As COVID-19 continues to disproportionately affect Montana’s Indigenous population, and as tribal governments continue to enact strict measures to slow the spread of the coronavirus, tribal leaders and health care advocates say a repeal of the Affordable Care Act would devastate health care in Indian Country. 

The ACA is set to be argued before the U.S. Supreme Court in November, with one possible outcome being essentially a repeal of the law. 

As of last week, 37% of the deaths attributed to COVID-19 in Montana were people who identify as Native American, even as Native Americans account for about 7% of the state’s population, according to the most recent state analysis

“It’s a tsunami impact upon our people across the nation,” said Rep. Sharon Stewart-Peregoy, D-Crow Agency. “We have lost generations to this disease.” 

Higher rates of pre-existing conditions like diabetes, historically underfunded health care services — which citizens of federally recognized tribes have a legal right to — and a pandemic disproportionately affecting many tribes make the ACA especially important for Indigenous people, panelists said Wednesday during a discussion about health care inequities and COVID-19 in Indian Country. The discussion was hosted by the Montana chapter of Protect Our Care, a group advocating for the continuance of the ACA. 

Last week Montana registered a “remarkable increase” of new COVID-19 cases, said Jim Murphy, the epidemiologist and chief of Montana’s Communicable Disease and Prevention Bureau, earlier this week during a press conference. Of the six counties accounting for most of the increases, two — Roosevelt and Rosebud — encompass reservations and significant populations of Native Americans.

On the Northern Cheyenne Reservation, tribal leaders have mandated a reservation-wide lockdown from Friday morning to Monday morning to help slow the spread of the virus. The order allows residents to leave their homes only for essential business or for safety or health reasons. The order also requests that privately owned businesses close during the lockdown, and mandates closure of tribally owned businesses. 

As of Monday, the Northern Cheyenne Reservation had recorded 188 confirmed active cases, 8 presumed positive test results and 12 hospitalizations among reservation residents. Twenty deaths of tribal citizens have been attributed to COVID-19, the tribe said

“The Tribe is at a crossroads and is faced with enforcing mandatory compliance with emergency measures to stop or reduce the spread of the Coronavirus,” Northern Cheyenne tribal leaders said in the lockdown order. “All of our families have been impacted by the COVID-19 pandemic.”

Other tribes in the state have taken similarly aggressive steps to contain transmission of the virus, like extending stay-at-home orders even after the state lifted its own similar directive and instituting travel restrictions and operating checkpoints on tribal lands. In June, the Blackfeet Nation closed the eastern entrances to Glacier National Park, which borders the Blackfeet Reservation, over concern about visitors spreading the virus to tribal citizens. 

And with a decision about the fate of the Affordable Care Act on the horizon, some in Indian Country are pleading that it remain in place, saying the program has improved health care options for Indigenous people, and that a repeal of the law would worsen the impact of the coronavirus pandemic in Indian Country or delay recovery. 

At Wednesday’s event, panelists discussed COVID-19’s impact in tribal communities and longstanding health inequities in Indian Country. Those disparities have only exacerbated the pandemic’s effect on tribal communities, the panelists said. 

In addition to high rates of preexisting conditions, many Indigenous people already faced social conditions like crowded housing and lack of access to healthy food or water — conditions that make it more likely for an Indigenous person to suffer serious consequences, including death, from the sickness caused by the coronavirus, said Damion Killsback, senior advisor for tribal affairs at the U.S. Department of Health and Human Services. 

“All these social determinants of health can really magnify the impact of COVID,” he said. Killsback is a member of the Northern Cheyenne Nation. 

Due to the political standing of tribes in the U.S., Indigenous people are the only group in the U.S. with a codified right to health care, according to a 2017 report by a group of researchers from the University of North Dakota, the National Indian Health Board and the Native American Rights Fund. 

But the Indian Health Service, which provides services to insured and uninsured tribal citizens, has been underfunded for decades, the report said. It has also faced criticism for poor care and facilities, among other inadequacies, in recent years.

The ACA permanently reauthorized legislation governing the Indian health system, according to the 2017 report. It also improved access to health care and the level of care available to patients. 

The law has led to IHS and tribally owned health care facilities collecting more from insurance companies for their services, allowing them to offer more services, hire more staff and upgrade equipment and facilities, the Government Accountability Office said last year. The law also created better access to specialized care at non-IHS and tribal facilities. 

“Now we see more than ever how important it is for people to have access to treatment of any kind, and how important it is to push prevention and to make sure that we can get rid of these health disparities among our vulnerable populations,” said Rep. Barbara Bessette, D-Great Falls, a member of the Chippewa Cree Tribe of the Rocky Boy’s Reservation.

In 2012, 40% of Montana resident American Indians and Indigenous Alaskans were uninsured — the highest percentage in the country, according to the 2017 report. Medicaid expansion in states including Montana has also led to many Indigenous people becoming insured. 

With ACA and Medicaid expansion, tribal citizens have also been able to access improved preventative care and education to help alleviate conditions like diabetes and heart disease, said Peregoy, who is a member of the Crow Nation. 

“If ACA is repealed, we are going to go back 30 years in terms of health, because right now Indian Health Service is able to provide us the preventative care, which we need to roll back the disparities,” she said. 

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Chris covers Native American issues as a Report for America Corps member based in Billings. He also monitors the Montana Supreme Court, federal courts and criminal justice issues. Before joining MTFP in 2020, Chris most recently covered tribal affairs and Wyoming's Wind River Reservation for the Casper Star-Tribune, and has also reported for the Wisconsin State Journal. Contact Chris at, 406-465-3386 ext. 4, and follow @cjaadland on Twitter.