Health Insurance Coverage and Access to Care for American

July 2021

ISSUE BRIEF

HP-2021-18

Health Insurance Coverage and Access to Care for

American Indians and Alaska Natives:

Current Trends and Key Challenges

KEY POINTS

• The uninsured rate among American Indians and Alaska Natives (AI/AN) under age 65 decreased

16 percentage points since the passage of the Affordable Care Act (ACA), from 44 percent in 2010

to 28 percent in 2018.

• However, according to 2019 Census data, the AI/AN population continues to have the highest

uninsured rate compared to other populations.

• The American Rescue Plan Act of 2021 (ARP) offers expanded financial assistance for purchasing

Marketplace health insurance, and the ARP has made zero-premium plans available to an

estimated 26,000 additional uninsured AI/AN people.

• Oklahoma expanded Medicaid as of July 1, 2021; prior to expanding Medicaid, Oklahoma had the

largest uninsured AI/AN population of any state - more than 79,000 people.

If remaining non-

expansion states were to adopt the ACA Medicaid expansion, approximately 55,000 more

uninsured AI/AN non-elderly adults would be eligible for Medicaid coverage.

• Significant disparities remain, as AI/AN people are disproportionately affected by chronic

conditions and die at higher rates than other Americans from chronic liver disease, diabetes, and

chronic lower respiratory diseases, as well as non-chronic causes of death such as suicide and

accidents.

• AI/AN have experienced higher rates of COVID-19 infection, hospitalization, and death compared

to White persons during the pandemic. However, after COVID-19 vaccines became available,

AI/AN communities have achieved higher COVID-19 vaccination rates compared to other racial

and ethnic groups.

• Strengthening the Indian health care system, together with broader efforts across the federal

government and cross-sector partnerships, can promote health equity by addressing social

determinants of health such as housing, education, and employment.

INTRODUCTION

American Indians and Alaska Natives (alone or in combination with one or more race) comprised 1.7 percent

(5.7 million) of the total population in 2019.

The AI/AN population increased by approximately 413,000 since

2013, representing an 8 percent increase in population size.

Alaska Natives (alone or in combination with

_______________________

Census does not classify the Indian Health Service as health coverage.

July 22, 2021

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ISSUE BRIEF

more than one race) represent a smaller portion of the AI/AN population, totaling approximately 172,000 in

2019. The AI/AN population estimate more than doubles when including individuals identifying with more than

one race, from 2.8 million for AI/AN alone to 5.7 million AI/AN individuals reporting more than one race or

ethnicity.

A higher percentage of AI/AN people ages 18 and over are in fair or poor health (20.6 percent) compared to all

people ages 18 and over in the U.S. (12.1 percent).

Social determinants such as high poverty and

unemployment rates, stemming from longstanding historical discrimination and structural inequities, are key

contributors to AI/AN health disparities.

The Affordable Care Act (ACA) expanded coverage options for AI/ANs via Medicaid expansion and Marketplace

coverage, as it did for all groups within the U.S. The Marketplace also provides special health coverage

protections and benefits for members of federally recognized tribes, including the ability to enroll in

Marketplace coverage throughout the year rather than just during the yearly Open Enrollment Period and

additional cost sharing reductions (CSRs) that can mean no copays, deductibles or coinsurance when receiving

care from Indian health care providers or when receiving essential health benefits (EHBs) through a qualified

health plan (QHP) with a referral from an Indian health care provider.

This Issue Brief is part of a series analyzing trends in coverage for different racial and ethnic groups since the

implementation of the ACA. This brief describes how the uninsured rate, health coverage, and access to care

for the AI/AN population have changed and discusses key policies for this population, including how the

American Rescue Plan Act of 2021 (ARP) builds on the ACA, along with permanent reauthorization of the

Indian Health Care Improvement Act, and invests additional resources into the Indian health care system.

BACKGROUND

There are 574 federally recognized tribes across the U.S. and 63 state-recognized tribes located in 11 states.

The five largest federally recognized tribes and their share of AI/AN population are Cherokee (26.3 percent),

Navajo (11.42 percent), Choctaw (5.49 percent), Blackfeet (3.62 percent), and Muscogee (2.81 percent).

Approximately 70 percent of AI/ANs live in urban areas, and 25 percent live in counties served by urban Indian

health programs funded through the Indian Health Service (IHS).

