Alaska Natives Wait… And Wait, For Health Law Exemption

Most Americans are supposed to have health insurance under the Affordable Care Act. But up to 50,000 Alaska Natives and American Indians in Alaska are excused from the requirement. They have to apply for that lifetime exemption though. And the federal government is mishandling many of those applications.

By Annie Feidt, Alaska Public Media Network

The form Alaska Natives and American Indians need to fill out to get an exemption from the individual mandate.
The form Alaska Natives and American Indians need to fill out to get an exemption from the individual mandate.

Evelyn Burdick thought it would be easy to apply for her American Indian exemption. As a member of the Cherokee Nation, the Anchorage resident sees a doctor at the Alaska Native Medical Center. Burdick likes the care she gets there and has no plans to sign up for private insurance under Obamacare. So she sent an exemption application to the federal government almost as soon as it was available, on January 9th:

“I have yet to receive any correspondence from them back whatsoever. Not even to let me know they’ve received my application.”

Burdick is not alone. The Alaska Native Tribal Health Consortium has helped hundreds of Alaska Natives and American Indians in the state who have had problems with their exemption applications. The exemption is a simple six digit number applicants need for their tax forms to avoid paying a penalty ($95 dollars or 1% of income, whichever is greater) for not having health insurance. Monique Martin, with ANTHC, has been working with the federal government to resolve the problems:

“Every time we call it’s a bear with us sort of request but we’ve been bearing with them since February when we first started reporting issues and we are anxious for a resolution to this issue.”

The Federal government has fumbled the applications in several different ways. Martin works closely with three other people at ANTHC who all applied for the exemption for themselves. Martin’s exemption number came back with no problems. But her three colleagues were not so lucky:

“One of our coworkers received her letter twice, with two different exemption numbers for her and her kids. One received the wrong exemption… and another one is still waiting to hear on her application. So we’ve seen all the errors come to us, so we have real world examples that we can show the federal government.”

No one from the Centers for Medicare and Medicaid Services was willing to do an interview for this story. In an e-mail, a spokesperson with the agency wrote that they are working to improve the process daily and committed to providing consumers with their exemption numbers in time for tax filing season. Martin says she’s cautiously optimistic that can happen:

“We are the squeaky wheel in Alaska and we’re really pushing the federal government to resolve this issue and to get this addressed for people so they aren’t negatively impacted.”

Martin worries about how the federal government will handle the rush of exemption applications as tax time approaches. She expects many Alaska Natives and American Indians haven’t even thought about sending in the application yet. Evelyn Burdick, who was proactive and applied early in the process, says the nine month long wait for a response has been frustrating:

“I don’t want to be penalized for not having the insurance. I’m trying to follow the rules and regulations that set up and they’re not making it any easier.”

Late last month, Monique Martin was able to get Burdick’s exemption number for her from a contact at the federal government. Burdick is happy to have the number, but she still wants to see it in writing. She says she has no idea when it will arrive in her mailbox, but at this rate she’s not expecting it any time soon.

This story is part of a reporting partnership between APRN, NPR and Kaiser Health News.

Why Should Tulalip Tribal Members Care About the Affordable Care Act?

By Kyle Taylor Lucas

The Affordable Care Act (ACA), signed into law in 2010, became effective January 2014. Many questions continue to roil in the minds of American Indians about just what the new health care law means to them.

The law helps make health insurance coverage more affordable and accessible for millions of Americans, including American Indians. Importantly, the law addresses inequities, increases access to affordable health coverage and prevention medicine for tribal members. The ACA is important to American Indians because it provides greater access to care and coverage unmet by the Indian Health Service (IHS).

The ACA requires all Americans to have health care insurance coverage. However, American Indians and Alaska Natives have the option to file a lifetime exemption. They are encouraged by the state Health Care Exchange to file the exemption regardless of their current insurance status in case their insurance should ever lapse.

There are numerous state and federal agencies working to implement and manage ACA health care delivery. Tulalip members can most directly obtain enrollment process advice from clinic staff members who have received specialized training as Tribal Assisters. They can help members through the enrollment process and refer you to a broker who is licensed to provide information and advice on qualified health insurance plans and policies. Tulalip Resource Advocate, Rose Iukes, has received intensive training on the ACA. She and Brent Case can answer questions and help enroll members. Fortunately, for Tulalip members, the Board of Directors contracted with a licensed broker, Jerry Lyons, to assist members in understanding and selecting the best-qualified health insurance plan for themselves.


Contact Information:


Tribal Assisters:

Rose Iukes, Resource Advocate – (360) 716-5632 /

Brent Case, Resource Specialist – (360) 716-5722 /



Jerry Lions, American Senior Resources – (206) 999-0317


Asked about the greatest impediment to enrolling tribal members, Rose Iukes said many tribal members assume IHS coverage is sufficient, so have been disinterested in the ACA. Even so, she noted, “We had almost 800 people apply. We got probably about 250 on qualified health plans and about 150-180 on Apple.” She said efforts were hampered by the state system “going down,” which required many tribal enrollments to be done in-person. “There were so many flaws that we started having people do paper applications here at the clinic. Now, we need to have them do follow-up. We didn’t get to do a test-run on the site. We thought we could go in and enroll them, but there were additional security questions. So, now we’re asking members who completed paper applications to come in and complete their application processes.”

Even with the challenges, Washington State fared better with its overall ACA rollout than other states, leading the nation in early enrollment numbers.

Rose Iukes noted significant confusion due to the state’s failure to provide clarifying information on special tribal provisions and exemptions on its websites and call centers. She said, “I’m hoping these call centers get educated on the tribal provisions and exemptions.” She could not say why there is little detail about income, age and other special provisions posted on state websites. Publicizing details of special federal poverty level provisions and exemptions for tribal members may be confusing to the general public. The result is that the rollout for American Indians, especially urban Indians without easy access or even referral to a Tribal Assister, has been challenging. However, despite the state’s system inadequacies, Iukes praised the American Indian Health Care Commission staff and Sheryl Lowe at the Washington Health Care Exchange whose support she felt was invaluable.

