Social Determinants of Health Affecting Urban American Indian and Alaska Native Communities: Key Findings & Recommendations

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The National Council of Urban Indian Health (NCUIH) has released new resources highlighting how key social determinants of health (SDOH) affect American Indian and Alaska Native (AI/AN) people living in urban areas across the United States, and specifically in California.

From 2025 to 2026, NCUIH conducted a scan of publicly available research and data, along with a survey of California Urban Indian Organizations (UIOs), to examine four key challenges related to SDOH:

  • Housing insecurity;
  • Transportation barriers to care;
  • Food insecurity; and,
  • Indigenous language and identity challenges.

Findings indicate that AI/AN people experience significant disparities across these areas. The research also highlights the interconnected nature of SDOH and their collective impact on health outcomes, as well as the need for increased investment and resources to reduce these disparities.

To support UIOs, providers, policymakers, and partners, the report offers key findings and actionable recommendations to address these challenges and improve health outcomes for urban AI/AN communities.

NCUIH has also developed two infographics that highlight findings from the survey of California UIOs on SDOH.

Visit ncuih.org/sdoh2026 to learn more and access the full report and infographics.

From Partnership to Practice: Lessons in Native Maternal Health from Bakersfield American Indian Health Project

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Authors: Nahla Holland and Alyssa Smith-Longee

Introduction

Current rates of pregnancy-related deaths in the United States emphasize gaps in care and support for different racial/ethnic groups. Non-Hispanic American Indian and Alaska Native (AI/AN) people experience deaths during pregnancy/up to one year postpartum at the highest rate compared to other groups, with a rate four times higher than non-Hispanic White people.1 However, even one death is too many; actionable, culturally relevant prevention efforts need to be a focus to ensure the wellness of AI/AN relatives.

The National Council of Urban Indian Health (NCUIH), in partnership with the Centers for Disease Control and Prevention (CDC) and the CDC Foundation (CDCF), supports Urban Indian Organizations (UIOs) in preventing pregnancy-related deaths in urban AI/AN communities. NCUIH also works to support connections of UIOs with local Maternal Mortality Review Committees (MMRCs) to help ensure that the stories of those who have passed, or transitioned, are treated with respect and that future prevention recommendations are culturally relevant. MMRCs are multidisciplinary groups that may include clinical and non-clinical committee members, and that convene at the state or local level to comprehensively review deaths that occur during or within 1 year of the end of pregnancy.2 AI/AN people living in urban areas may face distinct maternal health challenges. UIOs report that pregnancy and postpartum concerns affect outcomes before, during, and after pregnancy and reflect both clinical conditions and broader barriers to safety, stability, and care. These concerns include:

Pregnancy and postpartum health concerns identified by UIOs (2023)

These concerns make it clear that meaningful action is needed to support the health and well-being of urban AI/AN people during pregnancy and postpartum. UIOs play a critical role in identifying and responding to these needs within their communities. The following case study illustrates how one UIO is working to address these concerns and put these priorities into practice.

Case Study

As an example of the impacts that NCUIH has accomplished in working with UIOs to improve maternal health challenges in urban AI/AN communities, we would like to share a case study of the Bakersfield American Indian Health Project (BAIHP). BAIHP is an outreach and referral UIO located in Bakersfield, California, serving the AI/AN and larger community in Kern County. BAIHP embraces culturally community-driven models of wellness for its patients.

In 2025, BAIHP and NCUIH partnered under NCUIH’s CDCF MMRC grant to build capacity through NCUIH’s assistance for addressing maternal health concerns. One goal was to build a relationship by connecting the California urban AI/AN community and the local California MMRC, the CA Central Valley MMRC. BAIHP and NCUIH worked collaboratively to strengthen the MMRCs knowledge of UIOs and urban AI/AN communities through conversations with the CA Central Valley MMRC. With the support of the California Central Valley MMRC, two BAIHP staff members were onboarded to the committee to provide active input on AI/AN stories and values during the review process.

Additionally, with the dedicated funding for supporting pregnancy and postpartum health, BAIHP hired a part-time OB/GYN. The new OB/GYN supported RNs and FNPs at both BAIHP sites as they built out their perinatal and pediatrics programming. The BAIHP team developed obstetric policies and procedures and partnered with local Tribes, hospitals, and other health initiatives.

Indigenous Doula Scholarship Program 2025/2026 Graduates Trained by Three Moons Doula Collective. (Photo Credit: BAIHP)

BAIHP and NCUIH attended in-person and virtual national convenings on AI/AN pregnancy and postpartum health. During these discussions, BAIHP staff developed the idea to start an Indigenous doula scholarship program and a community doula plan. Indigenous doulas are a culturally rooted protective factor for our community, guiding our relatives through pregnancy and the post-partum period. This doula program was designed for Indigenous people to become trained and certified as a doula at no cost to them and provide care right in their communities. After certification, all the doulas who graduated provided care to BAIHP patients and to the larger community for one year. In April 2026, BAIHP graduated ten doulas from their program. This unique scholarship opportunity trained more Indigenous people to become doulas and allowed them direct access to their community to provide indigenous-centered birthing practices.

In August 2025, during their Bright Futures, Big Careers back-to-school event, BAIHP staff set up a maternity corner full of resources and professionals for expecting and recent parents, staffed by OB/GYNs, RNs, and a local doula. Over 500 attendees attended the event, where they could ask questions of care providers, receive perinatal supplies and resources, and learn about other trusted local specialty care providers in their community.

Bright Futures, Big Careers back-to-school event (Photo credit: BAIHP)

Additionally, after conversations with their California Central Valley MMRC, BAIHP joined calls with the California Maternal Quality Care Collective (CMQCC), a health initiative focused on improving perinatal health outcomes. BAIHP’s established partnerships with local doulas, graduate students, hospitals, health departments, Tribes, the California Maternal Quality Care Collective (CMQCC), and the Black Infant and Maternal Health Initiative informed the broader community about pregnancy and postpartum resources for AI/AN people in the area.

The work in progress at BAIHP exemplifies the exceptional role UIOs play in their communities as care providers but also in promoting strength-based programming and upholding Indigenous values of wellness. BAIHP and UIOs in general offer tremendous opportunities to connect our urban relatives with the best perinatal care and to create culturally relevant, strength-based initiatives developed by our communities.

BAIHP and NCUIH at National Indian Health Board Convening on Tribal Maternal Health 2025. From left to right: Alanna Costello (BAIHP), Alyssa Smith-Longee (NCUIH), Nahla Holland (NCUIH)

BAIHP and NCUIH at National Indian Health Board Convening on Tribal Maternal Health 2025. From left to right: Alanna Costello (BAIHP), Alyssa Smith-Longee (NCUIH), Nahla Holland (NCUIH)

Tara Gray, Tribal Liaison at BAIHP, presenting at the NCUIH 2026 Annual Conference Maternal Health Session, alongside other Subject Matter Experts.

Tara Gray, Tribal Liaison at BAIHP, presenting at the NCUIH 2026 Annual Conference Maternal Health Session, alongside other Subject Matter Experts. From left to right: Dr. Brian Thompson (Upstate Medical University), Janelle Palacios (Encoded 4 Story), Tara Gray (BAIHP)

Recommendations and Best Practices

UIOs like BAIHP are uniquely positioned to integrate clinical care with community trust and community-level programming. The partnership between BAIHP and NCUIH reinforced that investing in UIOs and their maternal health efforts yields both systemic change (MMRC representation) and direct community impact (doula graduates, outreach events, new care policies). To facilitate a community of learning, NCUIH hosted a maternal health session at its 2026 Annual Conference, where alongside other subject matter experts, BAIHP Tribal Liaison, Tara Gray, shared best practices and recommendations from the partnership. While the session addressed barriers and challenges facing AI/AN mothers, it centered on community-led solutions.

Recommendations and best practices to strengthen maternal health outcomes at UIOs:

  • Community Members as Care Providers. Training and certifying community members as doulas and birth workers (Indigenous Doula Programs/Scholarships).
  • Center Strength-Based, Culturally Driven Programming. Hosting community education and events grounded in Indigenous values of wellness and community strengths. (see image)
  • Meeting the community where they are. Integrating maternal health education and services during other community events or home visiting programs.
  • Incorporating community voices through local and national partnerships. MMRCs should make efforts to connect with the UIOs in their respective states, and vice versa, to ensure urban AI/AN voices don’t go unheard.
  • Consistent funding to ensure maternal health promotion efforts can continue without gaps or delays.
Protective factors within AI/AN communities for pregnancy and postpartum health

Protective factors within AI/AN communities for pregnancy and postpartum health

MMRCs also play an important role in strengthening maternal health through prioritizing community and AI/AN voices in the review process.

To strengthen maternal health outcomes for AI/AN communities, MMRCs should:

  • Address systemic biases and trauma of AI/AN people
  • Examine influences such as Indigenous determinants of health
  • Highlight protective factors within case abstraction
  • Protect AI/AN committee members throughout the review process
  • Respect traditional knowledge
  • Center the individual’s story and lived experience over data points
  • Fund and empower community-led maternal health solutions
  • Establish and uphold continued relationships with UIOs, Tribes, and other AI/AN serving organizations (including transparent data sharing agreements)
Conclusion

Recent data show that nearly all AI/AN pregnancy-related deaths reviewed were preventable.3 No voices should go unheard, no stories untold, and strengthening maternal health efforts should remain a priority with UIOs and Tribes, and local, federal, and national stakeholders. To learn more about how to get involved, please contact research@ncuih.org. For more information on AI/AN pregnancy and postpartum health, and how NCUIH is working with UIOs and national partners to promote healthier communities for our pregnant and postpartum relatives, please visit NCUIH.org/maternal-health.

