Trends in Physical and Mental Health, Mortality, Life Expectancy, and Social Inequalities Among American Indians and Alaska Natives, 1990-2019

US National Databases

Temporal data from the 1990-2019 National Vital Statistics System (NVSS), 2014-2018 National Health Interview Survey (NHIS), the 2014-2018 American Community Survey (ACS), the Health Center Program's 2019 Uniform Data System (UDS), and 2010-2019 RWHAP data were used to examine health, health care, mortality, and disease patterns for AIANs in relation to the other racial/ethnic groups and the general population.^10,17,19-24 The time periods for these datasets that were available at the time of this study, varied as described below.

The NVSS has been the primary source for mortality analyses in the US by age, sex, race/ethnicity, cause of death, geographic area, and time period for over a century.^10,13,25 The NVSS consists of both mortality and natality data systems. While the US Standard Certificate of Death, revised most recently in 2003, is the basis for the national mortality data, the natality component of the NVSS includes birth certificate data for approximately 4 million births that occur in the United States each year.^10,13,25 We used the 2015-2018 linked birth/infant death data file²⁶ and the 2015-2018 national natality file²⁷ to examine racial/ethnic disparities in age- and cause- specific infant mortality and associated maternal and infant risk factors and birth outcomes.

The ACS is the primary census database for producing socioeconomic, demographic, housing, and labor force characteristics of various population groups at the national, state, county, and local levels.^17,28,29 The unique advantage of the ACS is that it is conducted annually with a sample size of over 3 million records.^17,28,29 The ACS uses a complex, multistage probability design and is representative of the civilian non-institutionalized population, covering all communities in the US.^17,28,29 The household response rate for the ACS exceeds 98%.^17,29 In this study, we used the 2014-2018 ACS Microdata Sample to analyze socioeconomic, health insurance, and disability data.²⁹All ACS data are based on self-reports and obtained via mail-back questionnaire, telephone, and in-home personal interviews.^17,28,29 Substantive and methodological details of the ACS are available in census and previous publications.^17,28,29

The NHIS is a national sample household survey in which data on socioeconomic, demographic, behavioral, morbidity, health, and health care characteristics are collected via personal household interviews.^13,24,30 All information collected in the survey are based on self-reports. The NHIS uses a complex, multistage probability design and is representative of the civilian non-institutionalized population of the United States. The NHIS, one of the longest running federal health surveys, has been conducted annually since 1957 by the National Center for Health Statistics.^24,30 Response rate for an annual NHIS generally exceeds 87%. Data are obtained via in-home person interviews. Substantive and methodological details of the NHIS are described elsewhere.^24,30

HRSA's Health Center Program aims to improve the health of the nation's underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services.³¹ Nearly 30 million people nationwide receive primary medical, dental, and/or behavioral health care from approximately 1,500 HRSA-funded or supported health centers.^18,31 The UDS is the main data system of the Health Center Program, which collects data on patient demographic characteristics, clinical processes and outcomes, and a number of clinical quality measures, including low birthweight, access to prenatal care, preventive health screenings and services, and chronic disease management including blood pressure control and uncontrolled diabetes.³¹

The RWHAP program works with states, counties, cities, and community-based organizations to provide HIV care and treatment services to more than half a million people with diagnosed HIV in the US.^18,31 The program reaches more than 50% of all people diagnosed with HIV in the US and the majority of program clients are from low- income and racial/ethnic minority groups.³¹ One of the RWHAP health outcomes is viral suppression, which is a widely accepted outcome in HIV care and treatment. People with HIV who are virally suppressed have significantly lower risk of morbidity and mortality from HIV and have virtually no risk of sexually transmitting the disease to other.³¹

