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.