Houston Urban Indian Health - Native American Health Coalition

2011
Houston Urban Indian Health:
A story of Unmet Need
Native American Health Coalition – Houston
4407 Rose Street, Houston TX 77007
www.nativeamericanhealthcoalition.org
Houston Urban Indian Health
A Story of Unmet Need
Acknowledgements
Our appreciation and thanks go out to the many organizations and their staffs who
offered assistance and support throughout our needs assessment process.
Alabama-Coushatta Tribe
Alabama-Coushatta Workforce & Training Program
Asian American Health Coalition
Cherokee Nation
Citizen Band Potawatomi
City of Houston Health Department
Gulf Coast TiaPiah Gourd Dance Society
Houston Traders’ Village Powwow
Legacy Community Health Centers
Native American Methodist Church
Native American Chamber of Commerce
National Council of Urban Indian Health
United Southern and Eastern Tribes
More specifically, our thanks go out to:
Walter Celestine
Patrick Courtney
Beverly Gor
Chad Smith
Bob White
Finally, we acknowledge our dedicated volunteer members who worked tirelessly to
spread the word, staff powwow booths, maintain websites, conduct data entry and
analysis, visit city officials, and generally promote the needs of Urban American
Indian/Alaska Natives in Southeast Texas.
Walter Celestine, Cheryl Downing, Anna and Jim Edwards,
Maggie Heagy, Larry Laufman, Ken Masters, Deborah Scott
2
Table of Contents
Executive Summary
Houston Urban Indian Health: A Story of Unmet Need
Background American Indian/Alaska Natives in Texas
Medicaid Rates for AIAN & Identity
Indian Health Service in Texas
Population Comparisons in Texas
Population Comparisons across Urban Areas with IHS Clinics
The Native American Health Coalition
Accomplishments
Local Needs Assessment
Results
Summary of Needs Assessment Findings
Concluding Arguments
Resources
4
5
4
8
9
9
9
10
10
14
14
19
20
22
Tables
1.
2.
3.
4.
5.
6.
7.
7
8
9
14
15
16
17
Harris County Consolidated Metropolitan Area
Harris County Comparison Census
Urban IHS Clinic Sites
Household Size
Income
Characteristics of Insured versus Uninsured
Healthcare Providers
Charts
1. Total January 2011 Medicaid Enrolled – AIAN
8
Appendices
History of NAHC Activities
Comparison with Other Urban Centers
Letters of Support
21
23
24
3
Executive Summary
This report describes the background and health care needs of Native Americans in the
Greater Houston Metroplex and the results of a local needs assessment. Houston is the
fourth largest city in the United States, and is the regional center of the largest
population of American Indians/Alaska Natives (totaling over 65,000), without an Indian
Health Service facility. Since 1997, the Native American Health Coalition, a 501c3
organization with a 100% American Indian/Alaska Native (AI/AN) board of directors, has
worked to improve the health conditions of AI/AN living in the Greater Houston area. As
part of our mission, we initiated the needs assessment in order to strengthen the
request for Houston to be selected as an IHS urban site.
This is a summary of the results of 304 AI/ANs who completed the survey, either online
or during outreach efforts such as powwows and community gatherings.
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Greatest percentage lives in two-person households; many are elders on limited
income.
16.4% meet federal poverty level guidelines; over 70% earn $50,000 or less.
56% are employed full-time or part-time.
Education attainment is much higher than national norms; however, job
descriptions indicate many AI/AN in the community are underemployed.
Percentage of disabled AI/ANs is half the national average, suggesting that
persons with disabilities are likely to relocate away from Houston, possibly to be
nearer available/affordable healthcare.
Profiles of the insured versus the uninsured are very different. The uninsured
are typically younger, more likely to be unemployed, more likely to live in
poverty, more likely to have no health home, and much less likely to see a
physician. Additionally, when they do see a healthcare provider, the distance
traveled is much greater, indicating travel to places where healthcare is
available, e.g. Dallas Urban Indian Center or an IHS clinic in Oklahoma. People
also travel great distances to obtain prescription medications from IHS clinics,
where medications are free.
Primary causes for medical care are: diabetes; heart disease; influenza; cancer,
blood pressure; mental health care; or musculoskeletal problems. The
prevalence of cancer within the study population was an unanticipated finding.
Of those reporting cancer, 53% were uninsured and 43% were insured.
Primary barriers to accessing healthcare are costs and lack of insurance. The
cost of prescription medications is also a significant barrier (as reported in the
town hall meeting). Barriers unrelated to cost or insurance are: lack of AI/AN
providers; lack of awareness about available services or knowing where to go to
access services; and perception that healthcare providers don’t understand the
needs of AI/AN.
4
Houston Urban Indian Health:
A Story of Unmet Need
Background American Indians/Alaska Natives in Texas: A Chronology
Pre-1800
Many tribes traversed the area of present day Southeast Texas. Two tribes called
the area home—the Atakapa-Ishak and the Karankawa. Remnants of the
Atakapa-Ishak can be found today in coastal East Texas and at Grand Bayou,
Louisiana.
