The 100-year-old Indian Health Service clinic in Fort Washakie. The two HIS clinics on the reservation are federally funded at about 45 percent of what they need to treat all patients. They look forward to receiving more third-party funding through the Affordable Care Act. (WyoFile/Ron Feemster)

Obamacare health insurance faces hurdles on Wind River Indian Reservation

— October 29, 2013
by Ron Feemster

The Affordable Care Act’s new insurance system would benefit few institutions more than the Indian Health Service clinics that serve the Wind River Indian Reservation and other Native communities around the country.

The clinics, federally funded at about 45 percent of what the free treatment that they must provide actually costs, are allowed to bill private insurance companies and government programs like Medicaid and Medicare. But few reservation residents have insurance, so IHS submits most of its bills to programs for low-income families.

Renee Gamino, AARP outreach worker. (Ron Feemster/WyoFile — click to enlarge)

“We bill for the poorest people in the tribe and that helps pay for everyone,” said Debra Aragon, the benefit coordinator at the Arapahoe Health Center. “Those payments go to benefit all patients.”

Many of the reservation residents are in a low-income group — below 138 percent of poverty — that would qualify for coverage under an expanded Medicaid program. Under the ACA, every state may choose to expand Medicaid or not. So far, the Wyoming legislature has defeated a bill to expand Medicaid.

If Medicaid were expanded in Wyoming, or at least on the reservation, the IHS clinics could bill Centers for Medicare and Medicaid Services for care that is now paid for directly with the clinics’ federal appropriation.

“Medicaid expansion would solve everything for IHS,” said Heather SunRhodes, a benefit coordinator at the Fort Washakie clinic. “We would be able to bill for the care we give to the poorest members of the community. Some of the people who would qualify for Medicaid are our most expensive patients.”

SunRhodes and others involved in providing health care to the reservation community spoke last week at meetings in Ethete and Fort Washakie. Foremost on the agenda was how to make Indian families aware of the advantages of insurance under the Affordable Care Act.

If members of the Eastern Shoshone and Northern Arapaho tribes bought insurance through the ACA’s health insurance exchange, IHS could bill the insurance company for treatment.

But there is little in the structure of the new health care law that motivates Natives on the reservation to sign up. Unlike other residents of Wyoming, Natives do not have to sign up for health insurance under the Affordable Care Act. They pay no penalty if they do not purchase health insurance. And if they are willing to get their treatment from IHS, they already have a guarantee of free medical care.

“You’re covered,” said Cathy Keene, director of tribal health programs for the Eastern Shoshone Tribe. “You don’t have to do anything if you are an enrolled member of a federally recognized tribe.”

The ACA was written to dovetail with existing IHS coverage, which is free. If a tribal member gets a referral to an off-reservation provider to see a specialist or to get surgery, for instance, he or she would not pay a co-pay or deductibles. The specialist would bill IHS, instead.

So if a non-insured Native has surgery for $10,000 in Casper now, IHS pays the entire bill out of a fund called Contract Health Services or CHS. If the patient had insurance with a $2,000 deductible, for example, IHS would pay the deductible for the patient.

“That’s why we would like to see people get insurance,” said Keene. “We would like CHS to pay the $2,000 instead of the $10,000.”

Gary Collins

Both tribes hosted meetings on the reservation last week to encourage people to make members aware of the advantages of the new insurance program.

“The older people do not have to do anything,” said Renee Gamino, an outreach worker who attended the meetings for AARP. “Their Medicare and Medicaid benefits will not change. But we know that many of the elders have adult children and grandchildren. We want to inform the whole family.”

Most residents of the reservation lack insurance. The Eastern Shoshone tribe self-insures to cover its tribal workers, but it is illegal for IHS to bill a tribal self-insurance program, according to Keene. The Northern Arapaho tribe offers no health insurance to tribal employees beyond IHS coverage.

The free care available through IHS is not a giveaway. It is part of the federal government’s trust responsibility toward the tribes. In a series of treaties dating back more than 200 years, the federal government agreed, in exchange for the cessation of hostilities, to provide not only land but also social, medical and educational services to Native communities.

“We don’t get everything free,” said Gary Collins, the Northern Arapaho tribal liaison to the governor’s office. “We’ve already paid.”

— 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 ron@wyofile.com.

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