BCRA/ORRA: Medicaid Cuts and Expansion, FMAP and BCRA Section 138, Indian Health Care Improvement Act and Indian-Specific Affordable Care Act Provisions

July 24, 2017

BCRA/ORRA: Medicaid Cuts and Expansion, FMAP and BCRA Section 138, Indian Health Care Improvement Act and Indian-Specific Affordable Care Act Provisions

Dear Senator:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents 44 urban Indian health programs (UIHPs) across the nation, I urge you to take into account the concerns of urban Indians, as you consider on the floor health care reform legislation, whether the Better Care Reconciliation Act (BCRA) or Obamacare Repeal Reconciliation Act (ORRA). Urban Indians are the more than 70% of American Indian/Alaska Native (AI/AN) people who live off of reservations, because of the federal government’s forced relocation policy or absence of economic and educational opportunities.

As Congress and the courts have acknowledged the federal government’s trust responsibility to provide health care to AI/AN people follows them off of reservations and into urban areas. Urban Indians experience health conditions and outcomes that are comparable to AI/AN people who live on reservations, and they are markedly worse than non-AI/AN people who live in urban areas. UIHPs are public-private partnerships, which use their own employees to provide high-quality, culturally- competent health care, while receiving just slightly more than 1% of the Indian Health Service’s (IHS) budget.

1. Medicaid Cuts and Expansion

The value of Medicaid to AI/AN people is extraordinary, both in extending insurance coverage and in stretching the dollars of an under-resourced IHS that is already rationing services. If federal contributions to Medicaid must be drastically reduced, NCUIH urges the Senate to exempt UIHPs from those cuts, as it already has IHS and Tribal facilities. It is understood that the federal government’s Trust Responsibility is inconsistent with the adverse impact of those Medicaid cuts—fewer benefits, narrower eligibility, and provider payment cuts. However, that responsibility applies to urban Indians as well as reservation Indians. And if Medicaid Expansion must be curtailed, NCUIH urges the Senate to exempt AI/AN people, consistent with that Trust Responsibility.

2. Federal Medical Assistance Percentage (FMAP) and BCRA Section 138

There are countless efforts underway by Senators to address with billions and billions of dollars the needs of vulnerable populations. However, it is imperative that urban Indians not be overlooked. Services performed by UIHPs are reimbursed for considerably less than IHS and Tribal facilities, who receive an FMAP of 100%. NCUIH appreciates the bipartisan interest in extending 100% FMAP to UIHPs and urges the Senate to use the health care reform legislation to rectify this oversight. Medicaid revenues would help to offset the lack of funding from IHS.

NCUIH appreciates the attempt by the authors of Section 138 in the second BCRA discussion draft to extend 100% FMAP to UIHPs. It makes no sense that IHS and Tribal facilities should benefit from 100% FMAP, but not also UIHPs.

However, NCUIH believes that Tribes are raising very important concerns about Section 138, as expressed in recent correspondence from the National Indian Health Board (NIHB). The need for 100% FMAP for UIHPs is long-established—in fact, IHS has repeatedly asked Congress to make this change and costed it at just $2.3 million per annum. Moreover, there is broad and unanimous support in Indian Country for 100% FMAP for UIHPs, most recently in an NIHB resolution as well as a joint letter from the four most important Indian health care groups. On the other hand, expanding 100% FMAP to any provider of services to AI/AN people, per Section 138, is a significant change to Indian health care, and the proposal should be subject to significant consultation with Tribes.

100% FMAP was designed to hold states harmless from costs associated with using Medicaid dollars to replenish IHS’ limited funds, which is why it was linked to services received through the IHS system. If 100% FMAP is expanded to all providers, the additional money will not necessarily be invested in the underfunded Indian health system, and instead it could be used by states for any purpose.

3. Indian Health Care Improvement Act (IHCIA) and Indian-Specific Affordable Care Act (ACA)

It is not clear which measures or amendments will be considered, but we urge Senators to leave in place IHCIA and certain Indian-specific ACA provisions. IHCIA is the legal authority for IHS, requiring the agency to provide modern, state-of-the-art, culturally-competent services, including cancer screenings; mental and behavioral health treatment and prevention to address alcohol / substance abuse problems; long- term care, including home health care, assisted living, and community-based care for the elderly and disabled; dialysis; and care for military veterans. Significantly, IHCIA authorizes IHS to be reimbursed by Medicare, Medicaid, and third-party insurers. The law also authorizes IHS to collaborate with the Department of Veterans Affairs (DVA) on the provision of care to veterans.

There are also several Indian-specific provisions in ACA that should be retained even if Obamacare is repealed, particularly Section 2901 which ensures that IHS is the payer of last resort and Section 2902 which authorizes IHS to collect reimbursements for all Medicare Part B services. IHS is able to stretch its limited resources by being able to charge other programs for its services.

Finally, NCUIH urges you to oppose a repeal of the Affordable Care Act without immediately putting in place a satisfactory replacement, rather than one thrown together on the floor with a blizzard of amendments.

Thanks very much for your consideration. Please contact NCUIH’s Director of Governmental Affairs Francys Crevier (fcrevier@ncuih.org) if you have any questions.

Ashley Tuomi

National President