In the 2010 Census, 40.7 percent of the

AI/AN population lived in the West; the South had the second-largest proportion (32.8 percent); followed by

the Midwest (16.8 percent) and the Northeast (9.7 percent).

The states with the largest percentages of 2010

Census respondents who self-identified as American Indian and Alaska Native (alone or in combination with

another race) were California (13.9 percent of AI/AN respondents), Oklahoma (9.2 percent), and Arizona (6.8

percent).

People reporting multiple races represent a growing share of the overall AI/AN population.

METHODS

The American Community Survey (ACS) conducted by the Census Bureau is the largest national survey of

households. The Census Bureau surveys almost 300,000 households each month for the ACS and collects

health insurance and demographic information, including race and ethnicity, along with other types of

information. This brief uses ACS data from 2013 and 2019 for population, health insurance coverage and

demographic estimates. Race and ethnicity estimates using ACS or the U.S. Census rely on survey participants

self-identifying as an AI/AN and are not based on official tribal membership rolls. This brief also uses 2019

State-based Marketplace enrollment data from California and Washington and federal Marketplace enrollment

data as reported by the Indian Health Service Tribal Self-Governance Advisory Committee (TSGAC).

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Throughout this brief, unless otherwise specified, we use the term “American Indians and Alaska Natives” to

describe the population reporting AI/AN as their race, either alone or in combination with another

race/ethnicity.

There are several limitations with these data, including potential non-response bias for both race and ethnicity

data and source of health insurance. More specifically, both the ACS and the Census data historically

undercount the AI/AN population, and our results should be interpreted accordingly.

RESULTS

Health Coverage

In 2019, 15.2 percent of AI/AN individuals (all ages) were uninsured, 51.9 percent had private health insurance

coverage, and 42.1 percent of AI/ANs had Medicaid/CHIP, Medicare, or other public health coverage (Figure

1), according to the ACS.

†

This compares to non-Hispanic Whites, where the analogous figures were 6.3

percent, 74.7 percent, and 34.3 percent, respectively.

Individuals who receive their care through the Indian

Health Service (IHS) but do not have any health insurance are considered uninsured by Census surveys.

Figure 1. Health Insurance Coverage in American Indian/Alaska Native Population (All Ages), 2019

Source: 2019 American Community Survey 1 Year Estimates Selected Population Profiles

Note: Estimates sum to more than 100 percent since participants were able to report more than one form of health insurance

coverage. Private coverage includes employment-based, direct purchase and TRICARE. Public coverage includes Medicare,

Medicaid/CHIP, and VA coverage.

The uninsured rate among non-elderly AI/AN (under age 65) decreased by 16 percentage points between 2010

and 2018, after implementation of the ACA’s major coverage provisions (from 44 percent to 28 percent, see

Figure 2). Given the relatively small sample size in the National Health Interview Survey, however, this

estimate fluctuates more widely from year-to-year than for other racial and ethnic groups. Also,

sociodemographic differences across national surveys such as the NHIS and ACS can produce differing

estimates of the AIAN population.

_______________________

†

Estimates sum to more than 100 percent since survey participants were able to report more than one form of health insurance

coverage.

15.20%

42.1%

51.9%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

Private Health Insurance Coverage Public Health Insurance Coverage Uninsured

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Figure 2. Uninsured Rate for Nonelderly (under 65) US Population and By Race and Ethnicity, 2010-2019

Source: National Center for Health Statistics, National Health Interview Survey, 2010-2019

Notes: In this analysis, individuals were defined as uninsured if they did not have any private health insurance, Medicare, Medicaid,

Children’s Health Insurance Program (CHIP), state-sponsored or other government plan, or military plan. Individuals were also defined

as uninsured if they had only Indian Health Service coverage or had only a private plan that paid for one type of service, such as

accidents or dental care. Data are based on household interviews of a sample of the civilian non-institutionalized population. Native

Hawaiian or Other Pacific Islander and American Indian or Alaska Native populations did not have estimates available for 2019 due to

sample size considerations.

Marketplace Coverage

Opportunities for affordable health coverage through Marketplace health insurance plans have benefited the

AI/AN population. For purposes of the Marketplace, only members of federally recognized Indian tribes and

Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders (regional or village) are referred to as

AI/ANs. Under AI/AN Marketplace protections:

1. AI/ANs can enroll in coverage through the Marketplace any time during the year, not just during the

yearly Open Enrollment period. Non-tribal members applying on the same application as a tribal

member also are eligible for this special enrollment period.

