Maybe one out of every 100 patients has private health insurance when they pass through the doors of the Indian Health Care Resource Center in Tulsa, estimated Eddie Hathcoat, chief operating officer for the nonprofit organization.
"The majority of our patients are uninsured or indigent," Hathcoat said. By his estimate, "probably somewhere around 80 percent" have no health care coverage.
The resource center does what it can to provide mostly primary care services, like treatment for the flu or providing care for conditions like high-blood pressure or diabetes. Dental care, optometry, substance abuse counseling and behavioral health -- even dieticians -- also make up some of the care offered.
But, like health leaders for other medical and hospital facilities for Native Americans, Hathcoat described how funding issues keep the center from doing more for its patients. About 17,500 patients visited the clinic at least twice in the last three years, he said.
Already, the clinic relies heavily on the roughly 10 to 12 percent of patients enrolled in SoonerCare, the state's version of Medicaid. "If we didn't have that, we wouldn't be able to offer half the services we do right now," Hathcoat said.
Unsurprisingly, other Native American health leaders spoke about how Medicaid dollars can help -- and Medicaid expansion would ease their financial burden.
"I think all of Indian country hoped and thought all the states would do Medicaid expansion," said Dr. Charles Grim, deputy director for Cherokee Nation Health Services. The Cherokee Nation describes its health services as the largest of any tribal system in the United States, and Grim noted that any Medicaid dollars -- like any revenue from medical services -- goes right back into the tribe's health care system.
Medicaid expansion hasn't happened, of course. But, in Oklahoma, at least, alternatives being considered to help uninsured Native Americans may have broad support. It doesn't hurt that, while Gov. Mary Fallin has cited concerns about cost -- concerns disputed by some experts -- the federal government has fully funded services to Medicaid enrollees when such treatments have been done at facilities specifically operating to serve Native Americans.
The much anticipated Leavitt Partners report presented last month outlined ways to boost coverage for the uninsured statewide. It included specific recommendations for the state to develop "complementary proposals for the Indian Health System to preserve its unique program characteristics and maximize cost savings." The report recommended applying for a waiver to allow for "full federal reimbursement" for certain groups -- again, when treatment is done at health facilities specifically serving Native Americans.
It's a time of tremendous change in the health care system, but Grim said he's not aware of any request elsewhere seeking federal reimbursement for treatment at non-Native American facilities.
"I wouldn't expect that," he said. "If the state asks for that, I don't know if the federal government would approve it or not." He noted that because of geography, in Oklahoma, "a large majority of Indian people have access to Indian or tribal clinics."
Despite that difference, the Leavitt proposals could be viewed as a sort of Medicaid expansion. Grim was among the Native American leaders to meet with members of the Leavitt group before they wrote out their recommendations for the state, and the report notes that two of their recommendations were actually presented by tribal leaders.
"We've also been very pleased that both the governor's office and the health care authority have been very open to doing something different and special for tribes," said Grim.
Rep. Seneca Scott (D-Tulsa), is a member of the Native American caucus in the state's House of Representatives, a group formed in 2005 that has prioritized health care as an important issue.
"The health care issue is just huge for Indian country," Scott said.
Earlier this year, the Choctaw Nation provided funding for a report studying the uninsured Native American population in Oklahoma. If income limits for a Medicaid waiver matched those of the Medicaid expansion proposed by the federal government --and allow people to qualify with incomes up to 138 percent of the federal poverty level -- about 41,000 Native Americans statewide could qualify, the report states. The Tulsa area has almost 5,000 potential patients who would be eligible for such assistance, the report stated.
Hathcoat described a current system that's already unable to meet the health needs of the state's Native American population.
"If you're a Native American and you need specialty care, there's a very good chance you're going to be denied health services because there's not money to pay for it," he said. An influx of Medicaid dollars into the system would allow patients to be seen in a timelier manner, Hathcoat said.
Grim acknowledged that funding is a concern, though he said the Cherokee tribal health system makes it a high priority for patients to receive care, even if it can't be provided at a Cherokee-operated facility.
"We're not only a provider of care. We're a payer for care when we refer people out," Grim said, describing how the facilities partner with a network of private specialists, including many in the Tulsa area. He estimated that about $15 million yearly in care takes place through these partnerships.
