Expanding Medicaid in Oklahoma and Missouri a First Step to Improve American Indian and Alaska Native Health Care

Voters in Oklahoma and Missouri will decide on June 30 and August 4, respectively, whether their states will adopt the Affordable Care Act’s (ACA) Medicaid expansion, which would improve access to health care for hundreds of thousands of low-income Oklahomans and Missourians — including tens of thousands of American Indian and Alaska Native (AI/AN) people in these states. These ballot initiatives come at an important time: expanding coverage and improving access to health care for AI/AN people is especially crucial now, since COVID-19 has hit them particularly hard.

AI/AN people face persistent health disparities, including a higher uninsurance rate, more barriers to accessing care, and significantly greater physical and mental health needs than other groups. Like many other groups, however, AI/AN people have benefited greatly from the ACA’s coverage expansions. From 2013 to 2018, the AI/AN uninsured rate fell by nearly one-third, from 28 percent to 20 percent.

Not surprisingly, Medicaid expansion states have seen larger health coverage gains than non-expansion states. During this same time period, the share of uninsured patients at Indian Health Service (IHS) facilities fell by 17 percentage points in expansion states, compared to 8 percentage points in non-expansion states, a Government Accountability Office (GAO) study found.

By expanding Medicaid — which has been linked nationally to life-saving health benefits — Oklahoma and Missouri can take the next step in narrowing health disparities for their AI/AN populations.

While AI/AN people are entitled to care at IHS or tribal facilities regardless of whether they have health insurance, coverage gains boost their access to care in two ways:

First, health insurance makes it easier for people to access care from other providers when IHS facilities are geographically inaccessible or oversubscribed or when individuals simply prefer another provider.

Second, coverage gains among IHS or tribal facilities’ patients boost these facilities’ revenue. IHS is chronically underfunded, and it relies on Medicaid and other third parties to help cover the costs of care it provides to AI/AN people. Medicaid accounted for 65 percent of the $360 million increase in third-party revenue that IHS collected from 2013 through 2018, GAO found. The additional revenue from the ACA’s coverage expansions has helped IHS facilities improve access to care for AI/AN people by expanding onsite services; adding new specialty care services, like behavioral health and dental care; reducing appointment wait times; and buying life-saving medical equipment, the GAO study concluded.

Expanding coverage and improving access to health care are important goals under any circumstances, but they’re especially important during a pandemic. AI/AN people are at higher risk from COVID-19 because of longstanding health and economic inequities, including the federal government’s failure to adequately fund tribal health services, that make it harder for people to protect themselves from the virus and have contributed to high rates of underlying health conditions and barriers to accessing care. The devastating COVID-19 outbreak in the Navajo Nation has illustrated the effects: since March, the Navajo Nation has seen more cases of the virus than 12 states and more deaths than 15 states.

Medicaid expansion alone won’t solve the challenges created by inadequate federal funding, poverty, discrimination, and other forces. But these challenges also can’t be solved without major improvements in health coverage and access to care for AI/AN people. Expanding Medicaid in Oklahoma has garnered support from several tribes, including the Cherokee, Choctaw, Chickasaw, Citizen Potawatomi Nation, and Muscogee (Creek). It’s the right first step for Oklahoma, Missouri, and other states that haven’t yet done so.