Contemporary Native American issues in the United States Article

From Wikipedia, the free encyclopedia
Jump to navigation Jump to search

Contemporary Native American issues in the United States are issues arising in the late 20th century and early 21st century which affect Native Americans in the United States. Many issues stem from the subjugation of Native Americans in society, including societal discrimination, racism, cultural appropriation through sports mascots, and depictions in art. Native Americans have also been subject to substantial historical and intergenerational trauma that have resulted in significant public health issues like alcoholism and risk of suicide.

Demographics

Poldine Carlo, author of Nulato: An Indian life on the Yukon, a Koyukon writer from Alaska

A little over one third of the 2,786,652 Native Americans in the United States live in three states: California at 413,382, Arizona at 294,137 and Oklahoma at 279,559. [1] 70% of Native Americans lived in urban areas in 2012, up from 45% in 1970 and 8% in 1940. [2]

In the early 21st century, Native American communities have exhibited continual growth and revival, playing a larger role in the American economy and in the lives of Native Americans. Communities have consistently formed governments that administer services such as firefighting, natural resource management, social programs, health care, housing and law enforcement. Numerous tribes have founded tribal colleges.

Most Native American communities have established court systems to adjudicate matters related to local ordinances. Most also look to various forms of moral and social authority, such as forms of restorative justice, vested in the traditional culture of the tribal nation. Native American professionals have founded associations in journalism, law, medicine and other fields to encourage students in these fields, provide professional training and networking opportunities, and entree into mainstream institutions.

To address the housing needs of Native Americans, Congress passed the Native American Housing and Self Determination Act (NAHASDA) in 1996. This legislation replaced public housing built by the BIA and other 1937 Housing Act programs directed towards Indian Housing Authorities, with a block-grant program. It provides funds to be administered by the Tribes to develop their own housing.

Terminology differences

Common usage in the United States

Native Americans are also commonly known as Indians or American Indians. A 1995 U.S. Census Bureau survey found that more Native Americans in the United States preferred American Indian to Native American. [3] Most American Indians are comfortable with Indian, American Indian, and Native American, and the terms are often used interchangeably. [4]

They have also been known as Aboriginal Americans, Amerindians, Amerinds, Colored, [5] [6] First Americans, Native Indians, Indigenous, Original Americans, Red Indians, Redskins or Red Men. The term Native American was introduced in the United States by academics[ who?] in preference to the older term Indian to distinguish the indigenous peoples of the Americas from the people of India. Some academics[ who?] believe that the term Indian should be considered outdated or offensive while many indigenous Americans, however, prefer the term American Indian. [3]

Criticism of the neologism Native American comes from diverse sources. Some American Indians[ who?] question the term Native American because, they argue, it serves to ease the conscience of "white America" with regard to past injustices done to American Indians by effectively eliminating "Indians" from the present. [7] Others (both Indians and non-Indians)[ who?] argue that Native American is problematic because "native of" literally means "born in," so any person born in the Americas could be considered "native". Others point out that anyone born in the United States is technically native to America, so "native" is sometimes substituted for "indigenous." The compound "Native American" is generally capitalized to differentiate the reference to the indigenous peoples. Furthermore, Russell Means, an American Indian activist, opposes the term Native American because he believes it was imposed by the government without the consent of American Indians. He has also argued that the use of the word Indian derives not from a confusion with India but from a Spanish expression En Dio, meaning "in God". [8]

Societal discrimination and racism

A discriminatory sign posted above a bar. Birney, Montana, 1941.

Universities have conducted relatively little public opinion research on attitudes toward Native Americans. In 2007 the non-partisan Public Agenda organization conducted a focus group study. Most non-Native Americans admitted they rarely encountered Native Americans in their daily lives. While sympathetic toward Native Americans and expressing regret over the past, most people had only a vague understanding of the problems facing Native Americans today. For their part, Native Americans told researchers that they believed they continued to face prejudice and mistreatment in the broader society. [9]

Affirmative action issues

Federal contractors and subcontractors such as businesses and educational institutions are legally required to adopt equal opportunity employment and affirmative action measures intended to prevent discrimination against employees or applicants for employment on the basis of "color, religion, sex, or national origin". [10] [11] For this purpose, an American Indian or Alaska Native is defined as "A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment." However, self-reporting is permitted, "Educational Institutions and Other Recipients Should Allow Students and Staff To Self-Identify Their Race and Ethnicity Unless Self-Identification Is Not Practicable or Feasible." [12]

Self-reporting opens the door to "box checking" by people, who, despite not having a substantial relationship to Native American culture, either innocently or fraudulently "check the box" for Native American. [13] On August 15, 2011 the American Bar Association passed a resolution recommending that law schools require supporting information such as evidence of tribal enrollment or connection with Native American culture. [14]

Racial achievement gap regarding language

To evade a shift to English, some Native American tribes have initiated language immersion schools for children, where a native Indian language is the medium of instruction. For example, the Cherokee Nation instigated a 10-year language preservation plan that involved growing new fluent speakers of the Cherokee language from childhood on up through school immersion programs as well as a collaborative community effort to continue to use the language at home. [15] This plan was part of an ambitious goal that in 50 years, 80% or more of the Cherokee people will be fluent in the language. [16] The Cherokee Preservation Foundation has invested $3 million into opening schools, training teachers, and developing curricula for language education, as well as initiating community gatherings where the language can be actively used. [16] Formed in 2006, the Kituwah Preservation & Education Program (KPEP) on the Qualla Boundary focuses on language immersion programs for children from birth to fifth grade, developing cultural resources for the general public and community language programs to foster the Cherokee language among adults. [17]

There is also a Cherokee language immersion school in Tahlequah, Oklahoma that educates students from pre-school through eighth grade. [18] Because Oklahoma's official language is English, Cherokee immersion students are hindered when taking state-mandated tests because they have little competence in English. [19] The Department of Education of Oklahoma said that in 2012 state tests: 11% of the school’s sixth-graders showed proficiency in math, and 25% showed proficiency in reading; 31% of the seventh-graders showed proficiency in math, and 87% showed proficiency in reading; 50% of the eighth-graders showed proficiency in math, and 78% showed proficiency in reading. [19] The Oklahoma Department of Education listed the charter school as a Targeted Intervention school, meaning the school was identified as a low-performing school but has not so that it was a Priority School. [19] Ultimately, the school made a C, or a 2.33 grade point average on the state’s A-F report card system. [19] The report card shows the school getting an F in mathematics achievement and mathematics growth, a C in social studies achievement, a D in reading achievement, and an A in reading growth and student attendance. [19] “The C we made is tremendous,” said school principal Holly Davis, “[t]here is no English instruction in our school’s younger grades, and we gave them this test in English.” [19] She said she had anticipated the low grade because it was the school’s first year as a state-funded charter school, and many students had difficulty with English. [19] Eighth graders who graduate from the Tahlequah immersion school are fluent speakers of the language, and they usually go on to attend Sequoyah High School where classes are taught in both English and Cherokee.

