Health Policy$ense

The Affordable Care Act and Minority Health: Part V (American Indians/Alaskan Natives)

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This fifth post of a five-part series outlines the seldom-mentioned provisions for American Indians and Alaskan Natives.

We conclude our series with a post about American Indians/Alaskan Natives, a population that does not receive much attention in health policy circles, despite significant health disparities, a dedicated health care delivery system (the Indian Health Service) and special benefits and protections within the ACA. In the 2010 U.S. Census, 2.9 million people identified as Native American alone, and another 2.3 million identified as Native American along with one or more other race. (We will use AI/ANs and Native Americans interchangeably).

Indian Health Service
One might even wonder if the ACA’s focus on insurance coverage is relevant to a population entitled (by treaties) to federally-provided health care. In a word, yes. Care through the Indian Health Service (IHS) is limited by geography, scope of services, and chronic underfunding. As the GAO notes, coverage under the ACA (especially through expanded Medicaid) will improve access to care, provide more comprehensive benefits, expand choice, and reduce pressure on the IHS budget.

The ACA addresses the needs of this population in a variety of provisions. First, it permanently reauthorizes the Indian Health Care Improvement Act (IHCIA), the legal foundation of the commitment to provide health care to this population. Changes to the IHCIA expand programs and services for the 2.2 million Native Americans the IHS serves, and authorize IHS-operated hospitals and outpatient facilities to bill Medicare and Medicaid for services delivered.

Native Americans who enroll in marketplaces plans enjoy special benefits under the ACA. Among them:

  • Cost sharing. Native Americans under 300% of the federal poverty level have zero cost sharing. Those who are enrolled in marketplace plans also have zero cost sharing for services received from qualified Indian health providers.
  • Year-long enrollment. The enrollment window does not close. Native Americans can sign up for marketplace plans at any time in the year.
  • Exemption from individual mandate. Most Native Americans who do not purchase insurance are exempt from individual shared responsibility payments required by the IRS. A form must be completed.


Medicare Part B
Other ACA provisions remove the existing sunset for Medicare Part B reimbursement to Indian health providers, reserve significant portions of grants for organizations that promote maternal and child health among Native Americans, mandate investment in programs to treat behavioral health issues and chronic disease among Native Americans, and reserves grants for Native American trauma centers.

These provisions address some of the longstanding health disparities in this population.

Native Americans have a higher incidence of chronic diseases and mortality rates from chronic diseases. They have 2.8 times higher mortality from diabetes and 4.7 times higher mortality from chronic liver disease. Life expectancy among Native Americans is 4.2 years lower than the average.

Prior to the ACA, more than one-quarter of nonelderly AI/ANs were uninsured, more than double the rate of whites. Estimates show that as many as 94% of the uninsured have incomes under 400% of poverty, with more than half eligible for Medicaid if every state expanded its program. The Urban Institute report (mentioned in our second post of this series) models uninsurance levels in 2016 under three scenarios: without the ACA, with the current Medicaid expansion, and if every state expanded Medicaid. As shown, the current Medicaid expansion has likely produced a dramatic drop (nearly 50%) in uninsurance for AIs/ANs, which would drop even further if all states expanded Medicaid:

State decisions about expanding Medicaid are especially important for this population, which is concentrated in a few states. The states with the highest percentage of American Indian and Alaska Native population are Alaska (14.3%), Oklahoma (7.5%), New Mexico (9.1%), South Dakota (8.5%), and Montana (6.8%). The Urban Institute notes that four nonexpansion states -- Oklahoma, Texas, Alaska, and North Carolina -- would have the greatest impact on further reducing AI/AN uninsurance rates.

Will the combination of increased coverage and expanded programs under the ACA reduce the health disparities among Native Americans? The bar should not be set too high -- no one piece of legislation could undo the long legacy of unequal treatment. Nor should the bar be set too low -- we should expect significant health improvement stemming from improving access to mainstream health care, as well as improving quality of care within the Indian Health Service.