Financing a First Nations and Inuit Integrated Health System
- A Discussion
First Nations and Inuit Population Projections
First Nations and Inuit have experienced large population increases
over the past 15 years in response to two factors: a healthy fertility
rate and the reinstatement and registration of First Nations under
Bill C-31. An understanding of demographic change, including future
projections for population size is necessary to accurately project
future needs for programs and services. Unless otherwise noted,
the data included in this section on population projections has
been obtained from a Department of Indian Affairs and Northern
Development (DIAND) publication, Implications of First Nations
Demography.(Note 48: Four Directions Consulting Group. 1997. Implications
of First Nations Demography: Final Report. Minister of Public
Works and Government Services Canada: Ottawa.)
Implications of Demography
First Nations and Inuit populations are expected to increase substantially
over the next 15 years. The projections show a 14% increase between
1995 and 2000 (83,600 individuals), or a 36% increase between 1995
and 2010 (135,900 individuals). This projected increase is due
the following:
- although First Nations and Inuit fertility declined sharply
over the last 15 years, the reinstatement and registration provisions
of the 1985 Indian Act (Bill C-31) contributed to significant
First Nations growth. These increases, particularly in the size
of the population of childbearing age will more than offset the
impact of a lower fertility rate and contribute to a sustained
rise in First Nations population.
- due to declining mortality rates, life expectancy at birth
is projected to increase to about 79 years for First Nations
females and about 72 years for First Nations males by the year
2010.
Despite these absolute increases, the rate of population growth
is expected to decline between 1995 - 2010, with a greater decline
on reserve compared to off reserve. It is expected that the share
of First Nations population on reserve will decline to about 54%
by the year 2010 (from 71% in 1985). The difference between on
and off reserve is primarily due to the expectations of sizable
numbers of registrations under Bill C-31 off reserve. According
to the Indian Register, as of December 31, 1995, C-31 registrants
represented only 6% of the registered Indian population on reserve.
Even with the increased number of elderly, First Nations populations
will remain youthful, as the younger age groups will continue to
be the largest segments of the population. The implications of
the increasing population on health services include:
- higher demand in general for services, placing pressure on
the existing system to delivery services in a more efficient
and cost-effective manner.
- the number and cost of chronic conditions will increase substantially
as the population grows and ages. The 1991 Aboriginal Peoples
Survey (APS) demonstrated that chronic diseases were a significant
problem for both on and off reserve populations. These conditions
included diabetes, high blood pressure, arthritis or rheumatism,
and tuberculosis. An estimate for diabetes has predicted that
the number of First Nations adults affected by diabetes will
increase from 30,000 in 1995 to more than 50,000 in the year
2010, a 67% increase.
- the non-insured health benefits (NIHB) program will face great
demand. Pharmacy services are expected to increase over 50% in
utilization and 56% in expenditures (1995 dollars) between 1995
- 2010. For the same time period, dental services are projected
to increase 32% in utilization and 37% in expenditures.
Long Term Impact of Bill C-31 Status
Inheritance Rules
The 1985 rules governing registration of First Nations at birth
(Bill C-31) bear scrutiny, as the long term implications of these
rules may mean reductions in the number of First Nations with status
over time, or secondly, the creation of a category of First Nations
people with band membership, but without status and therefore potentially
no entitlement to federal services. These projected outcomes are
a result of two factors: Indian Act rules and band membership codes.
Indian Act Entitlement
With Bill C-31, registration is obtained at birth and cannot
be lost or taken away.
Entitlement rules include:
- a child is entitled to registration under section 6(1) if
both parents are (or are entitled to be) registered Indians
- a child is entitled to registration under section 6(2) if
one parent is (or is entitled to be) registered under sub-section
6(1) and the other parent does not have legal status (and is
likely non Indian)
- a child is not entitled to registration if one of the child's
parents is registered under 6(2) and the other parent is non
Indian.
The above means that after two successive generations of out-marriage
(i.e. marriage between a person registered under the Indian
Act, and a non-registered person), off spring are not entitled
to Indian registration. Therefore the rate of out-marriage will
directly influence the numbers of First Nations entitled to Indian
registration, and subsequent eligibility for certain federal
health and other programs, such as post-secondary education and
the NIHB Program.