Health Indicators and Outcomes

We considered the following health indicators from NVSS: life expectancy at birth; infant mortality rates by age and cause of death; child and adolescent mortality; age-adjusted mortality rates from all-causes combined and from leading causes of death such as cardiovascular disease (CVD), cancer, unintentional injuries, chronic liver disease and cirrhosis, diabetes, chronic obstructive pulmonary disease (COPD), suicide, kidney disease, and influenza and pneumonia, Alzheimer's disease, septicemia, viral hepatitis, drug overdose, alcohol-related causes, and firearm injuries. We analyzed the following measures from NHIS and HRSA program databases: self-assessed health, serious psychological distress (SPD), heart disease, diabetes, hypertension, disability, obesity, smoking, hospital admission, emergency room (ER) visits, health insurance, and delayed or forgone medical care due to cost; HIV viral suppression, controlled diabetes and hypertension. SPD is measured by a 6-item scale (K6) that asks respondents how often they experienced each of 6 symptoms of psychological distress in the past 30 days (feelings of sadness, nervousness, restlessness, hopelessness, everything an effort, worthlessness). The K6 varies from 0 to 24, with a score of 13 or more used to define SPD.^13,32 From the ACS, we considered the measures of overall disability status, cognitive and ambulatory disability, and health insurance.^17,28,29

Race/Ethnicity Definitions

Race/ethnicity is defined differently in each of the major databases analyzed in terms of racial and ethnic detail. In the national mortality database from the NVSS, we considered the following major racial/ethnic groups: Non-Hispanic Whites, Black/African Americans, AIANs, APIs, and Hispanics. For the linked birth/infant death dataset and the national natality file, we considered the five major racial/ethnic groups as described above as well as API subgroups (Chinese, Japanese, Filipino, Asian Indian, Korean, Vietnamese, Hawaiians, and other Asian/Pacific islanders) and Hispanic subgroups (Mexican, Puerto Rican, Cuban, Central/South American, and other Hispanics). For the NHIS, we considered the five major racial/ethnic groups plus a residual category consisting of other and multiple-race groups. For the ACS, In addition to the five major racial/ethnic groups, we considered 35 AIAN tribes that were identified in the public-use microdata sample.²⁸

Statistical Methods

Life tables, age-adjusted rates, prevalence, risk ratios, and logistic regression were used to examine health inequalities.⁶ We used the latest available county- level 2013 rural-urban continuum codes linked to the national mortality database to analyze rural- urban disparities in mortality among AIANs and other racial/ethnic groups.^6,16 All-cause and cause- specific mortality rates were age-adjusted by the direct method using the age composition of the 2000 US population as the standard.¹⁰ The latest available area-based deprivation index based on the 2008-2012 ACS was linked to individual-level mortality data at the county level to derive working- age premature mortality rates according to levels of socioeconomic deprivation.^6,33-35 Twenty-one indicators of education, occupation, wealth, income distribution, unemployment, rate, poverty rate, housing quality, and transportation were used to construct the index.^33-35

Health, disease, and mortality patterns for AIANs were compared with those for non-Hispanic Whites, the total US population, and other major racial and ethnic minority groups where possible. Multivariable logistic regression was used to examine racial/ethnic disparities in health, disease, health behaviors, and health care factors including infant mortality, self- assessed health, serious psychological distress (SPD), heart disease, diabetes, hypertension, disability, obesity, smoking, hospital admission, emergency room (ER) visits, health insurance, and delayed or forgone medical care due to cost. Adjusted prevalence estimates were derived from the fitted logistic regression models. Infant mortality analyses based on linked birth/infant death data and disability, health insurance, and sociodemographic analyses based on ACS data were conducted by using SAS 9.4.³⁶ To account for the complex sample design of the NHIS, SUDAAN software was used to conduct all statistical analyses of the NHIS data.³⁷ The Chi-square statistic was used to test the overall association between each covariate and health and health care measures, while the t-test was used to test the difference in prevalence, incidence, or mortality rates between any two groups or time periods.^6,35 Since multiple outcomes and comparisons were used, statistical tests of significance were carried out at the 0.05, 0.01, or 0.001 level when appropriate, although 95% confidence intervals of the estimates are presented throughout.³⁵

Disparities in Life Expectancy

In 2019, life expectancy at birth was 76.9 years for AIANs, significantly lower than that for Asian/Pacific Islanders (88.2), Hispanics (83.7), non-Hispanic Whites (79.1), and slightly higher than the life expectancy of African Americans (76.2) (Figure 1). Life expectancy for males ranged from a low of 72.6 years for African Americans and 74.2 years for AIANs to a high of 85.9 years for Asian/Pacific Islanders (APIs). Life expectancy for females ranged from a low of 79.5 years for African Americans and 79.6 years for AIANs to a high of 90.2 years for APIs (Figure 1).

