Phasing out Medicaid threatens Indigenous communities’ already weak access to care

About a year into the process to redetermine Medicaid eligibility following the Covid-19 public health emergency, more than 20 million people have been dropped from the joint federal-state program for low-income families.

A chorus of stories tell of the ways the discharge has upended people’s lives, but Native Americans appear particularly vulnerable to losing coverage and face greater obstacles in re-enrolling in Medicaid or finding other coverage .

“From my perspective, it wasn’t working the way it should have,” said Kristin Melli, a pediatric nurse practitioner in rural Kalispell, Montana, who also provides telehealth services to tribal members on the Fort Peck Reservation.

The realignment process has exacerbated long-standing problems people on the reservation face in seeking care, she said. She saw several patients who were still eligible for benefits deregister. And a rise in the number of uninsured tribal members is undermining their health care systems, threatening already weak access to care in Native communities.

One teen, Melli recalls, lost coverage while seeking life-saving care. Routine lab work raised flags, and upon follow-up examination, Melli discovered that the girl had a condition that could have killed her if left untreated. To protect the patient’s privacy, Melli has not released any details.

Melli said she worked with tribal nurses for weeks to coordinate lab monitoring and consultations with specialists for her patient. It wasn’t until the teen saw a specialist that Melli received a call that she had been dropped from Medicaid coverage.

The girl’s parents told Melli that they had reapplied for Medicaid a month earlier but had not heard back. Melli’s patient eventually got the medication she needed with the help of a pharmacist. Relaxation was an unnecessary and burdensome obstacle to care.

Pat Flowers, the Democratic Senate minority leader in Montana, said at a political event in early April that 13,000 tribal members in the state had been disenrolled.

Native American and Alaska Native adults are more likely to be enrolled in Medicaid than their white counterparts, yet some tribal leaders still did not know exactly how many of their members had disenrolled, according to a survey conducted in February and March. The Indian Health Service Tribal Self-Governance Advisory Committee conducted and published the study. Respondents included tribal leaders from Alaska, Arizona, Idaho, Montana and New Mexico, among others.

Tribal leaders reported many challenges associated with the realignment, including a lack of timely information provided to tribal members, patients not being aware of the process or their disenrollment, long processing times, lack of staff at the tribal level, lack of communication from their states, concerns with obtaining accurate tribal data, and in cases where states have shared data, difficulties in interpreting it.

Research and policy experts initially feared that vulnerable populations, including rural Indigenous communities and families of color, would face greater and unique barriers to renewing their health care coverage and would suffer disproportionate harm.

“There is a lot at stake and a lot to lose in this process,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and a research professor at the McCourt School of Public Policy. “I fear that prediction will come true.”

Cammie DuPuis-Pablo, director of tribal health communications for the Confederated Salish and Kootenai Tribes in Montana, said the tribes have not had the exact number of members enrolled since the redetermination began, but there are some who lost coverage as early as July. not re-registered.

The tribes hosted their first outreach event in late April as part of their efforts to help members through the process. The health department is meeting people at their homes, making calls and planning more events.

The tribes receive a list of members’ Medicaid status each month, DuPuis-Pablo said, but a list of those no longer covered by Medicaid would be more helpful.

Because of these data gaps, it is unclear how many tribal members have been disenrolled.

“We are at the mercy of Medicaid agencies in terms of what they want to share,” said Yvonne Myers, Affordable Care Act and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

In Alaska, tribal health leaders entered into a data-sharing agreement with the state in July, but did not receive information about their members’ coverage for about a month — at which point more than 9,500 Alaskans had already been disenrolled for procedural reasons.

“We’ve already lost those people,” said Gennifer Moreau-Johnson, senior policy advisor in the Department of Intergovernmental Affairs at the nonprofit Alaska Native Tribal Health Consortium. “That’s a real impact.”

Because federal regulations do not require states to maintain or report race and ethnicity data for people they disenroll, fewer than ten states collect such information. Although the data from these states does not show a higher rate of coverage loss by race, a KFF The report says data is limited and a more accurate picture would require more demographic reporting from more states.

Tribal health care leaders are concerned that high disenrollment rates among their members are financially undermining their health care systems and their ability to provide care.

“Just because they’ve dropped off Medicaid doesn’t mean we’re no longer serving them,” said Jim Roberts, senior executive liaison at the Alaska Native Tribal Health Consortium’s Department of Intergovernmental Affairs. “It means that we are more dependent on other sources of financing to provide that care, for which there are already too few resources.”

Three in 10 Native Americans and Alaska Natives under age 65 rely on Medicaid, compared to 15% of their white counterparts. The Indian Health Service is responsible for providing care to approximately 2.6 million of the 9.7 million Native Americans and Alaska Natives in the U.S., but services vary by region, clinic and health center. The agency itself is chronically underfunded and unable to meet the needs of the population. For fiscal year 2024, Congress approved $6.96 billion for IHS, far less than the $51.4 billion requested by tribal leaders.

Because of that historic shortage, tribal health care systems are leaning on reimbursement from Medicaid and other third-party payers, such as Medicare, the Department of Veterans Affairs and private insurance, to help fill the gap. Medicaid accounted for two-thirds of IHS third-party revenue in 2021.

Some tribal health care systems receive more federal funding through Medicaid than through IHS, Roberts said.

Health care leaders fear that dwindling Medicaid dollars will worsen long-standing health disparities — such as lower life expectancy, higher rates of chronic disease and poorer access to care — that plague Native Americans.

Unwinding has become “all-consuming,” said Monique Martin, vice president of intergovernmental affairs for the Alaska Native Tribal Health Consortium.

“The state really has that focus down to the smallest details of administrative tasks, like, how do we send text messages to 7,000 people?” said Martin. “We would much rather talk about: How do we deal with social determinants of health?”

Melli said she no longer hears about tribal members on the Fort Peck Reservation losing their Medicaid coverage, but she wonders if that means disenrolled people haven’t sought help.

“Those are the things we’re really concerned about,” she said, “all these silent cases. … We only know about the ones we actually see.”

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the key operating programs at KFF – an independent source of health policy research, polling and journalism. Learn more about KFF.

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