September 2017 Update | Issue Brief Medicaid and American Indians and Alaska Natives Samantha Artiga, Petry Ubri, and Julia Foutz Key Takeaways Nearly 5 million nonelderly individuals self-identify as American Indian or Alaska Native (AIAN) alone or in combination with some other race, representing nearly 2% of the total nonelderly population. This brief provides an overview of the role of Medicaid and the effect of the Affordable Care Act (ACA) Medicaid expansion for AIANs. It shows:  AIANs face persistent disparities in health and health care. AIANs have a high uninsured rate, face significant barriers to obtaining care, and have significant physical and mental health needs.  Medicaid provides coverage to more than one in four (27%) nonelderly AIAN adults and half of AIAN children. Medicaid coverage helps to fill gaps in employer-sponsored insurance for AIANs, enables AIANs to access a broader array of services and providers than they can access solely through services funded by the Indian Health Service (IHS), and provides a key source of financing for IHS and Tribal providers.  The ACA Medicaid expansion led to coverage gains among AIANs and increased revenue to IHS- and Tribally-operated facilities. The uninsured rate for nonelderly AIANs in states that implemented the Medicaid expansion fell by twice as much (from 23% to 15% between 2013 and 2015) as the rate in non-expansion states (from 25% to 21%). In addition, the expansion increased revenues to IHS- and Tribal facilities serving AIANs as a larger share of their patients gained coverage, enhancing their capacity to provide services. Reductions to Medicaid, including loss of the expansion, could result in coverage losses for AIANs and reductions in revenue to IHS and Tribal providers, limiting access to care for AIANs. American Indians and Alaska Figure 1 American Indians and Alaska Natives as a Share of the Natives and their Health Nonelderly Population, by State, 2015 Needs VT WA ME MT ND NH MN OR NY MA WI Nearly 5 million nonelderly individuals self- ID WY SD MI PA RI CT IA NJ identify as AIAN alone or in combination with NV UT NE IL IN OH WV VA DE MD CO KS MO DC another race, representing nearly 2% of the CA TN KY NC OK SC total nonelderly population. In most cases, AZ AR NM MS AL GA analysis in this brief uses this inclusive group of AK TX LA FL AIANs. Within this group, some 2.3 million nonelderly HI < 1% (15 states, including DC) individuals identify solely as AIAN, making up about Total: 4.8 million = 1.8% of Nonelderly Population 1-3% (26 states) > 3% (10 states) 1% of U.S. population. AIANs live across the country Note: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. SOURCE: Kaiser Family Foundation analysis of the 2015 American Community Survey (ACS), 1-Year Estimates. but are concentrated in certain states (Figure 1). While many AIANs live in rural areas, only 22% live on reservations or land trusts. As of 2010, 60% of AIANs live in metropolitan areas.1 Some AIANs belong to a federally recognized Tribe, some belong to a state-recognized Tribe, and others are not enrolled in a Tribe. Members and descendents of members of federally recognized Tribes have broader access to certain federal benefits and services. While the majority of AIANs are in working families, they have high rates of poverty. Over three quarters (76%) of nonelderly AIANs are in working families, but they are less likely than other nonelderly individuals to be in the workforce (83%) and have significantly higher rates of poverty (24% vs 16%) (Figure 2). AIANs face significant physical and mental health problems. Among nonelderly adults, AIANs are more likely than other adults to report being in fair or poor health, being overweight or obese, and having diabetes (Figure 3). Moreover, suicide is the second leading cause of death for AIAN adolescents and young adults, with a suicide rate one and half times higher than the national average.2 Figure 2 Figure 3 Income and Work Status for Nonelderly American Indians Health Status and Rates of Selected Chronic Diseases for and Alaska Natives, 2015 American Indian and Alaska Native Nonelderly Adults, 2015 Nonelderly AIANs Remaining Nonelderly AIAN Nonelderly Adults Remaining Nonelderly