2. AI/ANs have additional cost-sharing protections that differ from the standard CSRs available to

Marketplace enrollees with household incomes at or below 250 percent of the Federal Poverty Level

(FPL)(which are only available when enrolled in silver plans).

• AI/ANs with income between 100% and 300% of the FPL can enroll in a zero cost sharing plan,

which means no copays, deductibles, or coinsurance when receiving care from Indian health

care providers or when receiving essential health benefits (EHBs) through a qualified health

plan (QHP).

• AI/ANs with income below 100% and above 300% of the FPL can enroll in a limited cost

sharing plan, which means no copays, deductibles, or coinsurance when receiving care from

Indian health care providers. With a referral from an Indian health care provider, AI/ANs in

these income groups also can have zero cost sharing when receiving EHBs through a QHP.

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• AI/ANs can enroll in a zero cost sharing or limited cost sharing plan at any metal level (Bronze,

Silver, Gold, Platinum), unlike the general population that only can receive CSRs in a Silver

plan.

The TSGAC reports that more than 99,000 AI/ANs were enrolled in Marketplace coverage in 2019, based on

CMS data.

The majority of enrollees (nearly 55,000) in states using the HealthCare.gov platform received

official CSRs for meeting the ACA definition of Indian. The remaining HealthCare.gov AI/AN Marketplace

enrollees (approximately 37,000 AI/AN enrollees) were eligible for CSRs under the standard eligibility criteria,

requiring a household income less than 250 percent FPL and enrollment in a silver plan. We estimate nearly

165,000 of the remaining uninsured AI/ANs have incomes between 100-400% FPL, which qualifies them for

CSRs under the standard eligibility criteria (See Appendix Table 1).

Overall, most AI/AN enrollees (62 percent) are enrolled in a bronze plan, which is a higher share than for the

general population. Under the ACA, members of federally recognized tribes receive cost-sharing reductions

regardless of the metal tier plan they are enrolled in, and bronze plans offer the lowest premium options. The

percentage of AI/AN enrollees in bronze plans steadily increased since 2015, whereas the proportion of

enrollees in silver plans has decreased beginning in 2018 (45 percent in 2017 to 29 percent in 2019). This shift

in silver plan enrollment is likely explained by the change in CSR eligibility. AI/AN individuals who are eligible

for IHS services but do not meet the ACA definition of Indian are more likely to be enrolled in silver plans since

enrollees with an annual household income less than 250 percent of the FPL are eligible for CSRs. A growing

number of AI/AN Marketplace enrollees receive CSRs as members of federally recognized tribes, and those

enrollees without CSRs declined to an all-time low of 6 percent of enrollees. According to TSGAC, a possible

explanation for the growth in CSR eligibility and plan enrollment is in part due to a new “help box” on

HealthCare.gov that better explains CSR eligibility for Tribal members and how best to maximize savings when

the household contains both Tribal and non-Tribal members.

In 2019, approximately 8,000 AI/AN enrollees received coverage through a State-based marketplace, which

operated in 12 states and the District of Columbia that year.

‡

Of those states, only two publicly reported

information on AI/AN enrollment – California and Washington. California reported that 0.3 percent of its 1.4

million Marketplace enrollees were AI/AN. The majority (88 percent) of AI/AN enrollees received premium tax

credit subsidies for help affording coverage. Washington reported that 1 percent of its Marketplace enrollees

were AI/AN.

The ARP enhances and expands eligibility for premium tax credits to help people afford Marketplace coverage.

An estimated 26,000 uninsured AI/AN people gained access to zero-premium plans and 25,000 gained access

to low-premium plans (less than $50 per month) under the ARP, after application of premium tax credits.

This increase in availability of affordable plans presents an opportunity for uninsured AI/AN persons to gain

coverage.

Medicaid Coverage

Medicaid expansion under the ACA also helps improve health care access for AI/AN people.

According to the

Centers for Medicare & Medicaid Services (CMS), more than 1 million AI/AN people are enrolled in coverage

through Medicaid and CHIP, and many more are eligible for coverage as a result of the ACA’s Medicaid

expansion.

In 2017, over 50 percent of all AI/AN children were covered under Medicaid/CHIP.

