There has been much controversy about the Affordable Care Act, what some call Obamacare. The politics are beyond intense. And those computer glitches are making it virtually impossible for people to enroll.
But for American Indians and Alaska Natives there is a whole different story to tell about the Affordable Care Act. Native Americans have a right to health care. This is a deal the United States made, a promise that including sending doctors to the tribes that signed treaties in exchange for peace and for titles to lands.
Promise or not, treaty or not, the entire history of healthcare in Indian Country has been defined by shortages. There has never been enough money to carry out that sacred bargain.
The modern Indian Health Service was created in 1955. And over the following decades, more clinics were built, more doctors were hired, and health care for Native people improved. Still, the agency never had enough money.
In 1965 when Medicare and Medicaid were enacted into law there wasn’t even consideration about how these programs would impact American Indians and Alaska Natives. The Indian Health Service could not bill the agencies for serving eligible services. Native Americans were essentially left out of that health care reform effort.
That history of shortages is critical context to understanding the Affordable Care Act. Because from the very beginning of the legislative process, the Affordable Care Act included Indian Country. This happened because a decision was made by tribal leaders to roll the Indian Health Care Improvement Act into the larger legislation.
“Let me tell you why it was different this time,” said Jacqueline Pata, executive director of the National Congress of American Indians. For nearly twenty years tribes urged Congress to reauthorize the Indian Health Care Improvement Act. Then the discussion began about a health care reform.
“We were sitting at an NCAI board meeting, tribal leaders around the table, and said we really have to engage in this health care debate this time around. There were those that said, “no, let’s stay where we are,’” she said. But former NCAI President Jefferson Keel knew the health care industry and he agreed with the broader approach. “So we immediately started to look at the overall health care bill, working with the members of Congress, to be able to find all those other places that it was important to insert ‘and tribes.’ So not only did we get Indian Health Care (Improvement Act) reauthorized permanently. But we were able to get provisions into Medicaid, we were able to get the tax exemption (for tribes that purchase insurance for members), we were able to include a lot of places where tribes should have been considered but probably wouldn’t have been if we didn’t integrate those two pieces of legislation.”
But there still is a question of why? Why American Indians and Alaska Natives need insurance of any kind when there is a treaty right, a statutory call to healthcare, that transcends this latest national experiment? Then recall the long history of shortages. The Indian health system has never been adequately funded, probably less than half of the appropriation that would bring about some sort of parity with other federal health systems.
The main idea in the Affordable Care Act is to require health insurance for all Americans because that lowers the cost for everyone, the so-called “mandate.” But American Indians are exempt from that mandate (even if the Indian health system does not count as insurance). So the way that exemption works, this year at least, is that American Indians and Alaska Natives will have to fill out forms for an exemption (once granted, it’s a lifetime deal). The good news here is that the whole website mess does not apply.
Then insurance itself is a complicated idea for Indian Country. What is called “third party billing” has been a small, but growing part of the financial resources for the Indian health system.
You see there is this odd American idea that links health insurance to our jobs. That’s how most Americans now get their health care -- and will continue to do so even under the Affordable Care Act. But that one element is a big difference for Indian Country. Only 36 percent of American Indians and Alaska Natives have insurance purchased through work -- that’s half the rate for most Americans -- and 30 percent of us have no insurance at all. (more…)