Jim Roberts, Hopi
Brett Lee Shelton, Oglala Sioux Tribe

Federal Medicaid policy has evolved to incentivize cooperation and collaboration between state and tribal health systems while providing much-needed resources for health care for American Indian and Alaska Native (AI/AN) people. That policy is now under threat from a transparent attempt by the states to balance the budgets of their Medicaid programs with a money grab of federal funding that was meant to support Indian Health Service (IHS) and tribal health facilities

Members of the Senate Finance Committee have proposed to amend a tribal health provision in the Social Security Act, that would transfer to state Medicaid programs significant resources that were intended to help meet the United States’ obligation to provide health care to AI/AN people.

While the issue is technical, complicated, and probably boring for a lot of people to understand, its outcome should alarm every tribal leader, tribal citizen, and Congress. The measure is a dangerous precedent eroding the United States federal trust responsibility to tribal governments and to its citizens, and it undermines decades of progress under the most successful federal Indian policy in history.

In 1976, Congress amended the Social Security Act to allow Medicaid services provided to AI/AN people to be claimed by state Medicaid programs, at what is known as the 100% federal medical assistance percentage (FMAP.)

This means that, while states contribute from their own coffers to pay for Medicaid services provided to their state citizens, they do not bear the expense of services provided to tribal citizens in the Indian health system. Congress did this in express recognition of the federal trust responsibility towards AI/AN people, and designed the amendment to bring additional revenue into the overburdened Indian health system and allow it to gradually improve.

Congress accomplished fortification of the Indian health system by requiring that these services be “provided through” federal Indian Health Service (IHS) and tribally-operated health facilities.

Tribal governments have worked with federal agencies like the Centers for Medicare & Medicaid Services (CMS) and IHS under the existing 100% FMAP policy to improve the Indian health system’s capacity to deliver health care. With this program, tribes have constructed new health infrastructure, added new programs and services, expanded access, and improved healthcare quality—all while helping states achieve cost savings in Medicaid.

The policy has also led to unprecedented cooperation between state and tribal healthcare systems to maximize the benefits to both. This is critical in light of the fact that AI/ANs have some of the highest health disparities and lowest per-capita funding for health care of any subgroups in the nation.

Unfortunately, the Senate Finance Committee’s proposal, led by Senator John Thune (SD), would allow states to claim 100% FMAP even when services are not “provided through” IHS and tribal health facilities.

This is a political knee jerk reaction because one state—Thune’s South Dakota—has not been successful at working with IHS or tribal governments to maximize the benefits of the 100% FMAP policy. The policy has enjoyed success from both sides, state and tribal, across the rest of the country.

Thune threatens to eliminate a key incentive for states to work with tribal programs; and divert Medicaid program dollars away from tribal health programs. This creates an existential threat to the economic vitality of the Indian health system—along with starting us on the path of eroding the federal trust responsibility.

The simple fact that one state’s administrators can’t seem to get the job done under the rules should not give cause to tear down the whole system. Congress should not sacrifice the health care of AI/AN people in order to balance state budgets.

Thune’s gamble is that his political force is sufficient to overcome what is best for all the nation, in order to redress the implications of the administration of his state being unable, and likely unwilling, to come to terms with tribal governments within that state. But political might does not make right, from a moral standpoint.

The approach is just plain wrong. Regrettably, since Medicaid funding isn’t glamorous and headline-grabbing, the risk is very real that the proposal will slip by without sufficient opposition.

While tribal governments continually face daunting economic and social challenges, the policies of self-determination and self-governance have been remarkably successful, allowing tribes to be innovative and develop a range of services to meet the needs of tribal citizens. Tribal health programs in particular have flourished under these policies, in large part due to the 100% FMAP policy. The advances of the past three decades will begin to erode immediately if the proposal is allowed to become law.

We urge immediate and firm opposition to Senator Thune’s proposed Medicaid funding amendment; the matter is urgent and gravely serious to even the very health and well-being of a major cross-section of our population, and an especially vulnerable one at that.

Jim Roberts, Hopi, serves as a Senior Executive Liaison for the Alaska Native Tribal Health Consortium and has worked in federal Indian and health policy for over 30 years.

Brett Lee Shelton, Oglala Sioux Tribe, is a Senior Staff Attorney at the Native American Rights Fund and has worked in federal Indian and tribal law and policy for over 25 years.

The views represented in this op-ed are not any indication or reference to opinions of the authors’ employers.