_______________________

‡

During the 2019 Marketplace Open Enrollment period 39 states used the federal platform, Healthcare.gov, and the remaining 12

states and the District of Columbia operated their own state-based marketplace.

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The ACA Medicaid expansion allows states to extend Medicaid coverage to certain non-elderly, non-pregnant

adults with incomes up to 138 percent of the FPL. One analysis shows that a year after the ACA Medicaid

expansion went into effect, the national uninsured rate among AI/ANs dropped nationally from 24.8 percent in

2013 to 20.6 percent in 2014, and the largest gains in coverage occurred among those living on or near

reservations in states that expanded Medicaid.

As discussed further below, Medicaid expansion increased the

number of AI/ANs who have both access to both IHS services and Medicaid coverage, which allows IHS and

Tribal health agencies to bring in additional needed revenue to provide care. AI/AN Medicaid beneficiaries do

not have to pay premiums or enrollment fees, and Indian Health Service, Tribal, or Urban Indian (ITU)

providers can receive Medicaid reimbursement for services provided to AI/AN beneficiaries enrolled in

Medicaid managed care, even if the ITU provider is not in a Medicaid managed care plan’s network.

However, we estimate there still remain approximately 173,000 non-elderly, uninsured AI/AN adults eligible

for Medicaid in expansion states (See Appendix Table 2).

Oklahoma became the most recent state to expand Medicaid, which is notable since before the expansion it

had the largest uninsured AI/AN population (79,200) of any state in the country.

Oklahoma adopted

Medicaid expansion and began enrolling eligible individuals as of June 1, 2021, with coverage effective as of

July 1, 2021.

As of July 1, 2021, 13 states still have not expanded Medicaid to adults with incomes up to 138 percent FPL. If

the remaining 13 states were to expand Medicaid eligibility, approximately 55,000 more uninsured non-

Hispanic AI/AN non-elderly adults would be eligible for Medicaid coverage, a seven-fold increase in the

number of people eligible for Medicaid in the AI/AN population.

State expenditures for eligible Medicaid-covered services provided to AI/AN Medicaid beneficiaries by IHS

federal or tribally run facilities – and by non-IHS/Tribal providers pursuant to the terms of a care coordination

agreement between an IHS/Tribal facility and the non-IHS/Tribal provider – can be reimbursed at a rate of 100

percent Federal Medical Assistance Percentage (FMAP).

In addition, the ARP temporarily authorizes a 100

percent FMAP for eight fiscal quarters beginning April 1, 2021, for Medicaid services provided by Urban Indian

Organizations that have grants or contracts with IHS.

Impact of ACA Medicaid Expansion on the Indian Health Service

IHS is an agency within the Department of Health and Human Services responsible for providing federal health

services to AI/ANs. IHS is a health care delivery system that serves 2.6 million AI/ANs who belong to 574

federally recognized tribes in 37 states.

IHS providers are authorized to bill third-party payers and collect

reimbursements, which IHS refers to as third-party "collections," from third-party payers such as Medicaid,

Medicare, the Department of Veterans Affairs, and private insurance plans. IHS federally run and tribally run

facilities are allowed to retain third-party collections without an offset to the annual IHS appropriations. In

recent years, third-party collections have increased for federally and tribally operated IHS facilities, which use

third-party collections to maintain their operations and expand the services they offer.

In fiscal year 2019, federally operated IHS facilities collected $1.1 billion in third-party reimbursements,

according to IHS data.

Medicaid collections at IHS-operated facilities grew from $496 million in FY 2013 to

$729 million in FY 2018. The proportion of patients with insurance at federally operated IHS facilities grew

from 64 percent to 78 percent from fiscal years 2013 through 2018, and IHS facilities in states that expanded

Medicaid saw the largest increases.

Access to Care

IHS is responsible for providing federal health services to AI/AN people and provides funds for tribal and urban

Indian health programs across the country (Figure 3).

IHS is not a health insurance program, but IHS services

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are delivered through a system of federally run, tribally run, and Urban Indian health programs, and individuals

who are eligible to receive care at IHS-funded facilities are encouraged to enroll in health insurance coverage.

Marketplace Navigators help increase the awareness of health care coverage, educate AI/AN patients about

health plan options, and assist people with the Marketplace enrollment process.

The Indian Health Care

Improvement Act (IHCIA), a cornerstone legal authority for the provision of health care to AI/ANs, was made

permanent as part of the ACA. The IHCIA authorizes IHS providers to bill Medicare, Medicaid, and other third-

party payers.

