The diverse American Indian tribes in California have one thing in common when it comes to implementing health care laws: the need for a consistent definition of eligibility.
Members of the California Rural Indian Health Board, who prefer the term American Indians rather than Native Americans, outlined the issues last week at a meeting with Covered California officials in Sacramento. Covered California literature and officials — as well as tribal leaders — used the term American Indians. The label Native American was neither used in the meeting nor in written material.
Most notably, California tribes want Covered California officials to support a bill in Congress to establish a consistent of American Indian in the Affordable Care Act.
The third annual meeting between exchange leaders and the tribal health community included celebrating some of the successes in implementing the Affordable Care Act in the large network of health care for American Indians in California.
Mark LeBeau, executive director of CRIHB and member of the Pit River Nation, said just having the ability to reach the expansive American Indian community was a major win. CRIHB, with a Covered California grant to provide outreach and education materials specific to American Indians, created an ACA website geared to California tribes and trained more than 90 certified enrollment counselors. CRIHB also set up kiosks in clinics in regions where few people have Internet access and would otherwise be unable to shop for insurance online.
Looming over these incremental movements forward is the overarching issue of inconsistent definition of federally-recognized tribe status. Technical glitches and confusing materials still pervade enrollment processes, advocates said. To iron out the difficulties, CRIHB’s main recommendations to the exchange board were:
- Fix vague, inconsistent language on enrollment materials;
- Allow mixed families to enroll on a single application;
- Require qualified health providers to sub-contract with rural and urban tribal clinics;
- Assist in smooth adoption of new laws regarding tribal Medi-Cal administration; and
- Reach far-flung communities, many without internet access or directories.
Covered California determines eligibility based on the ACA’s definition of an American Indian, which is a far narrower definition than those used in other agencies such as the Indian Health Service, Medicaid and the Children’s Health Insurance Plan.
CRIHB has urged Covered California to support a bill introduced in Congress last year by Senators Mark Begich (D-Alaska), Brian Schatz (D-Hawaii), Al Franken (D-Minn.), Tom Udall (D-N.M.), and Max Baucus, formerly a Democratic Senator from Montana, now the U.S. Ambassador to China. Their bill, SB 1575 would streamline the definition of American Indian in the ACA so that it works better with the definition used by IHS and CHIP. The bill would also create additional protections to ensure American Indians are not subject to tax penalties for not having insurance.
While Covered California is barred from advocating legislation, members of the board said they will continue to work with federal partners to address policy issues affecting the American Indian community.
“There are still a lot of concerns on how the state is going to verify tribal status,” said Darryl Lewis, staff services manager at Covered California. “There are measures people can take, like certification through the Indian Blood Bureau, but that doesn’t mean they will be enrolled.”
Dale Newell, certified enrollment counselor for the Toiyabe Indian Health Project, which represents seven tribes in Inyo and Mono counties, said getting clients signed up was an exercise in frustration due to the ongoing issues.
Recalling an unsuccessful day of trying to sign up clients, he said, “I’ve never seen more angry people in my life. We need a system we can rely on.”
Virginia Hedrick, associate health policy analyst at the California Rural Indian Health Board, said it has been difficult to implement the ACA consistently across the reservations in rural areas of California when patient information is so scattered and uncertain.
“There is still conflicting information out there,” Hedrick said. “Each definition of an Indian is different, as well as definition of tribes. This makes a difference when you are trying to implement federal law.”
The Indian Health Board, a network of tribal health programs, is trying to expedite enrollment in health care programs in hundreds of tribes across California. It has coordinated efforts with Covered California since 2012 when a tribal advisory workgroup was first formed. That alliance has led to development of enrollment materials targeted specifically for the tribal community, including a resource guide and directory of tribes.
Solid Covered California enrollment numbers of American Indians are hard to come by because race is an optional question in the application, but of the 60% who answered during open enrollment, more than 4,000 identified as American Indians or Alaska Natives.
The Affordable Care Act offers a unique provision for American Indians and Alaska Natives: Individuals with income below 300% of federal poverty level bear no health care expenses if they obtain insurance through ACA exchanges, including Covered California.
Members of federally recognized tribes also are exempt from open-enrollment periods and they are able to change health plans once a month if they wish.
However, there has still been no agreement on what federally recognized status really means.
Covered California last year printed inaccurate information dealing with American Indians on application materials — a mistake that has since been corrected, but not without consequences. Some members of tribes who were recognized and eligible for care throughout California’s network of Indian Health clinics found that they did not satisfy federal requirements and were denied services at hospitals.
“We get a lot of conflicting answers from our federal partners,” said Katie Ravel, program policy director of Covered California. “It’s a question we are still working through.”
Covered California is working with the Indian Health Board to develop a center dedicated to assist American Indians in verification through the federal register. It’s a complicated task because not all tribes have directories themselves, or some choose not to participate in verification processes.
“If we had one comprehensive list of all the tribes in California and all the members, this could be easier,” said Ravel.
Covered California officials recognize the challenge of working with this community.
“We really have to live and breathe how diverse this state is,” said Peter Lee, executive director of Covered California. “It is, in many ways, about being a grassroots organization and having all these groups working together that will make this work.”
Yolanda Latham, chief executive officer at the Sonoma County Indian Health Project and chair of the advisory workgroup, pointed out that many tribes choose to remain outside the purview of online record-keeping and registry, primarily for historical and cultural reasons.
“This is a sensitive issue,” said Latham. “Sometimes you just have to get out there on foot in order to reach people and educate them about these new changes to their health care, and it’s important to take active part in this open conversation.”