ACLU Calls for strong enforcement to ensure access for women
Source: American Civil Liberties Union
Washington, DC — The American Civil Liberties Union today commends Indian Health Services (IHS) for issuing an updated policy to ensure that Native American women can obtain Plan B emergency contraception at IHS facilities.
The update comes more than two years after a federal court ordered the FDA to approve Plan B One- Step as an over-the-counter drug for women of all ages (without a prescription), and more than five years after Native American women first reported that IHS facilities were failing to provide the women they serve adequate and appropriate access to emergency contraception.
“The updated policy IHS released today is a long overdue and important step toward ensuring that Native American women have equal access to emergency contraceptive care,” said ACLU Legislative Counsel Georgeanne Usova. “The policy must now be rigorously enforced so that every woman who relies on IHS for her health care can walk into an IHS pharmacy and obtain the services she needs and to which she is legally entitled.”
An investigation by Sen. Barbara Boxer’s staff earlier this year found repeated examples of IHS pharmacies’ failure to comply with the up-to-date FDA guidelines, and a separate survey conducted by the Native American Women’s Health Education Resource Center last year found similar results. Some pharmacies surveyed did not offer emergency contraception at all; others required a prescription; and others wouldn’t provide it to women based on their age.
For some Native American women, if emergency contraception is unavailable at their IHS facility, the next alternative may be hundreds of miles away. However, emergency contraception is most effective the sooner it is taken, with effectiveness decreasing every 12 hours. The distance and potentially insurmountable transportation costs make timely access to emergency contraception difficult, if not impossible, for many women.
In addition, statistics show that more than one in three Native women will be raped in their lifetime — more than double the rate reported by women of all other races. A woman who is sexually assaulted and relies on IHS may not be able to take necessary steps to prevent a pregnancy that occurs as the result of rape.
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.
OPINION: The Affordable Care Act continues to evolve and improve, but more important, as more states expand Medicaid, they add real dollars to the Indian health system. 401(K)2013 / cc via flickr
These days “new” money is hard to find. That’s the kind of money that’s added to a budget, money that allows programs to expand, try out new ideas, and look for ways to make life better. Most government budgets are doing the opposite: Shrinking. Calling on program managers and clients alike to do more with less.
That’s why the news from Alaska last week is so exciting: Alaska’s new governor announced the expansion of Medicaid and this will significantly boost money for the Alaska Native medical system. Indeed, the significance of this announcement to the Indian health system was clear when Gov. Bill Walker and Department of Health and Social Services Commissioner Valerie Davidson made the announcement at the Alaska Native Medical Center on July 16. The governor took this action using executive authority because the Alaska Legislature had failed to even vote on legislation to accept Medicaid.
The governor says Medicaid expansion would reduce state spending by $6.6 million in the first year, and save over $100 million in state general funds in the first six years. “Every day that we fail to act, Alaska loses out on $400,000,” the governor said. “With a nearly $3 billion budget deficit, it would be foolish for us to pass up that kind of boost to Alaska’s economy.”
“We know Gov. Walker has worked tirelessly to expand Medicaid since he came into office on December first,” Davidson said at the news conference. It was one of the campaign promises made by the independent governor. “He included it in the budget. He introduced a bill both in the House and in the Senate side. It was a subject of both special sessions. And, it’s the right thing do do for Alaska.”
The expansion of Medicaid is one of key components of the Affordable Care Act. It’s critical a tool for the Indian Health System because it opens up a revenue channel for clinics and hospitals to bill Medicaid, a third-party insurance, for services. That boosts budgets at the local level, in a political climate where Congress is unlikely to spend more money on Indian health. How big a number? More than a million American Indians and Alaska Natives are now insured by Medicaid. The Kaiser Family Foundation estimated in 2013 that Indian health facilities collected $943 million in third-party payments.
