What Is The Indian Health Service Doing To Clean Reservations Of Drugs
Am J Public Wellness. 2006 Baronial; 96(8): 1469–1477.
Organization and Financing of Alcohol and Substance Abuse Programs for American Indians and Alaska Natives
Bentson H. McFarland
All authors are with the 1 Sky Center (the American Indian/Alaska Native National Resource Heart for Substance Abuse), Center for American Indian Health Education and Research, Oregon Wellness and Science Academy, Portland. Bentson McFarland, Douglas Bigelow, and Dale Walker are also with the Department of Psychiatry, Oregon Health and Science Academy, and Roy Gabriel is also with RMC Research, Portland, Oregon.
Roy Grand. Gabriel
All authors are with the Ane Heaven Center (the American Indian/Alaska Native National Resources Centre for Substance Abuse), Eye for American Indian Health Pedagogy and Research, Oregon Health and Science University, Portland. Bentson McFarland, Douglas Bigelow, and Dale Walker are also with the Section of Psychiatry, Oregon Wellness and Scientific discipline Academy, and Roy Gabriel is also with RMC Inquiry, Portland, Oregon.
Douglas A. Bigelow
All authors are with the One Sky Center (the American Indian/Alaska Native National Resource Middle for Substance Abuse), Eye for American Indian Health Education and Research, Oregon Health and Science Academy, Portland. Bentson McFarland, Douglas Bigelow, and Dale Walker are also with the Department of Psychiatry, Oregon Health and Scientific discipline Academy, and Roy Gabriel is also with RMC Inquiry, Portland, Oregon.
R. Dale Walker
All authors are with the 1 Heaven Center (the American Indian/Alaska Native National Resource Middle for Substance Abuse), Center for American Indian Health Didactics and Enquiry, Oregon Wellness and Science Academy, Portland. Bentson McFarland, Douglas Bigelow, and Dale Walker are too with the Department of Psychiatry, Oregon Health and Scientific discipline University, and Roy Gabriel is also with RMC Research, Portland, Oregon.
Abstract
Objectives. Although American Indians and Alaska Natives have loftier rates of substance corruption, few data about treatment services for this population are available. We used national data from 1997–2002 to describe recent trends in organizational and fiscal arrangements.
Methods. Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Wellness Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Agency, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures.
Results. One-half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what nosotros expected. Medicaid participation by tribal programs was not universal.
Conclusions. Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be central to expanding needed resources.
American Indians have the highest prevalences of substance corruption and dependence among the racial and ethnic groups comprising the United States1–8 simply are served past the land's most complicated behavioral health care organization.9–11 Substance abuse treatment services for Natives are provided past tribes, tribal organizations, urban Indian programs, the Indian Health Service (IHS), the Department of Veterans Affairs, and state, local, and other programs.nine,12–15
Recently in that location have been dramatic changes both in indigenous populations (due east.k., growth in size and urbanization)sixteen–eighteen and in wellness services for Native Americans.10,12–xix Although about Native Americans live in urban areas,twenty,21 only about 1% of the IHS budget is spent on urban Indian programs.xvi,18,22 In a contempo Kaiser Family unit Foundation survey, only xx% of American Indians reported that they had access to IHS programs.23 Also, many tribes have taken over wellness intendance delivery from the IHS, using assorted funding mechanisms.10,13,19,24–26 For example, contracts with the IHS allow tribes to manage specific programs.24 A contract is generally an agreement between the purchaser of services (the IHS) and the service provider (such as a tribal organization) that includes a detailed scope of work. Compacts between tribes and the IHS are somewhat coordinating to block grants and provide considerable flexibility for tribal programme pattern and management.24 A compact tin can exist regarded as an agreement between ii nations (the U.s. and the tribal authorities) almost transfer of funds and overall service provision.
