Changing Numbers, Changing Needs American Indian Demography and Public Health (1996) / Chapter Skim
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13 Health Care Utilization, Expenditures, and Insurance Coverage for American Indians and Alaska Natives Eligible for the Indian Health Service
13 Health Care Utilization, Expenditures, and Insurance Coverage for American Indians and Alaska Natives Eligible for the Indian Health Service
Pages 289-314
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From page 289... ...
IHS operates a network of inpatient and ambulatory care facilities across the continental United States and Alaska, many of which are now managed by American Indian tribes and Alaska Native organizations. In addition, IHS directly subsidizes healthcare services through contracts with private providers, particularly for specialized services and other services not available in IHS direct care facilities (known as Contract Health Services)
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From page 290... ...
Unlike most persons who have some form of private health insurance, IHS "beneficiaries" do not pay premiums for IHS coverage, and there are no deductibles or copayments involved in receiving IHS-sponsored services, regardless of personal or family income level. Because IHS services are essentially free of charge to eligible persons, one might expect not to see significant differences in access to care by socioeconomic status, as is the case for the general U.S.
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From page 291... ...
While private providers could be used more effectively in some areas, it is likely that IHS direct care facilities would continue to be the sole or primary source of care for persons living in some of the most remote and sparsely populated areas in the United States, even were they to obtain other private or public health coverage. The present discussion uses data from the 1987 Survey of American Indians and Alaska Natives (SAIAN)
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From page 292... ...
3segments were defined as 1980 census enumeration districts or individual blocks or block combinations. For cost-efficiency, the sample frame was further restricted by excluding segments with less than 0.5 percent population representation of American Indians and Alaska Natives.
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From page 293... ...
IHS services include all those obtained at IHS-owned and -operated hospitals, clinics, and health stations, including those managed by American Indian tribes or Alaska Native organizations (distinctions between IHS-operated and tribally managed facilities could not be made, however)
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From page 294... ...
Thus, the findings are not necessarily representative for all persons who identify themselves as American Indians or Alaska Natives, especially those who are not eligible for IHS services either because they reside outside of IHS service areas or because they are not members or descendants of federally recognized tribes. To avoid misinterpreting the results as being generalizable to all American Indians and Alaska Natives, findings from the SAIAN are discussed in terms of the "SAIAN population" or the "IHS eligible population." A second limitation with the SAIAN is that the effects of cultural factors on health service utilization cannot be thoroughly assessed because, as noted above, few direct measures of culture (e.g., health practices, attitudes regarding health and healthcare, use of traditional medicine)
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From page 295... ...
. Since employment and income are highly correlated with having private insurance or public healthcare coverage, it is not surprising that only 24.9 percent of the SAIAN population had private insurance coverage, compared with 70.7 percent of the general U.S.
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From page 296... ...
Almost 60 percent of the SAIAN population relied exclusively on IHS coverage for at least part of the year. Table 13-2 shows considerable variation in healthcare coverage by employment status, socioeconomic status, and place of residence.
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From page 297... ...
National Medical Expenditure Survey Survey of American Indians and Alaska Natives and Household Survey. employed (i.e., Medicare for elderly persons and Medicaid for unemployed nonelderly persons)
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From page 298... ...
SOURCE: Agency for Health Care Policy and Research. National Medical Expenditure Survey Survey of American Indians and Alaska Natives.
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From page 299... ...
Of greater interest is the extent to which IHS eligible persons identify a non-IHS facility as their regular source of care and whether particular demographic and socioeconomic characteristics are associated with this response. Table 13-3 shows that almost one-third of the SAIAN population identified a non-IHS provider as their regular source of healthcare, although this response was strongly associated with living in a metro area, having a higher income, having other healthcare coverage, and living in an area with relatively few IHS facilities.
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From page 300... ...
SOURCE: Agency for Health Care Policy and Research. National Medical Expenditure Survey Survey of American Indians and Alaska Natives.
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From page 301... ...
. The analysis involved logistic regression analysis of the likelihood of using any ambulatory care in 1987, the likelihood of making a visit to an IHS or tribal facility, and the likelihood of making a visit to a non-IHS facility.
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From page 302... ...
Measures of individual resources include family income and healthcare coverage. Community resources include metropolitan or nonmetropolitan residence, whether there is an IHS hospital in the county of residence, the number of IHS clinics and health stations per 10,000 persons in the county of residence, and whether the county of residence is part of a federally designated health manpower shortage area (as an indicator of the availability of private providers)
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From page 303... ...
While the likelihood of any ambulatory use increased along with the number of IHS clinics, the presence of IHS facilities had opposite effects on IHS and non-IHS use: persons living in counties with IHS hospitals were much more likely to have made an IHS facility visit but much less likely to have made a non-IHS visit compared with persons in counties with no IHS hospitals. Other results in Table 13-4 show a strong association between use of both IHS and non-IHS services and health status and chronic conditions.
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From page 304... ...
* Missing-0.09-0.14-0.28 Healthcare coverage (IHS only all year is omitted category)
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From page 305... ...
As in the previous analyses, these findings suggest greater barriers to the use of non-IHS providers for individuals who are less acculturated in the mainstream American culture. Out-Of-Pocket Expenditures Since IHS services both direct care and contract care services involve no deductibles or copayments for IHS eligible persons, one would expect out-of-pocket healthcare expenditures for this population to be quite low relative to the general U.S.
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From page 306... ...
* 0.05 Missing-0.19-0.05-0.18 Healthcare coverage (IHS only all year is omitted category)
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From page 307... ...
bIncludes visits to IHS contract care providers and providers with no affiliation with IHS. CPoor refers to individuals in families with incomes below the poverty line; low-income to those with incomes between the poverty line and 200 percent of the poverty line; middleincome to those with incomes over 200 to 400 percent of the poverty line; and high-income to those with incomes over 400 percent of the poverty line.
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From page 308... ...
For the SAIAN population, average out-ofpocket expenditures increased considerably with age, and persons in fair or poor health had somewhat higher expenses than persons in good or excellent health. The relationship between family income and out-ofpocket expenditures was not linear: poor and middle-income persons had somewhat higher expenses than persons with low and high incomes, possibly because of the confounding effects of differential health status and healthcare coverage by family income.
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From page 309... ...
National Medical Expenditure Survey Survey of American Indians and Alaska Natives and Household Survey. Out-of-pocket expenditures are a concern to the extent that they impose a heavy financial burden on families and households with sick family members who require intensive healthcare use.
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From page 310... ...
National Medical Expenditure Survey Survey of American Indians and Alaska Natives and Household Survey. Despite the overall lower level of financial burden experienced by the SAIAN population relative to the general U.S.
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From page 311... ...
IHS eligibles in metropolitan areas with high income and other health coverage especially private insurance tend to have a non-IHS regular source of care. The findings also show that persons with other healthcare coverage are more likely to make use of any ambulatory care than persons with IHS coverage only, mainly as a result of higher use of non-IHS care.
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From page 312... ...
This is a difficult issue to address from a policy perspective because it suggests that merely extending health insurance coverage or enhancing physical access to nonIHS providers could still leave disparities in access to care and health service utilization. Thus, having "culturally competent" providers available to serve the local population is an important consideration in reforming healthcare for IHS eligibles, especially for communities that are more culturally isolated from mainstream American society.
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From page 313... ...
DiGaetano 1991 National Medical Expenditure Survey. Survey of American Indians and Alaska Natives: Final Methodology Report.
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From page 314... ...
92-0042~. National Medical Expenditure Survey Methods 4, Rockville, MD: Agency for Health Care Policy and Research.
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