Changing Numbers,
Changing Needs

American Indian Demography and Public Health

Gary D. Sandefur, Ronald R. Rindfuss
and Barney Cohen, Editors

Committee on Population

Commission on Behavioral and Social Sciences and Education

National Research Council

NATIONAL ACADEMY PRESS
Washington, D.C. 1996



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--> Changing Numbers, Changing Needs American Indian Demography and Public Health Gary D. Sandefur, Ronald R. Rindfuss and Barney Cohen, Editors Committee on Population Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1996

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--> NATIONAL ACADEMY PRESS 2101 Constitution Ave., N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Support for this project was provided principally by the Public Health Service of the U.S. Department of Health and Human Services. The National Institute of Aging also provided funding to the Committee on Population for this project. Library of Congress Catalog Card No. 96-70052 International Standard Book Number 0-309-05548-2 Changing Numbers, Changing Needs: American Indian Demography and Public Health is available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). Order electronically via Internet at http://www.nap.edu. Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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--> Contributors ANNIE C. ABELLO, Economics Program, Research School of Social Sciences, Australian National University BARNEY COHEN, Committee on Population, National Research Council PETER J. CUNNINGHAM, Center for Studying Health System Change, Washington, D.C. EUGENE P. ERICKSEN, Departments of Sociology and Statistics, Temple University ROBERT G. GREGORY, Economics Program, Division of Economics and Politics, Research School of Social Sciences, Australian National University ROBERT JOHN, Minority Aging Research Institute, University of North Texas JAMIE JOHNSON, Department of Economics, University of Chicago CAROLYN A. LIEBLER, Center for Demography and Ecology, University of Wisconsin, Madison PHILIP A. MAY, Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico K.M. VENKAT NARAYAN, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services JEFFREY S. PASSEL, The Urban Institute, Washington, D.C. RONALD R. RINDFUSS, Carolina Population Center, University of North Carolina, Chapel Hill GARY D. SANDEFUR, Department of Sociology, University of Wisconsin, Madison C. MATTHEW SNIPP, Department of Rural Sociology, University of Wisconsin, Madison RUSSELL THORNTON, Department of Anthropology, University of California, Los Angeles RONALD L. TROSPER, Native American Forestry Program, Northern Arizona University T. KUE YOUNG, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba

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--> Committee On Population RONALD D. LEE (Chair), Departments of Demography and Economics, University of California, Berkeley CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University JOSE-LUIS BOBADILLA, The World Bank, Washington, D.C. JOHN BONGAARTS, The Population Council, New York JOHN B. CASTERLINE, The Population Council, New York LINDA G. MARTIN, RAND, Santa Monica, California ROBERT A. MOFFITT, Department of Economics, Brown University MARK R. MONTGOMERY, The Population Council, New York W. HENRY MOSLEY, Department of Population Dynamics, Johns Hopkins University ALBERTO PALLONI, Department of Sociology, University of Wisconsin, Madison ANNE R. PEBLEY,* RAND, Santa Monica, California RONALD R. RINDFUSS, * Carolina Population Center, University of North Carolina, Chapel Hill JAMES P. SMITH, RAND, Santa Monica, California BETH J. SOLDO, Department of Demography, Georgetown University MARTA TIENDA, Population Research Center, University of Chicago AMY O. TSUI, Carolina Population Center, University of North Carolina, Chapel Hill JOHN G. HAAGA, Director BARNEY COHEN, Program Officer TRISH DeFRISCO, Senior Project Assistant KAREN A. FOOTE, Program Officer JOEL A. ROSENQUIST, Project Assistant JOYCE E. WALZ,** Administrative Associate *   through October 1995 **   through May 1996

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--> The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is interim president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and interim vice chairman, respectively, of the National Research Council.

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--> Preface The Committee on Population was established by the National Research Council in 1983 to bring the knowledge and methods of the population sciences to bear on major issues of science and public policy. The committee's mandate is to conduct scientific assessments of major population issues and to provide a forum for discussion and analysis of important public policy issues related to population. The papers in this volume were first presented at a Committee on Population workshop on the demography of American Indians and Alaska Natives. The workshop, which was held in May 1995 at the request of the Public Health Service, brought together researchers from different disciplines to discuss recent issues in American Indian demography and their implications for health service delivery. At that time, a number of alternative plans for reforming healthcare were being considered, each of which offered explicitly and implicitly different options for providing healthcare to beneficiaries of the IHS. The papers prepared for the workshop were not designed to present the needed information directly, but to provide background data that could be used by the Public Health Service and the IHS in preparing such estimates for their deliberations. A major challenge for demographers concerned with American Indian and Alaska Native populations is to differentiate between changes in the size, characteristics, and distribution of these populations caused by fertility, mortality, and migration trends and changes caused by the increased tendency of people to identify themselves as Indians in response

