Passage of the Patient Protection and Affordable Care Act and the U.S. Supreme Court ruling on its constitutionality provided permanent reauthorization of the Indian Health Care Improvement Act.
The IHCIA, enacted in 1976 to address declining health conditions in Indian Country, provides – without cost – health care to American Indians and Alaska Natives who are members of federally recognized tribes. The IHCIA and the Snyder Act of 1921 form the basis for delivery of care via Indian Health Services, an agency within the U.S. Department of Health and Human Services.
Dr. Charles Grimm, senior director of Cherokee Nation Health Services, said the provision of health care to American Indians and Alaska Natives has more to do with ethnicity than a legal precedent.
“American Indians and Alaska Natives consider themselves the first Americans who prepaid for their health care through the cessation of thousands of acres of lands, mineral rights and forced relocation from their ancestral homes,” said Grimm. “So, to Native Americans, this care is not free, but has been paid for many times over.”
He pointed out American Indians are also the only racial group with a government-to-government relationship with the federal government based on treaties, laws, Supreme Court decisions and executive orders over the years.
“So, the relationship with the federal government is not one based on ethnicity, but one based on political and legal foundations upheld over the years that give tribes status as both separate nations and part of the U.S.,” he said. “One of the many promises made by the federal government to Indian nations was the delivery of health care services.”
According to www.ihs.gov, Indian health care may be available to anyone “who is of Indian of Alaska Native descent as evidenced by one or more of the following factors: Is regarded by the community in which he lives as an Indian or Alaska Native; is a member, enrolled or otherwise, or an Indian or Alaska Native tribe or group under federal supervision; resides on tax-exempt land or owns restricted property; actively participates in tribal affairs; or any other reasonable factor indicative of Indian descent.”
Services may also be provided to a non-Indian woman who is pregnant with an eligible Indian’s child for the duration of her pregnancy and through post-partum, which is generally about six weeks.
To receive IHS health care benefits, a tribal member or citizen must sign up at the patient registration office of the local IHS facility in person and present proof of enrollment in a tribe.
Those seeking services in Tahlequah would register at Cherokee Nation W.W. Hastings Hospital, which provides care not just to Cherokees, but to anyone who can prove membership in a federally recognized tribe.
Membership requirements are established by individual tribes. The Cherokee Nation has no blood quantum rule, so even those with a tiny fraction of Cherokee blood may receive cost-free health care through CN. Many other tribes require a substantial degree of Indian blood for membership, and thus for health care. The United Keetoowah Band, for instance, requires its members to be at least a quarter Indian.
Many local American Indians have been concerned about how PPACA might affect their health care. Pamela Thurman, a Cherokee who receives IHS care, is among those.
“Are we the example that everyone will look to for success of failure in ‘socialized’ medicine and contract health? Will natives be absorbed into the general public for health care?” she asked.
Grimm said many different groups have studied IHS and tribal health programs over the years, and have been pleasantly surprised at what they found.
“[They] marveled at how much quality health care is delivered with a lesser per capita funding than almost any other health system in the U.S.,” said Grimm. “Many have worried that health reform would mean the Indian Health Service would go away, and everyone would have an insurance card. That was a myth and is wrong. The IHS is still here, and the passage of IHCIA, along with the health reform law, reaffirms that IHS is here to stay. The [PPACA] permanently reauthorizes the IHS, and it contains numerous provisions to modernize and update the IHS and tribal programs.”
He said tribal members – like all Americans – will now have more choices for their health care, rather than additional restrictions some claim PPACA will impose.
“They may choose to purchase the new, more affordable health insurances described in the PPACA, while many more should be covered for state Medicaid programs in the expansions of eligibility that may occur,” Grimm said.
Tribal citizens who opt to buy insurance or participate in employer-provided plans would no longer be limited to services at only IHS or tribal facilities. For many lower-income Indians, this has been the only option.
Cherokee citizen Lu McCraw said Indians with serious health conditions often find themselves out of luck.
“For instance, [IHS] can help detect or screen for breast cancer, but you’re out of luck getting treatment,” said McCraw. “There’s a priority list, and they serve or help those according to available funding.
McCraw is referring to contract health services, or those provided by facilities outside the IHS-designated pool.
“Indians may receive any type of health care that is delivered at their local facility – or at any [IHS] facility in the nation, for that matter,” said Grimm. “[McCraw] is referring to what is known as the contract health service program [when mentioning] priority lists. If a type of care [cannot] be provided within the walls of the local IHS or tribal health facility, then a person may be referred into the private sector for health care needs.”’
Grimm said a number of factors affect a tribe’s ability to refer patients to outside medical providers.
“The combination of medical inflation, particularly for providing services in rural and remote locations; an increasing eligible population; and limited competitive pricing and options, requires strict adherence to specific guidelines, medical priority and eligibility to ensure the most effective use of CHS resources,” said Grimm. “CHS programs negotiate contracts with providers to ensure that competitive pricing for the services are provided, in spite of the limited number of providers available in the many local rural communities. [McCraw’s] statement about denial of cancer treatment is not accurate. The denial rate of our CHS program with regard to cancer care is virtually zero, or near 100 percent treatment.”
Elissa Lyons, also a Cherokee citizen, is concerned about the fine that will be imposed on those who refuse to purchase health care, as set out in PPACA. The new law makes most Americans responsible for carrying some form of health insurance, and compliance will be enforced through the use of tax penalties via the Internal Revenue Service.
“The law exempts members of Indian tribes on the basis of the federal trust relationship,” said Grimm. “So, while Indian people will be able to access health insurance made more affordable and more available under the PPACA, they will not be penalized if they choose not to purchase insurance.”
Other key PPACA elements pertaining to American Indians include those set out under Titles I, II, IX and X. These affect cost-sharing requirements, the Medicare Part B “sunset” date, Medicare Part D on prescription medications, and tax exemption on tribally provided insurance.
The first of three provisions under Title I will protect Indians from cost-sharing requirements at or below 300 percent of the Federal Poverty Level, which DHS guidelines define as an annual income of $61,950 for a family of four. The second provision protects Indians from cost-sharing for services delivered through an IHS program; the third will allow Indians to enroll in insurance exchange programs on a monthly basis.
The PPACA also removes the Medicare Part B sunset date of Dec. 31, 2009, giving IHS programs permanent authority to receive disbursement of some Part B services. According to Grimm, the provision initially passed in the Medicare Modernization Act of 2003 limited the authority to five years.
“Also, effective Jan. 1 of 2011, the value of drugs provided by IHS programs will now count toward true out-of-pocket costs for Indian Medicare beneficiaries,” said Grimm. “This effectively removes the ‘doughnut hole’ for patients seen at IHS or tribal facilities.”
Finally, effective March 23, 2010, PPACA excludes from an individual tribal member’s gross income the value of health benefits, care or coverage provided by IHS programs, a tribe or tribal organization.
Grimm said he believes the permanency of IHCIA will improve services to tribes across the board.
“Under IHCIA, the Indian Health Services and tribes have new and expanded authorities to provide cancer screenings and dialysis, ensure our elders are cared for, recruit more qualified health professionals, modernize dated health facilities, and bring more funding to hospitals and clinics through third-party collections,” said Grimm
“Even better still, IHCIA is permanent. It will remain in law, and tribes will never be forced to go through the reauthorization process again.”
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