Native American mascots in sports

A student acting as Chief Osceola, the Florida State University mascot

American Indian activists in the United States and Canada have criticized the use of Native American mascots in sports as perpetuating stereotypes. European Americans have had a history of "playing Indian" that dates back to at least the 18th century. [20] While supporters of the mascots say they embody the heroism of Native American warriors, AIM particularly has criticized the use of mascots as offensive and demeaning. In fact, many Native Americans compare this discrimination to examples for other demographics like black face for African Americans.

While many universities and professional sports teams (for example, the Cleveland Indians, who had a Chief Wahoo) no longer use such images without consultation and approval by the respective nation, some lower-level schools continue to do so. On the other hand, in the Bay Area of California, Tomales Bay High and Sequoia High have retired their Indian mascots.

Could you imagine people mocking African Americans in black face at a game?" he said. "Yet go to a game where there is a team with an Indian name and you will see fans with war paint on their faces. Is this not the equivalent to black face?

— "Native American Mascots Big Issue in College Sports", Teaching Tolerance, May 9, 2001 [21]

In August 2005, the National Collegiate Athletic Association (NCAA) banned the use of "hostile and abusive" Native American mascots in postseason tournaments. [22] An exception was made to allow the use of tribal names if approved by that tribe (such as the Seminole Tribe of Florida's approving use of their name for the team of Florida State University.) [23] [24]

Environmental justice

Environmental justice academic case studies examine the erasure of indigenous culture and ways of life, resource exploitation, destruction of sacred land, environmental and indigenous health, and climate justice. [25] From the arrival of white settlers, explorers and colonizers, Native Americans have suffered from genocide, introduced diseases, warfare, and the legacy of environmental racism persists in modern day. [25] The environmental justice movement has largely left out the Native American experience, but findings[ by whom?] have shown that Native land is being, and has been, used for landfills, dump sites, and locations to test nuclear weapons.[ citation needed] However, while these uses cause harm to the peoples health, they are not always unwanted.[ citation needed] The Mescalero Apache welcomed the proposal to have a monitored retrievable nuclear waste storage facility built on their land because over one-third of the tribal citizens were unemployed, and they lacked enough housing and any sort of school system. [26] Jamie Vickery and Lori M. Hunter have stated that the natives are being coerced into accepting the nuclear waste storage facility by their own economic hardships, which in turn has been caused by the US government direct exploitation and marginalization. [27]

Historical depictions in art

Secotan Indians' dance in North Carolina, watercolor by John White, 1585
American Indian on five-dollar silver certificate, 1899

A number of 19th and 20th-century United States and Canadian painters, often motivated by a desire to document and preserve Native culture, specialized in Native American subjects. Among the most prominent of these were Elbridge Ayer Burbank, George Catlin, Seth Eastman, Paul Kane, W. Langdon Kihn, Charles Bird King, Joseph Henry Sharp and John Mix Stanley. During the 16th century, the artist John Whitemade watercolors and engravings of the people native to the southeastern states. John White’s images were, for the most part, faithful likenesses of the people he observed. However, some like artist Theodore de Bryused White’s original watercolors to alter the poses and features of White’s figures to make them appear more European.

1892 sculpture by Alexander Milne Calder, installed on the Philadelphia City Hall.

There are also many depictions of Native Americans on federal buildings, statues, and memorials. During the construction of the Capitol building in the early 19th century, the U.S. government commissioned a series of four relief panels to crown the doorway of the Rotunda. The reliefs encapsulate a vision of European—Native American relations that had assumed mythic historical proportions by the 19th century. The four panels depict: The Preservation of Captain Smith by Pocahontas (1825) by Antonio Capellano, The Landing of the Pilgrims (1825) and The Conflict of Daniel Boone and the Indians (1826–27) by Enrico Causici and William Penn’s Treaty with the Indians (1827) by Nicholas Gevelot. The reliefs by European sculptors present versions of the Europeans and the Native Americans, in which the Europeans appear refined and the natives appear ferocious. The Whig representative of Virginia, Henry A. Wise, wrote about how Native Americans might think of the reliefs: "We give you corn, you cheat us of our lands: we save your life, you take ours." While many 19th-century images of Native Americans conveyed similarly negative messages, artists such as Charles Bird King portrayed Native American delegates with accuracy. His paintings are often used as records for Native American formal dress and customs. [28]

In the 20th century, early portrayals of Native Americans in movies and television roles were first performed by European Americans dressed in mock traditional attire. Examples included The Last of the Mohicans (1920), Hawkeye and the Last of the Mohicans (1957), and F Troop (1965–67). In later decades, Native American actors such as Jay Silverheels in The Lone Ranger television series (1949–57) came to prominence. Roles of Native Americans were limited and not reflective of Native American culture. For years, Native people on U.S. television were relegated to secondary, subordinate roles relative to the white protagonists as shown in notable works like Cheyenne (1957–1963) and Law of the Plainsman (1959–1963).