Services for American Indians with alcohol or other drug problems are in flux13 as tribes negotiate new relationships with the IHS and with state Medicaid agencies.11,19,24,25,27 Substance abuse treatment services are normally divided co-ordinate to the phase of abuse addressed: the astute detoxification stage, the rehabilitation phase, and the maintenance stage or recovery.28,29 Services include self-aid programs such equally Alcoholics Anonymous30,31 and brief interventions within primary care.32–35 Nosotros focused on treatments in the behavioral wellness specialty sector,28 including traditional American Indian healing practices that some might regard as complementary, alternative, or supplementary to those unremarkably offered in the "mainstream" service organization.1,36–38 Although the evidence is equivocal,39,xl it is more often than not agreed that professional substance abuse rehabilitation services are efficacious.28,29,41–44 Because people with substance corruption problems who receive treatment generally take better outcomes than those who do not,29,44–46 the idea is that treatment works.twoscore,45,47–49
Substance abuse handling in the United states is largely funded by the public sector.50,51 Coffey et al.52,53 reported that the largest payers for substance abuse treatment in 1997 were state and local governments (28% of full substance abuse expenditures) followed by Medicaid (twenty%) and the Substance Abuse and Mental Health Services Assistants'southward Substance Corruption Prevention and Treatment block grants to the states (16%). These percentages may accept increased recently, given turn down in private-sector chemical dependency insurance benefits54 and the limited enthusiasm of private-sector purchasers for these services.55
Medicaid may be peculiarly important for American Indians with substance abuse problems.22,56 Medicaid is a joint federal–state program designed primarily to fund wellness intendance for low-income people.57 American Indians take the highest Medicaid enrollment of any racial/ethnic grouping.22,23 Congress addressed the reimbursement relationship between American Indians and Medicaid in the Alaska Native and American Indian Straight Reimbursement Act of 2000, which modified Title Xix of the Social Security Act to authorize direct billing past tribes or tribal organizations that have compacts or contracts with the IHS. Nether the Direct Reimbursement Deed, tribes or tribal organizations with IHS compacts or contracts can bypass state Medicaid agencies and submit bills directly to the federal Center for Medicare and Medicaid Services.
At that place take been numerous calls for information about the organization and financing of health services for Native people,ten,23,58 only few information are available. Our goals were to provide background on substance abuse bug amid American Indians; to describe organizational and financial arrangements of substance abuse treatment services for Natives; to examine recent changes in those arrangements; and to provide guidance to policymakers responsible for Native chemical dependency treatment programs.
METHODS
Data on services provided past the IHS, funded by the IHS, or both were obtained from the 1997 Evaluation of the Indian Health Service Adolescent Regional Handling Centers,59 the IHS Accountability Written report, Fiscal Year 1998,sixty the 2002 Indian Wellness Service Alcohol and Substance Abuse Program National Consultation Briefing Book,61 and IHS budget justification and upkeep request documents for federal fiscal years 1999 through 2002.62–65 The budget justifications and requests provided data most revenues and expenditures too equally aggregate information on services such equally numbers of outpatient visits and days of residential treatment. Considering the service data were non unduplicated, an individual with 2 or more than visits or admissions would exist represented more than once in the database. The National Consultation Briefing Book included profiles of the 309 substance abuse treatment programs supported in 2002 by the 12 IHS area offices. Of these programs, 81 offered residential (nearly all nonhospital) services, whereas the others were almost exclusively outpatient nonmethadone programs.
The Alcohol and Drug Services Study (ADSS)66 provided detailed information about clients (including race and ethnicity) and services for a random sample of public-sector substance abuse treatment agencies (including tribal programs just excluding IHS facilities) studied from late 1996 through 1999. The ADSS Cost Study67 provided detailed information nearly expenditures for a random sample of those agencies.
We as well obtained data from the National Survey of Substance Abuse Treatment Services (N-SSATS),68,69 which began (in its nowadays grade) during 2000 and takes place more or less every other year. The survey is conducted through the post, with telephone follow-up. Information technology uses every bit its sampling frame the Inventory of Substance Abuse Treatment Services, which attempts to identify all public-sector entities in the United states that provide alcohol or drug abuse treatment services. Some private providers who receive no public funds may not be included in the Inventory70–73; however, the enumeration is believed to be consummate for entities that obtain public support. The response rate is said to exceed 90%. Specially important for this project were data on facility buying (i.e., tribal, IHS, or other) and Medicaid billing.
