摘要：Objectives. Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997–2002 to describe recent trends in organizational and financial arrangements. Methods. Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. Results. Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. Conclusions. Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources. American Indians have the highest prevalences of substance abuse and dependence among the racial and ethnic groups comprising the United States 1 – 8 but are served by the country’s most complicated behavioral health care system. 9 – 11 Substance abuse treatment services for Natives are provided by tribes, tribal organizations, urban Indian programs, the Indian Health Service (IHS), the Department of Veterans Affairs, and state, local, and other programs. 9 , 12 – 15 Recently there have been dramatic changes both in indigenous populations (e.g., growth in size and urbanization) 16 – 18 and in health services for Native Americans. 10 , 12 – 19 Although most Native Americans live in urban areas, 20 , 21 only about 1% of the IHS budget is spent on urban Indian programs. 16 , 18 , 22 In a recent Kaiser Family Foundation survey, only 20% of American Indians reported that they had access to IHS programs. 23 Also, many tribes have taken over health care delivery from the IHS, using assorted funding mechanisms. 10 , 13 , 19 , 24 – 26 For example, contracts with the IHS allow tribes to manage specific programs. 24 A contract is generally an agreement between the purchaser of services (the IHS) and the service provider (such as a tribal organization) that includes a detailed scope of work. Compacts between tribes and the IHS are somewhat analogous to block grants and provide considerable flexibility for tribal program design and management. 24 A compact can be regarded as an understanding between 2 nations (the United States and the tribal government) about transfer of funds and overall service provision. Services for American Indians with alcohol or other drug problems are in flux 13 as tribes negotiate new relationships with the IHS and with state Medicaid agencies. 11 , 19 , 24 , 25 , 27 Substance abuse treatment services are usually divided according to the stage of abuse addressed: the acute detoxification stage, the rehabilitation phase, and the maintenance phase or recovery. 28 , 29 Services include self-help programs such as Alcoholics Anonymous 30 , 31 and brief interventions within primary care. 32 – 35 We focused on treatments in the behavioral health specialty sector, 28 including traditional American Indian healing practices that some might regard as complementary, alternative, or supplementary to those usually offered in the “mainstream” service system. 1 , 36 – 38 Although the evidence is equivocal, 39 , 40 it is generally agreed that professional substance abuse rehabilitation services are efficacious. 28 , 29 , 41 – 44 Because people with substance abuse problems who receive treatment generally have better outcomes than those who do not, 29 , 44 – 46 the idea is that treatment works. 40 , 45 , 47 – 49 Substance abuse treatment in the United States is largely funded by the public sector. 50 , 51 Coffey et al. 52 , 53 reported that the largest payers for substance abuse treatment in 1997 were state and local governments (28% of total substance abuse expenditures) followed by Medicaid (20%) and the Substance Abuse and Mental Health Services Administration’s Substance Abuse Prevention and Treatment block grants to the states (16%). These percentages may have increased recently, given decline in private-sector chemical dependency insurance benefits 54 and the limited enthusiasm of private-sector purchasers for these services. 55 Medicaid may be especially important for American Indians with substance abuse problems. 22 , 56 Medicaid is a joint federal–state program designed primarily to fund health care for low-income people. 57 American Indians have the highest Medicaid enrollment of any racial/ethnic group. 22 , 23 Congress addressed the reimbursement relationship between American Indians and Medicaid in the Alaska Native and American Indian Direct Reimbursement Act of 2000, which modified Title XIX of the Social Security Act to authorize direct billing by tribes or tribal organizations that have compacts or contracts with the IHS. Under the Direct Reimbursement Act, tribes or tribal organizations with IHS compacts or contracts can bypass state Medicaid agencies and submit bills directly to the federal Center for Medicare and Medicaid Services. There have been numerous calls for information about the organization and financing of health services for Native people, 10 , 23 , 58 but few data are available. Our goals were to provide background on substance abuse problems among American Indians; to describe organizational and financial arrangements of substance abuse treatment services for Natives; to examine recent changes in those arrangements; and to provide guidance to policymakers responsible for Native chemical dependency treatment programs.
