Indianz.Com > News > Health care coverage improves in Indian Country amid toll of COVID-19
Cherokee Nation
Health and Human Services Secretary Xavier Becerra, far left, chats with citizens of the Cherokee Nation during a visit to the tribe’s reservation in Oklahoma on July 1, 2021. Photo: Anadisgoi / Cherokee Nation
Health care coverage improves in Indian Country amid toll of COVID-19
Thursday, July 22, 2021

The report was issued by the Office of the Assistant Secretary for Planning and Evaluation within the Department of Health and Human Services, not by the Centers for Medicare and Medicaid Services as previously stated.

An updated copy of the report is available at

Health insurance coverage has improved dramatically among American Indians and Alaska Natives, the Biden administration announced in a new report that highlights the disparities still being faced in tribal and urban communities.

According to the Department of Health and Human Services, only 28 percent of Native Americans went uninsured as of 2018. While the rate was still the highest among all racial and ethnic groups, it represents huge progress since the Affordable Care Act (ACA) became law more than a decade ago.

In between 2010 and 2018, in fact, the percentage of American Indians and Alaska Natives who went without health coverage decreased by an impressive 16 points, HHS said in the report on Thursday. The Biden administration is citing the figures as it seeks to improve insurance rates even more in the coming years.

“CMS is committed to working with our tribal partners to ensure American Indians and Alaska Natives have access to the coverage they need,” Administrator Chiquita Brooks-LaSur of the Centers for Medicare and Medicaid Services told Indianz.Com.

“Although American Indians and Alaska Natives can enroll year round, the Special Enrollment Period provides the opportunity to get coverage more quickly and we invite people who need coverage to sign up by August 15,” Brooks-LaSur said in encouraging people in tribal communities to explore their health insurance options.

Despite the gains, the report shows how Indian Country still has a long way to go. As of 2019, for example, health coverage among American Indians and Alaska Natives lagged significantly behind non-Hispanic Whites, Asians, African-Americans and Native Hawaiians, according to the data.

Then in 2020, the coronavirus took a major toll on tribes and their citizens. American Indians and Alaska Natives have suffered the highest infection, hospitalization and death rates throughout the COVID-19 pandemic, according to the report.

The situation has improved in 2021, due to high COVID-19 vaccination rates among Native people. As of July 9, more than 55 percent of adult patients within the Indian Health Service have received at least one dose of the vaccine, which was highest among all racial and ethnic groups, the HHS report noted.

And according to IHS data from July 15, which is the latest available, more than 1.47 million COVID-19 vaccine doses have been administered throughout the system. That accounts for 57.3 percent of the agency’s user population.

Navajo Nation Office of President and Vice President: COVID-19 Response Town Hall – July 21, 2021

But with the Delta variant leading to more infections, hospitalizations and deaths across the United States, tribes are growing increasingly worried. On the Navajo Nation, which suffered some of the worst impacts of the coronavirus, 90 percent of elders over the age of 75 and 64 percent of residents over the age of 12 have been fully vaccinated.

The same can’t always be said of outside communities.

“It’s just like going out to a battle in a war,” Navajo Nation President Jonathan Nez said during a COVID-19 town hall on Wednesday. “You equip yourself. You put your armor on, you put your face mask on and you get your vaccination.”

“People see Navajo people off the Navajo Nation and they know that we’re Navajo,” Nez said from a reservation that spans the states of Arizona, New Mexico and Utah. “You know why? Because we’re wearing masks.”

The Affordable Care Act became law in 2010, ushering in a new era of health options for tribes and their citizens. The law included a permanent reauthorization of the Indian Health Care Improvement Act and enabled states to extend services to more American Indians and Alaska Natives through an expansion of the Medicaid program, which is administered by CMS.

According to the HHS report, the increase in the number of Native people with health coverage can be attributed to the expansion of Medicare in dozens of states.

“One analysis shows that a year after the ACA Medicaid expansion went into effect, the national uninsured rate among AI/ANs dropped nationally from 24.8 percent in 2013 to 20.6 percent in 2014, and the largest gains in coverage occurred among those living on or near reservations in states that expanded Medicaid,” the report reads.

But not everyone has gotten on board. Oklahoma, for example, didn’t adopt an expansion of Medicaid until July 1. The state happens to be home to the second largest population of American Indians and Alaska Natives, behind California.

“Oklahoma became the most recent state to expand Medicaid, which is notable since before the expansion it had the largest uninsured AI/AN population (79,200) of any state in the country,” the report notes.

Status of State Action on the Medicaid Expansion Decision
As of July 9, 2021, 39 states, including the District of Columbia, have adopted the Medicaid expansion program while 12 states have not. A 13th state, Missouri, has adopted but not implemented the expansion. Source: Kaiser Family Foundation

Of the insured Native population in Oklahoma, about 35,100 would be eligible for coverage as a result of the Medicaid expansion, according to an estimate provided in the report. The Cherokee Nation, the largest tribe in the state, is already seeing the benefits, Chief Chuck Hoskin, Jr. said.

“More than 2,000 of our health system’s patients enrolled in Medicaid in just the first few weeks of the expansion,” Hoskin said in a news release on Monday.

“This means more Cherokee families are going to have peace of mind as they confront future health care needs here on the Cherokee Nation Reservation and throughout Oklahoma,” said Hoskin, who hosted CMS Administrator Brooks-LaSur and Secretary of Health and Human Services Secretary Xavier Becerra on July 1, the same day the Medicaid expansion became official.

Elsewhere in the nation, Another 20,000 or so American Indians and Alaska Natives would gain coverage if the other holdout states adopted the same program, the HHS data indicates.

Besides providing coverage to eligible Natives, the expansion program financially benefits the IHS, which has been chronically underfunded. According to the report, Medicaid dollars now account for the overwhelmingly majority of third-party reimbursements in the system.

“Medicaid collections at IHS-operated facilities grew from $496 million in FY 2013 to $729 million in FY 2018,” the report states.

“The proportion of patients with insurance at federally operated IHS facilities grew from 64 percent to 78 percent from fiscal years 2013 through 2018, and IHS facilities in states that expanded Medicaid saw the largest increases,” it continues.

The growth is significant, as federally operated IHS facilities collected $1.1 billion in third-party reimbursements in fiscal year 2019.

“Medicaid expansion increased the number of AI/ANs who have both access to both IHS services and Medicaid coverage, which allows IHS and Tribal health agencies to bring in additional needed revenue to provide care,” the HHS report states.

Health Insurance Coverage and Access to Care for American Indians and Alaska Natives: Current Trends and Key Challenges (July 2021) [PDF]

The Affordable Care Act and Indian Country