October 22, 2019

Research from faculty at the UNC Gillings School of Global Public Health shows insurance coverage among American Indians and Alaska Natives in midwestern regions is still lacking, despite Affordable Care Act (ACA) provisions for these historically underserved populations.

Dr. Leah Frerichs

Dr. Leah Frerichs

Dr. Kristen Hassmiller Lich

Dr. Kristen Hassmiller Lich

Leah Frerichs, PhD, assistant professor of health policy and management at the Gillings School, is lead author of the paper “Regional Differences in Coverage Among American Indians and Alaska Natives Before and After the ACA,” published in the September 2019 issue of Health AffairsKristen Hassmiller Lich, PhD, associate professor of health policy and management at the Gillings School, is co-author on the paper.

There are many barriers to health insurance coverage for American Indians and Alaska Natives, including low employment rates and a distrust of health care institutions. While a common misunderstanding persists that the Indian Health Service (IHS), the federally funded system of clinics and hospitals for American Indians and Alaska Natives, meets the health care needs of these populations, many individuals are not in areas covered by the IHS and experience significant gaps in insurance coverage.

Though the ACA, enacted in 2010, has specific provisions for Native American populations, Frerichs could find very little post-ACA research that focused on the health coverage of those groups.

“Native American populations are often overlooked and underrepresented across the spectrum of research. With specific reference to health services research, they have a very unique and complex health care system that deserves more attention,” she says. “As the nation continues to debate health care reform, data on American Indians and Alaska Natives need to be included in the conversation.”

Frerichs’ team used 2010–2017 American Community Survey data to examine trends in health insurance coverage among American Indians and Alaska Natives across ten different regions of the United States. In the West, the group found significant improvements in public insurance among American Indians and Alaska Natives, and disparities compared to non-Hispanic whites were reduced following the ACA.

Although there were unadjusted increases in insurance coverage across most regions, there were no significant post-ACA changes in public or private health insurance coverage among American Indians and Alaska Natives in the Oklahoma, Minnesota, Wisconsin or Alaska regions.

Structural racism and discrimination are likely substantial contributing factors to this disparity, says Frerichs. Those experiences lead to a collective distrust of institutions, which further feeds into delays or avoidance in seeking health care services.

“Despite treaty agreements between the federal government and tribes and legislation to further codify these treaties, the United States government has historically underfunded health care, along with other social and education services for this population. Inadequate funding has led to many Native Americans having poor outcomes from low-quality health care or substantial delays in health care access.”

Health care policies (both specific to Native American populations and the general population) will continue to be debated, and the team’s paper provides data specific to American Indian and Alaska Natives to include in these crucial conversations.

“There is considerable debate about the best strategies. In some ways, the ACA was seen as a potential avenue to improve such resources, and our analyses suggests this has been true in some areas,” says Frerichs. “Complicated Tribal-state-federal government relationships and the expansion of Medicaid are challenges that can only be faced with open discussions about ensuring equitable health care across these regions.”


Contact the Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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