Tribes seek Medicaid expansion on Wind River ReservationBy Ron Feemster — September 3, 2013
Leaders of the Northern Arapaho and Eastern Shoshone tribes are lobbying the state legislature to approve a demonstration project that would expand access to Medicaid coverage on the Wind River Indian Reservation.
The tribes have the ear of Rep. Elaine Harvey (R-Lovell), co-chair of the Joint Labor, Health and Social Services Interim Committee. Harvey’s original position on Medicaid expansion was across-the-board opposition, at least in the short term.
Now she has begun to champion a private-market expansion that would allow Medicaid eligible people to buy insurance in the new health-insurance marketplace run by the federal government under the Affordable Care Act, also known as Obamacare. But she is also willing to consider the tribes’ call for Medicaid expansion on the reservation.
“The tribes deserve to be heard,” said Harvey. “I’m listening. I would be open to a demonstration project.”
The tribes’ proposal comes at a time when the Northern Arapaho tribe has received major grants to expand medical facilities on the reservation. A $1.1 million grant to the Northern Arapaho Housing Authority will pay for additional examination rooms, laboratory technology and pharmacy services at the 100-year-old Indian Health Service building in Fort Washakie. A brand new community health center built with additional grant money will open in Arapahoe on September 12.
“This is part of an overall strategy to promote a healthier community,” said Patrick Goggles, chair of the Housing Authority and a member of the state House of Representatives. Goggles notes that the Arapahoe area has always lacked easy access to tribal medical services.
“We increase the facilities to serve the community,” Goggles said. “Now the question is how to increase access to third-party payers who can provide coverage to community members.”
Using a provision of federal law known as Section 1115 of the Social Security Act, the state and the tribes could apply to provide tribal members the same sort of expanded Medicaid health coverage that the legislature has so far declined to offer at least 17,000 of Wyoming’s poorest residents under an optional provision of Obamacare.
A report commissioned by the Department of Health estimated the number of newly eligible Medicaid recipients at between 17,000 and 44,000 residents of the state.
The 1115 expansion would primarily cover enrolled tribal members who are adults, but whose income is less than 138 percent of federal poverty level.
Allison Sage, Northern Arapaho Health Programs Director, admits that no hard numbers are available about how many low-income tribal members are without adequate health insurance on the reservation, but he estimates that between 4,000 and 5,000 people could qualify for Medicaid under an 1115 demonstration project. If the state’s lowest estimates of the number of newly eligible Medicaid recipients are correct, the 1115 project could cover as many as one in four of Wyoming’s poorest residents.
In addition to covering many young, unemployed and working adults — a large and vulnerable population on the reservation — the 1115 project would help the beleaguered Indian Health Service, which receives too little funding to provide comprehensive services to all who visit the clinics.
“People think that when you go to IHS that they have the money to pay for your treatment,” Sage said. “IHS will turn around and bill Medicaid. We need to get more people covered under Medicaid.”
Members of the two tribes met late last month with Tom Forslund, director of the state Department of Health, and asked for help expanding Medicaid for Natives in Wyoming.
“They wish to have Medicaid cover a greater amount of tribal members,” Forslund said. “They met with me and expressed their concerns. I told them it is not within my authority.” Forslund then suggested that they would have to make their case to the legislature.
Forslund’s hands are tied by House Bill 203, which was passed during the 2013 session. Section 5 of the bill reads: “No further expansion of eligibility for Medicaid shall occur without prior approval from the legislature.” This section of the bill was added as an amendment in committee by the Senate Labor, Health and Social Services Committee, chaired by Sen. Charles Scott (R-Casper).
The law also prevents Gov. Matt Mead from taking action on behalf of the tribes, although he appears to be at peace with that limitation.
“In a matter of this importance, the decision should be made by the governor and the legislature,” said Renny MacKay, Mead’s spokesman.
