Meredith Raimondi: Good afternoon and welcome. Thank you for joining us today for this really important conversation about what Medicaid cuts would mean for Indian country
Meredith Raimondi: in partnership with the Georgetown Center for Children and families.
Meredith Raimondi: My name is Meredith Ramandi, and I'm the Vice President of Policy and Communications at the National Council of urban Indian health.
Meredith Raimondi: and I am going to be moderating this webinar. I wanted to thank our partners at Georgetown Center for children and families for hosting this webinar and their commitment to really raising awareness about these important issues.
Meredith Raimondi: Today's webinar will focus on the key findings from the Georgetown Center for children's and families recently released report on Medicaid's role in rural areas and small towns with emphasis on the importance for native American communities.
Meredith Raimondi: We will also discuss the importance of Medicaid to native communities, potential effects of proposed Medicaid cuts being considered by Congress and the importance of Medicaid for urban Indian health programs and any impacts that those
Meredith Raimondi: patients would be affected by.
Meredith Raimondi: We have an esteemed panel of speakers today. Joan Elker is the executive Director of the Center for Children and Families, and a research professor at the Georgetown Mccourt School of Public Policy.
Meredith Raimondi: Wynne Davis is the Congressional Relations Director at the National Indian Health Board.
Meredith Raimondi: and I will give an overview of urban Indian health and Medicaid, and we'll end with Lisa James, Director of Development at the Montana Consortium for urban Indian or Montana Consortium. Yes, for urban Indian health, and she will discuss Medicaid and Montana
Meredith Raimondi: for a few housekeeping items. This webinar is being recorded.
Meredith Raimondi: We will take questions from media representatives via the raise hand function or the Q&A function, and we will be taking questions at the end of the webinar.
Meredith Raimondi: It will also be posted on the Georgetown website, and without further ado I will kick it over to Joan to get us started.
Joan Alker: Thanks so much, Meredith, and we are so honored to co-sponsor this webinar today with you and join with our guests here to talk about the impact of Medicaid on Indian country, and in particular, because we're at such a critical moment right now.
Joan Alker: when our elected officials are considering and making choices about what to do in terms of their priorities, and we know that Medicaid cuts are very much on the table, so I'll come back to that in a little bit. I want to acknowledge my co-authors in this work. Aubriana, Osorio, and Edwin Park.
Joan Alker: and I'm going to start with some background on Medicaid, and then go through some of our specific data, as it relates to native populations. And then we have some additional data that we didn't present when we released the rural report a few weeks ago. That looks at counties, and I think there's some really interesting findings here for native people, so we'll have. I'll have that at the end of my presentation.
Joan Alker: So okay, let's go to the next slide. And I'm going to start with just a little bit of a background about Medicaid in general and its role. And it's interesting because I often say that Medicaid is often the sleeper issue. And certainly when we
Joan Alker: we just went through a Presidential election, and during the campaign we didn't hear about Medicaid honestly from either candidate. Much. We didn't hear from President Trump about it at all, and Vice President Harris did release some written materials about it, but it just wasn't discussed.
Joan Alker: and of course Medicare gets discussed a lot. The Affordable Care act has been getting discussed more and more. But, as you can see here, Medicaid and the Children's Health Insurance program, which covers about 8 million.
Joan Alker: mostly children who are primarily in Medicaid are really the biggest sources of Federal of health insurance that's supported by the Federal Government. So Medicaid is really the backbone of many aspects of our healthcare system, and if we can go to the next slide, I'll talk about a few of those.
Joan Alker: This slide is looking at the enrollment, who are the largest group of Enrollees, and what is most of the money being spent on. And of course Medicaid is a Federal State matching program with the Federal Government, paying the majority of the funding and States matching those dollars and running the program.
Joan Alker: So, as you can see here on this bar chart children are by far the largest group of Medicaid enrollees constituting almost 40%. But they're relatively inexpensive to cover. So they're only accounting for 13% of the spending.
Joan Alker: It's less well known that seniors rely on Medicaid for many things. Of course, when you think of elders you think of Medicare, but Medicaid is playing a very important role in a couple of ways, and we'll talk more about this later when we look at some of the data. But overall in the general population. About 20% of seniors on Medicare are also on Medicaid.
