Senior Policy Analyst
Update, September 25: We’ve updated this post.
American Indians and Alaska Natives (AI/ANs) benefit greatly from the Affordable Care Act’s (ACA) coverage expansions, with 290,000 AI/ANs now enrolled in Medicaid, as we’ve explained. The most recent version of the ACA repeal bill from Senators Bill Cassidy and Lindsey Graham retains two provisions in the prior version that purportedly would help AI/ANs. But like the prior version, the bill’s overall changes to Medicaid would ultimately mean less health coverage for that group, not more.
Let’s take these provisions one at a time.
First, Cassidy-Graham would end the ACA’s Medicaid expansion starting in 2020, but it would let AI/ANs who remain continuously enrolled in Medicaid remain covered after the expansion ends for everyone else. Any help that this exception provides would be short-lived, however. Low-income people frequently move on and off Medicaid, depending on their economic circumstances, so most AI/ANs would likely lose Medicaid eligibility within a year or two because, starting in 2020, anyone who dropped off Medicaid and then became eligible again wouldn’t be able to get back on.
Second, Medicaid currently pays 100 percent of the cost of services that Indian Health Service (IHS) and Tribally operated facilities provide for AI/ANs. Like the ACA repeal legislation that the Senate rejected in July, Cassidy-Graham would enable Medicaid to also pay 100 percent of the cost of services that non-IHS and Tribally operated facilities provide for AI/ANs.
This provision, too, could benefit states with large AI/AN populations in the short term, but it wouldn’t help states, AI/ANs, or IHS or Tribally operated facilities in the long run. That’s because Cassidy-Graham has the same core structural elements of prior Senate ACA repeal bills, which would jeopardize coverage for AI/ANs and the financial stability of IHS and Tribally operated facilities.
In addition to ending the Medicaid expansion in 2020, Cassidy-Graham fundamentally overhauls Medicaid’s financing, ending the current federal-state financing partnership and converting all of Medicaid to a per capita cap that would not keep pace with rising per capita health care costs. These changes would force states to make cuts in eligibility and benefits (on top of ending their expansions) that would grow deeper over time. While payments for services to AI/ANs would fall outside of the per capita cap, AI/ANs would not be immune to benefit and eligibility cuts. If, say, a state cut home- and community-based services or organ transplants, these cuts would apply to everyone, including AI/ANs. If Medicaid no longer covers a service, Medicaid funding for that service isn’t available for anyone — period.