“The bottom line for tribal members, if they have ACA health care they can be taken care of. And they can get the help they need. That’s what drives me and why I advocate the way, I do. I don’t want somebody to go through the heartache,” said Iukes.

Tribal members often inquire about alcohol and chemical dependency treatment options, especially as many have a history of unsuccessful treatment attempts. Iukes said that beyond the Tribe’s one treatment option, “With qualified health plans, there is unlimited treatment, but we need to find a way to help them pay their premium. For example, a young man was ready to go to treatment, but his premium was $4. It must be paid with a debit card, but he didn’t have one. Ultimately, he didn’t go to treatment. I’ve asked the Board about setting up a way for the premium to come out of per capita, then we can issue them a card to use” to pay their premiums.

Broker, Jerry Lyons, is licensed with eighty (80) different insurance companies said, “In my brief time working with Tulalip, we feel confident in our efforts. We are being successful as we have been instrumental in assisting members with questions and we have enrolled more Native Americans into the ACA than any other tribe.” He added that never in his career has he been involved in a more “disorganized” insurance roll-out, but emphasized it was not due to the tribal efforts, but rather the bureaucracy. “Even so, we have helped about 250 people obtain insurance in one way or another.” Asked if he is available to all members many of whom reside off-reservation, Lyons replied, “We assist all members. There are also many special plans that most tribes are unaware of. Just have them call me.”

Several state, public/private, federal, and non-profit organizations are supporting tribal ACA implementation and enrollment. They are the Washington Health Benefit Exchange, the Health Care Authority, the Centers for Medicare and Medicaid Services (CMS) Region 10 office in Seattle, and the American Indian Health Commission.


Washington Health Benefit Exchange (HBE)

The Washington Health Benefit Exchange was created in 2011 state law as a “public-private partnership” separate and distinct from the state. The Exchange is responsible for the creation of Washington Healthplanfinder–the online marketplace to assist Washingtonians to find, compare, and enroll in qualified health insurance plans.

Many tribal members who rely upon IHS for their health care needs question the need to apply for ACA coverage. They also question the need to go outside treaty guaranteed health care services. Unfortunately, as most trust responsibilities, health care for American Indians/Alaska Natives has been historically and woefully underfunded and continues to be so today.

When asked why the ACA is important to tribal members, Sheryl Lowe, tribal liaison with the Washington Health Benefit Exchange, said, “Individual coverage offers tribal members more access to specialty care and even if the member uses their own tribal clinic, the tribe can then bill the health insurance company rather than the Indian Health Service. She emphasized that the basic tribal contract dollars can then be utilized for other urgent and uncovered care.

Lowe said the ACA benefits both individuals and tribes. “For most tribes, IHS only provides direct care and tribes have to pay Contract Health Care. And the IHS continues to be funded at less than fifty percent of need, so the ACA is another way for individuals and tribes to access health care. Also, most tribal clinics are Priority One clinics offering basic care and provide referrals only for life and limb.”

After working out many of the bugs and training, there are 93 Tribal Assisters, at least one in each of the federally recognized tribes in Washington, the state and the Tribal Assisters are now able to focus upon a more comprehensive effort to enroll tribal members. Lowe praised the Tribal Assisters who she credits with outstanding efforts to learn a complicated enrollment process to become certified as Tribal Assisters. She said Tulalip has four Tribal Assisters and she exclaimed, “Rose Iukes is so dedicated!” The HBE shared the following statewide training statistics:

– HBE-Certified Tribal Assisters:  93

– Tribal Staff in the process of becoming Certified:  34

– 66 Active Tribal Assisters helped 10,000 people enroll through the HPF (through 2/15/14)

– Tribal Assisters represented 25 Tribes, 2 Urban Indian Organizations, and SPIPA

The Health Benefit Exchange reports that statewide, of the 26,378 who answered “yes” to “Are you an American Indian/Alaska Native [AI/AN]?” on the ACA enrollment site, 21,201 of “enrolled tribal members” have enrolled in the Healthplanfinder. Significantly, 17,350 enrolled in Washington Apple Health (expanded Medicaid). Unfortunately, of the 3,885 AI/ANs eligible for Qualified Health Plans, only 1,110 actually enrolled even though many would likely have zero to low premiums and no cost shares.

Lowe said she couldn’t emphasize enough the importance of tribal members considering enrollment because those whose income falls in 138 – 300 percent of federal poverty level have no cost-sharing which means no co-pay or deductibles, “which is a huge benefit.” She added, “Depending upon household size and other factors, some may even have a premium that is zero. They can take the tax credit to lower their monthly premium or take it at the end of the year.           Those in the 138 – 400% of poverty level are eligible for premium tax credits. Depending upon income or household size you can get tax credits which will reduce your overall costs.” She pointed out that some plans have deductibles for $5000 for a family before they’ll pay anything, so the cost-sharing benefit is one of the biggest things for tribal members.” It is clearly worthwhile for tribal members to speak to a tribal assister and/or broker.

Those whose income is below 100 – 138 percent of federal poverty level qualify for expanded Medicaid or Apple Health as it is now called. However, children are eligible for Apple Health in households whose income is up to 300% of the federal poverty level. Therefore, although the adults may not qualify for Apple Health, it is important to consider that children may.

Unlike Apple Health, the Qualified Health Plans do not provide dental. Yet, the ACA does require that all children be covered by dental insurance. The HBE indicates there are two low-cost children’s plans available. Sheryl Lowe indicates there is also discussion about the potential of adult dental plans to be introduced in 2016. Broker, Jerry Lyons, encourages tribal members to ask him about low-cost and special plans that most tribes are unaware.


Washington Health Care Authority (HCA)

The HCA oversees Washington expanded Medicaid or Apple Health plan for low-income residents. Washington is one of 27 states implementing expanded Medicaid. Of the many benefits for American Indians from the new health care law, expanded Medicaid seems most significant. Eligibility for Apple Health (expanded Medicaid) is the same for tribal members and the general public–that is household income below 100 – 138 percent of the federal poverty level. Tribal members in the Apple Health Program would not be eligible for tax credit that is offered tribal members in the Qualified Health Plans. However, one important benefit is that effective January; dental coverage for adults was restored.