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Figure 1:

Life Expectancy at Birth (Years) by Race/Ethnicity and Sex, United States, 2019 Source: Data derived from the National Vital Statistics System

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The life table-based survival function indicates lower survival rates for AIANs compared to non- Hispanic Whites, APIs, and Hispanics (Table 1). For example, AIANs had a 78.3% probability of surviving from age 20 to age 65 years, while APIs had a 93.1% probability of surviving from age 20 to age 65 years (Table 1).

Disparities in infant, Child, and Maternal Health

During 2015-2018, the IMR (derived from the linked birth/infant death file) for AIANs was 8.71 per 1,000 live births, significantly higher than the rate for non- Hispanic Whites (4.87), APIs (4.07), Hispanics (4.97), and the total population (5.81), and lower than the rate of 11.05 for African Americans (Table 2). Indeed, the IMR for AIANs was 3.6 times higher than the rate for Chinese, and the postneonatal mortality rate for AIANs was the highest of all the major racial/ethnic groups. During 2015-2018, AIAN infants experienced higher risks of mortality from three leading causes of death, birth defects, sudden infant death syndrome (SIDS), and unintentional injuries compared to other racial/ethnic groups (Table 2). AIAN infants also experienced significantly higher risks of mortality from maternal complications and perinatal conditions compared to non-Hispanic Whites, Hispanics, and APIs.

With respect to several of the risk factors for infant mortality, AIAN mothers were generally worse off than the other racial/ethnic groups as they had some of the highest rates of teen birth, smoking before and during pregnancy, gestational hypertension, gestational diabetes, pre-pregnancy obesity, and delayed or no prenatal care (Table 3). Controlling for several sociodemographic risk factors, smoking during pregnancy, and prenatal care reduced excess risk of mortality among AIAN infants. However, compared to non-Hispanic White infants, AIANs continued to experience 36% higher adjusted odds of infant mortality, 22% higher adjusted odds of neonatal mortality, and 49% higher adjusted odds of postneonatal mortality (Table 4). When compared with Chinese infants, AIANs had 79% higher adjusted odds of infant mortality, 72% higher adjusted odds of neonatal mortality, and 60% higher adjusted odds of postneonatal mortality (Table 4). After controlling for risk factors, compared to non-Hispanic Whites, AIAN infants had 17% higher odds of birth defects mortality, 31% higher odds of mortality from low birthweight and prematurity, and 38% higher odds of SIDS mortality (Table 5).

During 2015-2019, the overall mortality rate for AIAN children and adolescents aged 1-17 years was significantly higher than the rates for non-Hispanic Whites, Hispanics, and the total population substantially and lower than the rate for African Americans (Table 6). Rural AIAN children had the highest all-cause child and adolescent mortality rates of all major racial/ ethnic groups. Rural AIAN children and adolescents had the highest mortality from unintentional injuries and suicide. Suicide mortality among AIAN children aged 5-17 was 5.18 per 100,000 population, compared with 3.78 for non-Hispanic Whites, 1.94 for African Americans, 2.29 for APIs, and 2.02 for Hispanics. Suicide mortality among AIAN children in rural areas was twice as high as the overall AIAN rate (Table 6).

The analysis of the 2014-2018 ACS data revealed that AIAN children had significantly higher disability rates (5.51%) than non-Hispanic Whites (4.22%), APIs (2.17%), and Hispanics (4.07%), and African- Americans (5.14%) (Table 7). Cognitive disability rates were also significantly higher among AIAN children than other children from racial/ethnic groups except African Americans. Approximately 13.01% of AIAN children lacked health insurance, compared with 3.94% of non-Hispanic Whites, 4.19% of African Americans, 4.08% of APIs, and 7.85% of Hispanics.

Child disability and health insurance coverage varied substantially across various AIAN tribes. Overall disability rates ranged between 7% and 10% for children from Blackfeet, Chicksaw, Iroquois, and Choctaw tribes (Table 7), while children from Crow, Yup'ik, and Seminole tribes had the lowest disability rates (<3%). Children from Blackfeet (12.30%), Iroquois (8.72%), and Chippewa (7.46%) had the highest mental disability rates, while those from Crow (1.45%), Yup'ik (1.63%), and Hopi (2.02%) had the lowest mental disability rates (Table 7).