By the 1970s some Native American film roles began to show more complexity, such as those in Little Big Man (1970), Billy Jack (1971), and The Outlaw Josey Wales (1976) which depicted Native Americans in important lead and supporting roles. Regardless, the European narrative perspective was prioritized in popular media. The "sympathetic" yet contradictory film Dances With Wolves (1990) intentionally, according to Ella Shohat and Robert Stam, related the Lakota story through a Euro-American voice for wider impact among a general audience. [29] Like the 1992 remake of The Last of the Mohicans and Geronimo: An American Legend (1993), Dances with Wolves employed a number of Native American actors, and made an effort to portray Indigenous languages. Many film scholars and Native Americans still criticize films like Dances with Wolves for its 'white savior' narrative that asserts European-Americans are the necessary saviors of people of color like Native Americans. [30]

Many documentaries have been created partly in response to unbalanced coverage of Native American perspectives in history and partly to educate the public about the shared history of conflict between Native Americans and European colonizers. In 2004 producer Guy Perrotta presented the film Mystic Voices: The Story of the Pequot War (2004), a television documentary on the first major war between colonists and Native peoples in the Americas. The documentary portrayed the conflict as a struggle between different value systems, which included not only the Pequot, but a number of other Native American tribes, most of which allied with the English. Perrotta and Charles Clemmons, another producer, intended to increase public understanding of the significance of this early event. [31] In 2009 We Shall Remain (2009), a television documentary by Ric Burns and part of the American Experience series, presented a five-episode series "from a Native American perspective". It represented "an unprecedented collaboration between Native and non-Native filmmakers and involves Native advisors and scholars at all levels of the project." [32] The five episodes explore the impact of King Philip's War on the northeastern tribes, the "Native American confederacy" of Tecumseh's War, the US-forced relocation of Southeastern tribes known as the Trail of Tears, the pursuit and capture of Geronimo and the Apache Wars, and concludes with the Wounded Knee incident, participation by the American Indian Movement, and the increasing resurgence of modern Native cultures since.

Gambling industry

Sandia Casino, owned by the Sandia Pueblo of New Mexico

Gambling has become a leading industry. Casinos operated by many Native American governments in the United States are creating a stream of gambling revenue that some communities are beginning to use as leverage to build diversified economies. Native American communities have waged and prevailed in legal battles to assure recognition of rights to self-determination and to use of natural resources. Some of those rights, known as treaty rights, are enumerated in early treaties signed with the young United States government. These casinos have brought an influx of money to the tribes; according to tribal accounting firm Joseph Eve, CPAs, the average net profit of Indian casinos is 38.85%. [33][ clarification needed]

Tribal sovereignty has become a cornerstone of American jurisprudence, and at least on the surface, in national legislative policies. Although many Native American tribes have casinos, the impact of Native American gaming is widely debated. Some tribes, such as the Winnemem Wintu of Redding, California, feel that casinos and their proceeds destroy culture from the inside out. These tribes refuse to participate in the gambling industry.

Crime on reservations

Prosecution of serious crime, historically endemic on reservations, [34] [35] was required by the 1885 Major Crimes Act, [36] 18 U.S.C. §§1153, 3242, and court decisions to be investigated by the federal government, usually the Federal Bureau of Investigation, and prosecuted by United States Attorneys of the United States federal judicial district in which the reservation lies. [37] [38] An investigation by The Denver Post in 2007 found that crimes in Indian Country have been a low priority both with the FBI and most federal prosecutors. [39] As of November 2012 federal resources were being reduced while high rates of crime continued to rise in Indian Country. [40]

Often serious crimes have been either poorly investigated or prosecution has been declined. [39] Tribal courts were limited to sentences of one year or less, [39] until on July 29, 2010 the Tribal Law and Order Act was enacted which in some measure reforms the system permitting tribal courts to impose sentences of up to three years provided proceedings are recorded and additional rights are extended to defendants. [37] [38] The Justice Department on January 11, 2010 initiated the Indian Country Law Enforcement Initiative which recognizes problems with law enforcement on reservations and assigns top priority to solving existing problems.

The Department of Justice recognizes the unique legal relationship that the United States has with federally recognized tribes. As one aspect of this relationship, in much of Indian Country, the Justice Department alone has the authority to seek a conviction that carries an appropriate potential sentence when a serious crime has been committed. Our role as the primary prosecutor of serious crimes makes our responsibility to citizens in Indian Country unique and mandatory. Accordingly, public safety in tribal communities is a top priority for the Department of Justice.

Emphasis was placed on improving prosecution of crimes involving domestic violence and sexual assault. [41]

Passed in 1953, Public Law 280 (PL 280) gave jurisdiction over criminal offenses involving Indians in Indian Country to certain States and allowed other States to assume jurisdiction. Subsequent legislation allowed States to retrocede jurisdiction, which has occurred in some areas. Some PL 280 reservations have experienced jurisdictional confusion, tribal discontent, and litigation, compounded by the lack of data on crime rates and law enforcement response. [42]

As of 2012, a high incidence of rape continued to impact Native American women and Alaskan native women. According to the Justice Department 1 in 3 women have suffered rape or attempted rape, more than twice the national rate. [43] 80% of Native American sexual assault victims report that their attacker was "non-Indian". [44] As of 2013 inclusion of offenses by non-native men against native women in the Violence Against Women Act continued to present difficulties over the question of whether defendants who are not tribal members would be treated fairly by tribal courts or afforded constitutional guarantees. [45] On June 6, 2012 the Justice Department announced a pilot plan to establish joint federal-tribal response teams on 6 Montana reservations to combat rape and sexual assault. [46]

Trauma

Trauma among American Indians can be seen through historical and intergenerational trauma and can be directly related to the abuse of alcohol and substances and high rates of suicide among American Indian populations.

Historical trauma

Historical trauma is described as collective emotional and psychological damage throughout a person’s lifetime and across multiple generations. [47] Native Americans experience historical trauma through the effects of colonization such as wars and battles with the U.S. military, assimilation, forced removal, and genocide. Even though many American Indians did not experience first hand traumatic events like the Wounded Knee Massacre, multiple generations are still affected by them. On December 29, 1890, over 200 Lakota were killed at Wounded Knee creek, South Dakota by U.S. soldiers. More than half were unarmed women and children. It was reported that fleeing women were even shot in the back. Unanswered pain from the Wounded Knee Massacre is still felt and has been related to present day substance abuse and violence. [48]

The loss of lands are also instrumental to the effect of historical trauma on American Indians. Four-fifths of American Indian land was lost due to the Dawes Allotment Act of 1887. The U.S. government gave American Indian men sections of land and opened the “surplus” to white settlers and government interests. The understanding of American Indian’s relationship to land is much more than a physical place, it is the bases for their entire worldview and well-being. The psychological effects of the Dawes Allotment Act can be better appreciated when looking at American Indians relationship to the land, which is similar for all Indian tribes. The land is the origin of the People, who came out of the earth, and is the interdependent and spiritual link to all things. [49]