Adults Work Status Income 83% 69%* 76%* 64% 26%* 15% 24%* 11%* 7% 5%* 4% 16% Fair/Poor Health Overweight or Obese Diabetes Cardiovascular Disease Full-Time Worker in the Family Family Income Below Poverty Notes: Includes nonelderly adults ages 18-64. Includes individuals identifying race as AIAN only, including those of Hispanic origin. NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with Does not include individuals identifying as AIAN in combination with another race. Cardiovascular disease includes adults who another race and those of Hispanic origin. report being told by a doctor they had a heart attack (myocardial infarction), angina or coronary heart disease. * Indicates a statistically significant difference from the remaining nonelderly population at the p < 0.05 level. * Indicates a statistically significant difference from the remaining nonelderly adults at the p < 0.05 level. SOURCE: Kaiser Family Foundation analysis of the 2015 American Community Survey (ACS), 1-Year Estimates. SOURCE: Kaiser Family Foundation Analysis of CDC, Behavioral Risk Factor Surveillance System Survey (BRFSS), 2015. The Role of the Indian Health Service The Indian Health Service (IHS) is responsible for providing health care and prevention services to AIANs. A network of hospitals, clinics, and health stations that are managed by IHS, Tribes or Tribal organizations, and urban Indian health programs provide IHS-funded services. In general, services provided through IHS- and Tribally-operated facilities are limited to members of and descendants of members of federally recognized Tribes that live on or near federal reservations. Urban Indian health programs serve a wider group of AIANs, including those who are not able to access IHS- or Tribally-operated facilities because they do not meet eligibility criteria or reside outside the service areas. AIANs receiving services through IHS providers are not charged or billed for the cost of their services. IHS funding is limited and Congress must appropriate funding each fiscal year. The appropriated funds are distributed to IHS facilities across the country and serve as their annual budget. If service demands exceed available funds, services are prioritized or rationed. In FY2017, Congress appropriated $4.8 billion for IHS services (Figure 4). In addition to direct appropriations, revenues from third-party payers are a significant part of IHS funding, including Medicare, Medicaid, the Veterans Administration, and private insurance. A total Medicaid and American Indians and Alaska Natives 2 of $1.3 billion will be collected from third-party payers in FY2017, with the largest share—$810 million— coming from Medicaid. Figure 4 Allocation of Indian Health Service Program Funding, in Billions, FY2017 Urban Health $0.04, 1% Appropriated Funds ($4.8 Billion) Collections and Other ($1.3 Billion) Health Care Preventive Health Services and Other Services (IHS) $1.52, 25% $1.42, 23% Medicaid $0.81, 13% Health Care Services (Tribally-operated) $1.81, 29% Medicare and Private $0.36, 6% Other, $0.18 , 3% Total IHS Program Funding: $6.15 Billion NOTE: Other services includes contract support and facilities costs; other collections includes Special Diabetes Program for Indians, VA reimbursement, and quarters return funds. SOURCE: DHHS, Indian Health Service, Justification of Estimates for Appropriations Committees, Fiscal Year 2017. IHS services historically have been underfunded to meet the needs of AIANs. The services provided through the IHS consist largely of primary care, and include some ancillary and specialty services. If facilities are unable to provide needed care, the IHS and Tribes may contract for health services from private providers through the Purchased/Referred Care (PRC) program. However, urban Indian health organizations do not participate in the PRC program. Although the IHS budget has increased over time, funds are not equally distributed across facilities and remain insufficient to meet health care needs. 