Report lays bare stark disparities in health care outcomes for Native Americans in Washington

A citizen of the Confederated Tribes of the Colville Reservation waits for her COVID-19 vaccination in this 2021 photo at Colville Tribes Indian Health in Nespelem, Washington. The Indian Health Service has a single doctor for the reservation, serving a population of about 5,000. (Photo by Tyler Tjomsland / Spokesman-Review)

For some citizens of the Confederated Tribes of the Colville Reservation, it’s not so easy to see a doctor.

There’s a single physician at the Indian Health Service clinic that serves a population of more than 5,000 in northeastern Washington. Wait times for appointments are long — and that’s if you can get a call back to schedule one. And, like other IHS facilities in the Northwest, the Colville Service Unit does not provide specialty care, forcing citizens to drive to Spokane or other cities for those treatments.

The impediments to access are so severe that some Colville tribal citizens are turning away from using the clinic entirely, according to tribal Chairman Jarred-Michael Erickson.

“Some just got, I think, sick and tired of it,” Erickson said. “I still go there for occasional things, but even me personally, I can’t trust that things will be done or handled properly.”

A lack of access to quality health care — and the resulting deleterious effects on the health of tribal citizens — reflects a widespread problem affecting Native Americans and Alaska Natives across Washington, a new report finds. Native Americans and Alaska Natives are living shorter lives, suffering from higher rates of preventable and treatable diseases — and dying from them more often — while living with dramatically worse access to health care when compared with white Washingtonians, according to the report from the Commonwealth Fund, a nonprofit dedicated to improving health care access.

The report ranked the health system performance for different ethnic groups on a 100-point scale.

White Washingtonians scored an 87.

Native Americans and Alaskan Natives in Washington scored an 8.

Those scores reflect long-standing problems, and they’re worsening, according to many measures. A regional dataset of IHS statistics reviewed by InvestigateWest, which is separate from the Commonwealth Fund report, shows that in category after category, health outcomes for Native Americans worsen as the non-Native American population’s health improves.

At the root of the crisis is basic access to care, experts say. Nearly 20% of Native Americans and Alaska Natives in Washington lack supplemental health insurance beyond IHS, according to the Commonwealth Fund. The IHS, which is charged with carrying out the federal government’s trust obligations to provide medical care for tribal citizens, is chronically underfunded.

“If somebody only has access to health care through the Indian Health Service, they’re still considered to be uninsured, and that, I think, really starts to be the sort of the key differentiator here,” said the report’s author, David Radley, who is a senior scientist for the Commonwealth Fund and director of data analytics at Oregon Health & Science University.

“If you don’t have health insurance, it doesn’t matter how good the quality of care in your particular state is — without health insurance, when people can’t get in the door, you guys can have the best health care in the world. But if everyone’s stuck outside, it doesn’t really matter.”

More than numbers

For the past 24 years, life expectancies for Washingtonians of all racial groups grew — except for Native Americans and Alaska Natives, whose average life expectancy has decreased by about two years since 2000.

A Native American or Alaska Native living in Washington has a life expectancy of just 71.6 years, compared with white Washingtonians’ life expectancy of 79.9 years, according to data from the Washington Department of Health that was highlighted in the Commonwealth Fund report.

Deaths before age 75 from treatable causes, like COVID and Type 2 diabetes, for Native Americans are more than double that of white people in Washington and nearly three times as high from entirely preventable causes, such as certain cancers that can be effectively treated if detected early, as well as higher incidences of obesity and heart disease.

Despite the well-known, stark disparities in health outcomes, the federally operated IHS lacks adequate, stable funding, forcing patients to delay or seek care selectively, according to tribal officials and researchers.

The Indian Health Service is a federally operated health care provider, similar to the Veterans Administration, but it operates under a different budget structure that requires congressional approval for its annual budget rather than guaranteed funds. That renders its funding unstable year to year. It also receives substantially fewer dollars per beneficiary compared to programs like Medicare, with the Government Accountability Office reporting IHS received $4,076 per beneficiary in 2019, compared with $15,027 for Medicare.

The agency admits it can only treat roughly half of the people it is responsible for under its current funding level, recommending that those who utilize IHS obtain a private insurance policy to supplement the care it offers.

On the Colville Reservation, as more eligible patients turn entirely away from using IHS services, it creates the false impression that the actual service population decreased — resulting in even less funding for Colville Service Unit, according to Erickson.

IHS’ low budget and unstable funding structure undercuts virtually every element necessary to reduce health disparities facing Native Americans, according to experts, making it hard to recruit and retain providers and maintain facilities.

IHS does not operate a single hospital in Washington, and there is only one IHS-funded oncology center statewide, meaning all patients must be referred to outside providers for specialty and hospital care.

IHS clinics often operate with long-standing vacancies, sometimes functioning with only a single doctor or dentist for an entire reservation, like the Colville Reservation.

