The CMS has finalized a decision to pay 100% of primary and specialty healthcare services that are purchased from private healthcare providers because they are not available at Indian Health Service or tribal healthcare facilities.
The decision, which covers only Native Americans eligible for Medicaid, frees up state funds that could offset Medicaid expansion. South Dakota officials have hinted this CMS decision could result in the state expanding Medicaid.
Republican Gov. Dennis Daugaard is pleased with the decision but doesn't think there is enough time to present a expansion proposal to the Legislature, whose session ends in 10 days, said Kim Malsam-Rysdon, South Dakota's health secretary. Still, it's possible a special session could be called before year-end, she said.
Some in the Native American community worry, however, that nothing in the CMS policy mandates they'll benefit from any state savings, leaving a vulnerable population again without some essential services that are not Medicaid-eligible.
“It is important to note that this is far more of a benefit to states than it is to tribes,” said Ed Fox, a member of a CMS tribal advisory group and health director for the Skokomish tribe in Washington state. “I am not sanguine that the states will share this benefit with tribes.”
For months, the CMS had been talking with tribes and states heavily populated by Native Americans about fully funding medical services that often are not available at tribal healthcare facilities. This can include hospital and outpatient care, as well as physician, laboratory, dental, radiology, pharmacy and transportation services.
The CMS was reimbursing standard Medicaid matching rates for these services. That payment averages 57% across states.
On Feb. 26, it sent a letter to state health officials (PDF) informing them they would now get a 100% federal match for care at nontribal facilities.
Approximately 5.1 million individuals self-identify as American Indian or Alaska Native, and as many as 41% live in poverty, according to the Kaiser Family Foundation. Prior to expansion, Medicaid was already covering 1 in 3 non-elderly American Indians and Alaska Natives.
This population is more likely to be overweight or obese than average. As a result, Native Americans struggle with diabetes and cardiovascular disease and experience frequent mental distress, according to the Kaiser Family Foundation. The suicide rate for American Indian and Alaska Native adolescents and young adults is 2½ times higher than the national average.
The CMS' announcement is great news for states like Alaska. People of tribal descent in the state who have chronic medical needs must travel far to get the care they need.
The Alaska Department of Health and Social Services offered an example of a meningitis patient living in the village of Shishmaref, on an island located 5 miles from the mainland. That person would need to be medevaced to the Alaska Native Medical Center in Anchorage. Chronic ailments tied to her initial diagnosis such as respiratory problems and intractable seizures mean she'll need to be medevaced back to the facility for care on multiple trips. She'll also need to fly back home.
A roundtrip flight from Shishmaref to Anchorage costs around $1,168. If the patient is a child traveling with an escort, that cost doubles.
“For children with chronic healthcare needs in rural Alaska, this is a very common story, and is one of the major reasons that Medicaid costs are so high in Alaska,” said Sarana Schell, a department spokeswoman.
Medicaid spending in the state hit $1.5 billion in fiscal 2014, up from $1.4 billion in 2013, according to federal data. Less than 130,000 people were on Medicaid last year.
Expanding Medicaid reimbursement to cover these services received outside of Indian Health Service and tribal facilities means that more state dollars are available to cover referral care for Native Americans that are not Medicaid-eligible, said Devin Delrow, director of federal relations at the National Indian Health Board, a Washington, D.C.-based not-for-profit that represents tribal governments on healthcare issues.
But Fox said he's disheartened that states have no obligation to provide additional assistance when substance abuse is ravaging tribes in his state, he said.
“States will always say they need more funds, but I submit our need is greater and these dollars should go to" Native Americans, Fox said.