Native Americans and Rural Arizonans Photo by Meg Potter, Arizona State University

A repeal of the Affordable Care Act will negatively impact hundreds of thousands of Arizona’s indigenous and rural populations.

More than 500,000 rural Arizona residents could lose crucial health benefits if the Affordable Care Act (ACA) is repealed in the latest lawsuit challenging its legality. That includes the indigenous groups who rely on coverage through the state’s expansion of Medicaid through federal funding.

The U.S. Court of Appeals for the 5th Circuit decision in Texas vs. United States could come down any day now.

Currently, there are 1,895,254 residents enrolled in the Arizona Health Care Cost Containment System (AHCCCS)—the state’s Medicaid program—which receives 78% of its funding through the federal government.

Marcus Johnson, director of state health policy and advocacy at Vitalyst Health Foundation, said a repeal of the ACA would strip AHCCCS of significant federal funding and put Arizonans who rely on the program in a precarious position.

“Medicaid in Arizona covers one-third of adults living in rural areas, and half of the children in these communities,” Johnson said. “Repealing the Affordable Care Act would create a significant problem for the people of Arizona, for our government, and for our communities.”

The uninsured rate has dropped six percent statewide since the expansion of Medicaid, Johnson added. In Arizona’s Native American communities, reports show that uninsured rates have dropped from 85% to less than 10%. Overall, roughly 57% of Native Americans now rely on AHCCCS for healthcare.

Prior to the passage of the ACA, Native Americans living in rural areas often had to travel to urban hubs, such as Phoenix and Tucson, to obtain medical care. This largely came as a result of the broader range of coverage offered by the Office of Urban Indian Health Programs. The expansion of Medicaid opened the doors for increased coverage at Indian Health Service facilities—23 of which are located in the state’s rural regions. 

Still, health advocates feel there needs to be more investment in bolstering the resources for Indian Health Service, the federal health program for American Indians and Alaska Natives. The National Congress of American Indians proposed a 2020 budget of $7 billion for IHS; President Donald Trump’s 2020 budget provides $5.9 billion.

During a U.S. Senate Committee on Indian Affairs in May, Sen. Martha McSally advocated for more funding for tribal healthcare centers in the federal budget.

“Indian Health Service facilities in Arizona provide critical care and services to vulnerable populations in some of the poorest and most geographically isolated areas around the country,” McSally stated during the committee meeting. “Because of the unique challenges that Native Americans experience in accessing health care in Arizona, it is essential that IHS facilities have the resources they need.”

The Copper Courier reached out for comment from McSally on how funding gaps resulting from a repeal of the ACA would be remedied, but her office did not respond for comment.

Overall, the health risk of repealing the ACA doesn’t stop in Indian Country. Nearly one-third of the 1.6 million Arizonans living in rural areas rely on AHCCCS for health care.

Expanding AHCCCS coverage has increased enrollment growth by more than 425,000, a trend that would reverse if funding were slashed. Additionally, reports have shown that 161 rural hospitals have closed since 2010, the vast majority of which were located in states that had not expanded Medicaid. Three of those hospitals were in Arizona; only one of them closed after Medicaid was expanded in 2014.

“The Affordable Care Act is woven into the fabric of the healthcare industry,” Johnson noted. “The consequences of repealing it would be crippling to health care and the economy.”

The National Rural Health Association (NRHA) estimates that 700 healthcare facilities nationwide would be in danger of closure should the ACA be repealed. Facility closures have the direct consequence of limiting access to care in the regions they service. 

But they also have an indirect impact: economic downturn.

Hospitals are responsible for as much as 20% of a rural community’s economy, according to the NRHA, and widespread closures would do long-lasting damage to regions that are already economically disadvantaged.

However, the uncertainty of AHCCCS is something patients are familiar with. Earlier this year, Arizona’s plans to implement a work requirement to receive health benefits received approval from the federal Center for Medicare and Medicaid Services. The added requirement is projected to put 120,000 AHCCCS patients at risk of losing coverage.

The law was originally introduced in 2014, one year after Medicaid expansion was signed into law by former Gov. Jan Brewer. Its passage was met with vehement opposition from the Republican-controlled Arizona Legislature, and Rep. Nancy Barto’s work requirement legislation was introduced as a quick retaliation to the expansion of aid.

“The fact that it will take nearly five years for these work requirements to be fully implemented highlights the massive regulatory bureaucracy that states must navigate in order to enact commonsense policies,” Barto declared in a prepared statement.

Originally slated to begin January 2020, the AHCCCS website for the program now states that it is indefinitely on hold “as court cases in other states play out to avoid disruptions to Arizona’s vulnerable population, including those in rural and indigenous communities, served by the Medicaid program.

As for repealing the ACA, Johnson said he believes the case will end up at the U.S. Supreme Court, leaving hundreds of thousands of Arizona residents in medical limbo for several months.

What he and other experts are concerned about, though, is how long these vulnerable communities will linger there before giving up.