1805
Approximately 1,000 Alabamas came to Tyler County’s Peach Tree Village. The
Coushattas were already in East Texas, having arrived in the area sometime after
1795.1 During the early 1800’s, other tribal groups, including the Cherokees,
Choctaws, Shawnees, Kickapoos, and Natchez sought refuge in Mexican-held
southeast and east Texas and settled near the Alabamas and Coushattas.
1837
Houston became the first capital of the new Republic of Texas. Numerous tribal
delegations from all over Texas, including Tonkawas, Comanches, Cherokees,
and Kickapoo traveled to Houston to air grievances and to seek the assistance of
the sympathetic first president, Sam Houston.
1840
Mirabeau Lamar, Sam Houston’s successor, saw the immigrant Indians as
unauthorized intruders. In fact, Indian removal was a prime directive of the
second President, and he removed them, sometimes by force, from Texas.2
Pockets of tribal people remained, Alabamas and Coushattas in the east Texas
forests, Kickapoos in the southwest, and Tigua of Ysleta el Sur Pueblo in the
west.
1
Alabama-Coushatta Tribe of Texas, http://www.actribe.com/ac/index.php?option=com_content&task=view&id=24&Itemid=133, accessed January
30, 2011.
2
The Handbook of Texas. "CHEROKEE WAR,"
www.tshaonline.org/handbook/online/articles/qdc01), accessed January 30, 2011
5
1848
In 1848 the Tigua of Ysleta el Sur Pueblo became part of the United States as a
result of the war with Mexico. Over the years, the land holdings were illegally
seized, but the group continued to hold Tribal Council meetings and maintain
their cultural ties. In 1967 the state recognized the Tigua Indians of El Paso as a
Texas Indian tribe.
1930
In 1930, the Texas State Board of Control began making appropriations for the
Alabama-Coushatta reservation. In 1950 this responsibility was transferred to
the newly-created Texas Board for State Hospitals and Special Schools. The
federal government relinquished federal control over the tribe in 1955. In 1965,
the Board was abolished and all responsibilities for the Alabama-Coushatta
Indians were transferred to the Commission for Indian Affairs (now defunct).
1950
In the 1950s, the Eisenhower Administration adapted a “termination” policy to
move Native people from reservations to urban areas to provide economic
opportunity. This is the genesis of the “urban Indian.” Dallas/Fort Worth was a
termination site and now has the largest concentration of Native people in the
state. Other spots of higher Native population density include Houston, Austin,
and El Paso. According to the 2010 US Census there are now 315, 264 American
Indians/Alaska Natives (AI/AN) (self-reported as either of single or of mixed
racial background) living in Texas.
1977
The Kickapoo Tribe of Texas was granted recognition in 1977. This was
challenged by the State of Texas and was rescinded in 1979. The Kickapoos then
worked through sister tribes in Kansas and Oklahoma and in 1982 they were
recognized as an official sub-group of the Oklahoma Kickapoo Indian Tribe,
enabling them to acquire their own reservation, under control of the Bureau of
Indian Affairs instead of the state of Texas.
1970-1980
Native people came to Texas, and to Houston, attracted by jobs in the oil and gas
industries and the low cost of living. During this time, AI/AN began to organize in
various communities such as the Dallas Inter-Tribal Council (now the Dallas
Urban Indian Center, and the Inter-Tribal Council of Houston (now defunct). The
Dallas Urban Inter-Tribal Center now serves Collin, Dallas, Denton, Ellis, Hood,
Johnson, Kaufman, Parker, Rockwall, Tarrant and Wise counties.
6
1980
The tribes began a move in the mid 1980s to have their trust responsibilities
transferred back to federal control. The federal government passed a law on
August 18, 1987, reassuming responsibility for the Texas Indian tribes. This
eventually contributed to the demise of the Texas Indian Commission.
After the State of Texas eliminated the Commission on Indian Affairs in the late
1980’s, there was no means for officially communicating or establishing
networks between American Indian organizations or learning what others were
doing to access or improve health conditions.
1997
The Native American Health Coalition was formed to begin to address the needs
of Urban AI/ANs living in Houston and the surrounding areas.
2000
The population of AI/AN in the Houston Consolidated Metropolitan Service Area
(CMSA) was 39,631.3
2010
The population of AI/ANs in the Houston CMSA increased over 57% from 39,631
in 2000 to 68, 736 in 2010.4 About 4.6% of AI/ANs received Medicaid, with Fort Bend
and Waller counties having the highest rates per hundred people.
Harris County
Consolidated
Metropolitan
Area
2000
US
Census
Harris County
Montgomery
County
Fort Bend County
Galveston County
Brazoria County
Liberty County
Waller County
Chambers County
Totals
Table 1.
28,501
2,821
2009 US
Census
American
Community
Survey
32,363
4,642
2,287
2.246
2,530
716
296
234
39,631
4,384
3,272
3,006
894
541
307
49,409
3
4
2010 US
Census
Number &
Percent All
Medicaid
Enrollment
Medicaid
Rates per
100
48,518
6,164
2,408 (0.41%)
156 (0.39%)
8.67
4.66
5,151
3,495
3,537
878
581
412
68,736
318 (0.81%)
115 (0.37%)
128 (0.43%)
32 (0.27%)
19 (0.34%)
3 (0.11%)
13.81
6.58
7.23
7.44
13.48
1.37
2000 US Census
2010 US Census
7
MEDICAID RATES FOR AMERICAN INDIAN/ALASKA NATIVES & IDENTITY
The University of Texas, Health Sciences Center conducted an analysis of
Medicaid utilization during an 8-month enrollment period.5 Distinctions
between race and ethnicity are problematic in that many AI/AN in East Texas are
reported as Hispanic. Many are in fact of mixed race, others self identify as
Hispanic to maintain confidentiality, while still others are classified by reporting
staff based upon appearance.6 The 2010 Census totals for Harris County, for
example, show that American Indians are disproportionately classified as
Hispanic.
