“American Indian 101”: Understanding the history and contemporary experiences of Native people in a United States health policy context

American Indian and Alaska Native (AI/AN) is a racial/ethnic category that describes people with ancestry indigenous to North America prior to colonization in 1492. As of the 2020 U.S. Census, there were approximately 9.7 million Americans who identified as Native American alone or as Native American in combination with another race. 

Despite millions of Americans identifying as AI/AN, Quin Mudry Nelson, MPH, SHADAC’s inaugural Health Equity Fellow, noticed a lack of attention on Indigenous and American Indian health and health care systems throughout their education. With their lens on health equity combined with their own experience as a Native person, they knew that Indigenous people in the U.S. face a number of health disparities compared to other groups, including, among others, the highest uninsured rate, lowest life expectancy at birth, and adverse impacts to health outcomes.

They also saw that it wasn’t only American Indian health services and systems being overlooked, it’s the people as well: data collection on AI/AN individuals is, and has been, a known challenge in the U.S. One report from the Department of Labor describes “substantial” criticism received “from tribes and other stakeholders regarding population undercounts, the accuracy and timeliness of the data, and the burden for tribes, due to lack of sufficient resources and trained personnel, in reporting the data to the Federal Government.”

After seeing these gaps between her education and her knowledge & experiences “as a two-spirit, Native person who is tribally affiliated with the Oneida Nation, I wanted to write a piece about AI/AN people’s history and identity in the context of health policy,” says Quin. 

Quin’s in-depth research combined with their experience and understanding of the AI/AN community has culminated in this important brief: “American Indian 101”: Understanding the history and contemporary experiences of Native people in a United States health policy context.

Focused on health care and health insurance access among American Indian and Alaska Native people, this brief provides readers with essential context and commentary on United States and American Indian health policy, health disparities, and AI/AN identity as it relates to health care and policy. 

The brief is divided into four sections, organized and grounded in the indigenous ways of knowing – outlining the present, reflecting upon the past, and using that context to chart a path for the future:

• Section 1 describes information about AI/AN people within the United States and the health care system presently, providing demographic data, a brief explanation on contemporary data collection issues, and a breakdown of the unique care delivery structure of the Indian Health Service
• Section 2 provides an overview of early U.S. history and American Indian health and social policies, including pivotal legal cases
• Section 3 contextualizes how this history constructed a unique identity for AI/AN people in comparison to other racial groups that impacts not only their access to care, but also to their “dedicated” health services
• Section 4 concludes with an overview of recent progress in AI/AN health and social policy, highlighting both potential future directions and limitations

This brief provides important historical context and actions that have shaped the landscape of American Indian health care today. Not only that, but this brief also provides a distinct perspective from an individual who has the lived experience of AI/AN people along with experience and education in public health and health equity. 

Quin’s voice and ideas found in this brief are as intriguing as they are important. Publications with a foundation of personal perspective & experience such as this one are essential for uplifting voices from historically marginalized groups, identifying & spotlighting the structural issues that individuals face, and learning from the stakeholders who are impacted directly and indirectly. 

Read the brief in full here or click on the image of the cover page above. We welcome any questions or comments – you can send them to Quin directly at nels9793@umn.edu. 

Are you curious about American Indian health statistics, data collection, health care, health disparities, and more? You can start by delving into the references that informed this brief - these resources are rich with information. You can continue learning with some of the following SHADAC products and resources:

• Explore State Health Compare: Health Insurance Coverage by Race/Ethnicity (Includes AI/AN Breakdown)
• SHVS Brief: Collection of Race, Ethnicity, Language Data on Medicaid Applications: New and Updated Information on Medicaid Data Collection Practices in the States, Territories, and D.C.
• SHADAC Brief: The Kids Aren't Alright. Adverse Childhood Experiences and Implications for Health Equity

Walsh, Elliot
Hest, Robert
Lukanen, Elizabeth

What Do the New Census Data Say About Insurance Coverage for Children and Adults? A Look at Both the National and State Level (SHVS Cross-Post)

The following Expert Perspective (EP) is cross-posted from State Health & Value Strategies.

Authors: Elizabeth Lukanen, Elliot Walsh, Robert Hest, SHADAC

Original posting date October 30, 2024. Find the original post here on the SHVS website.

Walsh, Elliot
Research Dissemination Coordinator

e wals0421@umn.edu

What Are Adverse Childhood Experiences (ACEs)? ACEs Definition, Data Challenges, and Resources

Basics Blog Introduction

SHADAC has created a series of “Basics Blogs” to familiarize readers with common terms, concepts, and topics that are frequently covered.

Children’s health is impacted by a number of factors – family life and income, housing, neighborhood, nutrition, health care access and cost, amongst others.

