Native American Health Care

UPDATES:
  • New informational materials on healthcare reform – The Center has developed new materials and put them on our Healthcare Toolkit & Trainings web page. Feel free to print and distribute these materials and check back for updates. (August 2013).
  • Tribal Consultation Meeting about Medicaid Expansion on August 29, 2013 – The Human Services Department will be meeting with tribal leaders and officials in a day-long session to discuss Medicaid and the Affordable Care Act, at the Balloon Museum  from 9:00-3:00 (August 2013)
  • HSD Medicaid “Centennial Care” materials contain inaccuracies – Native American leaders have expressed serious concern that presentations, brochures and an FAQ being distributed by the Human Services Department fail to provide clear information about Medicaid Expansion, the fact that people can start applying on October 1, 2013, and that Native Americans do not have to enroll in managed care organizations (MCOs). The state’s informational materials on Centennial Care can be found here. Comments about these materials can be sent to: Theresa.Belanger@state.nm.us and Julie.Weinberg@state.nm.us (August 2013)
  • Native American convening on key issues with healthcare reform – The Center hosted a gathering for over 150 tribal leaders, healthcare providers, and advocates to discuss key concerns and advocacy steps for healthcare reform implementation in New Mexico. Learn about these priorities from the Medicaid handout, Exchange handout, and Outreach & Enrollment handout. Contact information for Medicaid and Exchange officials and committees are available in this contact sheet.
  • Working together for healthcare – Join our email list and get updates and alerts by contacting Evelyn Blanchard at Evelyn@nmpovertylaw.org (June 2013).
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OVERVIEW OF INDIAN HEALTH SYSTEM

The federal government has a special obligation under numerous treaties and by statute to provide healthcare coverage to all Native Americans. Over the course of two centuries, Native Americans ceded over 500 million of acres of land in return for certain promises and protections from the U.S. government including the guarantee of healthcare coverage. Healthcare for Native Americans is delivered through the Indian health system – a system that is known and trusted in Native communities and that maintains a reputation of providing culturally competent services. It is funded by Congress through Indian Health Services (I.H.S.). The entire system includes IHS facilities, tribal health providers, and Urban Indian organizations — collectively known as “I/T/U”. However, I.H.S. remains chronically underfunded.

As a result, healthcare services vary widely in different areas. For example, emergency care or specialty services may be unavailable. If Native Americans seek care from non-Indian health providers or hospitals, the bills will be paid only if approved through “Contract Health Services”.  These claims are often denied to a lack of funding and strict regulations about who can access services.  See this flowchart that illustrates the complex eligibility rules. Native Americans that live off-reservation (“Urban Indians”) often cannot qualify for contract health services. As a result, thousands of Native Americans in New Mexico are in medical debt to non-Indian health providers and hospitals. Learn more about the difficulty that Native Americans living in Albuquerque have with accessing healthcare in the Center’s report on “Off Reservation Native American Access to Health Care in Albuquerque.”

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HEALTHCARE REFORM FOR NATIVE AMERICANS

In 2010, Congress passed the Affordable Care Act which promises new healthcare coverage and consumer protections with health insurance. In New Mexico, over 350,000 uninsured people will be able to access free or low cost healthcare through the expansion of Medicaid and a new marketplace called the “Health Insurance Exchange”. Over 45,000 Native Americans will be able to get healthcare coverage through Medicaid or the Exchange. This will help strengthen the Indian health system by bringing in new sources of funding. Native Americans will also be able to access to comprehensive healthcare services. Native Americans cannot be charged fees for Medicaid, and most Native Americans who seek health insurance on the Exchange will qualify for free coverage. Find more information on our Healthcare Toolkit & Trainings web site and our web page about healthcare reform.

Trainings and Outreach Materials: The Center provides trainings and materials about healthcare coverage for Native Americans. Please contact Evelyn Blanchard at 505-255-2840 or evelyn@nmpovertylaw.org for more information. Trainings can be provided to groups of 10 or more people and customized for each audience. Please see our Healthcare Toolkit & Trainings web site for our materials that can be printed and distributed widely.

Health Reform Advocacy: The Center has been working closely with tribal leaders, health providers, and advocates to ensure that health care reform implementation efforts in New Mexico protect the rights of Native Americans. In November 2012, the Center held a convening that resulted in tribal leaders developing and passing a resolution for Governor Martinez to support Medicaid expansion. One key objective now is to ensure the Exchange and Medicaid effectively serves Native communities and obtains meaningful consultation and input.  The Center is working with a statewide network of Native American leaders, providers and advocates to provide information and technical assistance on issues that arise with health reform implementation.

