10
Demography of American Indian Elders: Social, Economic, and Health Status

Robert John

Introduction

Although age 65 has become the standard age at which individuals are considered elderly in American society, there is no such consensus among Indians.1 The Older Americans Act permits individual tribes to determine the age at which elders are eligible to receive aging services provided by the tribe. In exercising their discretion on this issue, tribes differ in their designation of the chronological age at which a person is entitled to services. There is no dispute, however, that both the overall American Indian and American Indian elderly populations have grown substantially during the last decade. In 1980, American Indians aged 60 and over comprised approximately 8 percent of the total Indian population, compared with a figure of 16 percent for the general U.S. population. By 1990, these percentages had increased to 9 and 17 percent, respectively.

   

This chapter is an abbreviated version of a paper prepared at a Workshop on the Demography of American Indian and Alaska Natives, held at the National Research Council in May 1995. The original version is available from the author. Partial support for this research was provided by the National Institute on Aging grant number R01-AG11294. I would like to acknowledge the assistance of Heather Goggans, Research Scientist in the University of North Texas Minority Aging Research Institute, and Patrice H. Blanchard, Executive Director of the Southwest Society on Aging.

1  

For the purpose of this study, the terms "Indian" and "American Indian" are used inter-changeably and refer to American Indians and Alaska Natives (Eskimo and Aleuts).



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--> 10 Demography of American Indian Elders: Social, Economic, and Health Status Robert John Introduction Although age 65 has become the standard age at which individuals are considered elderly in American society, there is no such consensus among Indians.1 The Older Americans Act permits individual tribes to determine the age at which elders are eligible to receive aging services provided by the tribe. In exercising their discretion on this issue, tribes differ in their designation of the chronological age at which a person is entitled to services. There is no dispute, however, that both the overall American Indian and American Indian elderly populations have grown substantially during the last decade. In 1980, American Indians aged 60 and over comprised approximately 8 percent of the total Indian population, compared with a figure of 16 percent for the general U.S. population. By 1990, these percentages had increased to 9 and 17 percent, respectively.     This chapter is an abbreviated version of a paper prepared at a Workshop on the Demography of American Indian and Alaska Natives, held at the National Research Council in May 1995. The original version is available from the author. Partial support for this research was provided by the National Institute on Aging grant number R01-AG11294. I would like to acknowledge the assistance of Heather Goggans, Research Scientist in the University of North Texas Minority Aging Research Institute, and Patrice H. Blanchard, Executive Director of the Southwest Society on Aging. 1   For the purpose of this study, the terms "Indian" and "American Indian" are used inter-changeably and refer to American Indians and Alaska Natives (Eskimo and Aleuts).

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--> In absolute numbers, there were 108,800 American Indian elders out of a total Indian population of 1,423,043 in 1980 and 165,842 elders out of a total American Indian population of 1,959,234 in 1990, a 52 percent increase during the decade. American Indian elders may be particularly vulnerable to a number of conditions experienced by elderly populations generally, including social isolation, economic hardship, and health problems. Yet for various reasons, accurate demographic information has been difficult to obtain for American Indians in general and for American Indian elders in particular. Only the decennial census conducted by the U.S. Bureau of the Census and vital events data compiled by the National Center for Health Statistics represent attempts to collect information about the entire American Indian population. However, the accuracy of census data has been an area of debate among demographers for some time (Passel, 1976; Passel and Berman, 1986; Snipp, 1989; Harris, 1994), and the accuracy of vital statistics is now under scrutiny (Sugarman et al., 1993; Indian Health Service, 1995a). The general lack of demographic data on the American Indian elderly population must inevitably confound the targeting of efforts aimed at identifying and addressing their needs. The purpose of this chapter is to provide a description of the status and characteristics of American Indian elders in rural/reservation and urban environments. Using data primarily from the most recent census, the chapter presents a profile of the American Indian elderly population, focusing on marital status, household composition, economic status, and place of residence. This profile is followed by a review of mortality and disability patterns. The concluding section addresses the data limitations and the implications these limitations have for the well-being of American Indian elders. Marital Status And Household Composition Demographic information on social characteristics such as marital status and household composition is vital to understanding the needs of the American Indian elderly and to planning for the provision of appropriate healthcare and other services for this population. Overall, female American Indian elders aged 60 and over are far less likely than male Indian elders to be married (38 versus 66 percent) and nearly three times more likely to be widowed (45 versus 15 percent). Among American Indian elders aged 60 and over, 66 percent of males have a spouse, while 62 percent of females do not. In fact, the majority of male American Indian elders are married until advanced old age. In comparison, a majority of American Indian female elders aged 65 to 74 no longer have a husband. After age 85, when widowhood is extremely pervasive, only 9

