User:Gpp105/Native Americans and reservation inequality

Lack of healthcare providers
A lack of healthcare providers in reservations also detrimentally effects quality and continuity of care. Tribal communities are often sequestered in unfavorable and isolated locations. According to a study of provider vacancies in the IHS (Indian Health Service), conducted by the Department of Health and Human Services (2016), about half of the clinics studied identified their remote location as a large obstacle for hiring and retaining staff. Issues surrounding isolation, lack of shopping centers, schools, and entertainment also dissuades providers from moving to these areas. Such vacancies lead to cutting of patient services, delays in treatment, and negative effects on employee morale. Studies show that these problems may be addressed by growing a Native American healthcare workforce.

Native American healthcare workforce
A 2009 study finds that there is a strong prevalence of cross-cultural miscommunication, mistrust, and lack of satisfaction among Native American patients when it comes to healthcare. A connection between mistrust from a community and health disparities is established in a 2014 study on "Cultural Identity and Patient Trust Among Older American Indians". Native Americans have reported facing discrimination which has affected the quality of care they received. The Association of American Medical Colleges (the AAMC) supports that doctor-patient relationships and communication can be improved if members of their tribal communities themselves become healthcare providers.

Native American doctors Siobhan Wescott and Beth Mittelstet argue that greater funding should be directed towards educating and encouraging indigenous people to become physicians in order to help remedy issues with staffing, reduce discrimination in care, lower Native American poverty rates, and increase patient advocacy among physicians. In 2018, the AAMC reported that there American Indian and Alaskan natives constitute only .3% of the physician workforce. In 2018, they made up about 2% of the total US population. Assistant professors at the University of Minnesota School of Medicine have proposed creating new formal graduate medical education programs based in tribal communities which focus on delivery systems, social determinants of health, and community influenced solutions. The Indian Health Service offers loan repayment programs to encourage post-graduate doctors to take fellowships on reservations. Several institutions such as UCSF, The University of Washington, and Massachusetts General Hospital have fellowships dedicated to filling full-time coverage positions. Scholarships are also available to indigenous students pursuing medicine as well as those non-indigenous students who seek to work in tribal communities.

A summit in 2018 called "Populating the Native Health Care Workforce with American Indian and Alaska Native Physicians: Moving the Needle on Quality of Health Care in Indian Country" gathered tribal leaders, IHS administrators, and medical school leaders to find barriers and come up with solutions to low Native American provider rates. The solutions include garnering interest in medicine with students before college, creating a single online resource platform for AI/NA students, expanding financial aid opportunities, and enhance programs that aid students in academics.

Tribal sovereignty and healthcare
The Indian Self-Determination and Education Assistance Act of 1975 allows tribes to enter into a contract with the government to assume control over healthcare facilities, thus side-stepping the Indian Health Service and allowing tribes more autonomy over how they approach and deliver health care. It also gives tribes direct access to federal grants not available to the IHS. The Cherokee Indian Hospital in North Carolina is self-governed, with 50% of funds coming from the IHS. Other funds come from sources like Medicaid and casino revenue, which would not be available under IHS control. Construction of the hospital was deliberate in incorporating cultural history and creating a reduced stress environment. Not all communities, however, have other significant sources of revenue such as the casino.

One drawback to Tribal leadership in the context of provider retention is presented from a research survey of Navajo Area IHS physicians. A major reason cited for a provider leaving was due to the transfer of IHS control to the Navajo Nation. The uncertainty in benefits and pay from this transition contributed to their decision to leave.

Several policy options have been proposed to help expand funding for Native American health initiatives that revolve around recognizing tribal sovereignty. One includes having the Navajo Nation create its own Medicaid agency, effectively designating it as a state. This would come with its own logistical issues of transferring those in the Navajo nation already under Medicaid through the state. However, without having to navigate the varying laws of the multiple states the Navajo Nation exists in, tribal sovereignty could be upheld and administration would be smoother. Another policy opportunity would be to prevent cuts to Medicaid programs under the IHS. This would allow for better continuity of care in addressing the many health disparities they face. Another proposition is to utilize section 1115 of the Social Security Act which allows states to waive Medicaid requirements in favor of their own programs. Arizona already implemented this in 2012 by directing funds to the IHS and tribal facilities to cover care health costs for Native Americans.