MONTANA LAW PAVES WAY FOR COLLABORATION BETWEEN INDIAN TRIBES AND STATE

Volume 27, Issue 477 October 16, 2006

Christina Kent

A recent Montana law (HB 452) could serve as a model for states that are wrestling with one of the thorniest issues in health care: how to bring American Indians and Alaska Natives together with state officials to protect and improve tribal access to Medicaid financing.

As part of its trust obligations to Indian Nations, the federal government provides a 100 percent match for Medicaid for services provided in certain settings to American Indians and Alaska Natives. But, beyond federal regulations, states decide a number of issues such as eligibility rules, benefit packages, cost-sharing requirements or provider payment rates.

One impetus for the Montana law was a concern that the state might adopt certain Medicaid policies that would not produce savings for the state in Indian Country (since the feds provide a 100 percent match), but would harm American Indians and Alaska Natives.

Among other things, HB 452 requires the state to seek a federal waiver so that any reductions in Medicaid funds do not shift costs to tribal or Indian Health Service (IHS) facilities; directs the state to work with tribal governments to leverage federal funds for SCHIP; and mandates that the state work with tribes to review Indian eligibility issues.

“This is going to break through a lot of the bureaucracy (that hinders progress on health care in Indian country),” bill sponsor Rep. Jonathan Windy Boy said during a Robert Wood Johnson Foundation-sponsored NCSL web-assisted audioconference on the law. He added, “This is just the beginning of a huge process. We are thinking outside the box.”

There are more than 562 federally recognized tribes within the United States. Although a significant number reside in Alaska (227), the remaining tribes are located within the boundaries of 36 states.

The obstacles to improving care are enormous. The health status of American Indians and Alaska Natives is, on average, far worse than the health status of other Americans. Indians and Alaska Natives have rates of diabetes that are 291 percent higher than all U.S. races, suicide rates that are 91 percent greater, and pneumonia/influenza rates that are 67 percent higher.

Then there’s the fact that the complexities of blending Medicaid with other programs that serve Native Americans and Alaska Natives are “mind-boggling,” in the words of Kris Locke, consultant for the Northwest Portland Area Indian Health Board.

In addition to the IHS, many tribal members could qualify for Medicaid, so increasing enrollment in Medicaid would seem to be a win-win proposition. However, a history of IHS underfunding, and differing perspectives on treaty obligations and tribal autonomy can stall collaboration. Conflicting programs and values require negotiations to build trust, and coordination is needed to align Medicaid and IHS requirements.

At a recent roundtable on the IHS and Medicaid reform, sponsored by the Urban Institute, speakers noted that a distinct disadvantage of Medicaid, from the Indian perspective, is that it is a state program. As states do not share in the federal government’s special trust responsibility to Indian tribes, communication has often been difficult.

“HB 452 recognizes and acknowledges the unique situation of the tribes in Montana,” said Garfield Little Light, associate area director for the IHS. “It’s slow, but we’re kind of pioneers. I’m happy we’re starting the journey.”

For more, go to: http:www.ncsl.org/programs/statetribe/tribes.htm

For more on the continuing web-assisted conference series on cultural competency, http://www.ncsl.org/programs/health/webcast2.htm or contact kala.ladenheim@ncsl.org.