“By far the largest third-party payer is Medicaid, which accounts for $683 million or 70 percent of total third-party revenues, and 13 percent of total IHS program funding for FY2013,” Kaiser reported. Nearly 150,000 Alaska Natives and American Indians receive health services across the state from tribal and nonprofit health organizations funded by the Indian Health Service. By law IHS-funded clinics must seek third-party billing from patients, such as Medicaid, the Veterans Administration or private, employer-based health insurance.
Medicaid is an odd program for Indian country. Most of us understand the IHS to be the government’s fulfillment of its treaty obligations. However the agency has never been fully funded. Medicaid, however, is an unlimited check. If a person is eligible, then the money is there. Yet states, not tribes nor the federal government, determine the rules for Medicaid. And many Republican states have been determined to fight the Affordable Care Act, or “Obamacare,” at every turn, and that means refusing to accept Medicaid expansion (the U.S. Supreme Court ruled in 2012 that states could turn it down).
Alaska’s decision means the number of states rejecting Medicaid is continuing to shrink. Most recently, Montana agreed to expand Medicaid in April. The states with large American Indian and Alaska Native populations that have not expanded Medicaid include Oklahoma, South Dakota, Wisconsin, North Carolina, Maine, Wyoming, and Idaho. Utah is the next state considering an expansion.
The Affordable Care Act continues to evolve — and improve. But more important, steps that states are taking to expand Medicaid are adding real dollars to the Indian health system.
Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. He served two terms as the Atwood Chair of Journalism at the University of Alaska Anchorage. For updated posts, download the free Trahant Reports smartphone and tablet app.
The views expressed here are the writer’s own and are not necessarily endorsed by Alaska Dispatch News, which welcomes a broad range of viewpoints. To submit a piece for consideration, emailcommentary(at)alaskadispatch.com.
(CN) – The Pyramid Lake Paiute Tribe in remote northwestern Nevada won partial federal funding for its emergency medical services program serving the Fort McDermitt Tribe.
U.S. District Judge Christopher R. Cooper on Tuesday partially granted the tribe’s motion for summary judgment in its complaint against the Secretary of Health and Human Services and the Indian Health Services, which denied it funding this year.
The Fort McDermitt Paiute and Shoshone tribes, collectively called the Fort McDermitt Tribe, live in a small, remote community along the Nevada-Oregon border, where Indian Health Services (IHS) has operated a tribal health clinic since the 1970s. The clinic provides primary medical, dental and mental health care and drug and alcohol treatment programs.
The IHS has provided emergency medical services for the tribe since 1993, but the program’s costs increased greatly after a 2010 IRS rule requiring contract workers to be classified as employees, Judge Cooper Found. In 2012, the EMS incurred $502,611 in costs against $102,711 in revenue. The difference was paid through clinic revenue and IHS discretionary funds.
The Fort McDermitt Tribe last year designated the Pyramid Lake Tribe as its tribal organization in accordance with the Indian Self Determination and Education Assistance Act. Cooper says the Pyramid Lake Tribe requested $502,611 plus another $196,739 for startup costs and $136,139 for contract support costs from the IHS.
Previously, the Fort McDermitt Tribe designated Humboldt General Hospital as its base hospital for emergency medical services, but Cooper says the hospital in August 2013 notified the IHS it no longer would be the tribe’s base hospital.
“The agency explained that IHS had ‘ceased operation of the Fort McDermitt emergency medical services program’ due to its large operating deficit. Because IHS had discontinued the program, it reasoned that the base amount available for contracting was zero,” Cooper wrote in his 15-page opinion. “It therefore declined the tribe’s proposal as being ‘in excess of the applicable funding amount.'”
The Pyramid Lake Tribe responded by suing the IHS and Health and Human Services “seeking to require IHS to enter into a self-determination contract with the tribe to operate the Fort McDermitt emergency medical services program.”
Both sides sought summary judgment. HHS Secretary Sylvia Burwell also sought dismissal, “for failure to join indispensable parties, namely, other area tribes whose funding may be affected by the outcome of the case.”