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--> percent of female elders still have a spouse. In contrast, even at advanced old age, a substantial proportion of American Indian male elders are still married (43 percent) and in a proportion roughly equivalent to widowers (44 percent). In general, the sex-ratio imbalance among American Indian elders is not very different from that among the white elderly population, according to 1990 data. Approximately 57 percent of the American Indian population aged 60 years and over is female, compared with 58 percent of the white elderly population (U.S. Department of Commerce, 1993). However, the sex ratio differs substantially between urban and rural American Indian elderly populations. Females comprise 59 percent of the urban but only 53 percent of the rural American Indian elderly population. These differences in the marital status of male and female elders are reflected in the composition of their households. According to 1990 census data (U.S. Department of Commerce, 1992), 28 percent of all American Indian elders aged 65 and over lived alone. However, consistent with differences in marital status, only 20 percent of American Indian male elders aged 65 and over lived alone, compared with 35 percent of their female counterparts. Because of the lack of aging services, elderly American Indians often rely heavily upon family members for support and assistance with healthcare needs. However, as American Indian elders grow old, the likelihood of living alone increases, thus limiting their immediate access to care provided by family members. Twenty-four percent of American Indian elders aged 65-74, 35 percent of those aged 75-84, and 38 percent of those aged 85 and over lived alone in 1990. When gender and age are considered separately, women elders were far more likely to live alone than male elders: among those 65-74, 18 percent of males versus 29 percent of females; among those 75-84, 22 percent of males versus 43 percent of females; and among those over 85, 27 percent of males versus 45 percent of females. Economic Status The social characteristics discussed above have direct effects on economic status in later life. Two income measures are used to assess the economic status of American Indian elders: personal income or the individual income from all sources received by a particular American Indian elder, and family income, the sum of the incomes of all members of a family who are at least 15 years old.

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--> Poverty As defined by the federal government, the poverty line is meant to signify the minimum income required to provide the necessities of life.2 Many researchers, however, believe that the official poverty line does not provide an adequate standard of living and prefer using 125 percent above the poverty line (also known as near poverty) as a more accurate gauge of economic deprivation (Chen, 1994). If near poverty is used as the standard for judging economic deprivation, then 39 percent of American Indian elders over age 60 experienced this hardship in 1989. If the official poverty line is used, then 29 percent of all American Indians aged 60 and older lived in poverty in 1989 (U.S. Department of Commerce, 1994). Table 10-1 reveals the extent of poverty among American Indian, black, and non-Hispanic white elders using different poverty standards. The overall similarity between black and American Indian elders on this measure of well-being is conspicuous. Poverty among the general American Indian population increased during the 1980s. Regardless of age, poverty among American Indians is relatively common. Nearly 31 percent of all American Indians lived below the poverty line in 1989 (U.S. Department of Commerce, 1993:49). American Indian families also experience poverty. In 1979, there were 81,078 American Indian families (24 percent) with income below the poverty line. By 1989, this figure had risen to 125,432 (27 percent). Of these financially impoverished American Indian families, approximately 9 percent were headed by a householder 65 years of age or older. Marital status and living arrangements influence the likelihood of living in poverty among American Indian elders. In 1989, among households headed by an American Indian aged 65 or over, only 20 percent of married-couple families, compared with 37 percent of female-headed families with no husband present, lived in poverty. Poverty among unrelated American Indian individuals3 was even higher than among American Indian families in 1989: approximately 43 percent of unrelated American Indian individuals aged 65 and over were impoverished in 1989. Poverty among American Indian elders is also influenced by rural or urban residence: it is substantially higher among the former than the 2   The income level used to determine federal poverty status is lower for elders than for younger age groups. It is reasoned that elders do not need as much income since, for example, they do not incur commuting expenses or need to purchase clothes to participate in the labor force, and they no longer need to purchase a home. 3   According to the U.S. census definition, an unrelated individual is someone who lives alone or with nonrelatives, is not related to the householder, or is a person living in group quarters who is not living in an institution.