Thank you to Bakersfield American Indian Health Project for their thoughtful review and input on this post.

1 Centers for Disease Control and Prevention. (2025, December 18). Data from the Pregnancy Mortality Surveillance System. https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance-data/index.html?cove-tab=1
2 Centers for Disease Control and Prevention. (2024, May 15). About Maternal Mortality Review Committees. https://www.cdc.gov/maternal-mortality/php/mmrc/index.html
3 Centers for Disease Control and Prevention. (2025a, August 22). Pregnancy-related deaths among American Indian or Alaska native women: Data from maternal mortality review committees. https://www.cdc.gov/maternal-mortality/php/data-research/mmrc/aian.html?cove-tab=3

Urban Indian Organizations’ Programming Profile

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Urban Indian Organizations (UIOs) provide critical health care services to AI/AN people living in their service areas. UIOs play a vital role in upholding the federal trust responsibility that the United States (U.S.) Government holds with Tribes and American Indian/Alaska Native (AI/AN) people, as the large majority of AI/AN people live in urban areas. Currently, 41 UIOs are contracted with the Indian Health Service (IHS) under Title V of the Indian Health Care Improvement Act (IHCIA), representing 38 different urban areas within the U.S. These 41 UIOs consist of four different program types:

  • Full ambulatory facilities (24)
  • Limited ambulatory facilities (seven)
  • Residential and inpatient treatment facilities (five)
  • Outreach and referral facilities (five)

In 2025, the National Council of Urban Indian Health (NCUIH), reviewed all UIO services and programs provided as described on UIO websites, social media, and federal grant funding information databases. This overview of services demonstrates the wide range of multi-disciplinary programming that UIOs bring to their communities, with 80 percent of UIOs offering care for all four programming types: medical services, behavioral health services, social services, and traditional health practices.

Medical Services

All UIOs offer immunizations, healthy lifestyle programming, and chronic disease prevention programming.  Outside of those fundamentals, 85 percent of UIOs provide direct primary care services such as chronic disease management, regular physicals, urgent care, screenings, lab services, , and pregnancy and postpartum care.  The Special Diabetes Program for Indians (SDPI) is at 78 percent of UIOs, an embodiment of the unique care that UIOs provide their patients that utilizes strengths within Indigenous communities to promote wellness while also managing existing chronic diseases like diabetes. SDPI allows for indigenized diabetes care, so programs not typically allowed from standard grant sources like Indigenous food cooking classes to help manage A1C levels, community gardens, traditional dancing classes for fitness, and culturally based youth groups all are incorporated into diabetes prevention and management programs. When programs are specifically tailored to the communities they serve and incorporate community and culture, this can increase participation and patient buy in (National Council of Urban Indian Health, 2024).

Some UIOs with advanced service providers provide specialty care for their patients with many sites offering services such as nutritionists/dietician visits, dental care, optometry, and minor surgeries in house.  Several UIOs even include their own pharmacy, increasing accessibility and affordability for patients, which allows for supportive pharmacy-assisted chronic disease monitoring. Novel medical programs at UIOs include food prescription programs and mobile health vans increasing accessibility to care and promoting the inclusion of larger social drivers of health in healthcare programming.

Figure 1. Urban Indian organizations with a nutritionist or dietician on staff.

Interestingly, a little under half of UIOs provide cancer-related prevention services (49 percent) for their community members, which includes breast and cervical cancer screenings.  An uncovered unmet need is in identifying colorectal cancer in urban AI/AN people, as the ability to test is only at 12 percent of UIOs.  These services are less common because they are underfunded, not because they are not needed, and more funding and partnerships would bring more access to this area.

Figure 2. Urban Indian organizations’ cancer-related services offered

 

UIO providers emphasize the importance of their facilities offering care in house rather than referring out to ensure patient continuity of care, maintaining and strengthening patient relationships, and ensuring that care is culturally relevant for their patients. These medical services support all generations within these UIO communities bolstering much needed disease treatment and preventative care.

Figure 3. Commonality of medical services offered at urban Indian organizations

Behavioral Health Services

Behavioral health services are fundamental care at UIOs. All UIOs offer general counseling, with an emphasis on substance use disorders, and care for domestic violence/sexual assault victims. Counseling services vary in structure, with some offering family counseling, individualized counseling, and more. Other popular behavioral health services include consultation and assessment for diagnosis, support groups, intensive outpatient care, community education, and youth programs focused on promoting positive mental health practices for prevention.

Social Services

Figure 4. Urban Indian organizations with case workers or social workers available

With a holistic approach to health, non-medical factors must also be addressed to provide the best care for patients. UIOs offer a variety of social services to ensure all the needs of their patients are met. This approach to care is exemplified by the 85 percent of UIOs that employ social workers or case workers for their patients. Other popular social services at UIOs include assistance with insurance enrollment, transportation to care, support with housing and other necessities, and elder programs. While not as common, a few UIOs are able to offer housing for their community, directly addressing the larger non-medical needs of their patients that impact health and wellness.

Figure 5. Commonality of social services offered at urban Indian organizations

Traditional Healing

UIOs are set apart from standard health organizations as seen through the culturally relevant care they provide to their community. Many Urban Native people are unable to participate in traditional healing or ceremony due to living away from their Tribal communities, but almost all UIOs (95 percent) offer different ways to reconnect their patients with Traditional Healing as part of their programming. This programming highlights the significance of UIOs within their communities, providing culturally relevant care that is grounded in Indigenous concepts and practices of wellness. Talking circles are the most common traditional practice, with 61 percent of UIOs offering this practice. Traditional healing-based substance use treatment programs (i.e. Wellbriety), traditional drumming, traditional medicines, traditional arts, and Indigenous foods are also common traditional healing-based programs and practices that UIOs provide for their patients.

As shared by UIO staff in NCUIH’s 2023 report, traditional healing is in high demand within UIO communities (National Council of Urban Indian Health, 2023b). It offers a mechanism to combat social isolation, strengthen community and cultural connection, and promote wellness (National Council of Urban Indian Health, 2023b). However, many of these programs, as well as standard health services, are underfunded at UIOs, making it difficult for UIOs to fully meet the needs of the communities they serve (National Council of Urban Indian Health, 2023b).

Funding

It is vital that UIOs receive stable and sustained funding for their work to maintain their work in promoting healthier communities and providing life-saving care. Outside of IHS, Medicaid and the Children’s Health Insurance Program (CHIP) are the largest sources of funding for UIOs (National Council of Urban Indian Health, 2023a). Medicaid and CHIP reimbursement supplement the chronically low congressional appropriations to UIOs. Increased ability for Centers for Medicare & Medicaid Services (CMS) to reimburse for UIO services, like applying 100 percent federal medical assistance (FMAP) percentage would better support the work UIOs do to combat health disparities.

Many UIO programs and services are also funded through grants, but sustainability and relevance of grant opportunities do not always match the needs of AI/AN communities. Grants should adapt to better suit the Native communities they wish to support by extending grant life cycles, allowing funding for cultural activities and priorities, and increasing focus on preventative health programming (National Council of Urban Indian Health, 2023b).

UIO leaders outlined their priorities for 2026 with NCUIH with the top items emphasizing funding:

  • increasing congressional funding for Urban Indian Health
  • securing 100 percent federal medical assistance percentage (FMAP)
  • increasing general behavioral health funding (National Council of Urban Indian Health, 2025)

Despite the limited funding allocated to them, UIOs are integral parts of the AI/AN communities they serve and do much with the fraction of need provided. With more AI/AN people living away from Tribal lands, and thus Tribal health and IHS facilities, it is necessary that funding for AI/AN healthcare reflects the need for greater urban funding to uphold the trust responsibility to urban AI/AN people. By embracing an Indigenous holistic approach to care, UIOs uplift Urban AI/AN people when they most need it.

To cite information about UIO services and programming as detailed in this blog post, please use the following citation:

National Council of Urban Indian Health (2026). Urban Indian Organizations’ Programming Profile. https://ncuih.org/2026/05/18/urban-indian-organizations-programming-profile/

Citations:

National Council of Urban Indian Health. (2023a). An Overview of the Impact of Medicaid on Health Care for American Indians and Alaska Natives. https://ncuih.org/wp-content/uploads/Impact-Medicaid_NCUIH_D329_F2.pdf

National Council of Urban Indian Health. (2023b). (rep.). Recent Trends in Third Party Billing: Thematic Analysis of Traditional Healing Programs at Urban Indian Organizations and Meta-Analysis of Health Outcomes. Retrieved from https://ncuih.org/wp-content/uploads/03.25.24-FINAL-design-of-2023-TH-Report.pdf.

National Council of Urban Indian Health. (2024). (rep.). Recent Trends in Third Party Billing: Thematic Analysis of Traditional Food Programs at Urban Indian Organizations and Research on Traditional Healing. Retrieved 2026, from https://ncuih.org/wp-content/uploads/Traditional-Food-Report-NCUIH-D507_F2.pdf.

