ALBUQUERQUE, N.M. - In June, Deleana Other Bull was laid off. She lost her insurance, and turned to the Indian Health Service for her needs.
"I recently had a miscarriage, and it was very devastating for me," said Other Bull. "Going and following up and making sure that everything is okay. It was really scary because I didn't have insurance."
Indian Health Service (IHS) regulations essentially require tribal members to get medical help in their own home state. Other Bull's problem is she's Crow and Northern Cheyenne from Montana getting a graduate degree from the University of New Mexico in Albuquerque.
"I also had to get some testing done, and they said that I would actually have to go to my reservation in Montana to get seen," said Other Bull.
As for her prescriptions, Albuquerque IHS told her they wouldn't cover those either. She eventually put them on her credit card.
"Even just paying $40, $60 for medications was a really big decision I had to make," said Other Bull. "That money I could have used for food, or something like school related expenses."
Beginning January first, most Americans will be required to have health insurance or pay penalties under the Affordable Care Act (ACA). But Native Americans are one of just a few groups that won't be fined if they don't buy insurance. That exemption could mean status quo for a big part of Indian Country: high health disparities, and no access to care.
Since 1955, IHS has been the primary source of healthcare to many Native Americans, living near their reservations, free of charge. However, statistics show that since the 1970s, Native Americans have been migrating from reservations to urban areas of the country. The 2010 Census puts the urban Indian population at over 70 percent, and those cities usually don't have IHS to serve that population.
"There's certainly a sub-set of the urban Indian community that has historically been uninsured for a variety of different reasons," said Ralph Forquera, Executive Director for the Seattle Indian Health Board. "A big part of that is due to the high poverty experienced by the Native community in most large metropolitan areas, and the fact that that precludes them, to some degree, from getting access to the insurance marketplace."
Under the ACA, tribal members have a choice: If they live in areas not served by IHS, or don't have insurance through work, they can get covered through the ACA. But with no penalty for not signing up, Native Americans can forego coverage and take their chances. This makes some health professionals nervous.
"It is a very worrisome area," said Maria Clark, director of the Jemez Pueblo Health and Human Services Department in New Mexico. "And there's a lot of urban areas."
Jemez Pueblo is one of 22 Pueblos and tribes in New Mexico. The Pueblo has a modern clinic for tribal members, but if one of their citizens leaves the area - perhaps to Los Angeles, or New York - it's likely they'll no longer have access to IHS.
"So in the marketplace or the exchange, it would be up to them if they wanted to sign up for insurance on their own because they would be no longer covered by health services here at the Pueblo," said Clark. "Then their decision would be left entirely up to them if they wanted to pay those premiums."
And if they decide not to?
"They might find themselves uninsured and in trouble health-wise and facing a large bill," said Clark.
"Right now I don't have health insurance. It's crappy," said Other Bull, in Albuquerque. "My credit cards are maxed out, I'm barely making it by, but it's a struggle that I'm choosing."
Other Bull said it's her goal in the next four to six months to get insurance through a job, or the ACA. But, she adds that she may be in the minority when it comes to urban Natives making health coverage a priority.
"Just because I'm struggling now doesn't mean I'm going to struggle forever," said Other Bull. "It's just a temporary transition for me."