Harris County Comparison Census
White
Black
American Indian/Alaska Native
All
Table 2.
Non-Hispanic
Hispanic
1,349,646
968,810
754,258
21,234
8,150
19,613
2,420,919
1,671,540
For both AI/AN and
Hispanic
populations, most
Medicaid recipients
lived in the
southwestern
quadrant of Harris
County.
Chart 1.
5
Texas Health and Human Services Commission, Texas Medicaid Historical (8-Month) Enrollment
File.
6
Community comments during town hall meeting on June 21, 2011.
8
Indian Health Service in Texas
There are 12 IHS Regions nationally and each of the three federally recognized
tribes in Texas is under the jurisdiction of a different IHS region. The AlabamaCoushatta Tribe is under Nashville, TN; Tigua of Ysleta del Sur Pueblo reports to
Albuquerque, NM; and the Kickapoo Tribe of Texas is under Oklahoma City, OK.
The single urban Indian Health Center in Texas is in Dallas, and it also reports to
the Oklahoma City Region of IHS. Thus, statewide health issues for American
Indians living in Texas need to be negotiated across three IHS offices.
Population Comparisons in Texas
In Texas, a broad estimation of AI/AN living on or near
federal reservations and accessing Indian Health Service
clinics is about 3,000,7 or .09% of the total AI/AN population.
The remaining 312,264 or 99% of AI/ANs in Texas live in rural
or urban areas. This compares to national rates of
about 60% of the AI population living off the
reservation. Further, about half of these nonreservations AI/ANs (151,902) live near the two largest
cities in the state--Houston (45%; 68,736) or Dallas (55%;
83,166).
Population Comparisons across Urban Areas with IHS Clinics
In comparison to the nine largest urban areas with an Indian Health Service
clinic, Houston places fourth, with an AI/AN population of 68,736 and has more
than double the AI/AN population of most other locations.
Urban IHS Clinic
Sites
Boston
Minneapolis
Seattle
Albuquerque
Chicago
Denver
2010 AI/AN
Population
26,587
30,373
39,117
40,444
45,040
53,496
Houston
68,736
Dallas
83,166
Phoenix
New York
*Source: 2010 US Census
107,271
111,749
Counties in Service Area
Essex, Middlesex, Norfolk, Plymouth, Suffolk
Hennepin, Ramsey
King
Bernalillo
Cook
Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas,
Gilpin, Jefferson
Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty,
Montgomery, Waller
Collin, Dallas, Denton, Ellis, Hood, Johnson, Kaufman,
Parker, Rockwall, Tarrant
Maricopa
Bronx, Kings, New York, Queens, Richmond
Total
Population
4,184,036
1,661,065
4,931,249
662,564
5,194,675
2,789,669
5,891,999
6,602,468
3,817,117
8,175,133
Table 3.
7
Based on tribal counts, Alabama-Coushatta has 1200 members; Tigua of Ysleta del Sur Pueblo
has about 1200 members; Kickapoo Traditional Tribe of Mexico has about 420 members.
9
THE NATIVE AMERICAN HEALTH COALITION
The Native American Health Coalition (NAHC) was founded in 1997 as a
community task force to aid the Area Health Education Center in representing
the healthcare needs of minority communities in Houston. The organization was
incorporated as a 501c3, non-profit in 2000 with the mission of increasing access
to health care resources and information for American Indians/Alaska Natives
living in Southeast Texas.
The board is 100% AI/AN, and membership is made up of Native Americans,
healthcare providers, and representatives of local social service agencies.
Membership is free and open to all individuals or organizations interested in
helping achieve organization goals.
GOALS
In collaboration with community partners, members are dedicated to combining
resources and knowledge to make health services more accessible to all AI/AIs.
We strive to:
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Provide health promotion, education and information/referral services,
Ensure culturally sensitive resources for health professionals and the
community,
Advocate on the behalf of American Indians for essential health provision.
ACCOMPLISHMENTS
NAHC Conferences and Community Outreach (See Appendix for expanded
descriptions) Our first event was a Wellness Conference in 1999, with
subsequent conferences in 2002, 2007, 2009, and 2011. Each of these day-long
events brought speakers and new information to community providers about the
needs of AI/AN living in Texas.
In 2009, the group received funding from St. Luke’s Episcopal Charities to
provide quarterly health promotion/education programming activities.
Quarterly, NAHC conducted “Dine with the Doc” meetings to foster community
access to medical information. In these gatherings, NAHC member physicians
presented a variety of topics, including sessions on colon cancer, breast cancer,
10
depression and heart disease. Each meeting concluded with informal questions
and answers, allowing community members to gain medical insight regarding
areas of concern. Currently, NAHC is partnering with TMF, Inc., and the Centers
for Medicare and Medicaid to increase diabetes self management education
classes for Native Americans across the state.
