Indian Country politics and public policy

Commentary by Mark Trahant

Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).

Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).

Millions of Montanans, Alaskans and Native Americans wait for health insurance

MARK TRAHANT

The best case for Medicaid expansion in Alaska is being delivered by Valerie Davidson. She’s the recently appointed Commissioner of Alaska’s Department of Health and Social Services and a longtime advocate for improving Native health, most recently the senior director of Legal and Intergovernmental Affairs at the Alaska Native Tribal Health Consortium.

Davidson, who’s Yupik and a member of the Orutsararmiut Native Council, also chaired the Tribal Technical Advisory Group to the Centers for Medicare and Medicaid Services from its launch in 2004 until last year. In other words: She knows Medicaid cold. She knows how it benefits a state. She understands what works for Native communities. And, she conveys complicated ideas and statistics with ease.

This is the ideal time for that kind of logic.

Alaska’s Medicaid expansion has reached a decision point. The Alaska Dispatch News reported Tuesday that the governor is threatening a veto unless the Legislature takes on Medicaid reform and expands eligibility under the Affordable Care Act. (Update: The Alaska Dispatch News reports that Republicans are planning a caucus vote to kill the measure for this session.)

At a recent speech in Juneau, Davidson ticked off five reasons why Medicaid expansion makes so much sense.

First, it would expand health care insurance, thus improving health access for at least 42,000 Alaskans. Second, expansion would add money — and jobs — to a state that could use both right now. Third, expansion improves the state’s budget situation by adding more than a billion over the next six years. Fourth, it could be a catalyst for reform. And, fifth, expansion addresses uncompensated care.

Uncompensated care is perhaps the most important part of the Medicaid debate and it does not get a lot of attention. Even if government were to eliminate Medicaid or other insurance, people would still have health care costs. Someone always has to pay.

“We all end up paying for those uncompensated care costs. We pay through increased premiums. We pay for them when a hospital has to increase what it charges everybody else,” Davidson said. She said the hospitals provided more than $90 million worth of uncompensated care in Alaska.

Nationally the figures are huge. The Kaiser Family Foundation estimated uncompensated care at $84.9 billion in 2013. Most of that was paid for by hospitals (who pass the cost along to paying patients) and community-based clinics and health centers.

But here is the thing: The states that have expanded Medicaid are seeing the cost for uncompensated care figure dropping dramatically, saving those states some $5 billion.

The Indian health system has its own version of uncompensated care. We all understand and see the Indian Health Service as the government’s fulfillment of its treaty promises made to tribes. But the government does not fund IHS that way; the underfunding is substantial. The original Indian Health Care Improvement Act opened up new revenue from Medicare, Medicaid and other programs to add new dollars to the system.

So since the United States doesn’t fully fund IHS — and Indian Country has low insurance coverage — there remains a gap. Uncompensated care. Kaiser Family Foundation found that nearly a third, or 32 percent of American Indians and Alaska Natives are uninsured, and the cost to IHS for that care was at least $2.1 billion in 2013.

That’s why Medicaid expansion is critical to improve funding for Indian health delivery — especially in states with large Native populations such as Alaska and Montana.

Reservation Medicaid Benefits

Montana’s uncompensated care is nearly $400 million, according to the Montana Budget and Policy Center.

The Montana Legislature is nearing the finish line. Last week a key House committee voted to radically amend the legislation, essentially killing Medicaid expansion. For a bit. Then the legislation made it to the House floor where it passed 54 to 42 returning it to the Senate for minor changes. Supporters are hoping the Senate will make those changes and send the bill to the governor for his signature.

When the House passed the Medicaid legislation, a conservative group, Americans for Prosperity Montana, issued a press release saying the “decision stands directly against the voices of millions of Montanans who have made it clear that they do not want more Obamacare.” That phrase, #millionsofmontanans, quickly became a hashtag on Twitter (Montana has just barely a million citizens).

But Medicaid expansion would benefit millions — Montanans, Alaskans, Native Americans, and people in other states. What makes this argument interesting is that conservatives have lost on the evidence. In state after state the research continues to mount that Medicaid expansion was the best part of the Affordable Care Act and is creating jobs and pumping dollars into state economies. A study by Robert Wood Johnson Foundation says the total amount lost for states that have said “no” is more than $423 billion.

What makes this “debate” particularly maddening is that opponents to Medicaid expansion have no viable alternative — except the system that sticks hospitals, clinics and doctors with even more uncompensated care.

Mark Trahant serves as the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

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