There are more than 4 million American Indians and Alaska Natives (AI/ANs) in more than 560 federally recognized tribes and Native villages in the United States. These tribes and villages have many different cultures, languages, histories and lifestyles. Throughout this toolkit, the abbreviation AI/AN is used to refer to American Indian and Alaska Native people collectively, as are the terms "Natives," "Indians" and "Native Americans."
While we have provided an overview of AI/AN populations in this toolkit, it is important not to generalize too broadly and to understand the cultural differences in AI/AN communities. You should also understand local AI/AN people's values and attitudes toward traditional Indian medicine.
The federal government has a unique, historical and government-to-government relationship with Indian tribes. This relationship is often referred to as a "trust responsibility" based on signed treaties with Native nations that, among other things, promised health services in exchange for millions of acres of land. The federal responsibility to provide health services to AI/ANs has been administered primarily through the Indian Health Service (IHS), an agency of the U.S. Department of Health and Human Services, since 1955. It is important to note that IHS is not classified as "insurance" by federal agencies, and it does not provide comprehensive health care services to AI/ANs.
In addition to the IHS, there are two other components to the AI/AN health care system: the tribal programs that operate their own health care services and urban Indian health clinics. Together the three are known as the I/T/U (Indian Health Service/Tribal Health Programs/Urban Indian Health Programs) system. The I/T/U system provides a range of services, including limited outpatient and inpatient care. (See Frequently Asked Questions in the Introduction for a full explanation of the I/T/U system.)
Nearly a quarter (23%) of AI/AN children are uninsured. Many may be eligible for low-cost or free health care coverage through Medicaid or the State Children's Health Insurance Program (SCHIP). Unfortunately, many parents do not know that their children are eligible, do not realize the value of the programs, or have misperceptions about the impact that enrolling would have on the other health care services they receive through the I/T/U system.
Misperceptions about how Medicaid and SCHIP work with the I/T/U system reinforce the need for conducting outreach. When talking to parents about Medicaid and SCHIP, you should emphasize that these programs cover some health care services that I/T/U clinics may not cover. In addition, patients covered by Medicaid and SCHIP may be helping their local I/T/U clinics, because these clinics are reimbursed by the federal government for services provided to patients enrolled in Medicaid and SCHIP as part of the trust responsibility.
For most traditional AI/AN cultures, the notion of "health" is understood as being balanced spiritually, mentally, physically and socially. Ill health occurs as a result of being out of balance. The AI/AN fact sheet shows that several of the major health problems facing AI/AN populations today are considered lifestyle related and could be viewed as "being out of balance."
For many communities, the practice of traditional tribal medicine and spiritual ceremonies may be an important component of the overall approach to achieving good health and eliminating disease. On average, about half of all AI/ANs, regardless of whether they live on reservations, in villages or in urban areas, actively use some form of spiritual or traditional Indian medicine.
However, some individuals may not know where to locate traditional practitioners. Others may have access to traditional healing practices but feel it is inappropriate to incorporate this knowledge with contemporary treatments and/or organized religious beliefs. It is important to understand and respect the different approaches to health care among AI/AN cultures when conducting health care outreach. The best way to learn this is to develop long-term trusting relationships with tribal elders and others who work on AI/AN children's health care issues.
The need for special outreach to AI/AN families was recognized during the enactment of SCHIP with a special provision that requires states to describe the procedures used to ensure health care coverage for targeted low-income children in AI/AN families. Still, far more AI/AN children are eligible than are enrolled. It is important to understand the obstacles to outreach and enrollment. Throughout this toolkit, we have outlined strategies for turning these obstacles into opportunities. Some obstacles include:
• Health Care as a Federal Trust Responsibility: AI/AN parents are sometimes reluctant to enroll their children in Medicaid or SCHIP because they do not want to free the federal government from fulfilling this obligation. However, the IHS is considered the "payer of last resort." This means that government programs such as Medicaid and SCHIP pay first. The federal government reimburses states 100 percent of what it costs them for Medicaid services provided to AI/AN people. This reimbursement is part of Congress's commitment to fulfill its trust responsibility to those AI/ANs who are eligible for Medicaid or SCHIP. As a result, patients who are enrolled in Medicaid or SCHIP benefit I/T/U sites because they can generate additional revenue, which allows these sites to provide supplemental services such as dental care, eye care and specialty referrals.
• The I/T/U System: Some AI/AN parents do not believe that they need Medicaid or SCHIP because they have access to health care through the I/T/U system. However, services provided through the I/T/U system are not comprehensive. In addition, some parents may be misinformed by their local I/T/U clinic that if they access Medicaid or SCHIP services, they are no longer eligible for I/T/U services. By enrolling in Medicaid or SCHIP, AI/AN families may be able to seek additional services that the I/T/U system does not provide.
• State-Tribal Relations: State-tribal relationships vary from region to region. Most federally recognized tribes are sovereign nations with a direct federal government-to-government relationship, not political subdivisions of states. Because Medicaid and SCHIP are administered through the states, a functional working agreement between states and tribes is required in order to provide Medicaid and SCHIP benefits to tribes effectively.
• Co-payments for SCHIP: The implementation of SCHIP by state and federal governments was initially less effective in AI/AN communities for several reasons, although many of those barriers have now been addressed. Co-payments were eliminated when the Centers for Medicare & Medicaid Services (CMS) granted an SCHIP co-payment requirement waiver to AI/AN children. However, some states still charge co-payments for SCHIP services. Before you begin your outreach efforts, visit the CMS Web site at www.cms.hhs.gov to find out if your state still requires co-payments for certain services provided through SCHIP.
• Distinct Cultural Differences: Many AI/AN families and their children reside in culturally distinct communities. Unless targeted and culturally sensitive outreach is conducted, AI/AN parents will not have the opportunity to hear about and consider the benefits of Medicaid and SCHIP enrollment. For some tribal members, English may be their second, third or fourth language.
• Geographic Isolation: Many AI/AN families reside in isolated areas of rural and frontier America. This is particularly true for those residing on large, rural reservations or in Alaska Native villages. The likelihood that mainstream outreach efforts will reach these families is slim.