For some residents of the Confederated Tribes of the Colville Reservation, seeing a doctor isn't that easy.
The Indian Health Service clinic, which serves more than 5,000 residents in northeast Washington, has only one doctor, long wait times for appointments — if one is even booked by phone — and, like other Indian Health Service facilities in the northwest, the Colville Service Unit does not offer specialty medical care, forcing residents to drive to cities like Spokane for such care.
Jared Michael Erickson, chairman of the Confederated Tribes of the Colville Reservation, said delays and staffing shortages at Indian Health Service facilities on the reservation have led some tribal members to avoid using the facilities altogether.
Courtesy of the Confederated Tribes of the Colville Reservation
The barriers to access are so severe that some Colville tribal members have stopped using the clinic altogether, according to Colville Tribal Chairman Jared Michael Erickson.
“I think some people got fed up,” Erickson said. “I still go in there from time to time, but even for me personally, I don't trust that things are going to be done and handled properly.”
A new report finds that the lack of access to quality health care and the resulting negative health effects for tribal members reflects broader issues for Native Americans and Alaska Natives across Washington state. Native Americans and Alaska Natives live shorter lives, suffer from higher rates of preventable and treatable diseases, and die more frequently from those diseases than white Washingtonians, yet have significantly less access to health care, according to the report from the Commonwealth Fund, a nonprofit that works to improve access to health care.
The report ranked health systems' performance for different ethnic groups on a scale of 100.
Whites in Washington scored 87 points.
Native Americans and Alaska Natives in Washington state received eight points.
These scores reflect a long-standing problem, and by many measures, the problem is getting worse. According to a regional dataset of IHS statistics examined by InvestigateWest, separately from the Commonwealth Fund report, the health of Native Americans has worsened category by category as the health of the non-Native American population has improved.
At the root of the crisis, experts say, is basic access to health care. About 20% of Native Americans and Alaska Natives in Washington state have no supplemental health insurance outside of the IHS, according to the Commonwealth Fund. The IHS, which is charged with carrying out the federal government's trusteeship duty to provide health care to tribal members, is chronically underfunded.
“People who can only get health care through the Indian Health Service are still considered uninsured, and I think that's starting to become a key differentiator here,” said report author David Radley, a senior scientist at 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 health care is in your state. If you don't have health insurance, when people can't go to the hospital, you can have the best health care in the world, but if everyone can't get out, it doesn't mean much.”
More than just numbers
Over the past 24 years, life expectancy at birth has increased for all racial groups in Washington state except for Native American and Alaska Native people, whose life expectancy has declined by about two years since 2000.
According to Washington State Department of Health data highlighted in the Commonwealth Fund report, the life expectancy of Native Americans or Alaska Natives living in Washington state is just 71.6 years, while the life expectancy of white people in Washington state is 79.9 years.
In Washington state, Native Americans under age 75 are more than twice as likely to die from treatable causes such as COVID-19 and type 2 diabetes as white people, and are nearly three times as likely to die from entirely preventable causes, including certain cancers that can be effectively treated if caught early, as well as higher rates of obesity and heart disease.
Despite the stark and well-known health disparities, the federally run IHS lacks sufficient and consistent funding, forcing patients to delay or seek care selectively, tribal officials and researchers say.
The Indian Health Service, like the VA, is a federally run health care provider, but it operates under a different budget structure that requires Congressional approval rather than guaranteed funding, making funding less consistent from year to year. It also receives significantly less per beneficiary than programs like Medicare: in 2019, the Indian Health Service received $4,076 per beneficiary, compared with $15,027 for Medicare, according to a Government Accountability Office report.
The agency acknowledges that with current funding levels it can only treat about half of its patients, and encourages IHS patients to buy private insurance to supplement the care the agency provides.
On the Colville Reservation, eligible patients stop using IHS services altogether, creating the false impression of a decline in actual service population and further reducing funding for the Colville Service Unit, Erickson said.
Experts say IHS's low budget and unstable funding structure undermine nearly every element needed to reduce health disparities facing Native Americans, making it difficult to recruit and retain health care providers and maintain facilities.
Because IHS does not operate any hospitals in Washington state and there is only one IHS-funded oncology center in the entire state, all patients must be referred to outside providers for specialty care and hospital treatment.
IHS clinics often operate with vacancies for long periods of time and, as in the case of the Colville Reservation, sometimes operate with only one doctor or dentist for the entire reservation.
For Colville residents who use IHS, specialty care is out of reach: The nearest providers of dental or specialty care are often more than 100 miles away, in places like Wenatchee, Spokane or even Seattle. IHS patients must obtain a referral to receive care outside the agency's facilities, and sometimes there aren't even enough staff to make the initial referrals.
