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Tribes scramble to avoid $1 million in fines under Affordable Care Act

Diabetes patient Jay Littlewolf says he sought medical help for a diabetic ulcer at a Billings hospital after not receiving "adequate health care through the IHS in Lame Deer." He wants reimbursement from the IHS and sought Sen. Jon Tester's assistance.Photo/Larry Mayer, Gazette staff — Diabetes patient Jay Littlewolf says he sought medical help for a diabetic ulcer at a Billings hospital after not receiving “adequate health care through the IHS in Lame Deer.” He wants reimbursement from the IHS and sought Sen. Jon Tester’s assistance.
Photo/Larry Mayer, Gazette staff

BILLINGS – Montana’s Indian tribes, which until recently thought the Affordable Care Act would pass them by, could face fines exceeding $1 million for not offering insurance to employees.

Beginning in 2016, businesses with 50 or more full-time workers will have to offer at least a minimum amount of health insurance to employees. Those who don’t comply face tax penalties, and that includes tribal governments.

The requirement has been a surprise to tribes, said George Heavy Runner, Blackfeet Insurance Services health and wellness coordinator. As individuals, American Indians have the option of choosing not to follow Affordable Care Act rules. Many assumed tribal governments, which are sovereign, had that same option.

“We thought this was a ship kind of passing us by,” Heavy Runner said. “But it’s not just a ship passing through the night. We have been identified in this legislation, just not where we thought we would be.”

Tax penalties facing the Blackfeet Tribe for not complying could be as high as $1.1 million. Crow Tribal Chairman Darrin Old Coyote said the size of the fee depends on how many people a tribal government employs.

“If we don’t do the mandate, we’re going to be fined for the number of employees we have, and that number could be up to $1.5 million,” Old Coyote said. “We pay federal tax, and our employees pay federal tax and so we’re part of the large employer mandate.”

The tribes can avoid the fees by offering the insurance to their workers. Old Coyote said the Crow have hired a benefits manager to do just that.

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The change caught tribes off-guard because American Indians by treaty receive health care via the Indian Health Service on reservations. IHS is much maligned by tribal members for not providing adequate health care and for not covering services by specialists outside the IHS program.

Because IHS is limited, tribal members who work for their government would benefit from having other health care, Old Coyote said. The challenge is having a health care plan to offer by next year.

Suing to get off the employer mandate has already been tried. In February, Wyoming’s Northern Arapaho Tribe failed to convince a federal judge to block the employer mandate. The Northern Arapaho argued that subjecting tribes to the employer mandate was an oversight that overlooked treaty rights related to Indian health care, while also stating that tax credits and benefits granted to Indians under the Affordable Care Act would be denied.

Earlier this month, U.S. Sen. Steve Daines, R-Mont., and U.S. Rep. Ryan Zinke, R-Mont., announced a bill to exempt tribes from the employer mandate. Daines called the mandate a job killer for tribal governments, who wouldn’t hire as many employees if they had to pay significant penalties.

Other sponsors of the bill, such as Republican Sen. John Thune, of South Dakota, said it was unfair to exempt individual tribal members and not exempt tribal governments as well.

However, exempting tribes from the employer mandate won’t help the nagging problems with Indian health care, said a representative for Sen. Jon Tester, D-Mont.

“This bill does nothing to solve the underlying problem, which is crisis-level health disparities among Native Americans,” said Marnee Banks. “If we are serious about increasing access to quality health care in Indian Country, we will expand Medicaid and adequately fund the Indian Health Service.”

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IHS spending on Indian patients was $2,741 per person in 2013, according to the National Congress of American Indians, which asserts that IHS is severely underfunded. Medicaid spending, by comparison was $5,841.

The state of Montana is awaiting federal approval of the state’s plan to begin offering Medicaid to Montanans earning up to 138 percent of the federal poverty level.