Joan Alker: Those are the so-called dual eligibles, and they're having their cost sharing paid. These are the lowest income seniors. They're having their cost sharing, paid by Medicaid and getting some wraparound benefits. There are some seniors and elders who are not eligible for Medicare, because they don't have the requisite quarters, and for other reasons. And I think when is going to talk about this, and Medicaid is the largest payer for long-term care.
Joan Alker: and 5 out of 8 people in long-term care are financed by Medicaid. So that's critically important. When we think about the role Medicaid is playing, and the fact that it is top of the list for Congress to cut is very concerning because it's critical for children in this country, covering 40 to 50% of children.
Joan Alker: It's critical for maternal health and births again, depending on where you live, covering 40 to 50% of births. And it's the largest payer for nursing, home care and a critically important piece. People, disabilities, substance, abuse, treatment, behavioral health.
Joan Alker: All of these aspects of our healthcare system. Medicaid is playing a key role. And what you can see from this slide is that seniors and people with disabilities while constituting about 20% of Medicaid enrollees. That is where the majority of the spending is going 51%.
Joan Alker: And of course, with an aging society, we know that these demands on long-term care will only grow. And that's another reason to be very concerned about large Federal cuts and shifts to state budgets. States simply couldn't manage their way out of large cuts under any scenario. So let's go to the next slide.
Joan Alker: And of course we have a cost problem in our healthcare system. We all know that. But this slide is looking at cost, growth per person.
Joan Alker: And you can see here that Medicaid has had the lowest cost growth per person.
Joan Alker: and so to the extent that Congress is putting Medicaid right at the top of the list for large cuts when it's serving the most vulnerable populations, and it's already a relatively efficient payer, with not a lot of room to squeeze. There is extremely troubling. Go to the next slide.
Joan Alker: So now we're going to get to some of our data. And this is a look at the country Medicaid Enrollment. And you can see the darker areas have higher levels of Medicaid enrollment. And if we go to the next slide, just want to flag for folks that if you come to our website and we'll put the URL in the chat.
Joan Alker: you can go and look up your state, your county, your area, and for all of these counties, regardless of whether rural or urban, you can see the percentage of Medicaid enrollment total children, non elderly adults and seniors. So we have a ton of data. And this is, thanks entirely to the amazing work of my colleague Aubreyanna and
Joan Alker: our other team members, that all of this data is available to you right now. So we encourage you to do that. And
Joan Alker: one thing I do want to mention is that this data is drawn from the American Community Survey, and we know that the American community survey that's a big census bureau data set undercounts Medicaid.
Joan Alker: So these estimates are actually conservative. The numbers, we know are higher from looking at administrative data that states use.
Joan Alker: so we can go to the next slide.
Joan Alker: So here this was a general finding of our report. We see that for children and for non-elderly adults that Medicaid is playing an even more important role in rural areas and small towns. We define these as areas with less than 50,000 people.
Joan Alker: And and this is important, because if Congress moves ahead to make large cuts
Joan Alker: these areas, and as we'll hear from our speakers, Indian country more generally will be in big trouble. Already rural areas face greater challenges. Families and people there have lower incomes. They have higher rates of disability. There are acute provider shortages.
Joan Alker: and there are additional barriers like transportation and the lack of Internet connectivity which make it harder to access healthcare services.
Joan Alker: So these areas really have a lot at stake. And if we go to the next slide, you can see here we looked at the data using the census data of American Indian Alaska native areas. That's how the Census Bureau defines the term.
Joan Alker: And what you see is that for both small town and rural areas and Metro areas for all age groups and except seniors in metro areas that we see a greater reliance on Medicaid as a source of health insurance for native peoples.
Joan Alker: And that's quite a quite a dramatic for children. Quite a dramatic difference there. So we can go to the next slide.
Joan Alker: So I'm going to just run through 3 slides now, which are the same from our last webinar about rural areas just showing you where states that have at least half of their children in small term rows. This is a general slide. This is not specifically about native peoples, but you can see, obviously New Mexico. Important state here is is leading the way. We can go to the next slide.
Joan Alker: Here we're looking at non-elderly adults where at least 20% of all non-elderly adults are covered by Medicaid. Arizona is very high. There at 36%
Joan Alker: go to the next slide.
Joan Alker: And finally, looking at seniors. We looked here at the actually, we can go to the next slide. I wanna skip this one.
Joan Alker: Okay. So here's the new data we wanted to share.
Joan Alker: So we took a look at the counties across the country and pulled out the top. 20 counties.
