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Good brief from the Center on Budget and Policy Priorities

 (CBPP) on the impact of Medicaid work requirements on Native Americans:

Medicaid is an important source of coverage for American Indians and Alaska Natives (AI/ANs), a population that faces high unemployment and persistent health disparities, including a high uninsured rate, barriers to care, and significant physical and mental health needs. Medicaid plays a key role in addressing these challenges, especially in states with large AI/AN populations that have expanded Medicaid under the Affordable Care Act (ACA). …

Their high unemployment rates would put AI/ANs in states with approved or pending work requirements at particular risk of losing coverage, while their high rates of serious health needs would mean that these coverage losses would likely have especially harmful health impacts. As a bipartisan group of senators recently noted, imposing work requirements in Medicaid could have “potentially devastating impacts … on AI/AN health access.”

The Trump administration recently approved work requirements for certain populations in the Medicaid expansion program in three states — Arkansas, Indiana, and Kentucky. More such approvals are expected. None of those states exempted Native Americans. Tribal leaders have appealed to the Trump administration for exemptions but been rebuffed, Politico reports. Meanwhile, some states, such as Arizona, hope to create such exemptions, but Politico reports that the Trump administration is likely to block that request and force Native Americans to comply with any Medicaid work requirements that states impose:

The Trump administration says Native Americans might need to get a job if they want to keep their health care — a policy that tribal leaders say will threaten access to care and reverse centuries-old protections.

Tribal leaders want an exemption from new Medicaid work rules being introduced in several states, and they say there are precedents for health care exceptions. Native Americans don’t have to pay penalties for not having health coverage under Obamacare’s individual mandate, for instance.

But the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. “HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,” according to a review by administration lawyers.

It’s a complicated legal issue, with a complicated history. More from Politico:

The tribes insist that any claim of “racial preference” is moot because they’re constitutionally protected as separate governments, dating back to treaties hammered out by President George Washington and reaffirmed in recent decades under Republican and Democratic presidents alike, including the Clinton, George W. Bush and Obama administrations.

“The United States has a legal responsibility to provide health care to Native Americans,” said Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

Tribal leaders and public health advocates also worry that Medicaid work rules are just the start; President Donald Trump is eyeing similar changes across the nation’s welfare programs, which many of the nearly 3 million Native Americans rely on.

“Work requirements will be devastating,” Smith said. “I don’t know how you would implement it. There are not jobs to be had on the reservation.”

I’ve asked the Arkansas Department of Human Services how many Native Americans are enrolled in the state’s Medicaid expansion program and have not yet received a response; I will update this post if I do. CBPP produced estimates last year but was unable to get information for Arkansas. Around 1 percent of the state’s total population is Native American. The unemployment rate is about twice as high for working-age Native Americans in the state as compared to others in the state (see chart from CBPP above). 

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Trump administration won’t grant exemptions to Native Americans for Medicaid work requirements