The fight over the Affordable Care Act continues. A conservative “replacement” would create health savings accounts for patients in the Indian health service. That measure would also repeal the Indian Health Care Improvement Act.

On a tribal bulletin board this week these chilling words were posted: "Due to budget issues, Contract Health Service will be on Priority One until further notice."

Why are these words frightening? It means the underfunded local unit of the Indian Health Service is out of money on an important line item. It means that unless your illness is serious -- threatening life or limb -- you will have to wait.

Sometimes that wait can be deadly. And it’s wrong. It reflects a system that is out of balance and the consequences are life threatening to American Indians and Alaska Natives.

A couple of years ago, at a Senate hearing, a story was told about a heart attack patient who was left on a gurney with a note taped on her thigh that read: "If you admit this person, understand we're out of contract health care money. Do it at your risk."

The Affordable Care Act, or Obamacare, is supposed to eliminate this underfunding. The complicated mechanism is designed to increase the number of American Indians and Alaska Natives with basic insurance, Medicaid, tribal insurance, or a policy from a marketplace exchange, money that then goes into the Indian health system directly. The Affordable Care Act is designed to substantially increase third-party billing, a revenue stream that does not require appropriation from Congress. And, I should add, a revenue stream that could add a couple of billion dollars to the Indian health system. Full funding ... in theory.

So what’s the problem? Why is there a bulletin board warning patients that’s there is not enough money?

The main reason is that critics of the Affordable Care Act are determined to make certain that this law is a wreck. Instead of figuring how to make it so, many so-called leaders are working overtime to tank every aspect of the act.

Just a couple of weeks ago, Wisconsin Republican Sen. Ron Johnson said it was time to "recognize reality" and "deal with the people that are currently covered under Obamacare."

But that was then. Now three Republican senators, Richard Burr (N.C.), Tom Coburn, (Okla.), and Orrin Hatch (Utah), are launching a campaign to start the debate all over, promoting a "replacement" plan for Obamacare. That plan would make it even more difficult to fund the Indian health system. "Under our proposal, restrictions that limit the ability for veterans, service members, and individuals receiving care through the Indian Health Service would be removed in order to ensure that these individuals also have the ability to benefit from health savings accounts in managing their health care needs and expenses," according to the plan.

This bill would also repeal the Indian Health Care Improvement Act. And treaty rights? Gone. Unfunded.

That Republican bill will go no where as long as President Obama (or another Democrat) is in office. But a second, more serious, threat to the law is occurring in state capitals across the country. The way the law was drafted, the primary funding vehicle was to expand Medicaid to buy insurance for people who are currently uninsured. (According to the Kaiser Family Foundation, that’s one-in-three American Indians and Alaska Natives.)

The federal government made this a good deal for the states: Paying all of the cost for the first three years and nearly all of the cost after that. Half the states have said "no." Republicans are using this as their line in the sand again Obamacare.

A study published last week in Health Affairs said that this approach has serious consequences, the failure of Medicaid expansion will result in premature deaths. "We predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death," the study reported. "Disparities in access to care based on state of residence will increase. Because the federal government will pay 100 percent of increased costs associated with Medicaid expansion for the first three years (and 90 percent thereafter), opt-out states are also turning down billions of dollars of potential revenue, which might strengthen their local economy."

The study’s authors, Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler, charted the number of uninsured who would miss out on treatment and estimated a range of potential early deaths, some 7,000 to 17,000 across the country. Many of the "no" states have large American Indian and Alaska Native populations. Roughly half the Indian health system is in states without Medicaid expansion.

Conservatives are already discounting the Health Affairs report. Chris Conover counters: "I can state with great confidence that the authors have grossly overestimated any mortality gains to be had from Medicaid expansion."

But in neither study was there data or anecdotes about tribal communities with a bulletin board post warning patients that the clinic is out of money.

Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of the Shoshone-Bannock Tribes. Join the discussion about austerity. Comment on Facebook at: www.facebook.com/IndianCountryAusterity