There have been no statements that the American Indians may be covered by insurance issued by the urban Indian health clinics. So if the Indian is too poor to travel to their reservation clinic and they are at the federal poverty level, where will they find health care? Will urban American Indians be able to get increased Medicare or Medicaid assistance? Who will be the ones evaluating these potential American Indian clients? Will the IHS urban clinics be authorized to determine if an American Indian is eligible to receive increased Medicare or Medicaid? Will the Urban clinics be required to refer the Indian to another non-Indian office? Each State that is participating in the Affordable Care Act has to set up formal mechanisms to screen, determine eligibility and enroll new uninsured individuals which would include urban American Indians who meet/qualify for the expanded income eligibility requirements.

In Los Angeles County for example, there are more than 250,000 low income, uninsured individuals that are currently enrolled in the county's Healthy Way L.A. program. It is estimated that approximately 2,500 of these individuals are American Indian, but no one knows for sure. The county is presuming that all of these people will remain eligible for the expanded Medi-Cal Program - and effective January 1, 2014 - these individuals will be auto-enrolled into the Medi-Cal program. Those who do not qualify for expanded Medi-Cal will be expected to purchase private health insurance through the Covered California Health Insurance Exchange Program.

Will these new evaluators be trained on the various nuances in the American Indian community such as federally recognized, State recognized, non-recognized? And what if the client is American Indian but not enrolled in a federally recognized tribe due to lacking the necessary blood quantum in any tribe? There are many "ifs" and "ors" in the Affordable Care Act legislation as it pertains to health care.