GAO Report Finds ACA Helped Increase Coverage for American Indians, Alaskan Natives

Amid continued questions over whether the Affordable Care Act (ACA) will survive, the Government Accountability Office (GAO) released a report this week showing the 2010 landmark health law aided 2 vulnerable, high-risk populations—American Indians and Alaska Natives (AI/AN). The report also shows that those populations living in states that expanded access to Medicaid saw the biggest impact.

GAO’s analysis of Indian Health Service (IHS) data shows that from fiscal years 2013 through 2018, the percentage of patients at federally operated IHS hospitals and health centers who reported having health insurance coverage increased an average of 14 percentage points, from 64% in 2013 to 78% in 2018. Most gains occurred in fiscal years 2014 through 2016.

Federally operated IHS facilities’ third-party collections—that is, payments for enrollees’ medical care from public programs such as Medicaid and Medicare, or from private insurers—totaled $1.07 billion in fiscal year 2018, increasing 51% from fiscal year 2013.

Tribally operated facilities, which include hospitals and health centers not run by IHS, also experienced increases in coverage and collections over this period, according to officials the GAO interviewed.

All federally operated IHS facilities reported coverage increases, but those in Medicaid expansion states experienced an average increase of 17 percentage points in patients reporting any form of health coverage, compared with an average increase of 8 percentage points in nonexpansion states.

Historically, AI/AN individuals have experienced barriers to accessing needed healthcare services; they suffer from poorer health than the US general population, including a shorter average life span and higher incidence of certain medical conditions due to a lack of access to preventive primary care services. The GAO said IHS has not been able to pay for all eligible healthcare services, leading to an unmet need for healthcare.

Legislators in the House of Representatives asked the GAO to review how the ACA has affected healthcare coverage and services for American Indians and Alaska Natives. In a statement, the legislators who requested the report, House of Representatives Energy and Commerce Chairman Frank Pallone, Jr, D-New Jersey, and Rep. Raul Ruiz, MD, D-California, said they “are particularly encouraged by the expanded access to care, including increased onsite services. While we still have a lot more work to do to close the health disparities gap among American Indian and Alaska Native communities, we are heartened by the progress made in just the last few years.”

Increases in health insurance coverage and third-party collections helped federally operated and tribally operated facilities continue their operations and expand the services offered, according to officials from 17 selected facilities; these facilities have been increasingly relying on third-party collections to pay for ongoing operations including staff payroll and facility maintenance. Officials said that they expanded their onsite services, including increasing the volume or scope of services offered by, for example, adding new providers or purchasing medical equipment.

Increased coverage and collections also allowed for an expansion in the complexity of services provided offsite through the Purchased/Referred Care program, which enables patients to obtain needed care from private providers if the patients meet certain requirements and funding is available.

The IHS annually serves approximately 2.56 million AI/AN individuals who are members of 573 federally recognized tribes. The IHS provides services through a network of 662 health facilities located on or near reservations.