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

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


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.

Fight for Indian health funding is at a critical juncture

Medicaid & Indian Country

Fight for Indian health funding is at critical juncture


One of Indian Country’s most important debates about increasing funding for the Indian health system is occurring far from Congress in state legislatures across the country. And that is unfamiliar ground to discussions about Indian health and treaty obligations.

The Affordable Care Act — or Obamacare as some call it — significantly expands Medicaid health insurance to more Americans, including American Indians and Alaska Natives. But the Supreme Court ruled in August 2012 that Congress could not force states into accepting the expansion. Medicaid is a state-federal partnership. So the money flows from Washington into states based on complicated formulas. The cost to states for American Indians and Alaska Natives is negligible because the federal government pays the bill. Only the states, not the federal government, determine who is eligible for the program. Twenty-nine states and the District of Columbia have expanded Medicaid.

One study by Robert Wood Johnson Foundation found that in the states that have not expanded Medicaid meant that 6.7 million residents remain uninsured in 2016 and these states gave up $423.6 billion in federal Medicaid funds from 2013 to 2022, which shrinks both economic activity and job growth.

Two states with large native populations are considering Medicaid expansion now: Alaska and Montana.

The Montana Budget & Policy Center estimates some 70,000 people would be eligible for the insurance and some 19,000 American Indians. Tuesday a House committee killed the Medicaid expansion bill, but according to the Helena Independent Record there remains a chance the bill could go directly to the House floor for a vote.

Legislators in Juneau are also considering Medicaid expansion this week. The Alaska Native Tribal Health Consortium estimates that expanded Medicaid would cover 40,000 Alaskans adding more than $1.1 billion and 4,000 new jobs.

There is new data that shows just how effective Medicaid expansion can be.

Ed Fox, tribal health director of Washington’s Port Gamble S’Klallam Tribe and a health care reform expert, has estimated that Medicaid expansion would add $2 billion to the Indian health system across the country. In Washington, Medicaid expansion increased revenues to Indian health clinics by 38 percent statewide, or $14, 451,345 in additional funds, a total of some $54 million for American Indian and Alaska Native patients. Remember this is money that does not need to be appropriated by Congress. Of the 25 tribes reporting in Washington only one showed a decrease in funding and two tribes doubled their Medicaid revenue (four tribes are not included in the data).

Fox called the numbers great. The data pulled from Medicaid claims and could increase slightly. “We plan to hire 4 positions thanks to these increases:  2 Registered Nurses, one social services Case Manager, one Community Health Representative,” Dr. Fox said. “These are the good old days-perhaps. I will now have to thank both IHS and Medicaid for this opportunity to enhance services.”

He also noted now small these numbers are compared to Alaska, should the legislature expand Medicaid. “Maybe $200 million compared to $500 to $600 million for all American Indians / Alaska Natives and only $54 million is paid to WA tribes,” Fox said.

But if these are the good old days in expansion states, the flip side is increased budget pressure on states without Medicaid expansion. At a Senate hearing last May, A.T. Stafne, Chairman of the Assiniboine Sioux Tribes of the Fort Peck Reservation, said he still hopes for increased insurance coverage for American Indians but he remains “uncertain about implementation in Indian Country, especially in states like Montana that rejected the Medicaid expansion … Clearly there is more work to be done if the government is to fulfill its trust responsibility to provide quality healthcare to Indian people, a mandatory obligation under treaties and agreements entered into with Tribal governments.”

That quote captures the challenge: The Affordable Care Act opens up a roadmap for better funding of the Indian health system. But the rules of the road are being drafted in state capitals, one by one, especially in Helena and Juneau.

Mark Trahant holds 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.

Drafting next post: Medicaid expansion numbers show huge gains for Indian health system


Key point: Medicaid expansion fabulous for Indian health system, Wash 38% revenue increase.

Shows why expansion critical in Alaska, Oklahoma, South Dakota, Montana.

Building at least one interactive map to show data, a map of Washington with reservation by reservation numbers. Average across Washington is a 38 percent increase in revenue from Medicaid.

Telling the story with numbers. (By request — posting now.)

Source of data is Ed Fox,&Ph.D., Director of Health Services for Port&Gamble S’Klallam Tribe.