Impacts of intergenerational trauma

American Indian youth are confronted with the burden of intergenerational trauma; trauma experienced by family members that is passed from one generation to the next. Often youth begin to take on these traumas and can abuse alcohol and drugs to the point of death in some cases. This can contribute to American Indian adolescents exceeding the national average for alcohol and drug related deaths; being 1.4 and 13.3 times higher. [50] A study looking at two generations of American Indians and their relationship to psychological trauma found that participants who experienced traumatic events early in their lives were usually related to substance abuse of the offender. These experiences have shown to be associated with the beginning of their own substance abuse. [51] The abuse of alcohol and drugs are unhealthy coping mechanisms that many American Indians learn to use at a young age. A person’s substance abuse can be described as a defense mechanism against the user’s emotions and trauma. [52] For many American Indians, alcoholism is a symptom of trauma passed from generation to generation and influenced by oppressive behaviors and policies by the dominant Euro-American society. [53]

Boarding School

Many American Indians were assimilated into the Euro-American culture through boarding schools that were designed to 'civilize' them. “Kill the Indian and save the man” was the motto and belief. [54] After hundreds of years of discrimination, American Indians have developed a heavy sense of shame about their trauma.

Participants in a study who are survivors of American Indian mission schools reported that Native Americans were thought to be "dirty" people who needed to be treated with dichloro-diphenyl-trichloro-ethane (DDT), a pesticide used for insect control, before entering class each day. Accounts of DDT powder was applied to their hair occurred in the 1946 and 1957. Participants indicated a need for assistance to address their suffered abuse. [55]

Solutions

Many researchers, psychologists, counselors, and social workers are calling for culturally competent practitioners as well as using culturally appropriate practices when working with American Indian clients. This is largely due to the difference of worldviews between American Indians and Euro-Americans. American Indians do not view mind, body, and soul as separate from each other or themselves as the Western worldview does. American Indians believe all is connected and related to each other. [52] American Indian psychologists have been asked to use mental health practices that cultivate American Indian values rather than using conventional ways of counseling. [56] The Wellbriety Movement creates a space for American Indians to learn how to reconnect with their culture by using culturally specific principles to become and remain sober. [50] Some examples are burning sage, cedar, and sweetgrass as a means to cleanse physical and spiritual spaces, verbally saying prayers and singing in one’s own tribal language, and participating in tribal drum groups and ceremonies as part of meetings and gatherings. [53]

Public health

As of 2004, according to the United States Commission on Civil Rights: "Native Americans die of diabetes, alcoholism, tuberculosis, suicide, and other health conditions at shocking rates. Beyond disturbingly high mortality rates, Native Americans also suffer a significantly lower health status and disproportionate rates of disease compared with all other Americans." [57]

In addition to increasing numbers of American Indians entering the fields of community health and medicine, agencies working with Native American communities have sought partnerships, representatives of policy and program boards, and other ways to learn and respect their traditions and to integrate the benefits of Western medicine within their own cultural practices.

Alcoholism

The community suffers a vulnerability to and a disproportionately high rate of alcoholism. [58] Alcohol abuse is widespread in Native American communities. Native Americans use and abuse alcohol and other drugs at younger ages, and at higher rates, than that of all other ethnic groups. [59] Consequently, their age-adjusted alcohol-related mortality rate is 5.3 times greater than the general population. The Department of Health and Human Services, Substance Abuse and Mental Health Services Administration’s National Household Survey on Drug Abuse reported the following for 1997: 19.8 percent of Native Americans ages 12 and older reported using illegal drugs that year, compared with 11.9 percent for the total U.S. population. Native Americans had the highest prevalence rates of marijuana and cocaine use, in addition to the need for drug abuse treatment. [60]

Tribal governments have long prohibited the sale of alcohol on reservations, but generally, it is readily for sale in nearby border towns, and off-reservation businesses and states gain income from the business. As an example, in 2010, beer sales at off-reservation outlets in Whiteclay, Nebraska generated $413,932 that year in federal and sales taxes. Their customers are overwhelmingly Lakota from the Pine Ridge Indian Reservation in South Dakota. [61]

Acknowledging that prohibition has not worked, in a major change in strategy since the late 20th century, as of 2007, 63 percent of the federally recognized tribes in the lower 48 states had legalized alcohol sales on their reservations. [62] Among these, all the other tribes in South Dakota have legalized sales, as have many in Nebraska. The tribes decided to retain the revenues that previously would go to the states through retail sales taxes on this commodity. Legalizing the sales enables the tribes to keep more money within their reservation economies and support new businesses and services, as well as to directly regulate, police and control alcohol sales. The retained revenues enable them to provide health care and build facilities to better treat individuals and families suffering from alcohol abuse. [62] In some cases, legalization of alcohol sales also supported the development of resorts and casinos, to generate revenues for other economic enterprises.

Consequences of alcoholism

Native Americans and Whites have the highest rates of Driving Under the Influence (DUI). A 2007 study conducted by the National Survey on Drug Use and Health (NSDUH) reports that 13.3% of Native Americans report past-year DUI. [63]

Of 1660 people from seven Native American tribes, the lifetime prevalence of alcohol dependence ranged from 21%-56% for men and 17%-30% for women among all tribes. Physical and sexual abuse significantly increased the chances of alcohol dependence for men. Sexual abuse and boarding school attendance increased the odds of alcohol dependence among women. [64] Native Americans, especially women, are at high risk for alcohol-related trauma, such as rape and assault. [65]

Unintentional injuries due to alcoholism

Unintentional injuries account for the third leading cause of death for Native Americans and the leading cause of death for Native Americans under 44 years old. Unintentional injuries include motor vehicle crashes, pedestrian-related motor vehicle crashes, drowning, and fire-related injuries. From 1985 to 1996, 1,484 Native American children died in motor vehicle crashes, which is twice the rate for white children. [66]

National estimates of alcohol-related motor vehicle deaths show that Native Americans have a 250% higher death rate compared to the US population. [67]

Cancer

Studies have indicated that there is are fewer cases of cancer in Native Americans than other ethnic groups. However, cancer is prevalent in Native Alaskan women and Native American women as the leading and second leading cause of death, respectively. Death rates are 70% of that for whites, indicating that the ratio of death by cancer to new cancer cases is the highest for Native Americans compared to other ethnic groups. [68] Women have been diagnosed with later-stage breast and cervical cancer. Native Indian and Alaska Native people are disproportionately prone to colon and lung cancer. In some communities, this is consistent with a high prevalence of risk factors such as smoking.