Adverse Childhood Experiences (ACEs) is a broad term for a range of negative experiences people may experience as children that can have profound implications for their health. Sometimes ACEs may occur in the form of a single traumatic event, such as a violent incident, but ACEs may also be the result of recurring, lower-grade stress, such as continual food insecurity.

Many research studies conducted over the course of decades have found ACEs to be linked not only with short-term health implications for children, but also long-term health burden that can last well into adulthood. Unfortunately, they are quite common. One SHADAC brief reports that nearly half (46.3%) of U.S. children have experienced at least one adverse childhood experience, with the CDC reporting that 1 in 6 adults have experienced four or more ACEs in their childhood.

There is ample evidence that ACEs are linked to increased risk of chronic health conditions (asthma, chronic obstructive pulmonary disease, stroke, obesity, etc.), engaging in coping behaviors with health risks (drug use, heavy drinking, unprotected sex, etc.), and long-term behavioral and/or mental health issues (depression, anxiety, substance use disorders, etc.). Evidence also shows that those who experience ACEs have poorer health outcomes, lower educational attainment, and higher unemployment rates.

In this blog, we will provide you with:

• Adverse childhood experience definition and examples

• Data collection challenges

• Comments on ACEs and health equity

• Resources on ACEs and related topics from SHADAC

Gaining a better understanding of ACEs can help people recognize them. With that knowledge, people can seek to prevent ACEs and seek health care that recognizes them as underlying risk factors that can influence people’s health. Understanding ACEs and disparities in their prevalence may help to improve public health and enhance health equity. We can work towards reducing the prevalence of childhood trauma and stresses that can comprise ACEs, as well as their impacts on health in both the short- and the long-term for different and diverse communities.

What Are Adverse Childhood Experiences?

First coined by Vincent Felitti, Robert Anda, and their colleagues in a study published in 1998, Adverse Childhood Experiences (ACEs) are defined by the CDC as, “potentially traumatic events that occur in childhood.”

There is no single, comprehensive definition of what experiences do and don’t constitute ACEs. Initial definitions focused heavily on childhood abuse and neglect, and dysfunction and violence in the household, but some experts have proposed broader definitions that encompass systemic issues, such as housing instability and food insecurity, which research suggests can have similar long-term health impacts.

Some examples of potential adverse childhood experiences include:

• Experiencing neglect or abuse (e.g., emotional, physical, sexual)

• Separation from a parent, guardian, or caregiver due to death, incarceration or divorce

• Witnessing violence and/or domestic violence

• Family member attempting or dying by suicide

• Growing up in a household with substance abuse and/or mental health problems

• Housing instability and food insecurity

• Peer-based bullying

• Experiencing or witnessing racism

These only represent a small number of what could be considered an adverse childhood experience.

ACEs and Health Equity

It has been established by a number of studies that certain populations experience ACEs at a higher prevalence. In the SHADAC study on ACEs and Health Equity, we found that, “Black children had the highest rate of ACEs exposure, at 63.7%, followed closely by American Indian and Alaska Native children, at 63.0%. Each of those was significantly different from the total population rate of 46.3%.”

Figure 1. Percent of children with one or more adverse childhood experiences by race and ethnicity, 2016-2019

The CDC reports groups with the highest prevalence of ACEs in the U.S. include:

• Women

• Racial and ethnic minorities (particularly American Indian or Alaska Native (AIAN) people and multiracial people)

• Members of the LGBTQ+ community

• Those considered low-income

• Those who are unemployed or can’t work

• Adults with less than a high school education

It follows, then, that these groups with a higher prevalence of ACEs would also experience the health impacts of these events at higher rates, which goes on to impact quality of life, overall health, and can impact the children of people in these groups as well. This can perpetuate a cycle of generational trauma and continue to widen the disparities between these and other groups.

It is also worth noting that even with the finding that these groups have higher prevalence of ACEs exposure compared to the total population, it could still be an overall underestimation of ACE prevalence because of demographic data collection challenges both for minority groups and for collection of ACE data in general.

You can learn more about demographic data collection and its impacts in the SHADAC brief on The Collection of Race, Ethnicity, Language Data on Medicaid Applications.

Adverse Childhood Experiences and Data Collection Challenges

As noted earlier, there are challenges when it comes to ACEs data collection.

One such challenge is who the data is collected from. Many surveys are filled out by a parent or guardian reporting on their child. This can result in underestimation of ACEs experienced by the child for a few reasons. Firstly, the parent or guardian filling out the survey could be unaware of a traumatic experience their child has had. Additionally, the parent or guardian could feel uncomfortable or unable to report that their child has had certain adverse experiences, like abuse or experiencing a parent’s mental health issues.

If a child is filling out the survey themselves, some of the questions may be inappropriate to ask of young children, the children may be reluctant to report some forms of trauma, or they may not even recognize that an event was a traumatic one.

