By Pamela A. McAfee, Ed.D, MPA, OTR, CDE® and Akim Waldron, MHA
Each November, we celebrate Native American and Alaska Native Heritage Month, a time to recognize the rich history, culture, and contributions of Native American and Alaska Native peoples (Library of Congress, 2023). For healthcare professionals, it is also a moment to understand the unique health challenges faced by these communities and how we can work together to address health disparities. Writing this article we will delve into the history of this month, present information on the Native American population, explore current healthcare challenges, and highlight actionable strategies that we found in the research to improve health outcomes for Native Americans and Alaskan Natives.
History of Native American and Alaska Native Heritage Month
As chronicled by the Library of Congress and the National Museum of the American Indian, the journey to a nationally recognized month honoring Native Americans began in the early 20th century. In 1915, Red Fox James, a Blackfoot Indian, rode across the United States seeking support from state governments to establish a day honoring Native peoples. He presented endorsements from 24 states at the White House, but no national day was declared at that time. The first American Indian Day was observed in New York on the second Saturday of May 1916, and over the years, several states began inconsistently recognizing similar days.
In 1990, the federal government officially designated November as Native American Heritage Month, from a joint resolution signed by then President George H. W. Bush. The designation often includes Alaska Native recognition and is recognized by all states annually. Today, Native American and Alaska Native Heritage Month is a time for all Americans to reflect on the vital role Native peoples have played in shaping the nation’s history, present, and future.
Native American Population and Tribal Demographics
According to the Administration of Children and Families (2012), the Native American population in the United States has seen substantial growth in recent years. In 1990, the U.S. Census identified 1.96 million people as American Indian and Alaska Native. By 2023, this number had risen to 9.7 million. Although Native Americans now represent one of the fastest-growing ethnic groups in the country, they still make up only about 3 percent of the overall U.S. population. California is one out of 14 states to have more than 100,000 American Indian or Alaska Native residents (USA.gov, 2024).
Depending upon which article or census you read, there are 566 – 574 federally recognized tribes in the United States, including those in Alaska. The largest tribal population by ancestry is the Cherokee, with more than 1.5 million people, while the Navajo Nation has the largest American Indian population by self-identification, with 315,086 people. Among Alaska Natives, the Yup’ik and Tlingit tribes have the largest populations (Berg, 2023).
Native Americans live on or near 326 federally recognized reservations and trust lands, which cover 56.2 million acres across the country (Bureau of Indian Affairs, 2017). The largest is the Navajo Nation Reservation, spanning 16 million acres across Arizona, New Mexico, and Utah. Despite their growing population (USA.gov, 2024), Native Americans continue to face significant challenges related to health, economics, and social well-being.
Leadership Profile: Celebrating Native American Leaders in Health Care
Dr. Mary Smith, President of the Indian Health Service
Dr. Mary Smith, a member of the Cherokee Nation, has been a trailblazer in advocating for Native American health care. She has spearheaded efforts to modernize the Indian Health Service and improve access to quality care for AIAN populations. Dr. Smith has also focused on expanding mental health services and increasing funding for critical care infrastructure in tribal communities (Alaska Native Health Board, 2016).
Current Native American Healthcare Challenges
Despite the growth of the Native American population, significant disparities in healthcare access and outcomes remain. American Indian and Alaska Native (AI/AN) people are more likely to face preventable illnesses and die at higher rates than other racial groups in the U.S. Life expectancy for Native Americans is 4.4 years shorter than that of the general population. High rates of diabetes, chronic liver disease, lower respiratory diseases, and other preventable conditions contribute to these statistics (Smith, 2024).
The Indian Health Service (IHS), a federal agency within the Department of Health and Human Services, is the primary provider of healthcare for Native Americans. The IHS serves over 2.2 million Native Americans and Alaska Natives, fulfilling federal treaty obligations. However, the IHS has long been underfunded (Smith, 2024), resulting in limited healthcare services, particularly in rural and remote tribal areas.
