‘Medicaid expansion still very important’ on reservation

By Gregory Nickerson
— July 29, 2014

American Indian mortality rates due to accidents are double that of Wyoming’s general population. The diabetes mortality rate is four times higher. The death rate for chronic liver disease is nine times that of the general population.

“It’s very difficult to see young people die before their time,” said Richard Brannan, CEO of the Wind River Unit of the Indian Health Service. “We think of all the good things that can happen in their lives that they miss out on.”

On a recent weekday at the Wind River Casino, the gaming floor buzzed with the flashing lights of slot machines and the sound of ringing bells.

Just steps away beyond a set of tinted glass doors, a group of reservation leaders and government officials discussed the serious issue of improving the health of the American Indian community.

For the past two years, the Wind River Health Disparities Roundtable has worked on strategies for better healthcare among the Northern Arapaho and Eastern Shoshone.

American Indians in Wyoming suffer from an array of health challenges that put life expectancy at 53 years, while the general population has an expected lifespan of nearly 79 years.

Health disparities among minorities result from lower levels of education, which translate to lower incomes and lack of access to transportation, according to Lillian Zuniga of the Wyoming Office of Multicultural Health.

On the Wind River Indian Reservation, those factors mean people are less likely to go to health clinics and follow through with medical care.

Meanwhile, those very clinics are starving for revenue. Federal Indian Health Service (IHS) funding accounts for about $12 million of the $23 million in services provided by the clinics in Fort Washakie and Arapahoe last year. Another $11 million in funding comes from collections through private insurance and Medicare/Medicaid reimbursements.

“Without the Medicaid program, the doors on our clinics would not be open, or they would be open only half the time,” Brannan said. “The clinic is funded (by the IHS) at 45 percent of what you need.”

While IHS money pays for salaries for an array of nurses and specialists, it’s Medicaid that buys the 100,000 prescriptions filled by the clinics annually at a cost of $2.8 million, Brannan said. Medicaid also pays for most of the clinics’ primary care doctors.

“Medicaid money, that’s 99 percent of what pays our providers,” said Glen Fowler, health consultant for the Northern Arapaho. “If we don’t have that, we don’t have providers.”

Because of limited funding, the IHS regional office in Billings, Montana, requires all of its area clinics to provide only Level I care, meaning treatment to prevent loss of eyesight, loss of limb, or immediate death.

IHS does not provide level II and Level III care on the reservation, which include prevention and treatment of less serious ailments. That means patients have a lot of deferred care, or no care at all, Brannan said.

“When the money is running out they go to Level I, and beyond that they won’t treat you,” said Allison Sage, Northern Arapaho Health Programs director.

“You can’t get preventative care. It’s send you home, keep you comfortable, and die. Otherwise we go to the ER to get treatment.”

The two tribes on the Wind River Indian Reservation face two main obstacles to increasing IHS clinic funding by pulling in more Medicaid dollars.

The first comes from the popular misconception on the reservation that the IHS covers all medical expenses for tribal members. That leads patients to not sign up for Medicaid, or forego buying insurance through the federal exchange on Healthcare.gov.

Further, some tribal members are hesitant to report income on Medicaid eligibility forms. “Many tribal members are secretive because they think if they report income it will diminish their medical care,” said Gary Collins, tribal liaison for the Northern Arapaho.

In fact the Medicaid application form asks questions about income in order to deduct non-taxable tribal per-capita payments and land leasing payments from the income eligibility calculation.

The second obstacle to increasing Medicaid enrollment on the reservation is political. In the 2014 session, Wyoming’s legislature chose not to expand Medicaid to the state. Legislators also rejected House Bill 80 to study an “1115 waiver” for Medicaid expansion on the reservation.

Such a waiver would authorize expansion of Medicaid to an estimated 4,000 to 5,000 tribal members who are currently ineligible for the program. The bill only allowed for an investigation of the waiver.

Authorization of the waiver would have required further legislative action. Read this WyoFile story for more.

“Medicaid expansion would allow you to provide contract procedures outside of the clinic that you are unable to do in the (IHS) clinic — preventative healthcare treatment, and procedures that are not crisis care,” Brannan said.