Data on admissions to substance abuse treatment programs (also not unduplicated, so that a given person might be represented more than once) were obtained from the Handling Episode Data Set,74 which focuses on substance abuse treatment programs that obtain at to the lowest degree some public funding.75 Handling Episode Information Fix data are analogous to cumulative treated incidence.76 All states are required to submit minimum data set information on demographics, substance utilize, and intended treatment. Data such as age at first substance use and frequency of substance use were combined to form a severity measure similar to that used by Caspi et al.77 and Deck and McFarland.78 The mensurate reflects the seriousness of the person's addiction and ranges from 0 (least astringent) to 1 (most astringent).
Information from the 1990 US Demography and the 2000 US Census were used to approximate population,79,lxxx location (urban vs rural),79,81 and poverty condition.82–85 The IHS accountability written report for federal fiscal year 1998 provided information on the population served in 1997.sixty The IHS upkeep justification for federal financial year 2004 provided data on population served in 2002.65 Data from the Henry J. Kaiser Family unit Foundation were used to estimate Medicaid enrollment in 199886 and 2001.87 Rates of alcohol abuse and alcohol dependency in 1992 and 2002 were based on estimates from surveys conducted by the National Institute on Alcohol Abuse and Alcoholism.4
To estimate non-IHS spending on public outpatient and residential substance abuse treatment for Native people, we used 2 methods. Method A was based on ADSS phase 1 facility data and N-SSATS 2000 information (for IHS facilities), which showed there were 22 873 American Indian current clients in nontribal, non-IHS outpatient or residential programs. The total ADSS plus IHS facility current outpatient or residential client count was 923 463. Therefore, the percentage of American Indian clients in nontribal, non-IHS facilities was ii.48%. Method B was based on the Handling Episode Information Set for 1997, which showed there were 24 717 metropolitan American Indian or Alaska Native admissions, whereas the total number of Treatment Episode Data Set admissions in 1997 was 1 589 716. Therefore, the percentage of metropolitan American Indian or Alaska Native admissions was 1.55%. We then multiplied the average from the 2 methods (2.02%) by the US public outpatient and residential substance corruption spending estimate from Coffey et al.52,53
Nosotros used 2 approaches to estimate expected IHS Alcohol and Substance Corruption Program expenditures. We obtained national information from the 48 ADSS Toll Report agencies that offered nonhospital residential handling and the 222 ADSS Cost Report programs that provided only outpatient nonmethadone services.67 The rationale for this option was that IHS and tribal authorities programs are most exclusively residential (nonhospital) or outpatient nonmethadone programs, according to the National Consultation Briefing Book.61 Similarly, information from the 2002 N-SSATS showed only 2 hospital inpatient substance abuse treatment programs (owned by the IHS) and 3 methadone programs owned by tribal governments.69
The ADSS Cost Written report assay focused largely on measures of annual agency expenditures, which were highly correlated with bureau revenues (R = 0.99; n = 270). The ADSS Cost Report information showed that measures of agency expenditures varied by program size. For case, among outpatient non-methadone programs, in that location was a nonlinear relation between toll per visit and current client count. Nosotros examined several functional forms to find useful predictors of cost per visit based on current client count. In addition, nosotros estimated regression equations with and without exclusion of outliers. Some regressions were restricted to the not-for-profit programs in the ADSS Price Study. We estimated equations with weighted regression to account for the complex sampling scheme in the ADSS Cost Study. Several models were generated for each expenditure. One equation pertaining to outpatient nonmethadone programs (estimated without excluding outliers or for profit programs) was
(1)
for which R 2 was 0.13 (due north=221). According to this equation, an agency with only 1 electric current client would (on average) have a cost per visit of $89.69, whereas larger agencies would have lower costs per visit. For residential programs, i equation (estimated without excluding outliers or for-profit programs) was
(2)
for which R 2 was 0.32 (north = 48). Other models from the ADSS Price Written report addressed full almanac program costs for outpatient non-methadone and residential (nonhospital) agencies. For outpatient agencies, a log-log model was the best functional form. I equation (estimated without excluding outliers or for-profit programs) was
(three)
for which R 2 was 0.55 (n=222). For residential programs, a linear model was the best functional form. 1 model (estimated without excluding outliers or for-profit agencies) was
(4)
for which R two was 0.59 (n = 48).