The tribes for which child health uninsurance rates exceeded 20% included Pima (20.09%), Puget Sound Salish (21.04%), Blackfeet (21.66%), Comanche (22.29), Crow (29.66%), and Seminole (32.44%).

Lumbee (2.76%) and South American Indian (2.96%) had the lowest child health uninsurance rates (Table 7).

Socioeconomic conditions under which children of various ethnicities live vary greatly. Poverty among AIAN children is a major social problem. During 2014-2018, 32.99% AIAN children lived below the poverty line, compared with 34.78% of African American children, 11.92% of API children, 11.83% of non-Hispanic White children, and 28.50% of Hispanic children. Some of the tribes with the highest child poverty rates include Tohono O'Odham (51.62%), Sioux (49.73%), Pima (45.12%), Apache (44.11%), Yaqui (42.13%), Navajo (41.92%), Comanche (38.61%), Crow (38.20%), and Blackfeet (35.37%). Chicksaw (13.84%) and Tlingit-Haida (14.17%) tribes had the lowest child poverty rates.

Disparities in Mortality from Leading Causes of Death, 2019

CVD, cancer, unintentional injuries, chronic liver disease and cirrhosis, diabetes, COPD, suicide, kidney disease, and influenza and pneumonia, and Alzheimer's disease were the top 10 leading causes of death among AIANs and accounted for 74.28% of all deaths among them in 2019 (Table 8). All-cause mortality and mortality from CVD and cancer were significantly lower among AIANs compared with non-Hispanic Whites and the total US population. Unintentional-injury mortality among AIANs was similar to that for Whites but was 11% higher than the rate for the total population. The risk of diabetes mortality among AIANs was 62% higher than that for non-Hispanic Whites and 43% higher than the rate for the total population. Liver cirrhosis mortality among AIANs was at least 2.32 times higher than that for non-Hispanic Whites and the total population. Although drug overdose mortality was 26% lower among AIANs than non-Hispanic Whites, alcohol- related mortality was approximately three times higher among AIANs compared with non-Hispanic Whites and the total US population. The homicide rate for AIANs was 2.70 times higher than the rate for non-Hispanic Whites and 1.21 times higher than the rate for the total population. The risk of firearm- injury mortality was significantly lower for AIANs than for non-Hispanic Whites and the general population (Table 8).

Trends and Disparities in Mortality from Selected Causes of Death, 1990-2019

Working-age mortality between ages 15 and 64 years is sensitive to social and economic fluctuations and is greatly influenced by deaths due to suicide, homicide, injuries, drug overdoses, alcohol-related causes, CVD, and cancer.³⁴ While working-age mortality rates declined consistently between 1990 and 2010, there has been an upward trend in mortality since 2010 for all AIANs and rural AIANs as well as for non-Hispanic Whites and the total US population (Figure 2A). The increases in working-age mortality between 2010 and 2019 were more rapid for rural AIANs and for all AIANs than for non-Hispanic Whites and the total population. In 2019, rural AIANs were almost twice as likely to die prematurely in working ages as the total population.

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Figure 2

(A-F): Trends in Working-Age Mortality and Cause-Specific Mortality among American Indians and Alaska Natives, Non-His- panic Whites, and the total US Population, 1990-2019 Source: Data derived from the 1990-2019 National Vital Statistics System

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Youth suicide rates have risen since 2001 for all groups, but the rate of increase has been particularly high for AIAN youth (Figure 2B). Suicide rates increased by 56% for all AIAN youth and by 91% for AIAN youth in rural areas. In 2019, compared to the national average, suicide rates were 58% higher among all AIAN youth and 232% higher among AIAN youth in rural areas.

Cirrhosis mortality, for which heavy alcohol consumption is the most important risk factor, has historically been higher among AIANs than among non-Hispanic Whites or the national average. Cirrhosis mortality rates have been rising since 2006, and the rates are currently 4.2 times higher among rural AIANs than the national average (Figure 2C). Diabetes mortality, which is the highest among African Americans and AIANs, increased between 1990 and 2005, but declined between 2006 and 2019 for all groups, with AIANs experiencing a 23% decrease in their mortality rates (Figure 2D). In 2019, compared with the total population, the risk of diabetes mortality was 43% greater for all AIANs and 133% greater for rural AIANs.

