Senate Indian Affairs Committee Hearing
Chairman Barrasso, Vice Chairman Tester, and Members of the Committee, thank you for holding this important hearing on Indian Country Priorities for the 114th
The federal promise to provide Indian health services was made long ago. Since the earliest days of the Republic, all branches of the federal government have acknowledged the nation's obligations to the Tribes and the special trust relationship between
In passing the Affordable Care Act (ACA),
But despite these promises, our people continue to live sicker and die younger than other Americans. We experience significantly higher mortality rates from alcoholism, suicide, cancer, influenza and maternal deaths. Ninety percent of AI/AN children suffer from dental caries by the age of eight, compared with 50 percent for the same age in the US all races population. Our children ages 2 to 5 have an average of six decayed teeth, when children in the US all races population have only one. Devastating health risks from historical trauma, poverty and a lack of adequate treatment resources also continue to plague Tribal communities. According to IHS data, 39 percent of AI/AN women experience intimate partner violence, which is the highest rate of any ethnic group in
America is too great a nation to stand idly by while AI/ANs live with these realities. The 114th
Legislative Opportunities
Mandatory Appropriations for the Indian Health Service In 2013, the IHS per capita expenditures for patient health services were just
We realize that it is highly unlikely that Indian health will receive the funding it needs by continuing to chase ever dwindling discretionary dollars. Instead, the
As noted above, the requirement to provide funds for IHS has been long-established by over 200 years of American history. AI/ANs made sacrifices for this country that require the government to provide health care for our people, but with competing forces in the discretionary budget, the funds have never been realized to achieve this.
Moving IHS to the mandatory side of the federal budget would stabilize the IHS budget and ensure that the care that AI/ANs need is always guaranteed. For example, Indian Country would not have to wait months to know when it will get its funding for the next fiscal year. Tribes and the IHS facilities find it very difficult to plan and execute budgets by waiting for continuing resolutions (CRs). Additionally, the instability of the discretionary funding process continues to put the lives of AI/ANs at risk. Over the last several years we have been fortunate enough to have a supportive
As we look toward FY 2016, we nervously await the possibility of across-the-board sequestration. As the Committee is well aware, the IHS budget lost
We implore you - do not let the same thing happen in FY 2016. If sequestration cannot be avoided in FY 2016, this committee must show leadership in ensuring that the IHS is not subject to sequestration. This exemption should be permanent, just as the federal trust responsibility to Indian Country. Even two percent is too much.
Support for Advance Appropriations for the
Realizing that mandatory funding for the IHS could be a multi-year effort, NIHB reiterates its support for Advance Appropriations for the
As we saw in the FY 2014 with the government-wide shutdown, failure to fund critical health care needs for AI/ANs was a thoughtless consequence of this unrelated political battle. Since FY 1998, there has been only one year (FY 2006) when the Interior, Environment, and Related Agencies budget, which contains the funding for IHS, has been enacted by the beginning of the fiscal year. The lateness in enacting a final budget during that time ranges from 5 days (FY 2002) to 197 days (FY 2011). These delays make it very difficult for IHS/ Tribal/ or Urban (I/T/U) Indian health sites to adequately address the health needs of AI/ANs. Though IHS is a mandatory obligation that the government has made, it is still a discretionary program. That's the reality we live in. So we are asking this
In FY 2010, the
IHS, like the VHA, provides direct care to patients as a result of contractual obligations made by the federal government. To NIHB and Tribes, enacting advance appropriations for IHS is a civil rights issue and a matter of equality. Like Veterans, Tribal communities have made sacrifices for this country, both historically and contemporarily. However, under the current funding mechanism, AI/ANs do not have the same stability in the care they are provided.
Continuing resolutions mean that Tribal health programs are left to make long-term decisions with only short-term money guaranteed. Often programs must determine whether and how they can enter into contracts with outside vendors and suppliers, plan programmatic activities, or maintain current personnel. In
Tribes and organizations across the country support advance appropriations for IHS. In
Advance appropriations will undoubtedly require significant changes in the way
Medicare Like Rates for Purchased/ Referred Care
One common-sense solution to enable IHS funds to go further is for
On
In
Employer Mandate in the Affordable Care Act
American Indians and Alaska Natives (AI/AN) are exempt from the Individual Mandate to purchase health insurance. This is in recognition of the fact that AI/ANs should not be forced to purchase healthcare that is obligated by the federal government's trust responsibility and which is delivered through the
Applying the employer mandate to Tribal employers directly undercuts the ACA's Indian-specific protections in three ways. First, it punishes Tribes for assisting AI/AN enrollment in the Marketplaces, despite the multiple ACA provisions designed specifically to encourage such activities. Second, it can disqualify AI/ANs from eligibility for premium tax credits in Marketplace plans, thus leaving them unaffordable. Third, it ignores the fact that AI/ANs are exempt from the individual mandate and forces Tribal employers to pay for AI/AN insurance plans as a proxy for the individual. None of these outcomes benefit Tribal employers, individual AI/ANs, or the federal government.
