Last Friday the Biden administration announced a plan to spend $4 billion from the American Rescue Plan for pandemic relief in Indigenous communities. And of that amount half, or $2 billion, would be used to supplement third-party billing within the Indian health system.
This is Trahant Reports.
Two billion dollars for Medicaid and other third-party insurance programs is a really big deal. So Indian Country Today’s Aliyah Chavez asked about that at a White House briefing.
This question did not have an answer from the White House.
The Indian health system is a combination of the federal Indian Health Service, tribal and nonprofit hospitals and clinics, and urban facilities that serve 2.5 million American Indians and Alaska Natives in 37 states. About 60 percent of that system is run by tribes or nonprofits; the federal government’s direct services — the Indian Health Service we think about — is the shrinking part of the system.
This is where Medicaid and other third-party insurance programs come in. Officially third-party billing is $1.3 billion of a $6 billion budget (in fiscal year 2020). But there is an asterisk. And that’s because that budget line only includes federal facilities. Tribes, nonprofits and urban programs — the majority of the system — are not included. There is no reporting mechanism for 60 percent of the Indian health system.
That’s why Chavez’s question was so important. Medicaid is officially a state and federal partnership. The federal government pays each state a share of the cost and each state sets the rules for who is eligible and what services are covered. But the federal government also pays a 100 percent match for American Indians and Alaska Natives.
So a patient might go into a tribal facility in say, North Dakota, and be eligible for Medicaid insurance coverage and the clinic would be able to bill for those services. This is because North Dakota expanded Medicaid under the Affordable Care Act. But a family member who lives a few miles away, in South Dakota, would not get the same insurance coverage because the rules are different.
Yet in either case the federal government will reimburse the state Medicaid program at 100 percent.
This makes no sense.
But what if tribes, not states, set the rules for eligibility? This could happen by treating tribes as states (saving a lot of bureaucratic steps) or by issuing specific waivers or a managed care system that directs full Medicaid funding to the Indian health system as a direct entity.
Indeed, Medicaid reform could change the nature of funding in the Indian healthcare system.
There are questions still waiting to be answered. But one thing we know for sure is that a tribal expansion of Medicaid would reduce the number of uninsured in Indian Country — and provide a permanent funding boost for the Indian health.
I am Mark Trahant.