Letter to Senators in re Concerns of Urban Indian Patients and Providers about the Graham-Cassidy- Heller-Johnson Measure to Repeal and Replace the ACA

September 21, 2017

In re: concerns of urban Indian patients and providers about the Graham-Cassidy- Heller-Johnson measure to repeal and replace the Affordable Care Act

Dear Senator:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents over forty urban Indian health programs (UIHPs) across the nation, I urge you not to support the Graham-Cassidy-Heller-Johnson measure to repeal and replace the Affordable Care Act (ACA) until the measure is reformed to ensure it is consistent with the federal government’s Trust Responsibility to provide American Indian/Alaska Native (AI/AN) people with health care. This obligation has been reaffirmed, repeatedly, by all three branches of the federal government, one which cannot be passed on to the states, and one which follows AI/AN people off of reservations and into urban areas.

NCUIH represents the interests of UIHPs, as well as its patients and providers, before the legislative and executive branches and serves as a resource center for the education and training of UIHPs’ management and staff. An integral part of the Indian Health Service’s (IHS) I (direct care) /T (Tribal) /U (urban) system, UIHPs are public-private partnerships which employ their own staffs. UIHPs receive slightly more than 1% of IHS’ budget, but still manage to provide high-quality, culturally-competent health care to urban Indians, i.e., the more than two-thirds of American Indian/Alaska Native (AI/AN) people who live off of reservations, either because of the federal government’s forced relocation policy or they seek greater economic and educational opportunities. Urban Indians experience health conditions and outcomes that are comparable to those of AI/AN people who live on reservations and markedly worse than non-AI/AN people who also live in urban environments.

1. Mandates
NCUIH supports the measure’s repeal of the ACA’s penalties for employers which don’t provide insurance it with respect to their application to AI/AN people and employers because the ACA’s employer mandate are inconsistent with the federal government’s Trust Responsibility.

2. Block Grants
Medicaid is a program that has served AI/AN people very well, and it is vital in mitigating against the Congress’ chronic underfunding of IHS. The block granting of Medicaid would result in a significant reduction in the federal contribution to the program, culminating in the elimination of funding after 2026. The measure ostensibly exempts IHS and Tribal facilities from its Medicaid cuts; significantly, it would leave UIHPs fully exposed.

States would gut their Medicaid programs to offset the lost federal contributions: reducing the benefits available, narrowing eligibility for the remaining benefits, and slashing payments to providers. Significant numbers of AI/AN people would inevitably lose access to Medicaid and be forced to fall back on an IHS that has historically been resourced by Congress at well below capacity. Even if assuming arguendo ending any federal role in Medicaid constitutes good public policy, the federal government, consistent with the Trust Responsibility, would be obligated to work with Indian health care providers to exempt reimbursements for services received through I/T/U facilities from the resulting state-imposed limitations.

3. Medicaid Expansion
Medicaid Expansion has been an unqualified success in Indian Country, playing a key role in reducing the number of uninsured AI/AN people and increasing Medicaid revenues in the I/T/U system that can then be reinvested in Indian health care. NCUIH appreciates that the measure attempts to preserve Medicaid eligibility for AI/AN people enrolled in expansion states before 2020. However, we are uncertain such an exception for AI/AN people would even be viable because of the adverse impacts on states of reducing and then eliminating federal contributions to Medicaid as well as ending the expansion effort generally. Even if assuming arguendo ending Medicaid Expansion constitutes good public policy, the measure should be changed to ensure that Medicaid Expansion is preserved for all AI/AN people, regardless of their states of residence.

4. Federal Medical Assistance Percentage
NCUIH appreciates that the measure would extend a Federal Medical Assistance Percentage (FMAP) of 100 to UIHPs. This is a long overdue reform. It makes no sense, either as a matter of law or policy, to treat UIHPs differently from IHS and Tribal facilities, both of which already receive 100% FMAP. However, section 128 would also extend 100% FMAP to non-IHS providers without adequate consultation with Tribes or any consideration of how the increased savings to states of $3.5 billion over ten years,

according to the Congressional Budget Office, can be invested in Indian health care. Tribes, urban Indians, Republicans, and Democrats all agree that 100% FMAP for UIHPs is sound public policy and consistent with the Trust Responsibility, so this option should be implemented without delay. However, no such consensus exists with respect to non-IHS providers, so NCUIH urges lawmakers to consult further with Indian Country health care providers before proceeding any further.

5. Medicaid Work Requirements
The measure would allow states to impose work requirements on Medicaid recipients. AI/AN people should be exempt from such requirements because of lack of economic opportunities in large parts of Indian Country. Moreover, such requirements could induce AI/AN people to fall back on the already underfunded IHS, simply shifting the cost from one program to another. NCUIH supports job training and counseling, but such programs should not be mandatory for AI/AN people, and the measure should be revised accordingly.

6. Third Party Insurance Reforms
The measure would replace with block grants the cost-sharing protections created by the ACA, including those specifically for AI/AN people which make it possible for them to secure health insurance. Loss of these protections will inevitably induce AI/AN people to fall back on an IHS which the Congress has consistently failed to adequately fund. Whether states, which would be required by the measure to develop their own health care programs, would establish similar cost-sharing protections for AI/AN people is uncertain. What is not uncertain is that the measure would pass off the federal government’s Trust Responsibility for Indian health care to the states--which is contrary to treaty, law, and case law.

Please contact NCUIH Executive Director Francys Crevier (fcrevier@ncuih.org) if you have any questions about our views on the measure. Thanks for your consideration.


Ashley Tuomi