Powwows – Another early event was collaboration with the Cherokee Cultural
Society and the University of Houston, School of Optometry, to put on a
Powwow for Health in conjunction with the University’s Frontier Days event in
1998. Since that time, we regularly and on an ongoing basis, staff booths at the
Houston Traders’ Village Annual Powwow as well as powwows on the AlabamaCoushatta Reservation, the Tiapiah Gourd Dance Society, and the Rice University
Native American Students Association.
Expert Consultation – On numerous occasions, members of NAHC have been
called upon to give presentations to medical personnel and community members
about the health concerns and cultural norms of AI/AN in Houston and Texas.
Some of these events include the Native American Initiative on Public Health
Education (2003); Baylor College of Medicine (2004); Center for Research on
Minority Health (2008); and the United Southeastern Tribes Bi-Annual
Conference (2011).
Members of NAHC represent the AI/AN community on state boards including the
Center for Research on Minority Health and the Cancer Alliance of Texas.
Research – Since the beginning, the organization has collaborated and partnered
with many different entities. Our first activity was a needs assessment in
partnership with the Texas Rehabilitation Commission. Over the years, NAHC has
been a subcontractor for research about AI/AN living in the Harris County area.
We wrote a collaborative grant with the Houston Regional HIV/AIDS Resource
Group (2002) in order to conduct a needs assessment regarding HIV risk
behaviors in AIAN males and interviewed over 100 men. We partnered with the
Montrose Counseling Center on a Conference of Mayors funding opportunity
(2005) and developed the NiKan Project – a case management and support
group initiative for AIAN males at risk or living with HIV or AIDS.
Over September, 2011, NAHC worked together with the three federally
recognized tribes in Texas and with the Urban Intertribal Center of Texas (in
11
Dallas) to submit collaborative grant proposals to the National Institutes of
Health and other funders. A recent application proposes to develop a cancer
prevention services continuum of care for Native Americans in two urban
communities (Houston and Dallas) and on the rural reservations of the AlabamaCoushatta Indians (East Texas), Kickapoo Indians (Eagle Pass along the Mexico
Border), and Ysleta del Sur/Tigua Indians in El Paso).
Specific Aims of the proposal are to:
1. Develop, implement, and evaluate a culturally sensitive patient
navigation curriculum for cancer prevention among AI/ANs in Texas.
2. Implement and evaluate outreach and patient navigation for cancer
prevention and cancer survivor support among AI/ANs in the targeted
communities.
3. Provide cancer screening and prevention activities to AI/ANs living in
each of the targeted communities.
4. Address sustainability of project activities by providing training in cancer
related community based participatory research to the participating
AI/AN organizations and tribes.
For purposes of program evaluation, we propose to demonstrate the following
statistically significant (p < .05) increases compared with baseline data:
1. Knowledge about breast, cervical, and colorectal cancers; their related
risk factors; appropriate screening measures; and where to get screened.
2. Appropriate enrollment in Medicaid, Medicare, or other insurance for
continued coverage of recommended screening during and after the
period of grant funding.
3. Screening for breast, cervical, and colorectal cancers.
4. Numbers of diagnoses at earlier stages complemented by decreased
numbers of diagnoses at later stages of disease.
5. Submission of new collaborative grant proposals developed by the
participating AI/AN organizations and tribes.
This initiative is an unprecedented effort both to work together and to impact
AI/AN health care on a Statewide basis.
12
In 2010, we began a more aggressive data collection initiative in preparation
for the national needs assessment mandated by the US Congress in hopes of
locating an urban Indian health center in southeast Texas. More on our
findings are reported herein.
NOTE: The results of the needs assessment were presented to the community
and local officials during a town hall meeting on June 21, 2011. During this
meeting, we learned more about the gaps in services. The fundamental issue
appears to be difficulty in getting prescription medications. Several community
members reported on their personal stories of going with medications,
“stretching” prescriptions by taking partial doses, and traveling great distances in
order to get refills at a tribal clinic.
The Houston community, AI/AN members, healthcare providers, and City of
Houston officials were all responsive to the findings and validated the need for
better AI/AN community access to care. In support of our petition to be
considered as the next site for an Urban Indian Clinic, we have received letters
from the following individuals:
Annise Parker, Mayor of the City of Houston
Ed Gonzalez, Houston City Councilor and Vice-Mayor Pro-Tem
Melissa Noriega, Houston City Councilor At-Large
Jolanda Jones, Houston City Councilor At-Large
Mario Gallegos, Jr., Texas State Senator, District 6
Gene Green, U.S. Congressman
Sheila Jackson Lee, U.S. Congresswoman
Lovell A. Jones, PhD, Director of the Dorothy I. Height Center for Health Equity
and Evaluation Research (formerly the Center for Minority Health Research)
Ron Cookston, Executive Director of Gateway to Care, representing 167 area
organizations.