Medicaid expansion would extend benefits to as many as 11,000 tribal members over the next four years, said Jon Ebelt of Montana’s Department of Public Health and Human Services. The program would benefit tribal health care in general, Ebelt said.

“Medicaid expansion revenue will be critical for building health infrastructure, expanding the workforce, and keeping health care providers in tribal communities,” Ebelt said. “Medicaid revenues will bring new funds to the programs and further investment in the Indian health system infrastructure and workforce. This is an opportunity to provide more health care services, create more jobs and employ more Native Americans in tribal communities.”

Old Coyote said he’s concerned that state benefits representatives won’t be able to clearly explain the expanded Medicaid program to some Crow Indians who speak Crow as their primary language. He’s asked the state to provide a benefits representative who is fluent in Crow.

Ebelt said the state is able to provide translation assistance if necessary and in determining an outreach plan with members of the Indian Health Service at Crow Agency.

Native Americans may lack access to health insurance in Montana

Report highlights the disparity in insurance access among Native communities

By S. Vagus, Live Insurance News

A new report from the Alliance for a Just Society, Indian People’s Action, and the Montana Organizing Project suggests that Native Americans may not have as much access to Montana’s health insurance exchange as they should. Approximately 6.5% of Montana’s population is comprised of Native Americans, with an estimated 1.7% of enrollees in the state’s health insurance exchange falling into this demographic. The report highlights barriers that exist in the state that may be preventing Native Americans from receiving medical care.

There are significant barriers blocking Native Americans from the coverage that they need

The report notes that access to insurance coverage does not guarantee quality medical care. According to the report, the delay in expanding the state’s Medicaid program has prevented many people from receiving the care that they need, as a significant portion of consumers cannot afford coverage offered through the state’s health insurance exchange. The report also notes that there has been a significant lack in outreach to Native American consumers, which means that these consumers are not being made aware of the services offered by the state’s insurance exchange.

Efforts are underway to improve access to health insurance

In the earliest days of the state’s insurance exchange, Native American organizations were not provided with grants from the federal government that would pay for insurance navigators. These navigators are meant to assist consumers in enrolling for health insurance coverage through a state exchange. The navigators also provide information concerning the provisions of the Affordable Care Act and can provide some insight on the availability of subsidies being offered by the federal government. Without navigators, Native communities were unable to access the information that these navigators were meant to provide. Now, however, certified application councilors are available to take on the role of navigators.

Expanded Medicaid system may be helpful

Montana is still planning to expand its Medicaid system, but this could take time. Implementing the expansion may ensure that more Native peoples have access to health insurance coverage, but outreach efforts will have to increase if the state wants to ensure that these people are even aware of the expansion. Without outreach, many Native consumers may not know that they are becoming eligible for health insurance through Medicaid.

State, tribal leaders seek to expand Insure Oklahoma program to about 40,000 tribal members

By SEAN MURPHY, Associated Press

OKLAHOMA CITY — While state leaders remain steadfastly opposed to a Medicaid expansion offered under the federal health care law, some of Oklahoma’s 39 federally recognized Native American tribes are exploring opportunities for a federal waiver that could mean health insurance for about 40,000 low-income uninsured tribal members.

Oklahoma Health Care Authority CEO Nico Gomez said talks are underway about seeking an expansion of the state’s Insure Oklahoma program to include some of the estimated 80,000 Native Americans in Oklahoma without health insurance. Gomez estimated as many as half of those tribal citizens could qualify for the program, depending on where the income threshold is set.

Although still conceptual, Gomez said the idea would involve the tribal citizen paying a portion of the health insurance premium, the tribe paying a portion, and the federal government paying the largest part.

“We’re not looking at tapping into any state revenue, not now or in the future,” Gomez said. “Frankly, if it required any state revenue, I’m not sure we’d even be having this conversation.”

Gomez said the proposal was initially discussed last week with tribal representatives, and that he plans to brief members of the Health Care Authority’s governing board during its regular meeting on Thursday. Some of the state’s largest tribes, including the Chickasaw and Cherokee nations, are involved in discussions, Gomez said.