National Council of Urban Indian Health. (2025, November). Summary of NCUIH Policy Priorities Survey for 2026.

Syphilis Rates Among American Indian and Alaska Native Communities

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The following resource was developed by the National Council of Urban Indian Health (NCUIH) in 2025 to highlight disparities in syphilis experienced by the American Indian and Alaska Native (AI/AN) population.

Primary & Secondary Syphilis Disparities

Syphilis is a sexually transmitted infection (STI) that is transmitted through direct contact with an infected syphilis sore during oral, vaginal, or anal sex (Centers for Disease Control and Prevention [CDC], 2025a). Syphilis has four key stages: the primary stage (characterized by minimal sores typically found in, on, or around the genitals or mouth), secondary stage (characterized by sores and/or rashes in the mouth, vagina, or anus), latent stage (a period where there are no visible signs or symptoms), and tertiary stage (in which syphilis spreads to different organ systems, typically occurring ten to thirty years after the infection began) (2025a). Primary and secondary syphilis are considered the most infectious stages of syphilis (Centers for Disease Control and Prevention [CDC], 2024). If left untreated, syphilis can cause damage to the heart, brain and nervous system, and more (CDC, 2025a).

American Indian and Alaska Native (AI/AN) people experience disproportionately higher rates of primary and secondary syphilis compared to their counterparts (see Figure 1). In 2023, the rate of primary and secondary syphilis was 15.8 per 100,000 persons for the total population and 58.2 per 100,000 persons for the AI/AN population (Centers for Disease Control and Prevention, 2024). Specifically, the AI/AN population had the highest rate of primary and secondary syphilis in 2023 of all racial/ethnic groups in the United States, a rate 3.7 times that of the total population and 6.4 times that of their White counterparts (2024).

Figure 1. 2023 Primary and Secondary Syphilis Rates by Race/Ethnicity1

Primary and secondary syphilis disparities have also worsened disproportionately for the AI/AN population compared to the total population (see Figure 2). Between 2020 to 2023, the total rate of primary and secondary syphilis in the United States increased by 25.4 percent, while the AI/AN rate of primary and secondary syphilis increased by 116.3 percent (Centers for Disease Control and Prevention [CDC], 2021; CDC, 2022; CDC, 2023; CDC, 2024).

Disparities in primary and secondary syphilis also affect AI/AN males and females disproportionately compared to their counterparts (see Figure 2). In 2023, the male AI/AN rate of primary and secondary syphilis per 100,000 persons was approximately 2.7 times that of the national rate (CDC, 2021; CDC, 2022; CDC, 2023; CDC, 2024). Between 2020 to 2023, the rate of primary and secondary syphilis increased by 13.5 percent for all males and 95.1 percent for AI/AN males (CDC, 2021; CDC, 2022; CDC, 2023; CDC, 2024). In comparison, the female AI/AN rate of primary and secondary syphilis per 100,000 persons was approximately 6.5 times that of the national rate (CDC, 2021; CDC, 2022; CDC, 2023; CDC, 2024). Between 2020 to 2023, the rate of primary and secondary syphilis increased by 72.3 percent for all females and 148.4 percent for AI/AN females (CDC, 2021; CDC, 2022; CDC, 2023; CDC, 2024). While primary and secondary syphilis rates decreased between 2022 and 2023 (likely due to increased STI prevention efforts, such as the nationally coordinated response spearheaded by the National Syphilis and Congenital Syphilis Syndemic Task Force), further intervention is needed to address these impacts of these disparities on the AI/AN population (CDC, 2024).

Figure 2. Trends in Primary and Secondary Syphilis, 2020-20232

Congenital Syphilis Disparities

Congenital syphilis is a disease that occurs when syphilis is passed from pregnant people to their babies during pregnancy (Centers for Disease Control and Prevention, 2025b). Congenital syphilis can affect pregnancy by causing miscarriage, stillbirth, prematurity, low birth weight, or even infant mortality (2025b). Babies born with congenital syphilis can experience issues like bone deformity, severe anemia, jaundice, blindness or deafness, and more (2025b).

AI/AN people experience disproportionately higher rates of congenital syphilis compared to their counterparts (see Figure 3). In 2023, the rate of congenital syphilis was 105.8 per 100,000 live births for the total population and 680.8 per 100,000 live births for the AI/AN population (Centers for Disease Control and Prevention [CDC], 2024). Specifically, the AI/AN population had the highest rate of congenital syphilis in 2023 of all racial/ethnic groups in the United States, a rate 6.4 times that of the total population and 11.9 times that of their White counterparts (2024).

Congenital syphilis disparities have also worsened disproportionately for the AI/AN population compared to the total population (see Figure 4). Between 2020 to 2023, the rate of congenital syphilis per 100,000 live births increased by 76.3 percent for the total population, compared to an increase of 257.2 percent for the AI/AN population (CDC, 2021; CDC, 2022; CDC, 2023; CDC, 2024).

Figure 3. 2023 Congenital Syphilis (Rate per 100,000 Live Births) by Race/Ethnicity3

Figure 4. Congenital Syphilis (Rate per 100,000 Live Births), 2020-20234

Resources

These disparities highlight the need for improved access to syphilis prevention, testing, and treatment for AI/AN populations. Urban Indian Organizations (UIOs) play a crucial role in providing programs and healthcare to address syphilis disparities affecting urban AI/AN populations.

The National Council of Urban Indian Health (NCUIH) has developed an HIV and STI web page dedicated to providing relevant information and tools for UIOs serving urban AI/AN communities, including guides and infographics on sexually transmitted infection (STI) disparities and best practices, culturally-tailored educational videos on STIs, recordings of webinars and trainings such as Strengthening Syphilis Care in Indian Country, and more.

Additionally, NCUIH’s Knowledge Resource Center (KRC) is the first searchable resource center devoted to the dissemination of knowledge on Urban Indian health across the United States, and it features many resources on STIs and syphilis. Use the STI/STD tag to directly search for resources on STI research, prevention, best practices, and more in the KRC.

NCUIH has also developed a new Syphilis Rates Among American Indian and Alaska Native Communities infographic summarizing these AI/AN syphilis disparities which can be downloaded here.

Additional resources:

  1. Indian Country ECHO Syphilis Resource Hub
  2. CDC Syphilis Pocket Guide for Providers
  3. Medicaid Fact Sheet: Syphilis and Congenital Syphilis Resources
  4. CDC Syphilis Fact Sheet
  5. We R Native Sexual Health Resources
  6. IHS Syphilis Resources
  7. Reproductive Health National Training Center Syphilis Resource List
  8. I Want the Kit: STI Testing Resources
  9. IHS STI Toolkit
  10. CDC Syphilis Informational Resources by Audience
  11. SAMHSA Syphilis News and Resources
  12. Healthy People 2030: Female Syphilis Reduction
  13. Healthy People 2030: Congenital Syphilis Reduction
  14. Healthy People 2030: MSM Syphilis Reduction
References

Centers for Disease Control and Prevention. (2021). Sexually Transmitted Disease Surveillance 2020. https://www.cdc.gov/sti-statistics/media/pdfs/2024/07/2020-SR-4-10-2023.pdf.

Centers for Disease Control and Prevention. (2022). Sexually Transmitted Disease Surveillance 2021. https://www.cdc.gov/sti-statistics/media/pdfs/2024/07/2021-STD-Surveillance-Report-PDF_ARCHIVED-2-16-24.pdf.

Centers for Disease Control and Prevention. (2023). Sexually Transmitted Infections Surveillance 2022. https://www.cdc.gov/sti-statistics/media/pdfs/2024/11/2022-STI-Surveillance-Report-PDF.pdf.

Centers for Disease Control and Prevention. (2024). Sexually Transmitted Infections Surveillance 2023. https://www.cdc.gov/sti-statistics/media/pdfs/2025/09/2023_STI_Surveillance_Report_FINAL_508.pdf.

Centers for Disease Control and Prevention. (2025a, January 30). About Syphilis. https://www.cdc.gov/syphilis/about/index.html.

Centers for Disease Control and Prevention. (2025b, January 31). About Congenital Syphilis. https://www.cdc.gov/syphilis/about/about-congenital-syphilis.html.

1Data was sourced from the Sexually Transmitted Infections Surveillance 2023 report (Centers for Disease Control and Prevention, 2024). Rates for primary and secondary syphilis are presented as rates per 100,000 persons.

2Data was sourced from the Sexually Transmitted Infections Surveillance reports from 2020, 2021, 2022, and 2023 (CDC, 2021–2024). Rates for primary and secondary syphilis are presented as rates per 100,000 persons.

3Data was sourced from the Sexually Transmitted Infections Surveillance 2023 report (Centers for Disease Control and Prevention, 2024). Rates for congenital syphilis are presented as rates per 100,000 live births.

4Data was sourced from the Sexually Transmitted Infections Surveillance reports from 2020, 2021, 2022, and 2023 (CDC, 2021–2024). Rates for congenital syphilis are presented as rates per 100,000 live births.

Maximizing SDPI Impact: Effective Strategies and Data-Driven Solutions for UIOs

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Background

Urban Indian Organizations (UIOs) play a vital role in addressing diabetes disparities within urban American Indian and Alaska Native (AI/AN) communities through the Indian Health Service’s (IHS) Special Diabetes Program for Indians (SDPI). Established by Congress in 1997, SDPI has been a cornerstone in diabetes prevention and treatment efforts, providing UIOs with critical funding to support culturally tailored health interventions. Over the years, SDPI has contributed to significant reductions in diabetes-related complications and has improved overall health outcomes within AI/AN communities (IHS SDPI Overview and Outcomes).

