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About Smoke signals. (Grand Ronde, Or.) 19??-current | View Entire Issue (Feb. 15, 2017)
16 FEBRUARY 15, 2017 S moke S ignals ‘Obamacare’ repeal could affect Indian Country health care By Dean Rhodes Smoke Signals editor Concern is growing in Indian Country that repeal of the Af- fordable Care Act – also known as ‘Obamacare” – by the Republi- can-controlled Congress and Trump administration could have a nega- tive and possibly devastating effect on health care in Indian Country by limiting Tribes’ ability to generate revenue to fund their health care systems. Tribal Council Vice Chair Cheryle A. Kennedy, who has a long history of working in health care for the Grand Ronde Tribe, addressed the issue at the Jan. 25 Tribal Council meeting. She also chairs the Health Committee for the Affiliated Tribes of Northwest Indians and is vice chair of the Northwest Portland Area Indian Health Board. Tribal Attorney Rob Greene said during the same meeting that the Grand Ronde Tribe will send a letter to Speaker of the House Paul Ryan, Senate Majority Leader Mitch McConnell and the Oregon congressional delegation voicing its concerns. “It basically is to keep in place the Indian Health Care Improvement Act, which is a piece of the Afford- able Care Act,” Kennedy said. “It is the vehicle that delivers health care for Native Americans. “I believe most Tribes have sent in their letters already that try to refocus that health care is a big industry and there are jobs that are very important to all citizens. So we really wanted to emphasize that piece of it. Also that the var- ious states of the Northwest are working with Tribes already and do have some policies in place.” The Indian Health Care Improve- ment Act was originally approved by Congress in 1976, but the autho- rization for appropriations expired in 2000. In 2010, a new version of the act was approved by Congress as an addendum to the Affordable Care Act, which is now under fire from Republicans and President Donald Trump, who vowed to re- peal it during the 2016 election. The Indian Health Care Im- provement Act stated, among other things, that the Indian Health Service is the payor of last resort when an eligible Native American is covered by another health plan and excludes health benefits pro- vided by Tribal governments as tax- able income. Before passage of the Affordable Care Act, the Internal Revenue Service took the position that Tribes paying for health care services for their Tribal members should be taxable income. The National Indian Health Board issued a letter on Jan. 18 that stated, “The Indian Health Care Improvement Act amend- ments … are separate and distinct from the ACA and must be pre- served to ensure that the Indian health delivery system remains viable. … The IHCIA is clearly and easily severable from the ACA because it solely relates to the fed- eral trust responsibility to provide health care to Indian Tribes and their members.” Democratic Arizona Congress- man Raul were there Grijalva is- were the sued a press same Tribal release on leaders who Jan. 30 that were sit- highlighted ting across the damage from Presi- to Indian dent Trump Country when he tes- should re- tified about peal of the the effect of e n t i r e A f - Indian gam- Kelly Rowe Cheryle A. Kennedy fordable ing back in Care Act occur without a replace- the ’90s,” Finkbonner said. “Some ment. of those Tribal leaders talked about “Repealing the ACA would set their adverse relationship that they many Americans back years, but had at that time with Mr. Trump. it could set the First Americans They didn’t sound hopeful at all.” back decades, if not return them to If the Affordable Care Act is the health care of the dark ages,” repealed in its entirety, reim- Grijalva said. “This vulnerable bursement for Medicare services population – already a victim of furnished by Indian hospitals and historic, shameful mistreatment clinics would end, as could the by the United States government health care marketplaces where – deserves better. We should be tak- Native Americans can sign up ing further steps for health insur- forward toward ance and receive i m p r o v i n g t h e “Repealing the ACA government sub- health of Ameri- sidies to help pay would set many can Indians and for it. Americans back Alaska Natives, Northwest Port- rather than tak- years, but it could land Area Indi- ing a giant leap Health Board set the First Ameri- an back by repeal- Governmental cans back decades, A f f a i r s / P o l i c y ing the Affordable Care Act.” if not return them Director Laura Grijalva said Platero said that to the health care the Affordable between 2012 to Care Act re-au- 2014, American of the dark ages.” thorized the Indian and Alas- dormant Indian ka Native Medic- ~ Democratic Arizona Health Care Im- aid enrollment in Congressman provement Act Northwest states and increased increased by 13 Raul Grijalva funding and grant percent. authority for a “Those individ- wide range of chronically under- uals would lose their Medicaid funded services. The Indian Health coverage,” Platero said. “Those Service, which treats patients individuals would still go to an living on Tribal