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The Affordable Care Act Repeal: A Road Natives Shoud Not Be Forced to Go Down

The health status of Native peoples has consistently lagged behind other U.S. populations, but the Affordable Care Act was improving the conditions.
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By almost any measure, the health status of American Indians and Alaska Natives has consistently lagged behind other U.S. populations. This situation makes every effective health policy and program critically important to Indian country. Funding for health programs and policy strategies designed to prevent illness and keep families healthy as well as improving access for American Indian and Alaska Native populations are vital. The Affordable Care Act (ACA) has advanced these goals, and Indian country has been able to benefit from a number of provisions of the ACA. This includes the important reauthorization of the Indian Health Care Improvement Act (IHCIA). IHCIA allows for the Indian Health Service (IHS) to be reimbursed by Medicare, Medicaid and third-party insurers, which is crucial to providing supplemental funding to keep the system running. Third party reimbursements, especially Medicaid reimbursements are vital in the provision of direct health care services to American Indians and Alaska Natives.

Additionally, to help prevent serious illnesses, the Affordable Care Act has and continues to strengthen public health across American Indian and other communities. It provides more options and supports better access to health care services. ACA-supported insurance coverage, available through private plans on the Health Insurance Marketplace (or Exchange) and through Medicaid expansion, add an essential complementary tool to the programs provided through IHS. For example, through the health insurance options available through the ACA, many tribal members benefit by having expanded choices in where and when they obtain health care services. Additionally, for tribal members that reside in states that expanded Medicaid, more American Indian families are now filling some of the longstanding gaps in accessing health care services. These provisions were so important to the health of Indian communities that in 2016, IHS implemented efforts across Indian country to get more individuals enrolled in Medicaid expansion.


Now however, the benefits of the Affordable Care Act to Indian country are in serious jeopardy.

The U.S. House of Representatives is advancing legislation to replace the Affordable Care Act. This proposed legislation, the American Health Care Act (AHCA), guts the ACA’s public health provisions which support critical interventions from surveillance for emerging diseases to immunizations. The AHCA freezes and then rolls back support for Medicaid expansion that already has and could benefit so many more American Indian families. The House legislation decimates the ACA’s Health Insurance Marketplace where American Indians, unlike most other populations, currently can purchase health insurance anytime during the year and do so with substantial financial support that ties to income and helps make health care affordable. It eliminates cost sharing assistance which American Indians and Alaska Natives could access irrespective of their income. While it reduces support for health coverage, the AHCA provides tax breaks for wealthy Americans and certain health industries – with an average tax cut for millionaires of $57,000.

Underscoring its sweeping impact, the Congressional Budget Office (CBO), a federal agency that provides nonpartisan analyses for Congress, determined that over 24 million people will be uninsured under this partisan health care bill. Through the AHCA, access to health care for American Indians is rolled back, at the very time when efforts are underway in Indian country, efforts often led by tribal leaders, to take fuller advantage of the provisions of the Affordable Care Act.

More specifically, how does the Republican sponsored bill damage access for American Indians and Alaska Natives? To start, it would reduce the premium tax credits in the Health Insurance Marketplace by 50 percent according to CBO. It would no longer adjust those tax credits by income or local costs. Virtually all low-income Marketplace enrollees would pay more for less coverage, as the value of coverage would be lowered by the bill. People in states like Alaska and Oklahoma would pay more just because of where they live. The proposal lets insurers charge older Americans more while cutting back on their premium tax credit. And American Indian/Alaska Natives who participate in the Marketplace would lose their cost sharing reductions, which, under the ACA, makes private insurance and the associated coverage benefits far more accessible and affordable.

Without the Marketplace’s financial and health protections, many American Indians/Alaska Natives will not have affordable access to services outside of the Indian health system. The adverse impact can be readily seen. For example, private coverage through the Marketplace enables Alaska Native peoples to more easily access specialty services and important lifesaving diagnostic services, such as colonoscopies. And affordable Marketplace insurance coverage is especially important to Alaska Native peoples who don’t live near a tribal health facility and turn to other settings for care.