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--> to census or survey questions on race, ethnicity, and ancestry. Over the last 20 years, changes in self-identification have been substantial and have affected estimates of birth and death rates, as well as estimates of the geographic and income distributions of American Indians. Changes in self-identification and eligibility affect the estimates and projections, particularly the long-range projections, of the population relevant to Indian Health Service (IHS) and other agencies that provide services for American Indians. Many of the people newly identifying themselves as American Indian are unlikely to have been served in the past by the IHS. Hence, designing plans for coverage of eligible IHS beneficiaries, projecting enrollments, and estimating utilization and premiums, requires up-to-date estimates of the size, composition, distribution, economic characteristics, and health care needs of the potentially eligible populations. This volume pulls together information on the demography and health status of American Indians. The work would not have been possible without the efforts of several people, but two deserve special recognition. First, the committee was extremely fortunate in being able to enlist the services of Gary D. Sandefur, a distinguished scholar of American Indian demography, to collaborate on the project and ensure that it was a success. Second, committee member Ronald R. Rindfuss worked diligently to organize the workshop and share the editorial duties for this volume. The committee expresses its heartfelt appreciation to both of them for contributing so much of their valuable time and expertise. The committee is grateful to the Public Health Service for its financial support and to staff members Susanne Stoiber and Maruta Zitans for their interest and efforts during the development of the workshop. The Committee would also like to thank the National Institute on Aging for providing funding for this project. Finally, we thank the staff at the National Research Council, who made it all possible. The work took place under the general direction of John Haaga, director of the Committee on Population. Barney Cohen, program officer, provided a constant intellectual and managerial presence for the project, from the organization of the workshop to the publication of this volume. Trish DeFrisco, senior project assistant, efficiently and diligently took care of all the logistical arrangements and prepared the papers for publication. We also thank Rona Briere for her skillful editing of the manuscript. We are grateful to them all. Ronald D. Lee, Chair Committee on Population

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--> Contents 1   INTRODUCTION Gary D. Sandefur, Ronald R. Rindfuss, and Barney Cohen   1 I Overview of Demographic and Health Conditions     2   THE SIZE AND DISTRIBUTION OF THE AMERICAN INDIAN POPULATION: FERTILITY, MORTALITY, RESIDENCE, AND MIGRATION C. Matthew Snipp   17 3   RECENT HEALTH TRENDS IN THE NATIVE AMERICAN POPULATION T. Kue Young   53 II Identification: Indications and Consequences     4   THE GROWING AMERICAN INDIAN POPULATION, 1960-1990: BEYOND DEMOGRAPHY Jeffrey S. Passel   79 5   TRIBAL MEMBERSHIP REQUIREMENTS AND THE DEMOGRAPHY OF "OLD" AND "NEW" NATIVE AMERICANS Russell Thornton   103

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--> 6   PROBLEMS IN SAMPLING THE NATIVE AMERICAN AND ALASKA NATIVE POPULATIONS Eugene P. Ericksen   113 III Social and Economic Conditions     7   THE INDIVIDUAL ECONOMIC WELL-BEING OF NATIVE AMERICAN MEN AND WOMEN DURING THE 1980s: A DECADE OF MOVING BACKWARDS Robert G. Gregory, Annie C. Abello, and Jamie Johnson   133 8   AMERICAN INDIAN POVERTY ON RESERVATIONS, 1969-1989 Ronald L. Trosper   172 9   THE DEMOGRAPHY OF AMERICAN INDIAN FAMILIES Gary D. Sandefur and Carolyn A. Liebler   196 10   DEMOGRAPHY OF AMERICAN INDIAN ELDERS: SOCIAL, ECONOMIC, AND HEALTH STATUS Robert John   218 IV Health Issues and Health Care Access and Utilization     11   OVERVIEW OF ALCOHOL ABUSE EPIDEMIOLOGY FOR AMERICAN INDIAN POPULATIONS Philip A. May   235 12   DIABETES MELLITUS IN NATIVE AMERICANS: THE PROBLEM AND ITS IMPLICATIONS K.M. Venkat Narayan   262 13   HEALTH CARE UTILIZATION, EXPENDITURES, AND INSURANCE COVERAGE FOR AMERICAN INDIANS AND ALASKA NATIVES ELIGIBLE FOR THE INDIAN HEALTH SERVICE Peter J. Cunningham   289

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