Motor vehicle injuries are a prominent cause of death in the US, with AIANs having the highest risk of mortality of all racial/ethnic groups. Although motor-vehicle-related mortality declined significantly during 1999-2010, it showed a relatively stable trend for all groups between 2010 and 2019 (Figure 2E). In 2019, the risk of motor-vehicle-related mortality was 36% greater for all AIANs and 182% greater for rural AIANs compared with the total population.

Non-motor vehicle unintentional injury mortality rates doubled for the total population and non- Hispanic Whites and increased by 63% for AIANs between 2000 and 2019, with steep increases in drug overdose deaths contributing greatly to the rising trend. Increases in drug-overdose mortality have been more rapid for non-Hispanic Whites and the total population compared to AIANs (data not shown). Nonetheless, in 2019, AIANs in rural areas had 65% higher non-motor vehicle unintentional injury mortality than the national average (Figure 2F).

Working-age mortality varies greatly in relation to area socioeconomic deprivation levels (Figure 3). AIANs living in more deprived communities have 2.62 times higher premature mortality than those in more affluent communities (428 deaths vs. 163 deaths per 100,000 population). Similar socioeconomic patterns in premature mortality can be seen for other racial/ethnic groups, including rural AIANs (Figure 3).

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Figure 3:

Working-Age (15-64) Mortality by Race/Ethnicity and Socioeconomic Deprivation Level, United States, 2014-2018 Source: Data derived from the National Vital Statistics System

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Disparities in Disability, Chronic Conditions, Health insurance, and Risk Factors

The overall disability rate was highest among AIANs (Table 9). Approximately 17.55% of the AIAN population reported a disability during 2014-2018, compared with 14.49% of non-Hispanic Whites, 14.57% of African Americans, 7.20% of APIs, 9.12% of Hispanics, and 13.10% of the total US population. AIANs also reported significantly higher mental and ambulatory disability rates than other racial/ethnic groups.

Disability rates varied among AIAN tribes. Cherokee (24.15%), Blackfeet (21.73%), and Iroquois (20.85%) had the highest disability rates, while Crow (10.45%), Mexican American Indians (10.73%) and Yup'ik (11.94%) had the lowest disability rates. Blackfeet (10.93%), Cheyenne (10.93%), and Cherokee (10.12%) had the highest mental disability rates, while Yup'ik (4.25%), Puget Sound Salish (4.62%), and Potawatomi (4.99%) had the lowest mental disability rates. Cherokee (14.85%), Blackfeet (13.61%), and Iroquois (12.68%) had the highest ambulatory disability rates, while Mexican American Indians (5.34%), Yup'ik (5.73%), and Crow (6.47%) had the lowest ambulatory disability rates (Table 9).

During 2014-2018, AIANs had the highest rate of uninsurance. Approximately 21.14% of AIANS lacked health insurance, compared with 5.81% of non- Hispanic Whites, 11.71% of African Americans, 6.76% of APIs, and 17.47% of Hispanics. Among the AIAN tribes, Seminole (38.88%), Crow (36.23), Comanche (29.69%), Pima (28.25%), and Cheyenne (28.18%) had the highest rates of uninsurance, while South American Indians (11.99%), Lumbee (13.86%), and Iroquois (14.14%) had the lowest rates of uninsurance (Table 9).

Most racial/ethnic minorities in the US have historically been disadvantaged in terms of social and economic attainment and living conditions.^6,31 Current data on poverty, unemployment, and education continue to reflect these patterns (Table 9). During 2014-2018, AIANs had the highest poverty rate (25.82%), followed by Black/African Americans (24.20%), Hispanics (21.12%), APIs (11.79%), and non-Hispanic Whites (10.03%). Unemployment rates were more than two times higher among AIANs (11.08%) and Blacks (10.41%) compared with non-Hispanic Whites (4.66%). With respect to educational attainment, AIANs were least likely to have a college degree. About 9.92% of AIANs had a college degree, compared with 27.36% of non-Hispanic Whites, 14.6% of Blacks, 9.99% of Hispanics, and 40.14% APIs. These social determinants varied greatly across the AIAN tribes. The poverty rate was highest among Tohono O'Odham (42.18%), followed by Sioux (41.92%), Pima (36.10%), Navajo (33.19%), Apache (32.22%), Crow (32.21%), Cheyenne (32.13%), and Blackfeet (31.55%). Chickasaw (12.25%) and Potawatomi (16.17%) had the lowest poverty rates. Several tribes reported high rates of unemployment, such as Yup'ik (22.30%), Tohono O'Odham (20.98%), Inupiat (18.96%), Alaskan Athabascan (17.32%), and Apache (16.94%). Chicksaw (5.62%) and Choctaw (6.93%) had the lowest unemployment rates (Table 9).