Joan Alker: With, for all of the age groups that we've looked at. And here you can see for children.
Joan Alker: We've highlighted in yellow areas that are tribal lands, and or have a high preponderance of native peoples in these counties. And you can see for children that the highest number here 73% of children in Mckinley County in New Mexico.
Joan Alker: If we go to the next slide, we're looking at non elderly adults, and it's even more stark here.
Joan Alker: 6 out of the top 20 counties.
Joan Alker: Are areas that have a very high share of native peoples with high levels of Medicaid coverage.
Joan Alker: and then getting to our final slide of the day before I drown you in too much data.
Joan Alker: This is the same data looking at seniors and boy. This one really caught our attention. Really quite astonishing. Here you can see all of the counties in South Dakota and and elsewhere. How many counties on this list.
Joan Alker: where we have elders who are covered by Medicaid and native
Joan Alker: people. So this just underscores the the overlap here, both on the rural side, but also across the kinds of
Joan Alker: tribal lands and areas where already there are many, many challenges, and we'll hear about those from some of our next speakers. So with that we can go to the last slide. Just well, we'll put it in the chat just where you can go to find the data which I think we already have, and I will hand it over to win Davis.
Winn Davis | NIHB: Thank you so much, Joan.
Winn Davis | NIHB: So I think Joan's done a really excellent job of kind of setting the stage in terms of Medicaid enrollment nationally and particularly in rural communities. But I want to start by stating something that that may be obvious, but needs to be said again. Medicaid plays a really critical role in the Indian health system.
Winn Davis | NIHB: Ihs and tribal health. The tribal health system are funded at around 7 to 8 billion dollars annually, but the actual funding need to provide care is in the tens of billions of dollars
Winn Davis | NIHB: Medicaid, which is authorized expressly to help fill this funding need and meet the trust responsibility to tribes in healthcare provides significant resources to this effect.
Winn Davis | NIHB: It does this by covering services with 100% fmap or Federal medical assistance percentage for American, Indian and Alaska natives seen by or through Ihs and tribal providers.
Winn Davis | NIHB: for example, based on data from the American Community survey in 2023, 31% of American, Indian and Alaska natives were enrolled in Medicaid compared to 20% for the general population. When we look at children 0 to 18 that rises to 48.7% nationally.
Winn Davis | NIHB: And when we start looking at state specific data, as I think, Joan's data pointed out with rural communities that number can get significantly higher. For example, in New Mexico children are enrolled in Medicaid, American, Indian, Alaska, native children are enrolled in Medicaid around 70%.
Winn Davis | NIHB: And so you can see, there's there's a real
Winn Davis | NIHB: need for coverage in these areas to help pay for services. When we look at how that impacts funding for the Indian health system. Indian health facilities get about 30 to 60% of their funding from Medicaid dollars.
Winn Davis | NIHB: While that is a lot of impact on tribal communities. When we consider the overall Medicaid budget, it's not that much. I just projected billing for about 1.3 billion dollars in Medicaid visits for 2025, which represents only 0 point 2 1% of total Federal Medicaid spending, which was projected by Cms to be about 604 billion dollars just in Federal dollars for 2025
Winn Davis | NIHB: Medicaid is also the largest 3rd party payer for Indian health facilities.
Winn Davis | NIHB: These Medicaid dollars don't just fill a funding need. They also help with regular Ihs annual appropriations, making those dollars go further without third-party revenues like Medicaid services.
Winn Davis | NIHB: The service dollars that the Ihs receives and the purchase referred. Care program would not cover all of the need to provide care in Indian country with Medicaid. However, those dollars help folks who cannot get 3rd party health coverage to continue to have access to care across services and through referred specialty care. This provides important stability for the Indian health system.
Winn Davis | NIHB: We understand that Congress is working on imposing or is working on possible Medicaid reforms, and we know folks have heard lots of rumors and seen discussion in the news which may be causing unease. Right now, particularly across Indian country, we have been working to clearly message the role of Medicaid
Winn Davis | NIHB: and the importance that this has in tribal communities generally, we're concerned that Medicaid cuts can exacerbate health disparities in tribal communities. Medicaid reforms, if not done through a deliberative process could inadvertently impact tribal communities which rely on these dollars to furnish critical health care services.
