In rural Alaska, where the nearest hospital might be hundreds of miles away and winters make travel treacherous, access to health care has never been a simple matter. For generations, American Indian and Alaska Native communities have faced insurance rates that lagged far behind the rest of the country, compounding already steep barriers to care. But new research from the University at Albany suggests that one policy decision made by state governments helped shift that reality in a meaningful way.
A study published in Health Services Research found that Medicaid expansion under the Affordable Care Act reduced uninsurance among American Indian and Alaska Native populations by 9 percentage points between 2011 and 2019. The gains were especially pronounced for those who also had access to the Indian Health Service. Notably, the ACA's national insurance marketplace reforms — the subsidies and online exchanges often highlighted in public debate — did not produce statistically detectable effects on coverage for these communities.
"Our findings show that Medicaid expansion was the primary driver of insurance gains for American Indian and Alaska Native populations during this period," said Kate Strully, associate professor of sociology at the University at Albany and the study's lead author. "The results add to a growing body of evidence documenting the key role of Medicaid in reducing insurance disparities and the importance of states protecting Medicaid in this time of unprecedented cuts."
The research, co-authored by economists Pinka Chatterji and Han Liu, analyzed insurance outcomes for more than 12 million Americans across multiple racial and ethnic groups. By comparing states that expanded Medicaid with those that did not, the team was able to isolate the effect of state-level policy choices from national-level reforms. The distinction mattered: while Black Americans gained coverage from both Medicaid expansion and marketplace policies, and white Americans saw modest improvements, Hispanic and American Indian/Alaska Native populations benefited far more from Medicaid expansion specifically.
For tribal communities, the stakes extend beyond individual coverage. Medicaid reimbursements flow to Tribal and Indian Health Service health systems, which rely on that funding to keep clinics open and staff employed in areas where private insurers rarely operate. When states expanded Medicaid, those dollars supported a web of care that reached far beyond the people directly enrolled.
"One of the strengths of this research is that it allows us to separate the effects of different ACA policies rather than treating the law as a single intervention," said Chatterji. "Understanding which policy tools were most effective can help inform future efforts to reduce disparities in insurance coverage and access to care."
A companion study published in Health Affairs in 2024 by the same team found that Medicaid expansion increased coverage among American Indian and Alaska Native women in particular — a population that remains overrepresented in counties facing acute physician shortages. The researchers hope their work can guide future policy decisions in a moment when Medicaid faces potential federal cuts.
For communities that have spent decades fighting for equitable access to care, the data offers something rare: evidence that government policy, when structured thoughtfully, can translate into real, measurable progress.