Macro- and meso-level contextual influences on health care inequities among American Indian elders

Abstract

Background American Indian elders, aged 55 years and older, represent a neglected segment of the United States (U.S.) health care system. This group is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other aging populations in the country. Despite the U.S. government’s federal trust responsibility to meet American Indians’ health-related needs through the Indian Health Service (IHS), elders are negatively affected by provider shortages, limited availability of health care services, and gaps in insurance. This qualitative study examines the perspectives of professional stakeholders involved in planning, delivery of, and advocating for services for this population to identify and analyze macro- and meso-level factors affecting access to and use of health care and insurance among American Indian elders at the micro level. Methods Between June 2016 and March 2017, we undertook in-depth qualitative interviews with 47 professional stakeholders in two states in the Southwest U.S., including health care providers, outreach workers, public-sector administrators, and tribal leaders. The interviews focused on perceptions of both policy- and practice-related factors that bear upon health care inequities impacting elders. We analyzed iteratively the interview transcripts, using both open and focused coding techniques, followed by a critical review of the findings by a Community Action Board comprising American Indian elders. Results Findings illuminated complex and multilevel contextual influences on health care inequities for elders, centering on (1) gaps in elder-oriented services; (2) benefits and limits of the Affordable Care Act (ACA); (2) invisibility of elders in national, state, and tribal policymaking; and (4) perceived threats to the IHS system and the federal trust responsibility. Conclusions Findings point to recommendations to improve the prevention and treatment of illness among American Indian elders by meeting their unique health care and insurance needs. Policies and practices must target meso and macro levels of contextual influence. Although Medicaid expansion under the ACA enables providers of essential services to elders, including the IHS, to enhance care through increased reimbursements, future policy efforts must improve upon this funding situation and fulfill the federal trust responsibility.

Causes and Consequences of Not Having a Personal Healthcare Provider Among American Indian Elders: A Mixed-Method Study

“…In this research, experiences of barriers, fear/distrust, and a high level of self-sufficiency (either voluntary or because they had no one else to help them) were interconnected; at least half of the Elders who did not have a personal healthcare provider described some combination of these factors as influencing their decisions about seeking healthcare. Barriers to care—including difficulty making appointments, lack of transportation, and cost of medical care—are pervasive sources of health inequity in this population; analyses of these barriers and recommendations to ameliorate them are detailed in our previous work ( 16 , 17 , 20 , 36 , 40 ). In addition to these challenges, this analysis also underscores the role of fear, mistrust, and negative associations related to healthcare.…”

“…Addressing the barriers to care that hinder the formation of a reliable relationship with a healthcare provider for some American Indian Elders will require multilevel interventions, as we discuss in other publications. Key strategies include increasing health systems navigation to improve overall access to healthcare and connect reluctant patients with healthcare providers, workforce improvements to address turnover and continuity of care, and changes to health policy and funding at the state, tribal, and federal levels to establish and sustain a full complement of healthcare services that Elders need ( 17 , 36 , 40 ). However, the perspectives of Elders in this study also indicate that increasing access to care is not sufficient in itself to overcome the fear and distrust that deters some Elders from seeking care ( 16 ).…”

Types of Racism and Health Disparities and Inequalities among Cancer Patients: An Editorial Reflection of Articles in This Special Issue of IJERPH

“…Racism in the healthcare system not only increases the unmet needs of patients from minoritized groups, as described in a landmark publication from the Institute of Medicine [ 26 ], but has also increased the likelihood of the onset of various chronic diseases [ 27 , 28 ]. Disproportional increases in diseases in marginalized communities are also an example of health disparities and health inequalities.…”

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