Through SDPI, UIOs have developed comprehensive programs integrating traditional healing practices with modern medical care, fostering a holistic approach to diabetes prevention and management. These efforts reduce the prevalence of diabetes-related complications and empower AI/AN individuals to take control of their health through education, early screening, and lifestyle support. Despite significant progress, UIOs continue to face challenges such as resource limitations, workforce shortages, and evolving patient needs. By refining strategies, leveraging data-driven solutions, and building supportive partnerships, UIOs can build upon their SDPI successes and drive even greater impact in urban AI/AN communities.

Comprehensive SDPI Services at UIOs

To better understand how UIOs are leveraging SDPI resources, NCUIH analyzed 2025 program profiles to identify the most commonly offered services across urban Indian health settings.

Figure 1. Commonality of SDPI Services Offered by UIOs (n=32)

Source: NCUIH Program Profiles, 2025. Data reflect the number of Urban Indian Organizations reporting each SDPI-related service.

SDPI-funded programs at UIOs offer a robust and holistic suite of services designed to meet the diverse needs of AI/AN communities. Among the most frequently provided offerings are diabetes-related education programs and blood glucose monitoring through onsite lab services, underscoring the importance of early detection and proactive treatment. Additionally, services such as access to a nutritionist or dietician, nutritional counseling, and prevention programs are critical components of both diabetes prevention and long-term disease management. UIOs also provide fitness programming and culturally relevant education initiatives that empower individuals to make informed health choices.

The success of these services highlights the commitment of UIOs to patient-centered care, where both traditional knowledge and evidence-based medicine work in tandem. Expanding access to specialized offerings, such as medication monitoring and long-term follow-ups, can further enhance health outcomes and ensure continued progress in diabetes prevention and management.

Enhancing Diabetes Program Performance

Performance metrics, guided by the Government Performance and Results Act (GPRA), highlight SDPI’s impact. Between 2018 and 2019, UIOs demonstrated improvements in blood pressure control rates, with the average rate increasing from 62.8% in 2018 to a peak of 64.2% in 2019[1]. Although external factors like the COVID-19 pandemic disrupted recent trends, UIOs quickly adapted by incorporating innovative solutions, including telehealth and at-home monitoring tools.

Success Story: Expanding Diabetes Care with Telehealth

At NATIVE HEALTH in Phoenix, a UIO-supported SDPI program successfully expanded its diabetes care services by integrating telehealth and remote patient monitoring. By distributing wireless glucose monitors and offering virtual diabetes education sessions, NATIVE HEALTH significantly improved patient engagement and glycemic control among its urban AI/AN population. This approach has since been adopted by other UIOs, demonstrating the effectiveness of digital tools in chronic disease management. Programs that consistently achieve high performance often incorporate robust case management and proactive outreach strategies, which can serve as models for other UIOs.

Strategies for Strengthening SDPI Services

To build on current successes and address identified challenges, UIOs can implement the following five strategic approaches:

  1. Expand Specialized Diabetes Care
    • Increase access to medication monitoring, individualized dietary counseling, and comprehensive follow-up care.
    • Leverage telehealth services to improve patient access to specialized diabetes care (IHS Telehealth Resources).
  2. Standardize Data Reporting
    • Implement a universal service taxonomy to improve reporting accuracy and transparency.
    • Utilize comprehensive electronic tracking systems to ensure consistent data collection and analysis through patient electronic health management systems.
  3. Staff Training and Development
    • Conduct regular training to enhance accurate, standardized reporting practices (NCUIH Technical Assistance and Training).
    • Designate dedicated data leads at each UIO to oversee reporting and ensure data integrity.
  4. Continuous Quality Improvement
    • Perform routine data audits to identify strengths and opportunities for growth.
    • Establish peer learning networks to facilitate knowledge-sharing and best practice adoption, such as participation in NCUIH Learning Collaboratives.
  5. Align Services with Performance Metrics
    • Ensure service offerings align with GPRA performance metrics to maximize program impact.
    • Use data visualization dashboards to track service provision and patient outcomes more effectively (IHS Quality Metrics).

Collaborative Partnerships

Collaboration is key to maximizing SDPI’s impact. UIOs are encouraged to actively engage with NCUIH, IHS, other UIOs, and SDPI technical assistance teams to enhance service delivery, improve data collection methods, and share successful strategies. Strengthening partnerships with local health care providers and community organizations can also support program sustainability and expand patient access to diabetes care services (NCUIH Partnership Resources).

Conclusion

Through SDPI support, UIOs continue to make meaningful progress in combating diabetes in urban AI/AN communities. By implementing evidence-based strategies and leveraging data-driven insights, UIOs can further enhance diabetes care, reduce disparities, and improve overall health outcomes. Continued collaboration and strategic investment are essential to sustaining these advancements and ensuring healthier futures for AI/AN populations in urban settings.

Need tailored data insights for your SDPI program? Contact our research team for support. Submit a Request for Data Support (Research – NCUIH).

[1]FY 2018 Urban GPRA Report_FINAL.pub.pdf; FY 2019 Urban GPRA Report_FINAL.pdf

Advancing Sexual Health Programs at Urban Indian Organizations: Best Practices, Challenges, and Solutions

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This blog post explores best practices for improving STI programming, the challenges Urban Indian Organizations (UIOs) encounter, and effective strategies to enhance sexual health outcomes.

Sexually transmitted infections (STIs) represent a significant public health concern, particularly among underserved populations, which include urban American Indian and Alaska Native (AI/AN) communities.

According to the Centers for Disease Control and Prevention (CDC), AI/AN communities experience higher rates of STIs compared to other racial and ethnic groups, with chlamydia rates nearly 1.5 times the national average and gonorrhea rates approximately 4.6 times higher than the national average.1

AI/AN communities continue to face a significant increase in syphilis rates. The rate of primary and secondary syphilis among AI/AN individuals rose from 21.1 cases per 100,000 people in 2019 to 58.2 cases per 100,000 people in 2023. Additionally, congenital syphilis rates in this population increased from approximately 200 cases per 100,000 live births in 2019 to 680.8 cases per 100,000 live births in 2023.2

STI Graph

Figure 1: Rates of (STIs) and other infectious diseases per 100,000 among American Indian and Alaska Native (AI/AN) people, compared to non-Hispanic White people.

UIOs serve as essential providers of sexual health services, addressing the unique health care needs of their special population and resources. Through these efforts, UIOs have made meaningful STI prevention and care advancements and contributed to improved health outcomes. Continued support to enhance the STI service capacity of UIOs is vital for sustaining these efforts and addressing broader systemic challenges.

Additional NCUIH resources for this topic include:

Best Practices for Effective STI Programs

Community-tailored, inclusive, and accessible care is fundamental to improving STI prevention and treatment in urban AI/AN communities. UIOs have successfully adopted the following approaches:

Community-Based Programs
Programs that reflect the cultural values and traditions of AI/AN communities are far more effective in engaging patients and fostering trust. Successful practices include:

Expanding Accessibility
Ensuring that STI services are widely available and easy to access is essential. UIOs can enhance their offerings by:

  • Providing self-collection test kits for patients who prefer privacy.
  • Expanding expedited partner therapy (EPT) services, enabling partners of patients with STIs to receive treatment without separate clinic visits.
  • Offering extragenital screenings for infections in areas beyond genital testing, like throat and rectal swabs.

Collaborations and Resource Sharing
Partnerships with state health departments, Tribal entities, and other organizations are key to scaling services and sharing knowledge. Programs like the Health Resources and Services Administration’s (HRSA’s) 340B Drug Pricing Program can help UIOs access affordable medications, while initiatives such as “I Want the Kit” provide essential testing supplies at no cost.

Comprehensive Staff Training
Training health care providers is vital for delivering high-quality, patient-centered care. Staff should:

  • Stay updated on STI treatment and testing guidelines, including clinical laboratory improvement amendments (CLIA)-waived tests.
  • Create a welcoming environment for patients to discuss sensitive sexual health topics openly.

Challenges and Strategies for Improving Sexual Health Outcomes at UIOs

In 2023, NCUIH surveyed 15 UIOs to understand the status and impacts of their STI prevention and care service provision to patients and community members. Below is an overview of the challenges expressed by UIOs in the survey and potential strategies for overcoming these challenges.

Challenges Faced by UIOs

While UIOs are uniquely positioned to improve sexual health outcomes for urban AI/AN populations, they often operate under significant constraints. The most common barriers include:

Funding Shortages
Many UIOs report insufficient funding to support critical tools, testing materials, and treatment resources. Nearly half of the surveyed UIOs identified funding as a major challenge.

Staffing and Training Gaps
Limited staffing and inadequate training can result in inconsistent care delivery. UIOs may struggle to meet patient demand or implement new services without enough trained personnel.

Stigma and Misinformation
Stigma surrounding STIs can discourage patients from seeking care or discussing sexual health openly. This stigma is compounded by misinformation, making it harder for UIOs to reach at-risk individuals effectively.

