The state of Washington is helping Native Americans access health care after decades of barriers.

Health insurers have made it difficult for tribal members to get care covered, despite state and federal laws that bar this.

Vicki Lowe is the executive director of the American Indian Health Commission, which has led efforts to remove hurdles for Native Americans.

She said health insurers would try to make tribal clinics charge out-of-network rates, and wouldn't honor their referrals.

However, the Washington State Office of the Insurance Commissioner has come out with guidance to prevent this.

"Not only will tribes have more money to help pay for services for their tribal members, tribal members will get care in a more timely manner," said Lowe. "So those two things just are really important, and insurance companies have been a barrier for that for decades."

Washington is among the first states to move forward with guidance for insurers and also enforcement of the law so that insurers will stop putting up roadblocks for tribal members to get care in the state.

Todd Dixon is the deputy commissioner for consumer protection and the tribal liaison for the Office of the Insurance Commissioner.

He said one reason for releasing the guidance was that the agency has seen an uptick in complaints - the number one compliant typically coming from billing managers at clinics.

"It says, 'Hey, we have an enrolled member. He or she was seen at our clinic. We billed the insurance company. They said we're out of network and so "we're only paying 60%." And then they send a bill to the enrolled member,'" said Dixon. "It's not how it works."

The Insurance Commissioner's office has been sending notices to insurers who violate protections for Native Americans.

Lowe said before they got involved, tribes fighting with insurers on their own were getting them nowhere. But it's different with the state backing them.

"Knowing that if somebody violates these laws that they're going to get that outreach from the insurance commissioner and that they have 15 days to respond," said Dixon. "Where if a tribe asked them, they would maybe not respond or respond in some convoluted way - it's a power shift to really have the state agency behind this."

More than 14,000 incarcerated people in Washington are not able to vote and two bills in Olympia aim to change it.

One bill would make voting more accessible for people in jail by improving access to the voter's pamphlet and voter registration forms. Another would allow people in prison in Washington to vote for the first time in the state's history.

Charles Longshore is incarcerated at the Washington Corrections Center for Men in Shelton. He does advocacy work from prison and said without the right to vote, it is not easy to get a legislator's attention.

"I've helped draft a bill that's before the legislature this session and leading on several other bills," Longshore pointed out. "But I find that it's difficult because you have no reason to be accountable to me."

Longshore is a Skokomish tribal member and said giving the vote to incarcerated people would help right historical wrongs against Indigenous people, who were not given the full right to vote until 1965. Data show Native Americans are vastly overrepresented in the criminal legal system.

Opponents of allowing people to vote from prison said voting is a privilege and breaking laws should mean you lose your voice.

Anthony Blankenship, senior community organizer for the advocacy group Civil Survival, said everyone is a constituent, whether they get to choose who represents them or not. He argued allowing incarcerated people to vote will help with their rehabilitation.

"We have to be able to see and understand what they need to be successful and what they need to not recidivate or go back to prison or harm anyone ever again," Blankenship emphasized.

Blankenship added it is unlikely the bills will pass this session but it is important to keep raising the issue.

"We have to keep on pushing," Blankenship urged. "We have to keep on saying that these are opportunities for people to be part of our community and not be on the outside looking in."

Three Montana bills regarding Native rights and culture advanced from the Senate to the House this week, despite some previous setbacks. Bills to revise the Montana Indian Child Welfare Act and Indian Education for All laws, both tabled within the last month, were this week both passed the Senate and were transmitted to the House. The education bill would require more tribal consultation, more work with language and culture specialists, and more accountability from the state's Board of Public Education.

Keaton Sunchild, director of government and political relations for Western Native Voice, says understanding historical context is critical.

"I think it's hugely important that we continue to teach the history and the culture of Native Americans here in Montana," Sunchild said. "It's pretty hard to do any sort of Montana history without talking about Native American history."

Senate Bill 147 would expand the 2023 Indian Child Welfare Act to include more frequent and robust tribal participation, in recognition of the cultural losses an Indian child placed in a nonnative foster home may experience. In 2020, American Indian children made up 9% of all Montana children, but were 35% of kids in foster care, according to the state's judicial branch.

A bill to make voting more accessible for Native communities was heard last week, but still requires a vote. Sunchild said the major arguments he's heard against the bill are around the costs of implementing more resources for voters, but added that those one-time government costs would save many individuals' repeated costs.

"Between gas, food, child care, days off work, we have voters who are paying $200 sometimes, if not more, to go vote. Voting's inherently supposed to be free," Sunchild continued. "And we're saying that it's really not for Native American communities."

A bill to recognize Indigenous People's Day as a legal holiday in Montana passed the Senate on Wednesday almost unanimously. Sunchild said this version received more support than its predecessors because it calls for the holiday in conjunction with, instead of replacing, Columbus Day.

By Jazmin Orozco Rodriguez for KFF Health News.
Broadcast version by Alex Gonzalez for Nevada News Service reporting for the KFF Health News-Public News Service Collaboration

A few years before the covid-19 pandemic, Dale Rice lost a toe to infection.

But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program rolled out last year in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid at higher rates than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, with more than 1,330 members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households on the reservation.

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The American Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into Native languages spoken in the state, such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”


Jazmin Orozco Rodriguez wrote this story for KFF Health News.


get more stories like this via email