How Will American Indians Fare if the ACA is Repealed?

By Amit Chitre, R3Communications

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) bill, formally making “Obamacare” law. The move significantly reduced the number of uninsured Americans and became a literal lifesaver for many struggling with access to affordable health care. But the ACA also has its detractors, including President Trump, who signed an executive order to repeal the ACA and “minimize the unwarranted economic and regulatory burdens” it may bring. While the nation is watching the health care debate continue to unfold, American Indians in particular are paying close attention. American Indians uniquely benefited from the passage of ACA and could be significantly impacted by its repeal. 

Underrepresented in the Face of Change

While politicians and media pundits argued over mandates, costs and consumer choice during the development and enactment of the ACA, the law’s impact on American Indian populations was largely underrepresented in those debates. This comes as no surprise to those who advocate for American Indian issues. Dr. Donald Warne, MPH, MD, who was raised within the Lakota tribe in North Dakota, serves as the senior policy advisor to the Great Plains Tribal Chairmen’s Health Board. He has conducted extensive research on the relationship between indigenous peoples — particularly American Indians — and noncommunicable diseases. He says only 35 states have federally recognized tribes. This means tribes have virtually no voice in 15 states in the House or Senate to help shape the health care landscape. “I think it’s an issue of demographics and money,” Dr. Warne explained. “We’re not located where the media centers are. Also, we’re an impoverished population that has challenges in getting our issues at the forefront of any discussion, whether it’s policy, media or otherwise.”

American Indian Health in Perspective

When it comes to health care access and resources, American Indian populations have long been underserved. The Indian Health Service (IHS), an agency under the U.S. Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives (who are typically grouped with American Indian tribes). IHS reports native populations born today have a life expectancy that is 4.4 years shorter than that of every other race in the United States combined. They also carry a disproportionate burden for conditions such as chronic liver disease and cirrhosis, diabetes, unintentional injuries, assault and homicide, suicide and chronic lower respiratory diseases.

The root causes of these poor health conditions are layered and complex, meaning that mitigating or preventing them can be just as complicated. For many tribal members, social and economic conditions intertwine to create an environment that cultivates poor health. In 2004, a briefing to the U.S. Commission on Civil Rights highlighted five keys factors contributing to the health disparities of American Indians:

  1. Limited access to IHS services
  2. Poor access to health insurance
  3. Insufficient federal funding
  4. Quality of care issues
  5. Disproportionate poverty and poor education

Passage of the ACA immediately addressed many of these issues. American Indian and Alaska Natives gained access to health insurance when the ACA became law. The ACA also provides special benefits to American Indians and Alaska Natives who choose to purchase health care coverage by waiving out-of-pocket costs like deductibles, copayments and coinsurance for qualifying families.

The ACA covers many preventive services, such as well-woman visits, birth control methods and counseling, oral health checkups and vision care, but it also covers services that directly impact the health issues American Indian populations disproportionately face. Substance abuse, domestic violence, diabetes and depression all occur at high rates in American Indian populations, and these treatment services are all covered by the ACA.

Benefits and Challenges Under the ACA

Perhaps more important, the ACA permanently extended funding for the Indian Health Care Improvement Act (IHCIA). The federal government established the IHCIA in 1976 to improve health and education services for American Indians; however, funding expired in 2000, leaving the IHCIA dormant until a provision in the ACA rescued the program. In addition to direct funding, the ACA opens up Medicaid dollars for local and tribal health facilities. With the IHCIA fully funded, tribes have more opportunities to manage their health care programs and serve patients more effectively.

But one ACA benefit may have created an unintended consequence for American Indians and Alaska Natives. These populations are eligible for a waiver from the “individual mandate” tax penalty, which means there is no disincentive for not purchasing health insurance. USA Today reports more than 2 million American Indians receive free health care services through Indian health and tribal facilities. These individuals may find little reason to purchase additional insurance — even at a discount. ­­As a result, the CDC reports more than 28 percent of American Indians or Native Alaskans under the age of 65 are still uninsured. But what happens when these uninsured individuals face a serious health issue that can’t be addressed by the American Indian health or tribal facilities? Major surgeries and cancer treatments are referred to specialists outside American Indian lands, and at least two-thirds of those claims are rejected.

Still, many organizations are advocating to preserve the ACA or, at least, portions of the law beneficial to American Indian health. The National Indian Health Board testified before Congress on the impact of repealing the ACA. The Alaska Native Tribal Health Consortium and Indian Health Service continue to drive younger populations toward the ACA open enrollment. Medicaid funding, coverage of preventive programs and the viability of IHCIA all benefit American Indian health, and are all vulnerable with a potential ACA repeal. As Congress debates the specifics around “repeal and replace” over the next several months, Dr. Warne urges lawmakers to remember the human consequences to their proposals: “It’s not just an issue related to money; the revenues translate into access to more services, so it’s saving lives.” 

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