Leading up to when Oklahoma expanded Medicaid coverage, Oklahoma had a large uninsured population of American Indian and Alaska Natives (AI/ANs). But as a consequence of Medicaid expansion and the Oklahoma Health Care Authority’s (OHCA) inclusion of — and consultation with — Tribes, Oklahoma’s AI/AN uninsured rate has significantly declined, according to estimates from the Oklahoma Policy Institute. The relationship between OHCA and tribal governments emphasizes the importance of tribes’ health care needs and input. It also represents a crucial feature of the state agency that has helped facilitate tribal-federal-state government collaboration in providing access to health care and specialty care in Oklahoma.
Expansion of Medicaid in Oklahoma has started tackling a long discussed public policy issue across tribal communities — a lack of access to specialty care. The stark contrast between access to health care and specialty care is immense for people who are eligible for Indian Health Services (IHS). This disparity is due to the fact that the agency historically has been chronically underfunded to fully address AI/AN health care needs. For AI/AN residents in Oklahoma who meet income requirements — $17,796 (individual) or $36,588 (family of four) — Medicaid expansion has provided access to basic health care with IHS as well as specialty providers. Because of Oklahoma’s federally mandated tribal consultation (required by Section 1902(a)(73) of the Social Security Act), Medicaid expansion happened in direct partnership with Indian Health Care Providers (IHCP) across the state. (NOTE: IHCP is an umbrella term for the entities operated/funded by the IHS that provide health care services to AI/ANs. These providers are also collectively referred to as I/T/Us: IHS, tribal and Urban Indian Organizations.)
Medicaid Expansion has provided needed access to specialty care
IHS is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to AI/ANs across the U.S. The health service is available to citizens of federally recognized tribal nations in direct response to the special government-to-government relationship between the federal government and tribal nations based on treaties; Article I, Section 8 of the Constitution; and subsequent federal laws.
Despite treaty obligations requiring the federal government to provide adequate health care to AI/ANs, IHS does not guarantee access to specialty care. IHS is notoriously known for exhausting its yearly allocation for providing health care — often by June — more than three months before the federal fiscal year ends on September 30. This means patients without private insurance and solely reliant on the IHS are forced to go without specialty health care while they wait for the next year’s funding if their health needs are not categorized as priority.
Delaying care often manifests in worsened conditions by the time AI/AN patients are able to see a specialist. IHS spends about $4,078 per patient; in comparison, Medicaid — which is also a federal health program — spends almost twice that at $8,109 per patient. Setting aside the differences in those programs, the disparity in spending reflects the disparity in access to care.
Medicaid Expansion has provided access to health care services
Medicaid expansion in Oklahoma happened at a pivotal time. Expansion, combined with the influx of pandemic health care funding, positively impacted access to health care and IHCPs’ ability to provide basic, speciality, and emergency health care. Taken in combination, this resulted in an increase in health care funding and anticipated better health outcomes for those who utilize both IHCPs and Medicaid. Medicaid expansion increased AI/AN total enrollment by more than 56,000 newly eligible adults as of July 2022, and AI/AN expansion enrollees now represent about 1 in 4 of the total AI/AN Medicaid enrollees in Oklahoma. With the increased coverage provided through Medicaid expansion, these patients are now accessing ongoing, preventive care around their specific health concerns, issues, and disease instead of going without health care and/or missing specialty care altogether.
Specialty care is particularly crucial given the many health disparities AI/ANs face. AI/ANs continue to die at higher rates than other Americans in many categories, including (but not limited to) diabetes, liver disease, kidney disease, or influenza, and other preventable diseases. These health disparities are caused by long standing, persistent structural racism specifically manifested in residential segregation and unequal medical care. Newly eligible AI/AN members of SoonerCare (the state’s Medicaid program) are no longer forced to choose between paying out of pocket for specialty care or forgoing it altogether. Increasing health equity for AI/ANs will require the combined efforts of federal and state government agencies working cooperatively with tribal nations. The accessibility of specialty care is also a key component of improving overall health and well-being of AI/ANs.
Medicaid expansion improved AI/ANs’ health insurance coverage
Tribal health systems have been instrumental in connecting eligible Oklahomans to coverage. Health care coverage improved as a direct result of Medicaid expansion efforts, including those by IHCP’s Patient Benefit Coordinators (PBCs). As the graph below shows, PBCs at Indian health facilities were instrumental in getting people health insurance coverage immediately, with nearly 5,000 newly eligible expansion applications in June 2021, the first month that Oklahoma began enrolling people in Medicaid expansion. Medicaid has proven itself to be a lifeline for Indian Country, as inadequate funding for IHS continues to impact disparities in AI/AN health and health care experiences. The applications submitted by IHCP’s PBCs are a key insight to the coordination among health advocates, both Native and non-Native, to ensure AI/AN’s health insurance coverage improved in Oklahoma.
By increasing the insured rate for AI/ANs, IHCPs were also able to expand health services offered due to increased revenue generated by AI/ANs who gained Medicaid coverage. Additionally, Medicaid expansion has shown how increased funding positively impacts overall population health outcomes, financial security, and economic mobility, while it reduces the costs of uncompensated care for health care providers. Enhanced federal funding for IHS could help further boost the state’s overall health outcomes by ensuring that tribal communities have access to high quality health care services from IHCPs across the state.
Broadening cross-sector partnerships with IHCPs can promote health equity in our state, as we’ve seen through the robust enrollments of AI/ANs for Medicaid expansion in Oklahoma. OHCA expressed support for expansion implementation by continuing to maximize reimbursement to IHCPs to optimize the federally published federal Office of Management and Budget reimbursement rate and leverage 100 percent Federal Medical Assistance Percentage (FMAP), which enhances tribal health services and poses no detrimental impacts to the state’s budget.
Medicaid expansion is good intergovernmental policy but more work remains
Due to the federal and state governments recognizing tribal sovereignty, the federal Centers for Medicare and Medicaid Services mandates tribal consultation and special rules for meeting the needs of AI/ANs. All Oklahomans benefited when OHCA followed through on its duty to consult with tribes while developing the state’s health care policies and respecting tribal self-governance through its meaningful consultation with tribal officials.
The direct consultation with tribes has helped Medicaid expansion improve Oklahoma’s access to health care generally, while specifically increasing AI/AN access to specialty care. These efforts have proven effective in lowering the uninsured rate and improving health outcomes. However, significant disparities — both in terms of health care and funding — remain to be addressed. AI/AN people continue to be disproportionately affected by chronic conditions and die at higher rates than other Americans. This was readily apparent as AI/ANs experienced a decrease in life expectancy during the COVID-19 pandemic.
During its first year of implementation in Oklahoma, Medicaid expansion lowered the rate of AI/ANs without health insurance, while it increased access to life-saving specialty care. The cooperative efforts that made this happen are a prime example of creating better outcomes by incorporating government-to-government consultations and partnerships between tribal nations and the state and federal governments.