3 As such, access to services through IHS varies significantly across locations, and AIANs who rely solely on IHS for services often lack access to needed care. 4 Moreover, referrals through the PRC program are often limited to emergency services due to funding limitations.5 The Role of Medicaid Just as with other eligible individuals, AIANs who meet state eligibility standards are entitled to Medicaid coverage in the state in which they reside. AIANs may qualify for Medicaid regardless of whether they are a member of a federally-recognized Tribe, whether they live on or off a reservation, and whether they receive services (or are eligible to receive services) at an IHS- or Tribally-operated hospital or clinic. AIANs with Medicaid can access care through all providers who accept Medicaid for all Medicaid covered benefits. As such, they have access to a broader array of services and providers than those who rely solely on IHS services for care. Moreover, Medicaid has special eligibility rules and provides specific consumer protections to AIANs. Medicaid provides coverage to more than one in four (27%) nonelderly AIAN adults and half of AIAN children (Figure 5). AIANs have limited access to employer-sponsored coverage because they have a lower employment rate and those working often are employed in low-wage jobs and industries that typically do not offer health coverage. Medicaid and other public coverage help fill this gap. However, even with this coverage, nonelderly AIANs remain significantly more likely to be uninsured than the rest of the nonelderly Medicaid and American Indians and Alaska Natives 3 population (17% vs. 11%). Nationwide, over 900,000 AIANs lack coverage, although the number and share of AIANs who lack coverage varies across states (Appendix Table 1). Figure 5 Health Insurance Coverage for Nonelderly American Indians and Alaska Natives by Age, 2015 Uninsured Private Medicaid/Other Public 11% 10%* 5% 13% 17%* 21%* 40%* 56% 48%* 66% 52%* 71% 50%* 35%* 39% 23% 27%* 16% AIAN Remaining AIAN Remaining AIAN Remaining Nonelderly Children Adults Total Nonelderly Children (0-18) Adults (19-64) NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. Other public includes the Children’s Health Insurance Program, Medicare, and other public coverage. * Indicates a statistically significant difference from the remaining population at the p < 0.05 level. SOURCE: Kaiser Family Foundation analysis of the 2015 American Community Survey (ACS), 1-Year Estimates. Medicaid also provides a key source of revenue for IHS and Tribal facilities. In contrast to IHS funds, which are limited at a fixed amount appropriated per year, Medicaid funds are not subject to annual appropriation limits. In addition, since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs. As such, Medicaid revenues help facilities cover needed operational costs, including provider payments and infrastructure developments, supporting their ability to meet demands for care and maintain care capacity. The federal government covers 100% of costs for services provided to AIAN Medicaid enrollees through an IHS- or Tribally-operated facility.6 This 100% matching rate reflects a policy judgment that states should not have to contribute state general funds to the cost of care provided by a federal facility, whether operated by the IHS or on its behalf by a Tribe.7 In 2016, the Centers for Medicare and Medicaid Services (CMS) released guidance that expands the scope of services considered “received through” an IHS/Tribal facility that may qualify for 100% federal match.8 Expanding the scope of services that can qualify for 100% federal match provides potential increased savings to states and incentives to increase access to care for AIANs and expand capacity of IHS and Tribal services. Impact of the ACA Medicaid Expansion The ACA Medicaid expansion provided a new coverage option for many uninsured AIANs in states that have implemented it. The ACA expanded Medicaid to low-income adults with incomes up to 138% of the federal poverty level. As of August 2017, 31 states and DC have adopted the Medicaid expansion, making many parents and adults without dependent children newly eligible for the program. Although a number of states that include a relatively large share of the AIAN population have expanded Medicaid, such as California, Arizona, and New Mexico, other states that are home to a large share of the population have not, including