Because the Supreme Court struck down the Medicaid Expansion provision within the Affordable Care Act (ACA) as unconstitutional, the Medicaid Expansion is voluntary. Only 32 states including D.C have indicated their intent to expand Medicaid, while the rest are weighting their options. As a result, over 42% of Indian Country will not be covered under the Medicaid expansion, which would provide health insurance to those up to 138% federal poverty level (FPL).
There are two current alternate approaches to expanding Medicaid. One, is the premium assistance model, also commonly known as the Arkansas model, which is a relatively obscure provision of the Social Security Act, Section 1905a, which allows the state to use Medicaid dollars to buy insurance for individuals on the new health insurance marketplace. The other alternative is the Section 1115 Demonstration Waiver, which allows the HHS Secretary to allow a state to use federal Medicaid matching funds to pay for expenditures that otherwise would not be allowable under Medicaid statute.