Health Care Reform

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Medicaid Expansion To Provide More Care For Native Americans by Tristan Ahtone  April 29, 2013 3:00 PM  All Things Considered

Next year, just over 200,000 Native Americans will become eligible for Medicaid under the Affordable Care Act. The change translates to more money for the Indian Health Service. The expansion will also force Native American health providers to deal with something they’ve never faced before — competition from non-tribal health programs.      Copyright © 2013 NPR.


Another change coming courtesy of the Affordable Care Act: Next year, just over 200,000 Native Americans will become eligible for Medicaid. The change translates to more money for the Indian Health Service. But as KUNM’s Tristan Ahtone reports from Albuquerque, expansion will also force Native health providers to deal with something they’ve never faced before: competition from non-tribal health programs.

TRISTAN AHTONE, BYLINE: New Mexico has one of the largest Native American populations in the nation, and nearly 40 percent of that population currently lacks health insurance. Take John Armijo, for instance. He’s an enrolled member of the Pueblo of Jemez. And when he learned he would be eligible for Medicaid in 2014, he says it came as a relief.

JOHN ARMIJO: I was thinking, oh, God, you know, this will be great, you know, for me, one of the baby boomers, and my fellow tribal members. It’ll be a great thing. And if that happens, I won’t have to wait for the retirement age to have these services.

AHTONE: Armijo works part-time for the U.S. Forest Service, which doesn’t provide him with insurance, and currently makes too much money to be eligible for Medicaid. However, next year, when the state expands the program, Armijo will have coverage and choices.

ARMIJO: If my health deteriorates or goes bad, then I’ll be looking for other services, you know, like special doctors or special hospitals or whatever.

AHTONE: Like many Native Americans, Armijo has received medical care through the Indian Health Service or IHS for most of his life. The service provides free basic medical to tribal citizens, but more complex issues like knee surgery have to be referred to other facilities if there’s enough money to pay for it, and there often isn’t.

JAY STEINER: So because of the underfunding of the Indian Health Service, there isn’t the capacity to provide a lot of the services that our patients require.

AHTONE: That’s Jay Steiner with the National Council on Urban Indian Health. He says IHS has only enough money to pay for a quarter of the procedures patients need, and that small amount of funding is divided among more than 600 Indian Health Service facilities across the country. What Medicaid expansion ultimately means is that more Native Americans will have easier access to a higher level of care. And that means if they show up at an IHS facility, the service can bill Medicaid instead of paying with scarce IHS funds.

LINDA STONE: We realize that as people get insurance, they have more choices.

AHTONE: Linda Stone is the CEO of First Nations Community Health Source, an urban Indian clinic in Albuquerque.

STONE: And that, for us, could mean that some of our patients will seek care elsewhere. And likewise, some patients will come and seek care here.

AHTONE: In rural areas of the state, the challenge of competition may not be as fierce, as hospitals and health centers are often few and far between. However, in a city like Albuquerque, Stone points out that First Nations clinic has a number of competitors just blocks from its location.

STONE: We don’t know what it’s really going to look like, but we do know that that is always a possibility that yes, there is going to be competition.

AHTONE: But there’s a downside to that competition and to the injection of new Medicaid dollars into IHS, says Jim Roberts with the Northwest Portland Area Indian Health Board in Oregon.

JIM ROBERTS: There could be a mindset that would evolve in Congress that why should we continue to fund the Indian health system when you have access to Medicaid? You should go there to receive your care.

AHTONE: Health workers say that most Native Americans with Medicaid currently opt to use IHS as their medical home, and they suspect that will be the case under expansion as well. In January, John Armijo of Jemez Pueblo will join that population.

ARMIJO: I’d rather come here first than rather go outside. This is my hometown and the reservation I live on. I’m a tribal member, and I’d like to help the health center here first.

AHTONE: With Armijo’s Medicaid dollars flowing to IHS, better programs, new hires and expanded services may be on the horizon. For NPR News, I’m Tristan Ahtone in Albuquerque.

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Journal #2850 from sdc 5.13.13

Federal health reforms penalize some Native Americans     By: GARANCE BURKE (AP) for full story copy this into your browser:

The 2010 Census found that nearly one-third of the 6.2 million people who self-identify as American Indian or Alaska Native lack health insurance and that 28 percent live in poverty.

