and tribal facilities on the reservations can certainly still do so. These facilities can then bill Medicaid directly for services provided. That has served as a critical source of additional funds, supplementing the scandalously inadequate funding the Indian Health Service receives directly from the federal government.

To provide some perspective on funding for Native American health care, consider this: in 2014, the Indian Health Service spent just $3,107 per person, whereas Medicaid spent $5,563, the Veterans Health Administration spent $7,036, and Medicare spent $11,910. There is no doubt that the Indian Health Service is an afterthought on the long list of government health priorities.

It is hard to tell exactly how Medicaid expansion through the Affordable Care Act has affected health outcomes among Native Americans. Signs that it is having beneficial effects include improvements in staffing shortages, colorectal cancer screening rates, and blood pressure control among diabetics.

We are personally seeing more patients in our medical centers, a likely sign that coverage has indeed expanded and access to care is improving. When Mr. W returned to the clinic with a new large ulcer on his foot, the well-staffed team quickly began treating it. Under their excellent care, his wound is healing and he is unlikely to lose his foot. This is how diabetes care should be working. But it takes improved access to treatment, better staffing, and broader services, all of which are threatened by replacing the Affordable Care Act with something that restricts Medicaid expansion.

We let out a collective sigh of relief when the Republican’s initial attempt at repealing the act were put on hold in March. Now that Republicans have breathed new life into their repeal bill, and with Medicaid expansion still on the chopping block, the progress made in Native American health is in jeopardy.

Critics of the Indian Health Service and tribal facilities have long cited poor access to care, low quality of care, and agency mismanagement as problems that need to be addressed. There is no doubt that improvements must be made in all of those areas. But cutting Medicaid expansion as a key funding source for Native American health care is not the solution. And despite the flaws of the Indian Health Service and tribal health facilities, they still play an important and singular role, providing health care to more than 2 million Native Americans nationwide.

The national discourse regarding the potential effects of ACA repeal efforts will again reach fever pitch as the Senate takes up the bill. Who will suffer and who will benefit? Is it poor or rich Americans? Is it young or old Americans? Amid this discussion, one group that is sure to be left out of the conversation — and sure to suffer — is Native Americans.

Preserving current levels of health care access and funding for Native Americans won’t right the wrongs of several centuries. But it’s a start.

Kevin Duan, MD, is a physician at Tsehootsooi Medical Center and a volunteer assistant clinical professor at the University of California, San Francisco. Aaron Price, MD, is the chief of staff at Tsehootsooi Medical Center, a HEAL Initiative fellow, and a member of the Navajo Nation. This article reflects the personal views of the authors and not necessarily those of the Indian Health Service, Tsehootsooi Medical Center, the University of California, San Francisco, or the Navajo Nation Government.

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  • The worst of both parties have found ways to work together to make matters worse where health and health care is least. HITECH to ACA to MACRA did not sustain increases to the generalist and general specialty payments that are 90% of the services in 2621 lowest physician concentration counties – where all specialties evaporate to lowest concentrations due to payment designs shaping workforce over the past 30 years. These lowest concentration counties are essentially the Red Counties and about 60 Native, African American, and Hispanic dominant counties.

    Even worse, the new designs continue to disable practices with rapid change and insufficient revenue to cover substantial increases in cost of delivery and increasing complexity of practice and patient. The designs distract team members from care delivery where care is most lacking and is most complex.

    Since these lowest concentration counties have higher concentrations of least healthy populations, the new Pay for Performance designs send lesser payment and greater penalties. This is documented in the literature as discrimination by payment design. P4P is also not evidence based for outcomes improvements in major reviews and clearly has increased the cost of delivery while sucking more scarce health care dollars out of lowest physician concentration counties. But new articles are seen about the success of P4P and value based designs – which are more likely indications of better populations shaping better outcomes rather than clinical interventions, known to have least impact on outcomes.

    Now enter the slash and burn as seen in ReaganCare and TrumpCare. Rapid changes and cuts result in the largest and most organized practices and systems deflecting the impact while the smallest, generalist, office, cognitive, rural, and lower concentration practices take the most hits as in past decades.

    It is hard to tell which is worse – slash and burn without awareness of lowest concentrations and most access barriers or diversions of dollars for meaningless use. Together they are worst of all.

  • Medicaid is healthcare welfare.
    Many Medicaid patients smoke.
    Medicaid patients smoking are a $39,000,000,000 annual burden on Medicaid alone.
    Medicaid would cost a lot less if every Medicaid patient would do their part to be healthier by quitting.
    At least 12 types of cancer are caused by smoking, including 5 with the lowest chances of surviving 5 years after diagnosis.

  • I was diagnosed with type 2 Diabetes and put on Metformin on June 26th, 2016. I started the ADA diet and followed it 100% for a few weeks and could not get my blood sugar to go below 140. Finally i began to panic and called my doctor, he told me to get used to it. He said I would be on metformin my whole life and eventually insulin. At that point i knew something wasn’t right and began to do a lot of research. Then I found Lisa’s diabetes story (google ” HOW I FREE MYSELF FROM THE DIABETES ” ) I read that article from end to end because everything the writer was saying made absolute sense. I started the diet that day and the next morning my blood sugar was down to 100 and now i have a fasting blood sugar between Mid 70’s and the 80’s. My doctor took me off the metformin after just three week of being on this lifestyle change. I have lost over 30 pounds and 6+ inches around my waist in a month. The truth is we can get off the drugs and help myself by trying natural methods

  • Sorry docs. This is mostly dysinformation. I worked in the Indian Health Service in Oklahoma on several
    rotations. They are not welcome in private care. And so their Obamacare simply meant that you all could be paid more for the same care or do less in the same hours. Physician greed is the number one problem and this is the year of clawing back a trillion dollars from docs.

    Charles Phillips, MD – Hospital Cop

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