Unin­sured Na­tive Amer­i­cans of­ten lack needed pre­na­tal care

The Fresno Bee (Sunday) - - Front Page - BY YESENIA AMARO AND DEEPA BHARATH ya­[email protected]­nobee.com db­[email protected] Cen­ter for Health Jour­nal­ism News Col­lab­o­ra­tive

For al­most two years, Sylvia Valen­zuela re­lied on the fed­eral In­dian Health Ser­vice sys­tem to get the pri­mary care she needed.

But when she had to see an OB-GYN for her pre­na­tal care, she was on her own. What fol­lowed, she said, was a night­mare in which she strug­gled to ob­tain and keep Medi-Cal cov­er­age, leav­ing her unin­sured for a crit­i­cal stretch of her preg­nancy.

Valen­zuela says she would like to see bet­ter health care cov­er­age, not only for Na­tive Amer­i­can preg­nant women but for all Na­tive

Amer­i­cans.

“I would love to see changes. I have a daugh­ter my­self ... I would not like to see her go through what I went through.”

Na­tive Amer­i­can women face greater health chal­lenges and hard­ships dur­ing preg­nancy than the av­er­age Cal­i­for­nia woman. A Cal­i­for­nia Depart­ment of Public Health study shows a per­sis­tently high in­fant mor­tal­ity rate in the state, which has the na­tion’s largest Na­tive pop­u­la­tion.

The Na­tive Amer­i­can in­fant mor­tal­ity rate in Cal­i­for­nia “has re­mained high, while over­all in­fant mor­tal­ity in Cal­i­for­nia has de­clined steadily since 2005, sug­gest­ing that (Na­tive Amer­i­can) in­fants are not equally ben­e­fit­ing from so­cial and med­i­cal ad­vances that have re­duced in­fant mor­tal­ity for other Cal­i­for­nia pop­u­la­tions,” the June state re­port con­cluded.

The in­fant mor­tal­ity rate among Cal­i­for­nia Na­tive Amer­i­cans or Alaska na­tives was 6.03 per 1,000 live births from 2014-2016, com­pared with 4.32 for the state as a whole, ac­cord­ing to the most cur­rent data from the Cen­ters for Disease Con­trol and Preven­tion.

To com­bat the is­sue, the state is pro­vid­ing grants to help sev­eral coun­ties im­prove pre­na­tal care for Na­tive Amer­i­cans.

While Na­tive Amer­i­cans are en­ti­tled to spe­cial health care ser­vices by the fed­eral gov­ern­ment, the sys­tem can be dif­fi­cult to nav­i­gate, and has been his­tor­i­cally un­der­funded, providers say. As a re­sult, In­dian Health Ser­vice pro­grams are lim­ited and pri­mar­ily used by those who lack in­surance.

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THIS IS ONE OF THE HARSH RE­AL­I­TIES WE FACE. WE DON’T DO ANY FUNDRAIS­ING. THE CON­SOR­TIUM PRO­VIDES FUND­ING FOR MED­I­CAL EQUIP­MENT. BUT OTHER­WISE, IT’S ALL FED­ERAL FUND­ING.

Bill Thom­sen, chief op­er­a­tions of­fi­cer of River­side-San Bernardino County In­dian Health Inc.

LO­CAL HELP FOR NA­TIVE AMER­I­CANS

Many Na­tive Amer­i­cans in Fresno, Madera and Kings coun­ties who lack in­surance turn to Cen­tral Val­ley In­dian Health, Inc. for ba­sic health care. CVIH was formed by five lo­cal tribes: the North Fork Rancheria, Picayune Rancheria, Cold Springs Rancheria, Big Sandy Rancheria and Santa Rosa Rancheria.

CVIH op­er­ates five clin­ics in the three coun­ties but only of­fers pri­mary med­i­cal and den­tal care.

If pa­tients need spe­cialty ser­vices, such as see­ing an OB-GYN, lab work or imag­ing, CVIH refers them to clin­ics in the com­mu­nity, said Charles D. Fowler, chief ex­ec­u­tive of­fi­cer at CVIH. If their tribe is in Cal­i­for­nia, it will pick up their tab for spe­cialty care.

For out-of-state tribal mem­bers such as Valen­zuela, “they need in­surance, pos­si­bly Medi-Cal” for spe­cialty care.

The rule lim­it­ing spe­cialty care for Na­tive Amer­i­cans from out-of­s­tate tribes has ex­isted for decades at his clinic and is stan­dard prac­tice in Cal­i­for­nia be­cause of fund­ing short­ages, Fowler said.

There is no In­dian Health Ser­vice hos­pi­tal that could pro­vide in­pa­tient and spe­cialty ser­vices in Cal­i­for­nia, while some ar­eas in other states have mul­ti­ple IHS hos­pi­tals, Fowler said.

