American Indian and Alaska Native Veterans
Veterans from American Indian and Alaska Native populations have an exemplary tradition of military service and sacrifice, serving at one of the highest rates per capita of any ethnic group.
American Indian and Alaska Native (AI/AN) peoples have rich diversity in their tribal affiliations, cultural customs, and languages. As of 2022, there are 574 federally recognized AI/AN Nations (including tribes, bands, pueblos, native villages, nations and communities) in the United States, and as many as 400 non-federally recognized tribes. According to the 2020 Census, 9.7 million AI/ANs live in the U.S. and its territories. About 334,000 U.S. Veterans identify as AI/AN alone or in combination with other races. Within AI/AN communities, Veterans are often given special respect similar to that of elders for having accepted the role of protector and experienced personal sacrifice.
Some understanding of AI/AN cultures will help you provide higher quality care when working with Veteran clients who identify with these cultures. The resources below delve further into these cultural areas. They can help you ask questions about family, upbringing, languages, and spiritual beliefs to assess the extent to which Veterans identify with AI/AN cultures.
Mainstream belief systems influence how providers diagnose and treat health conditions. Examine your own belief system about AI/AN peoples as related to social issues, such as mental health stigma, education, poverty, teen suicide, and drug or alcohol use. How do your beliefs compare to the facts? What assumptions might you be making specifically about AI/AN Veterans? How does your own culture influence your interpretation of body language, oral communication, and other behavior?
In some ways, AI/AN Veterans have different experiences from other Veterans, in terms of reasons for serving, experience during service, and returning home.
AI/ANs may participate in the military for reasons other service members join. They may also serve to honor a warrior tradition, a tradition of accepting responsibility for protecting one's land and people.
AI/AN Veterans are more likely to have served in combat positions. Large studies of AI/AN Veterans have shown they are about twice as likely to have posttraumatic stress disorder relative to White Veterans, a discrepancy explained by differential exposure to warzone stress.
Some AI/AN Veterans also report experience with stereotypes and discrimination during their military service. For AI/AN Veterans rooted in traditional community values, emphasis on aggression is in conflict with traditional values and practices.
Trauma from natural disasters, accidents, and interpersonal violence is more common among AI/ANs than other populations. A context of trauma in the community, and of historical trauma to one’s people, may exacerbate PTSD. AI/AN Veterans are two to three times more likely than non-Hispanic White Veterans to report suicide ideation. Among AI/AN Veterans enrolled in the Veterans Health Administration, suicide rates increased from 19/100,000 person years to 47/100,000 person years between 2004 and 2018, with the highest rate among AI/AN Veterans aged 18-39 years (66/100,000 person years).
Historical precedent and continuing inequities give people from AI/AN communities reason to be guarded with outsiders.
Trauma from atrocious past events, including genocide and relocation, broken treaties, boarding schools and child removal policies has been passed across generations. Veterans may have further mistrust of mental health care, particularly government-sponsored care. Over time, try to improve your understanding of these issues, and acknowledge them. To help establish trust from the very beginning, be open and sincere about yourself. Listen carefully and calmly, honor your word, and be open to ideas about roots and paths to well-being that differ from your own.
Consider a Veteran’s health in the context of her/his community. What social determinants are factors? What resources can be leveraged to address them?
About 4 in 10 AI/AN Veterans reside in rural areas, more than Veterans of any other race, and thus face barriers to care characteristic of rural communities. Rural AI/AN communities face resource challenges, including employment and health care services that are distant, rural hospital closures, and other stressors, such as a lack of affordable housing, the influx of drugs into communities, rising costs, and low quality schools. These challenges may be exacerbated by other social factors such as lack of culturally responsive care.
Some barriers may be countered by the large degree of support for Veterans in many AI/AN communities. For example:
Relationships with family and extended family are prominent in many AI/AN communities. Extended family might be available to provide social support.
Local Veterans organizations are another source of social support, and might be able to connect clients in your care with resources.
Local tribes may provide additional assistance obtaining services and benefits. Encourage the Veterans you serve to contact their local tribe.
Telehealth programs have been established in collaboration with some AI/AN communities. Serving tribes in Montana, Wyoming and Oklahoma, these clinics strive to provide holistic, person-centered telemental health care through VA-tribal-academic partnerships. Clinics are currently run by the VA Montana Health Care System. See this handout for more information.
Connection to culture: For many AI/AN Veterans culture is healing. Despite the trauma that AI/AN populations have endured, they have maintained strong, healthy traditions. Some tribes have ceremonies to welcome home Veterans and help them re-enter the community. Tribal council leaders may recommend traditional healers (if appropriate for your client) who can provide authentic healing ceremonies. Elder Councils also offer Veterans’ healing ceremonies at a few VA facilities.
Holistic beliefs about health: Many (but not all) AI/ANs approach healing holistically (i.e. mind, body, and spirit) and frequently incorporate traditional healing methods (e.g. ceremonies, talking circles) with Western medicine. These methods are often facilitated by a healer and frequently involve investment of time and resources by the client’s family.
Bureau of Indian Affairs, Interior. 2022. Indian entities recognized by and eligible to receive services from the United States Bureau of Indian Affairs. Federal Register 87 FR 4636.
US Government Accountability Office. 2012. Indian issues: Federal funding for non-federally recognized tribes, GAO-12-348. https://www.gao.gov/products/gao-12-348
US Census Bureau. 2020. Decennial Census P.L. 94-171 Redistricting Data Summary Files. data.census.gov
Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank JA, Schlenger WE. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context. Journal of Traumatic Stress. 2002 Apr;15(2):89-97.
