There are 21 federally recognized American Indian tribes in Arizona. Over 250,000 American Indians make up Arizona’s population (2000 Census). Reservations and tribal communities comprise over a quarter of Arizona's lands and are located mostly in rural and frontier areas. (See Map 1). All data reported is for the Arizona portion of reservations only, and does not include those portions of reservations that are located in states outside of Arizona.
The Arizona Indian Reservation acreage and population for 1990 and 2000 are summarized in Table 1a. The 21 American Indian tribes reside on 24,753,480 acres in the state of Arizona. The two tribes with the largest reservation acreage are Navajo (14,775,068 acres) and Tohono O’Odham (2,848,541 acres), while the two tribes with the smallest acreage are Tonto Apache (85 acres) and Yavapai-Apache (653 acres).
There was an increase of 15.3% of American Indians (142,113 to 163,799) living on the reservation between 1990 and 2000. Of the 21 tribes, the Navajo had the highest reservation number increase between 1990 and 2000 (13,588), and the Hopi had the highest number of decrease (-426). The Maricopa (Ak Chin) had the largest reservation percentage increase (63.7%), and the Hopi had the largest percentage decrease (-6.0%) during the decade. The U.S. Census reported that 37 percent of Arizona’s American Indians lived off-reservation in 2000.1
Table 1b summarizes the Arizona American Indian gender and age breakdowns by reservation for the year 2000. The two tribes with highest percentage of children (0 to 17 years of age) in 2000 were Pascua Yaqui (46.5%) and Kaibab (44.4%). Cocopah (38.0%) and Fort Mohave (14.2%) had the highest percentage of seniors (65 years of age or older).
The Inter Tribal Council of Arizona (http://www.itcaonline.com/tribes.html) and ADHS Arizona Primary Care Area Statistical Profiles (http://www.azdhs.gov/hsd/profiles2005/profiles1.htm) websites provide additional information about each reservation. Indian community profiles are presented on the Arizona Department of Commerce website (http://www.commerce.state.az.us/ communities/indian%20profile.asp).
Tribal Health Profile
Selected measures of health status for Arizona’s American Indians living on and off reservations are examined in the Health Profile section. These include both natality and mortality measures. The Arizona Department of Health Services’ Health Status Profile of American Indians website provides additional natality and mortality information: http://www.azdhs.gov/plan/report/hspam/ index.htm.
Natality: Tables 6a – 6c provide selected American Indian natality information for 1997 – 2001. The natality data includes percentages of teen pregnancy and low birth weight, as well as infant mortality numbers. During the five-year period, the percentages of teenage American Indian new mothers (19 years old or younger) were consistently higher than the overall percentages for Arizona (Table 6a). In 2001, the two reservations with the highest percentage of teenage American Indian new mothers were Salt River (31.0%) and Colorado River (30.8%). A higher percentage of American Indian low birth weight births (under 2,500 grams) occurred on-reservation (7.9%) than off-reservation (6.9%) in 2001 (Table 6b). The 1997-2001 numbers of infant deaths among American Indians are presented in Table 6c.
Mortality: The mortality numbers for selected chronic health conditions for American Indians living on and off reservations are summarized in Tables 7a – 7i for 1997 – 2001. Beginning with the year 2000, a new revision of the International Classification of Diseases (ICD), used to classify causes of death, was implemented (using ICD-10 instead of ICD-9). The top eight causes of death (age-adjusted) for 2001, reported in the Arizona Department of Health Services’ Health Status and Vital Statistics, are presented in Tables 7b - 7i for (1) Cardiovascular Disease, (2) Cancer [total], (3) Cerebrovascular Disease, (4) Chronic Lower Respiratory Disease, (5) Accidents [unintentional accidents], (6) Pneumonia and Influenza, (7) Diabetes, and (8) Alzheimer’s Disease. During the five-year period, mortality numbers among American Indians for Cardiovascular Diseases, Cancers [total], Cerebrovascular Diseases, Accidents [unintentional accidents], and Pneumonia and Influenza were higher for those living on reservations than for those living off reservations.
Indian Health Service Coverage
The Indian Health Service (IHS), an agency within the Department of Health and Human Services (DHHS), is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health advocate for Indian people.2 The Indian Health Service is funded each year through appropriation by the U.S. Congress. Currently, the IHS is funded at about 60 percent of tribal need. This is not an entitlement program, not an insurance program, and not an established benefits program, but a discretionary program of the U.S. Congress.
