Healthcare Coverage Gaps Challenge American Indian and Alaska Native Patients in Oklahoma
Corey Still, a 34-year-old citizen of the United Keetoowah Band of Cherokee Indians, was diagnosed with an autoimmune liver disease while uninsured, relying mainly on the Indian Health Service (IHS) for healthcare.
IHS, a federal agency under the U.S. Department of Health and Human Services, provides health services to American Indians and Alaska Natives but is considered by the U.S. Census Bureau as non-comprehensive coverage, classifying those covered only by IHS as uninsured.
Though Still's primary care and most specialty needs are covered by IHS, the agency does not fund liver transplants, a critical treatment in his case. Oklahoma’s Medicaid expansion in 2021 helped reduce the uninsured rate among Indigenous residents by 4.5%, but the uninsured rate remains high at about 22.5%, compared to the state's overall 13.5% rate. Factors contributing to persistent uninsured status include difficulties navigating insurance options, financial barriers, and cultural preferences for IHS services despite chronic funding limitations.
IHS operates through three primary funding and service channels: encouraging enrollment in Medicaid, Medicare, or private insurance to supplement IHS funding; tribal health systems such as Cherokee Nation Health Services providing tribally governed care with reinvestment from third-party revenues; and the Purchased/Referred Care Program, which pays for outside services when unavailable through IHS but operates on limited congressional funds and prioritizes other payers first.
Access to specialty care can be constrained, leading to delays and difficult decisions for uninsured patients. Still recounts an experience where a delayed orthopedic specialist necessitated emergency referral out of the IHS system. While still managing current specialty care with the help of referrals, Still faces financial and coverage gaps for transplant candidacy, as his job does not provide insurance and he does not qualify for Medicaid or subsidies. This situation illustrates the ongoing healthcare challenges for many American Indian and Alaska Native Oklahomans, with approximately 58,000 uninsured individuals in the state, complicating access to necessary care. Tribal clinics employ benefits coordinators to guide patients through insurance applications and alternative resources, striving to bridge coverage gaps due to underfunding. Coordination efforts emphasize that IHS is not insurance but a health service provider with limited resources, reinforcing the importance of securing comprehensive insurance when possible. Medicaid plays a significant role, with around 30% of Cherokee Nation Health Services’ patients enrolled, and the federal government covers 100% of Medicaid costs for eligible American Indians when care is provided via IHS or tribal facilities.
Medicaid expansion has increased third-party revenues supporting enhanced specialty services and referrals. However, potential Medicaid funding cuts threaten to reduce services and lengthen wait times, underscoring the need for policy stability. Economic development remains a critical factor in expanding employer-based insurance coverage within Indigenous communities. Despite progress, tribes continue to aim for universal insurance coverage to reduce disparities and improve care quality.
After navigating these challenges, Still recently secured a more affordable insurance plan through IHS assistance and continues to pursue transplant evaluation, illustrating ongoing patient experience at the intersection of tribal health systems, public insurance programs, and federal services. The article highlights the structural complexities of health coverage for Indigenous populations in Oklahoma, emphasizing the interplay of IHS, Medicaid, tribal governance, and patient navigation in a context of persistent uninsured rates and underfunded health services.