Oklahoma and Texas. In states that have not expanded, many poor adults fall into a coverage gap. These adults have incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits, which begin at 100% of the federal poverty level (FPL). Medicaid and American Indians and Alaska Natives 4 AIANs have experienced gains in coverage since implementation of the ACA (Figure 6). Between 2013 and 2015, the uninsured rate among nonelderly AIANs fell by 7 percentage points from 24% to 17%. During the same period, the uninsured rate among the remaining nonelderly fell by 6 percentage points, from 16% to 11%. Despite similar gains in coverage, the nonelderly AIAN uninsured rate remains higher than the remaining nonelderly population. Figure 6 Uninsured Rate for Nonelderly American Indian Alaska Natives, 2013-2015 24% Nonelderly AIANs Remaining 20% Nonelderly 17% 16% 13% 11% 2013 2014 2015 NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. SOURCE: Kaiser Family Foundation analysis of the 2013-2015 American Community Survey (ACS), 1-Year Estimates. AIANs in Medicaid expansion states have experienced larger gains in coverage than those in states that have not expanded (Figure 7). Between 2013 and 2015, rates of Medicaid coverage for AIANs in expansion states increased by 5 percentage points from 34% to 39%, while Medicaid coverage rates for AIANs in non-expansion states remained stable in non-expansion states at 28%. Over the same period, the uninsured rate for AIANs in expansion states fell by 8 percentage points, from 23% to 15%, a decline that was twice as large as in non-expansion states, where the rate fell by 4 percentage points from 25% to 21%. As a result, the uninsured rate for AIANs in non-expansion states remains higher than in expansion states (21% versus 15%). Figure 7 Health Insurance Coverage for Nonelderly American Indians and Alaska Natives by Medicaid Expansion Status, 2013-2015 Uninsured Private Medicaid/Other Public 17% 23% 15% 21% 24% 25% 48% 46% 45% 43% 47% 51% 31% 35% 34% 39% 28% 28% 2013 2015 2013 2015 2013 2015 Overall Expansion States Non-Expansion States NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. Other public includes the Children’s Health Insurance Program, Medicare, and other public coverage. SOURCE: Kaiser Family Foundation analysis of the 2013 & 2015 American Community Survey (ACS), 1-Year Estimates. Medicaid and American Indians and Alaska Natives 5 The Medicaid expansion provided increased Medicaid revenues for IHS-and Tribally-operated facilities. As noted, Medicaid serves as a key source of revenue for IHS providers. In states that expanded Medicaid, the share of patients served by IHS providers with Medicaid grew, resulting in increased revenues for these facilities that may enhance their capacity to provide services. Overall, nationwide, total IHS program funding from Medicaid revenue increased from $720 million in 2013 to nearly $810 million in 2017.9 Some facilities have also pointed to positive effects of the Medicaid expansion. For example, in Arizona, one Tribally- operated health system reported that about half of visits were by patients covered by Medicaid in 2016.10 Additionally, an Urban Indian Health Program in Arizona indicated that its uninsured rate at one clinic fell from 85% pre-ACA to under 10%.11 In Montana, one study finds that the Medicaid expansion improved access to care for AIANs and allowed facilities broader ability to refer patients for services from private providers under the PRC program. As noted, PRC program referrals have historically often been limited to emergency services due to funding limitations. However, with increased Medicaid coverage among patients and gains in Medicaid revenues, facilities can stretch PRC funds further to cover more services.12 Looking Ahead In sum, AIANs have a broad range of physical and behavioral health needs and continue to face persistent disparities in their health and health care. Medicaid is a key source of coverage for AIANs, helping to fill gaps in employer-sponsored coverage for them and providing them access to a broader array of services and providers than available to them solely through IHS-funded services. In addition, Medicaid revenues provide an important