Trump administration maintains tribes are a race rather than sovereign governments and Indian Health should not be exempt from Medicaid’s ‘race-based’ work rules. Seema Verma, administrator for the Centers for Medicare and Medicaid Services confirmed in January that the Health and Human Services contends that tribes are a race as opposed to a separate sovereign government, thus not exempt from Medicaid work rules.

HHS / Vincent Schilling

Trump administration maintains tribes are a race rather than sovereign governments and Indian Health should not be exempt from Medicaid’s ‘race-based’ work rules. Seema Verma, administrator for the Centers for Medicare and Medicaid Services confirmed in January that the Health and Human Services contends that tribes are a race as opposed to a separate sovereign government, thus not exempt from Medicaid work rules.

Trump Administration Supports Changing Indian Health Programs That Will Sabotage Treaty Rights

Trump administration maintains tribes are a race rather than sovereign governments and Indian Health should not be exempt from Medicaid’s ‘race-based’ work rules

The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars to the Indian Health Service while also sabotaging treaty rights.

A story in Politico Sunday raised the issue. It said, “the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. ‘HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,’ according to a review by administration lawyers,” Politico said.

Seema Verma, administrator for the Centers for Medicare and Medicaid Services confirmed in January that the Health and Human Services contends that tribes are a race as opposed to a separate sovereign government, thus not exempt from Medicaid work rules.

The Trump administration has allowed Arkansas, Kentucky and Indiana to institute work-requirements in order to eligible for Medicaid. Other states are in the process of seeking similar requirements where Medicaid participants would have to work some 20 to 80 hours each month in order to continue receiving the health insurance.

A graphic on Medicaid expansion by state.

Screen capture via 'Families USA'

A graphic on Medicaid expansion by state.

The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws,” said Jacqueline Pata, executive director of the National Congress of American Indians. “Our political relationship is not based upon race.”

“The United States has a legal responsibility to provide health care to Native Americans,” Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation, told Politico. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.

Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).

But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.

Other states report similar increases. In 2016, Kaiser Family Foundation found that in Arizona, half of one tribally-operated health system’s patient visits were covered by Medicaid. And, an urban Indian Health program reported that its uninsured rate at one clinic fell from 85 percent before the Affordable Care Act to under 10 percent due to Medicaid enrollment.

Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). In Alaska more than two-thirds of those dollars are spent on private sector doctors and hospitals through purchased care for Alaska Native patients. And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.

A recent report by Kaiser Health News looked at Census data and found that 52 percent of residents in New Mexico’s McKinley County have coverage through the Medicaid.  That’s the highest rate among U.S. counties with at least 65,000 people. “The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program,” Kaiser reported. Most of McKinley County is located on the Navajo and Zuni reservations.

Kaiser Health News said Medicaid has opened up new opportunities for Native patients to “get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.”

However the growth of Medicaid is resulting in unequal care for patients in the Indian health system. The benefits in some states, including those that expanded Medicaid under the Affordable Care Act, are more generous. Other states not only refused to expand Medicaid and have been adding new restrictions such as requiring “able-bodied” adults to have their Medicaid eligibility contingent on work.

But the Indian health system — the federal Indian Health Service and tribally and nonprofit operated programs — are in a special case because there is a 100 percent federal match for most services. So states set the rules, but do not have to pay the bill. (Medicaid is often the second largest single item in a state budget behind public schools.)

Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.

Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.

A letter from the Tribal Technical Advisory Group for Medicare and Medicaid said American Indians and Alaska Natives “are among the nation’s most vulnerable populations, and rely heavily on the IHS for health care. However, the IHS is currently funded at around 60 percent of need, and average per capita spending for IHS patients is only $3,688.” The latest per person cost for health care nationally is $10,348 (totalling $3.3 trillion, nearly 20 percent of the entire economy).

Uninsured rate for nonelderly American Indians and Alaska Natives from 2013-2015.

Screen capture Kaiser Family Foundation

Uninsured rate for nonelderly American Indians and Alaska Natives from 2013-2015.

The tribal advisory group said it is “critically important” that there be a blanket exemption for IHS beneficiaries from the mandatory work requirements.

A report in September by the Kaiser Family Foundation showed that the majority of American Indians and Alaska Natives on Medicaid already work, yet continue to face high rates of poverty. It said over three-quarters of American Indians and Alaska Natives are in working families, but that’s a gap of about 8 percent compared to other Americans (83 percent).

Income and work status for nonelderly American Indians and Alaska Natives from 2015

Screen capture Kaiser Family Foundation

Income and work status for nonelderly American Indians and Alaska Natives from 2015

The Trump administration’s characterization of tribal health programs as “race-based” is particularly troubling to tribal leaders because it would reverse historical precedence.

