Writings and observations

Missed opportunities

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A new White House report details the economic impact of Medicaid expansion and is sharply critical of the 22 states that have not done so. The report is titled, “Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid.”

I like that: Missed opportunities. Why? Because this Council of Economic Advisers’ 44-page report fails to include any calculation of Indian Country as one of those missed opportunities.

I get that the population of American Indian and Alaska Natives is small, one percent or so. But you cannot build an economic case for Medicaid in Alaska, Oklahoma, Montana, North Dakota, South Dakota, Arizona, New Mexico (and even Washington and Oregon) without at least back of the envelope estimates. This is important because of the way Medicaid is structured; it’s a shared partnership between the states and the federal government. However American Indians and Alaska Natives are eligible for a 100 percent federal match, so the money spent by a state Medicaid program is fully reimbursed by the federal government.

This system, of course, makes no sense. And it’s probably why the White House failed or forgot to include Indian Country. A much sounder approach would be for the Indian health system — whether federal, tribal, urban or nonprofit — to get funding and administrative rules directly from the Centers for Medicare and Medicaid Services. Then Alaska, Oklahoma, or the other states that are currently rejecting Medicaid expansion would lose their say about what happens to American Indian and Alaska Native patients.

Let’s dig deeper into the White House report — then I’ll add numbers and context.

The administration is quite right to hail the Affordable Care Act’s economic success story. “Since the law’s major coverage provisions took effect at the start of 2014, the nation has seen the sharpest reduction in the uninsured rate since the decade following the creation of Medicare and Medicaid in 1965, and … the nation’s uninsured rate now stands at its lowest level ever.”

However 22 States—including many of the states that would benefit most—have not yet expanded Medicaid (although Montana has passed legislation to expand Medicaid and is working with the Centers for Medicare and Medicaid Services to determine the structure of its expansion). These 22 States have seen sharply slower
progress in reducing the number of uninsured over the last year and a half, and researchers at the Urban Institute estimate that, if these States do not change course, 4.3 million of their citizens will be deprived of health insurance coverage in 2016.”

In Indian Country, the big three non-expansion states are Alaska, South Dakota and Oklahoma.

The Alaska Legislature recently adjourned without a vote on Medicaid expansion (a measure was proposed by Gov. Bill Walker). But an expansion may be still possible if the governor acts without legislative approval.

The White House report estimates Alaska would gain some $90 million in federal funds by expanding Medicaid. But that number, I believe, misses out the intersection between Medicaid and the Indian health system. The Alaska Native Tribal Health Consortium estimated that 41,500 Alaskans would be eligible for Medicaid — including 15,700 Alaska Natives and American Indians. In other words, more than a third of potential enrollees are eligible for a 100 percent federal reimbursement. Forever.

The numbers are similar and striking in South Dakota and Oklahoma.

The White House report says health insurance also reduces the risk of death. “This analysis estimates that if the 22 states that have not yet expanded Medicaid did so, 5,200 deaths would be avoided annually once expanded coverage was fully in effect. States that have already expanded Medicaid will avoid 5,000 deaths per year,” the report says.

This is a bit complicated, but I doubt if that number includes American Indians and Alaska Natives who are at risk of death because of funding shortages in the Indian health system. What’s now called Purchased and Referred Care is better funded than it has been in recent years, but that budget line still runs out of money for some patients needing specialty care outside of the Indian health system.

But the key point is that the Indian health system is underfunded and as the Kaiser Family Foundation noted “not equally distributed across facilities and they remain insufficient to meet health care needs.”

That unevenness is dangerous for the Indian health system — and it’s states that are limiting dollars by refusing to expand Medicaid.

We are seeing the evidence about how the Indian health system is picking up additional resources in states where there has been Medicaid expansion. In Washington, for example, I recently reported that tribal health facilities have increased their Medicaid funding by nearly 40 percent since expansion. This is new money in an era of austerity and it’s automatic funding that does not require appropriation from Congress.

Of course it would be ideal if the White House was making this case with hard numbers. The Indian health system is a federal obligation,— a Treaty right — that does not cost states. Yet states are setting the rules, so at the very least our advocate ought to be chronicling the impact. A missed opportunity.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

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