Band Membership Provisions
Bill C-31 also contained provisions for individual First Nations
to establish their own rules governing eligibility for band
membership. There are currently four types of band membership
codes in force that govern a person's eligibility: (1)
both parents are members (or eligible for membership); (2)
a minimum blood quantum level, usually 50%; (3) Indian Act
rules for registration entitlement; (4) one parent is a member
(or eligible for membership).
The impact of Indian Act registration and band membership
codes is two fold:
- Fewer persons will be entitled to Indian Act registration.
Most of Bill C-31's impact with respect to increasing the size
of the registered Indian population will occur by the year 2000.
Between 1995 - 2010, children lacking entitlement is expected
to increase from about 10% to 18%. This will have a greater effect
on off-reserve populations compared to on reserve communities.
After 2010, populations of most First Nations communities (both
on and off reserve) are expected to include many individuals
not entitled to registration. As well, some First Nations will
likely experience sizable losses to their population in this
respect.
- Bands which have instituted one parent rules will face the
situation where a portion of their membership does not have registered
Indian entitlement. As of May, 1992, 90 or 15% of First Nations
were governed by one parent rules. In these First Nations, as
out-marriages occur, an increasing percentage of their band membership
will not be entitled to federal health services, such as NIHBs.
In a recent analysis, just over 50% of these First Nations were
estimated to have out marriage rates exceeding 40%. This analysis
concluded that the future population eligible for membership
is expected to include 15% or more of individuals who are not
entitled to Indian registration.
The implications of the changing demography of First Nations on
future financing formulae is obvious. If a per capita system used
in the calculation of funding levels is based on Indian Act entitlement,
then First Nation and Inuit communities will undoubtedly face declining
transfers within 15 years. It is unlikely that communities themselves
would be the impetus to instituting two classes of residents based
on the restrictive measures of the Indian Act. Up to now,
the numbers of non-registered Indians in First Nations communities
has not been a factor in resources allocated for federally funded
community-based services, as these numbers are small. Health status
does not discriminate among persons in a community, simply by virtue
of an invisible registration. A strong justification can be made
for basing a per capita allocation on community membership, irrespective
of Indian Act registration. In the event of a restrictive
definition of the population included in the per capita calculations,
even if a band would demand that a First Nation person without
status leave the community, the incremental costs of providing
service to that person which is saved by the health system, will
likely be less than the per capita entitlement on which the funding
level is based. Alternatively, if a per capita funding system uses
band membership not Indian Act registration in the formula,
then those First Nations communities which have a one parent rule
would be able sustain their current level of funding for a longer
period of time than communities with more restrictive membership
rules.
The NIHB program, which is available to all registered Indians
regardless of residence in Canada, is one area where registration
is mandatory for receipt of benefits. If an integrated financing
model includes funding for both on and off reserve NIHBs, and this
is calculated on a per capita basis, then decreases in funding
will certainly occur if out-marriages reach a level to cause a
registered population to decrease. These out-marriage projections
provide a compelling argument for communities to negotiate at least
the NIHB portion of resources based on historical aggregate levels
rather than per capita allocations.
In the short term however, the projected population increases
point to a very real need for critical change to the health system
in order to accommodate the demands of a growing and aging First
Nations population. Currently, First Nations and Inuit Health programs
musts be delivered within existing the Medical Services Branch
(MSB) resources. In 1998/99, this envelope grew by only 1%. The
federal Minister of Health, Alan Rock, has stated to First Nations
that if a strong case can be made, he would be prepared to seek
additional resources to address the priority health needs of First
Nations people. (Note 49: Correspondence from Mr. Alan Rock, Minister
of Health Canada, to Mr. Phil Fontaine, National Chief, Assembly
of First Nations, June 17, 1998.) The 1999 budget followed through
on this statement, with $190 million committed over 3 years in
two areas: an integrated continuum of services focusing on home
and community care, and development of health information systems
in First Nations communities. As well, additional resources have
been identified for the implementation of an Aboriginal Diabetes
Strategy.
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