source of support to IHS and Tribal facilities. The Medicaid expansion contributed to coverage gains among AIANs, enhancing their ability to access care. In addition, the expansion increased revenues to IHS- and Tribal facilities serving AIANs as a larger share of their patients gained coverage, enhancing their capacity to provide services. Given the important role of Medicaid and the Medicaid expansion to AIANs and IHS and Tribal providers, reductions to the program, including loss of the Medicaid expansion, could result in Medicaid coverage losses for AIANs and reductions in revenue to IHS and Tribal providers. Such changes would limit access to services for AIANs, leaving them reliant on IHS-funded services only. At the same time, the availability of IHS-funded services would likely become more limited due to the losses of Medicaid revenue. Medicaid and American Indians and Alaska Natives 6 Appendix A Table 1: Total Nonelderly American Indians and Alaska Natives, by State, 2015 Nonelderly AIANs as a Share of the State Number of Nonelderly AIANs Total Nonelderly Population United States 4,809,000 2% Alabama 187,000 1% Alaska 48,000 20% Arizona 131,000 6% Arkansas 340,000 2% California 43,000 2% Colorado 634,000 2% Connecticut 99,000 1% Delaware 34,000 1% District of Columbia NA NA Florida 169,000 1% Georgia 48,000 1% Hawaii 5,000 3% Idaho 98,000 3% Illinois 134,000 1% Indiana 78,000 1% Iowa 41,000 1% Kansas 464,000 2% Kentucky 37,000 1% Louisiana 79,000 1% Maine 111,000 2% Maryland 42,000 1% Massachusetts 22,000 1% Michigan 49,000 1% Minnesota 30,000 2% Mississippi 80,000 1% Missouri 14,000 1% Montana 50,000 9% Nebraska 38,000 2% Nevada 21,000 2% New Hampshire 59,000 1% New Jersey 45,000 1% New Mexico 121,000 12% New York 88,000 1% North Carolina 81,000 2% North Dakota 19,000 7% Ohio 66,000 1% Oklahoma 52,000 14% Oregon 78,000 3% Pennsylvania 26,000 1% Rhode Island 52,000 2% South Carolina 298,000 1% South Dakota 54,000 11% Tennessee 8,000 1% Texas 74,000 1% Utah 179,000 2% Vermont 8,000 2% Virginia 8,000 1% Washington 52,000 3% West Virginia 200,000 1% Wisconsin 89,000 2% Wyoming 18,000 4% NA: Estimate not reported; Relative Standard Error is greater than 30% or unweighted cell count is less than 50. NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. SOURCE: Kaiser Family Foundation analysis of 2015 American Community Survey (ACS), 1-Year Estimates. Medicaid and American Indians and Alaska Natives 7 Table 2: Changes in Health Coverage of Nonelderly American Indians and Alaska Natives, by State and Medicaid Expansion Status, 2013-2015 Private Medicaid/Other Public Uninsured State 2013 2015 Change 2013 2015 Change 2013 2015 Change United States 45% 48% 3% 31% 35% 3% 24% 17% -7% Expansion States 43% 46% 3% 34% 39% 5% 23% 15% -8% Alaska 33% 35% 2% 32% 36% 4% 35% 29% -6% Arizona 32% 34% 2% 39% 42% 3% 29% 24% -5% Arkansas 49% 53% 4% 32% 35% 3% 20% 12% -8% California 49% 51% 3% 31% 38% 7% 20% 11% -9% Colorado 54% 48% -6% 27% 36% 9% 19% 15% -4% Connecticut 57% 50% -7% 30% 40% 10% NA NA NA Delaware NA 59% NA NA NA NA NA NA NA District of Columbia NA NA NA NA NA NA NA NA NA Hawaii 64% 63% -1% 22% 32% 9% NA NA NA Illinois 55% 60% 4% 31% 33% 2% 13% 7% -6% Indiana 51% 58% 7% 25% 27% 3% 24% 15% -9% Iowa 31% 43% 12% 47% 46% -1% NA NA NA Kentucky 37% 50% 13% 33% 36% 3% 30% NA NA Louisiana 48% 50% 2% 31% 30% -2% 21% 20% -1% Maryland 60% 67% 6% 26% 25% -1% 13% NA NA Massachusetts 53% 50% -3% 44% 46% 2% NA NA NA Michigan 47% 51% 4% 36% 41% 6% 17% 8% -10% Minnesota 35% 49% 14% 42% 39% -3% 23% 13% -11% Montana 17% 30% 13% 39% 36% -3% 45% 34% -11% Nevada 49% 50% 1% 27% 35% 9% 25% 15% -10% New Hampshire 46% 61% 15% NA NA NA NA NA NA New Jersey 54% 56% 2% 27% 30% 3% 19% 14% -5% New Mexico 24% 28% 3% 39% 50% 11% 36% 22% -14% New York 47% 51% 4% 35% 35% 0% 18% 14% -4% North Dakota 32% 39% 7% 36% 35% -1% 32% 27% -5% Ohio 50% 40% -10% 33% 49% 16% 17% 11% -6% Oregon 49% 47% -2% 33% 43% 10% 18% 10% -8% Pennsylvania 52% 50% -2% 32% 41% 9% 16% 9% -6% Rhode Island NA 46% NA NA 48% NA NA NA NA Vermont NA NA NA NA NA NA NA NA NA Washington 44% 49% 6% 32% 39% 7% 25% 12% -13% West Virginia 38% NA NA 54% NA NA NA NA NA Non-Expansion States 47% 51% 4% 28% 28% 1% 25% 21% -4% Alabama 60% 58% -1% 23% 