This study documented the health status and access to health care services of American Indians in California, especially those in tribes that are not federally recognized. Through analysis of vital statistics and other databases, comparisons were made between California Indians who are members of federally recognized tribes and those who are not. On the basis of these and other comparisons, American Indians in non-federally recognized tribes in California generally were found to have poorer health status than those in federally recognized tribes. The health status of both groups is inferior to that of other populations, underscoring the importance of maintaining and expanding coverage to the entire American Indian population of California.
The Indian Health Service (IHS) provides comprehensive health care to American Indians and Alaska Natives throughout the United States. By Federal law, care is given to members of federally recognized tribes, except in California and a few other States, where care is given to all Indians, not just those who are members of federally recognized tribes.
This study analyzes and interprets numerous data sources to enhance understanding of the health status of American Indians in California, including members of federally recognized and non-federally recognized tribes.
In 1990, an estimated 242,000 American Indians resided in California. Approximately 100,000 are registered at California Indian tribal health clinics. According to IHS records, about 26,000, or one-fourth, are not members of a federally recognized Indian tribe of California. If they seek IHS-funded care in the State, they must rely on tribally operated facilities that operate under contract to the IHS. Throughout the State, there are a total of 21 tribally operated rural clinics, 7 Indian urban health programs, and 13 freestanding Indian alcoholism programs. Even though there are no tribally operated inpatient services, IHS provides for inpatient care through contracts with local providers.
In most States, IHS-funded health care is limited by law to members of federally recognized tribes. But in California, as well as some other States, there has been a longstanding tradition of providing care to all Indians, not just those in federally recognized tribes. This practice was codified in 1988 with Federal legislation, the Indian Health Care Amendments of 1988.
At the time this report was undertaken, information about IHS-funded care provided to California Indians was limited because participation in IHS reporting systems had only recently begun. In addition, the information systems of many non-Indian health care facilities either did not identify Indian clients or did not identify them correctly. Little was known about whether membership in a federally recognized tribe had an impact on health status.
The study conducted by the University of California, San Francisco, compared the health status of California Indians--including members of non-federally recognized tribes--with that of all Californians. On some measures, comparisons were made with Indians throughout the United States and/or with the U.S. population as a whole. The study relied on numerous existing sources of data, such as vital statistics, hospital discharge records, infectious disease case reports, and client and financial data (especially from California's Medicaid system). Information was also gathered from selected State and Federal health and welfare programs.
All persons identified as American Indian or Alaska Native were included in these analyses. Because federally recognized status could not be identified from vital statistics, inferential measures were used to classify California counties according to whether they were Indian or non-Indian counties. The Indian counties were further subdivided into those whose residents were primarily members of a federally recognized tribe and those whose residents were primarily not members of federally recognized tribes. Thus, residents of "non-federally recognized counties" were, for the purposes of the study, considered to be California Indians who were primarily members of non-federally recognized tribes.
In addition to using existing data sources, researchers collected information on a sample of 348 California Indians age 18 and older who were not members of federally recognized tribes. This information was collected by tribal health programs from patient registration files in tribal clinics. The information included current sources of health care, resources for payment, and availability and accessibility of alternatives to IHS-funded care.
Based on multiple measures, the health status of California Indians in non-federally recognized tribes was determined to be no better and, in some ways, worse than that of California Indians in federally recognized tribes. And those in federally recognized tribes generally had poorer health status than Californians as a whole.
From 1986 through 1988, 10.9 percent of all California births were to teenagers (women under the age of 20). Yet, 16.7 percent of all California Indian births were to teenagers, and an even higher proportion, 20.7 percent, were to Indian teenagers in non-federally recognized counties in California. Births to teenagers were most common in areas where Indian clinics were least available.
Among California Indian babies born during this time, 6.4 percent had low birth weight, compared with a statewide figure of 5.2 percent for whites and Hispanics. Only 68.3 percent of pregnant California Indians received prenatal care in their first trimester, compared with 74.4 percent of all pregnant Californians. In non-federally recognized California counties, 9.1 percent of pregnant Indians received late (third trimester) or no prenatal care, versus 7.6 percent of those in federally recognized counties.
Alcohol and tobacco use were found to have a major impact on the health of California Indians, irrespective of tribal status. Chronic liver disease and cirrhosis caused a higher proportion of deaths among California Indians (6.7 percent) than among all Indians in the United States (4.3 percent) and the total population of California (1.9 percent). Overall, 33.6 percent of deaths among Indian women and 42.1 percent of deaths among Indian men were alcohol-related, compared with 4.3 percent for women and 8.4 percent for men of all races in California.
Also in the years 1986 through 1988, 41.7 percent of deaths among Indian women and 37.4 percent of deaths among Indian men were attributed to cigarette smoking, compared with 12.4 percent and 17.8 percent of all female and male deaths, respectively, among all races in California.
Premature mortality was also a serious problem among California Indians. Deaths in that population between 1986 and 1988 were more than twice as likely to occur before the age of 45 than statewide (28.4 percent versus 13.3 percent). Mortality under the age of 25 accounted for 11.2 percent of Indian deaths, compared with 5.3 percent of all deaths in California.
The survey of members of non-federally recognized tribes revealed that 60 percent identified local tribal health programs as their usual source of care. They experienced restricted access to other sources of health care, given that 33 percent reported no health coverage. Members of non-federally recognized tribes were found to have unmet needs for a variety of health services, such as dental care, diabetic and orthopedic supplies, and eyeglasses.
Use of Results
The results suggest that access to IHS-funded tribal health programs and clinics in California is essential for non-federally recognized California Indians. There is no evidence that resources outside the IHS are adequate to meet their health care needs. In addition, tribally operated health services provide a valued source of care for those who prefer Indian-specific and culturally competent services. Restrictions in eligibility or inadequate levels of funding could have serious health consequences.
Study findings have broad implications for health promotion and disease prevention among California Indians. Strategies are particularly important for reducing tobacco and alcohol consumption, lowering rates of heart disease, expanding cancer screening programs, preventing accidents, and increasing early prenatal care.
Highlights are available through the Monograph Series of the Institute for Health Policy Studies, University of California, San Francisco: American Indians in California: Health Status and Access to Health Care.
Indian Health Service
Leo J. Nolan
Division of Program Evaluation and Policy Analysis
Indian Health Service
12300 Twinbrook Parkway, Suite 450
Rockville, MD 20857
(301) 443-4700 Fax: (301) 443-1522
University of California, Los Angeles, CA