Social Determinants of Health Among Rural American Indian and Alaska Native Populations
American Indian and Alaska Native (AI/AN) populations living in rural counties face socioeconomic challenges. The most obvious of these is poverty at both the individual and the community level. More than a quarter (28.8%) of AI/AN rural residents experience household poverty; this is more than twice the proportion among White rural residents. In addition, more than half of rural AI/AN residents (60.9%) live in counties that fall into the worst quartile for poverty. Relatedly, half of rural AI/AN individuals (50.7%) live in counties falling in the worst quartile for unemployment. Persons living in a high-poverty, low-opportunity context are hampered in efforts to change individual and family status.
Community poverty translates into a shortage of healthcare resources. AI/AN rural residents are more likely than their White peers to live in counties that are health professional shortage areas. This situation is not fully alleviated by AI/AN access to Indian Health Service (IHS) facilities and providers. Persons receiving care from the IHS are considered medically uninsured because there is no standard benefit that must be provided. Absence of standards is perceived to allow for historic underfunding of this service. Other options for providing access to care, such as Medicaid, vary regionally. Several states with high concentrations of rural AI/AN residents have not expanded Medicaid (South Dakota, Wyoming, Oklahoma). In addition, multiple states are considering or have acquired a waiver allowing the imposition of work requirements on adult Medicaid beneficiaries (Arizona, New Mexico, Montana, South Dakota, Utah) that may be difficult to meet in counties that have high levels of unemployment.
In the remote counties where many rural AI/AN populations live, options for rapidly improving health are difficult to envision. Governmental and philanthropic entities may wish to develop targeted programs for empowering AI/AN communities to improve local educational structures and to recruit potential employers as a necessary first step to improving health. Recruitment and retraining for AI/AN health professionals is also needed. Technological solutions, such as telehealth, should be addressed cautiously; standards need to reflect the culture and needs of varying populations.