Patty Talahongva

Indian Country Today

A proposal in the Senate Finance Committee could have a detrimental affect on tribal health facilities that rely on funding from Medicaid, warns a long time health advocate. 

In 1976 Congress amended the Social Security Act to allow Medicaid services provided to American Indian and Alaska Natives to be claimed by state Medicaid programs. This is known as 100 percent Federal Medical Assistance Percentage, or FMAP. 

It was meant to support the Indian Health Service and Tribal Health Facilities. 

Jim Roberts, Hopi, explains what the changes could mean to Indian Country. He is the senior executive liaison for the Alaska Native Tribal Health Consortium. 

Here are some of Jim Roberts comments: 

"In 1976, Congress amended the Social Security Act to provide IHS and tribal programs, the ability to bill Medicare/Medicaid. And in terms of Medicaid, they recognize that the program is a 50/50 type of participation program where the state pays a portion, 50 percent of the cost, approximately depending on a couple economic indicators. And then the federal government pays 50 percent."

"And in recognition of the federal trust responsibility, Congress recognized that it wouldn't be fair to have the states pay this share of the match when a tribal beneficiary has provided services in an IHS facility."

"So what they did in express recognition of the trust responsibility was they agreed to pay 100 percent of the costs when a tribal beneficiary enrolled in Medicaid received services through the Indian Health System."

"That was intended to not only fulfill an obligation that the United States had to Indian people." 

"This was a way to kind of supplement the appropriation to the Indian Health Service by providing a 100 percent. And also the Congress recognized that when that money came into the system, they wanted to direct how that resource would be used."

 So there was explicit provisions in the Indian Healthcare Improvement Act that directed that money that came in from Medicaid, Medicare had to be used to meet conditions of participation to meet facilities, accreditation and participation requirements in Medicaid/Medicare."

"The proposal from South Dakota would then eliminate the requirement that a hundred percent FMAP would have to flow through the Indian Health System anymore."

"So the states could unilaterally be able to claim 100 percent FMAP wherever a tribal beneficiary goes. The challenge there is that by disconnecting the requirement that Indian people be seen through the tribal system and states claim a hundred percent FMAP meant that those resources wouldn't flow back to the tribal system to support facilities, conditions of participation and expand care in the tribal systems."

"By removing that requirement, you would take away a leverage point where the states have an incentive to come to the table to work with tribes, to say, Hey, how can we work with you so that perhaps you could do, for example, patient housing that we've done in Alaska, where we've built out a patient facility and internalize that cost that normally the state would have had to pay 50/50 FMAP for, now is provided through the tribal system and the state can claim that at 100 percent FMAP."

"So it creates a win, win situation where we now have a patient facility or housing facility that translates to quality of care because patients are on campus, they're no longer standing out in the community and hotels in a fragmented system. There's cultural competency that goes along with them. We can, we can make a place for their families to be with them. We can create kind of food opportunities for them, so that, you know, they have traditional food pathways that they may not have had out in the community and it creates cultural competency and provides care in a way that people are accustomed to being treated."

"The challenge in South Dakota is that the state Medicaid programs did not, they felt that perhaps that was an administrative burden they didn't want to have to go."

"In the course of doing that too, in working with the state to get those care coordination agreements, we also created opportunities to increase Medicaid participation for Alaska Natives, so that we had more services that could be provided to our beneficiaries and that more resources could continue to come into the tribal system."

"In South Dakota's case, they may not have been willing to do that, or the tribes may not felt that they weren't getting their fair share out of what the state was creating through the 100 percent FMAP process. It is a partnership, it's a collaboration and both parties have to be willing to come together to create these mutual, beneficial opportunities that the state can save money. And also that expanded and increased care back to the tribal system."

"Recently there have been proposals by the by staff and also the finance committee, to look at including this in the next COVID funding package. I think the reaction from Indian country was so monumental that perhaps said they may have backed off that proposal."

"As the op-ed piece indicated it's complicated. I smile now because I'm thinking back to President Trump's comment about 'Who knew healthcare was so complicated,' right."

"And because of those complexities it's very difficult to get the consumer community, our patient customers and tribal citizens to kind of deal with this type of issue let alone tribal leadership. And I think the healthcare community understands it pretty well, but it takes a broadcast like you're doing and conversations at the local level with tribal health programs involving their community so that they can reach out to their congressional delegations. Let them know that this is not good policy."

"It's not consistent with congressional intent. It redirects resources away from the federal trust relationship that allows the states to claim and balance their budgets on the back of resources that were intended for their trust relationship. And I think that's the real dangerous thing here. It's healthcare today, so tomorrow it could be vouchers for education or housing. The precedence here is health but I think it starts to slippery slope that this could begin the course of eroding the federal trust relationship."

"COVID has revealed our weaknesses in the system, our need for resources to provide care testing and treatment, and making substantive or draconian policy changes in the wake of a pandemic is not always the best thing to do and it's certainly not good when it disadvantages a system that's underfunded by about 50 to 60 percent of its level of need."

Comments from Aliyah Chavez on the primary results and the DNC convention:

"The big news of the night came from Democrat Lynnette GreyBull who won her primary election. She defeated two other opponents and will go on to face Republican incumbent Liz Cheney in the general election."

Besides GreyBull the other three candidates in Wyoming, all women running for the state's legislature, won their primary elections as well."

"In Alaska, which is a heavily Republican state, we had two Democrats who were hoping to advance to November, both Edgar Blatchford, who ran for U.S. Senate and Ray Tugatuk ran for the U.S. house were defeated in Tuesday's primary election. There were a handful of other candidates running for Alaska state legislature who won their primaries. And we're still waiting to hear election results from six candidates as of Wednesday morning, according to the Anchorage Daily News, there were a record number of Alaskans who voted by mail, which could account for why there is a delay in getting those results."

""There were a total of nine Indigenous people that we counted who addressed millions of Americans on Tuesday night's DNC roll call. And for those who might not be aware, it's essentially the process where individuals are chosen as a spokesperson for their state to stand up and say a little bit about themselves and their state and officially cast the votes on behalf of their state for the democratic choice for president."

"And so we had four tribal leaders from Alaska, New Mexico, North Dakota, and South Dakota, which we're estimating as a record breaking number of spokespeople but in addition to that, there were Indigenous folks from Hawaii Guam, American Samoa and the Northern Mariana Islands. Something like more than 100 Native Americans and Alaska Natives some kind of a speaking role or participation yesterday at the convention itself."

"I was watching closely on social media last night and overwhelmingly, I would say that people were responding very positively. I read some posts talking about, I haven't traveled since the pandemic started. So they seemed almost happy to be able to travel to all of these different states and territories across the nation. People speaking in their Indigenous languages. And people really seem to love that as well. Many people dressing in traditional clothing as well, which was just really neat to see."

"I had the chance to talk with all of the four Native leaders across the four states yesterday. And all of them mentioned something that really stuck with me. They all said that they were very humbled to be asked to do this, but in addition, they wanted to do it correctly. We saw lot of them speaking in their traditional languages and saying, this is the Homeland of my ancestors which was just really need, especially on prime time television, when millions of Americans are tuning in."