13
LOCAL NEEDS ASSESSMENT
Methodology
In October 2010, the NAHC initiated a grass roots needs assessment effort in
response to the pending national needs assessment mandated by congress to
identify potential sites for new urban Indian clinics. The purpose of the needs
assessment was to identify and characterize the health concerns and needs of
the AI/AN community in Texas and determine for ourselves, the needs of our
community. A 22-question survey was developed and broadcasted via the
internet, emails, and during social events such as powwows or community
meetings from October, 2010 through August, 2011. Data was entered
electronically via SurveyMonkey (an internet survey program), either by the
participant, or by a volunteer entering information from paper surveys. A total
of 304 persons submitted an assessment. Data was downloaded into Statistical
Program for Social Sciences (SPSS) software for frequency analysis and reporting.
Questions on the survey collected information about demographics, health
provider experiences, and health concerns (instrument included in appendices).
The limitations to the generalizability of the findings are that it was a
convenience sampling, was self-administered, and completed anonymously, in
most cases, via the internet. The survey was brief, and many questions remain
unanswered.
RESULTS (N=304)
Tribally Affiliated - 81.6% (247).
Ages - The age range of participants was 18 to 94 years and the median age was
51.
Households - The greatest percentage live in two-person households (42% or
128), followed by single person households (17.8%; 54) then three person
households (15.8%; 48).
Household Size
One person
2 People
3 People
4 People
5 People
6 People
7 People or more
Percent
17.8%
42.1%
15.8%
11.5%
7.2%
3.0%
2.7%
14
Income – Income followed the Bell Curve, with 10% to 12% at each end of the
spectrum. The greatest percentage (27.9%) earned up to $50,000. The current
federal poverty (FPL) guidelines are set at $20,050 for a family of four and 16.4%
(44) of our study population met FPL criteria. The characteristics of these
respondents indicated they were either living alone or with one other person, so
were likely to be elders and retired.
Income
$10,000 or less
$10,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 or more annually
Table 5.
Percent
12.3%
10.8%
25.7%
27.9%
13.0%
10.4%
Gender - Slightly more females than males completed the survey (54.9% versus
45.1%).
Employment (N=277) While the majority of participants had employment, only
46% were employed fulltime. Of those employed, the majority (59%) worked in
blue-collar jobs or in the service sector. The rate of unemployment was 9%, the
same as for the City of Houston in June 2011. The percentage of retirees was
higher than the national average of 12.9%8 and the Texas rate of 10.2%9 for all
races. The percent of AI/AN who were disabled was about half the national
average of 17.4%.10
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46% were employed full-time
10% were employed part-time
o 59% of those employed work in blue collar/service jobs
o 17% of those employed work in technical/skilled labor
o 12% of those employed work in white collar/administrative jobs
o 10% of those employed work in white collar/administrative jobs
9% unemployed
16% retired
8% disabled
11% other (housewife, student, military)
8
2009 US Census, American Community Survey.
Ibid.
10
US 2011 Census
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?fpt=table
9
15
Education (N=284) Education attainment in Houston was much higher than the
national estimates. Nationally, 19.5% of the AI/AN do not complete high school,
compared to 6.3% of our study population; 28.5% complete high school,
compared to 19.4% in Houston; 35% complete some college, similar to the rate
in Houston of 36.3%; however, only 10.8% complete college and 6.1% go on to
earn a graduate degree, compared to Houston, where 22.5% have completed
college and another 15% have a graduate degree.11
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6.3% completed some high school or vocational training
19.4% completed high school
36.3% completed some college or vocational training
22.5% graduated college
15% were post graduates or held a professional degree
Insurance (N=304) Nationally, 47.5% of AI/AN had private health insurance,
while 73% of AI/AN in our study had private insurance. Nationally, 24.2% have
no insurance coverage compared to 27% of our study group.12
Socioeconomic Variables Between Insured and Uninsured (N=298) The profiles
of the insured versus the uninsured are very different. The uninsured are
typically younger, more likely to be unemployed, more likely to live in poverty,
more likely to have no health home, and much less likely to see a physician.
Additionally, when they do see a healthcare provider, the distance is much
greater, suggesting travel to places where healthcare they either can afford or
are comfortable with, is available, e.g. Dallas Urban Indian Center or an IHS clinic
in Oklahoma or New Mexico. This also reflects comments heard during the town
hall meeting, in that people were traveling great distances in order to obtain
prescription medications.
Characteristics
Insured N=216
Median Age
54
Percent Unemployed
3.5%
Average Distance to Doctor*
19.5 miles
Percent NO Doctor Visits in Past Year
8.5%
Percent Below $20,000 Household Income
15.2%
Percent No Regular Healthcare Provider
1.9%
 Miles to a provider ranged from 2 miles to 600 miles.
Table 6.
11
12
Uninsured N=82
43
25%
126 miles
33%
43%
37.5%
ibid
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?fpt=table
16
Type of Healthcare Provider (N=296) For the uninsured, 37.5% simply do not
access care; 26.3% travel to an Indian Health Service clinic (Dallas Urban Indian
Center or a clinic in Oklahoma); 25% pay a private physician out of pocket; and
11% use the emergency room.
Healthcare Providers
Private Physician
Health Maintenance Organization
Hospital Emergency Room*
Indian Health Service
Community Clinic
Veterans’ Administration
I do not get healthcare
Traditional Healer
County Health Department Clinic
*Average cost of ER visit in Houston is $20,000.8
Table 7.