One research about the Pacific Northwest Native Americans found that there were many misidentified rates of cancer between 1996-1997. This misclassification was due to a low Native American blood quantum, resulting in an over-reported amount of Native Americans diagnosed with cancer. Because the research took data from the Oregon State Cancer Registry, the Washington State Cancer Registry, and the Cancer Data Registry of Idaho to research tribes in the respected states, their findings show that cancer rates among tribes in the US are heterogeneous. [69]

However, data collected from cancer cases are limited. Regardless, experts have suggested that Native Americans experience cancer differently than other ethnic groups. This can be due to genetic risk factors, late detection of cancer, poor compliance with recommended treatment, the presence of concomitant disease, and lack of timely access to diagnostic and/or treatment methods. According to researchers, addressing underlying risk factors and low screening rates by implementing aggressive screening programs can prevent cancer from forming in Native Indian and Alaska Native communities. [70]

Diabetes

Native Americans have some of the highest rates of diabetes in the world, specifically Type 2 diabetes. Although mostly diagnosed in adults, children are increasingly being diagnosed with Type 2 diabetes as well. Type 2 diabetes may be manageable through healthy eating, exercising, oral medication, or insulin injections. [68]

A study published in Environmental Health Perspectives found that the prevalence of diabetes found in Native Americans of the Mohawk Nation was 20.2% due to traces of pesticides in food sources, where elevated serum PCBs, DDE, and HBC were associated. Mirex did not have a connection. [71]

Major cardiovascular disease

Heart disease accounts for the number one cause of death among Native Americans, causing them to have twice the rate of cardiovascular disease than the US population. High rates of diabetes, high blood pressure, and risk factors (unhealthy eating and sedentary lifestyle) contribute to the increased risk of cardiovascular disease. [72]

Mental health

Native Americans are at high risk for mental disorders. The most prevalent concerns due to mental health include substance abuse, suicide, depression, anxiety, and violence. High rates of homelessness, incarceration, alcohol and drug abuse, and stress and trauma in Native American communities might attribute to the risk. According to The Surgeon General's report, the U.S. mental health system is not equipped to meet the needs of Native Americans. Moreover, the budget constraints of the Indian Health Service allows only basic psychiatric emergency care. [73]

Suicide

Suicide is a major public health problem for American Indians in the United States.

Prevalence of suicide among Native Americans

The Suicide rate for American Indians and Alaskan Natives is approximately 190% of the rate for the general population. [57] Among American Indians/Alaska Natives aged 10 to 34 years suicide is the second leading cause of death with suicide ranked as the eighth leading cause of death for American Indians/Alaska Natives of all ages [74]

Youth who have experienced life stressors are disproportionately affected by risky behaviors and at greater risk for suicide ideation. Suicide rates among American Indians and Alaska Natives youth are higher than those for other populations. The rate of suicide for American Indian/Alaskan Natives is 70% higher than for that of the general population and youth between age 10 and 24 are the most at risk. [75]

College students are also among those most at risk for suicide; select data from the National College Health Association National College Health Assessment (ACHA-NCHA) found that approximately 15% of American Indian students reported seriously contemplating suicide over the past 12 months, compared with 9.1% of non-American Indian students; 5.7% of American Indian students reported attempting suicide, compared with 1.2% of non-American Indian students [76]

Suicide prevention

Prevention aims at halting or stopping the development of individual or social problem which is already evident. Prevention is different from intervention and treatment in that it is aimed at general population groups or individuals with various levels of risk. [77] Prevention's goal is to reduce risk factors and enhance protective factors. Suicide prevention is a collective effort of organizations, communities, and mental health practitioners to reduce the incidence of suicide. Social workers have an important role to play in suicide prevention. Social workers are the largest occupational group of mental health professionals in the USA, thus they play a significant role in the national approach to preventing suicide. [78] The social work approach to suicide prevention among Native Americans identifies and addresses the individual’s immediate clinical needs, community/environmental influences, and societal risk factors.

Possible programs to improve native health disparities

Indian Health Service

The Indian Health Service (IHS) was established within the Public Health Service in 1955 in order to meet federal treaty obligations to provide health services to members of federally recognized American Indian and Alaska Native tribes. The IHS consists of three branches of service: the federally operated direct care system, independent tribally operated health care services, and urban Indian health care services. [79]

Affordable Care Act

In addition to the Indian Health Services, researchers have data suggesting that the Affordable Care Act supplements Native American healthcare. With the two services, tribes have greater flexibility in health care availability. Tribes have direct access to IHS funds, which can be administered via contracts and other arrangements made with providers. However, it alters trust relationships. [80] The Affordable Care Act provides an opportunity for uninsured adults to gain Medicaid coverage. Although half of the uninsured adults are white, increases in coverage expand to all races to substantially reduce racial gaps in health insurance coverage. [81] With new outreach and enrollment efforts, streamlined enrollment systems, penalties for not having health insurance coverage, the availability of newly created health insurance exchanges, and the expectation under the ACA that everyone will have insurance coverage, enrollment in Medicaid will increase in low-income communities. [82]

The Indian Health Care Improvement Act, which is part of the Patient Protection and Affordable Care Act, does not guarantee a health care arrangement of the kind Americans have generally come to expect—namely, comprehensive inpatient and outpatient services available on the basis of need— a critical point when considering the IHS, which is often mistaken for a Native American health insurance program. According to the governor of the Pueblo of Tesuque Mark Mitchell, IHS does not cover everything that insurance does. [83] It is not an entitlement program, unlike Medicare or Medicaid. The IHS is a series of direct health care services provided at IHS facilities. A key distinction between IHS health services and insurance concerns the policy framework and logic of budgeting that underpins them.