Another 1115 Project in Wyoming
More than 40 of these 1115 projects are currently up and running around the country, with about 40 similar Medicaid expansion projects pending. The only such project in Wyoming is called WY Pregnant By Choice. The project, approved in September 2008, expands Medicaid family planning services to adult women of childbearing age who earn less than 133 percent of federal poverty level, but who do not qualify for Medicaid.
The project’s goal is to reduce the number of unintended pregnancies among women who would qualify for Medicaid prenatal and childbirth services. About half of all births in Wyoming are paid for by Medicaid, according to Wyoming Hospital Association figures. The federal government pays one-half the cost of each Medicaid birth. The state pays the other half. WY Pregnant By Choice is set to expire at the end of this month, according to the Medicaid website.
Hurdles in Cheyenne
Sage and Gary Collins, the Northern Arapaho liaison to Governor Mead’s office, spoke during public comment at the Joint Labor, Health and Social Services Interim Committee meeting in Lovell last week, calling for a Medicaid expansion project under Section 1115. Harvey said that the committee would consider the proposal.
“During public comment we don’t ask for bill drafts,” she said. “But we talk about it. We bat around what we can do to help. We may work a bill in November.”
On the whole, 1115 projects do not appear to be controversial. Of the almost 100 applications for Medicaid expansion demonstration projects listed on the Medicaid.gov website, including older, expired projects, only two were not approved.
The highest hurdles for tribal Medicaid expansion would appear to be in Cheyenne, not Washington. Reports by the state health department have indicated from the beginning that expanding Medicaid under the Affordable Care Act is less expensive for the state than not doing so, primarily because the federal government would take over programs that the state pays for now. Wyoming could save the money spent on those programs.
The feds cover 100 percent of the costs of expanding Medicaid for all newly eligible recipients in the first two years and reduce federal reimbursement gradually to 90 percent by 2020. In fact, the Department of Health has estimated the cost of not expanding Medicaid to cover the poorest Wyoming residents as high as $47 million over the next six years.
But even with the finances strongly in the state’s favor, the legislature has not gone forward. After months of data gathering and delays, legislative opponents to expansion, spearheaded by Scott, have embraced the argument that the federal government will run out of money and not be able to afford the costs of Medicaid expansion.
One of two problems is certain to emerge, according to Scott: Either the federal reimbursement level will drop below 90 percent, which is the level specified in 2020 and beyond, or the federal funding for Obamacare will dry up altogether. In either case, state lawmakers would be forced, at considerable political peril, to retract the benefit.
Expanding Medicaid with an 1115 project on the reservation carries less financial risk to the state than expansion under Obamacare, primarily because the federal reimbursement for all Native American Medicaid recipients is 100 percent. The law contains no sunset provision for this rate, so any coverage the state signs off on will be paid by the federal government. The Department of Health would be a simple pass-through agency for federal money if the tribal Medicaid expansion were passed.
In addition, Medicaid coverage for Natives would likely cut down on uncompensated care at the hospital emergency rooms in Lander and Riverton, the providers of last resort for reservation residents who need help when IHS clinics are closed.
It is unclear what attitude Scott will have toward an 1115 expansion. He could not be reached for comment for this story.
Scott has been a staunch opponent of Medicaid expansion in any form.
In the meantime, the tribes are redoubling their efforts to build support for a Medicaid expansion demonstration project. “We are meeting next with the Wyoming Coalition for Medicaid Expansion,” said Collins, referring to a group of organizations including the Wyoming Hospital Association and more than a dozen other medical and citizen organizations. “Then we’ll see what comes after that.”— Ron Feemster covers the Wind River Indian Reservation for WyoFile in addition to his duties as a general reporter. Feemster was a Visiting Professor of Journalism at the Indian Institute of Journalism & New Media in Bangalore, India, and previously taught journalism at Northwest College in Powell. He has reported for The New York Times, Associated Press, Newsday, NPR and others. Contact Ron at firstname.lastname@example.org.
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