Insured N=222 Uninsured N=82
65.7%
25.0%
22.2%
2.5%
8.8%
11.3%
8.8%
26.3%
5.6%
7.5%
3.7%
2.5%
1.9%
37.5%
1.9%
2.5%
1.8%
10.0%
Primary Reasons for Doctors’ Visits in Past Year (N=260) (Multiple responses
allowed) According to the Centers for Disease Control, the leading causes of
death within AI/AN populations, in order, are: heart disease; cancer;
unintentional injuries; diabetes; liver disease; stroke; chronic lower respiratory
disease; suicide; nephritis; and influenza.13
For AI/AN in Houston, the primary causes for medical care are: diabetes; heart
disease; influenza; cancer, blood pressure; mental health care; or
musculoskeletal problems. The prevalence of cancer within the study population
was an unanticipated finding. Of those reporting cancer, the uninsured reported
cancer at a higher percentage than the insured, 53% versus 43%. It is also
important to note that overall, 29.2% see health providers annually for general
exams and screenings.
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
13
Diabetes
Heart (heart attack, arrhythmia, congestive heart failure)
Breathing (influenza, pneumonia, COPD, bronchitis)
Cancer
High Blood Pressure
Mental Health (depression, counseling)
Musculoskeletal (broken bones, muscle pain)
Gastrointestinal (diarrhea, stomach)
37.7%
25.4%
17.3%
15.0%
13.8%
11.2%
10.4%
8.5%
http://www.cdc.gov/omhd/populations/aian/aian.htm#Ten
17



Have not seen a healthcare provider
Other reasons
Annual Exams
6.5%
37.7%
29.2%
Barriers to Accessing Healthcare (N=276)(Multiple responses allowed) The three
primary barriers to accessing healthcare are cost (52.5%), lack of AI/AN providers
(30.1%), and lack of health insurance (24.3%). It is important to note that 23.2%
do not know about available services and another 9.1% do not know where to go
for services (an aggregate of 32.1%).
 Cost (too expensive)
52.5%
 No/Too few Native American Providers
30.1%
 No health insurance
24.3%
 Don’t know what services are available
23.2%
 Don’t feel providers understand health needs of NA
18.8%
 Distance (too far to travel)
15.9%
 Don’t trust healthcare providers
13.8%
 Don’t know where to go
9.1%
 Lack of transportation
7.2%
18
SUMMARY OF NEEDS ASSESSMENT FINDINGS
The results of the Native American Health Coalition needs assessment present a
general profile of AI/AN living in Houston and southeast Texas. This profile
represents in great part, an older population due to the characteristics of
respondents and the recruitment channels of NAHC members.

The greatest percentage live in two-person households and many are
elders on limited income.

16.4% meet federal poverty level guidelines, and over 70% earn $50,000
or less annually.

56% are employed full-time or part-time.

Education attainment is much higher than national norms; however, job
descriptions are primarily for blue collar and service sector positions
indicating many AI/AN in the community are underemployed.

The percentages of disabled AI/AN in Houston are much lower than the
national average, suggesting that persons with disabilities are likely to
relocate away from Houston, possibly to be nearer available/affordable
healthcare.

A greater percentage of AI/AN in Houston report health insurance
coverage than national norms, and also report slightly higher rates of no
insurance. The profiles of the insured versus the uninsured are very
different. The uninsured are typically younger, more likely to be
unemployed, more likely to live in poverty, more likely to have no health
home, and much less likely to see a physician. Additionally, when they do
see a healthcare provider, the distance traveled is much greater,
indicating travel to places where healthcare is available, e.g. Dallas Urban
Indian Center or an IHS clinic in Oklahoma. As remarked above, people
also travel great distances to obtain prescription medications from IHS
clinics, where medications are free.

For AI/AN in Houston, the primary causes for medical care are: diabetes;
heart disease; influenza; cancer, blood pressure; mental health care; or
musculoskeletal problems. The prevalence of cancer within the study
19
population was an unanticipated finding. Of those reporting cancer, 53%
were uninsured and 43% were insured.

Primary barriers to accessing healthcare are costs and lack of insurance.
The cost of prescription medications is often more of a barrier than the
cost of medical care (as reported in the town hall meeting). Barriers
unrelated to cost or insurance are: lack of AI/AN providers; lack of
awareness about available services or knowing where to go to access
services; and perception that healthcare providers don’t understand the
needs of AI/AN. These findings support the need for health navigators,
specific to AI/AN, to increase the awareness of available resources.

Racial misclassification occurs on an individual and systemic level. During
the town hall meeting, AI/AN attendees reported first-hand experiences
with racial misclassification. Systemically, data specific to AI/AN is hard
to capture due to the data collection practices of local health
departments and hospital systems.
CONCLUDING ARGUMENTS
Despite the wary relationship between the State of Texas and American
Indian/Alaska Natives, the AI/AN population continues to increase, growing 57%
between 2000 and 2010. Due to misclassification, these numbers may in fact be
artificially low.
Counter to the national population , over 99% of AI/AN in Texas live offreservation compared to the estimated 60%14 of AI/AN nationally, indicating a
strong and consistent migratory pattern into the state, likely due to economic
factors such as jobs; this, despite the fact that many AI/AN are underemployed.