Through expanded Medicaid in Washington, countless low-income American Indians and Alaska Natives can now receive specialty care. As of March 25, 2014, of all who identified as AI/ANs at enrollment, 17,350 have enrolled in Washington Apple Health (or expanded Medicaid). Staff at the Tulalip Tribes health clinic is working to update Tulalip enrollment numbers. Rose Iukes reported it is difficult because many are in process of updating enrollment after the glitches in the state system caused the Tribe to revert to paper applications.

Tribal members can enroll monthly by the 23rd, and then the plan starts the first of next month.

Big changes in Medicaid/Apple Health became effective January 2014. Because of the ACA, more people are able to get preventive care, like check-ups and cancer screenings, treatment for diabetes and high blood pressure, and many other health care services they need to stay healthy.


Apple Health (Medicaid) Benefit Changes Effective January 2014

Dental Services for Adults:  Dental health benefits were restored for individuals 21 years of age and older in January. Ensure that your dentist is enrolled as a Medicaid provider.

Mental Health Services Unlimited Number of Visits: Beginning in 2014, there are no limits on the number of visits for mental health services in a calendar year.

Expanded Pool of Licensed Providers:  Previously, psychiatrists were the sole mental health provider approved for adults, but effective January 2014, mental health services can be sought from a variety of providers. Coverage is expanded to services by Licensed Advanced Social Workers, Licensed Independent Social Workers, Licensed Mental Health Counselors, Licensed Marriage and Family Therapists and Psychologists. Just ensure your provider is enrolled with Medicaid.

Preventative Care Shingles Vaccine: Beginning January 2014, Apple Health shall will cover the shingles vaccination for clients 60 years of age and older. Age 60 or older is considered the most effective time to receive the vaccine.

Oral Contraception: Effective 2014: Apple Health now allows eligible clients the option to fill birth control prescriptions for a 12-month period.

Early Intervention Screening for Substance Abuse: Apple Health will cover services provided by trained, certified medical providers who conduct screening, brief intervention, and referral for treatment for individuals who may present as facing challenges with substance abuse, including alcohol, drugs and tobacco.

Screening of Children for Autism: Funding has been approved so that Apple Health’s enrolled primary care physicians can screen your child, if they are under three years of age to assess for autism.

Licensed Naturopathic Physicians serving as Primary Care Doctors: Beginning in 2014, licensed naturopathic physicians are able to provide primary care services. Given there are a limited number of primary care physicians, individuals possessing a Washington Department of Health Naturopathic Physician license shall be able to provide care in the scope of care outlined by Department of Health, including diagnosing, administering vaccines and immunizations, provide referrals to specialists, conduct minor office procedures, and write limited Food and Drug Administration-approved prescriptions.

Vendors that Provide Wheelchairs and Accessories: In 2014, Apple Health will provide coverage of wheelchairs and accessories from vendors Medicare certified to provide Complex Rehabilitation Technology items.

Centers for Medicare and Medicaid Services (CMS) & Indian Health Care (IHS)

The federal CMS has a Region 10 office to assist tribes with questions about expanded Medicaid and Medicare services. They were unable to be reached for comment. Per the CMS website statement, “Within the vast reforms in PPACA, AI/AN populations will be affected not only by the general provisions, but through specific, explicit provisions, including the permanent reauthorization of the Indian Health Care Improvement Act.”

A question unanswered by both CMS and IHS is how the federal trust responsibility intersects with tribal elders no longer qualifying for expanded Medicaid or Apple Health once they reach age 65. The Washington Health Benefit Exchange is attempting to secure answers to the inquiry. Ideally, those elders would be covered by treaty guaranteed programs created through IHS in their federal trust responsibility and expanded Medicaid that continues beyond age 65.

Though the IHS did not respond to questions about its continuing federal trust responsibility for tribal health care, according to its website, IHS states “it will continue to provide quality, culturally appropriate services to eligible American Indians and Alaska Natives.” Both the CMS and IHS websites also point to the ACA as benefiting Indian elders with strengthened Medicare, affordable prescriptions, and free preventive services regardless of their provider.

The IHS website notes that if tribal members buy private insurance in the Health Insurance Marketplace, they will not have to pay out-of-pocket costs like deductibles, copayments, and coinsurance if their “income is up to around $70,650 for a family of 4.” The IHS assures members of federally recognized they are eligible to continue receiving services from the Indian Health Service, tribal health programs, or urban Indian health programs even if they have obtained insurance in the marketplace.

The Native American Contact (NAC) for CMS Region 10 is Deborah Sosa. Deb is the agency’s main contact for questions or clarification on:

  • health policies related to the Medicare, Medicaid, and CHIP programs
  • policies and programs under the Affordable Care Act, such as the new health insurance exchanges/marketplaces, and
  • emerging health policies and issues that arise in your community.

She can be reached directly at or by telephone at (206) 615-2267.

Basic ACA Details for Tribal Members


American Indian and Alaska Native consumers who are members of federally recognized tribes have access to a Tribal Membership Exemption from the shared responsibility requirement payment. The exemption applies to American Indian and Alaska Natives who are members of federally recognized tribes and are unable to maintain minimum essential coverage for any time during the year.
To receive an exemption, members may apply through the Marketplace, through their tax return submitted to the Internal Revenue Service by April 2015, or members can receive assistance from either Rose Iukes or Brent Case whose contact information is provided earlier in this story. Alternatively, members can access the form at the following website:

If you have health insurance coverage from your employer or if you have other health care coverage (through Medicare, Medicaid, CHIP, VA Health Benefits, or TRICARE), you are covered and don’t need to worry about paying the shared responsibility payment or enrolling for health coverage available through the Health Insurance Marketplace. However, tribal members are encouraged to complete the tribal lifetime exemption regardless of current coverage.