Policy and Administrative Barriers
Many UIOs lack access to key state and federal funding opportunities, such as Section 318 of the Public Health Service Act. Inconsistent policies across states can further complicate billing, reporting, and service delivery.

Effective Strategies for Overcoming Challenges

Despite these obstacles, UIOs are finding innovative ways to improve STI prevention and treatment in their communities. Below are some strategies that have proven effective:

Streamlining Patient Access

  • Offering walk-in STI testing and same-day appointments to remove barriers to timely care.
  • Hosting community events such as health fairs or educational workshops in schools and cultural centers can increase awareness and engagement.

Investing in Workforce Development

  • Providing ongoing staff training to ensure people are well-equipped to deliver compassionate, high quality care.
  • Offer training programs focused on inclusive communication and community competency to help address stigma and create safer spaces for patients.

Leveraging Technology

  • Robust electronic health record (EHR) systems to help track patient data, streamline reporting, and improve follow-up care.
  • Digital outreach through social media and other platforms to disseminate educational materials and promote available services.

Building Strong Community Partnerships

  • Collaborating with local health departments, Tribal Epidemiology Centers, and other stakeholders to enhance service coordination and resource sharing.
  • Involving community members in program development ensures that services are relevant and meet patient needs.

NCUIH’s Role in Supporting UIOs

NCUIH provides essential support to UIOs through technical assistance, training, research, and advocacy. These efforts focus on:

  • Securing funding to expand health promotion and treatment services for urban AI/AN communities.
  • Providing Tribal relevant training programs and educational materials.
  • Advocating for policy changes that address systemic inequities in access to sexual health care.
  • Conducting to support STI prevention, treatment, and improved health outcomes for urban AI/AN communities.
  • Offering to enhance UIO capacity in delivering effective STI prevention and care services.

By fostering collaboration and empowering UIOs, NCUIH helps ensure that urban AI/AN populations receive the care they need to lead healthier lives.

Moving Forward

UIOs are indispensable in addressing sexual health disparities among urban AI/AN communities. By adopting best practices, tackling barriers, and implementing innovative strategies, they can continue to make a meaningful impact.

With the support of NCUIH and , UIOs can expand access to high-quality, community-competent care and improve sexual health outcomes for the communities they serve. Together, we can create a future where everyone has the resources and support to thrive.

CDC Disclaimer: This publication was supported by grant number 5 NU50CK000601-04-00 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the U.S. Department of Health and Human Services (HHS).

Culture is medicine. People are medicine.

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Front entrance to the Urban Indian Center of Salt Lake in Salt Lake City, Utah.

Front entrance to the Urban Indian Center of Salt Lake in Salt Lake City, Utah.

About the Urban Indian Center of Salt Lake

Established in 1974, the Urban Indian Center of Salt Lake (UICSL) provides care for the American Indian and Alaska Native (AI/AN) communities in the greater Salt Lake City area. Their extensive list of services includes medical, behavioral health, social, and Traditional Healing programming. Demonstrated throughout the programming at UICSL, community and cultural connections are focal points for wellness and healing. The strength found in cultural identity, and the bonds people create with each other are fundamental aspects of these programs and within Indigenous concepts of health.

Clinic and behavioral programs notice board highlighting different events and resources for UICSL patients.

Clinic and behavioral programs notice board highlighting different events and resources for UICSL patients.

Kristie, a registered dietitian, and Allyson, a therapist, presented on UICSL’s Traditional Healing programming with NCUIH at the Association of American Indian Physicians (AAIP) conference in the summer of 2024.

Given that the Salt Lake City AI/AN community consists of members from many different Tribes, UICSL consciously allows everyone to practice their specific traditions and does not enforce the practice of any one tradition. For instance, some patients are court-mandated to attend UICSL programs who may or may not be comfortable practicing another Tribe’s tradition or customs. UICSL is mindful of making space for people to receive care in a method best suited for their background and comfort.

Special Diabetes Program for Indians (SDPI) Activities:

UICSL’s Special Diabetes Program for Indians (SDPI) incorporates standard medical interventions, nutrition, and traditional practices to best treat the patient, their community, and their needs.

A drum from the Calling Back Our Spirit workshop (Photo credit: UICSL).

A drum from the Calling Back Our Spirit workshop (Photo credit: UICSL).

The UICSL fitness program “In the Steps of Our Ancestors” is a running and walking group for all ages and all levels that runs regularly at the SLC Olympic Oval, rain or shine, as part of their SDPI program activities. This running group helps improve fitness and enhances participants’ social bonds and community connections. Participants might start barely able to finish one lap around the track but eventually, over time, go on to complete 5k races. The running groups create a sense of camaraderie where participants push each other to finish and cheer them on. Outside of the “In the Steps of Our Ancestors” group, UICSL offers an on-site gym with a physical trainer on staff. They conduct gym sessions and other exercise activities like All Nations Yoga in the park, archery, Zumba, Fitness Thursdays with an Indigenous focus, etc.

UICSL also offers cooking classes under SDPI to highlight the benefits and increase the consumption of more Traditional Foods. UICSL staff stress the importance of mindset when harvesting, preparing, and cooking with their patients so that the best intentions go into preparing nourishing meals. These cooking demonstrations happen on-site in the UISCL kitchen, and the produce is often sourced from a nearby community garden. UICSL partners with chefs from various Tribes, allowing for a multi-Tribal approach. These partnerships allow greater freedom for UICSL, the chef, and the participants in what is considered Traditional Foods and create a broader representation of cultural and Tribal traditions for the over 250 cooking class participants.

Overall, food is a focal point for the community at UICSL. They often hold highly attended feasts for their community and recently initiated a food voucher program, providing pre-loaded grocery cards to patients to alleviate some financial hurdles around regularly accessing healthy produce.

Other Traditional Healing Programs:
A ribbon tote bag created during the Reaching Out to Relatives support group (Photo credit: UICSL).

A ribbon tote bag created during the Reaching Out to Relatives support group (Photo credit: UICSL).

While many Traditional Healing programs fall under the SDPI umbrella, UISCL offers a variety of other programming that incorporates Traditional Healing to help address issues within the community. “Calling Back Our Spirit” utilizes the story of the drum and the traditions of drum making, drumming, and music to support intensive or general outpatient treatment for individuals with substance use disorder. The “Reaching out to Relatives” program illustrates the importance of connecting with oneself, one’s community, and cultural identity to promote mental health and larger healing. The community mental health support group teaches participants traditional crafts and the history behind their creations. The Medicine Pouch program is a community workshop for participants to learn more about traditional medicines and traditional wellness practices to utilize in their own lives. Participants craft medicine pouches and focus on creating positive experiences and maintaining balance throughout their lives through Indigenous frameworks.

Modern popular activities that promote happiness and wellness, such as gratitude, journaling, exercise, acts of kindness, and meditation, embody fundamental aspects of Indigenous views of health and wellness. UICSL helps promote these Indigenous practices through their programming to strengthen their community. For example,

  • Gratitude → offerings, ceremonies
  • Journaling → art, jewelry, songs
  • Exercise → dance
  • Acts of kindness → giveaways, gifting
  • Meditation → sweat lodge, prayer

In September 2024, UICSL celebrated its 50th anniversary by opening the doors to its new site in Murray, Utah, expanding its available services for patients! Future plans for UICSL include expanding its food prescription program, expanding staff, developing a nearby empty lot into a community garden, and opening an on-site pharmacy. For more information on UICSL, please visit https://uicsl.org/.

To see slides from the presentation, click here.

NCUIH and UICSL after their AAIP presentation. From left to right: Allyson Shaw, LCSW (UICSL), Kristie Hinton, R.D. (UICSL), Ryan Ward, MPH (UICSL) , Nahla Holland (NCUIH), Alexandra Payan, J.D. (NCUIH).

NCUIH and UICSL after their AAIP presentation. From left to right: Allyson Shaw, LCSW (UICSL), Kristie Hinton, R.D. (UICSL), Ryan Ward, MPH (UICSL) , Nahla Holland (NCUIH), Alexandra Payan, J.D. (NCUIH).

Utah and Nebraska State Medicaid Expansions in 2020 and AI/AN Health Insurance Access

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Introduction

The Affordable Care Act (ACA), enacted in 2010 and implemented in 2014, included two provisions to expand health insurance coverage, the creation of health insurance marketplaces, and giving states the option to expand Medicaid coverage to families with incomes to 138% of the federal poverty level.[1]

One goal of the ACA was to expand health insurance coverage of the American Indian and Alaska Native (AI/AN) population. In 2013, prior to ACA implementation, 24% of AI/ANs reported having no health insurance coverage, as measured by the 2013 American Community Survey 1-Year Estimate. In 2015, after the implementation of ACA, 17% of AI/ANs were uninsured. There were 25 states who adopted Medicaid Expansion during the first year of eligibility in 2014. In expansion states, the percentage of the AI/AN population without insurance dropped from 23% pre-expansion to 15% post-expansion.[2] Similarly, the National Indian Health Board compared the AI/AN uninsured rate between the 2008-2012 Five-Year ACS and the 2017-21 Five Year ACS, and estimated that the national AI/AN uninsured rate fell from 24.2% to 14.8%[3]

As of April 2024, 41 states have adopted the ACA’s Medicaid Expansion program[4]. The most recent states to adopt the program are:

  • North Carolina, which implemented expansion in December 2023.
  • South Dakota, which implemented expansion in July 2023.
  • Oklahoma, which implemented expansion in June 2021.
  • Missouri, which implemented expansion in October 2021.
  • Utah, which implemented expansion in January 2020.
  • Nebraska, which implemented expansion in October 2020.