But under President Barack Obama’s health care overhaul, DeRouen and tens of thousands of others who identify as Native American will face a new reality. They will have to buy their own health insurance policies or pay a $695 fine from the Internal Revenue Service unless they can prove that they are “Indian enough” to claim one of the few exemptions allowed under the Affordable Care Act’s mandate that all Americans carry insurance.

The Affordable Care Act takes a narrow view of who is considered American Indian and can avoid the tax penalty, which will reach a minimum of $695 when fully phased in. It limits the definition to those who can document their membership in one of about 560 tribes recognized by the U.S. Bureau of Indian Affairs. Yet more than 100 tribes nationwide are recognized only by states and not the federal government. Many tribes do not allow their members to enroll before they are 18, meaning some school-age children whose parents are American Indian might not be considered “Indian” under the definition in the act. Other tribal governments have complicated blood-quantum requirements or rules that all members must live on the reservation, even though nearly two-thirds of American Indians and Alaska Natives now live in metropolitan areas, partly a legacy of federal relocation and adoption programs.

In addition, many Alaska Natives who were born after December 1971 are prohibited from enrolling in their families’ tribal corporations, even if all four grandparents are Alaska Native, she added.

Budget cuts already are set to reduce basic federal health programs for Indians by up to 8 percent.

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Indian Health  Care Bill                           Did not pass in 2008

NALU June 13, 2008: Urge House to Vote on Indian Health  – Did not pass Please contact your representative today and urge her or him to call for a vote on the reauthorization of the Indian Health Care Improvement Act (H.R. 1828).

The bill is ready for floor action, but the House leadership is delaying a vote. The bill has cleared three committees in the House. After a successful campaign by Native American leaders and ally groups, the Senate bill passed in February.

Reauthorizing the bill, which would modernize health programs, is the top legislative priority of Indian Country. Tribes have been working for over a decade for passage; this year, they have almost succeeded. We urge your advocacy.


Better medical care for Indian families is a matter of public interest and moral concern. The United States signed treaties promising health care in perpetuity to Native Americans in exchange for land or the laying down of arms. This country needs to honor those promises.

But historic obligations are not the only concern. Congress has committed to a goal of reducing health disparities between people of color and others in the larger society. Great disparities exist between the health conditions and health care of Native Americans and others. Also, as public health professionals point out, diseases do not stop at the perimeters of tribal lands. Protecting the health of every population in this country protects all other residents.

Why the Bill Is Needed

The infant mortality rate is 150 percent greater for Indians than for Caucasians.

Indians are 2.6 times more likely to be diagnosed with diabetes.

Life expectancy for Indians is nearly 6 years less than the rest of the U.S. population.

Suicide for Indians is 2 1/2 times higher than the national average.

Indians have fewer mental health professionals available to treat them than does the rest of the U.S. population.

U.S. health-care expenditures for Indian men, women, and children are less than half of what the government spends on the health of federal prisoners.

What the Bill Does

It establishes objectives for addressing health disparities between Indians and non-Indians in the United States.

It enhances the ability of Indian Health Services and tribal health programs to attract and retain qualified Indian health-care professionals. It provides innovative mechanisms for reducing the backlog in health facility needs.

It establishes a continuum of integrated behavioral health programs – both prevention and treatment – to address alcohol and substance abuse problems, as well as the social service and mental health needs of Indian people.

It helps bring health care delivery in Indian communities into the 21st century.

Updated: 5/22/2008 Posted: 10/18/2007

”In his 1802 address to Indian nations, Thomas Jefferson said, ‘Made by the same Great Spirit and living in the same land with our brothers … we consider ourselves as of the same family; we wish … to cherish their interest as our own.’ But when it comes to the health care of our Native American brethren, the government has hardly cherished their interests as our own… We owe the first inhabitants of this nation better access to quality health care.”*