            A frequent question arises about enrollment periods. There is no enrollment period or deadline for members of federally recognized tribes and Alaska Native shareholders who can enroll in Marketplace coverage any time of year. Plans can be changed as often as once per month. Be sure to apply no later than the 23rd of the month for benefits to become effective on the first of the following month. Again, see Rose Iukes at the clinic for assistance. Otherwise, information can also be found at the Health Benefit Exchange – Health Plan Finder website:


Insurance Premiums

            Premium payment is due by the 23rd of each month for coverage beginning the following month. Payment can be made by echeck or debit card. Recurring payments can only be setup by echeck. Autopay requires an email address. Rose Iukes can assist you with this during enrollment.


Urban Tulalip Tribal Members

The Health Care Authority tribal liaison, Karol Dixon, recommends that enrolled Tulalip tribal members who reside off-reservation, but within Washington state, can access enrollment assistance by telephoning the Tribal Assister at their tribal clinic (Rose Iukes), but if it is more convenient–they can enroll through the HCA website. In fact, all tribal members can enroll there if they choose. At the website, they can locate a Navigator or Broker who can assist them with the process and in selecting a plan.  Select the question mark in the top right of the web page to see links to Navigator or Broker at:

Unfortunately, Tulalip members residing outside of Washington are not eligible to enroll through the Washington Healthcare Exchange. They will need to enroll in the state in which they reside. This is disappointing for any members who may be residing in one of the 24 states that have not expanded Medicaid.



Many American Indians/Alaska Natives are taking advantage of expanded Medicaid as demonstrated by enrollment data reported by the Health Care Exchange. However, enrollment in the Qualified Health Plans, which offer tribal members many tax credits and cost-share exemptions, could be improved. Moreover, the ACA offers American Indians many advantages expanded access and coverage in both Apple Health and the Qualified Health Plans.

Some political and policy questions remain unanswered such as the federal trust responsibility and how that extends to care for tribal elders 65 and over who have no Medicare coverage. One would hope that the ACA’s permanent reauthorization of the Indian Health Care Improvement Act, extending and authorizing new programs and services within the IHS will find a means to address that void in care for our dear elders.

Early enrollment reports from the Health Care Exchange indicate American Indians/Alaska Natives have taken advantage of expanded Medicaid in Washington State. Many of those tribal members were urban Indians who formerly had little access to any health care, so the ACA is proving itself critical to the health services of urban Indians. Those same individuals can also now receive what for many is urgent dental care.

From early indications, the ACA is fulfilling some of its promise in that it is reducing the number of uninsured Americans with more than 8 million Americans enrolling to date. And the number (17,350) of AI/AN enrolled in Washington’s Apple Health (Medicaid) plan as of March 25 seems to indicate the ACA is fulfilling some of its promise to low-income AI/AN and children. Increased tribal enrollment in the marketplace and in expanded Medicaid will free  IHS tribal contract dollars for the tribe to utilize for other urgent care needs.

Many political and policy questions remain unanswered relative to trust responsibility and treaty guaranteed expectations. The possibilities of tribal sponsorship have not yet been fully explored. However, in Washington, and at Tulalip, there is a determined effort by many dedicated individuals and organizations to right some of the historic federal oversights in Indian health care.


Kyle Taylor Lucas is a freelance journalist and speaker. She is a member of The Tulalip Tribes and can be reached at / Linkedin:


Mark Trahant: Obamacare brings new funds to Indian Country

Jacqueline Pata, executive director of the National Congress of American Indians, says the Affordable Care Act is a “very good thing for Indian Country.”
Jacqueline Pata, executive director of the National Congress of American Indians, says the Affordable Care Act is a “very good thing for Indian Country.”


There has been much controversy about the Affordable Care Act, what some call Obamacare. The politics are beyond intense. And those computer glitches are making it virtually impossible for people to enroll.

But for American Indians and Alaska Natives there is a whole different story to tell about the Affordable Care Act. Native Americans have a right to health care. This is a deal the United States made, a promise that including sending doctors to the tribes that signed treaties in exchange for peace and for titles to lands.

Promise or not, treaty or not, the entire history of healthcare in Indian Country has been defined by shortages. There has never been enough money to carry out that sacred bargain.

The modern Indian Health Service was created in 1955. And over the following decades, more clinics were built, more doctors were hired, and health care for Native people improved. Still, the agency never had enough money.

In 1965 when Medicare and Medicaid were enacted into law there wasn’t even consideration about how these programs would impact American Indians and Alaska Natives. The Indian Health Service could not bill the agencies for serving eligible services. Native Americans were essentially left out of that health care reform effort.

That history of shortages is critical context to understanding the Affordable Care Act. Because from the very beginning of the legislative process, the Affordable Care Act included Indian Country. This happened because a decision was made by tribal leaders to roll the Indian Health Care Improvement Act into the larger legislation.

“Let me tell you why it was different this time,” said Jacqueline Pata, executive director of the National Congress of American Indians. For nearly twenty years tribes urged Congress to reauthorize the Indian Health Care Improvement Act. Then the discussion began about a health care reform.

“We were sitting at an NCAI board meeting, tribal leaders around the table, and said we really have to engage in this health care debate this time around. There were those that said, “no, let’s stay where we are,’” she said. But former NCAI President Jefferson Keel knew the health care industry and he agreed with the broader approach. “So we immediately started to look at the overall health care bill, working with the members of Congress, to be able to find all those other places that it was important to insert ‘and tribes.’ So not only did we get Indian Health Care (Improvement Act) reauthorized permanently. But we were able to get provisions into Medicaid, we were able to get the tax exemption (for tribes that purchase insurance for members), we were able to include a lot of places where tribes should have been considered but probably wouldn’t have been if we didn’t integrate those two pieces of legislation.”
YouTube: Episode 1 of Treaty or Not? The Affordable Care Act & Indian Country

But there still is a question of why? Why American Indians and Alaska Natives need insurance of any kind when there is a treaty right, a statutory call to healthcare, that transcends this latest national experiment? Then recall the long history of shortages. The Indian health system has never been adequately funded, probably less than half of the appropriation that would bring about some sort of parity with other federal health systems.