For citizens of the Colville Tribes who use IHS, specialty care is out of close reach — the nearest providers for dental and specialty medical care are often 100 or more miles away in Wenatchee, Spokane and even Seattle. IHS patients must obtain referrals to receive care outside agency facilities, and at times there isn’t even enough staff to provide the initial referrals.

If a Colville citizen does manage to obtain a referral, the long-distance trips for medical care are costly. The Colville Tribes’ government often foots the bill for gas and even hotel stays for citizens who can’t afford it, according to Erickson. The Indian Health Service did not respond to requests for comment by InvestigateWest.

But for many IHS patients in Washington, 54% of whom live in small towns on or near reservations, there may be no alternative locally.

Without access to health care that includes screenings for conditions like diabetes or colon cancer, treatable and preventable conditions go unaddressed, leading to premature death. Inaccessible and delayed care contributes to disproportionate rates of Native Americans in Washington dying from preventable and treatable causes before age 75, according to the Commonwealth Fund.

“It starts with coverage,” Radley said. “When a person has got health insurance coverage, it makes the rest of the care delivery system available to them — they’re less likely to skip care because of its cost, they’re more likely to engage in chronic disease management. …  Even better, if you have a primary care doc who knows your circumstances (and) can provide care in a culturally sensitive way, and understands your context — those things are so critical and so important, and everything stems from that.”

Worsening disparities

An InvestigateWest analysis of data reported by the Indian Health Service as part of compliance with the Government Performance and Results, or GRPA, reflects consistently poor performance in the Oregon, Washington and Idaho service area over six years across a variety of metrics.

Across five randomly selected metrics measured by IHS, the Pacific Northwest showed worsening performance in each: general access to dental services, diabetics with appropriately controlled blood pressure, childhood immunization rates, adult depression screenings and general controlled blood pressure.

On the Colville Reservation, the myriad issues with the IHS clinic stop some patients from seeking preventive care.

“They could be going in, getting to a provider for stuff that needs to be seen, but a lot of people end up letting stuff like that linger,” Erickson said. “Preventative things, things that could be caught early, turn into big issues, and then they’re dealing with them because they weren’t getting the care they needed or were afraid they wouldn’t get the care they needed so they just held off, waited.”

Native Americans and Alaska Natives in Washington die from heart disease, cancer and diabetes at higher rates than any other racial group, according to the Washington Department of Health. The state’s Native Americans and Alaska Natives also report higher rates of depression and deaths from suicide than any other racial group, Washington DOH data shows.

Metrics reflecting infant and maternal health for Native Americans and Alaska Natives  in Washington also rank lowest of any group. Their rate of infant mortality and premature births is highest among any group, and Native American and Alaska Native mothers received the lowest rate of prenatal care in the first trimester of pregnancy and the lowest rate of postpartum visits for the mother.

In 2019, the Washington Legislature enacted Senate Bill 5415, mandating the creation of the Governor’s Indian Health Advisory Council to address issues in the state’s Indian health system. The group includes representatives from tribes, Indian health, legislators and state agencies.

The advisory council meets periodically to discuss data, Indian health issues and potential policy. It highlights poor and incomplete data as a barrier to addressing the true scope of disparities between Native Americans and other racial groups.

In its 2022-2023 biennial report , the council said incomplete reports drawn primarily from state and federal datasets don’t always include relevant tribal information, meaning it is difficult to truly understand the disparities, develop policy, make strategic plans and allocate the proper resources.

Lack of data sovereignty for tribes is another barrier, according to the advisory council, which notes there’s little investment in supporting tribal workforce development or improving tribal systems or technological capabilities that would help to better track relevant issues, like racial misclassification, which is a major problem for accurate monitoring of the health experiences of Native Americans and Alaska Natives.

Racial misclassification in Washington, Oregon and Idaho occurs in roughly 10% of birth and death certificates of Native Americans and Alaska Natives and in 60% of hospital records, according to the Northwest Tribal Center for Epidemiology.

Beyond data, the advisory council’s report notes a fundamental lack of trust in the health care system, resulting from intergenerational trauma and decades of abuse and compounded by ongoing failures to provide adequate care.

“To force the (American Indian and Alaska Native) population to work with agencies that only see the world from mainstream western cultural views is a form of assimilation and, compounded with intergenerational trauma, can make maneuvering through State programs and requirements emotionally exhausting,” the report said. “Institutional barriers to health improvement must be eliminated to raise the health status of AI/AN and improve the Indian health delivery system in Washington.”

For patients of the Colville Service Unit who have the means to seek care outside of IHS, the risks associated with relying on the agency for care, like a lack of follow-up or missing prescriptions, outweigh the benefits, according to Erickson.

“For some, it could be life and death,” Erickson said.

This article was first published by InvestigateWest (invw.org), an independent news nonprofit dedicated to investigative journalism in the Pacific Northwest.