Figure 3. Indian Health Service (IHS) Service population, by IHS Area

Source: HHS, https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf

Location of tribal communities in rural, remote, or isolated areas also creates challenges to accessing care.

AI/AN Medicaid enrollees, compared to white non-Hispanic Medicaid enrollees, are much less likely to report

easy access obtaining needed medical care, tests, treatments, or mental or behavioral health services; and

they are more likely to report never being able to see a specialist as soon as needed.

Although health

insurance coverage rates improved overall among AI/ANs following ACA implementation, disparities in health

care access for this population remain.

Disparities in Health Outcomes

AI/AN people are disproportionately affected by chronic conditions and die at higher rates than other

Americans from chronic liver disease and cirrhosis, diabetes, chronic lower respiratory diseases, as well as non-

chronic causes of death such as suicide and accidents.

Drivers of health disparities include poor

infrastructure, lack of adequate sanitation facilities, and lack of access to a safe water supply – problems more

common in tribal communities compared to the U.S. general population.

Historical trauma – the long term,

intergenerational impact of colonization, cultural suppression, and historical oppression of Indigenous peoples

– is a key underlying factor contributing to negative outcomes in AI/AN communities.

Recognizing that Tribes

are a political entity, research shows that racism in the U.S. has had a significant negative impact on

communities of color over centuries, affecting a range of social and economic factors including housing,

education, wealth, and employment.

Continuing efforts to enroll eligible AI/ANs in Medicaid and

Marketplace coverage can help address disparities in access to care. To increase access to care, it is also

necessary to build the IHS and Tribal health workforce by increasing number of physicians, nurses,

pharmacists, dentists, and other health professionals in tribal communities. Strengthening the Indian health

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care system, together with broader efforts across the federal government and cross-sector partnerships can

promote health equity by addressing social determinants of health such as housing, education, and

employment.

COVID-19 Pandemic

Analyses of available data indicate that AI/ANs experienced higher COVID-19 incidence and risk for infection,

hospitalization, and death compared to White persons during the pandemic.

However, after COVID-19

vaccines became available, AI/AN communities have achieved higher COVID-19 vaccination rates compared to

other racial and ethnic groups.

As of July 9, 2021, more than 55 percent of AI/AN adult IHS patients have

received at least one dose of COVID-19 vaccine.

During the pandemic, actions taken by CMS provided new flexibilities allowing payment for previously non-

billable services and made it possible for IHS to significantly increase the use of telehealth (from an average of

about 1,300 visits per month in early 2020 to over 40,000 visits per month in July of 2020).

Telehealth can

help address certain barriers to care such as living in remote rural areas, lack of transportation, and cultural or

language barriers.

The ARP increased resources to support COVID-19 response, access to mental health care, substance abuse

prevention and treatment programs, facilities improvements, and activities to strengthen the public health

workforce in Tribal communities.

CONCLUSION

Since coverage expansions under the ACA were implemented, rates of health coverage among AI/ANs have

improved significantly, although AI/ANs continue to have the highest uninsurance rate (15 percent in 2019),

compared to most other racial and ethnic populations. The ARP and additional state Medicaid expansions offer

the possibility of further coverage gains in this population. However, significant health disparities remain.

Increased resources for the Indian health care system and other policies to address social determinants of

health can help strengthen access to care and improve health outcomes among American Indians and Alaska

Natives.

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Appendix Table 1. Uninsured AI/AN Nonelderly Population, By Income, by State (2019)

