Essay on "Home and Community-Based Waiver Services Program"

Essay 15 pages (3924 words) Sources: 1+

[EXCERPT] . . . .

Home and Community-Based Waiver Services Program in Alaska

Needs Statement.

According to Goins and Spencer (2005), the provision of services to specific populations, particularly those groups who face barriers to equity in healthcare, has always been an important focus of public health. The public health perspective outlines a societal approach to protecting and promoting health, which emphasizes prevention, macro-level interventions, and the reshaping of public policy. A primary difference between public health and the more biomedical model is that the government often subsidizes care providers in public health, with a focus on preventing, rather than curing, disease (Goins & Spencer, 2005).

Older American Indians and Alaska Natives (AI/ANS) life expectancy has increased dramatically since the early 1970s. This increase, from 63.5 years in 1972 to 73.2 years in 1994, is largely attributed to the efforts of the Indian Health Service (IHS) to eliminate infectious disease and meet the acute-care needs of AI/ANS (Goins & Spencer, 2005). Despite these improvements, much remains to be done to bring the healthcare standards of these peoples up to the national standard. In this regard, Padgett (1999) emphasizes that, "Problems with health and mental health that face older American Indians and Alaska Natives are widespread and likely to intensify if current trends continue. Several publications have detailed their excess morbidity and mortality and in comparison with whites and other ethnic minorities" (p. 139).

The IHS reports that The Alaska Area Indian Health Service (IHS) works in conjunction with Alaska Native Tribes and Tribal Organizations (T/TO) to provide comprehensive health services to 139,107 Alaska Natives (Eskimos, Aleuts, and Indians). Approximately 99% of the Alaska Area budget is managed by T/TOs pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended. The Alaska Area negotiates and administers 14 Title I contracts and one Title V compact with 25 separate tribal funding agreements. The latter has resulted in the Alaska Tribal Health Compact, which sets forth terms and conditions for tribal management of a comprehensive system of health care that covers all 228 federally recognized tribes in Alaska.

IHS-funded, tribally-managed hospitals are located in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka. There are 37 tribal health centers, 166 tribal community health aide clinics and five residential substance abuse treatment centers. The Alaska Native Medical Center in Anchorage is the state-wide referral center and gatekeeper for specialty care. Other health promotion/disease prevention programs that are state-wide in scope are operated by the Alaska Native Tribal Health Consortium (ANTHC), which is managed by representatives of all Alaska tribes.

There are 37 residual positions in the Alaska Area IHS, which perform inherently federal functions that cannot be contracted to T/TOs. The Alaska Area supports USPHS Commissioned Corps officers and civil service employees to T/TOs to aide them in the provision of health services. Additionally, to address the critical shortage of medical providers in remote facilities, the Alaska Area IHS awards federal personal services contracts for itinerant and emergency providers to work in tribal facilities. During FY 2010, providers hired through Area Office PSCs numbered 44 dentists, 27 physicians, 3 nurses, 20 pharmacists, 3 optometrists and 4 nurse practitioners. Other federal agencies such as the Arctic Investigations Laboratory of the Centers for Disease Control (CDC), work closely with the Alaska Area IHS and the tribes to improve the health status of Alaska Natives. The Indian Health Service still holds title to six tribally operated hospitals and three tribally operated health centers in Alaska, and is responsible for their maintenance (Alaska Area Indian Health Service, 2011).

Although the life expectancy of AI/ANS has improved, it is still below the national average. Certain demographic characteristics make older AI/ANS particularly vulnerable to experiencing health disparities, compared to the general population. Poverty and low educational levels are common among AI/ANS; 27% of AI/ANS ages 65 to 74 live below the poverty level, compared to 10% of the general population and 8% of Caucasians, and one-third of AI/AN elders age 75 years or older live in poverty, compared to 17% for the general population and 15% for Caucasians. Some 8.9% of AI/ANS have a bachelor's degree or higher, compared to 20.3% of the general population and 21.5% of Caucasians. Taken together, poverty and low educational levels are strongly associated with poor health and an increased likelihood of chronic and disabling conditions (Goins & Spencer, 2005).