Given the small per­cent­age of Na­tive Amer­i­cans among the over­all state pop­u­la­tion, and the fact that tribes are not strong po­lit­i­cal en­ti­ties, “there’s not a lot of fo­cus on us,” Fowler said.

The Fresno Amer­i­can In­dian Health Pro­ject (FAIHP) helps cover re­fer­rals for med­i­cal care for out-of-state Na­tive Amer­i­cans who are not cov­ered by CVIH. In­dian Health Ser­vice pro­vides its largest source of grant fund­ing.

“We are able to pro­vide some (ser­vices),” says Selina De La Pena, chief ex­ec­u­tive of­fi­cer at FAIHP. But, she added, “there’s no way that we can pay for all of their med­i­cal care.”

The sit­u­a­tion is much the same at River­side-San Bernardino County In­dian Health, Inc., which con­sists of a con­sor­tium of nine tribes in the In­land Em­pire in South­ern Cal­i­for­nia. About 35% to 40% of its 18,000 ac­tive pa­tients are unin­sured, ac­cord­ing to Bill Thom­sen, the or­ga­ni­za­tion’s chief op­er­a­tions of­fi­cer.

The or­ga­ni­za­tion screens pa­tients to de­ter­mine whether they are el­i­gi­ble for Medi-Cal or other in­surance pro­grams, Thom­sen said. If not, it will pay the cost of what­ever treat­ment they re­quire, in­clud­ing spe­cialty care, as long as they be­long to one of the nine con­sor­tium tribes.

Na­tive Amer­i­cans who do not be­long to one of the tribes can still re­ceive ser­vices but may be asked to pay for spe­cialty ser­vices.

“This is one of the harsh re­al­i­ties we face,” he said. “We don’t do any fundrais­ing. The con­sor­tium pro­vides fund­ing for med­i­cal equip­ment. But other­wise, it’s all fed­eral fund­ing.”

Fed­eral fund­ing cur­rently cov­ers about 60 per­cent of the health care needs of el­i­gi­ble Na­tive Amer­i­cans across the coun­try, ac­cord­ing to the In­dian Health Ser­vice web­site. Its bud­get grew from $4.8 bil­lion in fis­cal year 2016 to $5.8 bil­lion in 2019.

“As with any or­ga­ni­za­tion de­liv­er­ing health care in ru­ral, re­mote lo­ca­tions, IHS faces a num­ber of chal­lenges re­lated to re­cruit­ment and re­ten­tion, in­fra­struc­ture, ag­ing fa­cil­i­ties and equip­ment, and ex­ist­ing health dis­par­i­ties,” the agency said in a state­ment. “In re­cent years, IHS has made sig­nif­i­cant progress in over­com­ing these chal­lenges with sup­port from Con­gress, the (Trump) ad­min­is­tra­tion and our tribal part­ners.”

State grants also will help, at least for Na­tive Amer­i­can women in need of pre­na­tal care. Fresno, Hum­boldt, Placer and Shasta coun­ties each re­ceived a grant of $267,250 through fis­cal year 201920 to pro­vide pre­na­tal care to Na­tive Amer­i­can com­mu­ni­ties.

The Fresno Amer­i­can In­dian Health Pro­ject is among the re­cip­i­ents.

“There was a big need in the pre­na­tal area as well (as) for our preg­nant moms,” De La Pena says.

The grants are to pro­vide cul­tur­ally ap­pro­pri­ate pre­na­tal case man­age­ment and home-vis­i­ta­tion ser­vices to im­prove Na­tive Amer­i­can ma­ter­nal and in­fant health, said Carol Sloan, a spokes­woman for the Cal­i­for­nia Depart­ment of Health Care Ser­vices.

In Tu­lare County, a re­cent fo­cus group study con­cluded that young Na­tive Amer­i­can women with­out pri­vate in­surance were un­likely to re­ceive any pre­na­tal care dur­ing the first trimester.

The bar­ri­ers to ac­cess­ing pre­na­tal care in­cluded not know­ing about the preg­nancy or hav­ing to reap­ply for health in­surance ben­e­fits an­nu­ally, ac­cord­ing to the find­ings.

One of the fo­cus group’s rec­om­men­da­tions was to im­prove the Med­i­Cal ap­pli­ca­tion process for the Tule River Reser­va­tion and Na­tive Amer­i­cans. An­other sug­ges­tion was to re­duce the amount of time it takes to process Medi-Cal ap­pli­ca­tions.

Karen El­liot, di­rec­tor of the Tu­lare County Depart­ment of Public Health, pointed to other un­der­ly­ing rea­sons Na­tive Amer­i­can women are not seek­ing pre­na­tal care, in­clud­ing trans­porta­tion and ed­u­ca­tion bar­ri­ers.

“We are dig­ging into an is­sue that needs to be ad­dressed,” she says.

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