Health Care Barriers For Incarcerated Indigenous Populations In The U.S. Prison System

By Aaliyah Moore and Jessica McCann

Introduction

November is National Native American Heritage Month, a time dedicated to honoring the rich histories, diverse cultures, and significant contributions of Indigenous peoples in the United States. To commemorate this, November’s policy blog raises awareness of the overrepresentation of Indigenous individuals in the U.S. prison system and the substantial barriers they face in accessing adequate health care during incarceration. Building upon our July 2024 blog—which examined Indigenous mental health barriers, programs, and policies–we explore these ongoing issues and potential solutions to improve health care access for Indigenous individuals in prisons.

Health Inequities and Overrepresentation In Prisons

Indigenous populations are experiencing a significant health crisis, with a disproportionate prevalence of mental health issues such as depression, anxiety, and substance use disorders, made worse by barriers to treatment. Centuries of colonization, forced assimilation, generational trauma, socioeconomic disparities, and systemic discrimination have resulted in these vulnerabilities, which exacerbate health disparities and increase the likelihood of encounters with law enforcement.

Indigenous people are incarcerated in federal and state prisons at over four times the rate of white people, which is exceptionally higher than their proportion in the general population. For example, in Montana, Indigenous people comprise 7% of the population but 30% of the incarcerated population. Unsurprisingly, these disparities negatively affect health. According to the National Library of Medicine, incarceration is associated with major depression, acute and chronic infections, heart disease, hypertension, and obesity. The study also found that incarceration negatively affects social determinants of health, such as employment and career prospects, relationship stability, and housing status. Further compounding these challenges, incarcerated Indigenous individuals encounter significant barriers to accessing adequate health care, particularly in Tribal facilities.

Lack of Mental Health Services and Culturally Competent Care

President George W. Bush, in his 2004 State of the Union address, emphasized the importance of rehabilitation within the U.S. prison system by stating, “America is the land of second chance, and when the gates of the prison open, the path ahead should lead to a better life.” Aligning with his vision, he signed the Second Chance Act (H.R. 1593) to reduce recidivism and improve the lives of people returning to society after incarceration. Yet, most correctional facilities lack adequate mental health services to address issues such as trauma, depression, and substance abuse, making rehabilitation less likely. According to the National Alliance on Mental Illness, 63% of people with a history of mental illness do not receive mental health treatment while incarcerated, and more than 50% of those taking medication for mental health conditions, when admitted, stop receiving their medication.

With prison facilities already struggling to meet the growing demand for mental health services, it is unsurprising that they fail to provide culturally competent care. For Indigenous communities, culturally competent care is essential for promoting healthy lives, which can translate to reducing recidivism. While it is difficult to pinpoint what culturally competent care methods should be adopted since Indigenous populations are diverse, it is important for health care providers in prisons to be knowledgeable and ask questions to identify what traditional and spiritual practice applies to individuals. Examples of this care can range from sweat lodges to traditional teachings. As this group is overrepresented in prisons in the U.S., the need to provide targeted interventions is necessary to achieve the U.S. vision of prisons as a tool for rehabilitation and successful reintegration.

Discrimination and Stereotyping in Health Care 

While qualitative research highlights the barriers Indigenous populations face in accessing health care in prison, it is essential to listen to their perspectives to develop the most effective and innovative solutions. In a 2020 study, incarcerated Indigenous women reported experiencing racism and discriminatory treatment from custodial and prison health care staff, including receiving poor quality health care rife with judgmental attitudes and stereotyping. They also revealed that prison health care staff did not take their symptoms seriously. Discrimination and stereotypes contribute to health disparities, including biased diagnosing and treatment, unequal access to quality care, mistrust, and psychological and emotional stress.

The Department of Justice’s 2024 report on inmate deaths in federal prisons supports these sentiments, finding that Native Americans make up 6% of deaths in prisons, the second most affected group, despite their smaller representation in the overall prison population. This disproportionate impact understandably fuels mistrust in prison health care, discouraging Indigenous people from seeking help and exacerbating health system inequalities. When people do not seek medical help out of fear that they will be ignored or mistreated, it creates a vicious cycle that worsens health outcomes and contributes to preventable deaths.

Limited Data, Research, and Advocates 

Indigenous people in prison suffer disproportionately from chronic illness, mental health issues, and substance abuse, yet their health needs are not well-documented. The lack of adequate mental health services, along with pervasive discrimination, contributes to this data gap. These systematic shortcomings and biases make it difficult to collect comprehensive data on the health needs of incarcerated Indigenous individuals. These data gaps make designing and implementing effective and targeted health interventions for incarcerated Indigenous populations even more challenging. Addressing these gaps is essential for advancing health equality, which is a fundamental human right, even for those incarcerated.

There is also a lack of advocates who understand Indigenous cultural and health care needs, making it challenging to address grievances and improve services. According to the American Bar Association, less than 1% of all lawyers in the U.S. are Indigenous Americans, yet 63% of Indigenous lawyers focus on Indigenous law, driven to serve their communities and protect Tribal sovereignty, highlighting the importance of increasing access to law professions among Indigenous populations. This work is crucial, as these attorneys play a vital role in advocating for Indigenous rights. Increased representation of Indigenous people in the legal profession could increase the visibility of Indigenous health disparities in prisons.

Improving Outcomes for Incarcerated Indigenous Populations  

By acknowledging and actively working to eliminate the barriers mentioned above, health care systems within prison facilities can move toward providing equitable care for incarcerated Indigenous populations. Based on the research conducted, we offer the following suggestions to policymakers, researchers, health care providers, advocates, and those working in the justice system:

1. Research. Commit to learning about the diverse cultures and healing practices within Indigenous populations.
2. Listen. Pay attention to scholars who amplify the voices of incarcerated Indigenous people and their health needs. Identify and read about their lived experiences and expressed health needs.
3. Explore Existing Studies. Familiarize yourself with existing studies and guides on this issue. This knowledge can help equip you to contribute meaningfully to this ongoing conversion.
4. Advocate for Increased Access to Traditional Healing. Equip health care providers with information on Indigenous health issues to facilitate understanding and access to traditional health practices.
5. Address Biases. Educate yourself and others on biases and stereotypes held about incarcerated Indigenous populations and work actively to overcome them.

As we commemorate National Native American Heritage Month, let us commit to these actions to support the health and well-being of Indigenous people in our prison systems and beyond.