Winn Davis | NIHB: Any reduction in funding to the Medicaid program could trigger State Medicaid agencies to reevaluate eligibility, criteria and optional service levels. Changes to these 2 elements alone could cause many thousands of American Indian Alaska native beneficiaries to lose access to coverage or needed services.
Winn Davis | NIHB: For example, tribes fully support employment opportunities and work assistance programs. But Medicaid work requirements do not work well in tribal communities for a variety of reasons.
Winn Davis | NIHB: Just some examples when there is a reporting requirement, generally a lack of Internet access in rural communities that are tribal or a lack of regular mail access can make reporting work compliance very difficult. Many tribal communities do not have postal designations which makes receiving mail a very difficult task. In many places.
Winn Davis | NIHB: Frequently American, Indian, Alaska, native communities are located in hard to reach places, and so there may not actually be work in the communities in which they live. Alaska, native communities, for example.
Winn Davis | NIHB: many 80% of those exist off the road system, and there may simply not be jobs in those communities which meet the requirements of work requirements. Further, the intensives of work requirements.
Winn Davis | NIHB: They do not work well in Indian country, because frequently American Indian Alaskan beneficiaries could fall back onto the annual appropriation for the Indian Health Service, which, as we discussed a little earlier, really puts strain on that very limited funding of what the Indian Health Service actually gets.
Winn Davis | NIHB: We are also worried that certain Medicaid reforms, such as per capita caps, would shift costs on to states which do not hold the same legal trust
Winn Davis | NIHB: obligations to tribes and their citizens that the Federal Government does. We've urged the American Indian Alaska. Native beneficiaries be exempted from these types of reforms, recognizing the role of Medicaid and that unique relationship for tribes, including the 100% Fmap
Winn Davis | NIHB: Medicaid cuts, can put rural tribal communities at serious risk. In Indian country. These types of changes can translate into increased work shortages for Indian health facilities, reduced hours staff layoffs.
Winn Davis | NIHB: It can create an elimination of critical care programs and medical services at facilities such as mental health services, maternal and child health programs and other types of specialty services that may be available because of the revenues from Medicaid, funding.
Winn Davis | NIHB: exacerbation of chronic conditions, such as diabetes, asthma, and hypertension, which would get worse if they didn't have regular access to treatment.
Winn Davis | NIHB: and finally, in some cases it can lead to shutting down rural facilities entirely so.
Winn Davis | NIHB: for those that are interested in in getting involved. I think the 1st piece is that we hope the main takeaway from today's discussion is that people understand the unique health challenges that American Indian Alaska native communities face
Winn Davis | NIHB: and recognize that Medicaid reimbursements allow for Ihs and tribal facilities to hire medical staff, expand services and purchase needed medical equipment and healthcare infrastructure
Winn Davis | NIHB: that folks understand the unique status of tribes in that government to government relationship.
Winn Davis | NIHB: and that folks are are sharing the education amongst your networks about the tribal protections in Medicaid.
Winn Davis | NIHB: supporting tribally led Medicaid initiatives and encourage meaningful tribal consultation to advance the government-to-government relationship between tribes and the Federal government and the role that Medicaid plays.
Winn Davis | NIHB: and for those who want to help out and really pitch in to help preserve Medicaid access for communities, you can always reach out to your representatives and Senators and share with them the importance of Medicaid for your specific communities. We have resources on Nihb's website that can be helpful for your advocacy, including letters, templates, and talking points as well as data and more information.
Winn Davis | NIHB: So with that I will turn it over to Meredith.
Meredith Raimondi: Thank you, Win, and thank you, Joan, for that important framing of this discussion.
Meredith Raimondi: I will now discuss how the Indian Health Service works with urban Indian organizations, who also support the fulfillment of the trust responsibility.
Meredith Raimondi: So urban Indian organizations are an integral part of the Indian health system which is made up of the Indian Health Service tribal organizations and urban Indian organizations.
Meredith Raimondi: One thing to know is that the Indian health system in and of itself is not an insurance program, and that is why Medicaid is so critical to the support of the Indian health system and the beneficiaries who utilize the Indian health system through Indian Health Service Tribal facilities or urban Indian organizations.
Meredith Raimondi: Urban Indian organizations are codified through the Indian Healthcare Improvement Act and serve over 500 tribes across 22 States.
