摘要：Objectives. We compared access and utilization of health services among American Indians/Alaska Natives (AIANs) with that among non-Hispanic Whites. Methods. We used data from the 1997 and 1999 National Survey of America’s Families to estimate odds ratios for several measures of access and utilization and the effects of Indian Health Service (IHS) coverage. Results. AIANs had less insurance coverage and worse access and utilization than Whites. Over half of low-income uninsured AIANs did not have access to the IHS. However, among the low-income population, AIANs with only IHS access fared better than uninsured AIANs and as well as insured Whites for key measures but received less preventive care. Conclusions. The IHS partially offsets lack of insurance for some uninsured AIANs, but important needs were potentially unmet. Although the health status of American Indians and Alaska Natives (AIANs) improved after the establishment of the Indian Health Service (IHS) in 1955, significant health disparities persist. 1– 3 The federal government attempts to meet its commitment to provide health care for AIANs through a system of hospitals and clinics on or near reservations, managed by the IHS and, more recently, by Indian tribes. 4 IHS facilities provide primary care services free of charge, and limited free specialty services are available through contracts with private providers. 5 However, services available through the IHS vary widely across tribes, and IHS hospitals are not available in all service areas. 6 Many communities have small clinics and must contract out for all specialty care, x-ray services, and other diagnostic tests and routine preventive care such as mammograms. Services can vary and may be limited by significant shortfalls in funding. 5 The IHS serves approximately 1.5 million people, but it does not serve all of the 4.1 million individuals whom the Census Bureau reports as being American Indian or Alaska Native, either alone or in combination with other races. 7 Some of these self-identified AIANs are ineligible for the IHS, primarily because they are not members or descendants of federally recognized tribes. In addition, most AIANs live in urban areas away from their home reservations and cannot access IHS services, forcing them to rely on other sources of coverage or become uninsured. 8 Previous studies have documented lower public and private coverage, poorer health status, and greater unmet needs among AIANs because of factors such as income, education, and the availability and utilization of IHS services. 9– 12 However, these studies used surveys from the 1980s and early 1990s. More updated information is needed, because there have been significant changes in the organization and financing of the IHS, with approximately half of the IHS budget now managed by tribes. 13 In addition, little research has been conducted to determine the impact of various sources of coverage on the health care of this population. Data from the 1997 and 1999 National Survey of America’s Families (NSAF) provide more recent information on insurance coverage, access, and utilization as well as race and ethnicity. In this study, we conducted an analysis to answer the following questions: (1) How do AIANs and non-Hispanic Whites (hereafter “Whites”) compare regarding socioeconomic/demographic characteristics? (2) How do AIANs and Whites compare regarding insurance coverage? (3) Are differences in access to care and utilization related to differences in socioeconomic/demographic characteristics between AIANs and Whites? (4) What role does the IHS play in affecting access and utilization among otherwise uninsured AIANs?