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--> TABLE 10-1 Poverty Status Among Persons 60 Years and Over by Race: 1990 (percent)   Poverty Status Race Below Poverty Below 125% of Poverty Below 150% of Poverty Below 200% of Poverty American Indian 28.5 38.5 46.4 58.5 Black 30.2 40.1 48.0 59.9 White, non-Hispanic 9.8 15.5 21.0 31.6   SOURCE: U.S. Department of Commerce (1994:Table 1) latter, regardless of living arrangements. In fact, 63 percent of American Indian elders in poverty lived in a rural environment in 1989 (U.S. Department of Commerce, 1993). Sources of Income Figure 10-1 contrasts the sources of personal income among American Indian and non-Hispanic white elders. It shows that American Indian elders receive substantially more of their income from Social Security; public assistance, including Supplemental Security Income; and other sources (which include all forms of native craft production). In comparison, non-Hispanic whites have a distinct advantage in the proportion of their income received from accumulated assets such as interest, dividends, and net rental income. These findings are consistent with previous research based on the 1980 census (John, 1995), which found that major differences in sources of income distinguished Indian elders who lived above the poverty line from their financially impoverished Indian counterparts who lived in the same type of family arrangement. Families headed by an American Indian elder with income above the poverty line had substantially more earnings (49 vs. 22 percent) and were far less dependent on Social Security (25 vs. 47 percent) and public assistance (5 vs. 25 percent) than financially impoverished families. Moreover, 7 percent of their income came from accumulated assets, compared with less than 1 percent among impoverished families. Significant earnings also distinguished the families headed by a female elder who had income above the poverty line (59 vs. 24 percent). These families, too, were far less dependent on Social Security income (19

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--> FIGURE 10-1 Source of income of persons aged 60 years and over: 1989. SOURCE: U.S. Department of Commerce (1994:Table 11b). vs. 36 percent) and public assistance (8 vs. 32 percent) than impoverished female-headed families. Moreover, they received significantly more income from accumulated assets (6 vs. 1 percent). Among unrelated American Indian elders with income above the poverty line, income from earnings, assets, and other sources was substantially higher than among financially impoverished elders in the same living arrangement. Indeed, unrelated individual American Indian elders with income below the poverty line received 89 percent of their income from Social Security and public assistance, compared with only 48 percent among unrelated Indian elders with income above the poverty line.