Native Convening: On June 27th, 2013 at the Indian Pueblo Cultural Center, the Center hosted a group of over 150 Native American leaders, health system administrators and workers, and interested parties to address questions about healthcare reform and develop strategies for future healthcare work. The following are the materials disseminated at the Convening, and the presentation slides. Please feel free to copy, print and share these resources widely:

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MEDICAID AND NATIVE AMERICANS

Medicaid is a public program that provides healthcare coverage for low-income people in New Mexico. Over 90,000 Native Americans are enrolled in Medicaid now, and over 25,000 more Native American adults will qualify for Medicaid when the program expands on January 1, 2014. The Indian health system relies heavily on Medicaid funding – with over 60% of total costs being paid by Medicaid. Indian healthcare providers benefit when Native Americans enroll in Medicaid – the new revenues can be used to strengthen the healthcare infrastructure in Native communities. Native Americans who enroll in Medicaid also get access to comprehensive coverage that pays for care outside the Indian health system without needing a referral through contract health services. Learn more about through our graph that shows the relationship of Medicaid to the Indian health system.

Centennial Care Advocacy:  In 2011, the New Mexico Human Services Department launched a plan to “redesign” the Medicaid program. This plan called “Centennial Care” would have required everyone to enroll into managed care organizations (insurance companies that coordinate care for patients), imposed new fees and co-pays on low-income people, eliminated retroactive coverage that pays for prior medical bills, and made other changes that are not allowed under federal law. Instead, the state had to seek a “waiver” of the federal law from the Centers for Medicare and Medicaid Services (CMS) to get permission to carry out the proposals.

While some features of the plan were well-received by the public, many proposals were controversial because they would harm Medicaid recipients. The Center worked closely with tribal leaders, healthcare providers and Native American advocates to oppose these changes, to ensure meaningful tribal consultation, and to request that the federal Centers for Medicare and Medicaid Services (CMS) reject several proposals to redesign Medicaid. The Center worked with a statewide network of Native leaders and advocates, shared information and strategies, and worked with CMS to detail the reasons why the state’s proposals should be rejected and why the federal government must defer to tribal leadership in Medicaid policy matters. See our final comments to CMS.

Our collective efforts were successful – in 2013, CMS announced that the state could not require Native Americans to enroll in managed care except for people who need long term care services. HSD clarified that Native Americans could not be charged co-pays and HSD withdrew its request to eliminate retroactive coverage in Medicaid after pressure to do so from CMS.

Despite these victories, there are still serious concerns about mandatory managed care. Native Americans can be placed in managed care for long term care services and materials from HSD about Centennial Care do not clearly inform Native Americans that they do not have to enroll in managed care. The state could also attempt to get federal approval for managed care again in the future. As a result, tribal leaders pushed for state legislation in 2013 sponsored by Representative Roger Madalena that would prohibit mandatory managed care for Native Americans. The Center took a large role in organizing efforts to support this bill. The bill passed the House and two Senate committees before stalling at the Senate Finance Committee in the very last days of the legislative session. The bill may be reintroduced in 2014.

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UNM HOSPITAL AND URBAN INDIANS

The Indian Health Services (I.H.S.) has suffered from chronic under-funding and was forced to drastically cut services at the Albuquerque Indian Hospital in 2005, leaving many Native Americans without access to critical healthcare services. However, the University of New Mexico Hospital (UNMH) is obligated by a 1952 contract to provide priority access to healthcare for Native Americans – a unique agreement that sets Albuquerque apart from other urban communities across the country. Indian land was transferred to Bernalillo County for the purpose of building what is now the University of New Mexico Hospital. In return for the land, Bernalillo County became obliged by the 1952 contract to provide healthcare services to all Native Americans in the area, and to provide priority access to services for Native Americans, making available at least 100 beds for Native Americans when needed. UNMH has taken over the operations of the hospital but remains bound by the contract. The hospital is required to seek payment for services from the federal government. Read the lease agreement between Bernalillo County and UNMH, in which the 1952 federal contract is attached as Exhibit E.

Learn more about the hospitals’ obligation in the Center’s report on “Off Reservation Native American Access to Health Care in Albuquerque.” The Center has worked with Native American advocates in Bernalillo County for many years to urge UNMH to comply with these contractual obligations.  The Hospital has no policies in place for admitting Native Americans for priority access to health care services or for billing the federal government in accordance with the contract. In response to public pressure, UNMH engaged in an outreach campaign to reach Urban Indians in Albuquerque and developed an office for Native American Health that helps patients with billing matters. Despite these steps, UNMH continues to routinely turn away uninsured Native Americans, or treat them and then send them the bill, neither of which are permissible under the 1952 contract. In addition, the federal government, through Indian Health Services, has failed to pay the hospital for the healthcare of Native Americans. This situation is likely to be improved with healthcare reform implementation that will expand Medicaid coverage for Native Americans and provide free or low cost options for health insurance through the Exchange. However, UNMH must continue to serve as a safety net for Native Americans who do not have coverage.

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