American Indian and Alaska Native populations experienced in-hospital COVID-19 mortality rates two to three times higher than all other races, as well as some of the top COVID-19 hospitalization and mortality rates in the U.S. overall, a new study found.

Despite having proportionally lower comorbidity risk scores than Black and white patients, American Indian and Alaska Native patients were more likely to die in the hospital due to COVID-19 than Black or white patients at every level of comorbidity risk, according to a JAMA Network Open report on Wednesday.

Native American communities struggled barriers to accessing adequate care during the pandemic, the study said. And in general, public health records have suffered from a lack of indigenous representation in population data.

The report looked at 18,731 adults in Mississippi hospitalized with a COVID-19 between March and December 2020, using hospital discharge data from the Mississippi Inpatient Outpatient Data System. Around 1.2% of individuals included in the study were American Indian and Alaska Native, 49.1% were Black and 48.7% were white.

Black and white patients across comorbidity risk groups had inpatient mortality rates that were 75% and 77% lower than American Indian and Alaska Native patients, respectively.

Among individuals with the most comorbidities, nearly 7 of every 10 American Indian and Alaska Native patients admitted to the hospital with COVID-19 died prior to being discharged, compared with less than 3 out of 10 Black or white patients.

One in 10 American Indian and Alaska Native adults with the lowest comorbidity risks died while in the hospital with COVID-19, compared with 1 or fewer of every 25 Black or white adults.

Native American individuals in the U.S. experienced a reported 296,967 COVID-19 infections and 8,983 deaths attributed to the virus by the end of 2021. American Indian and Alaska Native people were 1.6 times more likely to be infected, 3.3 times more likely to be hospitalized, and 2.2 times more likely to die as a result of COVID-19 than white people.

Around 40% of the healthcare needs of eligible American Indian and Alaska Native individuals are not covered by the government, the study stated, and the lack of nearby access to medical services is more likely a contributor to hospital mortality rates than comorbidities.

In general, Native American people have experienced lower life expectancy and die at higher rates than other racial groups due to a number of conditions, including chronic liver disease, diabetes, mental illness and chronic lower respiratory diseases.

All of the communities in the Mississippi Band of Choctaw Indians are federally designated as medically underserved regions, particularly because the reservation’s 20-bed Choctaw Health Center serves as the only Indian Health Services-affiliated hospital in the state.

Level one and level two COVID-19 centers in Mississippi are dozens of miles from the Choctaw reservation, and indigenous individuals seeking a non-IHS facility typically have to undergo a complex and lengthy reimbursement process of purchased or referred care. Often, these expenses end up not being paid due to chronic underfunding.