AMERICAN INDIAN/ALASKA NATIVE UNINSURED, BY INCOME, BY STATE

STATE

Income 100-400% FPL

Income > 400% FPL

Income < 100% FPL

ALABAMA

800

1,100

ALASKA

9,200

2,200

11,400

ARIZONA

22,700

6,000

41,600

ARKANSAS

1,800

2,500

CALIFORNIA

5,700

3,700

8,400

COLORADO

1,300

700

2,400

CONNECTICUT

DELAWARE

DISTRICT OF COLUMBIA

FLORIDA

3,100

1,100

2,800

GEORGIA

1,600

2,400

HAWAII

IDAHO

1,800

1,200

1,300

ILLINOIS

600

INDIANA

1,200

400

IOWA

600

1,500

KANSAS

1,200

1,300

KENTUCKY

100

200

LOUISIANA

600

300

800

MAINE

500

100

MARYLAND

300

MASSACHUSETTS

MICHIGAN

2,300

1,600

2,800

MINNESOTA

2,700

400

4,300

MISSISSIPPI

2,300

2,900

MISSOURI

1,500

200

1,600

MONTANA

6,100

2,700

10,700

NEBRASKA

1,300

400

2,400

NEVADA

900

800

1,100

NEW HAMPSHIRE

NEW JERSEY

NEW MEXICO

16,300

4,500

18,800

NEW YORK

1,400

400

2,800

NORTH CAROLINA

7,200

800

9,300

NORTH DAKOTA

3,300

1,000

5,400

OHIO

600

200

OKLAHOMA

36,900

7,300

35,100

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OREGON

1,500

1,400

2,400

PENNSYLVANIA

400

RHODE ISLAND

SOUTH CAROLINA

500

1,000

SOUTH DAKOTA

7,600

700

13,900

TENNESSEE

1,200

1,500

TEXAS

7,300

2,600

5,000

UTAH

4,100

800

6,700

VERMONT

VIRGINIA

400

800

WASHINGTON

3,000

900

6,100

WEST VIRGINIA

WISCONSIN

2,300

700

3,600

WYOMING

1,700

100

3,400

US TOTAL

164,600

48,300

221,800

Source: ASPE analysis of 2019 American Community Survey Data, details on definition of income used for these estimates can be found

in the Methodological Description page. https://aspe.hhs.gov/reports/state-county-local-estimates-uninsured-population-prevalence-

key-demographic-features

Note: Cells labeled ** have been suppressed for having fewer than 3 observations

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Appendix Table 2. Uninsured AI/AN Nonelderly Population, Number of People, by State (2019)

Medicaid Eligible Uninsured AI/AN in Medicaid Expansion States

State

Uninsured (#)

Alaska

11,400

Arizona

41,600

Arkansas

2,500

California

8,400

Colorado

2,400

Connecticut

Delaware

District of Columbia

Hawaii

Idaho

1,300

Illinois

600

Indiana

400

Iowa

1,500

Kentucky

200

Louisiana

800

Maine

100

Maryland

Massachusetts

Michigan

2,800

Minnesota

4,300

Missouri

1,600

Montana

10,700

Nebraska

2,400

Nevada

1,100

New Hampshire

New Jersey

New Mexico

18,800

New York

2,800

North Dakota

5,400

Ohio

200

Oklahoma*

35,100

Oregon

2,400

Pennsylvania

400

Rhode Island

Utah

6,700

Vermont

Virginia

800

Washington

6,100

West Virginia

Total

172,800

Source: ASPE analysis of 2019 American Community Survey Data, details on definition of income used for these estimates can be found in the

Methodological Description page https://aspe.hhs.gov/reports/state-county-local-estimates-uninsured-population-prevalence-key-demographic-features

Note: Cells labeled ** have been suppressed for having fewer than 3 observations.

*The estimate for Oklahoma is from data that predate the state’s 2021 Medicaid expansion.

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Working with American Indians and Alaska Natives Information and Tips for Agents and Brokers. Centers for Medicare

& Medicaid Services. Accessed at: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-

Marketplaces/Downloads/American-Indians_Alaska-Native-Fact-Sheet.pdf

AI/AN Enrollment in Marketplace & Medicaid. (2021, June 15). The Indian Health Service (IHS) Tribal Self-Governance

Advisory Committee (TSGAC) Brief. Accessed at: https://www.tribalselfgov.org/wp-content/uploads/2021/06/TSGAC-

Brief-AI-AN-Marketplace-Medicaid-Enroll-2019-2020-dated-2021-06-15-1.pdf

Health Coverage Enrollment Report Spring 2019 (2019, May). Washington Health Benefit Exchange. Accessed at:

https://www.wahbexchange.org/content/dam/wahbe/2020/02/HBE_EB_190531_Spring-2019-Enrollment-

Report_190530_FINAL_Rev2.pdf

Office of the Assistant Secretary for Planning and Evaluation. (2021, April). Count Estimates of Zero- and Low- Premium

Plan Availability, Healthcare.gov States Pre and Post ARP. HHS. Accessed at: https://aspe.hhs.gov/pdf-report/count-

estimates-of-zero-and-low-premium-plan

July 2021

ISSUE BRIEF

Ten Important Facts about Indian Health Service and Health Insurance for American Indians and Alaska Natives. (2016,