This produces a fundamentally different dynamic than that which drives programs such as Medicare or Medicaid, or especially private managed care plans. The IHS does what it can with the resources it is provided by Congress but is not obligated to provide the services required to meet the broader health needs of Native Americans in the pursuit of measurable outcomes. [84]

The Oregon Experiment

In 2008, Oregon initiated Medicaid to 10,000 of a randomized 90,000 low-income, uninsured adults to participate in what is now known as the Oregon Medicaid health experiment. Within 4 study groups of one study, researchers observed that utilization of primary care services will increase, as more individuals will begin and continue to use medical care. The study was limited to the Portland metropolitan area. [85] Researchers concluded that investment in primary care could help attend and mitigate the health care needs of individuals. [86]

See also

References

  1. ^ "Annual Estimates by Race Alone" (PDF). US Census.gov. Archived from the original (PDF) on 2006-02-16. Retrieved 2006-02-08.
  2. ^ Timothy Williams (April 13, 2013). "Quietly, Indians Reshape Cities and Reservations". The New York Times. Retrieved April 14, 2013.
  3. ^ a b "Preference for Racial or Ethnic Terminology". Infoplease. Retrieved 2006-02-08.
  4. ^ "American Indian versus Native American". Infoplease. Retrieved 2006-02-08.
  5. ^ W. David Baird; et al. (January 5, 2009). ""We are all Americans", Native Americans in the Civil War". Native Americans.com. Retrieved 2009-01-05.
  6. ^ Jack Larkin (2003). "OSV Documents – Historical Background on People of Color in Rural New England in the Early 19th Century". Old Sturbridge Inc. Retrieved 2009-06-12.
  7. ^ "What's in a Name? Indians and Political Correctness". All Things Cherokee. Archived from the original on 2006-02-28. Retrieved 2006-02-08.
  8. ^ Russell Means "I am an American Indian, not a native American!" (Treaty Productions, 1996); citation given here [1] and here [2] and they cover the general subject and some Means' contribution, but have no reference to "En Dio" and only those non-working links to text.
  9. ^ "Walking a Mile: A Qualitative Study Exploring How Indians and Non-Indians Think About Each Other". Public Agenda. Retrieved 2008-07-25.
  10. ^ "[Executive Order 11246]--Equal employment opportunity". The Federal Register. Archived from the original on 2010-03-30. Retrieved 2010-05-05.
  11. ^ "Office of Federal Contract Compliance Programs (OFCCP)". U.S. Department of Labor. Archived from the original on 2009-11-28. Retrieved 2010-05-05.
  12. ^ "Final Guidance on Maintaining, Collecting, and Reporting Racial and Ethnic Data to the U.S. Department of Education" (PDF). Federal Register/Vol. 72, No. 202/Friday, October 19, 2007/Notices. U.S. Department of Education. October 19, 2007. pp. 59266 to 59279. Archived from the original (Notice) on November 9, 2011. Retrieved 2012-06-09. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.
  13. ^ Bridget Neconie (Spring 2012). "removing educational Barriers for Native American Citizens of Federally- recognized tribes" (PDF). The American Indian Graduate: 10 to 14. Retrieved 2012-06-09. The Native American population is the only group in American that tends to experience systematic fraudulent behavior. Claiming to be Native American has become such a common and accepted practice that recently, the American Bar Association began to require verification of the identity of Native American applicants.[ permanent dead link]
  14. ^ American Bar Association (Spring 2012). "ABA Adopts Policy to Curb Box-Checking" (Press release). the American Indian Graduate: 15. Retrieved 2012-06-09. RESOLVED, That the American Bar Association urges the Law School Admissions Council and ABA-approved law schools to require additional information from individuals who indicate on their applications for testing or admission that they are Native American, including Tribal citizenship, Tribal affiliation or enrollment number, and/or a “heritage statement.”[ permanent dead link]
  15. ^ "Native Now : Language: Cherokee". We Shall Remain - American Experience - PBS. 2008. Retrieved April 9, 2014.
  16. ^ a b "Cherokee Language Revitalization". Cherokee Preservation Foundation. 2014. Archived from the original on April 7, 2014. Retrieved April 9, 2014.
  17. ^ Kituwah Preservation & Education Program Powerpoint, by Renissa Walker (2012)'. 2012. Print.
  18. ^ Chavez, Will (April 5, 2012). "Immersion students win trophies at language fair". Cherokeephoenix.org. Retrieved April 8, 2013.
  19. ^ a b c d e f g "Cherokee Immersion School Strives to Save Tribal Language". Youth on Race. Archived from the original on July 3, 2014. Retrieved June 5, 2014.
  20. ^ First Peoples, Colin G. Calloway, 2nd Edition, 2004
  21. ^ Teaching Tolerance. "Native American Mascots Big Issue in College Sports". Archived from the original on 2008-04-20. Retrieved 2008-08-26.
  22. ^ "NCAA Bans Indian Mascots". Online NewsHour. Retrieved 2006-02-08.
  23. ^ Powell, Robert Andrew (August 25, 2005). "Florida State wins its battle to remain the Seminoles". International Herald Tribune. Retrieved 2008-08-09.
  24. ^ "Florida State University thanks Seminoles for historic vote of support". Florida State University. Archived from the original on 2007-06-08. Retrieved 2008-08-09.
  25. ^ a b Vickery, Jamie (2015). "Native Americans: Where in Environmental Justice Research?". 29. Society and Natural Resources (1): 36–52. PMC  4835033.
  26. ^ Louis G., Leonard III (1997). "Sovereignty, Self-Determination, and Environmental Justice in the Mescalero Apache's Decision to Store Nuclear Waste". Boston College Environmental Affairs Law Review. 24 (3): 651–693.
