Key takeaways:
More than 113,000 American Indians and Alaska Natives (AI/AN) live in 492 counties that lack mental health providers (mental health deserts). Over 90% of these areas are in rural parts of the U.S., where healthcare resources are already limited.
States with the highest number of AI/AN living in mental health desert counties are South Dakota, Texas, Alaska, Georgia, Mississippi, Virginia, Nebraska, Kansas, Minnesota, and Oklahoma.
Native counties with no mental health providers also have a lower share of households with broadband internet (64%) than the national average. This makes it harder for rural AI/AN populations to receive telehealth.
New research from GoodRx finds that over 113,000 American Indians and Alaska Natives (AI/AN) live in a county that lacks an adequate amount of mental health providers. In these mostly rural counties, fewer than 1 mental health provider is available for every 30,000 people.
In general, AI/AN communities have worse health outcomes than other ethnic/racial groups in the U.S., and it’s no different for mental health. A driving factor is generational trauma, which stems from a long history of colonialism, genocide, and land loss due to forced relocation.
The effects of generational trauma are still apparent today. A 2016 study found that 70% of AI/AN men and 63% of AI/AN women will meet the criteria for at least one mental health condition over the course of their life. This number is significantly lower in non-white Hispanic individuals, where 62% and 53% of men and women, respectively, will meet the criteria. AI/AN are also more likely to suffer from substance use disorders.
But finding mental health care is not always easy for the AI/AN community. The Indian Health Service (IHS) is a federal health program that aims to provide quality, culturally competent healthcare via a network of hospitals, tribally run programs, and urban clinics. However, this program has gaps in care: Most IHS clinics and hospitals are on reservations, yet 87% of those who identify as American Indian/Alaska Native live outside of tribal statistical areas.
Our analysis looks at the amount of psychiatrists and psychologists in counties where at least 2.9% of the population is AI/AN (the same share of AI/AN in the total 2020 U.S. population), or in counties that contain reservations or tribal headquarters. Below, we walk through the number of AI/AN mental health deserts across the U.S. and what that means for the AI/AN population.
Almost 500 AI/AN counties lack mental health providers
To identify areas with mental health provider shortages, we used the Department of Health and Human Services’ federal mental health professional shortage threshold of 30,000 people to 1 provider. We focused on psychiatrists and psychologists, since these providers have the ability to diagnose mental health disorders, and psychiatrists can prescribe medication.
In the map below, counties shaded in orange lack a mental health provider.
It’s clear that mental health access is lacking in much of the central U.S. and Alaska. Texas (30 mental health desert counties), Kansas (13), Oklahoma (8), Nebraska (8), and Alaska (7) have some of the highest number of mental health deserts. Many of these areas are rural, less densely populated areas, which is no surprise as these are already areas generally lacking in access to healthcare.
South Dakota (14,650) and Alaska (11,171) in particular have the highest number of AI/AN residents living in mental health deserts. AI/AN communities in Alaska are especially impacted by the lack of mental health providers. The Kusilvak Census Area has a 96% AI/AN population with more than 10 tribes residing in 20 reservations, yet no mental health providers.
Read more like this
Explore these related articles, suggested for readers like you.
But it’s not all bad news. While over 113,000 AI/AN individuals live in a mental health desert, the majority of counties with a sizable AI/AN population have adequate access to a mental health provider.
Take New Mexico, a state where 32 counties have a sizable AI/AN population. Most counties meet the threshold for mental health providers. And in McKinley County, where 79% of the population is American Indian (largely from the Pueblo of Zuni Tribe), 76 mental health providers are available for a population of just over 72,900 individuals.
Also, due to the Indian Health Service, areas that are on reservations tend to always have at least one facility, whether that be a hospital, clinic, or community health center.
In addition, this analysis is most likely undercounting the amount of mental health resources available in most areas because it only accounts for psychiatrists and psychologists. Many other professionals, such as therapists, counselors, social workers, and primary care physicians, among others, provide important care and support to their communities.