Jobs are also likely the reason AI/AN live in or near metropolitan areas.
In this study, a relatively high population of retirees coincides with percentages
living alone or in a two-person household and living in poverty, indicating many
elders live on low incomes. Alternatively, the percentage of disabled individuals
is much lower, indicating a likelihood that persons relocate away from Houston if
they become disabled. They may, in fact, return to “home” communities or tribal
lands where access to IHS social services is much easier.
14
http://www.census.gov/prod/2006pubs/censr-28.pdf
20
Cost and lack of insurance are barriers to accessing healthcare, but perhaps
more importantly, cost is a primary barrier to accessing prescription
medications. This may also be a factor in the great distances some participants
travel to reach a health care provider, in that services at an IHS facility includes
free medications. Many from Houston travel to Dallas for care at the IHS clinic,
and others travel over 500 miles to Oklahoma or New Mexico, to get necessary
healthcare.
Of the 315, 264 AI/AN living in Texas, about half live near either Houston or
Dallas. Dallas is a “termination” location and boasts the only Urban Indian
Health Service Center in Texas that is available to any federally recognized
AI/AN. Following Dallas, Houston has the greatest AI/AN population in the state
and ranks higher than many other cities nationally that are currently receiving
Indian Health Service healthcare.
The Native American Health Coalition has a long history of conducting
community-driven research and providing health promotion and education
programming to AI/AN living in the Gulf Coast area. NAHC has long-standing
relationships with other area service providers, and is one of the only
organizations in Texas providing these types of services.
21
RESOURCES








US Census Bureau. 2000 US Census. [Online]
http://quickfacts.census.gov/qfd/states/48000lk.html
2. US Census Bureau. 2005-2009 American Community Survey 5-Year Estimates.
American Community Survey. [Online]
http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&_lang=en&_sse
=on&geo_id=04000US48&_state=04000US48
Urban Indian Health Institute. 2009. [Online] www.uihi.org/urban-indian-healthorganization-profiles
Alabama-Coushatta Tribe of Texas. 2011. Tribal History. [Online] http://www.actribe.com/ac/index.php?option=com_content&task=view&id=24&Itemid=133,
accessed January 30, 2011.
The Handbook of Texas Online. 2011. [Online] "CHEROKEE WAR,"
www.tshaonline.org/handbook/online/articles/qdc01), accessed January 30, 2011
Sage Associates, Inc. 2002. Great Houston Native America/Alaskan Native HIV
Testing Survey. Unpublished. Presented to CDC HITS Survey Meeting. San Francisco,
California.
Native American Health Coalition. 2010. Native American Health Coalition Urban
Indian Health Needs Assessment. Unpublished.
Asim Shah, MD. 2011. Deputy Director, Ben Taub Hospital Department of
Psychiatry, Harris County Hospital District. Associate Professor of Psychiatry, Baylor
College of Medicine. In discussion of the average cost of one visit for all reasons, to
the Ben Taub Hospital Emergency Center. Baylor College of Medicine Department of
Psychiatry Grand Rounds. February 02, 2011.
22
APPENDICE - History of Activities
Dates
June, 1997
March, 1998
Types of Activities
Community-based Needs
Assessment
Powwow for Health
Partner or Location
Texas Rehabilitation
Commission
Cherokee Cultural Society
and University of Houston
October 15, 1999
1999 Wellness Conference
June, 2000
The NiKan Project:
Houston/Harris County Native
American Prevention Case
Management Project
Annual Texas Championship
Indian Powwow
Directory of Native American
Resources in the Houston Area
Greater Houston HIV Testing
Initiative for AIAN males
United Way of Southeast
Texas
Montrose Counseling
Center
November 14-15, 2000
2002
2002
2002 and ongoing
Staffed health screening booth
Distributed throughout
Houston
Centers for Disease Control
and Houston Regional
HIV/AIDS Resource Group
Developed by NAHC
M D Anderson Medical
Center
Traders’ Village – Houston
5/17/2008
Annual Texas Championship
Indian Powwow
Alabama-Coushatta Health Fair
2008
Health Disparities Conference
July, 2008
Minority Tri-Caucus Conference
January 23, 2009
NAHC Health Conference
August 2009 – and
ongoing
August 2009 –
September 2010
Cancer Alliance of Texas
member
Dine with the Doc
Cancer Alliance of Texas
September, 2009
Circles of Sisters Mammography
Screening and Health
Information Day
Annual Texas Championship
Indian Powwow
Center for Research on
Minority Health
2004
August, 2007
September 2007
October, 2007
November, 2007
November , 2009
Sub-contracted with Montrose Counseling
Center to identify and provide case
management to AIAN males at risk for HIV.
