A Road Map for Strengthening Behavioral Health in American Indian and Alaska Native Communities

The need is great for behavioral health services in American Indian and Alaska Native (AI/AN) communities throughout the United States, which face disproportionately higher rates of substance use and mental health disorders than the non-Native U.S. population.

Courtesy of the National Council of Urban Indian Health

But insufficient funding for behavioral health services often prevents Native people from accessing quality care. Many Indian healthcare providers are chronically under-resourced, and urban and Tribal reservation AI/AN populations may not have access to various spending levels and services, depending on who they are and where they live.

Recognizing these financial challenges, the National Council of Urban Indian Health (NCUIH)—which advocates for the health and well-being of Native people living in urban areas—recently released a new toolkit. Created with support from The Pew Charitable Trusts and Bloomberg Philanthropies, the toolkit is aimed at helping Native communities better identify and leverage opportunities to financially support and sustain behavioral healthcare services.

This interview with Francys Crevier, the CEO of NCUIH, was edited for length and clarity.

What’s the state of behavioral health among American Indians and Alaska Natives? 

Behavioral healthcare within Native communities is a story of both progress and ongoing challenges. There's been tremendous work done in recent years. But these communities still face disproportionately higher rates of alcohol and substance use, mental health disorders, suicide, and violence than the general U.S. population. 

What services can help address these disparities?

Indian healthcare providers address mental health concerns such as depression, anxiety, and substance use disorders, as well as the effects of historical and intergenerational trauma from events such as forced relocation. To do this, they offer holistic approaches to address interconnected physical, emotional, and spiritual health needs with preventive programs, such as those geared toward Native youth, individual and group counseling, case management, crisis support, housing or employment support, and traditional healing practices. 

Can you tell us more about these traditional healing practices? 

These may include ceremonies, drumming, singing, dancing, practices that revive languages, and using traditional foods for healing. 

It's time to change the conversation about mental health and recognize that culture itself is a powerful protective factor for wellness. We've been healing ourselves longer than colonization has been here, and we will continue to heal ourselves.

In what ways do Native people access care?

When Native communities ceded our land as part of forced relocation, we entered into a trust-and-treaty obligation with the U.S. government. As part of that, the federal government committed to providing certain rights and resources to Native communities in perpetuity. As a result, healthcare services for Native communities are considered “prepaid” in exchange for our land. Today, the Indian Health System is the largest healthcare provider to Native people across the country and consists of federally funded facilities, Tribally operated facilities, and Urban Indian Organizations (UIOs). 

Is this “prepaid” funding sufficient?

No. Despite the federal government’s responsibility to provide healthcare to all Native people, there's a significant gap in funding levels between what our communities need and what they receive. This means that the Native populations do not have the same level of mental health and healthcare services as other groups in the U.S., and our communities must look to other funding sources, such as grants, to supplement the cost of care.

What are some of the impacts of this funding gap?

Grant management is time-consuming for UIOs, and even when grant funding comes through, it’s often restricted and short-term—which poses sustainability issues for programs. A lack of funding also presents workforce challenges, including recruitment and retention of qualified professionals, which can impact both the accessibility and the consistent delivery of care. And traditional healing programs are often not adequately funded or reimbursed by the Centers for Medicare and Medicaid Services or private insurers.

Could you explain the role of UIOs?

Sure. UIOs are Native-run nonprofits that were incorporated into the Indian Health Service in 1976, recognized by Congress to fulfill the trust-and-treaty obligation of healthcare for Native people who don’t live on reservations. Today, more than 70% of American Indian and Alaska Natives live in urban settings due to federal relocation efforts, so it's crucial that UIOs have access to strategies, tools, best practices, and data to effectively support their behavioral health programs.

So you’ve created a toolkit?

Exactly. The toolkit aims to help UIOs address the urgent need for sustainable funding and provides actionable strategies for developing sustainable financing models, optimizing Medicaid reimbursement, and accessing diverse funding opportunities from federal, state, local, and private sources. 

What else is in the toolkit?

There’s an overview of the current behavioral health landscape in Indian Country and guidance on understanding the patient journey from prevention through treatment and follow-up. The toolkit also addresses workforce challenges and advocates for expanding telehealth services to support a sustainable behavioral health workforce. 

How do you see this toolkit helping Native people?

Breaking down stigma barriers, meeting patients where they're at, and having adequate resources to address social determinants of health are essential next steps in improving access to healthcare and supporting better health outcomes for our populations. This toolkit is part of that effort. It's crucial that we keep pushing for greater funding and support to address the disparities between behavioral health services available in our communities and the services available to the rest of the U.S. population; we need to ensure that all American Indians and Alaska Natives have access to the resources and culturally competent healthcare they need to thrive.