The main idea in the Affordable Care Act is to require health insurance for all Americans because that lowers the cost for everyone, the so-called “mandate.” But American Indians are exempt from that mandate (even if the Indian health system does not count as insurance). So the way that exemption works, this year at least, is that American Indians and Alaska Natives will have to fill out forms for an exemption (once granted, it’s a lifetime deal). The good news here is that the whole website mess does not apply.

Then insurance itself is a complicated idea for Indian Country. What is called “third party billing” has been a small, but growing part of the financial resources for the Indian health system.

You see there is this odd American idea that links health insurance to our jobs. That’s how most Americans now get their health care — and will continue to do so even under the Affordable Care Act. But that one element is a big difference for Indian Country. Only 36 percent of American Indians and Alaska Natives have insurance purchased through work — that’s half the rate for most Americans — and 30 percent of us have no insurance at all.

But the Affordable Care Act is designed to change that. The new law offers incentives for people to get health insurance coverage at a reduced rate or even free. So why would American Indians and Alaska Natives purchase insurance?

“The Indian health system is only funded at about fifty percent,” said Valerie Davidson, senior director of legal and intergovernmental affairs at the Alaska Native Tribal Health Consortium in Anchorage.

“Anybody who’s ever been to a tribally-operated program or an urban program or an IHS facility, they know the services are limited. Unfortunately there isn’t enough funding. And so we rely on those third-party reimbursements (or insurance) to make those ends meet, to be able to keep the clinic’s lights on.”

She said the Affordable Care Act is an opportunity to make sure that American Indians and Alaska Natives have additional health care coverage. “So the things that the Indian Health Service funding typically doesn’t pay for is medically-necessary travel (unless it’s considered life or limb). So generally an emergency is taken care of,” Davidson said. “But it may not cover routine travel.” She said an example would be people who live in a community without a dentist — so the only available option requires travel. “Having that extra coverage could cover the medically-necessary travel,” she said.

Insurance that covers medical travel is one reason for individuals to purchase insurance — and there are other reasons as well. A diabetes patient who’s insured would get better care, more access to the wider selection of procedures and drugs.

But the problem is that the rules for the insurance marketplaces are doubly complicated for Indian Country. Who’s eligible? How much? And, just what are the rules?

Indian Health Service Director Yvette Roubideaux said answers will be found in every clinic, where you get your care now. “I don’t know,” she said, “is not an acceptable answer.”

But if the law is to be successful in Indian Country there has to be a greater effort at educating people about their options. The Government Accountability Office recently said it will take a major campaign to make that so. That means hiring more people, lots of people, to help Native Americans navigate through this maze.

But there are already models for this kind of campaign. The Census was effective with “Indian Country Counts.” And, as NCAI’s Pata points out, last year’s efforts to register Native American voters is the kind of operation that’s needed. “It’s so critically important that tribes get engaged in giving direction. Tribes need to think about this the way they would with their Native Vote campaign,” she said. “They need to be able to have sign-up fairs, where they can actually answer the questions.”

So will American Indians and Alaska Natives sign up for insurance? If that happens it won’t because of a working web site in Washington, D.C. It will happen because every clinic in the Indian health system explains to patients why insurance matters and how it means more money for all.

The most important insurance program for American Indians and Alaska Natives is Medicaid.

When the Supreme Court upheld the Affordable Care Act, the headline was that the majority affirmed the individual mandate. But the second part of that decision is that the United States could not force all 50 states to expand Medicaid coverage.

Medicaid is a particularly complex government insurance program for the poor. But what makes Medicaid so important is that its funding source is not appropriated by Congress. It’s an entitlement. If a person is eligible, then the money is there. Automatically.

Medicaid is also a partnership between a state government and the federal government.

But for American Indians and Alaska Natives, it’s an odd marriage. The federal government picks up 100 percent of the cost. But even though the bills are paid for by Washington, each state sets the rules for eligibility about who and what will be covered.

The result is that about half of Indian Country will be covered by states where Medicaid is expanding — and the other half live in states that have said no. This means that hundreds of thousands of American Indians and Alaska Natives will lose out on expanded insurance coverage that the Affordable Care Act was designed for.

So this means that the Indian health system will essentially be split in two. There will be more money for health care in states where Medicaid expands — and less in the states that have said no. In the “no” states that will be even less money for an already underfunded Indian health system.

Watch North Dakota and Arizona. Two conservative, red states, looked at their numbers — and especially their Native American population — have already decided to expand Medicaid. If the program works in those two states, then other states with large native populations, might join the party. But if not, there is always the possibility that Indian Country could be treated as a 51st state. (The Affordable Care Act even begins that consideration by allowing a beta test of sorts for the Navajo Nation.)

The numbers are huge. The GAO says: “Excluding those already enrolled, potential new enrollment in Medicaid could exceed 650,000 out of 2.4 million (27 percent) for those identifying as American Indians and Alaska Natives alone, and almost 1.2 million out of 4.8 million (25 percent) for those identifying as American Indians and Alaska Natives alone or in combination with another race.”

NCAI’s Pata says the Affordable Care Act also “makes it really important for tribes, as they look at their health care clinics, to think of them as businesses. And not just as businesses for their tribal members, but businesses for their community, particularly the smaller tribes.”

The flip side of that idea is a shift in power from the clinic to the individual. Once someone has insurance, either through Medicaid, the marketplace exchanges, or another program, then that person might not choose to remain in the Indian health system.

“That’s the other reason why tribes need to think of (clinics) as businesses,” Pata said.

In some ways the urban Indian clinics are ahead of the Affordable Care Act. Because so little IHS funding — about one percent — goes to urban clinics, they have had to act like business enterprises.

“The greatest challenge is balancing the historical manner in which we have provided services, which have been geared around the needs of the population, with the growing demand for reaching out to other communities to get sufficient volumes to get the revenues to keep the doors open,” said Ralph Forquera, executive director of the Seattle Indian Health Board. “That balance of natives to non-natives … has always been a complex thing to manage. Some clinics around the country have seen a dramatic drop-off in their Indian participation in their clinics because the economics just don’t work. They need to go out and seek non-native people and enroll them in their programs to keep the doors open.”

