Led by former U.S. Sen. Max Baucus of Montana, Congress in 2009 peppered the Affordable Care Act with several health insurance reforms specific to Native Americans.
They expanded access to care, brought more local control and funding to Indian Health Service facilities, and ultimately provided guarantees that the federal budget will pay the full cost for most Native users of state-managed Medicaid expansions.
In Montana and across the country, tribes are reporting significant improvements as a result of the reforms. It became easier for patients to sign up for insurance and seek health care at off-reservation hospitals. Tribal health programs, urban Indian centers and the Indian Health Service were able to collect more insurance revenues and reinvest those into expanding services. Health leaders saw the changes as key to reversing health disparities among Native Americans that cause Montana tribal members to die an average of 20 years sooner than other residents.
Now, state and tribal leaders fear much of that progress could be lost if the House GOP proposal to replace “Obamacare” passes as currently written.
“We would not be able to continue to build the capacity that the Affordable Care Act was allowing us to do, which essentially took care of the underfunding of the health care system for Indians in the first place,” said Northern Cheyenne President Jace Killsback, who had previously worked as health director and served on a federal committee to advise enrollment efforts in Indian Country. “It essentially stops the momentum, the progress and growth. ... Our tribes will continue to have some of the highest health disparities and the most negative health outcomes.”
For decades, Native Americans have typically accessed health care in a system separate from the rest of Americans. In exchange for ceding their lands and agreeing to peace, hundreds of tribes signed treaties with the United States that promised health care in exchange.
Today, the Indian Health Service provides care to more than 560 federally recognized tribes. But Congress does not consider IHS an entitlement program, so funding varies and falls short of need. Medicare and Medicaid, as well as health programs for veterans, are funded at a higher level per patient than IHS. Even to match the care guaranteed to federal prisoners, Congress would have to nearly double the Indian Health Service budget, according to an analysis by the National Congress of American Indians.
The Affordable Care Act included incentives for IHS facilities to bill insurance policies and encourage patients to enroll, such as guaranteeing for the first time that those collections would stay at the local unit and not result in diminished federal appropriations. Improvements driven by that reform might diminish under the GOP health plan.
Nationally, the rate of uninsured Native Americans dropped from 24.2 percent in 2010 to 15.7 percent in 2015 even though almost half of states with significant populations did not expand Medicaid, according to federal figures. In Montana, Native Americans are about 20 percent of the new enrollees under last year's Medicaid expansion. About 40 percent of Native Americans were uninsured in 2015.
The GOP proposal would cut funding for these expansions.
Under the Affordable Care Act, states that expand Medicaid receive a permanent 100 percent federal match for care provided to enrolled tribal members through IHS or tribal programs, including outside referrals. For all other newly enrolled clients, that federal match will drop to 95 percent in 2017 and 90 percent in 2020. Before expansion, Congress paid just 65 percent.
That extra funding has helped keep Medicaid expansions viable in states with large Native American populations, experts say, but it is unlikely to be enough to save expansions from rollback under pressure from the GOP plan.
Although the current proposal preserves the 100 percent federal reimbursement for tribal clients, Anna Whiting-Sorrell noted that might still mean Native Americans could lose coverage or see benefits reduced. After years leading the Montana Department of Public Health and Human Services and then the Billings Area Office of IHS, she works for the Confederated Salish and Kootenai Tribal Health Department and serves as an adviser to the Centers for Medicare and Medicaid Services on tribal issues.
“You can only provide services that go to everybody,"she said. "Let’s say they decide that in Montana because they no longer have that funding that they’re going to eliminate some kinds of dental care. Indian people would also be eliminated from that care even though the state might be reimbursed at 100 percent."
Several Montana tribes have launched Tribal-Sponsored Health Insurance Programs, which pay out-of-pocket costs from insurance purchased by tribal members. TSHIPs operate on the theory that it will cost less to pay for coverage than the full cost of care outright.
