Obamacare or IHS?

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Native Americans don’t have to utilize the Affordable Care Act, but some say it’s to their benefit to do so

As people struggle to understand how the Affordable Care Act affects them, and to navigate the U.S. government’s notoriously flawed web site, one segment of the population has an added layer of complexity to consider.

Native Americans must decide whether to continue to receive care through Indian Health Services or to enroll in an insurance plan through Obamacare. It is not necessarily an easy decision.

“I am aware that Native Americans are not required to enroll, but I do think that for most people it would be a benefit,” said Juantio Becenti, a member of the Navajo (Diné) Nation.

“Many services are provided through IHS; however, many are not, such as orthodontics,” Becenti said.

For instance, IHS does not provide anything beyond basic dermatological care. As a person with severe skin issues, he therefore would like the additional options available through Obamacare. “Essentially, it would contribute to our quality-of-life care rather than just basic care,” he said.

“As far as I understand, these quality-oflife services under the ACA are essentially guaranteed, and access to them may be superior to IHS. If the cost is right I see no reason any Native American should not enroll, unless they are absolutely indigent — which I think is one thing the ACA hopes to address and will, if successful.”

Cortez, Colo., photographer Lapita Arviso agrees. “If you need more care beyond what the IHS provides, you will need the insurance, but as far as getting just the basic care, I don’t think a lot of Natives will apply if they don’t have to. As for my family, we need care beyond IHS for our children.” Indian health care is a government mandate by treaty rights and obligations, and is provided through IHS.

In the Four Corners region, the Northern Navajo Medical Center in Shiprock, N.M., is the largest IHS facility, serving 45,500 (mostly Navajo) Native Americans. The facility has 55 beds and an average of 400 outpatient visits a day.

Clinics in Montezuma Creek, Blanding, Monument Valley and Navajo Mountain are not IHS facilities but are instead all part of the Utah Navajo Health System, which maintains a working relationship with the IHS via the 638 Self Determination contract arrangement. So is Tuba City Regional Health Care Corporation, whose efforts finally paid off when the Navajo Nation Council approved the organization change in 2010, to enter into 638 Title V Self Governance Compact. It serves the Navajo and Hopi Nations and the San Juan Southern Paiute Tribe. All the facilities are located on the Navajo Nation.

Although enrolled Native Americans in federally recognized tribes are exempt from having to buy coverage under the ACA, they can buy it if desired. If they don’t want to, it is critical that they go through the proper process for exemption so that they will not receive a large tax bill in 2015.

Signing up is a oncein- a-lifetime process, which makes sense, according to journalist Mark Trahant, “because it’s not like one year you’re not going to be tribal. If you are a Native American that won’t change from year to year.”

Yvette Roubideaux, director of IHS under the U.S. Department of Health and Human Services, wrote in her blog that she gets “questions all the time from American Indians and Alaska Natives (including my own relatives!) wondering why they should care about the Affordable Care Act since they already are eligible for the Indian Health Service. My response is that while the IHS is here to stay and will be available as their health care system, the Affordable Care Act brings new options for health coverage. It is another way that the federal government meets its responsibility to provide health care for American Indians and Alaska Natives.”

In an effort to give responsible and clear information to tribal communities, the IHS has launched a web campaign at www.ihs.gov/ACA/ that explains the benefits to enrolling in the ACA. It provides American Indians and Alaska Natives with more choices, depending on eligibility and the availability of state coverage.

Participants can continue to use IHS, tribal, and/or urban Indian health programs, enroll in a qualified health plan through the marketplace, and/or access coverage through Medicare, expanded Medicaid, and the Children’s Health Insurance Program.

Under the ACA, states have opportunities to expand Medicaid coverage to include Americans with family incomes at or below 133 percent of the federal poverty level – generally $31,322 for a family of four in 2013. This expansion includes adults without dependent children living at home, who have not previously been eligible in most states.

The 1921 Snyder Act granted authority to the Bureau of Indian Affairs to spend money “for the benefit, care, and assistance of the Indians throughout the United States for the following purposes: General support and civilization, including education; for relief of distress and conservation of health.”

