By Casey Cooper, Chief Executive Officer, Cherokee Indian Hospital Authority
November is Native American Heritage Month, or as it is commonly referred to, American Indian and Alaska Native Heritage Month.
The month is a time to celebrate rich and diverse cultures, traditions, and histories and to acknowledge the important contributions of Native people. Heritage Month is also an opportune time to educate the general public about tribes, to raise a general awareness about the unique challenges Native people have faced both historically and in the present, and the ways in which tribal citizens have worked to conquer these challenges.
One of those challenges that Native Americans continue to struggle with today is adequate access to healthcare.
The 2020 census found that the American Indian and Alaska Native population, alone and in combination with another race, increased 160 percent since the 2010 census, with just over 300,000 individuals living in North Carolina.
Nearly 5 million nonelderly individuals self-identify as American Indian or Alaska Native (AIAN) alone or in combination with some other race, representing nearly 2% of the total nonelderly population.
The AIAN populations face persistent disparities in health and health care. AIANs have a high uninsured rate, face significant barriers to obtaining care, and have significant physical and mental health needs.
The Kaiser Family Foundation (KFF) reports that Medicaid coverage helps to fill gaps in employer-sponsored insurance for AIANs, enables AIANs to access a broader array of services and providers than they can access solely through services funded by the Indian Health Service (IHS), and provides a key source of financing for IHS and Tribal providers.
For states that expanded Medicaid under the Affordable Care Act, coverage gains among AIANs and increased revenue to IHS- and Tribally-operated facilities. The uninsured rate for nonelderly AIANs in states that implemented the Medicaid expansion fell by twice as much (from 23% to 15% between 2013 and 2015) as the rate in non-expansion states (from 25% to 21%). In addition, the expansion increased revenues to IHS- and Tribal facilities serving AIANs as a larger share of their patients gained coverage, enhancing their capacity to provide services. Reductions to Medicaid, including loss of the expansion, could result in coverage losses for AIANs and reductions in revenue to IHS and Tribal providers, limiting access to care for AIANs.
With a predominate and growing AIAN population in North Carolina, many enrolled members are caught in the health insurance coverage gap… and to no fault of their own. Over three quarters (76%) of nonelderly AIANs are in working families, but they are less likely than other nonelderly individuals to be in the workforce (83%) and have significantly higher rates of poverty (24% vs 16%), according to the KFF.
While also facing barriers to accessing healthcare, many AIANs are also plagued with significant physical and mental health problems.
The Indian Health Service (IHS) is the agency within the U.S. Department of Health and Human Services (HHS) that is primarily responsible for providing health care services to American Indian and Alaska Native (AIAN) people (IHS 2020a). Medicaid is one of several programs that play a secondary but meaningful role in financing health services for this population: it provides health insurance coverage for AIAN people, covering more than one-third of AIAN adults in 2018 (KFF 2020). It is also an essential source of revenue for the facilities and programs that make up the IHS delivery system.
Although many AIAN people are eligible to receive services at IHS-funded facilities free of charge, its services are not available to those who are not members of a federally recognized tribe or live outside the geographic service areas of IHS-funded facilities and programs. Some are covered by Medicaid (see below). Others do not have another source of coverage, especially in states that have not adopted the Medicaid expansion under the Patient Protection and Affordable Care Act
In the months following Oklahoma’s vote to expand Medicaid in 2021, more than 23,000 eligible Native Americans enrolled in the program — which equated to 13 percent of the total population that enrolled. Looking at Oklahoma’s passage of Medicaid Expansion in 2021, Dr. Stephen Jones, the executive director of Cherokee Nation Health Services, said the expansion would have the largest effect on uninsured patients who had been unable to seek medical services outside their tribal hospitals.
Medicaid expansion is expected to improve not just access to care for low-income tribal members who had previously been shut out, but also the agency’s bottom line. The Indian Health Service spends about $4,078 per patient; in comparison, Medicaid spends $8,109, according to a 2018 study by the Government Accountability Office.