In Indian Country, the survival of Obamacare’s Medicaid expansion brings a sigh of relief

As members of Congress and the Trump administration point fingers over their failure to repeal the Affordable Care Act, one constituency is definitely celebrating: Native Americans.

Native Americans often receive care through the Indian Health Service, a chronically underfunded service provided by the federal government. But the Affordable Care Act's expansion of Medicaid provided a much-needed boost to the IHS — by making many Native Americans eligible for Medicaid and directing compensation for their care to IHS. 

Because Medicaid expansion remains, tribes can count on those extra Medicaid dollars to get them through the year. 

That's welcome news to health care practitioners like Angie Erdrich. She's a pediatrician working at the Minneapolis Indian Health Board clinic in south Minneapolis, which is home to one of the largest urban Native communities in the country. Its emphasis on culturally focused care, plus a largely Native staff, make it a safe and welcoming place. Erdrich says they make the most of what they have. 

“We don't want to spend all our money on crisis care instead of preventative care,” explained Erdrich, who has been working in Indian health since 1997. She's seen a dramatic increase in the number of people at the clinic who have health insurance since 2010. The number of people with insurance increased by 22 million, and Native patients are among that number. 

In addition to funding, she credits Medicaid expansion with helping people manage long-term diseases like diabetes, which has a disproportionate effect on Native people. The federal government promised to provide health care to Native Americans in many of the treaties it signed in the 19th and 20th centuries. How that promise is implemented has changed over the years — from doctors and nurses visiting tribes and providing vaccinations at the turn of the 20th century to today's IHS.

IHS received $4.8 billion in direct funding in 2016, but those dollars aren't enough to provide the care the government has committed to provide. 

Native American policy expert, journalist and writer Mark Trahant spelled out three ways that care could be improved and more money could be added to the system.

"More American Indians and Alaska Natives can sign up for Medicaid. The fact is, there are many more people eligible than have signed up," he says.

He says states that haven't expanded Medicaid should be encouraged to do so, now that the future of the program is somewhat more stable.

"Now that the Affordable Care Act remains the law of the land, there remains unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments, such as imposed work rules)," he says. 

Trahant would also like to see an increase in eligibility for Medicaid — for people who make up to 300 percent of the federal poverty level, not just 138 percent, the current threshold.

Of course, you could also provide more funding for Indian health directly. But Trahant doesn't think it's even realistic to talk about that.

"No Democrat nor Republican government has ever proposed fully funding the Indian health system," Trahant says. "Members of Congress often acknowledge the treaty responsibility, but have never followed those words with a budget."

There's a saying in Indian Country: "Don't get sick after June." Health care can be hard to find when the money runs out, often in June. From then until the next fiscal year, clinics often resort to rationing care and only treating those who have serious or life-threatening conditions. 

Stacy A. Bohlen, the executive director of the National Indian Health Board, a nonprofit agency in Washington that advocates for Indian health care, estimates that Medicaid expansion brings more than a billion dollars to tribal health care systems — increasing access to things like checkups, well-child care, dental care and other services.

Still, Trahant warns Indian community not to celebrate. There are still dangers ahead for Indian Country, he warns.

"The problem is that Congress is deeply divided and cannot govern," he says.

Caitrin McCarron Shuy, the health board's director of congressional relations, is quick to note that the issue of Indian health is nonpartisan and should be one where Democrats and Republicans can find common ground.

"We have champions on both sides of the aisle," she said. Indeed, if the Republican-sponsored American Health Care Act had passed without provisions pertaining to Native Americans that Obamacare provided, Oklahoma Republican Rep. Tom Cole had legislation ready to re-enact them.

For now, the Affordable Care Act remains the law of the land. That means Native patients living on and off the reservation will still benefit from Medicaid expansion and Indian Health Services will continue to see additional funding for the important care it provides.