Indian Health and Medicaid

The population of American Indians and Alaska natives living in the United States totals 5.2 million according to the Census Bureau. More than 1 million American Indians and Alaska Natives are enrolled in coverage through Medicaid and CHIP and many more are eligible for coverage as a result of the Affordable Care Act’s Medicaid expansion. Medicaid and CHIP can serve as a critical source of care for this community.

In 1976, the Indian Health Care Improvement Act amended the Social Security Act to permit reimbursement by Medicare and Medicaid for services provided to American Indians and Alaska Natives in Indian Health Service (IHS) and tribal health care facilities. In doing so, Congress recognized that many Indian people, especially those residing in very remote and rural locations, were eligible for but could not access Medicaid and Medicare services without traveling sometimes hundreds of miles to Medicaid and Medicare providers located off reservation. The Indian Health Care Improvement Act also provided states with a 100% Federal Medical Assistance Percentage (FMAP) for Medicaid services provided through an IHS or Tribal facility. The amendments to the Social Security Act created a direct relationship between CMS and the Indian Health Service delivery system that continues today. These protections were further augmented by Section 5006 of the American Recovery and Reinvestment Act (ARRA) of 2009.

The ARRA of 2009 provides certain protections for Indians that preclude states from imposing Medicaid premiums or any other Medicaid cost sharing on Indian enrollees who have used the Indian health system. Section 5006 also emphasizes the state-tribal relationship by formally requiring that states consult with the tribal community on Medicaid and CHIP policy matters. Specifically, states must seek advice from designees of Indian health programs and urban Indian organizations in the state when Medicaid and CHIP matters have a direct effect on Indians, Indian health programs or urban Indian programs. States must also describe the process for seeking advice from Indian health programs and urban Indian organizations in their Medicaid and CHIP state plans. 

For more information, see CMS’ policy regarding tribal consultation and a full listing of states’ approved state plan amendments (SPAs) regarding tribal consultation.

History

The federal government has a unique government-to-government relationship with American Indians and Alaska Natives that is based on the U.S. Constitution, treaties, court decisions, statutes and regulations. The government’s unique relationship was first articulated in the U.S. Supreme Court decision of Cherokee Nation v. Georgia (1831) as a trust relationship similar to that of a guardian and his ward. The trust responsibility has been upheld in subsequent court decisions, statutes and executive orders. It forms the underlying basis for federal services to Indian people based on their political status as members of Indian tribes having a government-to-government relationship with the United States.

The provision of health care to Indians dates back to treaties between the United States Government and Indian Tribes that included provisions for medical services, the services of physicians, or the provision of hospitals for the care of Indian people. The Snyder Act of 1921 and the Indian Health Care Improvement Act, which was reauthorized and made permanent as part of the Affordable Care Act of 2010 provide specific legislative authority for ensuring access to health care for Indian people.

Indian Health Care Improvement Act

The Indian Health Care Improvement Act (IHCIA), the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives, was made permanent when President Obama signed the bill on March 23, 2010, as part of the Affordable Care Act. The authorization of appropriations for the IHCIA had expired in 2000, and while various versions of the bill were considered by Congress since then, the act now has no expiration date. Read the IHS Press Release for more information.