The State of Indigenous America Series: Ten Indian Health Policy Challenges for the New Administration in 2009

The new administration that took office in January 2009 faces numerous challenges in the area of American Indian health. Media reports have recently shined a spotlight on disparate life expectancy rates in the United States based on race, ethnicity, culture, and income. Unfortunately, American Indians suffer among the worst health disparities in the nation with alarming gaps in life expectancy. Death rates from preventable causes such as diabetes and alcoholism are dramatically higher in American Indians than in the rest of the population. Nearly a third of our people live in poverty as compared to approximately 12 percent of the rest of the country. In Arizona, the average age at death is 72.2 years for the general population, but it is 54.7 years for American Indians.

Despite this gross inequality, American Indians are the only population born with a legal right to health care in this country. The treaties between the tribal nations and the federal government in which the tribes exchanged vast amounts of land and natural resources resulted in guarantees for social services including housing, education, and health care. The Bureau of Indian Affairs (BIA) and the Indian Health Service (IHS) were established to administer the federal government’s trust responsibility to provide health care and other vital services to American Indians.

At the same time we have an underfunded health system, other policies such as the damming of rivers and the loss of land and resources have led to significant lifestyle changes. Less physical activity, less access to healthy food, and less freedom combine with discrimination to worsen health disparities.

The solutions to American Indian health disparities are in the policy-making arena. Social policies, such as the federal trust responsibility to provide health care to American Indians, have a much greater impact on health outcomes than genetics or other physical causes of disease. The new administration is in a position to change the direction of Indian health policy, and it has the opportunity to focus on policy decisions that can have a significant impact on improving Indian health status and outcomes. There are multiple areas of Indian health in need of improvement. This article is organized into ten policy areas on which the new administration must focus to improve Indian health.

1. Health Disparities

Considerable health disparities exist between the American Indian (AI) and the general U.S. populations. The roots of health disparities for AI people are multifaceted: low incomes, inadequate housing, substandard educational systems, underfunded reservation schools without physical education programs or healthy food programs, poor nutrition, and cultural factors. These factors coupled with a severely underfunded health care system have led to decreased access to health care services and to the highest incidence of preventable diseases in the country. As mentioned, in the state of Arizona, the average age at death is 72.2 years for the general population, but only 54.7 years for AIs.¹

Figure 1.

Average age at death in Arizona.

Preventable diseases impact AI populations at a far greater rate than the rest of Americans. Death rates from preventable diseases among AIs are significantly greater than among non-Indians, including diabetes (249 percent greater), alcoholism (627 percent greater), accidents (204 percent greater), and suicide (72 percent greater).² In the Phoenix-area IHS, encompassing most of Arizona as well as Utah and Nevada, the rates of death due to diabetes and alcoholism are even worse than in the rest of the IHS.

Figure 2.

Diabetes death rates (deaths per 100,000 population).

Figure 3.

Alcohol-related death rates (deaths per 100,000 population).

High rates of diabetes, subsequent depression, and alcoholism create a significant need for effective behavioral health programs and interventions. At the same time, the policy framework for attacking this inequity is quite complex, and the level of care provided to AI communities is lower, in terms of per capita funding and provision of services, compared to...