For each cost mensurate in the ADSS Toll Study data, nosotros synthetic models with and without outliers as well as with and without for-turn a profit agencies. The several models were then used to generate ranges of expenditure estimates for alcohol and substance abuse programs funded by the IHS. Electric current customer count data were obtained from the N-SSATS for 2000 focusing on programs endemic by tribal governments (due north = 170 respondents) or the IHS (north = xl respondents). Means and medians were obtained after the distributions of expenditure estimates were generated.
Approach 1 generated estimates of full annual costs for "typical" residential and out-patient (nonresidential) agencies) funded by the IHS. We then multiplied these cost estimates past the estimated numbers of each type of agency (outpatient or residential) and summed the results to obtain total "expected" IHS Alcohol and Substance Abuse Program expenditures. The IHS reported that it funded some 300 alcohol and substance abuse programs in federal fiscal year 1998.sixty The numbers of residential and out-patient-simply programs were estimated at 79 and 221, respectively, on the basis of the distribution of program type for agencies endemic by tribal governments or the IHS in the 2000 N-SSATS.68
In approach 2, we multiplied the cost per visit and toll per day figures estimated from the ADSS Price Written report by the number of reported visits and days in the IHS upkeep justification for federal fiscal yr 1999.62 The residential days included an estimated 37 000 boyish regional handling middle days per year from the 1997 evaluation of IHS adolescent regional treatment centers.59
We reviewed administrative records of federally funded discretionary grant applications provided by the Centre for Substance Abuse Prevention and the Heart for Substance Abuse Treatment at the Substance Corruption and Mental Health Services Administration to determine the fraction of programs for American Indians and Alaska Natives that focused on Native people living in urban areas.
RESULTS
American Indians and Alaska Natives constitute about 1% of the US population (Tabular array i ▶). The "service population" encompasses American Indians or Alaska Natives who typically live on or near reservations and brand use of programs funded by the IHS. The "nonservice population" is defined as those Natives who do not employ programs funded by the IHS (although nonservice Natives may well use treatment programs not funded by the IHS). There are large numbers of nonservice Natives. Betwixt 1997 and 2002 in that location was an increase of 43% in the estimated nonservice population versus a 10% increase for the service population and a 22% increase in the Native population overall. In that location has been a notable increase in the percentage of American Indians living in urban areas.
TABLE 1—
Health Services Employ, Demographic Characteristics, and Substance Corruption in the General US and American Indian/Alaska Native (AIAN) Populations, 1997 and 2002
| 1997 | 2002 | |||
| US | AIAN | U.s.a. | AIAN | |
| Total population,a no. | 267 800 000 | 2 300 000 | 288 400 000 | 2 800 000 |
| Estimated IHS service population,b no. | NA | ane 460 000 | NA | 1 600 000 |
| Estimated nonservice population,c no. | NA | 840 000 | NA | 1 200 000 |
| Urban,d % | 75 | 51 | 79 | 61 |
| Living below federal poverty level,e % | 13 | 31 | 12 | 26 |
| Enrolled in Medicaid,f % | 10 | 17 | eleven | 25 |
| Abusing booze,g % | three.0 | viii.i | 4.six | 5.viii |
| Booze dependent,yard % | 4.iv | 9.0 | 3.viii | half-dozen.4 |
| Alcohol severity of admitteesh (SD) | 0.42 (0.35) | 0.49 (0.34) | 0.35 (0.36) | 0.45 (0.35) |
American Indians were greatly overrepresented among Medicaid recipients in 1997 and even more than and so in 2002, which is to be expected, given the large percent of Natives living beneath the federal poverty level. Indeed, the percentage of the Native population enrolled in Medicaid was roughly twice equally high every bit the percent of the overall population enrolled in Medicaid. Interestingly, the percent of Natives living below the federal poverty level apparently declined during the 1990s, but Medicaid participation increased.
Tabular array 1 ▶ shows the prevalence of alcohol abuse and dependence in epidemiological studies conducted 10 years apart.4 Native people have substantially higher rates of alcohol problems than the population overall. There were no statistically significant fourth dimension trends in Native alcohol corruption or dependence, whereas abuse increased but dependence declined in the full general population in the x years betwixt studies.four In other words, although in that location were alcohol abuse and alcohol dependence prevalence changes over time in the overall population, the prevalence of booze corruption and the prevalence of alcohol dependence among Natives apparently did not change over the 10 years. Too, severity measures for Natives admitted for treatment of alcohol problems are college than comparable figures for admissions overall. The severity measures for both Native and overall admissions declined from 1997 to 2002.