As they have for other ethnic groups, the most notable population health problems experienced by AI/ANS have shifted from infectious diseases to chronic diseases. Two of the most prevalent chronic diseases among older adults in this group are diabetes and arthritis. AI/AN elders experience some of the highest rates of diabetes in the world. In general, diabetes is four to eight times more common among AI/ANS than among the overall U.S. population. The prevalence of arthritis is also greater among AI/ANS than among non-AI/ANS, a difference most likely genetic in origin. Furthermore, the age of disease onset may be earlier. For example, half of one reservation population with rheumatoid arthritis was diagnosed with the disease before age 35, much earlier than is commonly found among non-AI/ANS. Mounting evidence suggests that such chronic and disabling diseases among AI/ANS are increasing and represent substantial healthcare costs (Goins & Spencer, 2005).

One of the strongest determinants of use of long-term care, either institutionalized or non-institutionalized, is health and functional status. Estimates suggest that AI/AN elders experience some of the highest physical disability rates of any U.S. ethnic group. While African-Americans are more likely than Caucasians to experience the disadvantages of shorter life and longer periods of health impairment, for AI/ANS, the levels of impairment and length of inactive life are the highest among all ethnic groups, with approximately 50% to 60% of the later years spent with disabilities (Goins & Spencer, 2005). Thus it is not surprising that long-term-care provision is especially important in Indian Country, because of the socioeconomic disadvantages to which AI/ANS are subject and the growing rates of chronic disease and physical disability that they experience, as described above. While one of the core functions of public health is to ensure that all populations have access to appropriate care, a number of issues present particular problems in delivery of services-especially provision of long-term care. Distinctive factors related to culture, AI/ANS political status, and related implications for health policy appear to compound the problems of low socioeconomic status and poor health for AI/ANS (Goins & Spencer, 2005).

Federally recognized tribes have a unique political status that has influenced provision of public health services that is based on the sovereignty of federally recognized tribal governments, the treaty-making process under which the U.S. assumed certain responsibilities to tribal governments, and the resulting federal-Indian relationship. A breakdown of the native peoples of Alaska is provided in Table __ below.

Table

Breakdown of Native Peoples of Alaska

Native People

Description/Status

Eskimos

More than half of all Alaska Natives are Eskimo. The two main Eskimo groups, Inupiat and Yupik, differ in their language and geography. The former live in the north and northwest parts of Alaska and speak Inupiaq; the latter live in southwest

Alaska and speak Yupik. Few Eskimos can still speak their traditional Inupiaq or Yupik language as well as English. Along the northern coast of Alaska, Eskimos are hunters of the bowhead and beluga whales, walrus and seal. In northwest Alaska, Eskimos live along the rivers that flow into the area of Kotzebue Sound. Here, they rely less on sea mammals and more upon land animals and river fishing. Most southern Eskimos live along the rivers flowing into the Bering Sea and along the Bering Sea Coast from Norton Sound to the Bristol Bay region.

Aleuts

Most Aleuts originally lived in coastal villages from Kodiak to the farthest Aleutian Island of Attu. They spoke three distinct dialects, which were remotely related to the Eskimo language. When the Russians came to the Aleutian Islands in the 1740s, Aleuts inhabited almost every island in the chain. Now, only a few islands have permanent Aleut villages. Severe and unpredictable weather conditions in the Aleutian Islands make transportation both expensive and time-consuming. The region is dependent on the fishing industry, which is variable from year to year.

Interior Indians

The Athabascans inhabit a large area of Central and Southcentral Alaska. They may have been the first wave of Natives to cross the land bridge over 15,000 years ago. Although their language is distinct, they may be linguistically related to the Navajo and Apaches of the Southwest U.S. There are eight Athabascan groups in Alaska. Characteristics of all eight groups include similar language, customs and beliefs.

Source: Indian Health Service Alaska Area Services (2011)

The Indian Health Service is a federal agency in the U.S. Department of Health and Human Services that provides free healthcare to tribally enrolled AI/ANS, more than 1.6 million individuals, principally through the operation of sixty-one health centers and thirty-six hospitals (Goins & Spencer, 2005). It should be noted, though, that the provision of these healthcare services is constrained by the vast… READ MORE

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