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--> Among U.S. elders aged 60 and over, regardless of race or ethnicity, Social Security is the foundation of old-age income security. Among the American Indian elderly population aged 60 and over, 52 percent depend on Social Security for half or more of their total income (U.S. Department of Commerce, 1994). Moreover, Social Security constitutes the only source of income for 30 percent of American Indian elders. What is surprising about this situation is the marginal difference among groups on this important measure of well-being. Even the most privileged group (non-Hispanic whites) is also highly dependent on Social Security: half of non-Hispanic whites receive half or more of their income from Social Security, and 26 percent rely on Social Security as their only source of income. At the same time, as indicated by personal income figures, non-Hispanic whites receive higher income from Social Security, thus preserving income differences into old age. According to census data (U.S. Department of Commerce, 1994), non-Hispanic whites aged 60 and over had a median personal income of $11,581 in 1989, compared with $7,109 for their American Indian counterparts. In other words, the median income of non-Hispanic white elders was $373 per month more than that of American Indian elders. The income difference is even greater if one looks at average income: the average income of white elders ($19,070) was approximately 1.7 times that of American Indian elders ($11,368). There is a similar income differential between the family incomes of American Indian and non-Hispanic white elderly householders (U.S. Department of Commerce, 1994). Whether one considers median or average family income, non-Hispanic white householders aged 60 and over have 1.6 times the income of their American Indian counterparts. Spatial Distribution Access to healthcare and other services varies by place of residence, so it is important to consider the geographic location of American Indian elders in addition to other social and economic characteristics. U.S. Census data show that the American Indian elderly population is highly concentrated. As of 1990, two-thirds of all American Indian elders aged 60 and over lived in ten states, and approximately half lived in five states (U.S. Department of Commerce, 1991). Oklahoma had the largest number of American Indian elders, with approximately 18 percent of the nation's total. Another 13 percent of all Indian elders lived in California, followed by Arizona (9 percent), New Mexico (6 percent), and North Carolina (5 percent). Alaska, New York, Texas, Washington, and Michigan are the remaining states with large American Indian elderly populations. Overall, 48 percent of the America Indian elderly population aged 60 years and over lived in a rural environment in 1990. Although there is a

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--> slight decrease after age 75, rural residence among the American Indian population tends to increase with age (John and Baldridge, 1996). This tendency contrasts with the non-Hispanic white and Hispanic populations, which both show a consistent negative association between advancing age and rural residence. Rural residence among aging blacks increases with age, although a much smaller percentage of the black population resides in a rural area. A related issue with significant policy and programming implications for health and social service providers concerns the extent of and reasons for migration associated with aging among American Indians. It is commonly held that urban American Indians move to a reservation environment upon retirement, although a study of urban American Indian elders living in Los Angeles found that this is not the case (Kramer et al., 1990; Kramer, 1991; cf. Weibel-Orlando, 1988). It is possible that urban-to-rural migration occurs for reasons other than retirement. For example, one factor that could contribute to this pattern is the migration of aging urban American Indians back to rural or reservation environments because of worsening health, based on the assumption that their healthcare needs will be addressed through access to free Indian Health Service (IHS) medical care. This suggests that reverse migration may be associated with health status rather than work status or advancing chronological age. Mortality And Disability Life Expectancy at Birth The last 50 years has seen a remarkable improvement in life expectancy at birth for American Indians. Based on calculations that exclude the IHS service areas with documented underreporting of Indian deaths, life expectancy at birth for American Indians increased by 19 years from 51 to 70 years during the 50-year period between 1940 and 1990-1992 (Indian Health Service, 1991, 1995a). This improvement is attributable largely to the efforts of IHS to eliminate infectious disease and meet the acute-care needs of the Indian population, including aggressive efforts to improve maternal and child health. Over the last 40 years since IHS assumed responsibility for American Indian healthcare, the shift in prevalence from acute and infectious diseases to chronic and degenerative diseases among American Indians has prompted several researchers to conclude that the American Indian population is undergoing an epidemiologic transition (Broudy and May, 1983; Kunitz, 1983; Manson and Callaway, 1990; Young, 1994; see also the chapters by Young and Snipp in this volume). Consistent with this interpretation, Johnson and Taylor (1991) documented the