Table 10 shows racial/ethnic disparities in selected leading health indicators and health-risk factors. During 2014-2018, the prevalence of heart disease among AIANs (18.26%) was 45% higher than that for non-Hispanic Whites (12.59%) and 160% higher than the prevalence for APIs (7.01%). After controlling for socioeconomic and demographic factors, AIANs had 38% higher odds of heart disease than non-Hispanic Whites and 176% higher odds of heart disease than APIs. The prevalence of physician- diagnosed diabetes was highest among AIANs (20.45%), 151 % higher than the prevalence for non- Hispanic White adults (8.13%) and 115% higher than the prevalence for API (9.52%) (Table 10). Controlling for sociodemographic factors, AIANs experienced 164% higher odds of diabetes than non-Hispanic Whites and 64% higher odds than Blacks. About 18.00% of AIANs assessed their health as fair or poor, a significantly higher percentage than any other major/racial ethnic group. The corresponding prevalence of self-reported health as fair or poor was 8.50% for non-Hispanic Whites and 7.98% for APIs. Controlling for sociodemographic factors, AIANs had 56% higher odds of reporting fair or poor health than non-Hispanic Whites and 1.90 times higher odds than APIs.

Regarding mental health problems, 10.01% of AIAN adults during 2014-2018 experienced serious psychological distress during the past one month, compared with 3.46% of non-Hispanic Whites and 1.80% of APIs (Table 10). Controlling for sociodemographic factors, AIANs experienced 77% higher odds of serious psychological distress than non-Hispanic Whites and 302% higher odds than APIs.

Smoking, obesity, and hypertension are major risk factors that are associated with increased risk of mortality and morbidity from several chronic diseases such as CVD, cancer, diabetes, and COPD.AIANs have one of the highest rates of adult smoking, obesity, and hypertension, significantly higher than the rates for non-Hispanic Whites, APIs, and Hispanics (Table 10). During 2014-2018, 27.88% of AIAN adults were current smokers, 45.57% were obese, and 35.22% were diagnosed with hypertension. Controlling for sociodemographic factors, AIAN adults had 38% higher odds of smoking than non-Hispanic Whites, 229% higher odds than APIs, 273% higher odds than Hispanics, and 119% higher odds of smoking than Blacks. Controlling for sociodemographic factors, AIANs had 89% higher odds of obesity than non- Hispanic Whites and 473% higher odds of obesity than APIs. Controlling for sociodemographic factors reduced excess risk of hypertension of hypertension among AIANs. However, they still had 33% to 36% higher adjusted odds of hypertension than their API and Hispanic counterparts (Table 10).

Figure 4 shows gradients in health outcomes and behavioral-risk factors among AIANs according to poverty/income level, an important social determinant. Although AIANs living below the poverty line had significantly higher risk of each negative health outcome than their high-income counterparts, income gradients in self-assessed fair/ poor health and serious psychological distress were particularly large and consistent. For example, AIANs living below the poverty line were 4.39 times more likely to assess their overall health as fair/poor than AIANs with family incomes at or above 400% of the poverty threshold (27.58% vs. 6.28%). AIANs living below the poverty line were 13.35 times more likely to experience serious psychological distress than AIANs with family incomes at or above 400% of the poverty threshold (16.82% vs. 1.26%).

