Urgent action needed on health inequities among American Indians and Alaska Natives.

1378 www.thelancet.com Vol 389 April 8, 2017 The population of American Indians and Alaska Natives (AIAN) in the USA, which comprise about 5 million individuals, have worse health outcomes than other Americans. Life expectancy among AIAN people is more than 4 years lower than that of the overall US population. AIAN death rates are about 50% higher than rates in the white population. More alarmingly, this disparity in mortality rates has increased in the past decade, with death rates falling in white people and increasing in AIAN people. Given these growing inequalities, the Lancet Series, America: Equity and Equality in Health, is welcomed. As detailed in the Series papers, socioeconomic disparities have a profound role in the persistence of health disparities in the USA, and are of particular importance for the AIAN population. As Zinzi Bailey and colleagues outline, structural racism—the institutionalisation of racial discrimination in systems such as housing, education, and health care, among others—can have a profound effect on population health, health inequities, and the health and wellbeing of individuals. Indeed, the worrying inequalities among AIAN raise fundamental issues for health care systems and providers. The social determinants of health play a prominent part in the health status of AIAN people. AIAN individuals are more likely than white people to have a family income below the poverty level (27% vs 10%), less likely to have a family member in fulltime employment (70% vs 84%), and are more likely to be uninsured for health (21% vs 8%). The leading contributors to excess mortality among the AIAN population include factors directly related to these high levels of social risk, such as unintentional injury, violence, and diabetes. The direct clinical consequences of these social risk factors are clear: compared with white individuals, AIAN people have a higher prevalence of obesity, tobacco use and physical inactivity, and lower consumption of fruits and vegetables. AIAN people report a “fair or poor” health status more frequently than white people (20% vs 9%), as well as an increased burden of diabetes, hypertension, asthma, substance use disorder, and mental illness. Providing adequate access to high-quality health care is therefore crucial. However, although AIAN populations increasingly reside in urban settings, a substantial proportion are clustered in rural and remote environments with restricted access to health care. Bailey and colleagues highlight the importance of segregation as a manifestation of structural racism, and in the case of the AIAN population, this issue has implications for the delivery of high-quality care. AIAN people are more likely than whites to report that they have no personal doctor (28·3% vs 18·7%), and isolated communities have difficulty in accessing tertiary care for conditions such as acute myocardial infarction and renal transplantation. The Indian Health Service (IHS), while not the only means for AIAN to receive health care, is a federal agency that provides health care to 2·2 million AIAN people who are members of federally recognised tribes through a system of hospitals and ambulatory health centres. The IHS has shown improvements in cancer prevention and chronic disease management and in the uptake of innovative health information technology, while incorporating culturally appropriate quality improvement strategies. Although the future of the Affordable Care Act (ACA), as discussed in this Series, is uncertain, the legislation has resulted in a significant decrease in the uninsured rate among Urgent action needed on health inequities among American Indians and Alaska Natives