"No experiment can be more interesting than that we are now trying, and which we trust will end in establishing the fact, that man may be governed by reason and truth. Our first object should therefore be, to leave open to him all the avenues to truth. The most effectual hitherto found, is the freedom of the press. It is, therefore, the first shut up by those who fear the investigation of their actions." --Thomas Jefferson to John Tyler, 1804.

Transparency and the ACA

trahant MARK


The Affordable Care Act is a grand promise. Basically it’s a complicated insurance mechanism that’s designed to reduce the number of uninsured Americans, including those who rely on the Indian health system.

But one thing the ACA is not: Transparent.

This is a critical flaw because we are near another major deadline — March 31 — and some six months into the Act’s implementation and there is not one official scrap of information reporting how well Indian Country is being served. We don’t know how many folks across the country have signed up for Medicaid or how many have purchased insurance or how many individuals have policies that were purchased by tribes as sponsors.

Why does this matter? Because policy is being implemented on assumptions, not data. We don’t know what we don’t know.

This we do know: March 31 is an odd deadline. It’s the day when open enrollment ends for most Americans, including Native Americans who are not tribal members. But that deadline does not apply to American Indians and Alaska Natives who are tribal members. Then a monthly enrollment is possible. (I know, confusing, right?)

Native Americans still can receive a life-time exemption from the insurance mandate. Fill out a simple form and mail to get a certificate that could be included in your next tax return.

But we also know that the individual exemption is not enough. The Indian health system is underfunded and third-party billing — money from private insurance, Medicaid, Medicare, and other programs — is the only way funding will improve. Like it or not, Treaty or not, the Congress is not going to pay for Indian health through appropriations. The $6 billion budget for the Indian Health Service shows the agency collecting more than a billion dollars from Medicaid and only $90,307,000 from private insurance. So there is a lot of room for growth. Again, if folks sign up, the Affordable Care Act is a different course from appropriations; it’s a money stream that’s automatic.

We also know that Indian Country has some of the highest uninsured rates in the nation, roughly one in three people. So every new insured American Indian and Alaska Native adds resources to the Indian health system (and especially medical care that is purchased outside of Indian health facilities).

This week there is a last minute push to get people in Indian Country to sign up. On Monday there was a national Tribal Day of Action sponsored by the White House. And in Montana, the state’s Insurance Commissioner, Monica J. Lindeen, has been traveling to the state’s reservations and urban Indian centers to sell the plan.

But it’s hard to know how well those efforts are working. There are too many questions: How many people signed up early? What’s the goal? Where is the transparency?

Early Affordable Care Act numbers are found in Washington state. Ed Fox, who directs health services for Port Gamble S’Klallam Tribe of Washington, said the Washington Health Care Authority released preliminary figures to tribes for consultation. These are early numbers and will change, but they are an open important look in a state where the Affordable Care Act is working.

Some key findings: Washington probably ranks first in the nation in Medicaid “take-up” for the newly eligible. Some 6,000 or so of the newly insured Native Americans were enrolled by urban programs or tribes, and one-third with state worker assistance, and one-third a bit uncertain (possibly by someone with assistance or on their own). Washington also shows some 7,000 Medicaid re-certifications.

Washington’s data indicates that American Indians and Alaska Natives are slow to buy insurance through the exchanges or qualified health plans, less than five hundred (compared to more than 13,000 for Medicaid).

Fox said this could be seen as a “dismal failure,” but he suggests it’s more complicated that that. People at the state have made a tremendous effort to inform people about these plans, and the numbers might not reflect what’s really occurring. For example a purchased insurance plan requires the company to report and that might take longer than Medicaid data to be complete.

Of course Washington is a state that is passionate about making the Affordable Care Act work. Indian Country has benefited already because of the expansion of Medicaid, the driver of people getting new benefits under the law.

Unfortunately about half the states have not expanded Medicaid — and that will result in far fewer people in Indian Country receiving benefits under the Affordable Care Act. But, again, that’s back to the realm of data we don’t know.

The Affordable Care Act is complicated and its full implementation is going to take a while as customers in the Indian health system adapt to the new landscape. But this much is certain: Transparency would make this whole enterprise a lot easier.

Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of The Shoshone-Bannock Tribes. Comment on Facebook at: https://www.facebook.com/TrahantReports

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