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Figure 4:

Age-Adjusted Prevalence of Selected Health Indicators and Health-Risk Behaviors among American Indians and Alaska Natives by Family Income/Poverty Level, United States, 2014-2018

Source: Data derived from the 2014-2018 National Health Interview Survey

Notes: Income/poverty gradients were statistically significant at p<.05 for all outcomes except heart disease (p=.055). Self-assessed health is for the entire population, including children and adults. Prevalence of serious psychological distress, heart disease, diabetes, smoking, obesity, and hypertension is for adults aged 18 years and older

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Disparities in Health Care Access, Quality, and Clinical Outcomes

An important measure of access to quality health care is affordability.^6,31 There were marked racial/ethnic disparities in unmet medical need. During 2014- -2018, 8.53% of AIAN adults and 7.98% of African- American adults reported not receiving medical care because they could not afford it, compared with 5.29% of non-Hispanic Whites, 6.53% of Hispanics, and 3.01% of APIs. Additionally, 10.22% of AIAN adults and 9.05% of African-American adults forwent or delayed seeking medical care because of the worry about the cost, compared with 4.34% of APIs and 8.00% of non-Hispanic Whites. After adjusting for sociodemographic differences, AIANs did not differ from non-Hispanic Whites in delayed medical care due to cost but had 46% higher odds of delayed medical care compared to APIs. After adjusting for sociodemographic differences, AIANs did not differ from non-Hispanic Whites in the non-receipt of needed medical care but had 54% higher odds of not receiving care compared to APIs (Table 11).

Emergency room (ER) visits are associated with substantially increased health care costs.^6,31 During 2014-2018, the likelihood of one or more ER visits in the past 12 months was greatest among AIAN adults (32.30%), followed by African Americans (26.30%), non-Hispanic Whites (19.02%), Hispanics (17.95%), and APIs (1 1.40%). After controlling for sociodemographic factors, AIANs had 67% higher odds of ≥1 ER visits than non-Hispanic Whites and 117% higher odds than APIs. The likelihood of two or more ER visits in the past 12 months among AIANs was 16.95%, 157% higher than non-Hispanic Whites and 406% higher than APIs. Controlling for sociodemographic factors, AIANs had 109% higher odds of ≥2 ER visits than non-Hispanic Whites and 179% higher odds than APIs (Table 11).

Hospital admission is an important health care outcome measure.³¹ During 2014-2018, the hospital admission rate for AIANs was 8.95%, not significantly different from the rate of 8.40% for non-Hispanic Whites but 86% higher than the rate of 4.81% for APIs and 35% higher than the rate of 6.63% for Hispanics. After adjustment for sociodemographic factors no statistically significant differences in hospital admission were found between AIANs and other racial/ethnic groups (Table 11).

The 2019 UDS data indicate the lowest rates of controlled blood pressure among African Americans (57.00%), AIANs (58.61%), and Native Hawaiians (60.31%) and highest among Asians (69.85%), non- Hispanic Whites (67.33%), and Hispanics (67.08%) (Figure 5). In 2019, 37.70% of AIAN diabetic patients had uncontrolled diabetes, compared with 30.58% of Hispanic patients, 33.73% of African Americans, 29.18% of non-Hispanic Whites, and 20.32% of Asian-American patients (Figure 5).

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Figure 5:

(A, B) Racial/Ethnic Differences in Hypertension and Diabetes Control (%), United States, 2019 Health Center Patients Source: Health Resources and Services Administration (HRSA). Bureau of Primary Health Care. 2019 Uniform Data System (UDS). https://data.hrsa.gov/tools/data-reporting/program-data/national

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HIV viral suppression among the RWHAP patients improved markedly between 2010 and 2019 for all racial/ethnic groups. For AIAN patients, the viral suppression rate increased from 70.4% in 2010 to 87.8% in 2019; for the total population, the viral suppression rate increased from 69.5% in 2010 to 88.1% in 2019 (Figure 6). Viral suppression rates in 2019 were significantly lower among AIANs (87.8%) compared with non-Hispanic Whites (91.8%), Asians (94.7%), and the general RWHAP patient population (88.1%).

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Figure 6:

Viral Suppression Rates (%) among Ryan White HIV/AIDS Program Clients (non-ADAP), by Race/ethnicity, 2010 and 2019, United States and Territories of Guam, Puerto Rico, and US Virgin Islands

Source: HRSA. Ryan White HIV/AIDS Program Annual Client-Level Data Report, December 2020

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