Tribal members rely on a broad network of health care services and financing mechanisms, not just the Indian Health Service or tribal programs. How will this complex network be affected by proposals to repeal and replace the Affordable Care Act?
The widespread impact of big changes will reach Indian country. Most Native Americans and Alaska Natives qualify for health care services through the tribal programs and the Indian Health Service, including Urban Indian Health Services. But these services cannot reach everyone, either because of distance or because of limited facilities or staff.
Many Indians also qualify for Medicare, Medicaid, Veterans Health Care, or another public health plan or employer-provided plan, and can access services through other channels. Because of the widespread reliance on this broad network of health care services, most American Indians and Alaska Natives will be deeply affected by whatever happens to health care programs under the move to repeal and replace the ACA.
There are also specific issues affecting Native American in this season of health care reform.
Indian Health Services could be affected directly by a repeal of the ACA. First, the Indian Health Care Improvement Act (IHCIA), which sets up the entire structure for the Indian Health Service and Urban Indian Health Services, is included (by reference) in the ACA. If the ACA is repealed,those few lines that authorize the Indian Health Care Improvement Act must be preserved.
How did the Indian Health Care Improvement Act end up in the ACA? Before 2009, the IHCIA had not been updated and reauthorized for fourteen years. A new and improved version of the IHCIA had been negotiated for many years and was ready to go to the floor of the House and Senate in the fall of 2009. The ACA was also heading to the floor in the fall of 2009 and was likely to occupy all available floor time. Rather than delay action on the IHCIA once again, leaders of both parties decided to incorporate the IHCIA by reference into the ACA. The reference said simply:
S. 1790 entitled ‘A bill to amend the Indian Health Care Improvement Act to revise and extend that Act, and for other purposes,’ as reported by the Committee on Indian Affairs of the Senate in December 2009 is enacted into law. (Section 10222 (PL 111-148)
Those few lines carry a huge amount of weight. They must be preserved.
Access to Medicare and Medicaid-funded services could be affected by repeal. Secondly, two specific provisions in the ACA ensure that Medicare and Medicaid programs will continue to operate in Indian country and support the work of the Indian Health Centers. These must also be carried over into any new structures:
Current law requires the federal government will reimburse states for 100 percent of the cost of providing Medicaid services to American Indians and Alaska Natives, ensuring that the federal government continues to carry its trust responsibility to Native Americans, and that the additional cost will not fall on states.
Two sections in the ACA coordinate coverage under Indian Health Serviceand tribal programs with Medicare (Section 2902) and confirm that the Indian Health Service, tribal health services and urban Indian health services are “payers of last resort” for services provided (Section 2901).
Finally, current law also specifies that health care benefits provided by a tribe to its members shall not be counted as taxable income, bringing these benefits on a par with employer-provided benefits or benefits from public programs, such as Medicare and Medicaid.
A state-based structure could leave Native Americans with few options. Senators Collins (ME) and Cassidy (LA) have introduced a replacement bill that puts states in charge of the structure of health care systems within their boundaries. So far, this legislation does not mention Indians or Indian Health Services. While legislation like this will go through many amendments and iterations before it — or anything else — becomes law, it is important for legislators who are considering legal structures for health care keep in mind all the levels of government on this continent: federal, tribal, state, and local.
Congress can ensure that the Indian Health Care Improvement Act is preserved as a separate piece of legislation, and that the provisions that directly affect Native Americans are carried over in to any replacement legislation. Find out how you can help make these things happen.
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