The Republican bill would end federal funding for Medicaid expansion and substantially constrain it for the entire Medicaid program, a program that has been critical to thousands of Native Americans in states from Alaska to New York. The bill will cap Medicaid costs paid per person by the federal government, resulting in substantial pressure put on state budgets to make up any difference. In addition to Democratic governors, this provision has raised significant concern across a number of Republican governors in Medicaid expansion states because it severely risks continued availability of health care services for their populations currently served through the expanded Medicaid program.

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A repeal of the ACA’s Medicaid expansion will likely have the most impact on American Indians/Alaska Natives as well as the Indian Health System. In FY 2016, the IHS collected over $649 million in Medicaid reimbursements—comprising over two-thirds of total third party reimbursements. Third party coverage also plays a significant role in the provision of health care services by non-Indian health care providers when certain services are not available through the Indian health system. Between 2014 and 2015, when Medicaid expansion took effect, IHS saw a considerable increase in the user population that presented Medicaid coverage when receiving care and it is part of the reason why IHS has been working to expand participation among American Indians and Alaska Natives in the Medicaid program.

The impact on individuals and families is very real. For example, in Alaska, Alaska Native peoples comprise about 40 percent of those covered by Medicaid. Beneficiaries can use their coverage to pay for services provided by the IHS, tribes or choose other providers who participate in Medicaid. Medicaid can pay for travel to IHS facilities such as the Alaska Native Medical Center in Anchorage.

The AHCA not only adversely impacts individual health, as mentioned, it impacts financial health of the Indian Health Service supported health care facilities. This happens because reimbursement for health services through both Medicaid and through Marketplace insurance coverage will be substantially reduced. This has a devastating effect as it directly erodes financial resources now available to many tribally-run and Indian Health Service facilities, services that are essential to better meeting the health care needs of tribal communities. Diminishing these funding streams that strengthen availability of Indian health care services occurs at the very time when tribal leaders are expressing strong concern that health services to American Indians and Alaska Natives are substantially underfunded.


Medicaid expansion and the availability of Marketplace plans has had a positive effect on the referral system that IHS uses to allow its patients to receive specialty care—the Purchased/Referred Care (PRC) program. Because of the added funding that has flowed to many Indian communities, many IHS and Tribally-managed PRC programs in Medicaid-expansion states such as Montana and Alaska have been able to leverage PRC dollars and approve referrals in priority categories above Medical Priority I (life or limb). Bottom line, Medicaid expansion and increased access to care directly improves PRC buying power and allows more programs to purchase more health care services beyond emergency care and services for only the most serious illnesses. In FY 2014, during which a number of states expanded their Medicaid programs, 66 percent of IHS-operated PRC programs were able to purchase services beyond Medical Priority I. From FY14 to FY15 the PRC unmet need decreased in the amount of $173 million. These newly available funds directly translate to more health care for American Indian and Alaska Native populations.

It’s also important to underscore the adverse impact of repealing and replacing the Affordable Care Act on American Indians who live off reservation. For example, for the roughly 40,000 people in Montana who live off-reservation, residency rules sometimes make them ineligible for IHS care. For others, insurance helps them receive treatments not available at an IHS clinic, or at least not without waiting on a referral review that might end in denial because it is not Medical Priority I.

The federal government should be about the business of strengthening access to critical health care services in order to improve the health status of American Indian and Alaska Native individuals, families and communities. The Affordable Care Act has provided a solid foundation upon which legislative improvements can be built. Instead, tearing apart the ACA takes off the table the very provisions that help to give Native Americans more choices, improved access, and better health care. Replacing the Affordable Care Act with the American Health Care Act decreases access to care and restores higher health care costs for American Indian and Alaska Native communities and the health care facilities that serve them. This is a road that Native people should not be forced to go down.

Mary Smith JD, Former Principal Deputy Director, Indian Health Service.

Mary Wakefield PhD RN, Former Acting Deputy Secretary, U.S. Department of Health and Human Services.