Senator Baucus, Finance Committee chair, at mark-up on Sept. 12, 2007 Bills to modernize medical care and reorganize the delivery of health services to Indian communities are advancing through congressional committees. Such services need improvement and staffing. The Indian Health Services is in need of dentists, radiologists, nurses, doctors, and pharmacists. The lack of availability of nearby health care facilities and specialized treatment is a major concern for tribes. In Utah, the Northern Ute Tribe must seek treatment from medical facilities in Salt Lake City, a 300 mile round trip from the tribal seat in Fort Duchesne. Goshute Indians living in Ibapah must travel even further to either Elko, Nevada or to Salt Lake City. Besides emergency treatment, prevention, mental health, and chronic diseases such as diabetes also require expanded programs. Leaders in Congress, handling dozens of other issues, have failed to make the crucial updating of the Indian health care system a priority. Nevertheless, they are aware of the below par system of medical services and the missing clinics and professionals in many parts of Indian Country. As a prime example, Senate Majority Leader Reid inadvertently highlighted the differences in resources when he spoke about the good fortune that led to the recovery of Senator Johnson (SD) who fell desperately ill on Capitol Hill, “Tim Johnson was taken immediately to George Washington Hospital where they have a team of physicians….. Had it happened the next day [during a scheduled trip to the senator’s home state], he would have been on an Indian reservation in South Dakota.”

What does IHCIA do?

The Indian Health Care Improvement Act was passed in 1976 to implement the federal responsibility, created by hundreds of treaties, for the care of the Native people by improving the services and facilities of federal Indian health programs and encouraging maximum participation of Indians in such programs. The objective was to bring the health status of Native Americans up to that of the general populace.

IHCIA provides the authority for the programs of the federal government that deliver health services to Indian people. IHCIA addresses the recruitment and retention of health professionals serving Indian communities, focuses on health services for Urban Indian people, and promotes the construction, replacement, and repair of health care facilities. However, IHCIA was last reauthorized in 1992. First steps to reauthorize the legislation were taken by Indian experts back in 1999 at the request of government agencies but true progress was not made until 2008 to correct deficiencies.

The amendments being deliberated would extend authorization for Indian health care through FY 2017, expand coverage for qualified Native Americans under SCHIP, Medicare, and Medicaid, and consolidate existing programs into a new program of comprehensive behavioral health, prevention, treatment, and aftercare for Indian tribes. The legislation creates important new Indian health programs and improves existing successful programs. It expands cancer screenings, improves communicable and infectious disease monitoring, and enhances recruitment and scholarship programs for Indian health professionals. Currently, programs available to the rest of the public such as community clinics, in-home care for the elderly, long term care, and hospice are unavailable in most Native communities because the Act has not been updated.

KEY PROVISIONS OF THE 2008 INDIAN HEALTH CARE IMPROVEMENT ACT Continues the program to increase recruitment and scholarship programs for Indian health professionals;

Expands current cancer screening programs for Native Americans; Improves communicable and infectious disease monitoring; Improves and expands the current diabetes screening including the treatment and control of the disease;

Expands the program to prevent domestic violence and sexual abuse among Native American communities;

Allows tribes to use maintenance funds for renovation, modernization, expansion or to construct a replacement facility, when it is not economically practical to repair a facility;

Directs the Secretary of Health and Human Services to fund urban Indian youth residential treatment centers to provide alcohol and substance abuse treatment services to urban Indian youth in a culturally competent residential setting;

Creates an Indian Youth Telemental Health Demonstration Project to address youth suicide prevention, intervention and treatment; Establishes requirements for privacy protections so that the Indian Health Service and tribal health programs are in line with other health agencies and departments;

Encourages states to increase outreach to Indians residing on or near a reservation and help them to enroll in the SCHIP and Medicaid programs. What is the Current Situation in Congress?

After securing of passage of S. 1200 in February, advocates are working with the House Natural Resources Committee and Majority Leader Pelosi to figure out ways to pass H.R. 1328. Indian health has not been a priority in the House as it was in the Senate. The highly politicized issue of abortion is complicating progress. Right-to-life and pro-choice factions are deadlocked over whether anti-abortion restrictions should be added to the bill. Serious procedural hurdles must be overcome to reauthorize the Indian Health Care Improvement Act. Time is short because the election in the fall will cut short the weeks that members of Congress will be in Washington, DC.

