Molin Malicay, director of the Sonoma County Indian Health Project clinic, has read all 976 pages of the Affordable Care Act—the legislation that created what’s become known as Obamacare. His copy has 46 tabs, each marking a point where Native Americans are mentioned.
The country’s First Peoples are uniquely affected by the federal reforms. But because of federal responsibility for tribal health is already in place, individual Native Americans may not notice the effects of Obamacare as much as Native American clinic directors.
American Indians and Alaskan Natives are exempt from the Obamacare mandate that most Americans must have health insurance or face a penalty by January 1, 2014. Thanks to the Constitution, multiple treaties, federal laws and Supreme Court decisions, the federal government is already required to provide health-care to all Native Americans. The government does this through a network of tribal health clinics in large part funded by the federal Indian Health Services. If a tribal member goes to any of these clinics, it is illegal to charge them a dime.
But Indian Health Services only reimburses about 60 percent of patient expenses and Native American clinics struggle to make up the difference.
“There’s an expression in Indian Country: ‘don’t get sick after July,’” said Frederick Rundlet, Executive Director of Consolidated Tribal Health Project clinic in rural Mendocino County. Funding often runs out by the end of the summer.
With the simplification and expansion of Medi-Cal under the Affordable Care Act, clinics will be better able to treat their Native American patients. The median income of Native Americans is $35,000 a year, $15,000 less a year than the national average. Anyone in a family of four making $31,000 a year or less will now qualify for Medi-Cal. Also, until now childless adults could not qualify for Medi-Cal no matter what their income. With Obamacare, individuals making $15,000 a year or less will qualify.
Jim Crouch, Executive Director of the California Rural Indian Health Board has an ‘I heart Obamacare’ bumper sticker on his car. He says the inclusion of childless adults makes a huge difference. “Tribal health policies in California are always very dependent on their Medi-Cal coverage for their community,” Crouch said.
Because of the federal responsibility to provide care, Native Americans enrolled in Medi-Cal are covered 100 percent by federal funds with no state contribution.
Patients may not notice the difference between programs because they will continue to get care at the health centers, but they will be better-funded health centers. Also, most clinics only provide primary care. Broader coverage allows patients more access to third-party providers.
“What I’m most excited about for our patients is that through healthcare reform they’re going to have access to specialty care,” said Lisa Davies,* CEO of Chapa-De Indian Health Program in Auburn and Grass Valley.
Obamacare also made the Indian Health Care Improvement Act permanent, something Native American health advocates have been requesting for more than a decade. The act expands programs for mental health, long-term care, veterans and urban Indians.
“That freed us to look at other issues with our limited resources and staffing,” Crouch said.
The act also permanently qualifies individuals from tribes that aren’t federally recognized for coverage.
One of the most basic issues in Native American health is who qualifies as an American Indian or Alaskan Native. This is of particular concern to California tribes, many of which aren’t federally recognized.
Molin Malicay said that issue has been a major concern of Native American leaders as the reforms roll out. The Affordable Care Act requires tribal consultation in the development of the state health benefit exchange.
Malicay chairs the 21-member Tribal Advisory Workgroup for the California exchange, which is now called Covered California.“The key issue really has been the definition of an Indian,” Malicay said.
The original legislation is rather vague, but Covered California finally settled on the broadest version; defining an Indian as a descendent of anyone listed in several surveys documenting the Native American population since 1851. This means Native Americans in California don’t have to be enrolled in a tribe and if they are, their tribe doesn’t have to be federally recognized.
With that issue resolved, their next concern is outreach and enrollment of Native Americans through Covered California. Jim Crouch thinks that since Native Americans are exempt from the mandate they will under-utilize the benefits available.
“In lieu of individual responsibly, I see it’s going to play out in our value system as communal responsibility,” he said.
Chapa-De Indian Health Program is going to hire one full time employee and one part time employee to sign newly-qualified patients up for benefits. With stimulus funds, they were also able to increase the capacity of their Grass Valley clinic in order to serve the influx of new clients. About half of their patients aren’t Native American and will be subject to the mandate. But the clinic also needs their Native American patients to enroll.
“This is a great law, but if patients don’t know about it, no one benefits,” clinic director Lisa Davies said.
Native Americans suffer from some of the worst health disparities in the nation. They face higher mortality rates for heart disease, cancer, diabetes and accidents than any other ethnic group.
The federal government has also increased the Indian Health Services budget by 29 percent since 2008 in an attempt to resolve some of these disparities.
With the new funding, clinics like Chapa-De Indian Health Program will continue to grow and meet the unique needs of their clients.
“Our philosophy really is whole person care,” Davies said. “Folks are coming in who’ve delayed care for years and they’re finally coming in to get some pretty serious things taken care of.”
* This post has been corrected. An earlier version of the story referred to Linda Davies as Linda Davis.