Medicaid under the ACA is dependent on whether or not the state authorizes it. If states do not approve expansion, fewer people receive comprehensive coverage and IHS and tribal facilities do not receive the extra sources of funding. The IHS and tribal clinics can direct money toward provider recruitment with better reimbursement for patient services. Opponents of using Medicaid to alleviate health inequalities argue that it takes responsibility away from the government to provide comprehensive health services. They argue that underfunding of the IHS would still be persistent and possibly intensify under Medicaid expansion as patients go to private providers. Some tribal members assert that provisions under Medicaid are not what was promised to the Native American people as they are based on expanding affordability via insurance and not on providing comprehensive health services that are fully covered. By relying on services reimbursed by Medicaid, this increases participation in private health services instead of public. Due to the rural nature of reservations and lack of communication about the system, the enrollment and logistical processes involved in having Medicaid can also pose a barrier to Native Americans signing up, and disrupt members' eligibility status. Some proposed that to avoid these disruptions, the federal money from Medicaid directed to tribe members could be directed straight to the IHS budget, allowing funding to go directly to tribes and giving them say over eligibility. In 2011, the Center for Medicare and Medicaid Services developed a mandate for tribal consultation regarding policy action in an effort to improve the quality of care for tribes. Another economic proposition to improve healthcare is to surpass consultation status for tribes when it comes to Medicaid policy and make them integral to the final decision making. This would help ensure that Medicaid programs are culturally aware and can treat behavioral medical issues better. Current issues Life expectancy for Native Americans is approximately 4.5 years less than the general population of the United States (73.7 years versus 78.1 years). Native communities face higher rates of chronic diseases like cancer, diabetes, and kidney disease. This is contributed to by the lack of public health infrastructure as well as the considerable distance to healthcare facilities for rural residents. In 2013, the IHS experienced funding cuts of $800 million, representing a substantial percentage of its budget. Over the past twenty years, the gap between spending on federally recognized American Indian/Alaska Natives and spending