Instead of a birthday party, the Affordable Care Act is getting oral arguments before the U.S. Supreme Court that could lead to its demise — and a lasting impact on health care in Indian Country.

The U.S. Supreme Court will hear arguments in California v. Texas on Nov. 10. The lawsuit, known as Texas v. U.S. in the lower courts, specifically challenges the ACA’s minimum coverage requirements, more commonly known as the individual mandate.

Attorneys general from 18 states, including Texas, Kansas, Arkansas, Missouri and Indiana are seeking to have it struck down. The federal government has sided with those 18 states and has indicated that it wants most of the ACA’s provisions eliminated. However, until the court issues a ruling, the Trump administration has continued to enforce the law.

Colton Woodall poses for a photo with his parents, Brian and
Keta Woodall, at their home in Shawnee, Friday, Oct. 23, 2020.

Oklahoma is one of four states not involved in any capacity on either side of the lawsuit, along with Alaska, Idaho and Wyoming. According to the Kaiser Family Foundation, 148,474 Oklahomans have health insurance through the ACA marketplace as of Sept. 22. Ninety-five percent receive at least a partial tax credit to help with the cost.

The litigation has also called into question the long-term viability of the law, despite its targeted impact on health in Indian Country.

“Repealing the ACA will exact a cruel toll on Indian Country,” Sen. Tom Udall (D-N.M.) said as part of an Oct. 15 panel at the National Indian Health Board’s virtual national conference.

“It’s important to realize and emphasize … that Native health is what’s at stake.”

Among the provisions of the ACA specifically aimed at Indian Country is the permanent reauthorization of the Indian Health Care Improvement Act. Initially passed in 1976, the IHCIA allows for Medicaid and Medicare funding to go to Indian Health Services. It also allows for tribally-operated facilities, including Citizen Potawatomi Nation Health Services’ two clinics, to collect third-party billing. Prior to the adoption of the ACA, IHCIA’s provisions were subject to reauthorization by Congress, which last happened in full in 1992.

The law is also responsible for the federal government completely covering Medicaid and Medicare costs for patient visits to IHS and tribally-operated facilities. As of September, Indigenous people account for 10 percent of all Medicaid recipients in Oklahoma. In Pottawatomie County, the rate is even higher, with 17.6 percent of SoonerCare and Insure Oklahoma participants identifying as American Indian or Alaska Native.

Nationwide, almost one-third of non-elderly Indigenous adults and half of all American Indian children are covered by Medicaid, according to the Kaiser Family Foundation.

Third-party billing, including Medicaid and Medicare, brought in $1.14 billion for IHS in 2019 alone. Those funds helped stretch the federal government’s $5.8 billion appropriation for all IHS facilities and services. Since the adoption of the ACA in 2010, IHS’ Medicaid billing has increased by 21 percent.

According to a study published in December 2018 by the U.S. Government Accountability Office, the federal per capita funding for IHS is less than half of what is provided to other government-operated health care systems. IHS receives $4,078 per patient, compared to $8,109 for Medicaid patients, $10,692 for patients seen through the Veterans Health Administration and $13,185 for Medicare.

As the vice chairman of the U.S. Senate Committee on Indian Affairs, Udall acknowledged at the NIHB conference that the ACA is imperfect, but its Medicaid provisions have been invaluable to IHS.

“Remember the old saying in Indian Country, ‘Don’t get sick after June or July because there’s no more money?’ The Affordable Care Act … added a lot more money into the Indian Health Services,” Udall said.

“If you’re underfunded, you can’t do the things you need to do.”

Third-party billing is not just limited to Medicaid and Medicare. IHS and tribally-operated facilities are able to bill patients’ insurance providers, including those purchased through the ACA marketplace.

One ACA provision deems tribal citizens who earn up to 300 percent of the federal poverty level eligible to choose health plans in the marketplace that do not have any cost sharing requirements, such as co-pays or deductibles, for in-network services.

Rather than wait for Medicaid expansion, the Citizen Potawatomi Nation Health Services launched a health insurance pilot program in 2014 for uninsured clinic patients who cannot receive affordable health insurance coverage through Medicaid, Medicare or their employer. A provision of the IHCIA permanent reauthorization that allows tribes to sponsor coverage through plans on the ACA marketplace made the program possible.

In fiscal year 2019, the Tribe paid $751,304 in premiums for 213 patients, including 99 CPN citizens. According to the CPN Office of Self-Governance, every dollar paid in premiums has generated about $8 in savings on purchased and referred care costs from physicians outside of the Tribe’s health care system.

For Alesha Brewer’s family, the program has been a lifesaver, both literally and figuratively.

Both of Brewer’s daughters, 22-year-old Breanna and 18-year-old Cassie, have a rare congenital condition that impacts the connective tissue in their bodies. The condition could not even be diagnosed without an appointment to see a geneticist after Breanna had to have multiple shoulder surgeries.

“We were constantly in the emergency room,” Alesha Brewer said. “We started getting sent to see specialists, which is why we were called in about the insurance program. Care was getting expensive.”

Additionally, the condition requires several medications that are not part of the standard IHS formulary, and typically, they costs upward of $1,000 per month without insurance.

Each daughter also has an additional medical issue that requires even more medications outside of the standard formulary and come with a four-figure monthly bill. Cassie Brewer also has postural orthostatic tachycardia syndrome, which impacts the body’s heart rate and circulation. Breanna Brewer has dysautonomia, which requires intravenous fluids three times per week.

Participating in the program allowed the Brewer sisters to get diagnoses and made it possible for them to get regular, prompt appointments with specialty providers that are often few and far between on the contract health list.

If the insurance sponsorship program ends due to a repeal of the ACA, the Brewer family does not have a backup plan for handling medical expenses or receiving continual treatment for a condition that few Oklahoma doctors are familiar with.

“I know contract health will give them the best care they can,” Alesha Brewer said. “They always have. However, the girls see orthopedic surgeons, neurologists, gastroenterologists, a geneticist and cardiologists. Those visits are extremely expensive. Just walking in the door can run $5,000 to $6,000.”

The program has also been a lifeline for Colton Woodall and his family. Now 23 years old, Woodall received his Crohn’s Disease diagnosis when he was 15. In order to get it in check, he eventually had to undergo Remicade treatments every six weeks, which came with a $1,600 price tag per visit. Medical professionals administer Remicade intravenously, and each of his appointments would take up to six hours.

Last year, he was able to transition to another medication that he can self-administer, but that adjustment would not have been possible without the Remicade appointments covered by CPN’s insurance sponsorship program.

“They gave me my life back,” he said.