The Indian Health Service is organized into 12 regional areas covering the contiguous 48 states and Alaska. The Navajo, Phoenix, and Tucson Area Offices are the core of IHS Administration and Management in Arizona. The following data provided by the IHS includes only those residing in Arizona. The Navajo Area IHS Office, located in Window Rock, administers 21 ambulatory facilities and 6 hospitals in the Four Corners area of Arizona, Utah, Colorado, and New Mexico. There are five Service Units (Chinle, Fort Defiance, Kayenta, Tuba City, and Winslow) in the Arizona Navajo IHS Area. The total estimated service population is over 226,460. The Navajo Nation, through the Navajo Division of Health (NDOH) in Window Rock, operates 43 health programs for infants, children, youth, adults, and elders. The NDOH program includes nutrition, aging, substance abuse, community health outreach representatives, and ambulance emergency medical services.
The IHS Tucson Area has two Service Units (Pascua Yaqui and Sells). The IHS serves the Tohono O’odham Nation with one hospital in Sells and two ambulatory facilities, Santa Rosa and San Xavier. A new ambulatory care facility is scheduled to open in the spring of 2006, in Pisinimo. Health care in the Sells Service Unit is a combined effort of IHS and the Tohono O’odham Department of Human Services. The Pascua Yaqui Tribe of Arizona is served principally through contracts that collectively provide a full spectrum of health care. The Yaqui Service Unit is jointly managed by the IHS and the Pascua Yaqui Tribe. The Yaqui tribe also administers a variety of health services through their Tribal Health Program. The Tucson Area’s total estimated service population is 29,470.
The Phoenix Area IHS office oversees the delivery of health care to approximately 153,500 Indian people. The Area Office operates primarily as an administrative center for seven Service Units in Arizona (Colorado River, Fort Yuma, Hopi, San Carlos, Phoenix, Gila River Health Care Corporation, and Whiteriver), three Service Units in Nevada, and one Service Unit in Utah. A Service Unit may include one or more health centers or hospitals. Reservation hospitals are located in Fort Yuma, Polacca, San Carlos, Whiteriver, Parker, and Sacaton. In addition, the IHS operates seven health centers and six health stations, and the Phoenix Indian Medical Center for specialized care not available on the reservations. A growing number of health facilities are tribally operated. Urban Indian Health programs and clinics are provided at sites in Flagstaff, Phoenix and Tucson.
For more information on the Arizona IHS Areas and Service Units, please refer to the IHS website at http://www.ihs.gov/FacilitiesServices/AreaOffices/AreaOffices_index.asp.
Outside Contracted Services: Contract Health Services (CHS) are services that the IHS is unable to provide with its own staff and in its own facilities. These services are provided by non-IHS health care providers and facilities. CHS payments are authorized based on clearly defined guidelines, and are subject to availability of funds. The IHS cannot guarantee that funds are always available. Thus, services obtained under CHS must be prioritized, with life-threatening illnesses or injuries given highest priority. It also means that the IHS formulary may not include all drugs and medications, but will include most medications that have been proven to be beneficial and cost-effective.
CHS are provided for members of federally recognized tribes who reside on or near the reservation established for the local tribe(s) in geographic areas called contract health service delivery areas (CHSDAs). The eligibility requirements are stricter for CHS than they are for direct care.
Eligibility: A member of a Federally recognized tribe may obtain care at any IHS hospital or clinic if the facility has the staff and capability to provide the medical care. The CHS Program policy has a residency requirement. Members are generally not responsible for any co-payments for medical, dental, pharmaceutical, or other direct health services.
Table 2a summarizes the Arizona IHS Area and Service Unit registrant and user numbers for 1997 to 2001. The IHS registrant numbers represent the total count of Indian registrants that are in the IHS Patient Registration database. The registrants are tabulated by their community of residence.3 The IHS user numbers represent American Indians and Alaska Natives who are eligible for IHS services and have used those services at least once during the last three-year period.4 In 2001, there were 411,581 IHS registrants and 254,362 users in Arizona. An examination of the number of users living in Arizona only (not in any other states) shows comparable numbers in the Navajo (115,862) and Phoenix (115,094) IHS Areas.
Many Indian people who move away from their home reservations are not eligible for CHS since they would be moving away from the CHSDA in which they have eligibility. CHS may cover urgent or emergency needs, as defined by the local service unit, and will require prior approval for non-emergency care and notification within 72 hours for emergency care.
Some tribally operated hospitals and clinics restrict services to members of their own tribe. Consequently, just because a patient is a member of a Federally recognized tribe does not mean that he/she will be provided medical care at a tribally operated hospital or clinic if he/she is not a member of that tribe.
Benefit Package: The Indian Health Service provides primary, dental, and inpatient care, and a number of medical programs, including: AIDS/HIV care; behavioral health; cardiology; pediatrics; dental; diabetes; elder care initiatives; epidemiology; injury prevention; maternal/child health; nutrition; optometry; pharmacy; substance abuse; violence prevention; and women’s health.
