American Indian and Alaska Natives (AI/AN) continue to have poorer health outcomes when compared to other Americans. Compared to all other races, American Indians and Alaska Natives have a lower life expectancy and higher rates of mortality from chronic diseases, drug-related overdoses, and self-harm/suicide. In 2022, the average life expectancy at birth for AI/AN was 67.9 years, compared to 77.5 years for non-Hispanic Whites. In addition, 31.9 percent of AI/AN adults have multiple chronic conditions, and they are almost three times more likely than non-Hispanic white adults to be diagnosed with Type 2 diabetes.

Disparities in health outcomes for AI/AN stem from many factors, including the role of intergenerational trauma, as well as high rates of poverty and associated barriers to nutrition, educational and economic opportunities, and other social determinants of health (SDOH). Efforts to address these health disparities have been challenged by limited funding of the Indian Health Service (IHS), the federal agency responsible for providing AI/AN health services, which comprises about half of AI/AN health care funding. Current funding is estimated to meet less than half of AI/AN’s health needs, contributing to lack of access, outdated health care infrastructure, delayed care and provider shortages. Rural access barriers and lack of culturally competent care create further barriers to ensuring adequate access to services and supports.

Medicaid can play an important role in addressing AI/AN health needs. Medicaid covers an estimated 36 percent of nonelderly AI/AN adults and helps to supplement federal appropriations to the IHS. In 2019, federal appropriations to the IHS totaled $5.8 billion and Medicaid reimbursements provided $808 million in additional support. States can work with Tribes to leverage Medicaid policy to shape services and programs that better serve the AI/AN who are covered by Medicaid. However, state policymakers seeking to partner with Tribes need to understand how services are delivered to AI/AN, as well as a few key concepts and policies that are unique to this work, outlined in the text box. This brief highlights how Washington and Arizona have partnered with Tribes to create innovative Medicaid programs, as shared in a recent NASHP webinar.

Key Concepts and Policies for Delivery of Health Services to American Indian and Alaska Natives

• Tribal sovereignty is the inherent authority of Tribes to govern themselves. This means that state-Tribal partnerships must be negotiated on a government-to-government basis.
• The federal trust responsibility provides the legal basis for the federal obligation to provide health care to AI/AN.
• The IHS delivers services through a three-part system of IHS operated, Tribally operated, and urban Indian health programs.
• Federal Tribal consultation policies require Medicaid agencies to “obtain the advice and input from Indian health care providers and Tribes prior to changes in the Medicaid programs having Tribal implications.”
• States can claim 100 percent federal matching funds for certain Medicaid services provided to AI/AN.
• Federal Medicaid rules establish certain requirements for participation of Indian health care providers and AI/AN people in Medicaid managed care programs.

Washington Leverages Medicaid State Plan, 1115 Waiver, and Managed Care Contracts

Washington state and Tribal governments with traditional lands in the state have been working together for decades. Two key structures facilitate this work: First, a 1989 Centennial Accord signed by Washington State and Tribal governments formally established a government-government relationship that respects Tribal sovereignty. Secondly, 29 federally recognized Tribes whose traditional lands included parts of Washington joined with two urban Indian health organizations to form the nonprofit American Indian Health Commission (AIHC) in 1994. The AIHC serves as an advocate and convener for these entities to work on health initiatives with Washington’s state government.

Washington implements this government-government relationship by centering the experience and perspective of Tribal governments in their work. Washington has regional Tribal liaisons, established Tribal workgroups, and hosts statewide Tribal conferences to share ideas and communicate with each other. Washington State’s Health Care Authority (HCA), which administers the state Medicaid program, has specific guidelines for Tribal relations. The HCA requires contractors to undergo training in government-government relations and partners with contractors to aid in navigating all communication with Tribes. Finally, as required by CMS, the HCA consults with Tribes in the development of Medicaid waivers and state plan amendments (SPAs).

This ongoing collaboration has resulted in several initiatives to address key priorities for Tribal communities in Washington, leveraging a variety of tools and levers within the Medicaid program to address priorities for improving AI/AN health outcomes. These include:

Community Health Aide Program: In 2024, HCA obtained approval of a SPA that allows the Medicaid agency to pay Indian health care providers for services delivered by Certified Community Health Aide Program (CHAP) providers, which includes community health aides, behavioral health aides, and dental health aides. This program works to expand Tribal self-governance and improve culturally adapted services by improving access to CHAP providers with knowledge and expertise of the health needs of their communities.