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--> fact that chronic diseases are rising among the IHS American Indian service population. This change in morbidity is leading to a change in the mortality profile of American Indian elders. Comparative Mortality Rates Despite recognizable health improvements, life expectancy at birth among American Indians remains below that of whites. This difference in life expectancy is attributable to higher age-specific death rates among American Indians under the age of 65 years. Indeed, according to IHS figures, among American Indian elders aged 75 and over the mortality rate from all causes of death is lower than that for elders among the general U.S. population. In addition to the differences in overall mortality, there are substantial differences in cause-specific mortality rates among American Indian elders and the general elderly population. American Indian elders had lower mortality rates than the general elderly population for the four leading causes of death—heart disease, cancer, cerebrovascular diseases, and chronic obstructive pulmonary disease—but higher mortality for all other causes (John, 1995). In particular, American Indian elders had higher mortality from diabetes mellitus, accidents, and pneumonia and influenza. Trends in Mortality: 1977-1988 Figure 10-2 shows changes in mortality for the six leading causes of death among American Indian elders between 1977 and 1988.4 Cardiovascular disease showed little change during the period, while two causes of mortality—malignant neoplasms and diabetes mellitus—increased. Three of the leading causes of mortality—cerebrovascular diseases, pneumonia and influenza, and accidents—showed improvement. Although mortality caused by cardiovascular disease appears to have decreased slightly from 1977 to 1983, the overall trend remained relatively constant if one considers the entire period. In contrast to the trend for cardiovascular disease, rates of death due to malignant neoplasms among Indian elders showed a steady increase of 19 percent during the period. Mortality rates from cerebrovascular disease decreased by approximately 26 percent. Death rates attributable to pneumonia and influenza fell by approximately 4   This figure does not reflect the recent modifications introduced by IHS in the calculation of mortality rates. Therefore, it should be interpreted as showing relative rather than absolute changes in mortality trends.

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--> FIGURE 10-2 Leading causes of mortality among American Indians aged 65 and over (1977-1988). SOURCE: Indian Health Service, Division of Program Statistics.

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--> 14 percent between 1977 and 1988. Diabetes appears to be a growing health problem among American Indian elders, and Figure 10-2 shows that diabetes mellitus replaced accidents as the fifth leading cause of mortality during the period, with death rates attributable to diabetes increasing by approximately 11 percent. Death rates due to accidental injuries decreased by approximately 18 percent between 1977 and 1988 among the American Indian elderly population. This trend is encouraging and appears to be sustained in the latest mortality figures, which show that death rates due to chronic obstructive pulmonary diseases among this population are now higher than those due to accidental causes. Nevertheless, despite continued improvement in mortality, accidents remain the seventh leading cause of death among American Indian elders, according to the most recent figures (Indian Health Service, 1995b). Disability Status In comparison with previous decennial census surveys, the 1990 census collected more data about a person's health or functional status. For the first time, the census included questions about the existence of two types of disability: a mobility and a self-care limitation. Each of these conditions was defined as the result of the existence of a physical or mental health condition that had lasted for 6 months or more. A mobility limitation is a global measure of the ability to perform instrumental activities of daily living outside the home, such as shopping or going to the doctor's office. A self-care limitation is a global measure of the ability to perform personal activities of daily living inside the home, such as dressing or bathing. As seen in Figure 10-3, the data suggest that such limitations are more common among female than male American Indian elders. This gender difference is particularly pronounced for mobility limitations; overall, the differences in the percentages of elders with self-care limitations are quite small. In contrast, far fewer whites experience either type of disability. Other data from the 1990 census (U.S. Department of Commerce, 1994:Table 6) indicate the level of work disability among the elderly U.S. population aged 60 years and over. According to these data, American Indian elders report the highest level of work disability among the five racial groups. Among American Indian elders, 44 percent report a work disability, compared to only 29 percent of non-Hispanic whites. Moreover, over one-third of American Indian elders (37 percent) report that their condition prevents them from working, compared to only 23 percent of their non-Hispanic white age peers.

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--> FIGURE 10-3 American Indian elders aged 65 years and over with a mobility or self-care limitation by age group and sex: 1990. SOURCE: U.S. Department of Commerce (1993:Table 40). Discussion The above sections have provided a sketch of the demography of American Indian elders. The meagerness of available information reflects a number of limitations inherent in the current state of demographic knowledge about aging American Indians (John, 1994). Researchers who study American Indian aging issues are highly dependent upon the decennial census and annual vital statistics collection efforts. With few exceptions, what can be known about the entire American Indian population comes from these two sources. Persistent questions about data quality, gaps in the types of information collected, lack of funding to sustain special demographic studies or publications, delayed or exceptionally cumbersome access to data on American Indians, and other fundamental problems hamper our ability to construct a basic description of the American Indian elderly population so necessary for effective social planning. The lack of comprehensive data and reliable research knowledge on the American Indian elderly population has obvious policy and programming

