Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act

Leah Frerichs, Ronny Bell, Kristen Hassmiller Lich, Dan Reuland, Donald K. Warne

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA. Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms. Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04–7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002). Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.

Original languageEnglish (US)
Pages (from-to)174-189
Number of pages16
JournalEthnicity and Health
Issue number1
StatePublished - 2022
Externally publishedYes


  • Indians
  • North American
  • Patient Protection and Affordable Care Act
  • United States Indian health Service
  • adult

ASJC Scopus subject areas

  • Cultural Studies
  • Arts and Humanities (miscellaneous)
  • Public Health, Environmental and Occupational Health


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