The COVID-19 emergency poses significant risks to the more than 5 million individuals who identify as American Indian and Alaska Native (AIAN) alone or in combination with another race. AIAN people live across the country, but are concentrated in certain states, with about half living in seven states (CA, OK, AZ, TX, NM, WA, and NY). Under treaties and laws, the federal government has sole responsibility for providing health services to NAIA people. The NAIA population faces disproportionate risks from the COVID-19 epidemic, given the significant underlying disparities in health, social and economic factors. Meeting their needs as part of COVID-19 response efforts will be key to preventing these disparities from worsening and fulfilling the federal government’s federal trust responsibility.
Data indicates brutal impacts of COVID-19 for AIAN people in some states. For example, since May 11e, AIAN people accounted for 18% of deaths and 11% of cases versus 4% of the total population in Arizona, 57% of cases versus 9% of the total population in New Mexico, and 30% of cases versus 2% of the total population of Wyoming, and (Figure 1). As of May 10e, the Indian Health Service (IHS) has reported nearly 5,500 positive cases in IHS, tribal and urban Indian facilities, including more than 3,300 among the Navajo nation, which spans Arizona, New Mexico and Utah.
Coronavirus poses significant health risks for people with AIAN because they face large underlying disparities in health. NAIA people have disproportionately high rates of many health conditions that can put them at a higher risk of serious illness if they contract coronavirus, including diabetes, heart disease, asthma, and obesity. Analysis examining how many adults are at a higher risk of developing serious illness if infected with coronavirus based on health risk factors identified by the CDC reveals that 34% of non-elderly adults with AIAN are at risk of severe disease versus 21% of non-elderly white adults (Figure 2). Living conditions also put AIAN people at increased risk of exposure to the disease. For example, compared to other groups, AIAN individuals are more likely to lack access to safe drinking water and plumbing and to live in substandard and overcrowded housing, which limits the ability to wash their clothes. hands frequently and socially distancing themselves.
AIAN people face barriers to healthcare that can make it difficult to obtain coronavirus testing and treatment services. The IHS is the primary vehicle through which the federal government fulfills its responsibility to provide health services to the people of the NAIA. However, IHS has always been underfunded to meet their healthcare needs. Additionally, not all people who identify as AIAN can access services through IHS. IHS services are generally limited to members or descendants of members of federally recognized tribes. However, not all people who identify as AIAN are from a federally recognized tribe. Additionally, while many AIANs live in rural areas, the majority live outside tribal areas, which can make it difficult to access an IHS provider. Given the limitations of IHS, Medicaid and other sources of health insurance remain important in expanding access to care for AIAN people. They also provide revenue that improves the capacity of IHS and Tribal facilities. However, in 2018, 22% of non-seniors from AIAN were uninsured, the highest of any racial and ethnic group (Figure 3). Reflecting the limitations of the IHS and the high rate of uninsurance for AIAN people, they face increased challenges in accessing care. For example, non-elderly adults in NAIA are more likely than their white counterparts to not have seen a doctor in the past year due to cost (19% vs. 13%) and to have delayed care for other reasons (36% versus 19%).
Coronavirus can also cause disproportionate financial challenges for people of AIAN. More than one in four non-elderly AIAN people (26%) have incomes below poverty, leaving them with a limited ability to absorb the declines in income that may result from the COVID-19 crisis. Additionally, tribes have lost key revenue sources to support operations and services due to the shutdown of businesses and services in response to social distancing policies.
Meeting the needs of the NAIA population as part of COVID-19 response efforts will be critical to preventing the worsening of their already significant health and economic disparities and fulfilling the federal responsibility to provide health care to the population of NAIA. The federal government has provided relief and support to tribes and federally recognized tribal business entities through the Coronavirus Relief Assistance and Economic Security Act, including approximately $ 1 billion in additional funding from IHS. Going forward, it will be important to assess the extent to which resources are adequate to meet the needs of AIAN individuals and communities, including access to testing and treatment, support to healthcare providers, resources to mitigate risks associated with living conditions, culturally appropriate awareness and education, and financial assistance. Additionally, comprehensive data will be critical to understanding how the COVID-19 outbreak is affecting the NAIA population, directing resources to meet needs, and measuring the effects of response and relief efforts.