As SHADAC researcher Colin Planalp mentions in his brief on ACEs and health equity, “Another approach [for data collection] could be to survey adults about their experiences as children, but that approach may also face some of the same limitations of reluctance to report some forms of trauma, and adults may simply not recall traumatic experiences that occurred decades ago. And by surveying adults about their own traumatic experiences as children, those data would by nature be retrospective— telling us little about the prevalence and types of ACEs among today’s children, which may change over time.”

Another issue is the feasibility of including all types of ACEs in a survey. As we mentioned in the previous section, we only listed a small number of possible ACEs. Surveys often condense or simplify the number of ACEs that it asks about – it simply isn’t feasible to list out every single type of ACE or trauma, which likely results in an overall underestimation of experienced ACEs in the population.

Adverse Childhood Experiences: Resources from SHADAC

Hopefully this has given you a general overview on the question, “What are ACEs?” But, as you could probably glean, this is a complex topic with many factors to consider and learn about. ACEs and their impact touch upon a number of issues, including health care cost & access, mental health care, housing, generational trauma, drug and substance use, structural oppression (like racism, homophobia, ableism, etc.), children’s health, and more. Each factor exists amongst and with the others, creating complex systems to unravel and intersectional identities to consider.

Additionally, this is a relatively new area of study, with that original Felitti et al. study published in 1998. New information and research continue to expand our understanding of ACEs, health disparities, and their impacts on health later in life – for example, a study published in Health Affairs in 2024 found a link between ACEs and adults experiencing financial and housing problems, social network problems, and food insecurity, and found that “those with ACEs had substantially higher [health care] utilization and 26.3 percent higher expenditures.”

Continued study and research can help us identify these issues, understand the groups impacted, and work towards both prevention and post-trauma support. Working on this issue has implications to improve the health of children and adults, reduce risk of chronic and mental health conditions, reduce related costs, and, hopefully, reduce the impact and prevalence of childhood trauma.

Keep learning about ACEs and related topics with some of the following SHADAC products:

Changing Dynamics in the Opioid Crisis Since the COVID-19 Pandemic

Soaring rates of fatal fentanyl, methamphetamine, and cocaine overdoses have worsened and spread to previously insulated groups, including teenagers and the elderly

It has been more than a decade since the U.S. Centers for Disease Control and Prevention (CDC) declared a national opioid “epidemic,” also known as the opioid crisis. In that time, hundreds of thousands of people have died, with the impact rippling out amongst friends, family, and communities: One in three U.S. adults know someone who has died of an overdose.¹ 

Despite knowledge of this crisis and efforts to reduce fatal overdoses and impacts of substance use disorder, we have seen the opioid epidemic continually worsen and evolve. Evidence suggests that increased regulations on prescription opioids pushed many to illicit alternatives.² The COVID-19 pandemic coincided with a huge increase in overdose deaths. Fentanyl, a once lesser-known contributor to the epidemic, has skyrocketed in its impact. Once insulated groups, like adolescents and the elderly, have seen overdose rates rise.

In this new brief from SHADAC, we examine changes in drug overdose death rates, and the types of drugs that cause these fatal overdoses, during the pandemic period (2019-2022). We also look at the history of the opioid epidemic: its beginnings, factors that influenced its evolution, and what it looks like now.

With this brief focusing on the four most common causes of drug overdoses — fentanyl, prescription opioids, methamphetamine, and cocaine — just some of the findings from this pandemic period include:

• Fatal overdoses from fentanyl increased 99%
• Fatal overdoses from methamphetamine increased 108%, and 
• Fatal overdoses from cocaine increased 69%

While overdose death rates generally increased across all the measured racial and ethnic groups, “we […] found evidence of dramatic and growing disparities across racial and ethnic groups in rates of fatal overdoses, with the crisis increasingly harming American Indian and Alaska Native people and Black people during the pandemic era,” lead author and Senior Researcher Colin Planalp says. 

In this brief, we explore these findings and more, including looking deeper at the impacts of the opioid crisis on different communities, demographics, and states. Click here to read the brief in full. The appendix for this piece is available here.

