For every $1 a state invests in Medicaid expansion, $13.41 in federal funds will flow into the state. Expanding Medicaid will likely also generate state savings and revenues that exceed expansion costs. Source: What is the Result of States Not Expanding Medicaid? / The Urban Institute

It's almost as if the Affordable Care Act has disappeared behind some screen.

Oh, sure, there are still questions about what each of us should do and when. And, just about every Republican in the country continues to campaign on a “repeal” platform (an idea that grows more complicated by the day).

But much of the execution of the law, the nuts and bolts of how it works, is behind the scenes. Especially in Indian Country. There might be insurance-related changes for some families, but the actual delivery of health care will seem the same.

As I’ve written many times before, this law over time will change the framework of the Indian health system. The law charts a new path for funding at the moment when Congress is unable to enact routine appropriations.

Health and Human Services Secretary Sylvia Burwell visited the Port Gamble S'Klallam Tribe in Washington state Monday to meet with the council and hear about those nuts and bolts. This might be the most ideal tribal community in the country for the secretary to visit because she saw first-hand an innovative operation. Port Gamble is also where you can find the most comprehensive data about Indian Country and the Affordable Care Act generated and analyzed by the tribe’s health director Ed Fox.

Dr. Fox estimates that some half a million American Indians and Alaska Natives remain eligible for certain subsidies under the law. That’s insurance plans that would add resources throughout the Indian health system. But the “take-up rate,” those actually signing up for health insurance through exchanges, is “expected to be lower than the general population.” Health insurance remains a hard sell because it’s so radically different than the Indian Health Service so many of us grew up with.

The story of Medicaid, however, is both the greatest success — and the greatest challenge going forward.

Fox said Medicaid is showing take-up rate that are “much higher” than qualified health plans. There’s no premiums, there will be more money in the pot, and it’s much simpler to enroll. “In states that provided outreach support, like Washington, it has been successful for American Indians and Alaska Natives,” Fox reports. The numbers from the Pacific Northwest are particularly inspiring with Oregon showing an increase of 52 percent and Washington an increase of 35 percent for the overall population. That means, according to Fox, some 10,000 more American Indians and Alaska Natives have Medicaid insurance now in Washington and 6,000 more in Oregon.

Unfortunately there is a different story to tell in the states that did not expand Medicaid. A new report from the Urban Institute says that for “every $1 a state invests in Medicaid expansion, $13.41 in federal funds will flow into the state. Expanding Medicaid will likely also generate state savings and revenues that exceed expansion costs.”

Consider the states with large American Indian and Alaska Native populations. In Alaska an investment of $147 million would return $1.5 billion in Medicaid funding and another $.6 billion in hospital reimbursements. In Montana $194 million returns $2.1 billion in Medicaid and $1.1 billion in hospital reimbursements. Oklahoma could invest $689 million and see a return of $8.6 billion in Medicaid and $4.1 billion in hospital reimbursements. And, in South Dakota, $157 million buys $2.1 billion in Medicaid funding and $.8 billion in hospital reimbursements. In all three of those states much of that extra cash would show up and benefit the Indian health system.

The Urban Institute estimates the  total number of uninsured in the states that do not expand Medicaid sty 6.7 million people. And on top of that one economic study reports that Medicaid expansion would add thousands of jobs. And the states that did expand Medicaid (including a conservative Arizona and North Dakota) the number of uninsured dropped by 38 percent since September 2013.

The Affordable Care Act gives states too much power over the Indian health system. If a facility is located in a Medicaid expansion state, then opportunity unfolds. But if not, well, the disparity in funding for Indian health will get worse.

Perhaps Secretary Burwell’s next visit to a tribal community ought to be in Alaska or some other state that’s rejecting help for its citizens, including those from Indian Country. She needs to see disparity first hand.

Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.