Despite the federal government shutdown, the individual mandate of the Affordable Care Act, a.k.a. Obamacare, is moving forward. While most U.S. citizens are mandated to have health insurance by March 31, 2014, or face a tax penalty, Alaska Natives and American Indians are exempt.
In Alaska, that's nearly 20 percent of the population, around 120,000 people. Yet some officials hope that Natives and American Indians who receive health care free of charge through tribal clinics, will sign up for private insurance, too.
But why bother? What do Alaska Natives have to gain from private health insurance?
Better health care?
Alaska Natives and American Indians already receive health care coverage through the federal Indian Health Services (IHS), which provides funding for 36 tribal health centers, 180 tribal community health aide clinics and five residential substance abuse treatment centers in Alaska.
The Alaska Native Tribal Health Consortium (ANTHC), a nonprofit tribal health organization based in Anchorage, hopes Alaska Natives will sign up for private health care under the exchange for two reasons -- but the organization may be fighting an uphill battle.
First, the tribal health consortium hopes Alaska Natives sign up for private health insurance to relieve some of the burden of costs on IHS. The federal agency provides for only about half the current need, Davidson said, and the federal sequester slashed funding further. That means tribal health centers rely on private insurance, and programs such as Medicaid, to pick up the other 50 percent of costs. More people signing up for individual health care means that more money remains in the communal pot to help others.
Second, individual health care plans offer a broader range of coverage than tribal health clinics, said consortium senior official Valerie Davidson.
Tribal health care is supposed to be used as something of a last resort -- "life or limb," Davidson said -- so that means some basic services aren't covered. While an optometry exam is paid for, glasses aren't. Neither are dentures, nor root canals in some cases. Private health insurance could cover these services and travel costs associated with the treatment. The consortium hopes people will sign up for individual health care to broaden their range of coverage, and then private insurers will pick up the tab for travel.
But will outreach efforts be fruitful?
'I don't think anyone is interested in it'
"We have folks in Nome as we speak," Davidson said on Wednesday. Others are headed to Kodiak soon.
Davidson believes the outreach efforts are working. In less than 24 hours, the consortium fielded 300 phone calls and visitors who showed at the Alaska Native Medical Center, she said. The consortium has received a $300,000 federal grant to train about 20 "navigators" who can guide individuals and small businesses through the ins and outs of marketplace insurance.
Yet convincing Alaska Natives to pay for additional health insurance may prove to be a challenge, said Donna Bach, spokesperson at the Yukon-Kuskokwim Health Corporation in Southwest Alaska. Alaska Natives have a "trust relationship with the government," she said, where they expect health care to be provided free-of-charge. "That's a very difficult paradigm shift to encourage," she said.
Barriers to access already exist -- and some rural residents may not welcome a whole new way of providing health care. Getting folks to bring in the right paperwork when they walk through clinic doors is "already enough of a challenge," Bach said, be it Medicaid documents or tribal identification.
Costs represent another barrier. Kaltag community health practitioner Jessica Mcginty has lived in the Interior community for all of her life. Kaltag's clinic serves around 210 people, many of whom use Medicaid or Denali KidCare. "The basic consensus is people don't have the money to afford that extra insurance," she said. "I don't think anyone is interested in it."
In the Western community of Deering, where the clinic serves 140 people, tribal health clinic administrative assistant Denise Iyatunguk wasn't even sure what the Affordable Care Act was. "That's the first I've heard about it," she said.
In the Southeast community of Yakutat, where the tribal clinic has received a grant to hire an outreach coordinator to help educate the public on the Affordable Care Act, details surrounding the law were unclear. Health aide Becky Latzel wasn't sure whether Alaska Natives needed to sign up, and she said that so far the clinic hasn't fielded any questions about the new law. "I think there is a lot of confusion," Latzel said.
A fact of life
Limited health care is a fact of life in rural Alaska, where doctors and dentists are in short supply.
In Yakutat, 600 people are served by a team of two health aides, a practitioners assistant and nurse practioner who handle such basic services such as immunizations, blood work and prescriptions. "For real serious stuff we fly them out" to Sitka, Latzel said. For Alaska Natives, the cost of those flights are covered by Indian Health Services.
Mental health and dentistry are among the services not offered, health aide Becky Latzel said. A doctor comes by every three months, and dentists fly in several times a year.
In Kaltag, three health aides provide acute care, emergency services, preventative care and immunizations. Travel is authorized on doctor's orders. Sick folks are medevaced to Fairbanks about once a month, noted community health practitioner Jessica Mcginty. "People feel like they could come to our clinic, and we'll do as much as we can," she said. The clinic is always looking for ways to improve (its) services, but overall, the basics are covered, all for free.
Alaska Natives and the Medicaid expansion
Donna Bach of the Yukon-Kuskokwim Health Corporation was annoyed with Gov. Sean Parnell's administration refusing, thus far at least, to expand Medicaid coverage.
Tribal health clinics rely on Medicaid to help pay bills. A Medicaid expansion would mean more coverage for some of the most vulnerable populations, while relieving some of the tribal health-care system's costs. "It's very disappointing," Bach said.
In Kaltag, some two-thirds of the serviced population use Medicaid, Mcginty said. In Deering, at least one-third of people use it, Iyatunguk said.
Mcginty wasn't aware that Medicaid expansion was an option on the table. "That would be nice," she laughed.
And should Parnell decide not to expand Medicaid, some of the poorest residents in Alaska will be stuck in a loophole where they don't qualify for low-cost insurance nor Medicaid -- leaving them without affordable health care.
Contact Laurel Andrews at laurel(at)alaskadispatch.com. Follow her on Twitter @Laurel_Andrews