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Table 2 Themes reflecting the interplay of macro, meso, and micro levels and recommendations to support alignment across these levels

From: Macro- and meso-level contextual influences on health care inequities among American Indian elders

Themes Interplay of Levels of Influence Recommendations for Alignment
1. Gaps in elder-oriented services
• Inadequate funding
• Limited availability and accessibility of services
• Workforce constraints
• Compromised quality of care
• Underfunding by Congress (macro) creates challenges for service provision in the I/T/U system (meso), while undermining access to, and availability, continuity, and quality of care for elders and their families (micro) • Congress can shift from discretionary to mandated annual appropriations for the IHS (macro), and allocate monies to invest in the workforce and support the full range of services in the I/T/U system (meso) to address the care needs of elders and their families (micro)
• Administrators in the I/T/U system (meso) can modify hiring practices and how appointments are both scheduled and managed to cultivate therapeutic relationships and continuity of care for elder patients (micro)
2. Benefits and limits of the ACA
• Permanent authorization of IHCIA
• Insufficient funding for IHCIA
• Medicaid expansion as source of increased reimbursement
• Creation of new services
• Fewer PRC restrictions
• Greater confusion regarding insurance among elders
• Financial penalties associated with reporting changes in income
• Profit motives in managed care
• Congress reaffirms but does not fully fund IHCIA (macro), key legislation that (a) has provisions for tribes to strengthen and expand their health systems; (b) allows tribes to collect third-party reimbursements; and (c) authorizes hospice, assisted living, long-term, and home- and community-based services (meso) for elders (micro)
• States accepting Medicaid expansion (macro) make it possible for greater numbers of American Indians to be insured (micro), providing a source of funding for the I/T/U system that reduces PRC restrictions and helps increase availability and access to services for all patients (meso)
• Income reporting requirements set by federal and state governments (macro), culturally incongruent outreach, and unclear rules and regulations among health insurers (macro and meso) contribute to confusion for elders and the potential that they incur financial penalties (micro)
• The presence of bureaucratic barriers in managed care plans underly concerns among tribal and I/T/U stakeholders that MCOs are more interested in generating profits (meso) than patient care (micro)
• Congress can fund IHCIA (macro) to support tribal health systems, elder-oriented services (meso), and the wellbeing of elders (micro)
• Federal government (macro) can incentivize more states to accept the Medicaid expansion and provide resources to states, tribes, and meso-level institutions to engage in culturally congruent outreach to American Indians, including elders not yet eligible for Medicare, so they are covered by insurance (micro)
• Federal and state governments (macro) and health insurers (meso) can reduce bureaucratic barriers that engender confusion and make it hard for American Indians to sign up for and keep health insurance and discourage patients from using health care (micro)
• Federal and state governments (macro) can cap the profits accrued by health insurers (meso) and incentivize them to promote better access to and use of quality care by beneficiaries (micro)
3. Invisibility of American Indian elders in policy
• Lack of knowledge about American Indian people among federal and state policymakers
• Dearth of data for funding allocation and advocacy purposes
• Need for fully funded infrastructures to collect and monitor data at the tribal level
• Problems of consultation between federal and state governments and tribal governments
• De-prioritization of elder services among tribal leadership
• Lack of knowledge about American Indians among federal and state policymakers (macro) places the onus for educating them on tribal leaders, diverting them from advocating for their communities (meso)
• Lack of data about elders and their communities makes it harder for tribes to advocate for increased service funding (meso) and reinforces the low prioritization of American Indians in health programming/policies (macro)
• The role of tribal consultations may be misunderstood and/or underutilized in decision-making within federal and state governments (macro), leading to the implementation of policies that may overlook tribal sovereignty or undermine the I/T/U system (meso)
• Tribal leaders are forced to assume leadership roles without having enough support from federal, state, and tribal partners, requiring them to prioritize agendas based on emergent tribal needs (macro and meso)
• Educate policymakers in state and federal governments (macro) about Native North America and the I/T/U system
• Congress can appropriate funding for IHCIA (macro) to support the TECs and develop infrastructures within tribes to collect, monitor, and make use of data (meso)
• Congress can appropriate funding to the BIA and BIE to bolster infrastructure and support to tribal leaders, allowing for balanced transitions and reprioritization of leadership agendas (macro and meso)
4. Perceived threats to the I/T/U system and the federal trust responsibility
• Apprehension that a new presidential administration would seek to cut programs on which elders rely
• Worry about repeal of the ACA and, thus, of the IHCIA
• Concern about the ACA undermining the federal trust responsibility to provide health care to American Indian people
• Changes in political will to support the ACA and other public programs at federal and state levels (macro) may threaten the funding for IHS and other public programs (meso) upon which many elders rely (micro)
• Insufficient representation of American Indian leaders in high-ranking federal positions may abet policy formulation and decision-making processes that undermine trust obligations and tribal sovereignty (macro)
• Congress can uphold its federal trust responsibility by implementing mandatory spending for IHS (and elder services), so its fiscal solvency is not dependent on an annual budget request of a presidential administration or the ACA (macro)
• Support, nominate, and elect American Indian leaders to federal leadership positions to lend expertise and insight into policy decisions that directly impact American Indians, including the ACA (macro, meso, and micro)
  1. Abbreviations: ACA Affordable Care Act, BIA Bureau of Indian Affairs, BIE Bureau of Indian Education, IHCIA Indian Health Care Improvement Act, IHS Indian Health Service, I/T/U IHS/Tribal/Urban, MCO Managed Care Organization, PRC Purchased Referred Care