At the time of the drafting of this report, the most recent year of American Community Survey 1-Year Public Use Microdata Sample (PUMS) is from 2021. Therefore, Utah and Nebraska are the most recent expansion states with available post-expansion ACS data. In both Utah and Nebraska, Medicaid Expansion was adopted by ballot initiative in November 2018. In both states, there were efforts by the state legislature to limit and delay implementation.[5][6]

Despite similar origin stories, the two expansions led to different outcomes for AI/AN residents in each state. In Utah, the AI/AN uninsured rate dropped from 32.1% in 2019 to 19.5% in 2021. The rate of Medicaid coverage increased from 12.8% to 14.8%. In Nebraska the AI/AN uninsured remained almost unchanged (from 30.8% to 29.9%). The AI/AN Medicaid coverage rate decreased by 3%, while the non-AI/AN Medicaid coverage rate increased by 3% (Table 1).[7]

Table 1: Uninsured and Medicaid Coverage Rates for AI/AN and non-AI/AN respondents (Ages 19-64)

Uninsured 2019 Uninsured 2021 Medicaid 2019 Medicaid 2021
Utah AI/AN 32.1% 19.5% 12.8% 14.8%
Utah non-AI/AN 12.1% 11.4% 6.3% 8.3%
Nebraska AI/AN 30.8% 29.9% 15.5% 12.9%
Nebraska non-AI/AN 11.4% 9.4% 6.8% 10.3%

Data and Methods

In interpreting changes over time, it is difficult to disentangle the effect of state Medicaid expansion from national conditions such as the Covid-19 pandemic, national economic conditions, and Federal health policy. To better understand specific factors, I employed two logistic regression[8] models on insurance coverage, one model using the ACS 2019 1-year data and a second model using the ACS 2021 1-year data. This model excludes respondents under 19 and over 64 to avoid complications from CHIP and Medicare policies.

To isolate state-specific factors from national effects, I created two ‘dummy’ variables. The variable “Utah” is coded as 1 if the respondent resides in Utah and 0 if the respondent resides in any of the other 49 states or the District of Columbia. The variable “Nebraska” is coded as 1 if the respondent resides in Nebraska and 0 if the respondent resides in any of the other 49 states.

The model includes the “AI/AN” variable, this variable is coded as 1 if the respondent self-identifies as American Indian or Alaska Native, and 0 if the respondent does not. The variable is coded as 1 even if the respondent identifies with multiple other racial categories. According to the Medicaid and CHIP Access Commission, “There are several challenges to enrolling eligible AI/AN people in Medicaid, including geographical remoteness, limited access to Internet or phone service, language barriers, cultural factors, distrust of government programs, or lack of knowledge of the benefits of coverage.”[9]

To isolate the State-level Indian health policy context, the model includes interaction effects between the state dummy variables and the AI/AN variable.

The ACS health insurance question administered to respondents includes IHS usage listed as a type of “coverage” but IHS is not coded as “coverage” when Census derives an “Any Insurance Coverage” variable from the response option. Depending on the availability of services, IHS users may not perceive a need for additional coverage, so it is important to include this variable in the model.

In the research literature on the uninsured, age and income are consistent determinants of coverage, so the model includes age and family income as a percentage of the federal poverty line.[10]

Results

In 2019, non-AI/AN residents of Utah had 7.9% higher odds of coverage as compared to the rest of the United States. The logistic regression model also produces an estimate of the marginal effect of each variable, when all other variables are set to their means. In 2019, Utah residents had a 0.7% higher marginal probability of coverage. The “Utah Effect” in 2021 is not substantially different for non-AI/AN residents (Table 2).

In 2019 non-AI/AN Nebraska residents had a 1.6% higher marginal probability of coverage as compared to the rest of the U.S. In 2021, non-AI/AN residents had 2.6% higher marginal probability of coverage, as compared to the rest of the U.S. It is possible that this difference reflects increased access to health insurance from the Medicaid expansion.

In 2019, the national AI/AN population (excluding Utah and Nebraska) had a 0.9% lower marginal probability of coverage as compared to the national non-AI/AN population. It is interesting to note that this AI/AN coverage ‘disadvantage’ is independent of family income and may reflect aforementioned coverage barriers. The magnitude of the disadvantage doubles between 2019 and 2021, despite policy efforts to preserve coverage.

The interaction term between Utah residency and AI/AN status can be interpreted as either:

  • The coverage disadvantage of Utah residency among AI/AN respondents, OR
  • The coverage disadvantage of AI/AN status among Utah residents.

Among AI/ANs in 2019, AI/AN Utahans have a 6.4% lower marginal probability of coverage than AI/ANs elsewhere. Among Utahans in 2019, AI/AN Utahans have a 6.4% lower probability of coverage than non-AI/AN Utahans. In 2021, the Utah X AI/AN interaction term coefficient is not significantly different from zero, suggesting that Utah’s Medicaid expansion possibly ameliorated disadvantageous coverage barriers specific to AI/ANs in Utah.

Table 2: Odds Ratio on Insurance Coverage ACS 2019 and ACS 2021

2019 Odds Ratio 2019 Marginal Effect at Means 2021 Odds Ratio 2021 Marginal Effect at Means
Utah 1.079** 0.7% 1.061* 0.5%
Nebraska 1.185** 1.6% 1.358** 2.6%
AI/AN 0.917** -0.9% 0.770** -2.7%
Utah X AI/AN 0.593** -6.4% 0.984 -1.1%
Nebraska X AI/AN 0.638* -5.3% 0.376** -13.3%
IHS User 0.405** -12.6% .532** -7.6%
Age In Years 1.009** 0.1% 1.008** 0.1%
Family income as % of fed poverty line 1.004** 0.4% 1.004** 0.0%

** 99% Statistical Significance
*95% Statistical Significance

While non-AI/AN Nebraskans saw an improvement in probability of coverage between 2019 and 2021, the opposite effect is observed for Nebraska AI/AN’s. The coverage disadvantage of Nebraska residency among AI/AN respondents increased from 5.3% to 13.3%. More research is required to determine how this occurred in the context of Medicaid expansion.

[1] HealthCare.gov. “Medicaid Expansion & What It Means for You.” Accessed November 7, 2023. https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/.

[2] Samantha Artiga, Petry Ubri, and Julia Foutz. “Medicaid and American Indians and Alaska Natives.” Issue Brief. Henry J. Kaiser Family Foundation, September 2017. https://files.kff.org/attachment/issue-brief-medicaid-and-american-indians-and-alaska-natives.

[3] Rochelle Ruffer. “State Health Insurance Status Report.” National Indian Health Board, July 2023. https://www.nihb.org/resources/NIHB%20State%20Health%20Insurance%20Status%20Report_July%202023.pdf.

[4] Published: “Status of State Medicaid Expansion Decisions: Interactive Map.” KFF (blog), October 4, 2023. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[5] Maresh, Sarah. “Expanding Medicaid in Nebraska and the Fight to Stop Harmful Waivers, Tiered Benefits.” National Health Law Program, November 2, 2022. https://healthlaw.org/expanding-medicaid-in-nebraska-and-the-fight-to-stop-harmful-waivers-tiered-benefits/.

[6] Musumeci, MaryBeth, Madeline Guth, Robin Rudowitz, and Cornelia Hall Published. “From Ballot Initiative to Waivers: What Is the Status of Medicaid Expansion in Utah?” KFF (blog), November 15, 2019. https://www.kff.org/medicaid/issue-brief/from-ballot-initiative-to-waivers-what-is-the-status-of-medicaid-expansion-in-utah/.

[7] Steven Ruggles, Sarah Flood, Matthew Sobek, Danika Brockman, Grace Cooper, Stephanie Richards, and Megan Schouweiler. IPUMS USA: Version 13.0 [ACS 2019 & ACS 2021]. Minneapolis, MN: IPUMS, 2023. https://doi.org/10.18128/D010.V13.0

[8] J. Scott Long. Regression Models for Categorical and Limited Dependent Variables. Vol. 7. Advanced Quantitative Techniques in the Social Sciences Series. Sage Publications, 1997.

[9] “Medicaid’s Role in Health Care for American and Alaska Natives.” Issue Brief. Medicaid and CHIP Access Commission, February 2021. https://www.macpac.gov/wp-content/uploads/2021/02/Medicaids-Role-in-Health-Care-for-American-Indians-and-Alaska-Natives.pdf.

[10] “Who Went Without Health in 2019, and Why?” Congressional Budget Office, September 2020. https://www.cbo.gov/system/files/2020-09/56504-Health-Insurance.pdf.

Driving Success: Best Practices for GPRA Compliance and Performance

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GPRA/GPRAMA OVERVIEW:

The Government Performance and Results Act (GPRA) of 1993 is a federal law that mandates agencies to demonstrate effective and efficient use of congressional funds.1 The Indian Health Service (IHS) has been reporting GPRA data for over a decade.1 This data helps the IHS to evaluate its progress towards achieving its goals and objectives, which ultimately benefits the health of Native Americans.