lands nationwide, ITU, but the ITU couldn’t get re- serves an estimated 2.2 million imbursed for those services, which Americans. means there would be a loss in Joe Finkbonner, executive direc- revenue.” ITU stands for Indian tor of the Northwest Portland Area Health Service, Tribal or urban Indian Health Board, attended a Indian health clinic. listening session with incoming Finkbonner said the average Trump administration representa- Tribal member will still have access tives that was held in Crystal City, to primary care if the Indian Health Va., in late January. The session Care Improvement Act is repealed was coordinated by the National along with the Affordable Care Act, Congress of American Indians. but they may see a difference in “They were there solely to listen accessing specialty care. and not to respond to any ques- “The Tribe might be more mind- tions or enter into any dialogue,” ful of their own Purchased and Re- Finkbonner said. “It’s hard to say ferred Care referral process versus how it went because Tribal leaders if they were eligible for either a were clear and very strong about subsidized (health care) premium what their priorities were, and or Medicaid,” Finkbonner said. what I don’t know is how that was “Then the referral would be much received or what the follow-up is quicker and simpler, and less re- going to be yet from the Trump source taxing to the Tribe.” administration.” Grand Ronde Health Services Early signs, however, indicate Director Kelly Rowe concurred that Indian Country’s relationship with Finkbonner, saying that with the Trump administration average Tribal members may see could be bumpy. The Trump ad- their health care options shrink ministration has greenlighted the as the Grand Ronde Tribe, along Dakota Access Pipeline, which with all Tribes, would have fewer galvanized nationwide Tribal sup- resources. port for the Standing Rock Sioux Rowe said she most fears Med- Tribe in North Dakota. Northeast- icaid turning into a block grant ern Tribes have a long history of program that would distribute a dealing with Trump, who lobbied set sum to every state. Then Native against Native American casinos Americans would be lumped in with in the 1990s when he was a private everyone else needing health care businessman. funding and Native Americans “Some of the Tribal leaders who have a long history of getting the short end of the stick. Rowe estimated that the Grand Ronde Tribe could lose about 33 percent of its estimated third-party receipts from services for Medic- aid-eligible patients. “The Indian Health Care Act fulfills a trust responsibility by the federal government,” Rowe said. “One of the Medicaid replacements that seems to be bandied about is this idea of block grants for the states. Right now, Medicaid does not have a cap on it as it’s an enti- tlement program and is guaranteed funding for enrolled participants. There’s not a limited budget. … If they put a cap on it and the state of Oregon only has a limited bud- get and the federal government feels that absolves them from their trust responsibility for health care for Native Americans, then we are combined with everybody else and the ability for us to have equitable resources would decrease because of that cap.” Rowe said those decreased re- sources could shrink further if the Tribe is no longer being able to bill Medicaid or Medicare for services, which are provisions included in the Indian Health Care Improve- ment Act. The federal government currently pays 100 percent for Na- tive American health care under Medicare and Medicaid and that would end if the Indian Health Care Improvement Act is scrapped with the Affordable Care Act. “Medicaid reimbursements are critically important in filling the gap created by chronic underfund- ing of the Indian Health Service, and are a critical source of funding for Tribes seeking to take over IHS hospital systems through self-gov- ernance agreements,” the National Indian Health Board said. Reduced funding and the end of 100 percent federal reimburse- ments would mean Tribal members could potentially lose health care services, especially referrals to specialists. “For the Tribal membership more or all health care resources would come from Tribal dollars,” Rowe said. “The program would shrink to available funding. That’s the possibility. “The biggest thing for me is that this is a federal trust responsibility and our government-to-government relationship is supposed to protect the promise made by the federal government to provide health care for us. To think that it could get totally devalued or washed away … it’s pretty appalling. It’s hard not to go back to that feeling of broken promises or broken treaties, that sense of losing what we have.” If the Indian Health Care Im- provement Act is scrapped because it is part of the Affordable Care Act, Tribal members might see only “ba- sic services” at the local health clin- ic, Rowe said, or the Tribe would have to devote more of its already taxed casino revenues to maintain current Tribal member health care. “There are multiple reasons the repeal of the ACA is alarming for Indian health care,” Rowe added. “I think we’re all on pins and needles right now.”