Meredith Raimondi: Additionally, the Medicaid
Meredith Raimondi: reimbursements are critical to serving American, Indian and Alaska. Native people who live in Metro areas and of the areas with the highest number of
Meredith Raimondi: Aian or American Indian Alaska. Native people enrolled in Medicaid as of 2022,
Meredith Raimondi: 9 out of 10 of those or 8 out of 10 of those are in areas served by an urban Indian organization.
Meredith Raimondi: As when noted, the Indian health system is critically underfunded, and the amount appropriated for the Indian Health Service does not even come close to the actual need for urban Indian health or the Indian Health Service overall.
Meredith Raimondi: So, to take a step back. The Indian Health Service
Meredith Raimondi: was authorized to build Medicaid initially in 1976, and this was designed to enable Medicaid funds to flow into Ihs institutions that would be the tribal programs, the Ihs and Urban Indian organization. These were considered to be a much needed supplement to the healthcare program
Meredith Raimondi: and to fulfilling the trust responsibility and the Federal Government is the one with the Federal Trust responsibility. So the responsibility lies with the Federal Government.
Meredith Raimondi: Medicaid also is a critical supplement to the Indian health system, as we noted, and it directly relates to the responsibility to provide health care to native people and provide all resources to implement that policy.
Meredith Raimondi: So at urban Indian organizations, in 2019, nearly 90 million dollars in Medicaid, reimbursements were provided
Meredith Raimondi: and urban Indian organizations are serving patients up to 59% of our patient population is native people who are on Medicaid. It is also the biggest source of funding for urban Indian organizations outside of the Indian Health Service.
Meredith Raimondi: So in terms of numbers, there were 2.7 million people enrolled in Medicaid in 2023 and 1.9 million American Indian Alaska native people on Medicaid in the 22 states that have urban Indian organizations.
Meredith Raimondi: And our data is from Nicui analysis of a 2023 American Community Service Survey, based on one year, estimates. It also includes the population that identified alone or in combination.
Meredith Raimondi: So I will now turn it over to Lisa to talk more about what's happening on the ground in Montana, and what's happening with the urban Indian organizations and the support that they are providing to people in Montana. My contact information is here, and I'll be back after Lisa to take questions.
Lisa James: Thanks, Meredith.
Lisa James: I just wanted to say Hello, everyone, and thanks for joining. My name is Lisa James, and I am the Director of development for the Montana consortium for urban Indian health. We also refer to it as Mccoui. It is a mouthful, so we have a great abbreviation. Mccoui was established in 2021, and we're a nonprofit whose purpose is empowering urban Indian organizations in Montana.
Lisa James: Our executive board consists of the executive directors from each of our urban Indian organizations, and we work alongside with that board to create opportunities for uios, that foster sustainable growth, empower advocacy, provide technical assistance data, support, workforce development and resource sharing.
Lisa James: There are 5 uios in Montana. We have all Nations Health Center in Missoula Billings, urban Indian health and wellness out of Billings, Butte, native wellness in Butte, Helena. Indian Alliance in Helena, and last Indian family Health clinic in Great Falls.
Lisa James: Across those 5 uios roughly, 30,000 clients are being served, including non-native clients.
Lisa James: Each of the uios are located in different counties. And so collectively, across those 5 counties, there's about 31% of the Montana, American, Indian, Alaskan native population.
Lisa James: as of January 2023 Montana had 54,900 American, Indian, Alaskan native beneficiaries, and of those roughly 16,000, resided in the county where Uio was located
Lisa James: as of November of 2024, Montana had 40,233 American, Indian, Alaskan, native Medicaid beneficiaries, and of those roughly 12,500 resided in a county where Uio is located. The significant drop in Medicaid clients from 23 to 24 was due to the Montana medicaid, unwind process, and that occurred after the covid-nineteen pandemic.
Lisa James: The unwind put significant strain on our uio clinics and further changes to Medicaid could have damaging effects on the uios and the American Indian Alaska. Native populations that they serve.
Lisa James: American Indian people in Montana have substantially higher rates of illness and mortality than other Montana residents.
Lisa James: For example, American Indian people in Montana die on average 17 years younger than other Montanans.
Lisa James: The death rate for American Indian people in Montana is far higher than other Montanans for common illnesses, such as heart disease, cancer, injuries, and diabetes.
Lisa James: American Indian people in Montana also suffer higher rates of mental distress and suicide.
Lisa James: 26% of American Indian people in Montana report, frequent mental health distress compared with 18% of all Montana adults.