  27. ^ Vickery, Jamie; Hunter, Lori M. (2016). "Native Americans: Where in Environmental Justice Research?". Society & natural resources. 29 (1): 36–52. doi: 10.1080/08941920.2015.1045644. ISSN  0894-1920. PMC  4835033. PMID  27103758.
  28. ^ "Charles Bird King". Smithsonian American Art Museum. Retrieved 2018-12-06.
  29. ^ Shohat, Ella, and Stam, Robert. Unthinking Eurocentrism: Multiculturalism and the Media. New York: Routledge, 1994.
  30. ^ "Oscar loves a white savior | Salon.com". www.salon.com. Retrieved 2018-12-06.
  31. ^ "The Pequot War: A Documentary ~ The Project". www.pequotwar.com. Retrieved 2018-12-06.
  32. ^ "About the Project: We Shall Remain". Retrieved 2009-06-16.
  33. ^ Joseph Eve (2012) [2010]. "The Cost of doing Business".
  34. ^ Steven W. Perry (December 2004). "A BJS Statistical Profile, 1992-2002 American Indians and Crime" (PDF). U.S. Department of Justice Office of Justice Programs. Retrieved 2012-06-02.
  35. ^ Kevin K. Washburn (February 2006). "American Indians, Crime, and the Law" (PDF). Michigan Law Review. 104: 709 to 778. Archived from the original (PDF) on 2012-03-11. Retrieved 2012-06-02.
  36. ^ Michael Riley (November 11, 2007). "1885 law at root of jurisdictional jumble". The Denver Post. Retrieved 2012-06-02.
  37. ^ a b "Expansion of tribal courts' authority passes Senate" article by Michael Riley in The Denver Post Posted: 25 June 2010 01:00:00 AM MDT Updated: 25 June 2010 02:13:47 AM MDT Accessed 2010-06-25
  38. ^ a b "President Obama signs tribal-justice changes" article by Michael Riley in The Denver Post, Posted: 30 July 2010 01:00:00 AM MDT, Updated: 30 July 2010 06:00:20 AM MDT, accessed 2010-07-30
  39. ^ a b c "Lawless Lands" a 4-part series in The Denver Post last updated November 21, 2007
  40. ^ Timothy Williams (November 12, 2012). "Washington Steps Back From Policing Indian Lands, Even as Crime Rises". The New York Times. Retrieved 2012-11-13.
  41. ^ "MEMORANDUM FOR UNITED STATES ATTORNEYS WITH DISTRICTS CONTAINING INDIAN COUNTRY" Memorandum by David W. Ogden Deputy Attorney General, Monday, January 11, 2010, Accessed 2010-08-12
  42. ^ "Public Law 280 and Law Enforcement in Indian Country – Research Priorities December 2005", accessed 2010-08-12
  43. ^ Timonthy Williams (May 22, 2012). "For Native American Women, Scourge of Rape, Rare Justice". The New York Times. Retrieved 2012-05-23.
  44. ^ N. Bruce Duthu (August 10, 2008). "Broken Justice in Indian Country" (op-ed by expert). The New York Times. Retrieved 2012-06-07.
  45. ^ Jonathan Weisman (February 10, 2013). "Measure to Protect Women Stuck on Tribal Land Issue". The New York Times. Retrieved February 10, 2013. If a Native American is raped or assaulted by a non-Indian, she must plead for justice to already overburdened United States attorneys who are often hundreds of miles away.
  46. ^ "New Teams to Counter Sex Crimes on Reservations". The New York Times. Associated Press. June 6, 2012. Retrieved 2012-06-07.
  47. ^ Myhra, L. L. (2011). “It runs in the family”: Intergenerational Transmission of Historical Trauma Among Urban American Indians and Alaska Natives in Culturally Specific Sobriety Maintenance Programs. American Indian and Alaska Native Mental Health Research, 18(2). 17-40. National Center for American Indian and Alaska Native Mental Health Research.
  48. ^ Weaver, H., & Congress, E. (2010). The Ongoing Impact of Colonization: Man-made Trauma and Native Americans. In A. Kalayjian & D. Eugene (Eds.), Mass Trauma and Emotional Healing Around the World: Rituals and Practices for Resilience and Meaning-Making (pp. 211-226). Santa Barbara, CA: Praeger.
  49. ^ Braveheart-Jordan, M., & DeBruyn, L. (1995). So She May Walk in Balance: Integrating the Impact of Historical Trauma in the Treatment of Native American Indian Women. In J. Adleman & G. M. Enguidanos (Eds.), Racism in the Lives of Women: Testimony, Theory, and Guides to Antiracist Practice (pp. 345-366). Binghamton, New York: Harrington Park Press.
  50. ^ a b Paul, T. M., Lusk, S. L., Becton, A. B., & Glade, R. (2017). Exploring the Impact of Substance Abuse, Culture, and Trauma on American Indian Adolescents. Journal of Applied Rehabilitation Counseling, 48(1). 31-39.
  51. ^ Myhra, L. L., & Wieling, E. (2014). Psychological Trauma Among American Indian Families: A Two-Generation Study. Journal of Loss and Trauma, 19. 289-313. doi: 10.1080/15325024.2013.771561
  52. ^ a b Cole, N. (2006). Trauma and the American Indian. In T. M. Witko (Ed.), Mental Health Care for Urban Indians: Clinical Insights from Native Practitioners (pp. 115-130). Washington, DC: American Psychological Association.
  53. ^ a b Coyhis, D., & Simonelli, R. (2008). The Native American Healing Experience. Substance Use & Misuse, 43. 1927-1949. doi: 10.1080/10826080802292584
  54. ^ Grayshield, L., Rutherford, J. J., Salazar, S. B., Mihecoby, A. L., & Luna, L. L. (2015). Understanding and Healing Historical Trauma: The Perspectives of Native American Elders. Journal of Mental Health Counseling, 37(4). 295-307. doi: 10.17744/mech.37.4.02
  55. ^ Carbonneau-Dahlen, Barbara; Lowe, John; Morris, Staci (2016). "Giving Voice to Historical Trauma Through Storytelling: The Impact of Boarding School Experience on American Indians". Journal of Aggression, Maltreatment & Trauma. 6 (25): 598–617. doi: 10.1080/10926771.2016.1157843.
  56. ^ Willmon-Haque, & S., Bigfoot, D. S. (2009). Violence and the Effects of Trauma on American Indian and Alaska Native Populations. In R. Geffner, D. Griffin & J. Lewis III (Eds.), Children Exposed to Violence: Current Issues, Interventions, and Research (pp. 48-63). New York: Routledge.
  57. ^ a b "Broken Promises: Evaluating the Native American Health Care System" (PDF). U.S. Commission on Civil Rights (2004). Retrieved 4 March 2013.
  58. ^ "Challenges to Health and Well-Being of Native American Communities". The Provider's Guide to Quality and Culture. Archived from the original on 2003-01-23. Retrieved 2007-06-22., Management of Science of Health