Aug). Centers for Medicare & Medicaid Services. MCMS ICN No 909322-N. Accessed at: https://www.cms.gov/Outreach-

and-Education/American-Indian-Alaska-Native/AIAN/Downloads/10-Important-Facts-About-IHS-and-Health-Care-.pdf

Indian Health & Medicaid. Accessed at: https://www.medicaid.gov/medicaid/indian-health-medicaid/index.html

Roygardner, L, Schneider, A and Steiger, D. (2019, Sep) Promoting Health Coverage of American Indian and Alaska

Native Children. Georgetown University: Center for Children and Families. Accessed at: https://ccf.georgetown.edu/wp-

content/uploads/2019/09/AI-AN-health-coverage.pdf

Frean M, Shelder S, Rosenthal MB, Sequist TD, Sommers BD. (2016) Health Reform and Coverage Changes Among

Native Americans. JAMA Intern Med.;176(6):858–860. Accessed at: doi:10.1001/jamainternmed.2016.1695

Medicaid & CHIP For American Indians/Alaska Natives. (2017, Feb). Centers for Medicare & Medicaid Services. CMS

Product 909442-N. Accessed at: https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-

Native/AIAN/Downloads/Medicaid-and-CHIP-Pocket-Card.pdf

Office of the Assistant Secretary for Planning and Evaluation. (2021, March). State, County, And Local Estimates of the

Uninsured Population: Prevalence and Key Demographic Features. Accessed at: https://aspe.hhs.gov/pdf-

report/estimates-of-the-qhp-eligible-uninsured

Oklahoma’s Medicaid Expansion will Provide Access to Coverage for 190,000 Oklahomans. (2021, July). Centers for

Medicare & Medicaid Services, Press Release. Accessed at: https://www.hhs.gov/about/news/2021/07/01/oklahomas-

medicaid-expansion-will-provide-access-to-coverage-for-190000-oklahomans.html

Branham DK, Peters C, and Sommers BD. (2021, May 28). Estimates of Uninsured Adults Newly Eligible for Medicaid If

Remaining Non-Expansion States Expand. Data Point No. HP-2021-12. Washington, DC: Office of the Assistant Secretary

for Planning and Evaluation, U.S. Department of Health and Human Services. Accessed at:

https://aspe.hhs.gov/reports/estimates-medicaid-eligibility-non-expansion-states

Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American

Indians & Alaska Natives. (2016, Feb 26). Center for Medicaid & CHIP Services (CMS): Federal Policy Guidance, SHO #16-

002. Accessed at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho022616.pdf

About IHS. U.S. Department of Health and Human Services: Indian Health Service. https://www.ihs.gov/aboutihs/

Indian Health Service: Facilities Reported Expanding Services Following Increases in Health Insurance Coverage &

Collections. (2019, Sep). Government Accountability Office (GAO): Report to Congressional Requesters. GAO 19-612.

Accessed at: https://www.gao.gov/products/gao-19-612

Indian Health Service: Actions Needed to Improve Oversight of Federal Facilities’ Decision-Making About the Use of

Funds. (2020, Nov). Government Accountability Office (GAO): Report to Congressional Requesters. GAO-21-20. Accessed

at: https://www.gao.gov/assets/gao-21-20.pdf

Indian Health Service: Facilities Reported Expanding Services Following Increases in Health Insurance Coverage &

Collections. (2019, Sep). Government Accountability Office (GAO): Report to Congressional Requesters. GAO 19-612.

Accessed at: https://www.gao.gov/products/gao-19-612

Under the authority of the Indian Self-Determination and Education Assistance Act (ISDEAA), Tribes can choose to

assume responsibility for health care services that would otherwise be administered by the federal government. Tribes

may contract with the IHS through self-determination contracts and annual funding agreements under Title I of ISDEAA or

self-governance compacts and funding agreements under Title V of ISDEAA.

Under 42 CFR 136.12, services will be provided "to persons of Indian descent belonging to the Indian community served

by the local facilities and program" and "an individual may be regarded as within the scope of the Indian health and

medical service program if he/she is regarded as an Indian by the community in which he/she lives as evidenced by such

factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active

participation in tribal affairs, or other relevant factors in keeping with general Bureau of Indian Affairs practices in the

jurisdiction."

