Health Coverage and Care for American Indians and Alaska Natives

American Indians and Alaska Natives face persistent disparities in health and health care, including high uninsured rates, significant barriers to obtaining care, and poor health status. Treaties and laws establish the federal government’s responsibility to provide certain rights, protections, and services to American Indians and Alaska Natives, including health care. The Indian Health Service (IHS) is the primary vehicle through which the federal government provides health services to American Indians and Alaska Natives. However, chronic underfunding for IHS and other barriers limit access to care for the population. The Affordable Care Act (ACA) offers important opportunities to increase health coverage and care for American Indians and Alaska Natives and reduce the longstanding disparities they face. This brief provides an overview of health coverage and care for American Indians and Alaska Natives today and the potential implications of the ACA coverage expansions.

A total of 5.1 million individuals self-identify as American Indian or Alaska Native alone or in combination with some other race, representing 2% of the total population. This includes some 2.5 million individuals who identify solely as American Indian or Alaska Native, making up roughly 1% of the total U.S. population. Some American Indians and Alaska Natives belong to a federally-recognized tribe, some belong to a state-recognized tribe, and others self-identify as American Indian and Alaska Native, but are not enrolled in a tribe. Tribal membership has important implications for access to benefits. Members and descendents of members of federally recognized tribes have broader access to certain federal benefits and services. American Indians and Alaska Natives live across the country but are concentrated in certain states (Figure ES-1). While many American Indians and Alaska Natives live in rural areas, only 22% live on reservations or land trusts. As of 2010, 60% of American Indians and Alaska Natives live in metropolitan areas.

While the majority of American Indians and Alaska Natives are in working families, they have high rates of poverty. Six in ten (63%) nonelderly American Indians and Alaska Natives are in working families, but American Indians and Alaska Natives are less likely than the overall population to be in the workforce and have significantly higher rates of poverty (41% vs. 25%).

American Indians and Alaska Natives face significant physical and mental health problems. Among nonelderly adults, American Indians and Alaska Natives are more likely than the overall population to report being in fair or poor health, being overweight or obese, having diabetes and cardiovascular disease, and experiencing frequent mental distress (Figure ES-2). Moreover, the suicide rate for American Indian and Alaska Native adolescents and young adults is two and half times higher than the national average.

The IHS provides health care and prevention services to roughly 2.2 million American Indians and Alaska Natives, but has historically been underfunded to meet the health care needs of the population. IHS-funded health services are provided through a network of hospitals, clinics, and health stations that are managed directly by IHS, by tribes or tribal organizations, and urban Indian health programs. Some services also are provided through contract with non-Indian providers. In general, services provided through IHS- and tribally-operated facilities are limited to members of and descendants of members of federally recognized tribes that live on or near federal reservations. Urban Indian health programs serve a wider group of American Indians and Alaska Natives, including those who are not able to access IHS- or tribally-operated facilities because they do not meet eligibility criteria or reside outside the service areas. IHS funding is limited and must be appropriated by Congress each fiscal year. In FY2013, total program funding was $5.46 billion. Although the IHS budget has increased over time, funds are not equally distributed across facilities and they remain insufficient to meet health care needs. As such, access to services through IHS varies significantly across locations, and American Indians and Alaska Natives who rely solely on IHS for care often lack access to needed care. Moreover, as a discretionary program IHS funding is subject to the automatic funding cutbacks under the sequester, which further limit access to services.

Nearly one in three American Indians and Alaska Natives is uninsured. Overall, American Indians and Alaska Natives have limited access to employer-sponsored coverage because they have a lower employment rate and tend to be employed in low-wage jobs that typically do not offer health coverage. Less than four in ten (36%) American Indians and Alaska Natives have private coverage, compared to 62% of the overall nonelderly population. (Figure ES-3).  Medicaid helps fill this gap, covering one in three non-elderly American Indians and Alaska Natives. Medicaid also provides key financing for IHS providers and has special financing rules and protections for American Indians and Alaska Natives. However, nearly one in three (30%) nonelderly American Indians and Alaska Natives remains uninsured.

The ACA offers opportunities to increase coverage and access to care for American Indians and Alaska Natives. For all Americans, the ACA seeks to reduce the number of uninsured through an expansion of Medicaid and new Health Insurance Marketplaces with tax credits to help purchase coverage. Nine in ten (94%) uninsured American Indians and Alaska Natives have incomes in the range to qualify for these coverage expansions (Figure ES-4). Moreover, the ACA permanently reauthorizes the Indian Health Care Improvement Act, extending and authorizing new programs and services within the IHS.

However, half of poor uninsured adult American Indians and Alaska Natives live in states not moving forward with the Medicaid expansion at this time, and, as such, will continue to face a gap in coverage. The ACA Medicaid expansion was effectively made a state option by the Supreme Court ruling on the ACA. As of September 2013, half of states are moving forward with the expansion to adults with incomes at or below 138% of the federal poverty level (FPL) ($15,856 for an individual in 2013). In these states, many American Indian and Alaska Native adults will become newly eligible for the program. However, in states not expanding Medicaid, many American Indian and Alaska Native adults will continue to face a gap in coverage since they will remain ineligible for Medicaid and those below 100% FPL will not be eligible for the tax credit subsidies for Marketplace coverage. Half of uninsured adult American Indians and Alaska Natives with incomes below 100% FPL live in the 26 states not moving forward with the expansion at this time. Moreover, state Medicaid expansion decisions will create unique equity issues for American Indians and Alaska Natives since some tribal nations extend across states that have made differing expansion decisions, which will drive variations in coverage, access, and health status both within and between tribes.

The Marketplaces provide new coverage options for many American Indians and Alaska Natives, but only members of federally-recognized tribes will receive certain consumer protections. Members of federally-recognized tribes who purchase coverage through the Marketplaces will receive special protections, including the ability to change health plans on a monthly basis and some exemptions from cost-sharing. However, these protections will not apply to the broader group of American Indians and Alaska Natives who are eligible for IHS services and are afforded certain Medicaid protections. This inconsistency will result in many American Indians and Alaska Natives not receiving the special Marketplace protections and likely lead to confusion that may hamper enrollment efforts.

In sum, while the federal government has the responsibility to provide health care to American Indians and Alaska Natives, many face challenges accessing care and the population continues to experience poor health outcomes. Due to limited funding, the IHS is not able to fully meet the need for care. American Indians and Alaska Natives also have limited access to employer-sponsored insurance. While Medicaid helps fill this gap, many remain uninsured. Looking ahead, the ACA provides important opportunities to increase coverage and access to care for American Indians and Alaska Natives, which could help reduce the longstanding health disparities they face. However, significant coverage gaps will remain in states that do not expand Medicaid and decreases in IHS funding may further limit access to IHS services.