To ensure that federal agencies make informed decisions, the Government Performance and Results Modernization Act (GPRAMA) was introduced in 2010 as an update to GPRA. This act requires federal agencies to leverage performance data in their decision-making processes. The GPRA and its modernization counterpart, the GPRAMA, play crucial roles in shaping how federal agencies are held accountable for their performance and results. For instance, in the context of healthcare services, GPRAMA shows Congress how well the IHS is providing care to American Indians and Alaska Natives who use IHS federal, tribal, and urban Indian health facilities.2

The IHS started reporting under GPRAMA in FY 2013, which involves a smaller set of measures compared to GPRA. 1 The 26 clinical GPRA/GPRAMA measures are collected throughout the GPRA year (October 1 to September 30) using the Integrated Data Collection System (IDCS) and exported to the National Data Warehouse (NDW).1 This data is cumulative and aggregates results from all reporting clinics, including federal, tribal, and urban Indian health programs, into national outcomes.1

Regardless of the electronic health record (EHR) system they use, urban Indian health programs can report GPRA data.1 This makes it easier for them to contribute to a comprehensive national database and ensures that the IHS has access to the information it needs to make informed decisions. By leveraging this data, the IHS can continue to provide effective and efficient healthcare services to Native Americans across the country.

COMPARATIVE UIO PERFORMANCE OF GPRA/GPRAMA MEASURES:3-5

GPRA/GPRAMA measures are indicators of how well the agency has provided clinical care to its patients. Overall, they measure how well the IHS has done in the prevention and treatment of certain diseases, and the improvement of overall health. The table below outlines the measures of performance of Urban Indian Organizations (UIOs) over three years (2018, 2019, 2020), comparing actual results against set goals. The measures are categorized into the “Top 3” and “Bottom 3” based on performance. In the “Top 3” category, Statin Therapy consistently exceeded its goals, demonstrating a significant improvement. Nephropathy and CVD Statin Therapy measures also performed well, with Nephropathy showing yearly increases in actual achievements. However, the “Bottom 3” measures faced challenges, with Exclusive/Mostly Breastfeeding meeting its goal in 2019, while IPV/DV Screening and Adult Immunizations fell short of their goals every year reviewed.  In 2020, two new measures, Topical Fluoride and Retinopathy Exam, were introduced as part of the GPRA tracking. However, in their first year, they did not meet their targets. This data underscores the substantial progress in some areas and the need for enhanced focus and improvement in others, particularly in preventative screenings and healthcare interventions.

TOP ACHIEVERS AND AREAS OF IMPROVEMENT (2018-2020) 3-5

   Top 3 Actual Goal Bottom 3 Actual Goal
2
0
1
8		 1 Statin Therapy 61.6% 37.5% Exclusive/Mostly Breastfeeding (Age of 2 Mos) 25.0% 39.0%
2 Nephropathy 50.2% 34.0% IPV/DV Screening 30.1% 41.6%
3 CVD Statin Therapy 41.9% 26.6% Mammography Screening 33.6% 42.0%
2
0
1
9		 1 Statin Therapy 61.4% 37.5% Adult Immunizations 33.5% 54.9%
2 Nephropathy 51.6% 34.0% Exclusive/Mostly Breastfeeding (Age of 2 Mos) 28.6% 28.6%
3 CVD Statin Therapy 40.3% 26.6% IPV/DV Screening 32.6% 41.6%
2
0
2
0		 1 Statin Therapy 62.6% 51.6% Adult Immunizations 25.9% 59.7%
2 CVD Statin Therapy 42.8% 35.7% Topical Fluoride 14.1% 34.5%
3 HIV Screening Ever 31.5% 28.4% Retinopathy Exam 36.0% 53.5%

Definitions of Performance Metrics See Appendix*

BEST PRACTICES TO ADDRESS PROBLEMS AND CHALLENGES IN GPRA DATA:7

UIOs face several challenges in their efforts to collect data and achieve GPRA metrics. These challenges include the need to troubleshoot issues, secure healthcare center buy-in, provide adequate training, lack of employee capacity, and implement technology updates and requirements.

To begin to address these challenges, it is essential to prioritize Electronic Medical Record (EMR) reminders or alerts for clinicians, and updated medical coding, taxonomies, and ICD-10 codes. These updates will allow for more efficient and streamlined healthcare services and reporting.

Another critical challenge is the lack of healthcare center buy-in. The prioritization of GPRA within Urban Indian Organizations is an essential aspect of enhancing the quality of care. By visualizing benchmarks as indicators of care quality, as opposed to solely numerical targets, UIOs can integrate these standards into their daily operations. It is recommended that sites hold themselves accountable for adhering to these standards for both internal assessment and external reporting purposes. In instances where metrics are not met, it is advisable that they are considered as opportunities for Quality Assurance Projects.

Establishing a dedicated GPRA team comprising of both medical and non-medical staff can ensure that responsibilities are clearly defined, thereby making the targets more attainable and allowing providers to focus more on patient interactions.7 Effective coordination and communication are crucial to overcoming these challenges. Therefore, establishing a GPRA Coordination Committee and holding regular structured interactions, such as morning huddles or weekly medical meetings, provide ample opportunities to discuss GPRA metrics. These interactions facilitate the sharing of insights and strategizing on how best to further improve metrics, fostering a collaborative environment for continuous improvement. Furthermore, ensuring the availability, improvement, and sharing of GPRA data is fundamental. Data should be readily accessible, regularly updated, and shared with all stakeholders, including medical and quality improvement staff, to allow for early identification of issues and collaborative problem-solving.7

Encouraging internal development and the use of technology can further enhance the effectiveness of GPRA measures.7 UIOs should foster local solutions and employ information technology to track care delays and community health statuses. Innovations such as electronic clinical reminders and specialized clinics that provide comprehensive care and use incentives can significantly improve patient outcomes.  Additionally, learning from peers or other UIOs by visiting sites that exhibit best practices can provide invaluable insights into effective strategies and areas requiring improvement. This peer learning helps in directly understanding what works and what doesn’t from those who have experienced it first-hand.

It is important to focus on the actual health outcomes achieved through the implementation of GPRA measures, rather than merely the activities performed. Adhering to an outcomes-focused approach ensures that the efforts are not solely geared towards meeting metrics but genuinely improving patient health, which is the ultimate goal of these measures. In conclusion, addressing the challenges faced by Urban Indian Organizations is essential to improving healthcare services for communities. By prioritizing the necessary updates and providing adequate training, we can ensure that healthcare centers are fully invested in delivering high-quality care to all patients, and by promoting effective communication, we can continuously improve our services.

For more information on best practices visit: https://www.ihs.gov/crs/toolbox/.

For more information on GPRA Performance Measures visit: https://ihs.gov/sites/crs/themes/responsive2017/display_objects/documents/crsv24/GPRA-FY-2022-2023-2024.pdf

APPENDIX

References:

  1. Claymore, V., & Boney, M. (2024, March). UIO GPRA/GPRAMA UPDATES. Indian Health Services. Online; Online.
  2. Indian Health Services. (n.d.). Understanding the Government Performance and Results Act (GPRA)/ GPRA Modernization Act (GPRAMA). https://www.ihs.gov/crs/includes/themes/responsive2017/display_objects/documents/toolbox/GPRAHandoutforPatients.pdf
  3. Weahkee, R., & Mueller, R. (2018). 2018 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  4. Weahkee, R., & Mueller, R. (2019). 2019 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  5. Weahkee, R., & Mueller, R. (2020). 2020 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
  6. Indian Health Services. (n.d.). 2011 GPRA Best Practices. 2011 GPRA Meeting. https://www.ihs.gov/california/tasks/sites/default/assets/File/GPRA/2011GPRAMtg-GPRABestPractices.pdf

Definitions:

  • Adult Composite Immunizations: Percentage of adults age 19 and older who receive recommended age-appropriate vaccinations.
  • Breastfeeding Rates: Percentage of patients who, at the age of 2 months, were either exclusively or mostly breastfed.
  • Cancer Screening: Mammogram Rates: Percentage of women ages 52 to 74 years of age, who have had mammography screening within the previous two years.
  • Diabetes: Statin Therapy to Reduce CVD Risk in Patients with Diabetes: Percentage of patients with diagnosed diabetes who received a prescription for statin therapy.
  • Diabetes: Nephropathy Assessment: Percentage of patients with diagnosed diabetes assessed for nephropathy.
  • Diabetes: Retinopathy: Percentage of patients with diagnosed diabetes who received an annual retinal exam
  • Domestic (Intimate Partner) Violence Screening: Percentage of women who are screened for domestic violence at health care facilities.
  • HIV Screening Ever: Percentage of patients who were ever screened for HIV.
  • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of patients with CVD or at high risk for CVD who receive a statin therapy prescription
  • Topical Fluorides: Percentage of patients ages 1-15 who received one or more topical fluoride applications.

Life Expectancy Rates for American Indian and Alaska Native People Dropped Drastically During the COVID-19 Pandemic

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Overview:

COVID-19 has impacted life expectancy across the globe, reversing trends of life expectancy gains.1,2 American Indian and Alaska Native (AI/AN) people have lower life expectancies than the non-Hispanic White (NHW) population. While the gap between life expectancies for the AI/AN and White populations decreased in the late 20th century and early 21st century, during the COVID-19 Pandemic, the difference in AI/AN and NHW life expectancies grew by over ten years. When looking at the top-of-the-decade life expectancies for each population, a 10+ year difference in life expectancy was last seen between the two populations in 1940.