The ACA contains several provisions designed to maximize AI/AN participation in Marketplace plans: for example, Indian-specific cost-sharing protections that help defray the cost of health coverage, special AI/AN enrollment periods, and the ability for Tribes to assist with Marketplace plan premium payments for Tribal members. Many Tribes and Tribal organizations have aggressively sought to facilitate AI/AN enrollment in Marketplace plans in order to take advantage of these protections. However, the employer mandate actively discourages
If a Tribe does offer employer coverage, AI/AN employees will almost certainly be personally responsible for paying premium costs, deductibles, co-payments, and co-insurance. Eligibility for IHS services acts as a natural disincentive for AI/AN enrollment in any insurance plan (employer sponsored or otherwise).
The employer mandate forces Tribes to divert funding necessary to sustain Tribal health programs, which by right should come from the federal government, and redirect it to the purchase of employee health insurance. In these circumstances, the employer mandate essentially results in Tribes funding the federal government: either they take their limited Tribal funding (some or all of which might be federal funding anyway) and pay it to the
Compliance with the employer mandate forces Tribes to either absorb the cost of employee health insurance or else pay non-compliance penalties of up to
Tribes are sovereign, governmental entities that are directly responsible for the health and welfare of their people, and are often the only major employers in Tribal territories. Forcing Tribes to pay millions of dollars in penalties - or, alternatively, to purchase costly insurance for Tribal member employees who are otherwise exempt from the individual mandate and eligible for IHS services - will not just affect Tribal business decisions concerning hiring or expansion, but will directly limit their ability to provide basic social, health, safety, and other governmental services on which their members and other reservation residents rely. Tribes cannot "pass on" the costs of compliance by raising prices on goods or services. Tribal governmental funding is a zero sum game, and any funding used to either comply with the mandate or pay the penalties will necessarily come from coffers used to provide what may be the only constituent services for hundreds of miles.
The ACA employer mandate creates a no-win situation for Tribal governments, forcing them to either pay for the cost of insurance for Tribal member employees who are otherwise exempt from having to obtain coverage, or pay a tax penalty in order to ensure that Tribal member employees qualify for the benefits and protections to which they are entitled. The mandate discourages Tribes from facilitating
Definition of Indian in the Affordable Act
As NIHB testified previously, we urge
Renewal of the
As part of the Balanced Budget Act of 1997,
According to the
But SDPI is working to overcome these challenges. Between 1995 and 2006, the incidence of End-Stage Renal Disease in AI/AN people with diabetes fell by nearly 28 percent - a greater decline than any other racial or ethnic group. ESRD costs
Today, SDPI is funded at a level of
NIHB wishes to express its gratitude for the work that members of this committee have done so far to support renewal of SDPI. With the deadline of
Oversight opportunities
In addition to considering the aforementioned legislative proposals, this committee has important oversight role for many of the issues and challenges affecting Indian Country. When it comes to health there are many challenges that merit some additional oversight for this committee, but we have chosen to highlight several of our top priorities for the purpose of this statement.
Implementation of the Affordable Care Act
The ACA recognizes the federal trust responsibility to provide healthcare for AI/ANs through its special provisions that outline protections for them. These special provisions include:
. Indian-specific cost-sharing protections that help defray the cost of health coverage
. Special AI/AN enrollment periods
. The ability for Tribes to assist with Marketplace plan premium payments for Tribal members
. An exemption for enrolled members in a federally recognized Tribe to the individual mandate to purchase insurance.
The current call centers have proven to be inadequate at answering questions related to the special benefits and protections available to AI/ANs and have often caused greater confusion and application errors. There are still thousands of exemption applications that have yet to be processed with no discernible reason as to what the problems are. A large portion of those applications that have been processed, have been processed incorrectly and require prompt resolution so that AI/ANs can be issued exemption certificate numbers. These problems have all contributed to low enrollment, as many AI/AN are still confused about the benefits of the ACA and see no reason to sign up. We request that CMS provide their call center or help desk staff with better training on AI/ANs protections and provisions of the ACA. NIHB has also advocated for the creation of an AI/AN specific help desk where AI/AN callers would be redirected. This helpdesk would be better equipped to answer questions for AI/AN customers. In addition, an AI/AN call center would be more culturally sensitive and in certain cases, linguistically equipped to answer calls where the caller only speaks their native language. Our request for an AI/AN call center has gone unanswered at CMS, despite the fact that the Administration has developed call centers for other minority groups (like native Spanish speakers), who the federal government does not have a special trust responsibility towards. AI/ANs, not only speak languages other than English, but the law applies to them in a completely different way, thereby increasing the need for a native-specific call center.
