Are American Indians and Alaska Natives (AIAN) likely to lack access to home health care

Objective: Research suggests that many chronic diseases/conditions disproportionately affect the AIAN population. Many of the AIAN population, however, live in areas with chronic shortages of health services, of particular concern as the population ages and the need for disability support increases. Our study sought to determine if areas with higher proportions of AIANs are at risk of lacking a Medicare-certified Home Health Agency (HHA). Method: We conducted a cross-sectional analysis of Medicare's Home Health Compare files and the Spatial Impact Factor databases developed by RTI International. The outcome of interest was whether a Medicare-certified HHA offered services in each Zip Code, dichotomized as HHA not present (n = 1,289) vs. HHA present (n = 30,466). We used multivariable logistic regression to assess the likelihood of this outcome. The unit of analysis was Zip Code (n = 32,239). We used two measures of AIAN concentration: High (≥ the 95th percentile) versus all other, and very high (≥ the 99th percentile) versus all other. We also examined the rural nature of the Zip Code, as a proxy for access, and income in the Zip Code, as a proxy for SES. We measured rurality using the 2000 Rural Urban Commuting Area (RUCA) classification developed by the USDA. Income level was determined using the median household income across all households for 2008 ($52,029) and separated into four levels: high (> $78,043); moderate (≥ $52,029 and <$8,043); low (< 52,029 and ≥ $26,014); and lowest (<$6,014). Results: Areas with high and very high proportions of AIAN were more likely (OR = 5.3; OR = 18.7 respectively), to lack a HHA, after adjusting for rurality and income level. In addition, the most rural areas were more likely (OR = 8.4) to lack a HHC provider than the most urban areas, after adjusting for a high proportion of AIANs and income. Conclusion: Zip Codes with higher proportions of AIANs and areas that are the most rural as opposed to the most urban are more likely to lack HH service. Without available resources in place, these areas are less likely to have access to needed care, resulting in poorer health outcomes, delays in receiving care, and lower quality-of-life than those with adequate resources in place. Factors contributing to this disparity must be addressed in order to ensure that adequate resources are available for the increasing elderly population of AIANs and residents of the most rural areas.