Cooper held a hearing on the motions on Aug. 28.
Summing it up, Cooper wrote that Burwell “argues that because the tribe’s proposal implicates the budget for other tribes served by IHS in the region, each of these tribes is a necessary party to this action. She reasons further that because the other tribes are protected by sovereign immunity, they cannot be joined and the case therefore must be dismissed.”
After citing four other cases in Native American law, Cooper says: “The Secretary’s position is that the Pyramid Lake Tribe’s proposal would unfairly benefit the Fort McDermitt Tribe by enabling it to receive more than its share of funding, to the detriment of neighboring tribes.”
The judge says Burwell “argues in her motion for summary judgment that IHS calculates funding for programs based on the ‘tribal share’ that supports the programs that are to be transferred to the tribe” and “contends that the funding level in the Tribe’s proposal was in excess of the tribal share IHS determined the Fort McDermitt Tribe was entitled to receive.”
Burwell claims that share amount came to just $38,746, according to Cooper’s analysis. The judge added that Burwell “argues even if the emergency medical services program remained in existence,” the Pyramid Lake Tribe’s proposal exceeded that sum.
However, “IHS never advanced this tribal share argument in declining the tribe’s proposal,” Cooper found. “It cannot now be used as a post-hoc to justification for the agency’s decision.”
In denying Burwell’s motions and partially granting the tribe’s, Cooper says that while “the court will issue an order declaring that the Secretary violated the ISDEAA by denying the tribe’s proposal outright, it will not direct her to enter into the tribe’s contract at the 2012 amount.”
“Rather, it will direct the Secretary to negotiate with the tribe over what the Secretary ‘would have otherwise provided’ for the emergency medical services program had IHS continued to operate it, plus the administrative and startup cost.”
Tulalip TV’s Tulalip Health Watch will air this summer and will focus on health issues Native Americans face today. Photo/ Brandi N. Montreuil, Tulalip News
TULALIP, WA – Tulalip TV viewers will soon be able to watch a new informational program called “Tulalip Health Watch,” which focuses on health issues Native Americans face today.
In the program’s first episode, “Diabetes,” the disease is examined through interviews with health professionals at the Tulalip Karen I. Fryberg Health Clinic. Viewers will learn the fundamental characteristics of diabetes, along with resources available for testing, prevention, and treatment.
Diabetes affects 57 million Americans, and only 8.3 percent are diagnosed. But more shocking are the epidemic proportions of diabetes in Indian Country with 16.2 percent Native Americans and Alaska Natives diagnosed.
According to the U.S. Department of Health and Human Services and Indian Health Service, Native Americans are at a 2.2 times higher risk than their non-Indian counterparts. Between 1994 and 2004 there was a 68 percent increase in diabetes diagnosis in American Indian and Alaska Native youth, aged 15-19 years old.
In “Diabetes,” viewers will learn how a poor diet, lack of regular exercise, and a genetic pre-disposition are the leading contributing factors for 95 percent of American Indians and Alaska Native with Type 2 diabetes, and 30 percent with pre-diabetes.
Viewers will also learn how clinic staff incorporates Tulalip culture and traditions into programs available at the clinic for diabetes education, prevention, and management.
“The providers that we have here are great. The Tribe is putting money into this clinic and our goal is to be here with an open mind and heart, and to be a partner here for them regarding their health needs. We have a collaborative team here that you don’t see at other clinics,” said Bryan Cooper, Tulalip Karen I. Fryberg Health Clinic Nurse Practitioner in “Diabetes.”
“Tulalip Health Watch,” will air this summer. Future episodes will explore heart disease, obesity, and other health issues Native Americans face.
You can watch “Tulalip Health Watch” on Tulalip TV at www.tulaliptv.com or on channel 99 on Tulalip Cable.
Brandi N. Montreuil: 360-913-5402; bmontreuil@tulaliptribes-nsn.gov
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.”
October 20, 2013