Key Challenges
The Indigenous Americans as with other minority populations has challenges to address when attempting to access healthcare and have money enough to receive the correct provision of service. The list we have defined is not conclusive, however, is representative of the key challenges identified by the National Institutes of Health and the Bureau of Indian Affairs.
- Underfunding: The IHS consistently receives insufficient funding to meet the healthcare needs of Native populations. To provide care comparable to that received by federal prisoners, IHS funding would need to double.
- Health Disparities: Native Americans experience higher rates of diabetes, kidney failure, heart disease, and chronic liver disease compared to the general population.
- Geographic Barriers: Many Native American communities are located in rural and remote areas, where access to healthcare facilities is limited.
- Uninsured Population: Around 579,000 Native Americans remain uninsured, and coverage gaps continue to hinder access to essential health services.
Addressing Native American Barriers to Health Care Access
AIAN communities often face geographical and economic barriers that limit access to necessary health services:
- Rural and Remote Locations: Many tribal communities live in rural or isolated areas, making access to care facilities and specialists difficult.
- Underfunded Health Systems: The Indian Health Service (IHS), which provides care to AIAN people, has been historically underfunded. In fact, “in 2017, IHS per capita spending was $4,078, as compared with $8,109 for Medicaid, $10,692 for the VHA, $13,185 for Medicare, and $8,600 for federal prisoners” (Chiang, 2022).
Despite the severe underfunding and persistent challenges, there are opportunities to improve Native American healthcare outcomes. Several initiatives are already in place, and more can be done to ensure that Native Americans receive the healthcare they deserve. Warne and Frizzell (2014) created this list of opportunities for improvement from their research on Indian Health Policy. What is significant was their list being generated in 2014 and remains very accurate for healthcare solutions needed in 2024.
- Increase Funding for the Indian Health Service (HIS): To improve healthcare delivery, it is essential to increase and sustain funding for the IHS. Increased funding would enable the agency to support evidence-based, community-focused, and outcome-oriented healthcare initiatives. Addressing high rates of chronic diseases such as diabetes and heart disease requires investments in public health, illness prevention, and health education.
- Expand Healthcare Workforce in Tribal Communities: Many Native American reservations, particularly those in rural areas, face severe shortages of healthcare professionals. The IHS Scholarship Program and Loan Repayment Program have been critical in attracting new healthcare professionals to underserved areas. The scholarship program has awarded funding to thousands of students since 1978, and the LRP continues to support students through educational loan forgiveness to qualified clinicians (Smith, 2024). Expanding these programs is vital to meeting the growing demand for healthcare services in Native American communities. Increasing the number of Native American healthcare professionals who understand the cultural context of their communities can also improve patient outcomes.
- Leverage Telemedicine and Health Technology: Telemedicine offers a way to reduce healthcare access barriers in remote areas, allowing Native Americans to receive specialized care without traveling long distances. Modernizing IHS’s health information technology (HIT) system, which dates back to the 1980s, would also improve the efficiency and quality of care delivery.
- Protect Medicaid Access and Increase Third-Party Coverage: In 2016, the IHS received over $649 million in Medicaid reimbursements. Medicaid expansion, under the Affordable Care Act (ACA), significantly increased the number of Native Americans with access to healthcare services (Smith, 2024). Protecting Medicaid coverage and expanding access to third-party insurance options can help Native patients receive the care they need, especially in areas where IHS services are limited.
- Promote Culturally Tailored Care and Health Literacy: To build trust and improve health literacy, healthcare professionals must present culturally sensitive health information. Native American patients often experience historical trauma and mistrust in the healthcare system. Presenting health information in ways that resonate with Native communities and align with their cultural values is critical to enhancing patient engagement and health outcomes.
