Indian Country & Health Care Reform
By Mark Trahant
Members of Congress receive effortless health care. Like all government employees, there is a federal benefit plan with a basket of insurance options. But that’s Plan B.
The better deal is the full service clinic staffed by Navy doctors. ABC News Medical Editor Tim Johnson reported last week about Capitol Hill clinics where “lawmakers receive top-notch, wait-free care, and money is largely no object. Members pay a flat annual fee of $503, and it covers all expenses – without submitting claim forms to their insurer.”
There is one fee, great medical service, and not even the bother of filing for insurance. And the Capitol Hill clinic never runs out of money in June. Effortless.
Indian country has a different financing mechanism. Plan A is, of course, the Indian health system, the combination of federally-run Indian Health Service facilities plus those health care programs managed by tribes or urban Indian organizations. Plan A is a system that’s regularly characterized as “starved” because it is funded with annual appropriations, instead of based on patient need. Here is the rub: the Indian health system is so under funded that it does not count as a qualified insurance plan (despite the treaty and statutory promises).
So Plan B is Medicaid. Medicaid is the country’s insurance plan for low-income families, pregnant women, people with severe disabilities and older people who do not qualify for Medicare (and for long-term care, but that’s another column). The funding for Medicaid is an entitlement. If someone is eligible, the money is there. Medicaid is a partnership between the federal government and state governments. States write the rules, under broad guidelines, and the federal government pays for part of sometimes all of the cost.
Medicaid is a growing source of funding for the Indian health system (and under law is supposed to supplement, not replace, IHS revenue). The Government Accountability Office found that the range of Medicaid reimbursements at IHS facilities were from 2 to 49 percent “and the facilities with higher reimbursements had additional funds to hire staff and purchase equipment and supplies.”
“Medicaid is a key element of American Indian Alaskan Native health care financing reform,” wrote Andy Schneider in the American Journal of Public Health in May 2005. Schneider went on to serve as the chief health counsel for the House Committee on Oversight and Government Reform.
But the practical problem of Medicaid is its administration by state governments, which have uneven relationships with tribes and Indian organizations. And even if those states do work well with tribes there is an entirely different set of rules for every state. “The Medicaid program differs considerably from that in neighboring Minnesota and the Medicaid program in Arizona varies substantially from that in neighboring New Mexico,” Schneider wrote. Imagine the added complexity for tribes with citizens in different states, such as the Navajo Nation, when clients must go through the eligibility process.
These days Medicaid is under increased financial stress because states don’t have enough tax revenue to pay their share, ranging from about half to more than 75 percent. Last year Medicaid cost states $1,555 billion or about twice the amount spent on elementary and secondary education. Medicaid’s continued growth is certain as more people are eligible because they’ve lost their job – or under health care reform more will apply when it will be required by an insurance mandate.
A study by the Kaiser Commission on Medicaid and the Uninsured found that for every one percent increase in the national unemployment rate, a 3-4 percent decrease in state revenues, and a one percent increase in Medicaid (and a children’s health insurance program) plus another 1.1 percent increase in the uninsured.
It’s no surprise that states aren’t keen on any expansion of Medicaid eligibility, but the program (along with the companion program for children’s health) ought to be thought of as a way to provide more access to health care system generally.
The current health care reform proposals don’t change the funding mechanism for Medicaid in Indian Country. But it remains worth considering because it could save money: Consider a simple transfer from Medicaid to the Indian health system without going through 35 different state systems each with its own transaction cost.
Schneider wrote in 2005 that such changes “are simply unachievable in the current political context.” Unfortunately we are no closer to that ideal.
But why should the poorest Americans be the one that must navigate through the complex grid of Medicaid? What if the system were turned around and federal guidelines made the states adjust their systems? It seems that American Indians and Alaskan Natives ought to have health care options as easy to understand as a clinic on Capitol Hill. You know, effortless health care.
Mark Trahant is an advisory board member of InvestigateWest and a Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at www.marktrahant.com