HHS Announces the Largest Ever Funding Allocation for Navigators and Releases Final Numbers for Marketplace Open

Enrollment. (2021, April 21). Centers for Medicare & Medicaid Service: Press Release. Accessed at:

https://www.cms.gov/newsroom/press-releases/hhs-announces-largest-ever-funding-allocation-navigators-and-releases-

final-numbers-2021-marketplace

Indian Health Care Improvement Act: Legislative History. Indian Health Service. Accessed at:

https://www.ihs.gov/ihcia/history/

July 2021

ISSUE BRIEF

Medicaid’s Role in Health Care for American Indians and Alaska Natives. (2021, Feb). MACPAC. Issue Brief. Accessed at:

https://www.macpac.gov/wp-content/uploads/2021/02/Medicaids-Role-in-Health-Care-for-American-Indians-and-

Alaska-Natives.pdf

Frerichs, L, Bell, Lich, KH, Reuland, D and Warne, D. (2019, Sep) Regional Differences in Coverage Among American

Indians & Alaska Natives Before & After the ACA. Health Affairs: Volume 38, No. 9: Neighborhoods & Health. Accessed at:

https://doi.org/10.1377/hlthaff.2019.00076

Sequist TD. Improving the Health of the American Indian and Alaska Native Population. JAMA. 2021;325(11):1035-1036.

Accessed at: doi:10.1001/jama.2021.0521

Indian Health Disparities. (2019, Oct). Indian Health Service: Fact Sheet. Accessed at:

https://www.ihs.gov/newsroom/factsheets/disparities/

Safe Water and Waste Disposal Facilities. (2021, May). Indian Health Service. Fact Sheet. Accessed at:

https://www.ihs.gov/newsroom/factsheets/safewater/

Kirmayer, L.J., J.P. Gone, and J. Moses. Rethinking Historical Trauma. Transcultural Psychiatry, 2014: 51(3): 299-319.

Accessed at: https://journals.sagepub.com/doi/full/10.1177/1363461514536358

Racism and Health. (2021, July). Centers for Disease Control and Prevention. Accessed at:

https://www.cdc.gov/healthequity/racism-disparities/index.html

Williamson LL, Harwell TS, Koch TM, et al. (2021, April 9). COVID-19 Incidence and Mortality Among American

Indian/Alaska Native and White Persons — Montana, March 13–November 30, 2020. MMWR Morb Mortal Wkly Rep

2021;70:510–513. Accessed at: http://dx.doi.org/10.15585/mmwr.mm7014a2externalicon.

Risk for COVID-19 Infection, Hospitalization and Death By Race/Ethnicity. (Updated 2021, June 17). Centers for Disease

Control and Prevention. Accessed at: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-

discovery/hospitalization-death-by-race-ethnicity.html

COVID Data Tracker: Vaccination Demographics Trends. (Updated 2021, July 12). Centers for Disease Control and

Prevention. Accessed at: https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

Bi-Weekly COVID19 Update for Indian Country. (2021, July 9). Newsroom: Press Release. Indian Health Service. Accessed

at: https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/Bi-WeeklyCOVID-

19UpdateforIndianCountry07092021.pdf

COVID-19 Pandemic Impact in Native Communities. (2021, April 14). Retrieved from Senate Committee on Indian Affairs

Oversight Hearing. Transcript. Accessed at:

https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/testimony/117/117th-Apr-

14-2021.pdf

Biden Administration Invests Additional $1.8 Billion in American Rescue Plan Funding to Combat COVID-19 In Indian

Country. (2021, June 16). Newsroom: Press Release. Indian Health Service. Accessed at:

https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/Press-Release-Additional-

1.8-billion-in-ARP-funding-6162021.pdf

July 2021

ISSUE BRIEF

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D

Washington, D.C. 20201

For more ASPE briefs and other publications, visit:

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SUGGESTED CITATION

Issue Brief No. HP-2021-18 “Health Insurance Coverage and

Access to Care for American Indians and Alaska Natives: Current

Trends and Key Challenges.”https://aspe.hhs.gov/reports/health-

insurance-coverage-changes-aian Office of the Assistant

Secretary for Planning and Evaluation, U.S. Department of Health

and Human Services. July 2021.

All material appearing in this report is in the public domain and

may be reproduced or copied without permission; citation as to

source, however, is appreciated.

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