27% 4% 18% 14% -3% Florida 53% 54% 1% 22% 24% 2% 25% 22% -3% Georgia 54% 55% 1% 22% 23% 1% 24% 22% -1% Idaho 41% 44% 3% 34% 32% -2% 25% 24% -1% Kansas 63% 58% -6% 21% 26% 6% 16% 16% 0% Maine 43% 36% -7% 43% 48% 5% NA NA NA Mississippi 25% 33% 9% 30% 44% 14% 45% NA NA Missouri 51% 62% 11% 30% 29% -1% 19% 9% -10% Nebraska 41% 48% 7% 32% 30% -2% 27% 22% -5% North Carolina 43% 49% 6% 34% 33% 0% 23% 17% -6% Oklahoma 44% 47% 3% 26% 27% 0% 29% 26% -3% South Carolina 45% 58% 13% 29% 26% -3% 26% 16% -10% South Dakota 18% 18% 0% 44% 46% 1% 38% 36% -2% Tennessee 46% 51% 6% 32% 38% 6% 22% NA NA Texas 54% 58% 4% 22% 24% 2% 24% 18% -5% Utah 52% 47% -5% 25% 23% -3% 23% 30% 7% Virginia 63% 69% 5% 19% 19% 0% 18% 13% -5% Wisconsin 44% 50% 6% 37% 35% -2% 19% 14% -5% Wyoming 36% 51% 15% 29% 22% -7% 35% 26% -8% NA: Estimate not reported; Relative Standard Error is greater than 30% or unweighted cell count is less than 50. NOTES: Includes nonelderly individuals ages 0-64. Includes American Indians and Alaska Natives alone and in combination with another race and those of Hispanic origin. Other Public includes Medicare, Tricare or other military coverage, and other public coverage. MT and LA adopted Medicaid expansion in 2016. SOURCE: Kaiser Family Foundation analysis of 2013 & 2015 American Community Survey (ACS), 1-Year Estimates. Medicaid and American Indians and Alaska Natives 8 ENDNOTES 1 Office of Minority Health, Profile: American Indian/Alaska Native Profile, http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62 2 National Center for Injury Prevention and Control, Division of Violence Prevention, Suicide: Facts at a Glance (2015), (Atlanta, Georgia: Centers for Disease Control and Prevention (CDC), 2015), https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet- a.pdf. 3 Edward Fox and Verné Borner, Health Care Coverage and Income of American Indians and Alaska Natives: A Comparative Analysis of 33 States with Indian Health Service Funded Programs, for Tribal Affairs: Centers for Medicare and Medicaid Services, (2012), http://www.crihb.org/files/Health_care_coverage_and_income_of_aians.pdf; Ed Fox, Health Care Reform: Tracking Tribal, Federal, and State Implementation, Tribal Affairs Group, Centers for Medicare and Medicaid Services, (May, 20, 2011) http://www.cms.gov/Outreach-and-Education/American-Indian-Alaska- Native/AIAN/Downloads/CMSHealthCareReform5202011.pdf; and Government Accountability Office, Indian Health Service, Health Care Services Are Not Always Available to Native Americans, GAO-05-789 (Washington DC: Government Accountability Office, August 2005), http://www.gao.gov/products/GAO-05-789. 4 Ibid. 5 “Requirements – Priorities of Care,” Purchase/Referred Care (PCR), Indian Health Service, https://www.ihs.gov/prc/index.cfm?module=chs_requirements_priorities_of_care. 6 Section 1905(b) of the Social Security Act (third sentence). 7 This 100% federal matching rate is separate from the 100% federal matching provided to the “newly eligible” ACA expansion population and will remain in place when the 100% federal matching rate provided for all new eligibles begins to phase down. 8 Centers for Medicare and Medicaid Services, op cit. 9 Indian Health Service, Department of Health and Human Services, Justification of Estimates for Appropriations Committees, (Washington, DC: HHS, FY 2015), https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY2015CongressionalJustification.pdf; Indian Health Service, Department of Health and Human Services, Justification of Estimates for Appropriations Committees, (Washington, DC: HHS, FY 2018), https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/display_objects/documents/FY2018CongressionalJustificatio n.pdf. 10 Jessica Bylander, “Propping Up Indian Health Care Through Medicaid,” Health Affairs 36, 8 (2017):1360-1364, http://content.healthaffairs.org/content/36/8/1360.full.pdf+html. 11 Ibid. 12 Deborah Bachrach, Patti Boozang, Anne Karl, and Kier Wallis, Repealing the Medicaid Expansion: Implications for Montana, (Los Angeles, CA: Manatt, March 2017), http://www.mthcf.org/wp-content/uploads/2017/03/Repealing-the-Medicaid-Expansion- Implications-for-Montana_March-2017.pdf. 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