off the charts
POLICY INSIGHT
BEYOND THE NUMBERS

No “Fix”: Revised Senate Bill Still Puts Coverage for American Indians, Alaska Natives at Risk

American Indians and Alaska Natives (AI/ANs) have benefited greatly from the Affordable Care Act’s (ACA) coverage expansions, with 290,000 AI/ANs now enrolled in Medicaid, as we’ve explained. (See table.) The supposed AI/AN “fix” that Senate Republican leaders inserted in their revised health bill doesn’t eliminate the risk to these coverage gains for AI/ANs from GOP efforts to repeal the ACA’s Medicaid expansion and put a cap on annual federal Medicaid funding.

Medicaid not only provides coverage to AI/ANs, but it also provides much-needed revenue to Indian Health Service (IHS) and Tribally operated facilities. Today, Medicaid pays 100 percent of the costs of services provided to AI/ANs by IHS and Tribally operated facilities. The Centers for Medicare & Medicaid Services (CMS) issued guidance last year to expand the scope of services eligible for this enhanced Medicaid match. This guidance, coupled with the Medicaid expansion, has allowed IHS and Tribally operated facilities to claim more Medicaid funding, helping them to expand services and hire and retain more staff.

The revised Senate bill would change the availability of the enhanced Medicaid match by allowing states to claim 100 percent of the costs of services covered under a state’s Medicaid plan that are provided to AI/ANs by non-IHS and Tribally operated providers. While states with large AI/AN populations could see short-term benefits from this change, this “fix” doesn’t help states, AI/ANs, or IHS or Tribally operated facilities in the long run. revised bill still has the same core structural elements of the original Senate bill, which would jeopardize coverage for AI/ANs and the financial stability of IHS and Tribally operated facilities.

First, the revised bill would still effectively end the Medicaid expansion. That would mean fewer AI/ANs would be enrolled in Medicaid, and fewer enrollees would mean less revenue for IHS and Tribally operated facilities. The revised bill’s “fix” of extending the enhanced match wouldn’t matter for services that would go to people who are no longer eligible for Medicaid. States can’t claim Medicaid funding at any match rate for people who aren’t eligible.

The revised bill would still fundamentally change Medicaid’s financing, ending the current federal-state financing partnership and converting the entire Medicaid program to a per capita cap or block grant starting in 2020. This change would force states to make cuts in eligibility and benefits (on top of ending their expansions) that would grow deeper over time. While payments for services to AI/ANs would fall outside of the per capita cap, AI/ANs would not be immune to eligibility and benefit cuts.

For example, if a state returned eligibility for parents to pre-ACA levels, that would apply to all parents in the state, including AI/ANs. Likewise with benefits, if a state cut home- and community-based services or organ transplants, these cuts would apply to everyone, including AI/ANs. If a person wasn’t eligible for Medicaid, or if a service was no longer covered by Medicaid, Medicaid funding wouldn’t be available — period.

The revised bill could give states a short-term benefit by allowing them to claim 100 percent of the funds for services provided to AI/ANs by non-IHS and Tribally operated facilities before Medicaid cuts kick in, but it doesn’t change the bill’s long-term effects. The revised bill would still cause cuts to Medicaid eligibility and benefits, putting coverage for AI/ANs at risk and reducing revenue for IHS and Tribally operated facilities.

APPENDIX TABLE 1
Senate Bill Would Lead to Coverage Losses for American Indians and Alaska Natives in Nearly Every State
  Estimated Number Losing Medicaid Expansion Coverage
Alabama   -  
Alaska   5,400  
Arizona   12,900  
Arkansas   N/A  
California   88,900  
Colorado   16,300  
Connecticut   N/A  
Delaware   N/A  
District of Columbia   N/A  
Florida   -  
Georgia   -  
Hawaii   N/A  
Idaho   -  
Illinois   5,200†  
Indiana   N/A  
Iowa   N/A  
Kansas   -  
Kentucky   4,100  
Louisiana   N/A  
Maine   -  
Maryland   N/A  
Massachusetts   N/A  
Michigan   13,500  
Minnesota   8,800  
Mississippi   -  
Missouri   -  
Montana   11,228  
Nebraska   -  
Nevada   5,000†  
New Hampshire   N/A  
New Jersey   N/A  
New Mexico   45,600  
New York   3,100  
North Carolina   -  
North Dakota   3,900†  
Ohio   13,600  
Oklahoma   -  
Oregon   24,100  
Pennsylvania   9,700  
Rhode Island   N/A  
South Carolina   -  
South Dakota   -  
Tennessee   -  
Texas   -  
Utah   -  
Vermont   N/A  
Virginia   -  
Washington   30,700  
West Virginia   N/A  
Wisconsin   -  
Wyoming   -  

†Estimates have high margins of error, between 30 and 33 percent of the estimate, and should be used with caution.

Notes: Medicaid expansion: Figures are the latest available month (December 2015 for North Dakota, March 2016 for other states) except Montana, which are reported by the state as of May 1, 2017.  Estimated numbers are the statewide total of expansion enrollees from the Centers for Medicare & Medicaid Services multiplied by the AI/AN percentage, based on a CBPP analysis of the 2015 ACS public use microdata sample, rounded to the nearest 100.   Sufficient data were not available to reliably estimate the number of AI/ANs in some expansion states, which are noted with “N/A.” Cost sharing reductions reduction subsidies: Data represent AI/ANs purchasing coverage on the federally facilitated marketplace.

Sources:  Medicaid expansion enrollees: Centers for Medicare & Medicaid Services for total of expansion enrollees; CBPP analysis of 2015 American Community Survey for estimates of the AI/AN percent.  For Montana, http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/Medicaid%20Expansion%20Member%20Profile%20050117.pdf. Cost sharing reductions: Department of Health and Human Services, Health Insurance Marketplace Cost Sharing Reduction Subsidies by Zip Code and County 2016.