Progress and the Path Forward for Native American Healthcare
While the challenges in Native American healthcare are significant, there are signs of progress. For example, the IHS has made strides in reducing kidney failure from diabetes among Native Americans, cutting rates by 54 percent between 1996 and 2013 (Smith, 2024; Warne & Frizzell, 2014). This significant decrease appears to have continued through 2019, however there is no current statistics that demonstrate this good decline has continued. More research is needed to verify the decline in chronic kidney failure is occurring today. However, this improvement demonstrates that targeted interventions, like population management and clinical care improvements, can make a difference.
Much more needs to be done to achieve health equity for the Indigenous populations whether they are on or off reservation lands or are a recognized or non-recognized tribal designation. The U.S. government needs to continue its commitment to created adequate funding, promote strong and collaborative leadership, and advocate for policy reforms that uphold the federal trust responsibility to Native Americans. Expanding the healthcare workforce, investing in technology, and strengthening partnerships with tribal leadership are critical steps toward improving Native American healthcare outcomes.
Policy Watch: Advocating for Native Health Care Rights
In recent legislative developments, California has proposed the Indigenous Health Equity Act, which seeks to address health disparities by increasing funding for AIAN health care services. The bill proposes funding to improve access to telemedicine, mental health resources, and substance abuse treatment programs in rural and underserved areas to enable a more accurate understanding of their unique health needs.
Conclusion
As CAHL and the CAHL JEDI Committee celebrates Native American and Alaska Native Heritage Month it is important to take this opportunity not only to celebrate the history and culture of these communities but also to raise awareness of the persistent challenges they face—especially in healthcare. We as healthcare professionals have a vital role to play in addressing these disparities and initiating more positive outcomes. Through informed advocacy, culturally competent care, and sustained efforts to close the funding gaps, we can make meaningful strides toward health equity for Native Americans and Alaskan Natives.
The road ahead requires commitment, innovation, and collaboration with Native communities, but by working together, we can honor the heritage of Native peoples and fulfill the promises to all Nations.
References
Administration of Children and Families. (2012). American Indians and Alaskan Natives by the numbers. acf.hhs.gov: https://www.acf.hhs.gov/ana/fact-sheet/american-indians-and-alaska-natives-numbers#:~:text=While%20there%20are%20currently%20566,Oklahoma%20tribal%20statistical%20areas%2C%20tribal
Alaska Native Health Board. (2016, March 9). New IHS Principle Deputy Director, Mary Smith | Alaska Native Health Board. https://www.anhb.org/new-ihs-principle-deputy-director-mary-smith/
Berg, K. (2023, November 8). U.S. census bureau releases key stats in honor of 2023 Native American heritage month. Native News Online: https://nativenewsonline.net/currents/us-census-bureau-releases-key-stats-in-honor-of-2023-native-american-heritage-month#:~:text=Tlingit%20was%20the%20largest%20Alaska,tribes%20in%202023%20was%20574
Bureau of Indian Affairs. (2017). What is a federal Indian reservation? Bureau of Indian Affairs.gov: https://www.bia.gov/faqs/what-federal-indian-reservation#:~:text=Approximately%2056.2%20million%20acres%20are,%2C%20communities%2C%20
Chiang, J. (2022, April 28). Medical debt implications in Native American communities. Community Catalyst. https://communitycatalyst.org/posts/medical-debt-implications-in-native-american-communities/
Library of Congress. (2023). Native American Heritage Month. National Museum of the American Indian: https://www.nativeamericanheritagemonth.gov/about.html
Smith, M. (2024, January). Native Americans: A crisis in health equity. Human Rights – The State of Healthcare in the United States, 43(3). American Bar Association: https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/native-american-crisis-in-health-equity/
USA.gov. (2024, September). Federally recognized Indian tribes and resources for Native Americans. USA.gov: https://www.usa.gov/tribes#:~:text=The%20U.S.%20government%20recognizes%20574,enrolling%2C%20and%20tracing%20your%20ancestry.
Warne, D., & Frizzell, L. B. (2014, June). American Indian health policy: Historical trends and contemporary issues. American Journal of Public Health, 104(3), 263-267. doi:10.2105/AJPH.2013.301682