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American Indians and Alaska Natives Would Be Disproportionately Hurt By Proposals to Take Away Medicaid from People Not Meeting Work Requirements

The Trump Administration reportedly said that it will not exempt American Indians and Alaska Natives (AI/ANs) from its new policy that lets states take away Medicaid coverage from beneficiaries who don’t work or participate in work-related activities for a specified numbers of hours each month. That’s rightly raised concerns about the impact on AI/ANs. But the best way to protect AI/ANs and other vulnerable populations from harm would be for the Administration and states to reject these proposals to impose rigid work requirements altogether.

As we’ve written, Medicaid work requirements would reduce access to care and worsen health outcomes for people with disabilitiesolder Americanschildren, working people with unstable jobs, and other vulnerable groups — but the harm to AI/ANs would be especially severe.  As a bipartisan group of senators wrote, work requirements in Medicaid could have “potentially devastating impacts…on AI/AN health access.”

Medicaid plays a critical role in AI/Ans’ health, covering more than 1 in 4 adult AI/ANs and half of AI/AN children. Medicaid improves access to care, helping reduce the significant mental and physical health disparities that AI/ANs face:  compared to non-Hispanic whites, AI/AN adults are twice as likely to be overweight, obese, diagnosed with diabetes, and experience symptoms of mental illness.  But the Affordable Care Act’s expansion of Medicaid has enabled hundreds of thousands of AI/ANs to gain coverage, making it easier for them to get treatment for their physical and mental health needs.

Proposals to take away Medicaid from people not working or participating in work activities for a specified number of hours each month would reduce access to care and worsen health outcomes for all low-income adults, but especially for AI/ANs, who are disproportionately likely to be unemployed.  That’s because AI/ANs are likelier to live in areas with limited job opportunities while also experiencing other barriers to employment.  The AI/AN unemployment rate averaged 13.1 percent from 2012 through 2016, almost 40 percent higher than the 8.1 percent rate for all other adults. The disparity was even greater in several states that have large AI/AN populations and are now considering work requirements, such as Alaska and Arizona (see table). This suggests that AI/ANs are especially likely to lose coverage under work requirement policies.

Unemployment Rate Higher Among American Indians and Alaska Natives Unemployment rate, 16- to 64-year-olds, nationally and in states imposing or considering work requirements
State American Indians and Alaska Natives Others in the State
United States 13.7% 8.1%
Alaska 20.5% 7.1%
Arkansas 9.7% 7.6%
Arizona 19.2% 8.4%
Indiana 11.5% 7.5%
Kansas 11.7% 5.9%
Kentucky 12.4% 8.1%
Maine 12.2% 6.4%
Mississippi 17.8% 10.9%
New Hampshire 4.9% 5.5%
Oklahoma 8.8% 6.4%
Pennsylvania 16.7% 7.9%
Utah 11.8% 5.4%
Wisconsin 11.1% 5.8%

Source.  CBPP analysis using American Community Survey tables from the American FactFinder.  All estimates are five-year averages from 2012-2016 to achieve adequate sample size. States listed are those with approved or pending Medicaid waivers seeking to take away Medicaid coverage from beneficiaries who don’t work or participate in work-related activities for a specified number of hours each month or considering legislation to do so:

Losing coverage due to work requirements would put any enrollee’s health at risk, which is why physician organizations like the American Medical AssociationAmerican Academy of Family Physicians, American Academy of Pediatrics, and others oppose Medicaid work requirements. But coverage losses and coverage interruptions would be especially harmful for AI/ANs, since they’re likelier than non-AI/ANs to have serious health needs. For example, compared to non-Hispanic whites, AI/AN adults are 30 percent likelier to have high blood pressure, twice as likely to have a stroke, and are three times likelier to die from Hepatitis C.

Through the debate about exempting AI/ANs from work requirements, some policymakers have come to recognize how harmful these measures would be to this group. But the right lesson to draw is that no vulnerable low-income enrollees — including AI/ANs — should lose their health coverage and access to care if they can’t meet rigid work requirements.