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Summary Report
The major Medicaid cuts now being discussed by policymakers could have serious ramifications for the health and well-being of American Indians and Alaska Natives. Any changes in eligibility rules, benefits packages, cost-sharing requirements, provider payment rates, and financing might hinder the ability of the Indian health programs to provide essential services to some of the poorest U.S. communities. To respond, the Northwest Portland Area Indian Health Board partnered on August 31, 2005
with the Indian Health Service (IHS), the Kaiser Family Foundation, and the Urban Institute to hold a National Roundtable on the Indian Health System and Medicaid Reform. The Roundtable met at the Urban Institute, in Washington, DC. Urban Institute president Robert Reischa uer welcomed program officials, advocates, and health care analysts and remarked that "this Roundtable is occurring at a terribly important juncture in policy history."
"Change is inevitable," Reischauer said, and "the direction of that change is not in question."
The day after the Roundtable, September 1, the Medicaid Commission submitted to Congress recommendations for achieving $11 billion in savings over the next 5 years through changes in prescription drug reimbursement, in rules on transferring assets for Medicaid eligibility, and in cost-sharing. The Commission now has until the end of next year to make longer-term recommendations on the future of the Medicaid program, with proposals that address such issues as eligibility, benefits design, and delivery.
Roundtable participants expressed concerns that any changes in national Medicaid policy may damage the severely underfunded Indian health system—a broad organizational structure that includes services provided directly by the federal Indian Health Service ("I"), tribally operated programs ("T"), and urban Indian clinics ("U"). This health delivery structure, often referred to as ITU (or I/T/U), is considered "prepaid" with the land ceded by tribes in more than 800 ratified treaties and presidential executive orders. So tribal members using ITU health programs are not charged for services.
This provision of health care to American Indians and Alaska Natives falls under the federal trust responsibility, rooted in the U.S. Constitution, that recognizes the debt owed to Indian tribal governments. With the recognized responsibility to indigenous people has come respect for tribal sovereignty and willingness to work with the tribes on a culturally sound health delivery system. A major shortcoming is chronic underfunding, according to Indian participants at the Roundtable.
Medicaid reimburses IHS for services to Medicaid enrollees. But unlike Medicaid or Medicare, the IHS is not an entitlement program in the federal budget process. Indian health funding, subject to discretionary annual appropriations from Congress, currently meets only about 60 percent of need. Roughly 20 percent of the IHS clinical services budget comes from Medicaid, while less than 0.5 percent of Medicaid expenditures go to Indian health.
The patient must be a descendent of a member of a tribe to qualify for Indian health care services. Approximately 1.8 million American Indians and Alaska Natives meet these standards, and 1.6 million are active users of the Indian health system. At present, there are 562 federally recognized tribes spread across 35 states. The Indian health system is comprised of 49 hospitals, 247 health centers, 5 school health centers, 309 health stations, and 34 urban health clinics, as well as satellite clinics and Alaska community health aide clinics. Access to primary, specialty, and long-term care and emergency services is limited by geographic constraints and by the historic and chronic underfunding of the Indian health system.
Any further cutbacks in Medicaid funding wo uld result in an even greater rationing of services, participants and speakers said. "Because of the small size and relative obscurity of Indian health programs, these negative consequences may go ignored outside Indian health for years," said Kris Locke, a consultant from Washington State. The general public should be better educated on the issues, many agreed. Although government has supported some health care services to Indian tribes since 1849, the health status of Indians is far below that of the general U.S. population. Factors that contribute to the health disparity in Indian country are the continued underfunding of the IHS, high rates of poverty, low education levels, poor housing, and inadequate transportation. Many of the diseases that plague Ind ian populations, including obesity and diabetes, are preventable and treatable. If ignored now, these health problems will become more costly to the federal government as Medicare or disability payments.
More than a dozen areas require special consideratio n in any Medicaid reform, participants said, including the special "trust" relationship between the federal government and American Indians that provides the legal justification and the moral imperative for the federal provision of health care. A distinct disadvantage of Medicaid, from the Indian perspective, is that it is a state program. As states do not share in the federal government's trust responsibility, the challenge has been to ensure the funding from the federal government reflects the federal responsibility.
One of the key Roundtable recommendations is to continue the current 100 percent Federal Medical Assistance Percentage (FMAP), the portion of the Medicaid program paid by the Federal government rather than the states, for all Medicaid services provided to American Indian/Alaska Native (AI/AN) enrollees through IHS, tribal, and urban facilities. The federal government's share of Medicaid normally ranges from 50 percent to 83 percent, with states with lower per capita incomes receiving more federal funds.
The future of the Indian health system is intrinsically tied to Medicaid as the government's health program for the poor, despite the federal trust responsibility that predates Medicaid. As Carol Barbero, a partner in the Washington, DC, law offices of Hobbs, Straus, Dean & Walter, explained, "Congress recognized that it had the responsibility for these individuals as IHS beneficiaries, and should have the same responsibility for them as Medicaid beneficiaries."
Other recommendations included continuing the exemption that many states have requested for AI/AN Medicaid beneficiaries from required premiums, deductibles, copayments, or other cost sharing; and rejecting any waiver without tribal consultation.
The Roundtable audience included a cross section of individuals from the health policy arena, tribal representatives from each of the 12 Indian Health Service areas, and members of the National Indian Health Board and Tribal Technical Advisory Committee. Congressional staff members and representatives from the Medicaid Commission, health policy foundations, the IHS, and the Centers for Medicare and Medicaid Services (CMS) also attended. Indian health policy and Medicaid experts had prepared policy papers on Medicaid reform issues that served as discussion pieces with the audience.
Note: This report is available in its entirety in the Portable Document Format (PDF).
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