The affordability of private insurance as well as the cost-benefit ratio making TSHIP programs possible hinge in large part on special no-cost sharing provisions for members of federally recognized tribes. Tribal health insurance programs also could be hit hard by a 30 percent enrollment penalty for people who buy insurance after a long gap in coverage – particularly common among Native Americans who, for instance, might drop private insurance if they move back to the reservation where IHS must provide care regardless of coverage status.
The net result of those premium and tax credit changes will be more need for TSHIPs but less funding to make them sustainable.
“If people aren’t covered by Medicaid or can’t afford to purchase a plan, the need for us to purchase some kind of insurance for them is going to increase. And the money is not going to increase,” Whiting-Sorrell said. “We know what happens in that case. People die. That’s why this is so frustrating to me. These are really life and death decisions. Why would you penalize people that are trying to get insurance?”
The all-too-serious quip in many tribal communities has long been, “Don’t get sick after June.” With so little funding, IHS hospitals have only been able to offer some basic preventative services and could not afford to hire or retain medical specialists. Referrals to off-reservation hospitals had for years been limited to Priority Level 1 or "life and limb." In effect, tribal members often had to wait for care until they were so sick their life was at risk. In many cases, patients were prescribed pain medications as a holdover while they waited years for enough funding to treat the underlying cause.
A request first made in January to interview the Billings Area Director of the Indian Health Service, which oversees facilities in Montana and Wyoming, was unscheduled as of publication.
An increased number of Indian Health Service patients reported insurance coverage since Montana’s Medicaid expansion, according to IHS figures shared with the Montana Healthcare Foundation. The number of uninsured patients dropped from 17,000 to 13,000 as the number covered by Medicaid increased from 17,000 to nearly 21,000 in 2016.
Self-governed tribes like the Confederated Salish and Kootenai as well as the Chippewa Cree reported similar or even higher coverage rates to Lee Newspapers last fall. Hospitals and clinics have told the state that they have seen a decrease in the amount of uncompensated care they provide, often through the emergency room, where many uninsured Native Americans had turned after being denied a referral by IHS facilities.
With more people covered by insurance – and with expanded billing departments – tribal and IHS facilities have collected millions more in revenue, which law requires them to reinvest in health services.
The nonprofit Helena Indian Alliance, which operates the Leo Pocha Memorial Clinic, tallied 1,118 more visits in 2016 than it did in 2014, an increase of 27 percent that coincided with a dramatic shift in the number of patients who had some form of coverage. Those increased revenues led the clinic to add behavioral health and substance use disorder services to its existing slate of primary care offerings. Today, about 70 percent of their clients are Native American, including many members of the Little Shell tribe who are not eligible for IHS services or the insurance discounts afforded by the ACA to federally recognized tribes.
Faced with the possibility of clients losing coverage – as well as potential cuts to the federal grants that support community health centers – Director Tressie White said the Leo Pocha clinic might have to scale back to "a limited number of patients with a limited number of providers.”
Killsback said he has urged fellow tribal leaders to defend the Affordable Care Act as a whole because the improvements seen in Montana and around the nation rely on more than just the provisions specific to American Indians.
“Tribes are continuing to think or believe it’s OK to sacrifice the Affordable Care Act to save the Indian Health Care Improvement Act, which is part of the overall bill that passed. That can’t be our stance. We have to protect both,” he said. “We will lose a lot of protections, we will lose the Indian provisions in the Affordable Care Act that allow us to increase our billings and become self-sufficient and self-determined.”
Whiting-Sorrell said she personally is torn about how to think about the GOP health plan. So many details remain in flux that she cautions against alarmism, partly because she just cannot believe coverage would be rolled back so extensively for so many people – even though that’s what she fears.
Meanwhile, she continues her daily work.
“People need to have confidence that they will have health care. That’s exactly what’s hard for me. We’re out promoting that you’ve got to get good preventative health care and you’ve got to go see your doctor earlier,” she said. “Now, we have this whole narrative out there saying we just don’t know what the future holds.”