Johnson PJ, Carlson KF, Hearst MO. Healthcare disparities for American Indian veterans in the United States: a population-based study. Med Care. 2010;48(6):563-569.
U.S. Department of Veterans Affairs. American Indian and Alaska Native Veterans: 2015 American Community Survey. August 2017.
U.S. Department of Veterans Affairs. National Veteran Health Equity Report, FY2013.
The SAMHSA Culture Card was designed by Public Health Service Officers, tribal community members, and AI/AN behavioral health professionals to enhance cultural competence while serving AI/AN communities. Content includes roles of Veterans and Elders, strengths in AI/AN communities, wellness challenges, and self-awareness and etiquette.
SAMHSA’s Treatment Improvement Protocol 61 is a detailed tool for behavioral health service providers who want to enhance their cultural competence in relationships with AI/ANs. The first section is designed for individual service providers who are working with AI/AN clients and communities, to improve cultural competence. Vignettes are provided for demonstration. The second section is an implementation guide for behavioral health program administrators who are looking to form more culturally responsive policies, procedures, and practices.
Health Care Resources
Indian Health Service
AI/AN Veterans often qualify for services from both the Veterans Health Administration and the Indian Health Service. Misperception about care eligibility being “either/or” can result in Veterans being turned away for care. Inform your staff that some Veterans may have dual eligibility at Veterans Health Administration and Indian Health Service. Empower Veterans to use both systems, but remember that there may be some limitations on eligibility.
Veterans unsure of their eligibility can use resources available through each agency to determine if they qualify for care:
Establishing and navigating reimbursement agreements:
- Office of Tribal Government Relations
- VA Community Care: Indian Health Service/Tribal Health Program/Urban Indian Organization (I/T/U)
Resources at local VA facilities
Some VA facilities that serve a higher percentage of AI/AN Veterans offer specific programs for this population, which may include mental telehealth clinics as well as linkages with traditional healing endorsed by local tribes, care coordination, and benefit services navigation.
In addition to other VA services and benefits, a couple of resources support housing of AI/AN Veterans who reside on reservations. First, AI/AN Veterans – and AI/AN spouses of Veterans – who are buying, building, or improving a home on federal trust lands may qualify for Native American Direct Loans. Second, some tribes participate in the Tribal HUD-VA Supportive Housing program (Tribal HUD-VASH), providing rental assistance and supportive services to AI/AN veterans who are Homeless or At Risk of Homelessness living on or near a reservation or other Indian areas.
Representatives at VA facilities and beyond
Other individuals and organizations advocate for AI/AN Veterans and assist them in obtaining VA benefits. The following representatives give Veterans choices about where to seek help, depending on proximity, level of comfort, and past experience (none accept payment for services):
Veterans Service Organization (VSO) Representatives: Accredited VSOs are particularly helpful when a Veteran requires assistance with filing a benefits claim or responding to a denied claim. VSOs represent Veterans in the claims process. They also have the ability to track a claim from beginning to end and to act as power of attorney, and they can assist with access to other VA and community resources. VSO representatives are usually Veterans themselves, often volunteers with non-profit organizations. As of 2017, a tribe may have its own VA-accredited VSO, akin to state VSOs. Additionally, other accredited VSOs may be located near tribal communities.
Tribal Veterans Representatives (TVRs): Tribal Veterans Representatives are excellent resources for Veterans who live in remote communities and thus find it difficult to access the VA or VSOs. They are volunteers (not employees) trained by VA who help Veterans and their families access VA, federal, state, tribal, and non-government resources. TVRs often live in tribal communities. They can meet at times and places convenient for the Veteran. The TVR role was created to build knowledge and trust in accessing VA services from within tribal communities. Contact tribal leadership to find out if representatives are available in your client’s community.
Minority Veterans Program Coordinators (MVPCs): Minority Veterans Program Coordinators might be particularly helpful for Veterans who have encountered gaps in or barriers to VA care and benefits. MVPCs serve Veterans from a variety of backgrounds, outreaching to promote their use of VA benefits and services. As VA employees, MVPCs can provide warm hand-offs to program specialists in the VA and can advocate within their VA facility to improve service delivery. Supported by the Center for Minority Veterans, MVPCs are located at VA health care facilities, regional benefit offices, and national cemeteries and can be contacted directly by email.
For more information about American Indian and Alaska Native tribes, Native American Veterans, and VA Services for Native American Veterans, please see our FAQ.
VHA Office of Rural Health
The Veterans Health Administration (VHA) Office of Rural Health strives to improve access to care for Veterans living in rural and remote communities who rely on VA for health care. Their website includes video resources (e.g., a caregiver video series) for all rural Veterans as well as information about programs for rural Native American Veterans, and brief explanations of promising practices promoting the health of all rural Veterans. A 2013 report examined rural Native American’s perceptions of strengths and challenges in their communities (Ulrich-Schad, J.D., 2013).
Telemental Health Clinics for Rural Native American Veterans are one of the Office of Rural Health’s Promising Practices. Serving tribes in Montana, Wyoming and Oklahoma, these clinics strive to provide holistic, person-centered telemental health care through VA-tribal-academic partnerships. Clinics are currently run by the VA Montana Health Care System.
Native American Veteran Homelessness Toolkit – Homelessness among rural Native American Veterans poses unique challenges. This toolkit provides detailed information for individuals and organizations working to solve homelessness among Native American Veterans who live on reservations or in Alaska Native Villages.
Fact Sheet: Tribal Colleges and Universities – Tribal Colleges and Universities (TCUs), located on tribal lands, provide post-secondary education opportunities for American Indian and Alaska Native populations. This fact sheet explains how TCUs are relevant to Veterans, especially those who served in recent conflicts. It also provides resources pertaining to higher education.