ALBUQUERQUE, N.M. – An ordinary glance might see Chinle, Arizona as sparse and unyielding. But it is the site of a bona fide bonanza. At this Navajo Reservation community, 734 have enrolled and nearly 20,000 residents have been provided with Affordable Care Act (ACA) information, local health officials said. The potential density for enrollment here could make Chinle ground zero for ACA recruitment in Indian country.
In this part of the Navajo reservation, there are 16 Navajo Nation chapter communities that gather once a month. Here, residents can signed up for ACA, get assistance on how to enroll or if requested, be visited by ACA navigators and assisted to register on their computer if they have one, said Ursula Knoki-Wilson, Chinle community relations coordinator.
“We still have a few more we need to do,” she said. “Most people want to come in (for enrollment).”
Getting residents here interested in a federal health care initiative has been done in teams, usually of two or three, who are bi-lingual. Navajo is still the primary language spoken at many of the 110 community chapters (the reservation equivalent of a county) dotted across the 27,400 sq. miles of the vast Navajo Nation Reservation. Its land territory spans four states, Arizona, New Mexico, Utah and Colorado. Its human territory counts more than 300,000 residents and the largest number of Native speakers in the country. This four-state territory is the most expansive Indian reservation in the United States.
Because Navajo is the first language for many of the outlying communities, translating the ACA jargon into their language was one of the first steps when health centers across the reservation started formulating plans for enrolling tribal citizens in the federal health care initiative, Knoki-Wilson said.
She said for the Chinle health service area, a task force committee was formed and a brochure was designed to be specifically culturally relevant. The brochure is in English but highlights specific questions that Natives usually want answered when dealing with health care, officials said.
“The translation (of jargon) is the big thing, we’ve been able to reach out to social gatherings and in local stores,” Knoki-Wilson said. “Out here, they’ve [outreach navigators] gone to the local ball games, Navajo Nation Fair, powwows and other gatherings. It’s been the most challenging to reach out to single adults with no children.”
Chinle navigators disperse the brochures at the monthly chapter meetings to those who drive in. The Chinle Comprehensive Health Care facility also sponsored public service announcements that went out on KTNN, a reservation-based radio station listened to by thousands. The goal is to get Navajos Qualified Health Plans (QHP) right where they are.
Even if that means walking up and down the streets in Chinle, Ryan Goldtooth, administrative support assistant at Chinle’s Comprehensive Health Care Facility, said. Outreach worker, Leo Dodge, took it upon himself to canvass inside the local Dine’ College and the Navajo Technical University.
Chinle has fields that are ripe for for ACA harvest, organizers said. Numbers continue to grow.
Just to the east of Chinle in New Mexico, ACA outreach to its Native population has been honed to a skill at the Native American Professional Parent Resources (NAPPR) in Albuquerque. In addition to the basic enrollment information, NAPPR navigators have learned that it takes about seven or eight “touches” to expose potential enrollees to the possibility of ACA enrollment. Lessons they did not study for came from their urban outreach, said interim director, Roxane Spruce Bly, of NAPPR.
“We are finding out that women are the decision makers when it comes to acquiring family insurance coverage,” Bly said.
Conversely, NAPPR has seen a decline in enrollees for men in the 18-35 age categories. ACA advocates theorize that women are most often left to tending the children; therefore they are more open to the possibility of unexpected illness and hospitalization. Unlike the Chinle Chapter Community, they outreach to a variety of tribal peoples including Zuni, Pima, Tewa and Navajo. The area contains some 22 state and regional tribes while citizens of around 400 additional tribes are also located in this city, said Bly.
“This is a labor of love,” she said of the local ACA recruitment that they do under the auspices of the New Mexico Health Insurance Exchange (NMHIX). “As we move forward, there’s no way to tell what could happen in our area. We leveraged technology early on in this drive despite the myth that Indians don’t use technology.”
NMHIX teams went out to the streets of Albuquerque armed with mobile phones and computers. When a possible enrollee was found, the phones and laptops came out and pulled up ACA enrollment forms that could be filled in instantly. Bly said she couldn’t imagine doing such strategic outreach without them.
Three states away in North and South Dakota, ACA Native enrollment includes navigators from the Great Plains Tribal Chairman’s Health Board (GPTCHB). Their federally funded navigator program targets Indians who live in and around the reservations in North and South Dakota. Sandra Lujan, a navigator, is a relatively new recruiter for the ACA. She works a satellite area of the Turtle Mountain (Chippewa) reservation, about 10 miles from the Canadian border.
In this remote part of the state, opportunities for outreach might occur at a local tribal casino where recruiters have a good chance to solicit enrollment from a strategically placed booth.
“There are those who don’t have insurance and then you have those who still have to file an exemption,” she stated via email. “My mom is on Medicare or I’d try to enroll her.”
Lujan stated that Indians who have insurance through their work are the minority in a minority, but it’s expensive. Most of the people that they see are on other federal health programs. Still, there are those who go to the local community college or are self-employed who may benefit from enrolling in the federal health plan.
Navigators from GPTCHB serve a wide swath of sparsely inhabited regions. But the Indians are there. They may be Turtle Mountain Band of Chippewa; Flandreau Santee Sioux; Rosebud Sioux; Lower Brule Sioux; or Mandan, Hidatsa and Arikara among 12 other tribal groups that the GPTCHB serves.
In California, the landscape contrasts sharply with the flat Northern Plains. That also goes for the drive to enroll Natives in ACA where tribes are numerous but small. Mark Le Beau and the California Rural Indian Health Board (CRIHB) in Sacramento push ahead because of the high level of health disparities for Indians. Those two words mean one thing, he stated via email. Shorter lives.
Le Beau, CRIHB’s executive director, stated ACA is pivotal in the group’s efforts to eliminate disparities. Insured Indians can see grandchildren grow up and live longer lives.
“One of the most effective methods for educating AI/ANs (American Indian/Alaska Natives)…is for (Indian) health organizations to design their own educational material and present it to the AI/AN people,” he wrote. “Although many AI/AN communities have received information about the ACA, the law is complex and this work needs to continue and be expanded to other communities.”
– This story was funded by the University of Southern California’s (USC) Annenberg School of Journalism as one project undertaken by the 2014 class of national health journalism fellows. S.E. Ruckman is writing a three-part series on the Affordable Care Act (ACA) in Indian Country. In addition to mainstream viewpoints, Indian health advocates and Indian enrollees are visited to gauge the national health plan’s implementation in Native populations. To read more National Health Journalism Fellow stories, go to www.reportingonhealth.org
