A yearlong effort to launch a state program that would help increase tribal communities’ access to health care and health insurance became fully operational last week.

But proponents of the program, a collaboration between tribes, insurers and Nevada’s health insurance exchange, caution that more work needs to be done for the voluntary program to be successful.

“We're off and running right now,” the exchange’s executive director, Russell Cook, said in an interview. “However, I want to really emphasize that we definitely have some outstanding questions that we need to address with our insurance carriers in order to convince them to be willing stakeholders in this process.”

The tribal sponsorship program consists of three parts that proponents say are aimed at improving tribes’ health care access: offering Nevada tribal members enrollment assistance through the Nevada Health Link website platform via tribal exchange representatives, allowing tribes to make payments to insurers in one single monthly payment (known as aggregated billing) and a policy advocacy arm.

One reason for the need for voluntary participation is that the tribal sponsorship program is a supplementary service sanctioned but not mandated by the Affordable Care Act (ACA). The only other state that appears to have implemented a similar program with an aggregated billing workflow is Washington.

The executive director of the Reno-Sparks Tribal Health Center, Angie Wilson, has been one of the leading voices advocating for the program. She said that establishing the tribal sponsorship program’s apparatus is a good first step, but the state has only one qualified health plan on the exchange that has agreed to conduct the aggregated billing component, and that’s a challenge, especially for tribes that are spread across the state.

“We want to be able to exercise the full flexibility and really work with all the [qualified health plans], but right now we only have one,” she said, noting that aggregated billing is critical for tribes that face challenges with processing health insurance claims and payments for individual members. They would have an easier time if those payments were aggregated, she noted.

Cook said that though only one carrier is actively participating in the program, others have expressed “implicit support for the process” as long as some of the insurers’ questions are answered. 

When the Affordable Care Act was implemented 10 years ago, it sought to address health disparities in tribal communities by expanding existing Indian health care laws and sanctioning new programs and services.

Under the ACA, Nevada has established open continuous enrollment for tribal members through the state’s health insurance marketplace, Nevada Health Link, allowing tribal members to enroll in an insurance plan outside of the yearly open enrollment period. It has also implemented zero and limited cost-sharing for tribal members who qualify, allowing for reduced or no co-payments, deductibles or coinsurance costs when receiving care from a tribal clinic or a marketplace plan.

Even with those options, data provided by Nevada Health Link indicates that, as of Feb. 1, 1,644 individuals who self-identified as American Indian or Alaskan Natives submitted applications for 2024 medical coverage, while 774 of those individuals are actively enrolled in marketplace medical coverage. The U.S. Census Bureau estimates that about 54,000 people identifying as American Indian or Alaskan Natives live in Nevada. 

Cook described the rates as “low” but said he was encouraged that half of those who submitted an application selected a plan. He said that the exchange is working to see how the tribal sponsorship program addresses these rates and what more can be done.

In a presentation to the joint Interim Standing Committee on Health and Human Services last week about advancing Nevada tribal health care, Wilson highlighted that members of Nevada’s American Indian or Alaskan Native population have almost twice the infant mortality rate of non-Hispanic whites and higher rates of diabetes, among other health disparities. 

She described her ability to present and have a dialogue with the interim committee as a “historic moment” and said tribes have been advocating for the recent tribal sponsorship program ever since the ACA passed. She added that having a tribal representative on the insurance exchange board would allow the tribes to better express their needs and share information about the laws and regulations that need to be followed.

“That seat’s so important because lives depend on it,” Wilson said. “When people don't have access to health care in Indian country, they go without.”

Wilson, who is an enrolled member of the Pit River Tribe of Northern California, said that the open enrollment and zero and limited cost-sharing for tribal members policies are vital and guaranteed under the law, but tribal members still face barriers when receiving these services. 

For example, she said that to receive limited cost-sharing benefits, the law stipulates that Indian patients need a referral from an Indian health care provider to receive specialized care. She said some patients have received referrals but have been denied those cost-sharing benefits because the Indian health care provider that referred the patient wasn’t an in-network provider, even though that’s not stipulated by law.

“It doesn't matter if a tribal clinic is in network or not,” Wilson said. “It's a lack of understanding of the law, and how it applies to Indian people.”

Navigating insurers’ and health insurance board’s lack of understanding is one reason Wilson said she is asking the Legislature to consider a measure to establish a permanent tribal seat on the Silver State Health Insurance Exchange Board of Directors.

Although one member of the state’s health exchange board is a member of a federally recognized tribe in Nevada, Cook noted that the governor appointed her, and the seat is not specific to a tribal representative. He added that the exchange is “100 percent” in support of Wilson’s desire to have a dedicated seat for a tribal member on the board. 

As an organization, he said that Nevada Health Link would like to remove administrative barriers to entry and provide education and policy support to increase access to care. 

“We're hoping to provide education and policy support,” Cook said. “Everything we're doing is aimed at not only increasing the autonomy and the self-sufficiency of these tribes to be able to share this information with members of their own community but hopefully capitalize … on the trust that these tribal health clinics that these tribal governments have already established”