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.”