The care offered by Cherokee Nation Health Services is provided regardless of tribal affiliation. Patients generally need to show some sort of proof of belonging to a federally-recognized tribe.
"One of the big reasons that people come to us is that we're very culturally competent and sensitive to, you know, a particular tribe's beliefs and ways," Grim said.
He and other health care leaders point out the federal government has long acknowledged responsibility for providing health care services to Native Americans. The federal Indian Health Service agency notes on its website the "provision of health services to members of federally-recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes," describing this relationship as going back to 1787 and the U.S. Constitution.
In modern times, the health care system includes two urban-based health clinics in Oklahoma. Hathcoat said the Tulsa organization and an effort in Oklahoma City are the only two to have been singled out to receive special consideration in the 2010 Indian Health Care Improvement Act.
"We have a contract with the Indian Health Service. We get money from the Indian Health Service to provide the services we provide here, whereas the other programs don't get that contract," Hathcoat said. But the nonprofit also relies on grants to help pay for the care it delivers.
The larger system also includes hospitals that are operated by the Indian Health Services like one in Claremore, and also tribally-operated facilities like the Cherokee Nation's medical center in Tahlequah. According to statistics from the Choctaw Nation cited by the Leavitt report, there are 63 facilities statewide that provide treatment to nearly 124,000 Native Americans.
Federal funding makes up roughly half the budget for the Cherokee health system, Grim said. The tribe has taken steps to boost funding for health care, including a recent legislative move to have five percent of enterprise revenue go to health care. Plans call for new clinics to be built, and a feasibility study is underway looking at the possibility of a new hospital in Tahlequah.
But health programs serving Native Americans have been hit hard by the recent federal sequestration. Cathy Abramson, chair of the National Indian Health Board, told federal legislators in April that the sequestration would shave away $228 million from health services. "IHS is already a devastatingly underfunded agency and across the board cuts of this nature will have a devastating impact on the lives of American Indians and Alaska Natives throughout the country," Abramson said, according to a written statement of her remarks posted on the board's website.
Hathcoat said he'd like to see Medicaid expansion, and it would allow the clinic to offer more specialized services needed by patients. "I really think the most realistic way to help is with Medicaid expansion," Hathcoat said.
The Choctaw-sponsored report pointed out the relative health of the group that might be eligible to have care paid for under the Medicaid waiver -- the apparent implication being that the cost might not be quite so high to having the federal government reimburse their care.
"Nearly half of the waiver population are employed and yet lack health insurance. Nearly 70 percent have a high school education or less. The waiver population is also relatively young. Sixty percent of the waiver population is between 19 and 34 years old, compared with only 42 percent of adults currently on Medicaid," the report noted.
It continued: "Just over 12 percent of the waiver population is in fair or poor health. This is a far lower share than among current Medicaid enrollees (39 percent), but a nontrivial share of those whose costs would be covered by the waiver have higher-than-average health needs."
Grim said that the Indian Health Care Improvement Act, made into permanent law at the same time as the Affordable Care Act, means there are some differences in how the federal legislation affects Native Americans.
For example, one aspect of the federal legislation imposes a tax on many who choose not to purchase health insurance; such a tax will not apply to Native Americans, potentially leading fewer to sign up for coverage.
Political conversations in Oklahoma about improving coverage for uninsured Native Americans have centered on having something in place by January of next year, Scott said, though he acknowledged that it may be difficult to keep to that timeline.
"I think the urgency side is pressing as never before because of our health care situation in the state," he said.
House legislation in the most recent legislative session called for pursuing a Medicaid waiver. But Scott said the politicization of the issue seemed to halt the bill in its tracks.
"I think that anything with the word Medicaid in the lingo just came to a giant deadlock standstill," he said. Not unlike the report paid for by the Choctaw Nation and presented in March, the phrase "uncompensated care" is now how the issue is being framed, according to Scott. "What we're trying to do is make the case we have an uncompensated care issue," Scott said.
Despite the difficulties, he described an opportunity for Oklahoma. "We could really lead the nation to come up with a solution," he said.
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