Traders’ Village – Houston
Center for Minority Health and
Research – MD Anderson
NAHC Conference
Native American Initiative on
Public Health Education and
Careers
Presentation on AIAN Health
Needs
American Indian/Alaska Native
Working Meeting in Colorectal
Cancer
Colorectal Cancer Prevention
Events
Created two advisory
committees (rural and urban) to
inform community event
NAHC Conference
October, 2002
August 14-15, 2003
Activities of NAHC
Assisted TRC with data collection regarding
AIAN population in Houston
Partnered with the Cherokee Cultural Society
to put on a powwow with health vendors and
screening opportunities
Host organization for conference
Subcontracted with the Houston Regional
HIV/AIDS Resource Group to conduct needs
assessment of 102 AIAN males and risk
behaviors for HIV
Represent AIAN as community board member
Ysleta del Sur Pueblo, El
Paso, TX
Guest presenter
Baylor College of Medicine,
Houston
Spirit of Eagles,
Portland, OR
Guest presenter
Prevent Cancer Foundation
Conducted two educational events—an
evening dinner with Houston community and
luncheon with Alabama-Coushatta community
– Cancer prevention topic and testimonial
from cancer survivor.
Hosted IHS presenters from 3 regions to
education about how services are
administered in Texas
Health screening booth
United Way – Houston
Alabama-Coushatta
Reservation
Center for Research on
Minority Health
Center for Research on
Minority Health
United Way
St. Luke’s Episcopal Health
Charities
Traders’ Village – Houston
Represented Texas in colorectal planning
Health Information booth
Conference Presenter
Represented AIAN community and informed
on health needs
Coordinated local conference for healthcare
providers
Represent AIAN at quarterly meetings
Conducted four quarterly dinners with AIAN
community in Houston, featuring a different
health concern at each dinner.
Coordinated day of events and transported
participants from Alabama-Coushatta
Reservation
Health screening booth
23
March, 2010
June 4, 2011
Circles of Sisters Mammography
Screening and Health
Information Day
Began local needs assessment
data collection
Health for Life, Diabetes Self
Management Education
Program
Annual Texas Championship
Indian Powwow
United Southeastern Tribes
Conference
Methodist Church Native
American Day
NAHC Conference
June 21, 2011
Town Hall Meeting
October, 2010
October, 2010
November, 2010
February 7-9, 2011
May, 2011
Center for Research on
Minority Health
Traders’ Village – Houston
Coordinated day of events and transported
participants from Alabama-Coushatta
Reservation
Data collection and reporting on needs of
American Indians/Alaska Natives in Houston.
Outreach to AIAN in rural and urban areas to
recruit into diabetes self management
education programs.
Health screening booth
Washington, DC
Presentation on needs assessment findings
Methodist Church
Staffed information booth
Alabama-Coushatta
Reservation
United Way of Greater
Houston
Coordinated local conference for providers
and community members
Presentation to community of needs
assessment findings
NAHC
TMF, Inc., and JB
Management Solutions
24
COMPARISON With OTHER URBAN CENTERS
Urban Indian Centers
Boston
Counties/AIAN Pop.
Essex – 6151
Middlesex – 7942
Norfolk – 3228
Plymouth – 3571
Suffolk - 7695
Counties/Total Pop.
Essex 743159
Middlesex, 1503085
Norfolk, 670850
Plymouth, 494919
Suffolk, 772023
Minneapolis
Hennepin – 21,106
Ramsey – 9,267
Bernalillo – 40,444
King – 39,117
Cook – 45,040
Adams – 10,957
Arapahoe – 10,264
Boulder – 3,987
Broomfield - 741
Denver – 14,995
Douglas – 2,937
Gilpin – 98
Jefferson – 9,517
Harris, 48518
Montgomery, 6164
Fort Bend County, 5151
Galveston County, 3495
Brazoria, 3537
Liberty, 878
Waller, 581
Chambers, 412
Totals 68,736
Collin – 9.503
Dallas – 30,403
Denton – 9,501
Ellis – 1,865
Hood - 702
Johnson – 2,108
Kaufman – 1,453
Parker – 1,880
Rockwall – 933
Tarrant – 23,858
Wise – 960
Totals 83,166
107,271
Bronx – 32,011
Kings – 26,571
New York – 19,415
Queens – 30,033
Richmond – 3,719
Alameda -26,089
Contra Costa – 17,327
Marin – 3,787
San Francisco – 10,873
San Mateo – 8,367
Hennepin, 1152425
Ramsey 508640
Bernalillo 662564
King 4931249
Cook 5194675
Adams, 441603
Arapahoe, 572003
Boulder, 294567
Broomfield, 55889
Denver, 600158
Douglas, 285465
Gilpin, 5441
Jefferson 534543
Harris, 4092459
Montgomery 455746
Chambers 35096
Fort Bend 585375
Galveston 291309
Brazoria 313166
Liberty 75643
Waller 43205
Los Angeles – 140,764
San Diego – 52,749
Los Angeles, 9818605
San Diego 3095313
Albuquerque
Seattle
Chicago
Denver
Houston
Dallas
Phoenix
New York
N. California
S. California
Collin, 782341
Dallas, 2368139
Denton, 662614
Ellis, 479610
Hood, 51182
Johnson, 150934
Kaufman, 103350
Parker, 116927
Rockwall, 78337
Tarrant, 1809034
Wise 59127
Maricopa 3817117
Bronx, 1385108
Kings, 2504700
New York, 1585873
Queens, 2230722
Richmond 468730
Alameda, 1510271
Contra Costa, 1049024
Marin, 252409
San Francisco, 805235
San Mateo 718451
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32
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