The problems within the Indian Health Service (IHS) are well known. The Senate Special Committee on Indian Affairs held a hearing in February on the problems facing IHS, and have posted a video of the hearing, available on the Committee’s website. The footage shows hours of testimony from individuals and leaders detailing personal accounts and systemic issues within the IHS system. Despite this recent hearing, some solutions are appearing, but not where you might expect: The Affordable Care Act (ACA). Sarcastically called, “Obama Care,” by its opponents, the ACA can address many of the issues facing enrolled Tribal members, as well as helping IHS with it’s funding shortfalls.
One of the most significant issues facing IHS is chronic under funding. As Mark Trahant puts it in his 2010 article, "The Indian Health Paradox," “The IHS has a frugal nature. The agency spends roughly $2,130 per-capita – about the same as the average for other industrial nations. But that compares to the $3,242 for federal prison inmates, $4,653 at the Veterans Administration and $7,784 for Medicare.” Of course, the cost of healthcare in the United States is a discussion in its own right, as Dan Murno reported in Forbes January 4, 2015, “… 2015 looks to be the first year healthcare spending will reach $10,000 per person.” That is a separate issue however, as this discrepancy clearly leads to problems within our current system, a system that funds healthcare differently based upon who is using it.
Medicaid is an entitlement program and, ignoring the negative connotation those words have taken on, funding is guaranteed for the program. This is not the case for IHS. Despite the fact that access to healthcare for Tribal members is guaranteed by treaty rights and Federal legislation, such as the Snyder Act, IHS receives its funding through appropriations, which means that it can (and does quite often) run out of money. This results in medical centers being put on “deferment,” and sending patients away without receiving care. Despite the ominous predictions for death-panels and rationed care that elected officials were all too eager to spout before ACA took effect, the government hasn’t had a problem to allow Tribal members to live under those conditions for decades
However, the ACA offers solutions for Tribal members facing the hurdles of IHS. According to Imram Cronk and Janet Weiner in the article, The Affordable Care Act and Minority Health: Part V (American Indians/Alaskan Natives):
The ACA addresses the needs of this population in a variety of provisions. First, it permanently reauthorizes the Indian Health Care Improvement Act (IHCIA), the legal foundation of the commitment to provide health care to this population. Changes to the IHCIA expand programs and services for the 2.2 million Native Americans the IHS serves, and authorize IHS-operated hospitals and outpatient facilities to bill Medicare and Medicaid for services delivered.
Native Americans who enroll in marketplaces plans enjoy special benefits under the ACA. Among them:
· Cost sharing. Native Americans under 300% of the federal poverty level have zero cost sharing. Those who are enrolled in marketplace plans also have zero cost sharing for services received from qualified Indian health providers.
· Year-long enrollment. The enrollment window does not close. Native Americans can sign up for marketplace plans at any time in the year.
· Exemption from individual mandate. Most Native Americans who do not purchase insurance are exempt from individual shared responsibility payments required by the IRS. A form must be completed.
What the individual will see when signed up with insurance through the ACA is improved access to health care by being able to go to non-IHS hospitals. These plans have special rates for enrolled members based upon income. IHS also see’s a benefit in being able to bill Medicare and Medicaid for services, allowing them to maintain better funding.
It may seem odd that tribal members must go outside of the IHS, the institution that is intended to fulfil a treaty right, to receive medical care. And, of course, the ACA doesn’t fix all of the health care concerns facing life on Reservations, far from it. But until the United States government becomes serious about honoring promises made to Tribes and their people, it seems that the ACA can help. Perhaps the notion that American Indians should have separate health care will go by the wayside as healthcare and access to it improves for everyone. But, at least for now, the reasons for IHS and the disparities that exist within our healthcare system must be understood.
Roger Birdbear is a member of the Three Affiliated Tribes. He also practices law, working with mineral rights leases, landowner representation, tort litigation, and criminal defense. His office is in New Town, North Dakota.