• Tribal Behavioral Health and Crisis Initiatives: HCA contracts with regional behavioral health-administrative service organizations (BH-ASO) to deliver behavioral health crisis services to everyone in the region they serve and also help people navigate through behavioral health treatment services. These contracts include Tribal specific provisions, services, and guidelines which, among other things, call for following Tribal care coordination protocols, and recognizing Tribal-designated crisis responders. Additionally, HCA supports the Native and Strong Lifeline, and Tribal mobile crisis teams and can directly reimburse Tribes for involuntary treatment assessment services.
• Incentive Funds for Indian Health Care Providers and the Native Resource Hub: HCA designated funding within its Section 1115 Medicaid Transformation waiver to pay incentives to Indian health care providers (IHCP) for achieving milestones in improvements to health care capacity, enhanced care coordination, and reductions in usage of unnecessary intensive care. Between 2018 and 2023, HCA distributed over $17 million through these incentives. This waiver also created a Native Resource Hub, which serves as a centralized information center and phone line to help AI/AN people and their health care providers address social and health needs.

Arizona Leverages Primary Care Case Management

The American Indian Medical Home (AIMH) program was developed as a partnership between Arizona Health Care Cost Containment System (AHCCCS), which administers the state’s Medicaid program, and Tribal leaders. Implemented through a 2017 SPA, the AIMH program serves AI/AN members enrolled in AHCCCS’s American Indian Health Program (AIHP), Arizona’s fee-for-service Medicaid program for AI/AN people. The AIMH program was implemented under federal Medicaid managed care authority as a Primary Care Case Management (PCCM) program. Indian health care providers that choose to participate in the AIMH are supported and incentivized to deliver additional case management and care coordination services to better support AIHP patients.

AIHP members can voluntarily choose to receive their care through an AIMH provider. These IHS and Tribal facilities may qualify for one of four tiers based on the services they offer. To qualify for the first tier, providers must have national patient-centered medical home accreditation and offer 24/7 telephone access to the care team. To attain higher tiers, providers must meet additional requirements, such as having an accredited diabetes education program and participating in the state’s health information exchange

In 2024, the prospective per-member-per-month reimbursement rates for AIMH providers ranged from $18.17 for tier one to $31.18 for tier four. AIMH providers also continue to receive payment for the services they provide to Medicaid beneficiaries. Providers can advance tiers at yearly renewals by meeting the additional requirements. AIMH program requirements and the additional funding the program brings have helped facilities expand their scope of services and improve coordination of care. AIMHs provide extensive case management services, with funding for case managers and care coordinators, allowing for better communication and more individualized care for patients.

Chinle Comprehensive Health Care Facility obtained AIMH status in 2018. It offers an example of how the AIMH funding has been used to improve care. The funding allows the facility to provide 24-hour care, and enhanced services include integrated behavioral health (including substance use disorder treatment), diabetes health coaching, multidisciplinary pain management, and telemedicine options. While data to support evaluation of the program’s health impact are still being collected, patient surveys support the value of the program.

“We feel that the AIMH program allows a patient-centered medical home to actually be patient centered in more than just name. … The facility can actually provide the care that’s multi-disciplinary, true wraparound care.

— Jessica Weeks, Chinle Comprehensive Health Care Facility

Summary

As seen in Arizona and Washington, states can use Medicaid to support Indian health care providers, improve access to culturally relevant services, and reduce health disparities. Washington’s strategies, rooted in government-to-government consultation and collaboration, have produced multiple programs tailored to AI/AN and implemented through SPAs, waivers, and contracts. Arizona’s AIMH program enables Tribes to implement patient-centered, innovative models of primary care delivery that address health disparities. Both serve as examples of state-Tribal partnerships to promote improved health care outcomes for AI/AN.

Acknowledgments

The authors thank Leslie Short of the AHCCCS, Jessica Weeks of Chinle Comprehensive Health Care Facility, Vicki Lowe and Kathryn Akeah of the American Indian Health Commission for Washington State, and Lucille Mendoza of the Washington State Health Care Authority for their contributions to this brief.

The webinar and presentations are available on NASHP’s website.