But even though most counties meet the threshold for the minimum number of providers needed, that doesn’t always mean the care is easily accessible, affordable, or culturally competent. Care in IHS services areas is provided at no cost to members of tribes in that area, regardless of insurance status. Yet the IHS is severely underfunded. For example, California has America’s largest Native American population, but it hasn’t received millions of dollars of IHS funding that was promised over four decades ago. What’s more, a 2018 study by the U.S. Government Accountability Office found that 25% of IHS positions aren’t filled.
For AI/AN that live outside reservations, services may depend on eligibility and may be poorly funded. That means members must rely on other programs like Medicaid, Medicare, or private insurance, if they have insurance at all.
What's even more difficult is finding culturally responsive care that takes other factors into consideration, like spiritual health. Many AI/AN seek out traditional healers, which have long played an important role in native communities. In the Navajo Nation, the largest reservation in the U.S., the Chinle Comprehensive Health Care Facility has traditional healing available alongside western medicine. But this crucial aspect of care is rare to find on Native American lands, especially when there are very few providers that are AI/AN.
Poor broadband access limits telehealth in mental health deserts
Telehealth has helped to fulfill unmet mental health needs. Since the COVID-19 pandemic began, telemedicine for mental health services has skyrocketed, with up to 40% of mental health visits conducted by telehealth in 2020. Telemedicine can help fill the gap in areas where few providers are available.
One barrier to using telehealth, however, is broadband access. Broadband, or high-speed internet, is different from slower dialup internet and is preferred for video or online care.
In the map below, we look at broadband access in counties that either have a reservation or tribal headquarters or where at least 2.9% of the population is AI/AN. Yellow areas indicate counties where broadband access is below the national average. In total, 418 counties have lower broadband access than the national average.
GoodRx Research found that counties that had a higher population of AI/AN residents had a lower percentage of households with any form of broadband. For example, when we looked at counties with 50% or more AI/AN residents, a vast majority of these counties (94%) had broadband access below the national average (64% versus the national average of 78.5%).
Take Apache County in Arizona, one of the few counties in the U.S. with a population of more than 20,000 AI/AN. The Navajo Nation reservation is located there, and the Navajo and Hopi tribes live there. This county has a high number of mental health providers, yet only 41% percent of people have adequate broadband access.
We can see that heavily AI/AN counties, especially rural counties in the central U.S., lack broadband access. North and South Dakota both have several counties that are heavily American Indian, and they have some of the highest numbers of mental health desert counties.
South Dakota has a high percentage of tribal land (12% allocated as reservations or trust lands), and 9% of the population is American Indian. After Texas, South Dakota has the second-highest number of mental health deserts, with 31 counties having no mental health providers at all. And more than half of these counties have inadequate broadband access.
There are nine tribes in South Dakota, many of which are in counties that are both mental health deserts and have low access to broadband. Mellette County, for example, is 64% AI/AN, and less than half of households have access to broadband. Ziebach County, which overlaps with the Cheyenne River Indian Reservation, has an over 80% native population. Ziebach is also a mental health desert with no providers, and only around 63% of households have broadband.
Summing it all up
In light of American Indian/Alaska Native Heritage Month, it’s important to highlight some of the health disparities this population faces. This community deals with some of the worst health outcomes in the U.S., compared to whites. They are also more likely to have poor health and are more likely to be uninsured.
While Indian Health Services provides needed care in tribal areas, it’s an underfunded program and doesn’t reach those who don’t live on tribal lands. Those who live in rural areas have to find mental health care online (which may not always be feasible), travel to the nearest provider (which may be hours away), or forgo care altogether.
Moving forward, equitable access to mental health providers should be a priority, especially for communities that already face so many gaps in healthcare. One such option is to provide more funding to support mental health telehealth programs such as those implemented by the Blackfeet tribe in Montana.
