Editor’s Note: This blog post was supported by a yearlong Reporting Fellowship on Health Care Performance sponsored by the Association of Health Care Journalists and supported by the Commonwealth Fund. Additional pieces in the series were published in Health Affairs in April 2017, August 2017, and January 2018.

Jordan Lewis, a professor at the University of Anchorage Alaska and director of the National Resource Center for Alaska Native Elders, doesn’t like the phrase “silver tsunami.” As a glib nod to the rapidly aging US population, it unfortunately “assumes destruction,” he says. He has a point: These are people we’re talking about, not natural disasters. Still, without a solid infrastructure in place to care for our nation’s elderly, the results indeed could be devastating. That fact is keenly felt in Indian Country, where the long-term care infrastructure leaves much to be desired. Today, American Indians and Alaska Natives are living longer, with more functional disabilities than the rest of the population, suggesting that the population needing long-term care will balloon in the coming years. In 1940, the life expectancy of American Indians was about 52 years—now it’s nearly 74 years (although still lower than the most recent life expectancies reported for whites, blacks, and Hispanics). Between 2000 and 2010, the number of American Indians and Alaska Natives age 65 or older increased by 40.5 percent, growing at double the rate of the overall older population. Existing mechanisms for funding long-term care in Indian Country will be hard-pressed to keep pace with demand.

Currently, tribes pay for long-term care with a mishmash of funding from various federal agencies, such as the Centers for Medicare and Medicaid Services and the Administration for Community Living, along with their own resources from tribal ventures such as casinos. Dedicated funding from Congress for long-term services and supports for tribes, authorized under the Affordable Care Act (ACA) but never appropriated, would allow them to devise creative ways to support older natives and those with serious disabilities. However, is there any additional funding on the table for the taking?

Indian Health Service: We Have Authority But No Funds

The Indian Health Service (IHS), which provides direct health care services to more than 40 percent of tribes and provides funding and support to nearly 60 percent of tribes who manage all or part of their health systems themselves, was initially set up to deliver only hospital-based, acute care. Today, the system does much more, and with the lowest per capita budget of most government health programs. The agency’s authority to provide long-term services and supports wasn’t solidified until 2010, when a permanent reauthorization of the Indian Health Care Improvement Act passed as part of the ACA. The updated Indian Health Care Improvement Act made it clear that the Department of Health and Human Services could fund hospice care, assisted living services, long-term care services, and home- and community-based services in Indian Country. However, just because the law allowed resources finally to be spent on a wider range of services, doesn’t mean that more resources actually became available. From 2003 to 2012, the IHS provided some grant funding to support tribes in developing long-term services and supports programs, but dedicated funds for long-term services and supports have never been included in the agency’s federal budget.

“If Congress appropriated a line item for long-term services and supports, that money would be given to tribes,” explains Bruce Finke, the elder health consultant for the IHS, who works in the Nashville, Tennessee, area. Finke is a family physician and geriatrician who has been working with the IHS and tribes programs for more than 20 years to develop services for American Indian and Alaska Native elders. “Right now they have the authority but no money.”

A Patchwork Approach

Today, many tribes provide long-term services and supports to their members through funding from the Administration for Community Living’s Administration on Aging, under Titles III and VI of the Older Americans Act. Title III and Title VI programs pay for nutrition services, transportation, in-home services, caregiver support, and other supportive services. About 1.2 percent of older Title III beneficiaries are American Indians and Alaska Natives, and Title VI programs are specifically targeted at older American Indians, Alaska Natives, and Native Hawaiians.

These programs play “a huge role” in the lives of American Indian and Alaska Native elders, in many cases serving as the hub of long-term services and supports for the tribe, the IHS’s Finke says. However, they’re not funded to provide the full suite of long-term services and supports that elders need. Over the years, Older Americans Act funding has remained flat or declined, despite the growing number of people who could benefit from the support.

Medicaid also pays for a lot of long-term care for American Indians and Alaska Natives, as it does for the rest of the population. Medicare pays for some skilled care in nursing homes or at home but only for a short time after a hospitalization and for nonchronic conditions.

For providers and programs, meeting Medicare and Medicaid’s conditions of participation can be a struggle, however, tribes say. For instance, to receive Medicare reimbursement for home health services and hospice services, programs must obtain Medicare certification through a rigorous licensure process, which may require that care providers have certain levels of education and pass thorough background checks.

“There are challenges around getting people licensed or credentialed because of background checks,” says the University of Anchorage’s Lewis, who is Alaska Native. “If you had a DUI 40 years ago, that’s on your record [and] you can’t care for a vulnerable population.”

Another critical source of funds for native elders comes from the Department of Veterans Affairs (VA). Nearly 1 percent of veterans identify as American Indian or Alaska Native, and compared with all other veterans, more native veterans have a disability. A 2009 study found that of 64,746 IHS enrollees who sought care from the Veterans Health Administration (VHA), IHS, or both, 25 percent accessed care at both health care organizations, but most accessed IHS care only. Another 2009 study found there was little coordination between the VHA and the IHS, resulting in care delays and treatment conflicts. Tribes and the IHS have been working to improve the coordination of services funded by the Administration on Aging, the IHS, and the VA to stretch these existing resources.

Dedicated Funding Would Provide Flexibility

Having dedicated funding for long-term services and supports for Native Americans would give tribes flexibility in designing programs that meet their populations’ unique needs.

Like many older Americans, Native American elders prefer to live at home or in home-like settings. However, many native communities are located in extremely rural areas, may lack electricity and running water, and may be accessible only by dirt roads. All of this makes it difficult to “age in place” or receive home-based care.

“It’s not unusual in Navajo [Nation] to see elders enter facility-based care in the fall and go back home in the summer,” Finke says. “You might see the same thing in Alaska.”

In western Navajo Nation, which encompasses parts of Arizona and Utah, communities are isolated from one another, and some remain completely cut off from modern amenities such as electricity and water service.

The Tuba City Regional Health Care Corporation, a tribally run health organization that serves the western Navajo region, confronts these issues on a daily basis. The health system wants to open a 24-unit independent living center in the town of Kaibeto, for residents older than age 65 who can no longer remain at home, or no longer want to.

“We wanted to create a community where elderly could live longer,” says Lynette Bonar, CEO of Tuba City Regional Health Care. “If we could get elders into those homes, they don’t have to chop wood, use an outhouse, and haul their water.”

However, finding the resources for this and other long-term care projects has proved challenging. Bonar hopes to fund the independent living center in part with Housing Choice (Section 8) housing subsidies from the Department of Housing and Urban Development. In nearby off-reservation towns, the vouchers are available to low-income families, the elderly, and the disabled to subsidize rent. Bonar is seeking to adapt the program for people living on the Navajo reservation.

The health system also has designed, with the help of the Navajo Housing Authority, a 90-bed long-term care facility that would include nursing home care (there are currently about 17 tribally run nursing homes in the US) but needs an additional $30 million in funding to complete the project, Bonar says.

Each tribe is different, as are the needs and preferences of their members, and the limitations or opportunities presented by their geographies. In Alaska, tribes have begun focusing on home- and community-based services as an alternative to nursing homes, which some villages have struggled to fill and staff, Lewis says. In particular, tribes are exploring small group homes for semi-independent elders, with a community member on site to help prepare meals but no health services provided, as one potential model.

A one-size-fits-all approach to enhancing long-term care in Indian Country is unlikely to satisfy everyone. Tribally run health systems have shown themselves to be innovators when it comes to using the funds available to them to meet the unique needs of their members. As the older native population grows, these innovations should be supported. Tribes want to care for their elders, Finke says. “But they can’t do that without resources.”