Health disparities

For American Indians, Health is a Human and Legal Right

Sam Aptekar
Phuoc Le

By PHUOC LE, MD and SAM APTEKAR

Most will be surprised to learn that American Indians and Alaska Natives represent the only populations in the United States with a legal birthright to health care.[1] Even though Article 25 of the UN’s Universal Declaration of Human Rights declares, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including…medical care and necessary social services,” U.S. federal policy only guarantees this human right to enrolled tribal members. The source of this juridical entitlement is what the United States Supreme Court has defined as the federal trust responsibility.

Between 1787 and 1871, the United States signed nearly 400 treaties with Indian tribes, in which, for the exchange of millions of acres of tribal land, the U.S. government promised in perpetuity to respect their sovereignty and provide benefits, including housing, education, and healthcare. Argued in March 1983, United States v. Mitchell is the most recent Supreme Court case establishing this principle as a matter of law. This week marks the 36-year-anniversary of that seminal case, providing us the opportunity to discuss the federal government’s failure to adequately fund the healthcare institutions that serve American Indians and Alaska Natives despite its legal responsibility to do so.

Supreme Court Justice Thurgood Marshall penned the majority opinion of United States v. Mitchell.

The current life expectancy for American Indians and Alaska Natives is 73 years, 5.5 years less than that of the general population. American Indians die at higher rates from heart disease, cancer, diabetes, stroke, and kidney disease. When we consider why Native communities suffer from preventable and treatable diseases at disproportionate frequencies, we must first evaluate the inequity in Congressional funding for Indian Health Services (IHS), the national agency within the Department of Health and Human Services that is responsible for providing comprehensive healthcare to the country’s enrolled American Indians and Alaska Natives.

Data Source: Indian Health Service

Based on the most recent available data, per capita spending on Indian Health Services is far lower than any other federal health care agency, including Medicare, Medicaid, and the Bureau of Prisons. In 2016, Congress invested$3,337 per capita on Indian health care, compared to $5,000 on prisoners and $12,744 on Medicare beneficiaries. For anyone intent on remedying the perpetuation of chronic health disparities that afflict Native communities, Congress’ stark underfunding of IHS should be prioritized rectification.

Date Source: The National Tribal Budget Formulation Workgroup’s Recommendations of the Indian Health Service Fiscal Year 2019 Budget

According to a report published by the U.S. Commission on Civil Rights, an independent, bipartisan agency established by Congress, “Over the past 300 years, Native Americans have traded hundreds of millions of acres to the federal government in exchange for benefits to guarantee the survival and integrity of their tribes, including health care.” So why does the only population in the United States with a guarantee to healthcare at birth suffer from preventable diseases at grossly disproportionate rates? There is no easy answer to this question as it is both morally and legally reprehensible.

If we, as physicians, wish to see the actualization of the historical promises made by the U.S. government to its American Indian citizens, we must be aware of, and speak up for, the urgent need for increased funding to IHS. To be sure, this is not where the fight ends; more equitable health outcomes will only occur if we also target systemic inequality in housing, education, and income, but it is certainly a starting point we can all rally behind.

[1] There is no universally agreed-upon term for the first peoples of North America. In his influential 1998 essay, “I Am an American Indian, Not a Native American!” South Dakota activist Russel Means denounced “Native American” as a “generic government term used to describe all the indigenous prisoners of the United States.” Other activists, however, have provided differing perspectives. Ultimately, the decision lies with individuals among these communities. However, the authors of this post have selected the imperfect term “American Indian” because of its legal implications; at a 1977 United Nations conference in Geneva, the Native representatives unanimously elected the use of “American Indian,” which now predominates in legal settings.

Internist, Pediatrician, and Associate Professor at UCSF, Dr. Le is also the co-founder of two health equity organizations, the HEAL Initiative and Arc Health.

Sam Aptekar is a recent graduate of UC Berkeley and a current content marketing and blogging affiliate for Arc Health Justice.

This post originally appeared on Arc Health here.

