Medicaid expansion would close gaps for American Indians and Alaska Natives

Due to the limited funding and scope of Indian Health Service (IHS) programs, many American Indians and Alaska Natives are not able to access the health services they need. While Medicaid fills some coverage gaps, American Indians and Alaska Natives are significantly more likely than the national average to be uninsured. According to a Kaiser Family Foundation Issue Brief, the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in states that have not yet expanded would significantly close existing coverage gaps and provide support to IHS providers.

Poverty

Nonelderly American Indians and Alaska Natives experience high rates of poverty. Despite the fact that 74 percent of nonelderly American Indians and Alaska Natives are in working families, 26 percent of nonelderly American Indians and Alaska Natives are in poverty whereas 16 percent of the overall nonelderly population experiences poverty. The impact on health is measurable. Among nonelderly adults, American Indians and Alaska Natives are more likely than the overall population to report being in fair or poor health. Additionally, the suicide rate for American Indian and Alaska Native adolescents and young adults is two and half times above the national average.

IHS

IHS is the agency responsible for providing health care and prevention services to American Indians and Alaska Natives. However, there is a coverage gap for some American Indians and Alaska Natives because 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. The benefit of IHS is also limited by its discretionary funding, which is historically too low to meet the needs of American Indians and Alaska Natives. As a result, many American Indians and Alaska Natives turn to Medicaid as a source of health insurance coverage.

Medicaid expansion

While some states with large shares of the American Indian and Alaska Native population have expanded Medicaid under the ACA—California, Arizona, and New Mexico—several of the remaining 19 non-expansion states are also home to a large share of the American Indian and Alaska Native population. Medicaid expansion provides significant coverage opportunities for the American Indian and Alaska Native population. Nationwide 440,000 currently uninsured American Indians and Alaska Natives are eligible for Medicaid. However, an additional 65,000 uninsured poor adult American Indians and Alaska Natives fall into a coverage gap created by states that have not expanded Medicaid. If the remaining states elect to expand Medicaid, more than 550,000 currently uninsured American Indians and Alaska would be eligible for Medicaid. In addition to increasing coverage, the expansion would provide additional support for IHS facilities in the form of Medicaid revenues, allowing those facilities to expand and increase access to care.

Federal matching

The impact of expansion is increased by the fact that, while federal matching for Medicaid costs generally varies across states from 50 percent to 74 percent, the federal government covers 100 percent of costs for services provided to American Indian and Alaska Native beneficiaries through an IHS- or tribally-operated facility. Additionally, in October 2015, CMS announced that it was considering expanding the 100 percent match to include any Medicaid benefit covered by the state plan that the IHS or tribal facility is authorized to provide. The result would be the potential coverage of emergency and non-emergency transportation, home and community based services, personal care, and other services that do not qualify as “facility services” under the current policy. CMS believes that the changes would significantly improve access to care for American Indians and Alaska Natives.