For more than a year, NIHB and its partners in the
We therefore request that
Implementation of the Indian Health Care Improvement Act
As noted above, when
We believe that more needs to be done on behalf othe the IHS and
Through the ACA, the American health care delivery system was revolutionized; meanwhile, the Indian health care system still waits for the full implmentation of the IHCIA, despite the fact that it was passed in the same law. For example, mainstream American health care increased focus on prevention as a priority and a treatment, and coordinated mental health, substance abuse, domestic violence, and child abuse services into comprehensive behavioral health programs that is now standard practice. Reflecting these improvements in the IHCIA was a critical aspect of the reauthorization effort. The time and resources paid off with the permanent reauthorization of IHCIA. Highlights of what is contained in the IHCIA Reauthorization include:
o Updates and modernizes health delivery services, such as cancer screenings, home and community based services and long-term care for the elderly and disabled.
o Establishes a continuum of care through integrated behavioral health programs (both prevention and treatment) to address alcohol/substance abuse problems and the social service and mental health needs of Indian people.
All provisions of the IHCIA are critcal to advancing the health care of American Indian and Alaska Native people and should be implemented immediately. Additional funding will only beign to scratch the surface of implementing these new budget authorities. We believe that with proper Tribal consultation, and assistance from
Access to Quality Medical Providers
One of the significant barriers to achieving good care is a lack of good providers at IHS and Tribal facilities. Remote and rural locations; lower pay; lengthy hiring processes and ill-equipped IHS facilities all effect the ability for providers to be recruited and retained within the IHS system. IHS has an estimated 46% turnover rate for their physicians every year, which leads to significant issues when building trust between patients and physicians and enriching care.
One solution supported by the IHS and Tribes is making IHS scholarships and student loan repayments tax exempt. This would create parity between IHS and other federal health providers such as the
But this is just one small solution to a very complex problem. We believe that oversight by the Committee on this topic could be a positive step toward increasing providers, and thus improving care, in Indian Country. Possible solutions could include streamlining the federal hiring process; additional incentives for physicians who stay with IHS or Tribal providers for multiple years, or providing greater flexibility for scholarship and loan reimbursements. It is vital that
Public Health Infrastructure for Indian Country
Earlier in this testimony, we listed some of the health disparities for AI/ANs including alcoholism, substance abuse, obesity, diabetes, behavioral health and suicide. Many of the top health concerns for AI/ANs of these afflictions are preventable, chronic conditions. Small, targeted, investments in public health infrastructure are an important first step in combating some of these health discrepancies. Public health is the science of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. While health care systems like the
The health disparities experienced in Indian Country are often the areas of health that benefit the most from a public health approach. For example, chronic/preventable diseases like diabetes, heart disease, and chronic lower respiratory disease are some of the leading causes of death for AI/AN people. A 2011 study published in Health Affairs found that increased spending by local public health departments can save lives currently lost to many of these and other preventable illnesses. The study found that a 10% increase in spending translated to a 3.2% decrease in cardiovascular disease mortality. The additional cost to local health departments, on average, was
However, in Indian Country, public health support is virtually non-existent. While much of the U.S. population has access to government-sponsored, accredited, health departments, behavioral health facilities or alcohol and substance abuse treatment facilities, these facilities rare in Indian Country. Combine this with high rates of poverty, widespread historical trauma, and adverse childhood experiences (See text box), and the problems seem insurmountable.
However, we believe that a focused, multi-jurisdictional approach could help combat some of these difficult problems in Indian Country. In
In the 114th
Contract Support Costs
Contract support costs (CSC) are the funds that Tribes and Tribal organizations receive from the government to manage health and other programs that were previously operated by the federal government. For many years,
It was clearly not the intent of the
In the 114th
Conclusion
Thank you for the opportunity to offer this testimony for
1) Achieving increased appropriations and mandatory funding for the IHS
2) Advance Appropriations for the IHS
3) Legislation to enacted to provide Medicare Like Rates for Non-hospital providers and suppliers
4) Tribal exemption for the Employer Mandate in the ACA
5) Streamlining the Definitions of Indian in the Affordable Care Act
6) Long-term renewal of the
The 114th
1) Implementation of the Affordable Care Act
2) Implementation of the Indian Health Care Improvement Act
3) Access to Quality Medical Providers
4) Public Health Infrastructure for Indian Country
5) Contract Support Costs
NIHB stands ready and willing to serve as a resource for the committee was you work toward bipartisan solutions to improve the lives of AI/ANs in the 114th
n1 The National Health Board (NIHB) is a 501(c) 3 not for profit, charitable organization providing health care advocacy services, facilitating Tribal budget consultation and providing timely information and other services to all Tribal Governments. Whether Tribes operate their own health care delivery systems through contracting and compacting or receive health care directly from the
n2 Indian Health Care Improvement Act, [Sec.]103(2009).
n3 GAO-13-272: "Capping Payment Rates for Nonhospital Services Could Save Millions of Dollars for
n4 "Ending Violence So Children can Thrive," Attorney General's
Read this original document at: http://www.indian.senate.gov/sites/default/files/upload/files/1.28.15%20SCIA%20Witness%20Testimony%20-%20Stacy%20Bohlen%20-%20NIHB.pdf
House Veterans’ Affairs Subcommittee on Health Hearing
Advisor News
Annuity News
Health/Employee Benefits News
Life Insurance News