Enrollment counselor Shaina Ramone conducts outreach at a laundromat in Farmington, New Mexico.(Photo: Heidi de Marco, Kaiser Health News)

ALBUQUERQUE, N.M. — As a member of the Navajo tribe, Rochelle Jake has received free care through the Indian Health Service (IHS) her entire life. The clinics took care of her asthma, allergies and eczema – chronic problems, nothing urgent.

Recently, though, she felt sharp pains in her side. Her doctor recommended an MRI and other tests she couldn’t get through IHS. To pay for it, he urged her to sign up for private insurance under the Affordable Care Act.

“I couldn’t wrap my head around it,” said Jake, 45, sitting on the porch swing of her home in Albuquerque. She didn’t think Obamacare applied to her.

“I thought [IHS] should be responsible for my health care because I am Native American.”

Tribes, health care advocates and government officials across the nation are trying to enroll as many Native Americans as possible in Obamacare, saying it offers new choices to patients and financial relief for struggling Indian hospitals and clinics.

Native Americans can get an exemption from the requirement that everybody have health insurance. But under the health law, many can get coverage under Medicaid, which serves low-income Americans or buy subsidized plans through insurance exchanges. That allows them to receive treatment from private doctors and hospitals rather than rely solely on government and tribal facilities.

And the coverage allows Indian health facilities – which tribal leaders say are chronically underfunded -- to offer new services and bill insurers for care they already provide.

Advocates also see the health law as a chance to reduce the health disparities that have long afflicted Native Americans, including rates of diabetes that are three times higher than the U.S. population.

“The Affordable Care Act is starting to fill the gap between need and current resources,” said Doneg McDonough, a consultant to tribes on implementation of the health law. “And it is a huge gap that has to be filled in.”

The Indian Health Service provides care to about 2.2 million American Indians and Alaska Natives in 35 states. But the federal agency, with a fixed budget of $4.6 billion, can’t afford comprehensive services at all its far-flung facilities.

“I don’t know if you guys have all heard of this saying, ‘Don’t get sick after June because IHS runs out of funding in June,’” enrollment worker Shaina Ramone recently told a crowd at a Navajo business near Farmington, N.M. “So don’t get sick in July or August.”

Margaret Thompson, 59, has arthritis and diabetes. Thompson signed up for a private plan through the New Mexico exchange for herself and her husband. The tax credits cover the entire monthly premium of $811. (Photo: Heidi de Marco, Kaiser Health News)

Enrollment workers have an uphill battle, however, because many Native Americans are unfamiliar with insurance or mistrust the government.

“We are just now starting to scratch the surface,” said Sonny Weahkee, outreach coordinator for Native American Professional Parent Resources, which has a contract with New Mexico to do outreach and enrollment among Native communities. “Insurance has always been available to other people, but it is brand new for us.”

Weahkee’s job is to travel across the state to talk to Native Americans about Obamacare. His organization persuaded Jake to enroll in a plan through New Mexico’s exchange that costs about $37 a month. She can finally schedule an MRI.

Native Americans in federally recognized tribes can sign up year-round. Weahkee, who is part Navajo and part Pueblo, meets one on one with potential enrollees, answering questions and promoting the benefits of insurance.

At a traditional tribal feast in Santo Domingo, a small pueblo about 45 minutes from Albuquerque, he stands in front of a shaded table, handing out brochures and fans with the logo of the New Mexico exchange.

The next day, he travels to the hilltop Navajo reservation in Shiprock, where he talks to customers at busy grocery store and a small restaurant where a handwritten menu features mutton stew, Navajo burger and fry bread.

Helping Hospitals, Too

Doctor Angelina Shigeura checks a patient's record at the Zuni Comprehensive Community Health Center. (Photo: Heidi de Marco, Kaiser Health News)

In New Mexico, Leonard Thomas, acting IHS director for the Albuquerque region, says the money is helping modernize aging facilities and add medical staff. Thomas says the IHS can now pay for more services, such as diagnostic tests from outside facilities.

Brian Garretson, director of patient financial services for the San Juan Regional Medical Center, a nonprofit community hospital in Farmington, is more than willing to lend space to outreach workers to sign up new enrollees. His hospital contracts with IHS to provide care to Native Americans. “There are times when we get to the end of their fiscal year and they have already gone through all their money so we aren’t going to get paid,” he said.

At the Zuni Comprehensive Health Center on a reservation west of Albuquerque, CEO Jean Othole said she’s excited about the future. With added revenue, she plans to expand the number of exam rooms throughout the hospital.

Still, Othole said, the hospital struggles to recruit doctors, and patients have to leave for surgeries and most emergency and specialty care.

Much More To Do

Fedelia Perez, a 29-year old Navajo woman from Pinehill, New Mexico, is recovering after giving birth to her baby, Marcos Perez, at the Zuni Comprehensive Community Health Center on Thursday, August 6, 2015. The hospital is not equipped to perform C-sections, so patients need to leave for surgeries and most emergency and specialty care. (Photo: Heidi de Marco, Kaiser Health News)

Some people are more receptive to health insurance than others. Galen Martinez, a teacher who lives on the Acoma pueblo west of Albuquerque, hasn’t signed up. As he cooked chicken wings at a tribal ceremony in Gallup, Martinez said the U.S. government should provide comprehensive health care to Native Americans for free, as promised. Insurance doesn’t solve the problem – even if you have it, getting from remote reservations to cities for care is burdensome, he said.

Weahkee and his team say that is part of their challenge. Along with signing Native Americans up for insurance, they also teach them how to use it.

They recently helped enroll 59-year-old Margaret Thompson in an exchange plan. It was the first time the Navajo woman had been insured. Sitting at an outreach office in Farmington, Thompson said now she’s nervous about seeking out private doctors to treat her arthritis and diabetes. She’s used to the Indian Health Service.

“I don’t know where to begin,” she said.

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.

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