He adds that Seattle has been fortunate because it’s been able preserve that balance.

But Seattle has a larger population base, something that is not true in all communities.

“It does change the dynamic,” Forquera said. “Those are some huge challenges but they are not unique to us. The tribal community clinics may be in even more challenging situation if the dynamic changes.”

He said one thing to watch is a shift away from fee-for-service payments to clinics to a more managed-care approach. For managed care to work, there has to be a larger scale, more people. “In order to be able to work in that kind of environment, you have to enroll large numbers of individuals in order to generate the revenues to pay for staff and the facilities, all the things necessary to provide the services” Forquera said. That concept could make it more difficult for Indian programs with small numbers of people.

But the Indian health system does have one huge advantage over the larger health system — and that’s underfunding. Underfunding as an opportunity? Yes. Because it’s already led to smarter, more efficient ways of operating. It’s made innovation possible.


Alaska’s dental health therapist program is a great example of that kind of thinking. “We recognized that we’re not going to be able to have a dentist in every community,” said Davidson. “So we developed a two-year training program to be able to train people to provide mid-level oral health care. Most of their work is in prevention, but they can also do exams, develop treatment plans, they can do fillings, and simple extractions.”

The payoff? “The tribal health system has been innovative by necessity. And a lot of these programs can and have served as models for the rest of the United States,” Davidson said. “Tribes have shown time and time again that we are a really good investment. We can do more with less. If you take a look at what we are able to do today, compared with what we were able to do before we were able to assume ownership of our own system, the difference is tremendous. We can take innovation to a whole different level.”

So will the Affordable Care Act work?

It’s too early to know that answer. But this is not new in history. More than sixty years ago the Bureau of Indian Affairs ran health care programs. It was awful. One doctor wrote: All we really need are good doctors, facilities and pharmaceuticals. I am weary.” Congress finally got the message in 1955 and created the Indian Health Service. But that shift — as dramatic as the one today — worked and it significantly improved the quality of life for American Indians and Alaska Natives.


Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of the Shoshone-Bannock Tribes.

Government Shutdown Frustrates Tribal Leaders

Rob Capriccioso, ICTMN

The federal government has a trust responsibility to tribes and their citizens. It is a unique relationship, which means there will be unique – and painful – consequences as a result of the government’s current shutdown, tribal leaders say.

The shutdown, which began at 12:01 a.m. on October 1, occurred because U.S. House Republicans passed several short-term continuing resolution budgets that included provisions to delay and/or defund portions of the Affordable Care Act, widely known as Obamacare. Both the Democratic Senate and White House would not agree to those provisions, which set the stage for the first federal shutdown in 17 years.

Tribal leaders, widely tired of political games surrounding the federal budget – as well as the profound impacts of ongoing sequestration – are frustrated, to say the least.

“What is just partisan game playing in Washington, D.C. is a battle for survival in Indian country where many of us barely subsist,” said Edward Thomas, president of the Central Council of Tlingit and Haida Indian Tribes. “Many of our 28,000 tribal citizens live at the very edge of survival and depend upon our tribe’s ability, with federal funding, to provide critical human services.

“Any interruption in federal funding, especially for a self-governance tribe like ours without gaming or other substantial economic development, means we must borrow money – from an expensive line of credit we cannot afford – to meet our payroll obligations to child welfare workers, to job trainers, to housing workers, and to natural resource subsistence protection,” Thomas said.

Ron Allen, chairman of the Jamestown S’Klallam Tribe, said he was disappointed in Republican House tea party members for insisting on defunding Obamacare as part of the budget process. “’My way or the highway’ is not a way to run the federal government,” Allen said. “Tribal leaders have many frustrations with the federal government, but we try to find ways to make it work. That’s what Congress needs to be doing.”

Allen predicted that the shutdown would be “devastating” for over half of the tribes he estimates do not have gaming or other enterprises to fall back on for funding during a federal shutdown. “So many of us – the majority – of tribes are dependent on federal resources,” he said. “It’s going to be tough for the tribes.”

Dozens of tribal leaders have voiced similar concerns to officials with the Departments of the Interior, Health and Human Services, and other federal agencies that serve large amounts of American Indians, according to federal officials. The White House, heeding that concern, held a teleconference with some tribal leaders on September 30 during which administration officials blamed the House Republicans for the shutdown. Kevin Washburn, Assistant Secretary for Indian Affairs at Interior, also sent a letter to tribal leaders explaining the department’s contingency plan.

The House’s attempt to tie a suspension of Obamacare to a budget bill is unpopular with tribal leaders, as many tend to support the law, since it includes provisions to support the Indian Health Care Improvement Act. If Republicans had their way, a new way to support that Indian health-focused part of the law would be necessary unless lawmakers agreed they no longer wanted to focus on improving Indian health via that law. Republicans will not have their way, however, as Obamacare is the crown jewel of Barack Obama’s presidency to date, and Democrats have been trying to pass universal healthcare since Franklin D. Roosevelt in the 1930s.

The real impact on tribes will depend on how long the government is shuttered. It will stay closed until the House Republicans and Senate Democrats can agree on a plan to fund it.

Congress and the president will still be paid during the shutdown.

Public opinion to date is largely against the House Republican position, yet many tea party GOPers, over objections of more moderate Republicans, continue to favor a budget bill that ties Obamacare to it. They have made the case that Obamacare, which goes in effect October 1, is too costly, so they believe it is worth delaying. But Obamacare is intended to reduce health-care costs for individuals and the country, Democrats have countered. And even with the shutdown, Obamacare will still be implemented.

Ironically, the most recent continuing resolution that has passed both the House and Senate thus far – excluding the Obamacare portions – is good for Indian country in that it does not include provisions pushed by the White House Office of Management and Budget that would limit the federal government’s payment of contract support costs to tribes. “That’s encouraging,” Allen said, noting that the White House proposal to cap tribal contract support costs was originally included in the Senate continuing resolution, but faced with widespread tribal opposition, it was withdrawn by Senate leadership. “We have some key people who are supportive of keeping it out.”