Preventive measures involving environmental, educational, and outreach activities are combined with therapeutic measures into a single health system. IHS services are provided directly and through tribal and urban contracts, as well as partnerships (MOU/MOA) with other federal agencies, universities, foundations, and corporate entities. Health services also include health care purchased from more than 2,000 private providers. Through Public Law 93-638 Self-determination contracts, the tribal health programs also provide comprehensive preventive and curative services. 638 refers to an agreement which states that tribes can operate part or all of their health program, including hospitals and clinics, under a P.L. 93-638 Indian Self-determination contract (Title I) or self-governance compact (Title III). Most Arizona tribes operate part(s) of their health program. Currently, there is one tribal nation in Arizona – the Gila River Indian Community – which administers their entire health care program, and the Navajo Nation has three 638 pilot sites. All hospitals operated by the IHS and tribal programs are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The health care that most Indian people receive comes from a blend of Indian Health Service (IHS), state, local, and private providers. Unfortunately, seamless access to care is still lacking.
Indian Health Service Facilities
In 2003, there were 9 IHS hospitals located in the state of Arizona. Three of these are located in the Navajo IHS Area and five are located in the Phoenix IHS Area. Of the 9 IHS, 4 were Critical Access Hospitals (Hopi Health Care Center, Parker PHS Indian Hospital, Fort Yuma PHS Indian Hospital, and Whiteriver PHS Indian Hospital) and one Tribal 638 hospital (Hu-Hu-Kam Hospital). All of these hospitals are located in the Phoenix IHS Area. Table 4a lists all the IHS facilities located within the state of Arizona in 2003.
Indian Health Service Health Practitioner Workforce
This section describes selected Indian Health Service (IHS) health workforce trends for the three Arizona IHS Areas and the IHS state total. The IHS provided the health practitioner data. Those persons who are practicing in IHS health care settings are included in the work force numbers. These numbers do not include Tribal 638 health care settings (e.g., Sacaton Service Unit) or numbers for those portions of IHS Areas that lie outside of the state of Arizona. One of the limitations of the IHS data provided is there was no data available for the Tucson Area in 1997 and 1998. Thus, the comparison health workforce trends for the three Arizona IHS Areas are presented for 1999 to 2001.
The 2001 practitioner to population ratio presented in this section is based on the IHS recommendation that the ratio include only the IHS user population.5 A user is any American Indian or Alaska Native eligible for IHS services who has used those services at least once during the last three-year period.4 The Navajo (115,862) and Phoenix (115,094) IHS Areas had similar numbers of users. The Tucson IHS Area had 23,406 users in 2001.
In 2001, the largest IHS health care practitioners group in the state was the nurses (853), followed by medical officers (336). Of the seven health professional areas examined, IHS nurses showed the greatest increase in numbers during the period from 1999 to 2001 (+32 and 3.9%), followed by medical officers (+22 and 7.0%). The workforce section is divided into the following health professional areas.
Health Services Utilization
The availability of preventive services and medical care utilization data for public use is very limited. This section compares prenatal care use in those tribes for which the Arizona Department of Health Services (ADHS) has data, as well as hospitalization rates for IHS/Tribally owned hospitals. The ADHS Health Status Profile of American Indians website provides additional prenatal care information: http://www.azdhs.gov/plan/report/hspam/index.htm. The figures presented in the tables below are only for those Service Units located within the state of Arizona.
Prenatal Care: Tables 5a-b summarize prenatal care use among Arizona’s American Indians from 1997 through 2001. The state rate for prenatal care starting in the first trimester increased during the last three years (1999-2001). Two tribes showed the same trend: Fort Apache (52.4% to 61.5%) and Havasupai (10.0% to 41.7%).
The National Year 2010 Objective is to increase the proportion of expectant mothers who receive prenatal care in the first trimester of pregnancy to 90 percent. In 2001, Arizona’s rate of prenatal care beginning in the first trimester was 75.5 percent, while the American Indian percentage was 64.6. The off-reservation percentage (65.0%) was slightly higher than the on-reservation percentage (64.1%). Of the 12 reporting tribes, Gila River (72.1%) had the highest percentage of prenatal care beginning in the first trimester while Havasupai (41.7%) had the lowest.
From 1999 to 2001, Arizona’s rate of prenatal care consisting of five or more visits rose steadily from 88.4% to 90.6%. Two of the 12 tribes providing data over the three years showed similar trends: Fort Apache (70.3% to 84.4%) and Salt River (81.2% to 87.4%). The off-reservation percentage of prenatal care with five or more visits (86.9%) was higher than the on-reservation percentage (83.9%).
IHS Hospital Services: Tables 5c-e provide summaries of IHS hospital services. The number of Arizona IHS admissions declined from 1998 to 2001 (17,931 to 16,761). The same trend was seen for the number of births (2,609 to 2,363). In 2001, births comprised 14.1 percent of all hospital admissions. Of the three Arizona IHS Areas, the highest number of births in 2001 occurred in the Navajo Area (1,472). In 2001, Sells PHS Indian Hospital (7.0) had the highest average length of stay, while Hopi Health Care Center (1.8) had the lowest.