Satisfaction and Cost-Related Access Barriers Among American Indian and Alaska Natives Adults by Insurance Type

American Indian/Alaska Native (AIAN) adults face structural barriers such as inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. The result is higher rates of poor health, obesity, hypertension, and diabetes compared to the general population. Given their worse health and greater care needs, they may experience more access and cost-related access barriers. Although some AIAN individuals receive health care via the Indian Health Service (IHS), many receive care in the private sector via other forms of insurance coverage. Research conducted over two decades ago demonstrated that AIANs covered solely by IHS had better access to care than AIANs with no coverage. In comparison to AIANs with other forms of coverage, AIANs with IHS were less likely to have unmet medication needs. Using recent data, we compared cost-related access barriers and satisfaction with care among AIAN individuals covered by the IHS to those covered by other forms of insurance.


INTRODUCTION
American Indian/Alaska Native (AIAN) adults face structural barriers such as inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. The result is higher rates of poor health, obesity, hypertension, and diabetes compared to the general population. 1 Given their worse health and greater care needs, they may experience more access and cost-related access barriers. 2 Although some AIAN individuals receive health care via the Indian Health Service (IHS), many receive care in the private sector via other forms of insurance coverage. Research conducted over two decades ago demonstrated that AIANs covered solely by IHS had better access to care than AIANs with no coverage. 3 In comparison to AIANs with other forms of coverage, AIANs with IHS were less likely to have unmet medication needs. 3 Using recent data, we compared cost-related access barriers and satisfaction with care among AIAN individuals covered by the IHS to those covered by other forms of insurance.

METHODS
Using pooled data from 2016-2018 Behavior Risk Factor Surveillance (BRFSS), we identified all individuals who self-identified as AIAN among a random sample of adults in 17 states and DC. 4 To assess coverage, we used the question, "What is the primary source of your health care coverage?" Of 2699 AIAN individuals who responded, we excluded 13 individuals who had reported no insurance coverage resulting in an analytic sample of 2686 AIAN adults representing about 700,000 AIAN adults. Survey details are available on the BRFSS website. 4 We examined two domains among this sample: selfreported cost-related access barriers and satisfaction with care.
Experience with cost-related access barriers was assessed by the following questions: (1) "Was there a time in the past 12 months when you needed to see a physician but could not because of cost?" (2) "In the past 12 months was there a time when you did not take your prescription medications due to cost?" (3) "Do you currently have any health care bills that are being paid over time?" Satisfaction was assessed with the question, "In general, how satisfied are you with the care you received?" We examined the baseline characteristics of the respondents and then performed multivariable analyses, controlling for age, gender, and baseline health, comparing AIAN adults with IHS to other forms of insurance coverage (Medicare, Medicaid, VA/Military, private employer/individual, other insurance). The analyses accounted for non-responses and the complex survey design.

RESULTS
Among the 2686 AIAN adult respondents, 640 were covered by IHS and 2046 had other forms of insurance. Adults covered by IHS were younger (median age 37.7 (±2.3) versus 46.6 (±1.1) years) and reported better health compared to those with other coverage (Table 1). Table 1 demonstrates that AIAN adults who had coverage through the IHS less commonly reported not taking medications due to costs (5.1% vs. 13.4%, P<0.001). There was no significant difference in other outcomes. Multivariable analyses demonstrated that AIANs with IHS were less likely to report not taking medications due to costs in comparison to AIANs with other coverage (odds ratio (OR), 0.39; 95% CI, 0.20-0.75). No differences were found in difficulty seeing a physician because of cost (OR, 1.28; 95% CI, 0.72-2.27), medical debt (OR, 0.70; 95% CI, 0.39-1.25), or satisfaction with care (OR, 0.76; 95% CI, 0.51-1.15) between AIAN individuals with IHS and other coverages ( Table 2).

DISCUSSION
Prior studies have demonstrated that cost is an important driver of health care utilization and medication adherence with detrimental downstream effects on health outcomes. 5 We found that AIAN adults with IHS coverage were less likely to report cost-related medication adherence issues compared to other types of insurance. Higher patient satisfaction scores are associated with better health outcomes, adherence, and lower utilization. 6 AIAN satisfaction was low overall across insurance types with no significant difference by coverage type suggesting there may be other access and quality barriers that were not measured in this study. Several limitations deserve comment: (1) we cannot account for all unmeasured confounding of assignment to IHS and (2)   Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/ .