Despite claims that the federal health care overhaul needs the so-called individual mandate in order to require everyone to buy health insurance and keep the system stable, it turns out many have been granted an exemption from that requirement.
Those who will not have to comply with the mandate to buy insurance include some religious groups, and inmates, as well as victims of domestic violence and natural disasters. But the largest group of Americans exempt from the individual mandate is Native Americans, whose unique treatment under the law is raising more questions about the basic fairness of the legislation.
The reason behind the exemptions stems from the fact that the federal government, through treaty obligations, has assumed a responsibility for Native Americans.
"This is part of the federal government's trust responsibility to the American Indians -- to provide health, education and housing," said health care consultant David Tonemah.
Consequently, Native Americans already receive free health care through the $4 billion-a-year taxpayer-funded Indian Health Service, which operates hundreds of hospitals and clinics around the country. Because they already have health care, the new law does not require them to make any additional effort to sign up for a new plan.
Yet Native Americans will also be offered subsidies to buy private insurance through the ObamaCare insurance exchanges.
To some, that sounds like double-dipping.
"There is no particular reason why they should be in the exempt category," said Ed Haislmaier, a health care analyst with the conservative Heritage Foundation. "There is an argument (taxpayers) are paying twice. All these things wind up raising questions of fairness, and that is a big part of why this law remains unpopular."
Under ObamaCare, individuals earning less than $47,100 and families of four earning less than $94,200 are eligible for subsides. According to the 2010 census, the poverty rate among Native Americans and Alaska Natives is double the national average, with a median household income of just $35.062. About 30 percent lacked health insurance, also double the national rate.
Proposed subsidies for individuals range from $630 to $4,480 a year, depending on income, according to federal estimates. For families, the subsidies will range from $3,550 to $11,430 a year.
Gila River Tribal Councilwoman Cynthia Antone said many tribal members are confused. Outreach to Native Americans will have to be convincing to overcome their distrust of the federal government.
"They have the option not to sign up for insurance and we do have some members who won't sign up because we have the hospital across the street," said Antone. "But we encourage our members to do it because, like I said before, it's a safety net."
Native Americans are also exempt from financial penalties for not having insurance. The Congressional Budget Office expects 6 million Americans, mostly young adults, will pay the penalty, which ranges from $95 for an individual to almost $300 for a family beginning in January.
"Anytime you are going to say to people 'go out and buy this' you are going to have people say, 'I don't use insurance, I don't believe in it, I can't afford it,'" said Haislmaier. "When Congress gives in to those objections, you are just going to get more people who want a break. It does create an unfair situation in the end."