It’s hard work trying to get people to sign up for health insurance when their care is mostly free to them. Andrea Thomas is working to get Alaska Natives in Sitka, Alaska, to do just that. She’s the outreach and enrollment manager at SouthEast Alaska Regional Health Consortium (SEARHC), and it’s her job to sign people up for health insurance coverage through exchanges created as a result of the Affordable Care Act.

To get a sense of just how uphill Thomas’s battle is, consider this: Of the more than 100,000 people who live in Alaska and self-identify as Alaska Native or American Indian, only 115 had signed up for health insurance through an Affordable Care Act exchange as of March 31.  Alaska Natives and American Indians are exempt from tax penalties for not signing up for health insurance.

“There is some resistance. And I think that comes from people feeling that our nation, our federal government, made a vow to the native people of our country to provide health care for them,” said Thomas.

That vow, which is the result of treaties between the U.S. government and tribes, is documented in the Constitution. The federal government allocates funds — currently $4.4 billion per year — to Indian Health Service (IHS), a division of the Department of Health and Human Services. IHS then administers care directly to tribes, administers individual services through contracts with tribes, or turns over funding to tribes so they can administer care themselves. Most tribes in Alaska have chosen to do the latter and have created a comprehensive statewide health-care system as a result. But the funding that health-care consortiums receive from IHS falls short of the overall cost of care.

“As an organization, we could chose to take our money from the IHS and provide that amount of services, but then again that’s less than half of our total funding,” said Kristina Randolph, clinic administrator at SEARHC’s Ethel Lund Medical Center in Juneau.

So consortiums such as SEARHC are hoping that health insurance will cover more of their funding gaps. But that will only work if they can convince people that they should sign up.

“Not everything is covered by the Indian Health Service. So this broadens what’s covered … because there’s limited funds,” Thomas said. “And sometimes you have to make choices about who needs the care the fastest. Travel is really expensive in Alaska. And to go from a small village up to Anchorage, where they can get a higher level of care, or certain care that you can’t get in a smaller village — all of that is really expensive.”

There are 229 federally recognized tribes in Alaska, and most of them are in small, remote villages accessible only by ferry or airplane. Many of these villages have only community health clinics with no doctors. Complicated procedures, ranging from childbirths to chemotherapy, require patients to fly to hospitals at regional hubs or to the Alaska Native Medical Center in Anchorage. Tribal health consortiums often pick up the tab for patients to make these trips, which is a significant strain on their budgets.

The Alaska Native Tribal Health Consortium (ANTHC) and SEARHC are trying out a special program in hopes of signing up more of their patients for health insurance. They plan to pay the premiums for 500 of their patients — 65 in the southeast region — who fall between 100 percent and 300 percent of the federal poverty level. They want to see if the insurance payments they receive through patients’ coverage are greater than the cost of the premiums.

“So it’s a trial program, and SEARHC is involved with that,” said Thomas. “And you’d think that it would be really extremely easy to fill 65 — I mean, free insurance. But again, the perception is, ‘Well, what’s in it for me? Why would I get additional insurance?’ So even when it’s completely free. And I think that part of it is — it’s really difficult to get the word out about it.”