Lisa James: The suicide rate for American Indian people in Montana is estimated at 42 per 100,000,
Lisa James: compared with a rate of 28 per 100,000 for all Montanans.
Lisa James: and at 14.5 per 100,000 for us. Residents overall
Lisa James: uios utilize Medicaid to provide services to clients, such as behavioral health, primary care, dental care, disease, prevention, health, education, and substance use, and providing these services, has assisted in addressing some of the health disparities that are experienced by American, Indian and Alaskan natives.
Lisa James: Uios are not just healthcare providers. They're essential hubs for wellness, education and cultural preservation.
Lisa James: They serve as a lifeline for urban native communities ensuring access to quality care while respecting and integrating cultural values.
Lisa James: Over the last 2 fiscal years Montana's 5 uios have increased revenue by roughly 2,947,000.
Lisa James: As Meredith touched on, the health care for American Indian people living in urban areas is severely underfunded, accounting for less than about 1% of the total Ihs budget.
Lisa James: So that increased revenue from Medicaid for our clinics was really instrumental, and they were able to add services which traditionally had to be contracted out or referred out for some of those services they were able to provide allowed for access to specialty care. They were able to hire more providers, improve access to behavioral health services and expand building capacity to meet the growth of clients.
Lisa James: Helena, Indian Alliance, for example, renovated and expanded their primary care clinic, and they recently broke ground on a new behavioral health expansion.
Lisa James: All nations was able to expand and grow. Their behavioral health services and Indian family health clinic increased its patient intake by 112% by expanding its hours, adding 2 primary care providers and a walk-in provider.
Lisa James: They were also able to grow their behavioral health team and support mental health evaluations at the Cascade County Detention Center focusing on the American Indian inmates.
Lisa James: The funding from Medicaid has led to cost savings by reducing the need for expensive medical care to treat diseases and illness.
Lisa James: Montana's expansion program is set to sunset this year. If the Legislature doesn't reauthorize it. So Mccooey has been working with our partners to bring awareness to the importance of Medicaid for uios, not only at a State level, but a Federal level.
Lisa James: Cutting Medicaid at any level would require ruios to cut essential services and would limit their ability to address health disparities.
Lisa James: Medicaid not only supports patients, but it also directly contributes to the local workforce by enabling uios to sustain jobs and provide essential health care services to community members.
Lisa James: In closing, I just wanted to share that Medicaid is not just a funding source. It's a lifeline for uios and thousands of native and non-native patients. They serve across Montana. The continuation of Medicaid ensures that uios can sustain and grow, their services.
Lisa James: reduce costly emergency care and improve overall community health. Any cuts or restrictions to Medicaid would not only harm individual patients, but also weaken the healthcare system that so many rely on.
Lisa James: Thank you and Meredith, I will give it back to you.
Meredith Raimondi: Thank you so much, Lisa, for that important overview, as we've seen from both presentations from Wynn and Lisa. The importance of sharing your stories, federally and on a State level locally, are very critical at this time.
Meredith Raimondi: We will now open up for Q. And A. The 1st question we have received, I will
Meredith Raimondi: start with. Can you elaborate on how proposed cuts such as per capita caps would impact the native health system?
Meredith Raimondi: And I will have that sent that to Joan.
Joan Alker: Thanks, Meredith. Thanks for the question, everybody and I'll share some thoughts, and then happy to hand it over to others. Who want to jump into on the panel.
Joan Alker: So just to give a little bit of context of what Congress is thinking about right now, we have seen various leaked documents from the House Budget Committee and a document that we saw a couple of weeks ago indicated. The House Budget Committee was considering 2.3 trillion with a T
Joan Alker: cuts to Medicaid
Joan Alker: that would absolutely devastate the program, and a per capita cap or a block. Grant is is one way that that could happen and generate huge cuts. So I'll come back to that proposal in a minute. But even more recently we've seen that the house is trying to
Joan Alker: to muster up a plan, and everybody knows the house is a very tight margin, and that's why you know, these Medicaid cuts are not a foregone conclusion, and I want to really emphasize that. And I, 100% agree with Wynn and Meredith emphasizing. That's really important to be talking about this now and sharing your stories because these are not a foregone conclusion.
Joan Alker: More recently we saw that the the speakers plan leaked out and they were just gonna establish floors for cuts.
Joan Alker: And in that document we saw that Medicaid was tagged for 200 billion dollars of cuts.