Tabular array ii ▶ provides information virtually substance abuse handling in all programs and in programs serving at least one private identified every bit American Indian or Alaska Native. Near a quarter of tribal and IHS agencies offered residential care, which was very close to the overall percentage.
Tabular array two—
Characteristics of Substance Abuse Treatment Programs Overall and Those Serving at Least 1 American Indian/Alaska Native (AIAN) Customer, 1997 and 2002
| 1997 | 2002 | |||
| All Programs | AIAN Programs | All Programs | AIAN Programs | |
| All programsa | ||||
| Programs, no. | 12 425 | ii 844 | 13 720 | . . . |
| Clients, no. | i 090 009 | 33 455 | 1 136 287 | . . . |
| No. of clients per programme, average (SE) | 87.eight (6.6) | 148.7 (17.3) | 89.6 (i.4) | . . . |
| Programs with residential (nonhospital) beds, % | 25.2 | 21.8 | 27.6 | . . . |
| IHS programsb | ||||
| Programs, no. | NA | 39 | NA | 27 |
| Clients, no. | NA | ii 316 | NA | 1 339 |
| No. of clients per plan, boilerplate (SE) | NA | 59.4 (13.5) | NA | 49.vi (15.1) |
| Programs with residential (nonhospital) beds, % | NA | 27.5 | NA | 25.0 |
| Tribal authorities programsb | ||||
| Programs, no. | NA | 167 | NA | 170 |
| Clients, no. | NA | 12 082 | NA | 10 127 |
| No. of clients per program, average (SE) | NA | 72.iv (xiv.4) | NA | 59.6 (half-dozen.4) |
| Programs with residential (nonhospital) beds, % | NA | 27.half dozen | NA | 26.seven |
| Admissionsc | ||||
| No. | 1 607 957 | 41 402 | 1 882 584 | 44 346 |
| % In metropolitan areas | 83.9 | 59.7 | 83.2 | 66.8 |
| % Residential (nonhospital) | sixteen.8 | 23.2 | 16.i | nineteen.0 |
| % Outpatient, nonmethadone | 57.4 | 50.3 | 58.3 | 52.2 |
| % Detoxification (hospital and residential) | 21.five | 22.3 | 22.5 | 23.0 |
| % With alcohol as principal substance | 49.five | 67.seven | 43.9 | 59.6 |
| Alcohol severity mensurated (SD) | 0.42 (0.35) | 0.49 (0.34) | 0.35 (0.36) | 0.45 (0.35) |
| Aggregate measurese | ||||
| Visits to outpatient nonmethadone programs | 123 857 124 | 590 000 | . . . | 750 000 |
| Days in residential (nonhospital) intendance | 36 461 675 | 322 000 | . . . | 402 000 |
| Ratio of visits to days | 3.40 | 1.83 | . . . | 1.87 |
In 1997 (the year for which the most complete data were available), American Indians and Alaska Natives were served past numerous public sector treatment agencies in addition to those operated by tribes or the IHS; 2844 agencies apparently served at to the lowest degree 1 person identified as American Indian or Alaska Native at the time of the survey (Table 2 ▶, summit row). Indeed, some 22 956 American Indians or Alaska Natives were estimated (from ADSS stage 1) to be receiving services in facilities other than those operated by tribal governments or the IHS. These nontribal, non–IHS programs manifestly served more than Native clients than the agencies operated by tribes or the IHS. American Indians and Alaska Natives represented ii.8% of overall electric current clients (or more than twice the percentage expected on the basis of population).
Another of import betoken illustrated in Table 2 ▶ is the size of tribal and IHS programs. These programs had notably smaller electric current client counts (per program, on average) than nontribal, non–IHS programs. When nosotros compared IHS almanac revenues for 285 American Indian nonresidential outpatient substance corruption programs in 200261 with revenues for 222 outpatient-only not-methadone agencies in the ADSS Cost Study (1997), nosotros found that even without adjustment for inflation the Native programs had much lower revenues than programs run by nationally representative agencies (median of $120 000 vs $324 000; P < .001 past Mann–Whitney exam).
