Medicaid and American Indians and Alaska Natives Samantha Artiga and Anthony Damico

This brief provides an overview of the health needs of American Indians and Alaska Natives, discusses the role of Medicaid and the potential impact of the Medicaid expansion for this population, and summarizes new guidance from the Centers for Medicare and Medicaid Services (CMS) that expands the scope of Medicaid services provided to American Indians and Alaska Natives that may qualify for 100% federal match. It shows: 

American Indians and Alaska Natives face persistent disparities in health and health care. Nearly 5 million nonelderly individuals self-identify as American Indian or Alaska Native alone or in combination with some other race, representing nearly 2% of the total nonelderly population. American Indians and Alaska Natives have a high uninsured rate, face significant barriers to obtaining care, and have significant physical and mental health needs.

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The Medicaid program plays an important role for American Indians and Alaska Natives given their low incomes and the limitations of services available through the Indian Health Service (IHS). The Affordable Care Act (ACA) Medicaid expansion provides an opportunity to enhance this role by increasing coverage among American Indians and Alaska Natives and providing additional revenue to IHS- and Tribally-operated facilities. In states that do not expand Medicaid, American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities.

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New guidance expands the scope of Medicaid-covered services provided to American Indians and Alaska Natives for which the federal government will pay 100% of the costs. CMS indicates these changes are intended to “help states, the IHS, and Tribes to improve delivery systems for American Indians and Alaska Natives by increasing access to care, strengthening continuity of care, and improving population health.”1 The changes also may provide for savings to states, since some costs that were previously reimbursed at the regular state match rate can now be matched with 100% federal funds. Additionally, the changes may reduce state costs associated with the Medicaid expansion for American Indians and Alaska Natives (when the state share begins phasing in), since a larger share of costs for this population can be reimbursed at 100% federal match.

American Indians and Alaska Natives face persistent disparities in health and health care, including a high uninsured rate, 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. Given the low incomes of American Indians and Alaska Natives and the limitations of IHS services, the Medicaid program plays an important role for the population. The Affordable Care Act (ACA) Medicaid expansion provides an opportunity to enhance this role by increasing coverage among American Indians and Alaska Natives and providing additional revenue to support IHS- and Tribally-operated facilities. Moreover, the Centers for Medicare and Medicaid Services (CMS) recently released new guidance that expands the scope of Medicaid-covered services provided to American Indians and Alaska Natives for which the federal government would pay 100% of the costs. These changes are intended to help improve access to care for American Indians and Alaska Natives and may provide savings to states. This brief provides an overview of the health needs of American Indians and Alaska Natives, discusses the role of Medicaid and the potential impact of the Medicaid expansion for this population, and reviews the new CMS guidance that expands the scope of Medicaid services provided to American Indians and Alaska Natives that can qualify for 100% federal match.

Nearly 5 million nonelderly individuals self-identify as American Indian or Alaska Native alone or in combination with some other race, representing nearly 2% of the total nonelderly population. In most cases, data analysis in this brief is based on this inclusive group of American Indians and Alaska Natives. Within this group, some 2.4 million nonelderly individuals identify their race 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 or Alaska Native but are not enrolled in a Tribe. 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 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. 2 Figure 1

American Indians and Alaska Natives as a Share of the Nonelderly Population, by State, 2014 VT

WA

NH

MN

OR

MI

WY

CA

AZ

CO

PA

IA

NE UT

NY

WI

SD

ID

NV

IL

KS OK

NM TX

IN

OH WV

MO

VA

KY

MA RI

DC

SC

AR AL

CT NJ DE MD

NC

TN MS

AK

ME

ND

MT

GA

LA FL

HI

Total: 4.8 million = 1.8% of Nonelderly Population

Less than 1% (17 states) 1-3% (24 states) More than 3% (10 states)

Note: Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. SOURCE: KCMU analysis of 2014 ACS.

Medicaid and American Indians and Alaska Natives

2

While the majority of American Indians and Alaska Natives are in working families, they have high rates of poverty. More than seven in ten (74%) of nonelderly American Indians and Alaska Natives are in working families, but American Indians and Alaska Natives are less likely than the overall nonelderly population to be in the workforce and have significantly higher rates of poverty (26% vs. 16%) (Figure 2). Figure 2

Income and Work Status for Nonelderly American Indians and Alaska Natives, 2014 US Nonelderly Population

American Indians and Alaska Natives

Work Status 82%

Income

74% *

26% * 16%

Full-Time Worker in the Family

Family Income Below Poverty

Notes: Includes American Indians and Alaska Natives alone and in combination with another race, and those of Hispanic origin. * Indicates statistically significant difference from U.S. nonelderly population at p < 0.05 level. SOURCE: KCMU analysis of 2014 ACS.

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, and having diabetes (Figure 3). Moreover, the suicide rate for American Indian and Alaska Native adolescents and young adults is two and half times higher than the national average.3 Figure 3

Health Status and Rates of Selected Chronic Diseases for American Indian and Alaska Native Nonelderly Adults, 2014 Nonelderly Adults

American Indian and Alaska Native Nonelderly Adults 64%

70% *

26% * 16% 8% Fair/Poor Health

Overweight or Obese

11%

Diabetes

* 2%

3%

Cardiovascular Disease

Notes: Includes nonelderly adults 18-64. Includes individuals identifying race as AIAN only, including those of Hispanic origin. Does not include individuals identifying as AIAN in combination with another race. * Indicates a statistically significant difference from nonelderly adults at p