RELATED: White House Trying to Cheat Tribes on Health Costs

Tribal advocates are widely hopeful that once a long-term budget is agreed on – however long that takes – funding for tribal contract support costs will be included without a cap, despite lingering White House opposition to paying its tribal bills.

Despite progress on the contract support cost front, the continuing resolution supported by the House, Senate and White House maintains funding for Indian country at a sequestered level, which means programs that support tribes continue to face dramatic cuts. A joint decision by Congress and the White House, first made in 2011 and carried out on March 1 of this year, allowed an across-the-board 9 percent cut to all non-exempt domestic federal programs (and a 13 percent cut for Defense accounts). This sequester has dramatically harmed Indian-focused funding, and tribal leaders across the nation have claimed it is a major violation of the trust responsibility relationship the federal government is supposed to have with American Indians, as called for in historic treaties, the U.S. Constitution and contemporary American policy.

“The tribes would rather their budgets be exempt from this stuff,” Allen said. “But the political ability for that to happen is next to nil. The new options that people are considering is pushing for two years or longer forward funding for Indian health programs and essential government services, like some programs for veterans.”

Tribal leaders have been pushing hard to get sequestration on Indian programs removed, Allen noted, but the White House has said that it is not going to protect any programs. When asked by tribal leaders if tribes could be exempted from sequestration given the Obama administration’s stated belief in federal-tribal trust responsibility, Charlie Galbraith, the Associate Director for Intergovernmental Affairs at the White House, said at a February gathering of the United South and Eastern Tribes, “That’s just not going to happen. We have the entire military machine, every lobbyist, every contractor, trying to exempt the military provision—the president is not going to cut this off piecemeal. We need a comprehensive solution that is going to address the real problem here.”

RELATED: A Miscalculation on the Sequester Has Already Harmed Indian Health

Beyond Obamacare, contract support costs and sequestration, the immediate impact of the shutdown will be on the federal workforce, and that impact will soon trickle to Indian country. Overall, approximately 800,000 non-essential government employees are expected to be furloughed.

At the U.S. Department of the Interior, 2,860 of 8,143 employees focused on Indian affairs will be laid off during this shutdown. At the Bureau of Indian Affairs (BIA) alone, the following programs will cease, according to the website: management and protection of trust assets such as lease compliance and real estate transactions; federal oversight on environmental assessments, archeological clearances, and endangered species compliance; management of oil and gas leasing and compliance; timber harvest and other natural resource management operations; tribal government related activities; payment of financial assistance to needy individuals, and to vendors providing foster care and residential care for children and adults; and disbursement of tribal funds for tribal operations including responding to tribal government request.

The situation is less dire at Interior for Indian affairs cutbacks than it had been during previous shutdowns in the 1990s, Interior officials said, because they have since implemented a forward-funding plan in the areas of education and transportation, which will keep the employees in those areas working. There is also a comparatively larger law enforcement staff that will remain on duty through the shutdown, and power and irrigation employees will be able to continue working to deliver power and water to tribal communities because their salaries are generated from collections, not appropriated funds.

Employees at the Indian Health Service (IHS), which provides direct health service to tribal citizens, will be largely unaffected by the shutdown. Under Department of Health and Service’s shutdown plan, IHS will continue to provide direct clinical health care services as well as referrals for contracted services that cannot be provided through IHS clinics. On the negative side, “IHS would be unable to provide funding to Tribes and Urban Indian health programs, and would not perform national policy development and issuance, oversight, and other functions, except those necessary to meet the immediate needs of the patients, medical staff, and medical facilities,” according to a plan released by the agency.

Chris Stearns, a Navajo lawyer with Hobbs Straus, said the current shutdown is another hit to the relationship between the federal government and tribes. “The trust responsibility, and the right to federal services, which Indian country has already paid for with its lands, will be diminished,” he said of the current situation. He should know, having worked on Capitol Hill during the government shutdowns of the mid-1990s, which saw thousands of BIA employees laid off, and lease payments to tribes and individuals delayed.

Now, like a bad dream, it’s happening all over again.

“Perhaps it might be fair, if during a shutdown, Indian tribes got to take back our lands in lieu of payments,” Stearns said.



Study offers early look at new health law’s premiums


This Oct. 11, 2012 file photo shows a basket of medical supplies await storage in Brookhaven, Miss. The No. 1 question about President Barack Obama’s health care law is whether consumers will be able to afford the coverage. Now the answer is coming in: The biggest study yet of premiums posted publicly by states finds that the sticker price will average about $270 a month if you’re a 21-year-old buying a mid-range policy. That’s before government tax credits that will act like a discount for most people, bringing down the cost based on their income.ROGELIO V. SOLIS, FILE — AP Photo
This Oct. 11, 2012 file photo shows a basket of medical supplies await storage in Brookhaven, Miss. The No. 1 question about President Barack Obama’s health care law is whether consumers will be able to afford the coverage. Now the answer is coming in: The biggest study yet of premiums posted publicly by states finds that the sticker price will average about $270 a month if you’re a 21-year-old buying a mid-range policy. That’s before government tax credits that will act like a discount for most people, bringing down the cost based on their income.

WASHINGTON — The No. 1 question about President Barack Obama’s health care law is whether consumers will be able to afford the coverage. Now the answer is coming in.


Published: September 4, 2013



The biggest study yet of premiums posted by states finds that the sticker price for a 21-year-old buying a mid-range policy will average about $270 a month. That’s before government tax credits that act like a discount for most people, bringing down the cost based on their income.

List-price premiums for a 40-year-old buying a mid-range plan will average close to $330, the study by Avalere Health found. For a 60-year-old, they were nearly double that at $615 a month.

Starting Oct. 1, people who don’t have health care coverage on their job can go to new online insurance markets in their states to shop for a private plan and find out if they qualify for a tax credit. Come Jan. 1, virtually all Americans will be required to have coverage, or face fines. At the same time, insurance companies will no longer be able to turn away people in poor health.