  59. ^ Barry, M; Reynoso, Cruz (2004). "Broken Promises: Evaluating the Native American Health Care System" (PDF). Retrieved April 21, 2018.
  60. ^ U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (1998). "Drug Use Among Native Americans Is Higher than Other Racial/Ethnic Groups". National Clearinghouse for Alcohol & Drug Information. Retrieved April 26, 2018.
  61. ^ Stephanie Woodward, "Gold Mines in Hell", 100Reporters, February 2012
  62. ^ a b James N. Hughes III, "Pine Ridge, Whiteclay and Indian Liquor Law", Federal Indian Law Seminar, December 2010, p. 7, University of Nebraska College of Law, accessed 2012-02-27
  63. ^ Chartier, Karen; Caetano, Raul (2009). "Ethnicity and Health Disparities in Alcohol Research". National Institute on Alcohol Abuse and Alcoholism. Retrieved March 20, 2018.
  64. ^ Koss, M.P.; Yuan, N.P.; Dightman, D. (2003). "Adverse childhood exposures and alcohol dependence among seven Native American tribes". American Journal of Preventive Medicine. 25 (3): 238–244. PMC  2022671. PMID  14507531.
  65. ^ Wahab, S.; Olson, L. (2004). "Intimate partner violence and sexual assault in Native American communities". Trauma Violence and Abuse. 5 (4): 353–366. doi: 10.1177/1524838004269489. Retrieved March 20, 2018.
  66. ^ UNITED STATES COMMISSION ON CIVIL RIGHTS (2004). "Broken promises: evaluating the Native American health care system". Washington, DC, U.S. Commission on Civil Rights: 14. Retrieved March 20, 2018.
  67. ^ Centers for Disease Control and Prevention, (CDC) (2009a). "Alcohol and suicide among racial/ethnic populations: 17 states, 2005-2006". MMWR. Morbidity and Mortality Weekly Report. 58 (23): 637–641. PMID  19543198. Retrieved March 20, 2018.
  68. ^ a b UNITED STATES COMMISSION ON CIVIL RIGHTS (2004). "Broken promises: evaluating the Native American health care system". Washington, DC, U.S. Commission on Civil Rights. Retrieved March 20, 2018.
  69. ^ Becker, Thomas M. (2002). "Improving Cancer Incidence Estimates for American Indians and Alaska Natives in the Pacific Northwest". American Journal of Public Health. 92 (9): 1469–1470. doi: 10.2105/AJPH.92.9.1469. PMC  1447260. PMID  12197975. Retrieved March 20, 2018.
  70. ^ Espey, D. K.; Wingo, P.A.; Lee, N.C. (2008). "An update on cancer in American Indians and Alaska Natives". Washington, DC, U.S. Commission on Civil Rights. 113 (S5): 1113–1273. Retrieved March 20, 2018.
  71. ^ Codru, Neculai; et, al. (2007). "Diabetes in Relation to Serum Levels of Polychlorinated Biphenyls and Chlorinated Pesticides in Adult Native Americans". Environmental Health Perspectives. 115 (10): 1442–1447. doi: 10.1289/ehp.10315. PMC  2022671.
  72. ^ UNITED STATES COMMISSION ON CIVIL RIGHTS (2004). "Broken promises: evaluating the Native American health care system". Washington, DC, U.S. Commission on Civil Rights: 15. Retrieved March 20, 2018.
  73. ^ Services, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration (2003). "Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General". Retrieved March 20, 2018.
  74. ^ "Suicide Among American Indians/Alaska Native" (PDF). Suicide Among American Indians/Alaska Natives. Retrieved 4 March 2013.
  75. ^ Dorgan, Bryon (2010). "The tragedy of Native American youth suicide". Psychological Services. 7 (3): 213–218. doi: 10.1037/a0020461.
  76. ^ Meuhlenkamp, J.J.; Marrone, S.; Gray, J. S.; Brown, D. L. (2009). "A college suicide prevention model for American Indian Students". Professional Psychology: Research and Practice. 40: 134–140. doi: 10.1037/a0013253.
  77. ^ Doyle, Jerry. "Prevention and Early Intervention" (PDF). Retrieved 14 April 2013.
  78. ^ Manderscheid, RW; Atay JE; Male A; et al. (2002). "Highlights of organized mental health services in 2000 and major national and state trends". Center for Mental Health Services: Mental Health.
  79. ^ Sequist, T. D.; Cullen, T.; Bernard, K.; et al. (2011). "Trends in Quality of Care and Barriers to Improvement in the Indian Health Service". Journal of General Internal Medicine. 26 (5): 480–486. doi: 10.1007/s11606-010-1594-4. PMC  3077488. Retrieved April 25, 2018.
  80. ^ Hatch, Brigit; et al. (2016). "Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act". American Journal of Public Health. 106 (4): 645–650. doi: 10.2105/AJPH.2016.303060. PMC  4894650. Retrieved March 20, 2018.
  81. ^ Kenny, G.; Anderson, A.; Zuckerman, L.; Dubay, L.; Huntress, M.; Lynch, V; Hayley, J. (2012). "Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage". Timely Analysis of Immediate Health Policy Issues. Retrieved April 23, 2018.
  82. ^ Buettgens, M; Dorn, S.; Carroll, C. (2011). "Consider Savings as Well as Costs: State Governments Would Spend at Least $90 Billion Less With the ACA than Without It from 2014 to 2019" (PDF). Washington, DC: The Urban Institute. Retrieved April 14, 2018.
  83. ^ Hatch, Brigit; et al. (2016). "Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act". American Journal of Public Health. 106 (4): 645–650. doi: 10.2105/AJPH.2016.303060. PMC  4894650. Retrieved March 20, 2018.
  84. ^ Hatch, Brigit; et al. (2016). "Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act". American Journal of Public Health. 106 (4): 645–650. doi: 10.2105/AJPH.2016.303060. PMC  4894650. Retrieved March 20, 2018.
  85. ^ Katherine Baicker, Sarah Taubman, Heidi Allen, Mira Bernstein, Jonathan Gruber, Joseph P. Newhouse, Eric Schneider, Bill Wright, Alan Zaslavsky, Amy Finkelstein, and the Oregon Health Study Group, "The Oregon Experiment – Effects of Medicaid on Clinical Outcomes", The New England Journal of Medicine, 2013 May; 368(18): 1713-1722.
  86. ^ Hatch, Brigit; et al. (2016). "Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act". American Journal of Public Health. 106 (4): 645–650. doi: 10.2105/AJPH.2016.303060.