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[1] Kennedy-Hendricks, A., Ettman, C. K., Gollust, S. E., Bandara, S. N., Abdalla, S. M., Castrucci, B. C., & Galea, S. (2024). Experience of Personal Loss Due to Drug Overdose Among US Adults. JAMA health forum, 5(5), e241262. https://pubmed.ncbi.nlm.nih.gov/38819798/

[2] Pitt, A.L., Humphreys, K., & Brandeau, M.L. (2018). Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. American Journal of Public Health, 108(10), 1394-1400. https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2018.304590

 

Walsh, Elliot
Hest, Robert
Stewart, Andrea

Children’s Health Insurance in 2023: Exploring Rising Uninsured Rates for Low-Income Children

• The total U.S. population
• Nonelderly adults (age 19-64), and 
• Children (age 0-18)

As seen in our full blog post on the 2023 ACS data release and our blog & infographic on the 2023 CPS data release, we found that overall rates of public coverage and private coverage remained unchanged in 2023. However, it is important to note that alongside that indicator of coverage stability at a national level, we also found that:

• Changes in uninsured rates for nonelderly adults' (age 19-64) varied depending on Medicaid expansion status and poverty level
• Rates of uninsured children (age 0-18) rose significantly

These findings sparked questions: After two years of falling rates, what could be contributing to rising uninsurance among children? Changes in nonelderly adults’ uninsured rates between 2022 and 2023 varied by poverty level and the status of Medicaid expansion in their state – could either of these factors also be impacting children’s uninsured rates in the newly released data?

While more research into causes behind these changes is needed, SHADAC began by looking at the ACS HI-11 tables, which include data specific to health insurance coverage rates for children below 200% of the Census poverty threshold. 

Keep reading to see some of our findings on how the insurance coverage of low-income children (those with family incomes below 200% of the Census poverty threshold) changed between 2022 and 2023 both nationally and at the state level.

Nationally, Children’s Uninsured Rates Increased while Public Coverage Rates Decreased

Looking at 2023 ACS data for children below 200% of the Census poverty threshold, we found that uninsured rates for this group mirrored overall trends at a national level, rising by 0.4 percentage points (PP) to 7.3%. This significant increase was likely driven by a 0.6PP decrease in public coverage (bringing that national rate down to 72.6%) and a statistically unchanged rate of private coverage (27.0%). 

Further, low-income children’s uninsured rate was 1.9PP higher than the 5.4% rate of uninsured children overall, a statistic which saw its own significant rise from 5.1% in 2022.

State-Level Coverage Changes for Low-Income Children

When we delve into state-level data for low-income children, we see that Louisiana (+1.5PP), Michigan (+1.2PP), South Carolina (+1.6PP), and Texas (+1.5PP) all saw significant increases in uninsurance, rising to 5.5%, 4.3%, 8.0%, and 15.4%, respectively.   

As with the national uninsured rate, our analysis found that a couple of these states mirror a simultaneous decrease in public coverage that likely influenced the increase in uninsurance. For example, Michigan saw a 3.1PP decrease in public coverage, bringing it down to 73.2%, and Texas saw a 2.5PP decrease in public coverage, bringing it down to 65.0%. 

Again, similar to trends at the national level, none of the states that saw increased uninsurance for low-income children saw any significant changes in private coverage among that group. 

No states saw decreases in uninsurance. 

Looking Closer at Public & Private Coverage Rates for Low-Income Children   

Looking at public coverage, states saw a wide range of changes:

• Four states, Arkansas (-4.8PP ), Michigan (-3.1PP), Nebraska (-5.4PP), and Texas (2.5PP), saw significant decreases in public coverage.
• Kansas (+4.5PP), Tennessee (+3.2PP), and Wyoming (+15.8PP) saw significant increases in public coverage

Looking at private coverage, states also saw a wide range of changes:

• Alaska (-8.1PP), Kansas (-5.3PP), Tennessee (-3.8PP), and Wisconsin (-4.9PP) all saw decreases in private coverage
• Kentucky (+3.4PP), Nebraska (+6.5PP), and New York (+2.5PP) all saw increases in private coverage

One thing to note here is that Nebraska, the state with the largest significant decrease in public coverage for low-income children, did not appear on the list of states with significant increases in uninsurance for the same group. But it did also see the largest increase in private coverage for this group, which could have mitigated any change in uninsurance.

Conclusion & Discussion 

By looking deeper into low-income children’s health insurance coverage in 2023, we hoped to find more information on why uninsured rates have increased both overall and specifically for this group. 

At the national level and in a small number of states, we observed increases in uninsurance that coincided with decreases in public coverage. This could be a result of the unwinding of the Medicaid continuous coverage requirement that began during 2023. According to an issue brief on children’s poverty and health insurance coverage published by KFF in January 2024, Medicaid covers 8 in 10 children living in poverty. This brief goes on to report that based on reported unwinding data from 23 states, almost 4 in 10 of those disenrolled from Medicaid during the unwinding are children, likely impacting the many children living in poverty with this public coverage.

However, this story of falling public coverage and rising uninsurance was not consistent across the states. We did not observe significant changes in uninsurance in most states, either because decreases in one type of coverage were offset by increases in another type of coverage, or because there was little movement in coverage overall. 

Coverage estimates for 2024 (to be released next fall) will give a more complete picture of coverage during the unwinding and may clarify how coverage evolved during this dynamic period.