In an article published on ReznetNews. org, Trahant wrote that the enactment of the 1975 Indian Self-Determination and Education Assistance Act and the Indian Health Care Improvement Act in 1976, commonly known as “638 Self-Determination,” gave tribes as well as tribal and urban Indian organizations the right to contract for the management of federal programs.

“Today more than half of IHS is run under contract by tribes or independent health care centers – and that number could grow even more significantly because of changes under the Patient Protection and Affordable Care Act, or health care reform,” he stated.

In March 2010 President Obama signed the permanent reauthorization of the Indian Health Care Improvement Act, which had expired in 2000. It is the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives. It expands access to coverage, controls healthcare costs and improves health care and quality, while authorizing new programs and services within the IHS.

According to Trahant, who currently serves as the 20th Atwood chair of journalism at the University of Alaska in Anchorage, “The tribes that have not chosen 638 Self Determination are locked into IHS funding and the vulnerability found in the annual federal budgeting process. The ACA lives up to unlimited funding in programs such as expanded Medicaid and the Exchange. Those bring significant subsidized money into health care for Indians.”

Naomi Chuckwuk, a member of the Aleknagik Tribal Council, Aleknagik, Alaska., and a clinical research associate for almost five years, said, “There is no easy answer here. But the federal government is responsible for the health care of Native Americans through a series of agreements they made. However, IHS has been chronically, grossly and always underfunded.”

Chuckwuk is pursuing her master’s degree in public health. While researching a paper about the IHS, she found a study published in 2008 that was alarming, she said. “The IHS is so severely underfunded that its funding was half the amount per patient of the amount spent on a federal prisoner.”

The federally funded facilities under IHS, which furnish essential services, operated throughout the 16-day government shutdown in October, with personnel working for no compensation.

If the differences between the House and Senate Budget resolutions cannot be reconciled for FY 2014 by Dec. 13, then automatic cuts will occur, directly affecting the quality of patient care at both IHS and 638 Self Determination contract clinics.

Contract Support Services is one example. If enacted, services such as neurological testing, dermatology, ophthalmology surgeries which are normally contracted out of the facility, will be limited by budget caps.

“Get your contract care before June,” is a common approach to out-of-facility patient needs.

The IHS must develop a voice in federal policy-making, Chuckwuk said, and also focus on becoming a program that is not discretionary in order to receive a consistent budget that increases with the amount of patients the IHS serves as well as inflation. “Consistent funding will enable the IHS to be better equipped to handle the growing population it serves as well as the additional tribes that are becoming federally recognized.”

The answer to consistency is the ACA. In a recent telephone interview with the Free Press, Trahant said, “”The U.S. has never lived up to its treaty obligations. The ACA lives up to unlimited funding, whereas the Indian Health Service has always been underfunded. Natives who sign up for ACA programs like Medicaid and [insurance] policies found on the exchange can go to any doctor. More important IHS facilities will be able to do third-party funding [like contract services].”

However, patients who seek better care elsewhere through the ACA than what is provided at IHS facilities will greatly influence the quality of care and funding at IHS.

“The government is not talking about the potential of people leaving IHS for better care,” added Trahant. “If the money’s there, then that changes the equation.” In other words, if Natives have access to affordable and higher-quality health care through policies offered through the ACA, then they may go to providers of their choice instead of settling for the care IHS will provide, which could push IHS to improve.

Trahant added, “Paying into the system benefits everyone, including future generations who hopefully will not have to endure what we all have. I will go so far as to say that if you are a young Native American and have the means to enroll, it is a duty, as it will benefit not only yourself but everyone.”

Trahant, a member of the Shoshone-Bannock Tribe and a former president of the Native American Journalists Association, is launching a series of five-minute films on YouTube in November. Access to the films, titled, “Treaty or Not,” is free. He hopes the work will educate people who want to learn more about treaty obligations, including Indian health care.

“Passing health-care reform was easy,” he said. “Sure, it was a legislative mess: It was too slow, too fast, too many pages and too short on specifics, too open to the influence of special-interest lobbies – and too secretive, partly because the language was so complicated and difficult to translate into a simple narrative. Yet enacting health-care reform was easy. Executing on real reform — now, that’s a challenge.”

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From November 2013.