Screenshot 2015-04-05 11.02.14Screenshot 2015-04-05 10.59.30

Indian Country and the Affordable Care Act — twists and turns

February 5, 2015

The House of Representatives voted to repeal the Affordable Care Act on February 3. Then, this is not new. The House has voted nearly sixty times to either revoke the law or to make huge changes. But this time the House and the Senate are in Republican hands. So that means what was a symbolic act now has the potential of becoming law.

Well, maybe.

The Affordable Care Act is like a national soap opera that should rivet any audience. Will the law survive? What sort of challenges does it face legally and politically? And, most important, what does this daytime drama mean to Indian Country?

Here is the story so far.

Turn back to to 1974. President Gerald Ford signed the Indian Health Care Improvement Act into law, a measure that modernized the federal delivery of health care in Indian Country. But that law had an expiration date; it needed another act of Congress to renew it. And that did not happen. Congress let the bill lapse despite repeated attempts. That’s where the story takes a turn. The whole health care reform debate was heating up and folks in Congress decided to roll the Indian Health Care Improvement Act into the Patient Protection and Affordable Care Act. This language was shortened to the Affordable Care Act or “Obamacare” — and it’s now the law of the land. The Indian health provisions were made permanent so future Congresses would not have to renew them.

The Affordable Care Act had other benefits to Indian Country. The law improved funding channels for Indian health facilities, a source of money that’s growing during lean budget years. Next year’s Indian Health Service budget estimates more than $1.1 billion collected from Medicaid, Medicare, Veterans Health Administration and private insurance.

But Republicans have been adamantly against the Affordable Care Act. Four years ago a Republican House was elected and that body started voting over and over to repeal the law.  But nothing ever happened because the Democratic controlled Senate ignored the actions in the House.

But like any good soap opera there are new characters joining the story. The Supreme Court could strike down part of the law, causing a lot of confusion. And the Senate is now run by Republicans who will definitely consider the House legislation to repeal the law. This will not be easy. The Senate usually needs 60 votes in order to pass legislation (stopping the threat of a filibuster). And there are not 60 votes to repeal the Affordable Care Act.

That’s another twist. Democrats were short 60 votes back in 2010 — so they turned to an arcane process called budget reconciliation that allowed the legislation to pass with a simple majority, or 51 votes. Now many Republicans are asking their party leaders to do the same thing and use the budget reconciliation to repeal the Affordable Care Act. That idea would probably work if there was a Republican in the White House. But you can bet that President Barack Obama will veto any attempt to roll back his signature health care legislation. So that means Congress would need a two-thirds majority to override a presidential veto. There are not nearly enough votes in either the House or the Senate to do that.

But many Republicans see repeal (enacted or not) as an important statement that will define the 2016 election campaigns.

If Republicans find a way to repeal the Affordable Care Act that would raise new questions and chaos. For example what happens to those people who’ve purchased insurance now or who signed up for the expanded Medicaid programs? Would people lose coverage and get nothing in return?

The questions for Indian Country are troubling, too. What happens to the Indian Health Care Improvement Act? Or how will the Indian health system replace money from Medicaid and other sources opened up through the Affordable Care Act?

A few Republican Senators have started a “framework” about what kinds of alternative law they would pass to replace the Affordable Care Act. Utah’s Sen. Orrin Hatch, chairman of the Finance Committee, said in a Senate floor speech:  “Our plan rests on four simple principles. First: Repeal Obamacare – with all its costly mandates, taxes, and regulations – in its entirety. Second: Reduce costs by taking the government out of the equation, and, instead, empowering consumers to make choices about their own health care. Third: Provide common-sense consumer protections to protect individuals with pre-existing conditions. And, finally: Reform our broken Medicaid system by giving states more flexibility to provide the best coverage for their citizens.”

There are key issues here for Indian Country. First, the Indian health system is not part of the debate. It must be. Any repeal of the Affordable Care Act is also a repeal of the Indian Health Care Improvement Act. Second, there is no easy way to eliminate “government” from the Indian health system. And, finally, a reform of Medicaid, especially one that grants more power to states, will reduce health care funding for Indian health facilities. Already nearly half the Indian health system is shortchanged by the states that refuse to expand Medicaid. This is a real problem.

Cue the organ music. This daytime drama has many twists and turns ahead. But the story’s ending should be simple: the United States promised American Indians and Alaska Natives healthcare. The only question should be, “how will that promise be delivered?” Stay tuned.

Mark Trahant holds 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.