American Indian ACA enrollees say it's not smart to count on IHS

Susan Ruckman reported this story as a fellow in the 2014 National Health Journalism Fellowship, a program of the USC Annenberg School for Communication and Journalism. Other stories in her series include: 

How American Indians fit into the Affordable Care Act

Affordable Care Act recruiters step up efforts to reach Indian Country

KENAI, Alaska – Stephanie Big Crow has covered a lot of ground in her thirty-five years. The Oglala Lakota Sioux woman grew up as a child on the Pine Ridge Reservation in South Dakota where the mantra was to learn the Anglos’ ways while following what their ancestors said.

“I sang our songs, I spoke the language,” she said.

A one-time resident of Arizona, she and her family now make their lives in Kenai, Alaska, 156 miles southwest of Anchorage. She is also one of the several thousand American Indians who have enrolled in federal health insurance paved by the Affordable Care Act (ACA).

 She recalls her first contact on the federal initiative through the Great Plains Tribal Chairmen’s Health Board (GPTCHB) outreach headquartered in Rapid City, South Dakota. She knew from a friend that their ACA outreach was Native friendly.

“I saw they had a navigator program in South Dakota,” she said. “It was their culturally tailored materials. It gave me insight and I’m a visual hands-on kind of learner.”

Big Crow said the materials spoke to her and she felt comfortable exploring the option because she understood the terminology they used and at the same time, the materials referenced a historical perspective relating to her tribe. It helped that she was a healthcare consultant, she laughed.

“All of us are pretty healthy with no pre-existing conditions,” she said. “It was a win-win situation for us because health care is an investment.”

Their alliance with the federal insurance program evolved as the family of four found themselves in Alaska to grasp an employment opportunity. She points to Alaska as an example of an ideal model of a tribally managed healthcare program. Tribes in the 50th state take advantage of the 638 process, is a system of federal Indian Trust Self-Governance and Self-Determination programs that allows them control over their own healthcare systems. Since the Native groups in Alaska are considered corporations rather than tribes, they operate as businesses – businesses that buy health insurance for its members.

Big Crow’s other half, John Molina, is the health systems director for the Kenaitze tribal group –indigenous to the Kenai area. Together, the two raise their two teenage children, in a place they have only been in for a few months. Molina, who is Yaqui and Apache, said the bottom line on their ACA sign-up was having medical insurance that was affordable. Due to Big Crow and Molina’s income, they did not qualify for federal subsidies to make the cost easier. Here, it wasn’t a deal breaker.

The plan they chose seemed to fit. Molina thought it was not smart to count on comprehensive care in the Indian Health Service (IHS) system without ACA. IHS’s contract health (out-of-system) services would not always cover all their health costs, Molina said.

“We are blessed and in good health now, but I know of other families who aren’t,” he said. “We knew we would need help for unexpected health incidents that might occur, like a broken leg or something.”

While Big Crow and Molina chose ACA because they were figuring on a likelihood of unexpected medical expense, pop-up medical calamities are not a worry for financial lender, Jim Stanley of Seattle, Washington who has coverage through his employer. The Quinault citizen is well insured, according to his self-description. He forgoes using Indian Health Services (IHS) even to bill his insurance for the visits.

“Some Indians are covered by their employer. One of my greatest fears is a collector will show up on my credit report,” Stanley said. “But I want Indians to have a choice (with ACA) because life changes and that makes ACA more relevant to me.”

Stanley is not a lone figure, he is one of approximately 1.9 million American Indians are who insured through employer or other federal programs like Medicare and Medicaid.  It’s the gap of the 1.1 million estimated uninsured American Indians that the ACA is likely to reach. While they can opt out of ACA and use only IHS for care, advocates for insuring Natives say that IHS care should not be considered equivalent to health insurance.

As more resources for tracking American Indian ACA enrollees are culled, the federal health insurance plan has a good hook into Indian Country, proponents say. ACA backers think a multi-sided approach coupled with persistence will increase the number of American Indians who enroll. Going directly to their communities is more likely to stimulate Native enrollment numbers than any single factor.

Advocacy events, like the National Tribal Day of Action in November 2014, also help make ACA visible in every tribal jurisdiction, organizers said.

Meanwhile, some health advocates said that tweaking qualifiers for credits (federal subsidies to pay for health premiums) might help encourage enrollment. At the Oklahoma City Indian Clinic (OCIC) in Oklahoma, benefits coordinator Michelle Baker said of 500 patients she screened, only 25 were able to enroll. The disqualifier was income, they made too much to qualify for subsidies that would help make premiums easier on their part.

“They were very disappointed,” she said. “It’s very misleading sometimes, their income was too high for Medicaid but not enough to get a credit.”

If increasing enrollment in the federal health plan is not the top priority in American Indian communities, relying on old-fashioned tradition can sometimes reach where other attempts at ACA enrollment fail, Big Crow theorizes.

“I have a responsibility as a Lakota woman to improve the quality of our lives and ensure our way of life” she said. “I’m Lakota, my people are pretty competitive anyways. We look for ways to thrive.”

For more information on the Affordable Care Act (ACA), call 1-800-318-2596 or log on to

This article was originally published by the Native American Times.

Photo Credit: Sage Garland