For Tribal Members in Oklahoma, Medicaid Expansion Improves Access to Specialty Care
Medicaid expansion is expected to improve not just access to care for low-income Native Americans who had previously been shut out of health insurance, but the finances of the Indian Health Service.,
TAHLEQUAH, Okla. — There’s a saying in Indian Country: “Don’t get sick after June.”
The warning alludes to a problem that has long dogged the Indian Health Service, which provides government medical care to 2.2 million of the 3.7 million American Indians and Alaska Natives in the nation and which is routinely criticized for providing substandard care.
A lack of medical expertise and specialists often forces members of tribal communities to seek treatment outside the system, with no guarantee from the Indian Health Service that it will cover their medical bills once it exhausts its yearly allocation from the federal government for referred care — often by summer.
That has left many families to choose between an expensive trip to a private hospital and forgoing specialized care — until now. In July, Oklahoma expanded free Medicaid coverage to an additional 200,000 low-income adults, including many tribal members, after voters passed a ballot initiative compelling the state to do so.
“They’ve had to choose between getting the specialty health care they need and feeding their family,” said Rhonda Beaver, the chief administrative officer for the Muscogee (Creek) Nation’s Health Department. “This Medicaid expansion helps our Native American people who had to make those choices.”
Since the expansion took effect on July 1, more than 23,000 eligible Native Americans have enrolled in the program, according to state officials — about 13 percent of the total 171,056 people who have signed up statewide.
Madison Secratt, 19, is among those benefiting from the expansion. Her mother, Heather Bridges, said that when Ms. Secratt was 14, doctors discovered holes in her heart: a small one in the top chamber and another at the bottom.
Since then, Ms. Bridges had taken her daughter to Dr. Kent Ward, a pediatric cardiologist in Oklahoma City, more than 170 miles away from their home in Tahlequah, every six months for monitoring. Because the tribal hospital lacked a specialist, Ms. Secratt had to be referred outside the Cherokee Nation’s hospital system.
She had been eligible for Medicaid as a child, but her mother had long feared that once she aged out of the program at 18, she would stop receiving private specialized care because she would not be able to afford it. Ms. Bridges herself went without health care after she turned 18, until she secured a good job after college.
“This worked out perfectly,” she said. “We would not have been able to continue to see Dr. Ward and continue care with him if we didn’t have Medicaid expansion.”
For Jonathan Martin, 37, his family of five in Park Hill, Okla., lost their health insurance after he was laid off from his job in March because of the pandemic. Soon after, Mr. Martin, a diabetic, contracted Covid-19 and nearly died following a weeklong stint in the hospital with pneumonia and weakening kidneys.
His wife, Adrian Martin, 30, said her husband recovered but the mental strain that the virus had caused left him needing behavioral health treatment. He was afraid to leave his home for fear of catching the virus again and dying, she said. Without insurance, Ms. Martin said, they were unable to find him the help he needed in the tribal health care system, which she said had a long waiting list for such care.
After qualifying for Medicaid expansion, Ms. Martin was able to obtain the free coverage for her family and get her husband into therapy.
“It is a relief to know that if something happens again,” she said, “I won’t be worrying about trying to find a way to get my husband treated.”
Dana Miller, the director of tribal government relations at the Oklahoma Health Care Authority, said the state had been working with its tribal partners to enroll as many people into the program as it could, especially in its most rural and remote communities. Those who earn less than 138 percent of the federal poverty level — currently about $18,000 a year for an individual or $36,000 for a family of four — are eligible.
“Some folks in rural areas don’t have access to internet or a computer and they need help on filling out documentation,” Ms. Miller said.
Dr. Stephen Jones, the executive director of Cherokee Nation Health Services, said the expansion would have the largest effect on uninsured patients who had been unable to seek medical services outside their tribal hospitals.
“There is quite a large population that weren’t eligible for Medicaid and couldn’t afford marketplace insurance so they were left kind of uninsured,” Dr. Jones said.
The Indian Health Service is chronically underfunded, and Indigenous Oklahomans disproportionately lack insurance coverage. For Native Americans, the death rates for preventable diseases, like addiction, diabetes and liver disease, are three to five times higher than for any other races.
Medicaid expansion is expected to improve not just access to care for low-income tribal members who had previously been shut out, but also the agency’s bottom line. The Indian Health Service spends about $4,078 per patient; in comparison, Medicaid spends $8,109, according to a 2018 study by the Government Accountability Office.
But now that more of its patients in Oklahoma will have Medicaid coverage instead of being uninsured, the health service can increase its revenue by billing Medicaid more often.
The agency’s hospitals and clinics can use that new revenue to improve and expand health care. The facilities have already benefited from more of their patients having private coverage under the Affordable Care Act, with the new reimbursements from private insurers helping reduce appointment wait times, buy new equipment and add services, according to a 2019 GAO study.
Joshua Barnett, a spokesman for the Indian Health Service, said Medicaid collections were an important source of revenue for the agency, and would be all the more so now that the program covered more of its patients.
“By increasing our third-party collections, it allows us to hire more people, add more equipment, extend our purchased-referred care program dollars and ultimately provide more services,” Mr. Barnett said. “Ultimately, it’s a benefit for the patient and the Indian Health Service.”
The Muscogee (Creek) Nation already doubles its per capita funding for health care through Medicaid and is expected to gain $9 million more after expansion.
Many Native Americans have already benefited from the Affordable Care Act, with the national uninsured rate falling from 28 to 20 percent from 2013 to 2018, census data shows. The rate of uninsured Indian Health Service patients fell by 17 percentage points in states that expanded Medicaid, compared with eight points in states that did not, the 2019 study found.
The remaining dozen states that have not expanded the program are Republican-controlled and have largely shown little to no interest in changing course. The American Rescue Plan, passed this year, provides an additional five percentage points of the federal share of Medicaid funding for a state, as an incentive to expand. But the incentive did little to move the needle in those states.
In South Dakota, which has some of the country’s worst health care outcomes for Native Americans, two groups are trying to get a Medicaid expansion on the ballot next year. Supporters of expansion have until November to gather enough signatures.