Joan Alker: So we have a huge that's a big range there, right? 200,000,000,002.3 trillion. But unfortunately, what is common in both of these documents is that Medicaid is the number one target for cuts.
Joan Alker: and that is, that is what is unacceptable.
Joan Alker: Because these are to fund other priorities, you know, do things like tax cuts which will primarily benefit
Joan Alker: the richest among us, so as specifically getting to a per capita cap or a block grant, this would change the fundamental way that Medicaid has been financed for 60 years, and this this year is Medicaid's 60th birthday.
Joan Alker: By the way, and in essence it would change the guarantee that exists right now in terms of the financing that States are assured of a federal partner, and it potentially would change the guarantees that individuals have, regardless of where they live, but also certainly influenced by where they live in their State's choices
Joan Alker: and states, would really not be able to manage their way out of cuts. This magnitude. And I wanted to really elaborate on what Wynn had raised. And I think they're clearly
Joan Alker: additional issues because of of the State and the sovereignty issues that that are imperative. But, as a fundamental matter, states, for example.
Joan Alker: many 40 States have done Medicaid expansion. Lisa was just talking about this in Montana. That's made enormous difference in reducing the uninsured rate.
Joan Alker: And many of these proposals are targeting medicaid expansion by lowering the match rate or maybe capping that group.
Joan Alker: And there's just no way for States to make up for these huge cuts. Medicaid is the largest source of revenue going to States.
Joan Alker: and they really would only have a few choices, and when identified some of them, one would be to reduce eligibility. And that's the kind of debate that's happening right now in Montana, and if the expansion match were cut or capped, there are many states that have trigger laws in place, and they would automatically get rid of their expansion, and there are other States that would likely do so because of the reduction of Federal funding would be so great they couldn't possibly tax their way out of this.
Joan Alker: and it would leave these vulnerable populations competing against each other
Joan Alker: for very limited dollars. And there's really only way, only a few ways, to cut the spending here. You cut people, you cut the services that they get, or you cut provider rates.
Joan Alker: and that's the reimbursement to providers, as we can see with the Indian Health Service, which is woefully underfunded. To begin with, that would be disastrous, too. So there are no good choices here when you're talking about cuts of this magnitude.
Meredith Raimondi: Thank you, Joan, again, this really does reiterate why it's so important to be having these conversations with your elected officials. Now I have seen reports that is hard to get through to DC. Congressional offices, and I've seen reminders that you can call your State offices. They have state numbers, and so if you can't get through, try the State office or the district office for your representative, because they will have people there to take your phone calls as well.
Meredith Raimondi: Next question we have is regarding 100% fmap. And it's does 100% fmap apply anywhere? A native American gets service, or does it only apply to Ihs facilities. I will send that to win.
Winn Davis | NIHB: Yeah, thank you, Meredith. And this is a good question. So as we talked about earlier, that 100% fmap is in recognition of this, the special, unique relationship that tribal nations have with the Federal government and the role that Medicaid specifically plays in closing the gap for meeting that trust responsibility in health.
Winn Davis | NIHB: And so the way that that's been set up is that the 100% fmap is not portable. So what that means is, it doesn't follow the person. It's linked specifically to the Indian health facility. In this case it's either linked to the Ihs facility or it's linked to the tribal facility. If the tribe runs its own clinics through a 6, 38 program.
Winn Davis | NIHB: and then, if that patient is referred out for specialty care, and they come back to their home provider, either at an Ihs facility or a tribal facility, that 100 fmap will cover all of those services. But if an individual who is American, Indian, Alaska native, who is enrolled in Medicaid, but doesn't go to a tribal or Ihs facility to receive their care.
Winn Davis | NIHB: That would not be paid at 100% fmap. It would be paid at the regular fmap for that particular eligibility group, or what that state receives as its regular fmap.
Meredith Raimondi: Thank you, Wynn, and
Meredith Raimondi: we are also able to touch on the fact that urban Indian facilities do not currently get 100% Fmap. But what Lisa was explaining during a period of COVID-19 there was an increased reimbursement rate which did allow for the expansion of services for community members which was critical before unwinding, began.
Meredith Raimondi: The next question we have is regarding unwinding, and it is from Jasmine.
Meredith Raimondi: and it's for Lisa. Is there a sense of whether American, Indian, and Alaska native people lost coverage, were able to get re-enrolled.