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--> implications. Even if resources are made available, it is possible that efforts to address the needs of this population will be poorly targeted. If the well-being of American Indian elders is to be improved, a sustained effort to determine the basic socioeconomic and health characteristics of rural and urban American Indian elders is imperative. References Broudy, D.W., and P.A. May 1983 Demographic and epidemiologic transition among the Navajo Indians. Social Biology 30(1):7-19. Chen, Y.P. 1994 Improving the economic security of minority persons as they enter old age. Pp. 22-31 in Minority Elders: Longevity, Economics and Health. Second Edition. Washington, D.C.: Gerontological Society of America. Harris, D. 1994 The 1990 Census count of American Indians: What do the numbers really mean? Social Science Quarterly 75:580-593. Indian Health Service 1991 Trends in Indian Health—1991. Rockville, MD: Indian Health Service. 1995a Regional Differences in Indian Health—1995. Rockville, MD: Indian Health Service. 1995b Trends in Indian Health—1995. Rockville, MD: Indian Health Service . John, R. 1994 The state of research on American Indian elders' health, income security, and social support networks. Pp. 46-58 in Minority Elders: Longevity, Economics and Health. Second Edition. Washington, D.C.: Gerontological Society of America. 1995 American Indian and Alaska Native Elders: An Assessment of Their Current Status and Provision of Services. Rockville, MD: Indian Health Service. John, R., and D. Baldridge 1996 The NICOA Report: Health and Long-Term Care for American Indian Elders. A Report by the National Indian Council on Aging to the National Indian Policy Center. Washington, D.C. Johnson, A., and A. Taylor 1991 Prevalence of Chronic Diseases: A Summary of Data from the Survey of American Indians and Alaska Natives. AHCPR Pub. No. 91-0031. Rockville, MD: Public Health Service, Agency for Health Care Policy and Research. Kramer, B.J. 1991 Urban American Indian aging. Journal of Cross-Cultural Gerontology 6:205-217. Kramer, B.J., D. Polisar, and J.C. Hyde 1990 Study of Urban American Indian Aging. Final Report to the Administration on Aging. Grant No. 90AR0118. City of Industry, CA: The Public Health Foundation of Los Angeles County. Kunitz, S.J. 1983 Disease Change and the Role of Medicine: The Navajo Experience . Berkeley, CA: University of California Press. Manson, S.M., and D.G. Callaway 1990 Health and aging among American Indians: Issues and challenges for the biobehavioral sciences. Pp. 63-119 in M. Harper, ed., Minority Aging: Essential Curricula Content for Selected Health and Allied Health Professions. Washington, D.C.: U.S. Government Printing Office.

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--> Passel, J.S. 1976 Provisional evaluation of the 1970 census count of American Indians. Demography 13:397-409. Passel, J.S., and P.A. Berman 1986 Quality of 1980 census data for American Indians. Social Biology 33:163-182. Snipp, C.M. 1989 American Indians: The First of This Land. New York: Russell Sage Foundation. Sugarman, J.R., M. Holliday, K. Lopez, and D. Wilder 1993 Improving Health Statistics Among American Indians by Data Linkages with Tribal Environment Registries. Washington, D.C.: National Center for Health Statistics. U.S. Department of Commerce 1991 The Population 50 Years and Older, by Sex, Race, and Hispanic Origin for the United States, Regions and States: 1990. Washington, D.C.: U.S. Government Printing Office. 1992 General Population Characteristics: United States. Washington, D.C.: U.S. Government Printing Office. 1993 Social and Economic Characteristics: United States. Washington, D.C.: U.S. Government Printing Office. 1994 Census of Population and Housing, 1990: Special Tabulation on Aging (STP 14). Washington, D.C.: U.S. Government Printing Office. Weibel-Orlando, J. 1988 Indians, ethnicity as a resource and aging: You can go home again. Journal of Cross-Cultural Gerontology 3:323-348. Young, T.K. 1994 The Health of Native Americans: Towards a Biocultural Epidemiology . Oxford: Oxford University Press.

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