NMICoA Health Committee (elders) position

The NMICoA is a grassroots organization representing the Native American elders and disabled of the 19 Pueblos and the 2 Apache Nations of New Mexico (NM).  NMICoA is dedicated to enriching the lives of elders and disabled through education, information and advocacy of senior and disabled rights.  Under the direction of the late President Archie Chavez, the Health Committee was formed in response to increasing confusion among elders concerning changes in the delivery of healthcare services via the Coordination of Long Term Services (CoLTS) program.  The NMICoA Health Committee has been mandated to analyze the current Native American healthcare delivery system, in order to educate elders on the services and benefits available through State and Federal programs. Recently, the Health Committee has been analyzing the National Healthcare reform and the state of NM’s plans for redesign of Medicaid and the development of a Health Insurance Exchange.

In full cooperation with Pueblo communities the Health Committee has contributed this position paper to the Tribal Leadership of the Pueblo of Acoma, and hopes to continue working to elevate the education and health of Tribal Communities.

After careful consideration of New Mexico’s healthcare re-modification proposal, the NMICoA Health Committee believes the current plan does not present a viable solution to healthcare disparities within New Mexico’s Native American communities. The NMICoA Health Committee has the following comments regarding NM Human Services Departments’ Centennial Care concept paper as it affects Native Americans. The “Opt out” Fee For Services category must remain intact for Tribal members.  It is our belief that the State mandate for all Native Americans to be included into Managed Care Organization (MCO) directly challenges Tribal sovereignty, Tribal self-determination and self-governance.  As Sovereign Nations, it is the right of each tribal government to deal directly with the Federal government of the United States; Tribes are not required to accept State law that inhibits this “Government to Government” relationship.  Federal law prohibits Native Americans from being mandated to join an MCO.   According to federal regulations(PPACA), Native Americans are also exempt from proposed Cost Sharing, a promise that we hope the State will honor.

As the State of NM and the Federal Government develop Health Care Reforms, the State should allow for specific Native American Health plans to be incorporated into the designated New Mexico MCOs, which would allow Native Americans to choose a health plan tailored to each Tribe’s geographic region and access to care.  Exemptions from cost sharing should also be part of these plans, especially for rural Native American who access emergency rooms and urgent care after hours, which may require expensive co-pays that are difficult (the Pueblo of Acoma currently has a 50% unemployment according to recent US Census data) if not impossible for many Native Americans to pay out of pocket. 

The Federal and State Governments need to develop networks at both regional and local levels that will work with “opted-out” individuals in areas with no MCO presence on Reservations or in rural areas. Considering the development of health networks, the State should give preference to, invest in, develop, and train existing Tribal programs working on reservation providing Medicaid type services instead of contracting non-reservation based providers.  By developing the ability for Tribes to become healthcare providers, employment and infrastructure on reservations will grow.  The Federal Government needs to increase outreach and understanding of public law 93-638 pertaining to Self Governance of Governmental services so that Tribal providers can take full advantage of Federal funding. Funding meant for Native Americans should go directly to Tribal programs such that 100% of the Federal Medical Assistance Percentage (FMAP) funds are used appropriately in IHS and tribal 638 facilities.  With new funding sources Tribes could develop local Non-medical Transportation, which would cut down on costs associated with care and maintenance of transport vehicles.  Additionally, by using new funding sources current Tribal funding can be used on those Tribal members not eligible for services under Social Security. 

The NMCoA Health Committee believes that consultation sessions between Tribal officials and the State government needs to be more than one informational session with all Tribes participating to be meaningful. The State needs to understand that they are negotiating with Sovereign Nations that, much like foreign governments, have their own unique cultures and protocols. It is inappropriate to host a meeting where Tribal government is absent and declare this a “Tribal Consultation”. The State needs to go to each Tribe individually to better understand the unique needs of each community as well as the available infrastructure.  In previous sessions the State of NM has held a statewide consultation, where all Tribes were invited, yet only one Governor and a few Tribal representatives were ever in attendance (August 2011).  Instances like these do not constitute meaningful consultations or collaboration with all Tribes.   

Regarding the development of a New Mexico Health Insurance Exchange by the Office of Health Care Reform, the NMICoA Health Committee has the following comments: Starting with the Snyder Act of 1921, the Federal Government is mandated to provide “cradle to grave” health care for Native Americans. This mandate takes precedence over the State of NM’s inclusion of Native Americans into the proposed Health Insurance Exchange. It is the responsibility of the United States Government to provide health insurance or comparable health care packages to Native Americans, honoring the Snyder Act and its promises to the Native people of North America. Tribes should negotiate with the Federal Government directly, and vice versa.

The Indian Health Care Improvement Act (IHCIA), part of the Patient Protection and Affordable Care Act (PPACA) signed in 2010, gave Tribes the right, under Section 405, to create or invest in a private health insurance plan, or to purchase insurance through a national Health Insurance Exchange.  To our knowledge, IHS has not made any progress in developing a comparable benefits package for all Tribes or creating Long Term Care Services by 2014 as mandated in the IHCIA. Tribes should develop their own health insurance plan where funding by the Federal Government pays for premiums, co-payments and healthcare.  Those Tribes with smaller populations should be allowed to use Federal Funding to contract with a private insurance provider or to purchase private insurance for its community members.  If Tribes are unable to create their own, or contract with private insurance, then the Federal Government should create a nationwide Exchange or Option for Native Americans in which Native Americans are exempt for cost sharing.  As it stands, Centennial Care would do away with this Opt-Out program, and does not allow Tribes to create an independent, creative and culturally appropriate health care package for their people.

Health care reform has many components and options, including: Medical Health Homes, Money Follows the Person and Community First.  A similar component to these programs is the idea of Health Navigators, or Coordinators, who would help individuals navigate the healthcare system to determine eligibility for Medicare and Medicaid, or select an insurance package appropriate to their needs.  The Office of Health Care Reform (OHCR) has proposed that a special Native American Health Navigators office be created to help tribal members with eligibility and purchasing health insurance from exchanges.  The NMICoA Health Committee believes that Native American Tribes should be allowed to develop the Health Navigator’s office proposed by the State of NM Office of Health Care Reform.  The Tribes should also have direct input to develop the special Native office within the OHCR. The Pueblos should have a member designated by the All Indian Pueblo Council (AIPC), on any governing board proposed by the OHCR. Public Law 93-638, as well as the IHCIA, allows for Tribes to enter into Shared Agreements with Federal and State Agencies.  Having members on a governing board would ensure compliance with Public Law 93-638, the IHCIA and Executive Order 13175, all of which are relevant to Tribal involvement in the development of the Health Insurance Exchange.

It is the opinion of this Committee that the New Mexico State Human Services Department and their consultants did not actively include the individuals who are enrolled in Medicaid, namely the 19 Pueblo and 2 Apache Nations in the State, in the creation of the existing Medicaid modernization proposal.  The Health Committee believes that despite a consultation held on March 20, 2012, a meaningful consultation was not appropriately achieved because not all Tribal leadership was present at the consultation sessions described in the Centennial Care concept paper. We demand that more consultation sessions be called in which all Tribal Governors are present and the above recommendations made by the NMICoA Health Committee are addressed.