Native American

Healthcare Reform

How the Affordable Care Act Applies to Native Americans

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Native American

American Indians and Alaska Natives Don’t Have to Buy Health Insurance, So Why Would They?

Plenty of Americans are signing up for the healthcare exchange simply to avoid the penalties that would come from not having coverage. However, the decision for American Indian and Alaska Natives is a little less cut and dry.

“The conversation that’s happening in this country about insurance and the need to have insurance coverage is also happening in Indian country.”

Due to treaties between tribes and the United States, members of these populations are guaranteed healthcare for free. They also will not be penalized for being uninsured under the Affordable Care Act.

Yet, even with these special allowances, many Native American health organizations are encouraging their members to get insured.

“The conversation that’s happening in this country about insurance and the need to have insurance coverage is also happening in Indian country,” says Geoffrey Roth, senior advisor to the Director of the Indian Health Service (IHS).

In the United States 1.2 million American Indians and Alaska Natives lacked health insurance in 2011, according to the Center on Budget and Policy Priorities. That is nearly a quarter of their total population.

Living away from tribal lands often means no access to healthcare services.

For comparison, about 15 percent of Americans countrywide are uninsured. In theory, because of treaties with the U.S., even uninsured Native Americans can go to an IHS or tribal-run facility for healthcare services. However, this seemingly straightforward system has some glaring issues.

First of all, most IHS and tribal-run health facilities are housed on tribal lands. Therefore, living away from those lands often means no access to tribal health services. This is a big problem because around 78 percent of Native Americans are now living in non-tribal areas, according to the 2010 Census.

For uninsured Native Americans, that can mean forgoing healthcare all together.

For those tribe members who can readily visit tribal healthcare facilities, getting the care they need is still complicated. “We’re not funded at the entire need for our population,” says Roth. “So we, in many cases, have to prioritize medical needs, and by doing that we’re not able to provide all of the care that individuals need.”

With coverage, Native Americans on and off the reservation can receive the same care as anyone else on their health insurance plan.

The IHS receives funding from the government to provide their members with care, and they can also seek funding from other third-party organizations. Still, the money is running short. Because of this, they have to prioritize which people need care the most. Individuals whose health problems are considered a lower priority may wait years to get treated, says Roth.

On the other hand, if tribe members purchase health insurance through the exchange, funds availability and access to care look very different. With coverage, Native Americans on and off the reservation can receive the same care as anyone else on their health insurance plan.

Additionally, Native Americans who are under 300 percent of the federal poverty level — roughly $66,000 for a family of four — would have no cost sharing (no matter the facility) if they sign up. Those who are above this income line would have no cost sharing if they receive care at an IHS or tribally-run facilities. Instead, the federal government covers the cost.

Some tribe members already have some insurance coverage through work but it is often incomplete.

This creates an increased inflow of money to these facilities, which can then be used to provide care to members of the community who are still not covered.

Some tribe members already have some insurance coverage through work but it is often incomplete. Dr. Eva Smith, a family physician who provides care to the Hoopa Valley Tribe in Northern California, said by email that Alaska Natives and American Indians sometimes get insurance through seasonal work, such as positions in the timber, fishery, and wildfire industries, but that lapses when the jobs are off-season. Sometimes the insurances fails to cover their families even when they are on the job.

For these groups  Medicaid expansion is of particular interest. The expansion will provide coverage for individuals up to 133 percent of poverty level (around $30,000 for a family of four) in certain states, which could cut the number of uninsured Native Americans in half.

Some tribal leaders are even considering buying insurance for their whole tribe in an attempt to increase their community’s level of care.

The general consensus among Alaska Native and American Indian health groups is that the ACA has a lot of potential to help their members. As of June, the IHS completed 350 trainings over the last three years to educate various individuals, tribal leaders, and facilities heads on the ACA. Roth says the overall response has been positive. Some tribal leaders are even considering buying insurance for their whole tribe in an attempt to increase their community’s level of care and many individuals, he says, are excited about their inclusion in the Medicaid expansion.

However, Dr. Smith said the advertising needs to be even more aggressive on the reservations than it has been elsewhere. That means advertising outside of the clinics, in places like tribal newspapers, radio stations, and even at school sporting events where community members can be reached.

Roth agrees that there is still a ways to go. “It’s an education process”, says Roth, “and we’re going to continue to work on helping people understand the benefits of having health insurance and what it can mean to their local community as well as their own individual healthcare.”

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