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5 replies »

  1. “If we, as physicians, wish to see the actualization of the historical promises made by the U.S. government to its American Indian citizens, we must be aware of, and speak up for, the urgent need for increased funding to IHS. To be sure, this is not where the fight ends; more equitable health outcomes will only occur if we also target systemic inequality in housing, education, and income, but it is certainly a starting point we can all rally behind.”

    Let me educate the authors about Native Health – at least in Alaska.

    My wife and I lived in Alaska for 5 years while my wife was a nurse at the Alaska Native Medical Center (ANMC) in Anchorage. Natives there get excellent care, and it is the fly to hospital from remote native communities and the village medical clinics. There is no hesitation to jet difficult cases to Anchorage for care as all the outlying clinics are in daily communication with doctors at ANMC . Many native communities in Alaska also have the advantage of oil revenue to fund their communities. In Barrow for instance there is a state of the art hanger with ready to go emergency jet and helicopter – funding is not a problem. ANMC is now managed by natives, not by the federal government, as was the case when we lived in Alaska.

    The real problem with native health, at least in Alaska, is terrible diet, drugs, alcohol and just plain boredom from no fulfilling jobs or future in outlying villages, I suspect that is the case for all native communities in the U.S. Better health care will not solve these problems.

    Natives have the option of getting free education as well, but many are tied physiologically to their villages where there is little to no local support for leaving to pursue a better educated future.

    I am appalled at how the North American native has suffered it’s own holocaust (where is their museum) via white man’s brutal manifest destiny. However many native tribes used the white man to attempt to dominate, conquer and settle scores against other tribes – they were in fact tribal communities that did not unite to battle white man’s oppression. In Alaska there are generally 5 native tribes and during my wife’s time in ANMC there were, still to this day, conflicts between tribal members.

    Natives have the resources to fix this, but not the commitment to accept that their better future exists only off the reservation and local native villages. The past life will never come back.

  2. Use of this Blog will continue to decline without better editing, including me when appropriate.

  3. In effect, each American Indian historically became an emigrant on their own land. Our nation’s legal tradition of assumed property rights drove this immigration. They were not recognized as persons with standing by the USA until 1879. Within a Federal Court, Judge Elmer Gundy granted a writ of “habeus corpus ad subjiciendum” that had been filed in behalf of Chief Standing Bear of the Ponca Tribe. Two attorneys who worked for the Union Pacific railroad had filed the writ. The 1879 decision occurred 14 years after the 13th Amendment prohibited slavery.

    Simultaneously, our nation’s progressive loss of Social Capital has inordinately affected both our American Indian and African American citizens. We should also add our now burgeoning Central American immigrant population. Basic survival requires housing, good food, healthcare, employment and education as well as our First Amendment rights. All of these need an equitably driven variety of public and private institutions, at all scales.

    However, Social Capital is community driven and represents the ultimate driver of each person’s Well-Being. For the last 30 years, it is currently in a dramatically worsening phase as measured most precisely by our nation’s progressively worsening maternal mortality, childhood obesity, substance abuse, mass shootings and mid-life depression/disability.

    As a reminder, projects that offer early childhood education to children living in a poverty level household have a demonstrated 7:1 return on investment. And, projects that reduce community flooding risks have a 3-4:1 return on investment. So, I offer a contemporary definition of Social Capital.

    .”A community’s norms of Trust, Cooperation and Reciprocity that
    .its citizens are more likely to use for resolving the SOCIAL DILEMMAS
    .they encounter daily within their community’s Municipal Life
    .WHEN Caring Relationships broadly permeate
    .the social networks of the community’s citizens, especially
    .the enduring Caring Relationships connecting each citizen’s Family
    .with their Extended Family and Micro-Neighborhood Networks.”

    Amidst the turmoil of our nation’s social cohesion, let me remind you that 90% of the world’s citizens live in a nation without our enforced First Amendment rights of speech, press, religion, assembly and petition. However inequitably our nation has pursued these obligations to each person’s community neighbors, we still have the capability to honorably recognize the needs of our African Americans and Native Americans. In the midst of healthcare reform, it is JOB ONE.

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