The study points to the emergence of a competitive market, said lead author Caroline Pearson, a vice president of the private data analysis firm. But it’s a market with big price differences among age groups, states and even within states. A copy was provided to The Associated Press.

The bottom line is mixed: Many consumers will like their new options, particularly if they qualify for a tax credit. But others may have to stretch to afford coverage.

“We are seeing competitive offerings in every market if you buy toward the low end of what’s available,” said Pearson, a vice president of Avalere.

However, for uninsured people who are paying nothing today “this is still a big cost that they’re expected to fit into their budgets,” Pearson added.

The Obama administration didn’t challenge the study, but Health and Human Services spokeswoman Joanne Peters said consumers will have options that are cheaper than the averages presented. “We’re consistently seeing that premiums will be lower than expected,” she added. “For the many people that qualify for a tax credit, the cost will be even lower.”

With insurance marketplaces just weeks away from opening, the Avalere study crunched the numbers on premiums filed by insurers in 11 states and Washington, DC.

Eight of them are planning to run their own insurance markets, while the federal government will run the operation in the remaining four. There were no significant differences in premiums between states running their own markets and federal ones.

The states analyzed were California, Connecticut, Indiana, Maryland, New York, Ohio, Rhode Island, South Dakota, Vermont, Virginia and Washington. No data on premiums were publicly available for Texas and Florida — together they are home to more than 10 million of the nation’s nearly 50 million uninsured people — and keys to the law’s success.

However, Pearson said she’s confident the premiums in the study will be “quite representative” of other states, because clear pricing patterns emerged. Official data for most other states isn’t expected until close to the Oct. 1 deadline for the new markets.

The study looked at premiums for non-smoking 21-year-olds, 40-year-olds and 60-year-olds in each of the 11 states and the District of Columbia.

It compared four levels of plans available under Obama’s law: bronze, silver, gold and platinum. Bronze plans will cover 60 percent of expected medical costs; silver plans will cover 70 percent; gold will cover 80 percent, and platinum 90 percent.

All plans cover the same benefits, but bronze features the lowest premiums, paired with higher deductibles and copays. Platinum plans would have the lowest out-of-pocket costs and the highest premiums.

Mid-range silver plans are considered the benchmark, because the tax credits will be keyed to the cost of the second-lowest-cost silver plan in a local area.

The average premium for a silver plan ranged from a low of $203 a month for a 21-year-old in Maryland to a high of $764 for a 60-year-old in Connecticut.

The silver plan premiums for 40-year-olds were roughly $75 a month higher than for 21-year-olds across the states. But the price jumped for 60-year-olds. The health law allows insurers to charge older adults up to three times more than younger ones. That’s less of a spread than in most states now, but it could still be a shock.

“It’s striking that the curve increases quite dramatically above age 40,” said Pearson. “As you get older and approach Medicare age, your expected health costs start to rise pretty quickly.”

But older consumers could also be the biggest beneficiaries of the tax credits, because they work by limiting what you pay for health insurance to a given percentage of your income.

For example, an individual making $23,000 would pay no more than 6.3 percent of their annual income — $1,450 — for a benchmark silver plan.

That help tapers off for those with solid middle-class incomes, above $30,000 for an individual and $60,000 for a family of four.

The study also found some striking price differences within certain states, generally larger ones. In New York, with 16 insurers participating, the difference between the cheapest and priciest silver premium was $418.

ObamaCare mandate skips over Native Americans

By William La Jeunesse, Fox News

Despite claims that the federal health care overhaul needs the so-called individual mandate in order to require everyone to buy health insurance and keep the system stable, it turns out many have been granted an exemption from that requirement.

Those who will not have to comply with the mandate to buy insurance include some religious groups, and inmates, as well as victims of domestic violence and natural disasters. But the largest group of Americans exempt from the individual mandate is Native Americans, whose unique treatment under the law is raising more questions about the basic fairness of the legislation.

The reason behind the exemptions stems from the fact that the federal government, through treaty obligations, has assumed a responsibility for Native Americans.

“This is part of the federal government’s trust responsibility to the American Indians — to provide health, education and housing,” said health care consultant David Tonemah.

Consequently, Native Americans already receive free health care through the $4 billion-a-year taxpayer-funded Indian Health Service, which operates hundreds of hospitals and clinics around the country. Because they already have health care, the new law does not require them to make any additional effort to sign up for a new plan.

Yet Native Americans will also be offered subsidies to buy private insurance through the ObamaCare insurance exchanges.

To some, that sounds like double-dipping.

“There is no particular reason why they should be in the exempt category,” said Ed Haislmaier, a health care analyst with the conservative Heritage Foundation. “There is an argument (taxpayers) are paying twice. All these things wind up raising questions of fairness, and that is a big part of why this law remains unpopular.”

Under ObamaCare, individuals earning less than $47,100 and families of four earning less than $94,200 are eligible for subsides. According to the 2010 census, the poverty rate among Native Americans and Alaska Natives is double the national average, with a median household income of just $35.062. About 30 percent lacked health insurance, also double the national rate.

Proposed subsidies for individuals range from $630 to $4,480 a year, depending on income, according to federal estimates. For families, the subsidies will range from $3,550 to $11,430 a year.

Gila River Tribal Councilwoman Cynthia Antone said many tribal members are confused. Outreach to Native Americans will have to be convincing to overcome their distrust of the federal government.

“They have the option not to sign up for insurance and we do have some members who won’t sign up because we have the hospital across the street,” said Antone. “But we encourage our members to do it because, like I said before, it’s a safety net.”

Native Americans are also exempt from financial penalties for not having insurance. The Congressional Budget Office expects 6 million Americans, mostly young adults, will pay the penalty, which ranges from $95 for an individual to almost $300 for a family beginning in January.

“Anytime you are going to say to people ‘go out and buy this’ you are going to have people say, ‘I don’t use insurance, I don’t believe in it, I can’t afford it,'” said Haislmaier. “When Congress gives in to those objections, you are just going to get more people who want a break. It does create an unfair situation in the end.”