Valerie Davidson is Alaska’s Lt. Governor and the principal architect of the state’s Medicaid expansion.
The Indian Health system was on the ballot across the country last week (even if the words were not explicit.) A few wins. And Alaska is at risk for a big loss.
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Voters in three states added new money that will go directly to clinics and basic health services through Medicaid expansion. One of the most important provisions of the Affordable Care Act was to allow states to expand Medicaid making it easier for citizens to quality for basic health insurance. Medicaid is a third-party insurance fund that directly benefits Indian health clinics and hospitals.
But in other states there were costly setbacks. Montana rejected a funding mechanism for Medicaid expansion sending it back to the legislature for further debate.
And the election of Mike Dunleavy as the new governor in Alaska means changes ahead for Medicaid in that state. (And Republicans, who never did favor Medicaid expansion, now control both houses in the state legislature.)
Medicaid has become a significant funding stream for the Indian health system, it’s particularly important for the non-profit and tribally-operated clinics and hospitals because by law that money remains at the local unit. And, unlike federal appropriations for the U.S. Indian Health Service, the amount of money grows as more patients become eligible for services. What’s more: The federal government reimburses states 100 percent for treatment at Indian health clinics or tribal facilities.
This is how it works: The Indian Health system — the federal Indian Health Service and the facilities operated by tribes and non-profit organizations — gets funding directly from Congress through appropriations. That appropriation is currently $5.5 billion but Medicaid is a partnership with state governments, and thus, must be approved by each state.
Nebraska is one of the states that voted for expansion.
The Winnebago Tribe of Nebraska recently assumed operational control of the Indian Health Service hospital and renamed it the 12 Clans Unity Hospital. Medicaid expansion could add revenue streams to this facility because more patients would qualify for the insurance. One specific benefit is that Medicaid claims are processed on a regular basis to help facilities cover operational costs, including infrastructure.
Medicaid expansion could also benefit urban clinics in Lincoln and Omaha (as well as a clinic in Salt Lake City). According to the Kaiser Family Foundation one urban Indian health program in Arizona reported that its uninsured rate fell from 85 percent before the Affordable Care Act to just under 10 percent after.
Alaska’s election could result in the biggest changes to Medicaid and the Alaska Native medical system. Nearly 40 percent of Medicaid clients are Alaska Natives and one in five Alaskans is now covered by Medicaid. Last month at the Alaska Federation of Native convention, Lt. Gov. Valerie Nurr’araaluk Davidson, Yup’ik, said Medicaid expansion has benefited every community in the state. As director of the state’s health agency, Davidson was the architect of the state’s Medicaid expansion.
I am Mark Trahant.
New Medicaid rules by the Trump administration undermine the treaty right to health care.
The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.
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A story in Politico Sunday raised the issue, saying the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules would be illegal preferential treatment.
The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians.
Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.
Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).
But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.
Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.
Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.
Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.
I am Mark Trahant.
Alaska Sen. Dan Sullivan will have to decide what’s more important: Tax cuts or Medicaid? The Senate vote is expected to be close. Both Sullivan and Sen. Lisa Murkowski have said they remain undecided about the legislation because of its impact on Alaska.
The Senate healthcare bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions of dollars away from public health insurance and passes that savings to wealthy Americans via tax cuts.
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How bad could the legislation be? The official financial review from the Congressional Budget Office is expected soon. The scoring of a similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured.
The important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) — a public insurance program for people who are poor or disabled — and gives that money back to high-income taxpayers ($664 billion).
The Senate bill takes a little longer to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid is automatic: If you are eligible, the money is there.)
Medicaid accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.
But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or especially, what’s covered by insurance.
This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent match. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. The states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.
The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity.”
The Senate vote is expected to be close. And that means the bill could change again as leaders try and round up enough votes for passage. I am Mark Trahant.