The majority of American Indian and Alaska Native admissions were to programs (presumably operated past nontribal, non–IHS agencies) in metropolitan areas. Past 2002 about 2 thirds of Native admissions were to such programs. American Indian and Alaska Native admittees were somewhat more than likely to seek residential treatment than were admit-tees overall. However, differences between Native and overall admissions with regard to residential treatment decreased betwixt 1997 and 2002. Alcohol remained the primary substance of abuse for Native admittees in 2002. Differences between American Indian and Alaska Native admissions and all admissions with regard to primary substance of abuse declined between 1997 and 2002. Overall, American Indians and Alaska Natives accounted for 2.half-dozen% of admissions to all programs (tribal; IHS; and nontribal, non–IHS) in 1997 and two.iv% of admissions to all programs in 2002 (or more than twice the pct expected on the basis of population).
Table two ▶ also provides aggregate data on visits to outpatient programs and days in residential treatment. National data can exist compared with IHS information for 1997 (the only year for which national figures are available). The national data evidence about iii outpatient visits per residential day, simply the Native agencies' figure is roughly 2 visits per residential day. This ratio changed little between the 2 written report years. The implication hither is that programs supported by the IHS generate more residential bed days (vs outpatient visits) than would exist expected from national data.
The expenditures compiled in Table 3 ▶ represent the most current comparable financial data for all programs and programs serving at least one private identified equally American Indian or Alaska Native. On boilerplate, the United states spent about one% of health care dollars on substance corruption treatment in 1997–1998. This overall substance abuse handling figure includes services provided by public and individual programs involving solo practitioners, for-turn a profit agencies, and hospitals. Publicly funded outpatient and residential programs accounted for nearly half the substance abuse treatment spending.
Table 3—
Expenditures for Health Intendance and Substance Abuse Treatment in US Programs Overall and Those Serving at To the lowest degree ane American Indian/Alaska Native (AIAN) Customer, 1997–1998
| All Programs | AIAN Programs | |
| Total health care,a $ millions | ane 057 493 | NA |
| Full public wellness care,b $ millions | 458 548 | 2460c |
| Substance abuse treatment overall,a $ millions | 11 419 | NA |
| Substance abuse handling, public outpatient and residential,a $ millions | 5 321 | NA |
| IHS Alcohol and Substance Abuse Program,d $ millions | NA | 91.78 |
| Urban Indian alcohol programs,d $ millions | NA | three.05 |
| Total IHS-supported substance abuse handling programs, $ millions | NA | 94.83 |
| Not-IHS public outpatient and residential care, estimated,e $ millions | NA | 107.48 |
| Total public outpatient and residential substance abuse treatment for Natives, $ millions | NA | 202.31 |
| Substance abuse treatment every bit proportion of total wellness care expenditures,f % | ||
| Overall as proportion of total | i.08 | NA |
| Public outpatient and residential care every bit proportion of full public wellness care | ane.16 | NA |
| IHS Alcohol and Substance Abuse Program | NA | 3.73 |
| Urban Indian alcohol programs | NA | 0.12 |
| Total IHS-supported substance corruption treatment programs | NA | 3.85 |
| Substance abuse treatment expenditures per capita,m $ | ||
| Substance corruption treatment overall | 42.85 | NA |
| Public substance abuse treatment, outpatient and residential | 19.97 | NA |
| Substance corruption treatment for IHS service population, estimated | NA | 64.95 |
| Substance abuse treatment for American Indian nonservice population | NA | 127.95 |
| Substance abuse treatment for total American Indian and Alaska Native population | NA | 87.96 |
The IHS spent about iv% of its budget on substance abuse services in federal fiscal twelvemonth 1998 (Tabular array 3 ▶). The electric current figure is similar. It is important to capeesh that the figures for national spending on total health intendance and for spending on substance abuse handling overall were calculated in ways quite different from the methods used to determine total IHS spending and IHS spending for substance corruption treatment. However, it is reasonable to compare national spending on public outpatient and residential substance abuse treatment with the analogous expenditures by the IHS. This comparison suggests that the fraction of IHS funds devoted to substance abuse treatment is roughly iii times what would be expected from national data.
