House Republican Leaders in re American Health Care Act, H.R. 1628

April 24, 2017

The Honorable Greg Walden
House Committee on
Energy and Commerce
2125 Rayburn House
Office Building
Washington, DC 20515

The Honorable Kevin Brady
House Committee on
Ways and Means
1102 Longworth House
Office Building
Washington, DC 20515

The Honorable Diane Black
House Committee on
the Budget
207 Cannon House
Office Building
Washington, DC

Dear Chairmen Walden and Brady and Chairwoman Black:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents urban Indian health care programs (UIHPs) across the nation that provide high-quality, culturally-competent health care to urban Indians, I thank you for your service to the American people.

NCUIH was founded to represent the interests of UIHPs before Congress and federal agencies, and to address the health conditions experienced by urban AI/AN. NCUIH is devoted to support the development of quality, accessible, and culturally sensitive health care programs for AI/AN living in urban communities. NCUIH fulfills its mission by serving as a resource center providing education, training, and leadership for UIHPs to Congress and the Administration. NCUIH strives for healthy AI/AN living in urban settings, supported by quality, accessible health care centers and governed by leaders in the AI/AN community. NCUIH represents UIHPs receiving grants under Title V of the Indian Health Care Improvement Act and the AI/AN they serve.

"Urban Indian" refers to any AI/AN person who is not living on a reservation, either permanently or temporarily--often because of the federal government's forced relocation policy or lack of economic opportunity, which now makes up more than 70% of the AI/AN population.

Given the on-going efforts of many House lawmakers to advance legislation to reform health care, I wanted to convey to you our appraisal of The American Health Care Act of 2017 (H.R. 1628) so that you are familiar with the interests and concerns of urban Indians as you prepare any alternative legislation.

I would be remiss if I did not write that we are very appreciative of the work of Representative Markwayne Mullin (R-OK), a member of the Energy and
Commerce’s Subcommittee on Health and a Vice-Chairman of the House Native American Caucus, for his efforts to ensure that our interests and concerns are considered during the preparation of health care reform legislation.

NCUIH is very appreciative that H.R. 1628 would have left in place the permanent authorization of the Indian Health Care Improvement Act (IHCIA); retained three key provisions from the Affordable Care Act (ACA) [including Section 2901(b), which makes the Indian Health Service (IHS) the payer of last resort; Section 2902, under which IHS bills Medicare for Part B services; and Section 9021, which excludes health care benefits provided by IHS to eligible individuals from taxable gross income]; and replaced the ACA’s individual mandate with the imposition of a penalty if an individual loses coverage and then re-enrolls.

There are several matters which NCUIH urges you to address in any alternative to H.R. 1628:

1. Medicaid is a program on which the AI/AN people are disproportionately reliant and one which has served Indian Country very well.

Between 2013 and 2015, AI/AN enrollment in Medicaid increased by 217,000, or 15%, despite almost one-half of states with Tribes not participating in Medicaid Expansion. In significant part because of Medicaid Expansion, the uninsured rate of AI/ANs has dropped 30% since 2010, from 24.2% (2010) to 15.7% (2015). If current law is unchanged, an additional 550,000 uninsured AI/ANs could be made eligible for comprehensive coverage under current and planned ACA Medicaid Expansions.

Today, the federal government pays a percentage of the bill for all who qualify for Medicaid. Under the per capita caps that would have been imposed on Medicaid by H.R. 1628, the federal government would have paid only a certain amount per enrollee. NCUIH fears that per capita caps will likely reduce the quality of care and access to care because federal payments would not be adjusted by population and states would be unable to confront unexpected health care challenges, e.g., an opioid outbreak and staggering high health disparities among AI/AN.

Under H.R. 1628, states could have also chosen to instead take block grants, which would have been calculated by computing the per capita cost for the eligible population, multiplied by the number of enrollees in the previous year. It is believed that this approach would also significantly reduce the federal government’s contribution to Medicaid. Moreover, many in Indian Country are generally skeptical about block grants because states’ practices are not always transparent and states do not always use the funds as Congress directs.

H.R. 1628 would have exempted from the per capita caps to the federal government’s contribution to Medicaid payments to IHS and Tribal facilities, but not UIHPs, an inequitable arrangement that also applies to the bill’s proposed block grants. Even if UIHPs were to also be exempted from per capita caps and block grants, Medicaid’s financing would be fundamentally altered in ways which will inevitably impact all AI/AN people. In particular, states are likely to offset lost federal contributions by making eligibility for Medicaid more difficult.

If per capita caps and block grants are used by the federal government to shift Medicaid costs to the states, the program’s benefit must be preserved for
AI/ANs. Consistent with the federal government’s Trust Responsibility, all of Indian Country, including urban Indians, should be shielded from the adverse impacts of the inevitable measures states will undertake to slash spending and narrow eligibility.

H.R. 1628 would have also ended Medicaid Expansion, under which participating states receive higher federal payments for enrolling poorer

Americans. Cutting off enrollment in Medicaid Expansion will cause existing enrollees to lose their eligibility for the full federal subsidy whenever they lose coverage for more than two months. The Congressional Budget Office estimates that there would be 14 million fewer Medicaid enrollees by 2026, which includes people who are currently eligible (of which a high disproportionate number would be AI/AN)and would lose coverage as well as those who might have become eligible had the existing law been left in place.

Finally, H.R. 1628 would have allowed states to impose work requirements for Medicaid, even though many AI/AN people live in isolated areas with often staggering levels of unemployment and few opportunities for job retraining and placement services. If denied eligibility for Medicaid because of unrealistic work requirements, those AI/AN people will be forced to secure health care from an IHS which is already severely overwhelmed and unable to always provide sufficient care. If work requirements are imposed on Medicaid enrollees, there should be an exception for AI/AN people. Treaty health care obligations never included or intended working/ employment to be a “criteria” to health coverage.

2. Protections against cost-sharing which allow less-advantaged AI/AN people to secure health insurance would be repealed.

These protections against cost-sharing help AI/AN people with incomes at or below 300% of the federal property level or through referral by the IHS purchased and referred care (PRC) program. The rationales for these protections are compelling: they help to fulfill the federal government’s Trust Responsibility to provide health care for AI/AN people, reduce the high number of uninsured AI/AN people (compared to the general population), and take into account that AI/AN families have disproportionately lower incomes (compared to the general population) and thus less money to spend on health care. IHS, however poor the service may be at times, is already a disincentive to AI/AN people to purchase health insurance, and a cost-sharing requirement would exacerbate the problem.

Ultimately, repeal of protections against cost-sharing will cause health insurance to become unaffordable for significant numbers of AI/AN and deprive IHS System (I/T/U) of third party revenues that pay for its already underfunded PRC program and other health services. If any successor legislation is to eliminate protections against cost-sharing protections, NCUIH urges you to include an exception for AI/AN people.

Thank you for your consideration. Please contact Francys Crevier, NCUIH’s Director of Governmental Affairs, if you have any questions.


Ashley Tuomi National President

c.c.: The Honorable Markwayne Mullin (R-OK-2)