Legislative History The Indian Health Care Improvement Act (IHCIA) was passed in 1976 as the instrumentality by which to address health disparities between Native Americans and the rest of the populace. The Act establishes the administrative framework to carry out the national trust responsibility established by laws and treaties. It provides the programmatic foundation for health programs for American Indians and Native Alaskans, recruits professionals who practice in Indian Country, and coordinates financing with other government programs such as Medicare, Medicaid, and the State Children’s Health program. Like other key legislation such as No Child Left Behind, the IHCIA must be regularly updated to stay current and meet needs. Without reauthorization, programs such as in-home health care for elderly Native Americans cannot be provided. Regrettably, it was last reauthorized in 1992.

In 1999, with the law due to expire in 2000, Native leaders and experts were asked to obtain a consensus about priorities for the next reauthorization. They did this promptly and helped draft an initial bill. Reauthorization was expected to be imminent. Instead, today in 2007, the Act is still not reauthorized—despite bi-partisan support and intense efforts by Native leaders who have worked closely with appropriate congressional committees and administrative agencies to address their concerns. The bill would bring the medical system for Native Americans into the 21st century. Last year, a bill in the Senate went through four committees and was poised for a positive vote until the Justice Department blocked it in the last days of the 109th Congress.

What happened during 2007-2008? Max Baucus (MT), chair of the Senate Finance Committee, criticized the delay in strong terms, “We owe the first inhabitants of this nation better access to quality health care. We owe them medical care consistent with the medical care found in mainstream hospitals and clinics. We owe them the same medical care that we provide to the other members of our family” ( website, 9/13/07). A presidential candidate is among the co-sponsors for the Indian Health Care Improvement Act of 2007. Sen. Barrack Obama (IL) says, “For more than 14 years, Congress has failed to reauthorize the Indian Health Care Improvement Act and complete a comprehensive review and modernization of Native American health care. This is simply unacceptable” (, 9/13/07). The Senate bill is S. 1200 and the House bill is H.R. 1328.

The goal of Native Americans is to obtain reauthorization before legislators get distracted by the 2008 elections. Native leaders were heartened when the Senate Finance Committee approved the section of the bill over which it has jurisdiction. “As Baucus declared the health care provisions had passed, most of the more than 100 American Indians and Alaska Natives in the hearing room burst into prolonged applause. Moments like that are few and far between on Capitol Hill,” wrote Jerry Reynolds for Indian Country Today newspaper. Now, S. 1200 can be debated on the floor; Majority Leader Harry Reid (NV) has promised Senator Byron Dorgan (ND), chair of the Indian Affairs Committee, floor time for debate.

After securing of passage of S. 1200 in February, advocates are working with the House Natural Resources Committee and communicating with Majority Leader Pelosi about ways to pass H.R. 1328 and reauthorize the Indian Health Care Improvement Act. Even then, passage is not certain, as the administration continues to raise objections, usually belatedly so they are difficult for the Indian community and its Hill supporters to address. For example, comments from the administration were not sent to the Senate Finance Committee until the night before the mark-up, the process whereby a committee examines a bill and passes it forward.

Rally to Build Momentum for Passage

On September 12th, over 100 grass roots and national supporters of Indian health vigorously walked the halls of Congress, solemnly attended an important committee meeting en masse, and enthusiastically celebrated the victory in that committee in an energizing pep rally designed to keep up the momentum for reauthorization of IHCIA. The National Indian Health Board and the National Congress of American Indians co-sponsored the rally along with the National Council on Urban Indian Health, the National Indian Education Association, and the National American Indian Housing Council. Congressional advocates were invited to make short statements at the rally. In the order that they addressed the crowd, the speakers were Senator Bingaman (NM), Senator Baucus (MT), Senator Inouye (HI), Senator Dorgan (ND), Senator Murkowski (AK), Senator Tester (MT), and Representative Pallone (NJ). (See The room was filled and dozens of people spilled out into the hall. A journalist captures the moment below:

“Rosebud Sioux Tribe councilman Robert Moore launched his trained singing voice on the national anthem. Alternating soft tenor passages with the familiar soaring phrases, Moore seemed to lift the room itself about a foot off the ground, and it’s safe to say there was no climbing down after that – not with one congressional member after another putting on a game face and vowing to get the job done, each to louder cheers than the one before.” Jerry Reynolds, “Finance Committee sends health care reauthorization to Senate,” Indian Country Today, 9/14/07