It is besides instructive to compare the ratios of expenditures (national vs IHS) with the prevalence and severity data. Surveys suggest that alcohol dependence is roughly twice as common among Natives as in the overall population (Table 1 ▶). Severity information suggest that the degree of addiction for admitted American Indian clients was about 20% to thirty% greater than that for the overall population. The ratio of alcohol dependence prevalence amongst Natives to alcohol dependence prevalence in the general population was 2.04 for 1997 (from Tabular array 1 ▶). The ratio of Native admittee severity to the severity of full general population admittees was one.17 (from Table 1 ▶). Multiplying these ratios yields a figure of ii.39, which is a chip smaller than the ratio of substance corruption expenditure percentages shown in Table three ▶.
Information technology is as well illuminating to examine per capita expenditures. Overall, the United states of america spent virtually $43 per capita for substance abuse treatment in 1997. One can summate several per capita figures pertaining to American Indians and Alaska Natives. Maybe the almost informative such figure combines services delivered by tribes or the IHS with treatment provided by programs unaffiliated with tribes or the IHS. This total figure was about $88 per capita in 1997. The per capita expenditure ratio betwixt American Indians and the overall population is simply 2.1, which is less than would be expected given population differences in substance abuse prevalence and severity.
Another of import attribute of Table 3 ▶ is estimated spending on American Indian and Alaska Native clients by substance abuse treatment programs unaffiliated with tribes or the IHS. Both the current client count information and the metropolitan admissions data for 1997 suggest that treatment for American Indians and Alaska Natives in nontribal, non–IHS programs accounted for roughly 2% of spending on public sector outpatient and residential services. The expenditure figure (some $107 million) is very close to the IHS substance abuse spending (roughly $95 million) during that twelvemonth. Spending on substance corruption handling for American Indians and Alaska Natives in programs unaffiliated with tribes or the IHS is substantial. Given the rising in the percentage of metropolitan area treatment program admissions for American Indians and Alaska Natives between 1997 and 2002 (Table 2 ▶), this consequence is increasing in importance.
Observed spending for the IHS Alcohol and Substance Abuse Plan was $94.83 million. We estimated expected expenditures at $75.37 one thousand thousand to $87.04 million past using arroyo one and at $56.41 meg to $58.30 meg past using approach 2. Omission of outliers and private programs from the national data had footling impact on estimates, whereas using means versus medians in the estimation of expenditures for American Indian programs made a considerable difference. Consequently, these ranges importantly reflect differences between means and medians. Given the challenges of these calculations, it appears that IHS Booze and Substance Abuse Program expenditures are more or less what would be expected from national figures, given program sizes and possible underreporting of residential days and outpatient visits.
Some other important finding is that Medicaid participation by tribal or IHS programs is non uniform beyond the country. During 2002 in that location were 7 states (of the 25 that had tribal or IHS substance abuse programs) in which no Native facility reported Medicaid billing. For 2003 the figures were 7 states (Colorado, Idaho, Iowa, Louisiana, Missouri, Texas, and Utah) of 26. In the N-SSATS data there were few predictors of Medicaid billing by tribal or IHS agencies other than Medicare billing (P < .001 by χ2 test).
Finally, the Substance Abuse and Mental Health Services Administration devoted some 6% of its total 2002 discretionary grant plan to American Indian or Alaska Native addiction prevention or treatment programs. A review of 102 programs aimed at American Indians or Alaska Natives supported by the Heart for Substance Abuse Prevention or the Center for Substance Abuse Handling in 23 states since 2000 showed that a quarter were focused on urban areas (including country incentive grants addressing prevention).
Discussion
Given the express information available almost Native substance corruption treatment and outcomes, nosotros must exist circumspect in interpreting these results.ten,88 The IHS's Integrated Behavioral Wellness data engineering science initiative89 may exist an opportunity to compile more consummate data. In addition, substance abuse programs funded by the IHS should be encouraged to participate in the N-SSATS. It may be helpful to create an additional category in the Northward-SSATS to identify urban Indian programs that are neither tribal nor IHS but do receive IHS funds.