A memo last month from the law firm of Hobbs, Straus, Dean & Walker said the Centers for Medicare and Medicaid Services “has ample legal authority to single out IHS beneficiaries for special treatment in administering the statutes under its jurisdiction if doing so is rationally related to its unique trust responsibility to Indians. Under familiar principles of Indian law, such actions are political in nature, and as a result do not constitute prohibited race based classifications. This principle has been recognized and repeatedly reaffirmed by the Supreme Court and every Circuit Court of Appeals that has considered it, and has been extended to the actions of Administrative Agencies like the Department of Health and Human Services even in the absence of a specific statute.”

(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.)

Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. Follow him on Twitter

Comments
  • Bruce W.

    I am Oglala and am required to use Private Health Insurance because Pine Ridge Hospital participates with healthcare as a payer of last resort. My wife is not a “member” of any federally recognized tribe and is prohibited from using the Pine Ridge Hospital based on her race. She gave birth to my three children at the hospital and billing was paid by insurance. My wife is prohibited from using the hospital and travels to a hospital away for the Pine Ridge agency for medical care. My wife has lived on the Pine Ridge Agency longer than anywhere else her entire life and yet cannot vote in tribal elections. She cannot vote for me if I chose to become a candidate for tribal office. It is because of her race. On the other hand, as a member of a clipped or granted sovereign tribe (not a nation), I can and have voted or became a candidate for state and federal offices. If President Trump’s thoughts are accurately represented by the media then he is correctly identifying that Indian Health Care is race based with view exceptions related to emergency or maternity. Anywhere USA, hospitals are seen as gems in a community but no so in “Indian” country. Anywhere USA, folks purchase homes based on closely adjacent resources such as school, hospitals, government offices or shopping to name a few. This model is difficult to duplicate in “Indian Country” because of race. At best essential personnel live in federally issued quarters or communities and rarely establish roots in the community or are allowed to vote in any affair, including management of hospitals. Simply put, “Indian Reservation” are modeled after military installations and are family friendly to the extent of fulling a mission as funded by Congress. My wife may be buried at the Pine Ridge Agency never having voice in quality of life here all due to race. If “Indian Reservations” held more than clipped or granted sovereignty then it would not be long before family became more important than “blood quantum”, which is absolutely race based and act of political genocide.

  • Karen B.

    “Race” is a construct that has no basis in reality. There are no “races” among people. We are human beings, or homo sapiens, with physical differences as determined by genetic variations, but we are all one species. Native Americans deserve good health care and easy access to it simply because they are Native Americans and have been exploited and mistreated. African Americans have been burdened with the consequences of slavery, and Native Americans with the consequences of conquest. These are the factors to be taken into account, not some social construct such as race.

  • Reader L.

    Native Americans are the least mobile group in the United States. The most discriminated against. And whose circumstances are the least publicized and most misunderstood. The government allows Americans to think Indians get “free money” of their tax dollars. That misconception has never been clarified in the mainstream media or by any politician, leaving many Americans to resent and even hate the “free ride” Indians get. They have no understanding of the treaties that have never been honored, of how reservation land is not under the control of ribes, of the number of Native women who disappear and are sexually abused by non-Indians and how their abusers are never prosecuted, or of how.. of all the ethnic groups in this country.. there is not now nor has there ever been a data base compiled by the FBI or missing Native American women and children. Until this misconception of “free money” is addressed on a national level, fighting this work requirement will receive no sympathy, empathy or concern from the average American. In fact, most will say “About time they had to work for what they get like the rest of us.” Native Americans need a publicist to get concerns and truth to the “outside.” It is public opinion that appears to run the government today.

  • Craig S.

    When it suits them, the racist Trump Administration ignores federal law recognizing First Nations as Sovereign nations, otherwise cutting deeper into the budgets, rights and operations of the already underfunded, undermined health educational, religious and commercial resources and interests of the Nations.

  • Reader L.

    Time to help our young people understand a work ethic through education. What bothers me reservations ha e no rights to what they can do with the land that is held in trust. So the leadership had better find a way to create ways to work for profit. I don’t have any answers except to say get it together and decide what you can do for change.
    I understand it is a hard decision but something must change. We were spared the reservation life because my Great Grandfather said enough and went to work with his wife finally ending up owning a business in Missouri therefore able to help those on reservation. I would rather see our young people live and not die. Blessings to all never meaning to offend just concerned. You cannot blame the government for all rez problems. Haze

  • Stephen L.

    Most everything Trump and Republicans are pushing is European race war against non-Europeans. Trump and Republicans are against brown-skinned people coming up from the south. Trump and Republicans are against Native Americans protecting their land from oil polluters. Trump and Republicans are for NRA and guns, are for police shooting non-European citizens. Trump and Republicans are for European Jews taking Palestine away from Palestinians. It’s all about European race war that began 600 years ago and is still going on where Europeans want to own and control the world.

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Trump Administration Supports Changing Indian Health Programs That Will Sabotage Treaty Rights

URL: https://indiancountrymedianetwork.com/news/native-news/trump-administration-supports-changing-indian-health-programs-will-sabotage-treaty-rights/