Life Expectancy Definition:

Life expectancy at birth is the calculated estimate of years a given population (i.e., sex, race/ethnicity, place of residence, etc.) is expected to live if born in the given year, based on current mortality and life trends.3

Life expectancy for the AI/AN population from 1940-1990 was calculated using Indian Health Service (IHS) patient records to calculate life expectancy, so those decades would include single-race or combination-race IHS patients in the given timeframe. From 2000-2021, life expectancy for the AI/AN population was measured using National Vital Statistics System (NVSS) Centers for Disease Control and Prevention (CDC) data, which only included the single-race-identified AI/AN population.

Explanation of Data:

Historically, AI/AN people experienced significantly lower life expectancies than NHW people in the United States. Currently, the life expectancy for an AI/AN person born in 2021 is 65.2 years, 11.2 years less than an NHW person’s life expectancy born in the same year (76.4 years).4 The life expectancy for AI/AN people in 2021 was comparable to the overall life expectancy for Americans during the first two years of US military involvement in World War II (1942 and 1943).5,6

  • 2021 -> AI/AN pop. 65.2 years4
  • 1942 -> All Races/All Sexes US 66.2 years5
  • 1943 -> All Races/All Sexes US 63.3 years5

In addition, within the inaugural year of the COVID-19 pandemic, a universal decline in life expectancies was observed across the US. However, the decrease was particularly larger within the AI/AN community, where life expectancy decreased by nearly five years between 2019 and 2020. In contrast, the life expectancy for NHW populations diminished by approximately 1.5 years during the same period. This stark contrast underscores the profound inequities experienced among AI/AN people in the United States, highlighting the catastrophic repercussions of the COVID-19 pandemic on Native communities. Table 1 showcases the historic gap in life expectancies for AI/AN people compared to NHW people in the United States.

Table 1.

Historic Life Expectancy (at Birth) for AI/AN Population Compared to NHW Population

Year Life Expectancy for AI/AN Life Expectancy for NHW
1940 51.6 y/o7 62.1 y/o7
1950 60.0 y/o7 69.1 y/o7
1960 61.7 y/o7 70.6 y/o7
1970 65.1 y/o7 71.1 y/o7
1980 71.1 y/o7 74.4 y/o7
1990 73.2 y/o 76.1 y/o8
2000 73.1 y/o9 77.3 y/o10
2010 73.5 y/o9 78.9 y/o10
2019 71.8 y/o9 78.8 y/o4
2020 67.1 y/o4 77.4 y/o4
2021 65.2 y/o4 76.4 y/o4

Note: The table includes a summary of AI/AN and NHW populations’ life expectancy (at birth) for all sexes data by the decade in the same table. See Limitations of Data for more information on population.

Figure 1.

Historic Life Expectancy (at Birth) for AI/AN and White Populations in the United States

Note: See Table 1 for more information on population data for data sources for each decade.

Chart: Historic Life Expectancy (at Birth) for AI/AN and White Populations* in the United States by Decade

Limitations of the Data:

Life data tables for the AI/AN population were not produced by the CDC/US Census Bureau until 2019.8 Much of the life expectancy data comes from IHS and then is linked by researchers with data from NVSS, the US Census Bureau, or other government agencies, to collect an estimate on the AI/AN population’s life expectancy for a given year. For example, NVSS grouped different races/ethnicities into “White” and “Nonwhite” until 1969.11 Historic life expectancies for the Black population had to use “Nonwhite” data until additions were made to the racial categories for vital statistics data in 1970.12 Despite the addition of “Black” as a racial category in the ‘70s, the non-Hispanic AI/AN demographic was not included as a racial category for the NVSS United States Life Tables until the publication of the United States Life Tables, 2019 in 2022.13 However, the United States Life Tables, 2019 only include single-race-identified AI/AN people due to the 1997 Office of Management and Budget’s (OMB) standards on classifications for race and ethnicity.13–15 It is important to note that in 2019, the National Center for Health Statistics published a study  in the  Mortality and Morbidity Weekly Report  that sounded the alarm of a Public Health Emergency for the existing health disparities within the  AI/AN population, stating,

“My hope is that policymakers and health care providers recognize the very large disparity between this population and all other populations in this country… they have the worst health profile and mortality risk in this country. So, I would call it an emergency. It is something that should be taken very seriously.” 16

The study also showed that AI/AN people have higher mortality rates for most of the top leading causes of death and in most age groups compared with White, Black, and Hispanic people.

Specifically, the data in Table 1 for the life expectancy for AI/AN people from 1940-1990 used IHS records to calculate AI/AN life expectancy, while the NHW life expectancy used census data. The IHS data only uses a sample of AI/AN people who received services or care from an IHS facility. The IHS user population is not representative of all AI/AN people within the United States in that timeframe or in another timeframe.7,17

2000-2021 data for the AI/AN population use a more inclusive population from NVSS that encompasses more AI/AN people compared to IHS datasets, which are inclusive of AI/AN-identified people who do not receive care from IHS. However, due to NVSS following OMB standards for reporting, only single-race-identified AI/AN people were included in the AI/AN population.4,18

Additionally, death records for AI/AN people are frequently misclassified for race. There is continuous documentation of racial misclassification of AI/AN people in death certificates. This racial misclassification would undercount the mortality rate of AI/AN people due to their deaths being labeled as another race/ethnicity and counted towards that indicated race. Given the limited data publicly available on the AI/AN population, the NCUIH Research and Data Team could not account for the misclassification of the death rate. NVSS life tables did try to account for racial misclassification by linking death records to the 2010 decennial census.14 However, the census underreports AI/AN people, and thus, misclassification could still persist in NVSS life expectancy calculations.19

Works Referenced:

  1. Soucheray, S. WHO: COVID-19 pandemic reversed decade of life expectancy gains | CIDRAP. Center for Infectious Disease Research and Policy, University of Minnesota https://www.cidrap.umn.edu/covid-19/who-covid-19-pandemic-reversed-decade-life-expectancy-gains (2024).
  2. World Health Organization. COVID-19 eliminated a decade of progress in global level of life expectancy. World Health Organization https://www.who.int/news/item/24-05-2024-covid-19-eliminated-a-decade-of-progress-in-global-level-of-life-expectancy (2024).
  3. Centers for Disease Control and Prevention National Center for Health Statistics. NVSS – Life Expectancy. National Center for Health Statistics https://www.cdc.gov/nchs/nvss/life-expectancy.htm (2023).
  4. Arias, E., Tejada-Vera, B., Kochanek, K. & Ahmad, F. Provisional Life Expectancy Estimates for 2021. https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf (2022) doi:10.15620/cdc:118999.
  5. Bastian, B., Tejada-Vera, B. & Arias, E. Mortality Trends in the United States, 1900-2018. National Center for Health Statistics https://www.cdc.gov/nchs/data-visualization/mortality-trends/index.htm (2020).
  6. Library of Congress. World War II | Great Depression and World War II, 1929-1945 | U.S. History Primary Source Timeline | Classroom Materials at the Library of Congress | Library of Congress. Library of Congress, Washington, D.C. 20540 USA https://www.loc.gov/classroom-materials/united-states-history-primary-source-timeline/great-depression-and-world-war-ii-1929-1945/world-war-ii/.
  7. Snipp, C. M. American Indians: The First of This Land. (Russell Sage Foundation, 1989).
  8. Products – Life Tables – Decennial Tables – 1989-1991. https://www.cdc.gov/nchs/products/life_tables/89liftbl.htm (2019).
  9. Dwyer-Lindgren, L. et al. Life expectancy by county, race, and ethnicity in the USA, 2000–19: a systematic analysis of health disparities. The Lancet 400, 25–38 (2022).
  10. Arias, E. United States Life Tables, 2010. https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_07.pdf (2014).
  11. Grove, R. & Hetzel, A. Vital Statistics Rates in the United States 1940-1960. https://www.cdc.gov/nchs/data/vsus/vsrates1940_60.pdf (1968).
  12. Sanghi, S. & Smaldone, A. The Evolution of the Racial Gap in U.S. Life Expectancy. https://www.stlouisfed.org/on-the-economy/2022/january/evolution-racial-gap-us-life-expectancy (2022).
  13. Arias, E. & Xu, J. United States Life Tables, 2019. National Vital Statistics Reports 70, (2022).
  14. Arias, E., Xu, J. & Kochanek, K. United States Life Tables, 2021. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 72, (2023).
  15. Arias, E. & Xu, J. United States Life Tables, 2020. National Vital Statistics Reports 71, (2022).
  16. Arias, E., Xu, J., Curtin, S., Bastian, B. & Tejada-Vera, B. Mortality Profile of the Non-Hispanic American Indian or Alaska Native Population, 2019. Natl Vital Stat Rep 70, 1–27 (2021).
  17. YOUNG, T. K. Recent health trends in the Native American population. Population Research and Policy Review 16, 147–167 (1997).
  18. Life expectancy by county, race, and ethnicity in the USA, 2000–2019: a systematic analysis of health disparities. Lancet 400, 25–38 (2022).
  19. Zeymo, A. Urban American Indian Undercount in the 2020 Census Went Underreported. National Council of Urban Indian Health Research Blog https://ncuih.org/2023/08/28/urban-american-indian-undercount-in-the-2020-census-went-underreported/ (2023).