Insure Oklahoma provides health coverage to about 18,000 low-income Oklahoma residents, mostly through a program in which the cost of premiums are shared by the state (60 percent), the employer (25 percent) and the employee (15 percent). The state portion of the program is funded through a tax on tobacco sales, but a federal waiver that allows the program to operate has only been approved through the end of the year.

Gomez said expanding the program to include a tribal option could help ensure the federal waiver continues.

Billy James, a 31-year-old University of Oklahoma student and a citizen of the Chickasaw Nation, said he wants to have health insurance but can’t afford the premiums.

“I’m trying to hold out as long as I can,” said James, who is finishing his master’s degree and currently unemployed. “I’m kind of scared about not having insurance, but I’ve got to tough it out a little while longer.”

A spokesman for Gov. Mary Fallin, a staunch supporter of the Insure Oklahoma program, said the governor is excited about the potential of a tribal expansion.

“We’re particularly excited about the fact that it would not cost the state any tax dollars, which is important as we deal with our current shortfall,” Fallin spokesman Alex Weintz said.

Currently, there are about 130,000 Native Americans in the state’s Medicaid program, which is about 16 percent of the overall Medicaid population in Oklahoma.

Navigators help get Native Americans insurance

October 20, 2013

SIOUX FALLS, S.D. (AP) — Insurance enrollment helpers are encouraging Native Americans to sign up for coverage under the nation’s new health care law, saying it will help them better access X-rays, mammograms, prescription drugs and trips to specialists not covered under Indian Health Service.

American Indians are exempt from the Affordable Care Act’s requirement that people carry insurance, but the law opens up resources that for years have been limited through IHS, said Jerilyn Church, executive director of the South Dakota-based Great Plains Tribal Chairmen’s Health Board.

“There’s a huge gap in access to services, so being enrolled in the marketplace is going to make a big difference in terms of accessibility to health care,” Church said.

The Indian Health Service, a branch of the U.S. Department of Health and Human Services, provides free health care to enrolled members of tribes, their descendants and some others as part of the government’s treaty obligations to Indian tribes dating back nearly a century.

Critics long have complained of insufficient financial support that has led to constant turnover among doctors and nurses, understaffed hospitals, sparse specialty care and long waits to see a doctor.

The Great Plains Tribal Chairmen’s Health Board received $264,000 in South Dakota and $186,000 in North Dakota to assist with Native American signups on the states’ reservations and urban areas.

The new law health care law will especially benefit people who seek treatment at urban Indian health clinics, which collectively are funded by just 1 percent of the IHS budget, said Ashley Tuomi, executive director of the American Indian Health and Family Services clinic in Detroit.

“Our resources are extremely limited, even more so than the tribes,” Tuomi said. “What we have within our walls is what we can offer for free.”

The clinic has seen a lot of patient interest in the health care marketplace, but “navigators” helping with signups have had to cancel many appointments because of continued issues with the federal healthcare.gov website, Tuomi said.

The Ponca Tribe of Nebraska has received about $38,000 in federal grant funds to encourage signups for tribal members scattered in 12 counties in Nebraska, two in Iowa and one in South Dakota.

The tribe’s IHS-contracted clinic in Omaha, Neb., has a medical doctor and two nurse practitioners, but the X-rays, specialists and prescriptions that are outsourced are not covered, said Jan Henderson, the tribe’s navigator project director. “And if they don’t have insurance, they have to pay for it themselves,” she said.

Tribes across the country get some federal money for referrals, but the small pools run out quickly, Henderson said.

She views the new health care law as a great step for Native Americans, but the greatest challenge is educating tribal members who are weary from decades of promises of improved health care.

“Education is very important in this right now to get people to be open to actually hearing about it,” Henderson said. “We hear a lot of people who say they don’t need this, they don’t want this.”