Indian Country Today
The news can be exhausting these days. A crisis on the border. A global trade war. And three more Republican plans to repeal the Affordable Care Act and slash spending on healthcare, including Indian Health.
The first plan is a new effort to repeal the Affordable Care Act. This plan would leave traditional Medicaid alone, but would convert the expansion into block grant funding for the states.
This is the key for Indian Country: Medicaid expansion under the Affordable Care Act has become a significant resource for the Indian Health system. That budget number is pegged at $800 million for the Indian Health Service, but that number is misleading because it does not include money that is collected by tribal and nonprofit facilities.
How large is the real number? Unclear. But a lot more than $810 million.
A Kaiser Family Foundation report said in Arizona, in just one tribally-operated health facility about half the visits were by patients covered by Medicaid in 2016. And an Urban Indian Health Program in Arizona indicated that its uninsured rate at one clinic fell from 85 percent before the Affordable Care Act to under 10 percent.
Medicaid insurance funding is often the difference between treatment and no treatment for many patients in the Indian health care system, especially those whose medical needs would not result in immediate, high priority treatment.
Some 12 million people in 31 states and the District of Columbia are covered as a result of Medicaid expansion under the Affordable Care Act. Nationally, Medicaid provides coverage to more than one in four, or 27 percent, non-elderly American Indian and Alaska Native adults and half of Native children.
The latest ACA repeal plan is unlikely because there are not enough votes in the Senate.
The second Republican plan is the budget proposed by the House. That plan would balance the federal budget in nine years and pay with deep cuts to entitlement programs, including Medicaid. The House bill: “Reforms Medicaid to ensure the program works best for the most vulnerable and gives states more power to tailor their Medicaid programs to meet the unique needs of their populations.”
In other words, shift the burden of health care back to the states. The federal government would give states a block grant that would be at a set amount. Again this is particularly critical for Indian health programs because the federal government now reimburses states 100 percent for patients who are served by IHS or tribal or nonprofit facilities within the Indian health system. So in a cap-based system, the states would spend less, and the reimbursement to Indian health facilities would drop as well.
Another Kaiser Family Foundation report shows the potential impact in Alaska. “Medicaid covers two in three (66 percent) American Indian and Alaska Native children and more than one in four (28 percent) American Indian and Alaska Native adults.” That is money that is added to the IHS appropriations and stays within the Alaska Native healthcare system. A previous proposal to cap spending would have resulted in $1.8 billion fewer federal funds just for Alaska.
“The Medicaid expansion has helped reduce longstanding disparities in health coverage faced by American Indians and Alaska Natives and increased Medicaid revenues for IHS and Tribally-operated facilities, enhancing their capacity to provide services,” Kaiser said.
The House has yet to consider the budget committee’s proposal.
The third issue is a plan at the state level that now involves a legal challenge to the Trump administration’s support for state work rules. Because Medicaid is a state-federal partnership, states would write the rules for what’s considered acceptable work in order to remain eligible for health care funding.
The legal challenge is in Kentucky and the governor has said he will roll back Medicaid expansion should he lose the case. In April, a bipartisan group of U.S. Senators urged the Trump administration to grant exemptions for Native Americans from any state work rules. The senators said the federal government has an obligation to deliver health care based on a political relationship and that state work rules could be "potentially devastating."
More than three-quarters of American Indians and Alaska Natives who are insured through Medicaid are already working. That compares to 83 percent of the Medicaid population nationally. Even then, Kaiser found, many American Indians and Alaska Natives “have limited access to employer-sponsored coverage because they have a lower employment rate and those working often are employed in low-wage jobs and industries that typically do not offer health coverage. Medicaid and other public coverage help fill this gap.”
Even so: Tribal citizens are significantly more likely to be uninsured than the rest of the non-elderly population, 17 percent versus 11 percent, Kaiser researchers reported. Nationwide, over 900,000 American Indians and Alaska Natives lack insurance coverage.