Assay of the financial picture is as well challenging considering IHS budgets are subdivided in complex ways (with tribal contracts and compacts introducing even more complexity). Besides, Native substance abuse services are financed by numerous programs (e.g., Medicaid) in addition to the IHS.8 Moreover, Alaska Native programs are notably different from American Indian services in the lower 48 states.
Notwithstanding, several conclusions tin be drawn from these data. Substance misuse is a considerable trouble for Native people and has changed fiddling in the past decade. Large numbers (probably the majority) of Native clients treated for substance corruption disorders are served by agencies evidently unaffiliated with the IHS or tribal governments. Similarly, the Substance Abuse and Mental Wellness Services Administration earmarks a notable percentage of its funds for American Indians and Alaska Natives but urban indigenous people may be underrepresented in allocation of this money. One business organisation is the extent to which the federal government is meeting its treaty responsibilities.19,ninety
Another concern is the treatment provided to American Indian clients in mainstream (i.e., not affiliated with tribal governments or the IHS) agencies. The per centum of programs funded past the IHS that offer residential intendance is about the aforementioned every bit the percentage of programs with residential services in mainstream agencies. Moreover, both Native and mainstream programs presumably take waiting lists. However, tribal governments and the IHS operate small programs, whereas Native clients in agencies unaffiliated with tribal governments or the IHS may find themselves existence treated past relatively big institutions that may not deliver culturally competent services. A notable qualitative report conducted two decades ago raised serious questions almost the cultural ceremoniousness of mainstream substance abuse treatment programs for urban Indians with alcohol problems.91 Quality of care needs to exist examined.ten,92,93 Indeed, an important topic for future research is the effectiveness of culturally relevant treatments.
The expenditure calculations address the "efficiency"94 of substance abuse treatment programs supported by the IHS. Given the crude data, funding for IHS alcohol and substance abuse programs seems more or less what would exist expected from national information when program size and possible underreporting of services are taken into business relationship.
In 2003 only half the tribal or IHS substance corruption treatment programs reported accepting Medicaid. Given their small size (nearly accept customer counts of one-half to two thirds those found in programs overall), it is not surprising that Native agencies may have difficulties with Medicaid hierarchy. The Robert Forest Johnson Resources for Recovery program is designed to facilitate access to Medicaid substance abuse treatment funding.95 Policymakers should consider providing preparation and technical assist to American Indian agencies in Medicaid billing, along with publicizing findings from the Resources for Recovery programme.
Medicaid funding and substance corruption handling for American Indians and Alaska Natives non in the "service population" should besides exist scrutinized.96 As noted, during 2003 there were 7 states (of the 26 that had Native substance abuse programs) in which no American Indian facility reported Medicaid billing. Policymakers should consider expanding Medicaid eligibility definitions in order to increment American Indian Medicaid enrollment and thereby satisfy federal treaty obligations to Native people.97 Expanding the Medicaid budget for increasing enrollment will be very difficult, nonetheless, given current constraints on federal spending, including the IHS.98
Finally, consideration should be given to prevention.99 American Indians and Alaska Natives represent more 500 sovereign nations that can adopt, and have adopted, policies designed to foreclose substance corruption.100,101 Tribal sovereignty offers opportunities for universal prevention policies that may include, among others, booze and tobacco sales restrictions, alcohol and tobacco taxes, minimum drinking ages, and claret alcohol concentration legislation.100,101 As with treatment services, evaluation of outcomes for substance abuse prevention programs will exist of import. Numerous approaches must be undertaken to run into the needs of urban and reservation American Indian and Alaska Natives for substance abuse prevention and treatment services.
Acknowledgments
This written report was supported by the Substance Abuse and Mental Health Services Administration (grant 1U79 SP10346), the Robert Wood Johnson Substance Abuse Policy Research Plan (contract 482_878), and the National Establish on Alcohol Abuse and Alcoholism (grant 1R21 AA014050).
Notes
Peer Reviewed
Contributors
B. H. McFarland, R. M. Gabriel, and R. D. Walker obtained the data, and B. H. McFarland conducted the data analysis. All authors participated in designing the study and writing the article.
Human Participant Protection
Institutional review board approval was waived for this report, which used just publicly available information.
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