Co-contributors: Tori Marsh, MPH
Methodology
American Indian and Alaska Native demographic and tribal area data: The number of American Indian and Alaska Natives in each U.S. county was obtained from the 2020 Decennial Census Redistricting data PL-94-171. Counts include census-reported single and multi-raced American Indian and Alaska Natives. Federally recognized American Indian reservations data was obtained from census American Indian Reservations, Statistical Areas. Tribe and tribal leadership headquarters data was obtained from the U.S. Department of the Interior Indian Affairs Tribal Leaders Directory Datasets. For reservation and tribe headquarter information lacking county information, reverse geocoding was performed using the R package tidygeocoder, which returns the closest county for a given latitude and longitude in the federal dataset. In some cases, tribe information was also obtained directly from tribal websites accessed at the time of this publication. Where indicated, data was filtered for counties that had at least 2.9% AI/AN residents, or contained a reservation or tribal head quarter. This represents the total 2020 share of AI/AN in the U.S.
Mental health provider data: The mental health provider data was obtained from ABC News, which sourced and aggregated this information from the Centers for Medicare & Medicaid Services’ (CMS) National Plan and Provider Enumeration System. This dataset only includes psychiatrists and psychologists. The list of providers were restricted to these professions because of their ability to diagnose mental health conditions. A county without a CMS mental health provider was designated a mental health desert. The HRSA federal mental health professional shortage threshold used in this study is 30,000 to 1 provider.
Broadband, income, health outcomes, health factors, and clinical care data: The share of households in each county with any type of broadband access was obtained from Table S2801 2020 ACS 5-year estimate. The average share of households with broadband of any type is 78.5%. The 2022 County Health Rankings dataset was used to obtain county-level estimates for median household income, quality of life (poor mental health days), alcohol and drug use (excessive drinking), and access to care (uninsured). County health rankings data is an aggregation of various federal datasets. Poor mental health days is the average number of days in a 30-day period where respondents reported experiencing mentally unhealthy days. Excessive drinking corresponds to the percent of adults in a county that reported drinking heavily within a 30-day period. Uninsured represent the percent of adults in a county under the age of 65 without health insurance coverage. Income estimates were sourced from the 2020 Small Area Income and Poverty Estimates. Poor mental health and excessive drinking estimates were obtained from the 2019 Behavioral Risk Factor Surveillance System, while uninsured estimates were sourced from the 2019 Small Area Health Insurance Estimates.
References
Amaro, Y., (2021). California Native Americans won healthcare settlement. Federal government hasn’t delivered. The Fresno Bee.
American Broadcast Company. (2022). Mental health shortage Github.
Bargfield, L., (2022). Healing through culture: Increasing access to Native American practices to treat mental health. Cronkite News.
Brave Heart, et al. (2016). Psychiatric disorders and mental health treatment in American Indians and Alaska Natives: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. Social Psychiatry and Psychiatric Epidemiology.
Cambon et al. (2021). Tidygeocoder: An R package for geocoding.
County Health and Rankings & Roadmap. (2022). 2022 county health rankings.
Indian Health Service. (2019). Fact sheets: Disparities.
Kaiser Family Foundation. (2019). Health and health care for American Indians and Alaska Natives (AIANs) in the United States.
Kauffman & Associates. (2021). Tribal/Urban Tour Report.
Kraker, D. (2022). Native American communities prioritize culture, recruitment to treat mental health. MPR News.
Lo, J., et al. (2022). Telehealth has played an outsized role meeting mental health needs during the COVID-19 pandemic. Kaiser Family Foundation.
Mental Health America. (2019). Native and Indigenous communities and mental health.
National Plan and Provider Enumeration System. (2022). NPI files.
Nguyen, A. (2021). Mapping healthcare deserts: 80% of the country lacks adequate access to healthcare. GoodRx.
U.S. Census Bureau. (2020). 2020 Census.
U.S. Census Bureau. (2020). American Indian and Alaska Native population.
U.S. Census Bureau. (2022). American Indian and Alaska Native programs.
U.S. Census Bureau. (2022). Table S2801 2020 ACS 5-year estimate.
U.S. Department of Health and Human Services. (2022). HPSA and MUA/P scoring criteria.
U.S. Department of Interior Indian Affairs. (2022). Tribal leader directory dataset.
U.S. Government Accountability Office. (2018). Indian Health Service: Agency faces ongoing challenges filling provider vacancies.
Why trust our experts?