Thirty-three Wyoming Representatives voted to introduce the bill, but it failed to get the 40 votes needed for introduction on the floor of the House.

Four Fremont County representatives voted to introduce House Bill 80: Lloyd Larsen (R-Lander), Patrick Goggles (D-Ethete), David Miller (R-Lander), and Rita Campbell (R-Shoshoni).

Rep. Nathan Winters (R-Thermopolis) opposed introduction.

Sen. Cale Case (R-Lander) didn’t vote on House Bill 80 because it never made it to the Senate, but he told WyoFile he supported the idea of gathering more information about the 1115 waiver — even though he opposes Medicaid expansion in principle.

“The Health Department can’t actually apply for a waiver under the bill,” Case told WyoFile during the session. “We need more information about the 1115 waiver. I’m not sure anyone has all the information.”

Fowler said the bill was part of an effort to get legislators informed with what is happening with healthcare on the reservation. “We wanted to push for Medicaid expansion,” he said. “It would mean about $4.5 million more to this area. It is very significant.”

Tribal officials say the money would help boost the IHS budget on the reservation, and it would also enable tribal members to seek Medicaid-covered care for special procedures at hospitals in Riverton, or elsewhere. The additional Medicaid money would inject money into the local healthcare system and be an economic boost to the reservation and Fremont County.

Importantly, the federal government would cover 100 percent of the expense for expanding Medicaid to Wyoming’s American Indian population. Without this 1115 waiver project, the state of Wyoming presently pays 50 percent of the cost for any tribal member who is a current Medicaid enrollee and seeks care off the reservation.

Expanding Medicaid for the Eastern Shoshone and Northern Arapaho would not cost the state of Wyoming anything Brannan explained. It would save money by shifting existing Medicaid costs from the state to the federal government for this population. Further, the 1115 waiver requires the expansion to be cost-neutral to the federal government by preventing more expensive uses of medical services.

“Medicaid expansion is still very important,” Fowler said.

For now, the tribes will concentrate on boosting enrollment in conventional Medicaid, Medicare, or the federal health insurance exchanges.

“When we touch our patients, we need to make sure we are getting them on some program that will (provide payment),” Fowler said. “If you don’t do that, every day you are losing money and not resolving health disparities.”

One possibility for increasing enrollment is holding sign-up fairs or on-the-ground campaigns. The Northern Cheyenne implemented such a program with notable success, said Sunny Goggles, director of the White Buffalo Recovery program.

The Northern Arapaho could include Medicaid and Healthcare.gov sign-ups as part of its back-to-school fair to be held at the Wind River Casino later this summer.

“Part of (increasing enrollment) is education. The second part is building the health information infrastructure so that when you touch the patient you have a process to get them on Medicaid, the health insurance exchanges, or Medicare, so you can reduce the amount of care that is uncompensated,” Fowler said.

The tribes will also keep pushing for Medicaid expansion in the state legislature, but that may be a tough sell.

“We have a component of the Wyoming legislature who don’t understand, and have never been without,” Collins said.

Sage said he’s known of a number of teen women who became pregnant but lost their babies due to a lack of prenatal care. That’s what motivated him to seek improved healthcare on the reservation, which led to the formation of the Wind River Health Disparities Roundtable.

“We’ve got to do something about it,” Sage said. In his view, getting better healthcare requires battling — and partnering — with the state and local government to get the same quality of healthcare that other people in Wyoming have.

“We are trying to do that, and keep the peace at the same time,” he said. “It might ruffle some feathers, but we’re going to do something about it.”

Upcoming meetings of the Wind River Health Disparities Roundtable will happen on Friday, August 22; Friday, September 19; and Friday, October 10 at the Wind River Casino.

For more on this topic, read:

Tribes seek Medicaid expansion on Wind River Reservation, by Ron Feemster.

Bill to expand Medicaid on Wind River reservation fails, by Ron Feemster.

— Gregory Nickerson is the government and policy reporter for WyoFile. He writes the Capitol Beat blog. Contact him at greg@wyofile.com or follow him on twitter @GregNickersonWY.

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