1. Update
  2. Native Americans

UPDATED: Effects of Health Care Repeal in Indian Country

By Ruth Flower, May 9, 2017


Until last week, Congress was unable to pass a repeal of the Affordable Care Act (ACA). But the House decided to try again, with a modified version of the defeated proposal, the American Health Care Act (H.R. 1628). The House passed the bill with a very slim margin (5 votes) on Friday, May 5.

Until last week, Congress was unable to pass a repeal of the Affordable Care Act (ACA). Many member of the House of both parties had heard from their own constituents about the positive difference that the Affordable Health Care Act had made in their lives. For other members, the repeal did not go far enough, as it left some aspects of the current law in place.

The President had said that he wanted to “move on” to tax reform and budget issues, but the House decided to try again, with a modified version of the defeated proposal, the American Health Care Act (H.R. 1628). The House passed the bill with a very slim margin (5 votes) on Friday, May 5.

WHAT PASSED? The new bill, in its current form, would be devastating to health care in Indian country. Provisions that limit, cap or otherwise affect Medicaid, in particular, will have a huge impact on the Indian Health Service and on Native people’s access to other health services.

By 2020, the bill would phase in major changes, including:

  • Providing a fixed payment to states to cover services now covered by Medicaid, forcing states to reduce the number of people eligible for care or to reduce the kind and amount of care given, (Note: the largest portion of Medicaid spending is for frail elderly people in nursing homes.)

  • Ending the federal subsidy that helped states to expand Medicaid availability to more people,

  • Requiring states to set their own quality standards for health insurance, and

  • Ending the requirement that insurers cover individuals with pre-existing conditions.

GOVERNMENT TO GOVERNMENT: Note that tribes are not states, and have no legal relationship to states. Their constitutional relationship is with the federal government which has a long-standing trust responsibility to provide health care and other supports to Indians in exchange for the 90 million-plus acres of land taken from tribes, even after they were forcibly settled on what was supposed to be “reserved” homes for them.

WHAT’S THE IMPACT? A team of tribal health and legal experts coordinated by the Public Health Department at North Dakota State University has released a [report] detailing the potential effects in Indian country of repealing the ACA.

Called the “Impact of ACA Repeal on American Indians and Alaska Natives”, the report reviews both broad and specific effects on programs and services.

In addition to the concern to keep the permanent authorization of the Indian Health Care Improvement Act, the report also details the relationship between Medicare and Medicaid and the Indian Health Service and tribally operated health facilities. Because Medicare and Medicaid reimbursements can significantly supplement the insufficient funding that is typically available to the Indian Health Service, the expanded availability of Medicaid in Indian country has been a major plus.

The “marketplace,” through which uninsured individuals may purchase insurance, certifies the basic quality of participating insurance plans. Native Americans and Alaska Natives who fall between 100 percent and 300 percent of the federal poverty line have access to limited or no deductibles and cost- sharing, and advance payments of the premium tax credits. These benefits combine to make participation more affordable for those who have been essentially locked out of the health insurance market before the ACA.

The ACA also authorizes grants to provide and test innovative approaches to health support and disease prevention, including home visits for families with young children, smoking cessation, and improving access to immunizations and other preventive services.

The report also includes assessments of the impact of several proposals currently under discussion:

  • Health savings accounts – which abandon the federal trust responsibility and are not a solution for impoverished families
  • Sale of insurance plans across state lines – where purchasers of insurance would have little or no protection from a distant state where the insurance company was located
  • Capping federal Medicaid spending – which places a responsibility on states to disburse an appropriate level of funds to tribes, contrary to recent experience with state “block grants” that are expected to “pass through” to tribal governments.
    Most of the proposals affecting tribes involve an abdication of the federal trust responsibility – and sometimes treaty obligations – to provide health services to Native peoples.

ACTION

The bill has not been approved the Senate yet. Talk to your Senators to:

  1. Support preservation of the permanent authorization of the Indian Health Care Improvement Act.

  2. Oppose repeal of the Affordable Care Act until Congress can deliver a program that honors the federal trust responsibility and provides better health care to more American Indians and Alaska Natives.

Ruth Flower

  • Consultant, Native American Policy

Ruth leads FCNL’s lobbying, education, and coalition work as our consultant on Native American issues. She leads a coalition of faith groups who lobby on issues such as funding for tribal schools, support for “healing” justice systems, protection of religious and cultural rights, and support for tribal governance authority.