Even if Colville residents do manage to get a referral, traveling long distances to get medical care is expensive; Erickson said the Colville tribal government often even covers gas and hotel fees for residents who can't afford it. The Indian Health Service did not respond to Investigate West's request for comment.
But many IHS patients in Washington state – 54 percent – live in small towns on or near reservations and may not have local alternatives.
Lack of access to medical care, including screening for diseases like diabetes and colon cancer, leads to treatable and preventable illnesses going untreated and premature death. According to the Commonwealth Fund, lack of or delayed access to medical care contributes to a disproportionately higher rate of deaths from preventable and treatable causes before age 75 among Native Americans in Washington state.
“It starts with coverage,” Radley says. “If you have health insurance, you're better equipped to navigate the rest of the health care delivery system. You're less likely to forego care because of cost, and you're more likely to address chronic disease management. … Even better, if you have a primary care physician who understands your situation, who delivers care in a culturally sensitive way, who understands your situation, those are really important, and it all starts from there.”
Worsening Inequality
An InvestigateWest analysis of data reported by the Indian Health Service as part of its compliance with the Government Performance and Results Act (GPRA) found that service areas in Oregon, Washington and Idaho consistently underperformed across a range of metrics over a six-year period.
Across five randomly selected indicators measured by the IHS, the Pacific Northwest was shown to perform worse in general access to dental services, people with diabetes who had adequately controlled blood pressure, childhood vaccination rates, adult depression screening, and general blood pressure control.
On the Colville Reservation, a variety of issues at the IHS clinic have stopped some patients from receiving preventive care.
“Patients may go to the doctor and seek medical attention to get the care they need, but many people end up procrastinating on those treatments,” Erickson said. “Preventive measures, things that could be detected early, become a big problem, and people end up just putting it off and waiting because they don't get the care they need or are afraid they won't get it.”
Native Americans and Alaska Natives in Washington state have higher death rates from heart disease, cancer and diabetes than any other racial group, according to the Washington State Department of Health. Native Americans and Alaska Natives in Washington state also have higher death rates from depression and suicide than any other racial group, according to data from the Washington State Department of Health.
Indicators reflecting the health of Native American and Alaska Native infants and mothers in Washington state also rank lowest of any group. Infant mortality and preterm birth rates are higher than any other group, and Native American and Alaska Native mothers are the least likely to receive prenatal care early in pregnancy and the least likely to receive postpartum maternal care.
In 2019, the Washington State Legislature passed Senate Bill 5415, which mandates the creation of the Governor's Indian Health Advisory Council to address issues in the state's Indian Health System. The council includes representatives from tribes, Indian Health, legislators and state agencies.
The advisory committee meets regularly to discuss data, Indian health issues, and potential policies. The committee has highlighted that poor quality and incomplete data are obstacles to addressing the true extent of disparities between Native Americans and other racial groups.
In its 2022-2023 biennial report, the council said the incomplete reports, which are built primarily from state and federal datasets and don't always include relevant tribal information, make it difficult to truly understand disparities, develop policy, strategic plans and allocate appropriate resources.
Lack of tribal data sovereignty is another barrier, according to the advisory committee, which noted there has been little investment in supporting tribal workforce development or improving tribal systems and technological capabilities to help track related issues, such as racial misclassification, which poses major challenges to accurately monitoring Native American and Alaska Native health experiences.
According to the Northwest Tribal Epidemiology Center, racial misclassification in Washington, Oregon and Idaho occurs in about 10 percent of birth and death certificates and 60 percent of hospital records for Native American and Alaska Native people.
Beyond the data, the advisory committee's report points to a fundamental lack of trust in the health care system, due to intergenerational trauma, decades of abuse and a continuing failure to provide adequate care.
“Forcing American Indian and Alaska Native residents to work with institutions that can only see the world through the lens of mainstream Western culture is a form of assimilation that, combined with intergenerational trauma, can make navigating state programs and requirements emotionally draining,” the report states. “Improving AI/AN health outcomes and improving Washington's Indian health care delivery system requires eliminating systemic barriers to health improvement.”
For Colville Service Unit patients who have the means to get care outside of IHS, the risks associated with relying on an agency for care, such as lack of follow-up or lost prescriptions, outweigh the benefits, Erickson said.
“For some people it's a matter of life and death,” Erickson said.
InvestigateWest (invw.org) is an independent news nonprofit specializing in investigative journalism in the Pacific Northwest. Reporter Melanie Henshaw covers Native American issues and communities in the region. To contact her directly, please email [email protected] or (971) 258-1430.