Lisa James: Yeah. So actually, from conversations with our clinics, we have had multiple reports from them that there's issues for those who had lost coverage getting re-enrolled. Most often. It's not due to them being ineligible. It's due to barriers with our office of public assistance and the processes internally, there.
Joan Alker: And I'll just jump in on quickly on this unwinding conversation. This is something. We worked a great deal on this issue, and as Lisa just said, a lot of these folks who lost coverage remained eligible. So it was just a red tape snafu
Joan Alker: And but Montana, you know, States perform very differently during this unwinding period, and how well they did frankly, in terms of making sure that eligible people didn't
Joan Alker: didn't lose coverage, and there were a number of states like Montana, like South Dakota, that have large American Indian populations that did very poorly.
Joan Alker: So I think that was critical. And I think, yeah, it's it's a great question. Jasmine and and Lisa, curious to see how long, in your opinion, do you have any data on how long were the gaps in coverage? I mean, the problem with gaps in coverage is, not only is this a problem for the provider, but people also incur medical debt.
Joan Alker: And that's a huge problem. So any gap in coverage is problematic. But, Lisa, I'll hand it back to you to see if there's any
Joan Alker: anything else to be said. There.
Lisa James: Yeah, thanks, Joan. We still to even, I would say October we had consultation with our state partners, and we still are having
Lisa James: challenges with re-enrolling individuals who lost coverage and those who are still eligible. So it's it's still an ongoing process for us.
Meredith Raimondi: We've heard the same thing from our partners in South Dakota as well that they were able to get thousands and thousands of people enrolled, but due to unwinding a lot of people that were enrolled were removed, many of whom just didn't receive a piece of paper in the mail, and did not realize they needed to re-enroll.
Meredith Raimondi: Some of them were had been covered during the time of a pregnancy, for example, and then didn't realize they had to then unroll.
Meredith Raimondi: So we estimate that there were very high numbers of people who lost coverage during this time, and we don't have good numbers on how many have been able to be re-enrolled, yet.
Winn Davis | NIHB: Yeah. And I want to kind of add on there to what Meredith was saying about
Winn Davis | NIHB: people getting mail. I think it really underscores something that we raised earlier about just
Winn Davis | NIHB: kind of the red tape of compliance when it comes to either churn or it comes to meeting very specific requirements in the Medicaid program that can make it
Winn Davis | NIHB: that would be normally very difficult even for the regular population can be even more exacerbated in American Indian Alaska native communities because of lack of regular access to things that most Americans take for granted. And I don't think that we can underscore it. Enough that
Winn Davis | NIHB: you know the procedural difficulties of meeting some of those requirements can be the sole reason that a person loses access to Medicaid coverage, even though they continue to be eligible, based on other factors in their lives.
Meredith Raimondi: I have also seen a couple of questions come in here related to maternal health and the impact on maternal health.
Meredith Raimondi: If anyone on the panel would like to speak to those questions.
Winn Davis | NIHB: Yeah, I actually would like to address this. I think there's been a question about data, and I don't have any data right now. But I do want to talk about medicaid coverage for pregnancies. Birthing and postpartum coverage. Currently.
Winn Davis | NIHB: women who are pregnant have medicaid eligibility.
Winn Davis | NIHB: the children when they're born can move over to either regular medicaid coverage or chip, and then the mother will usually have a period of postpartum. That's quite short. It's 60 days.
Winn Davis | NIHB: typically, several years ago, Congress passed a new optional service that allows for 12 months of continuous postpartum coverage
Winn Davis | NIHB: and States can elect to offer that many States have, in fact, elected to offer that. But when we talk about any type of changes to the Medicaid program, even if it's for just the general population, I think there's been some discussion about, you know.
Winn Davis | NIHB: turning up or down kind of the the Federal medical assistance percentage for thing, for groups like medicaid expansion or or other eligible categories.
Winn Davis | NIHB: States can choose to end optional services because they are by their nature something that the State elects to cover. And so if the State loses access to additional funding, it can put those additional services in jeopardy. And so one of those really critical ones that's helped a lot of postpartum mothers gain access to extended care, particularly behavioral health care in that really critical period of postpartum.
Winn Davis | NIHB: Could go away as an optional service. If States are looking to trim their Medicaid budgets due to reduced resources.
Joan Alker: Yeah, I'll just say that that was beautifully said. When we couldn't agree with you more, we work on this issue a lot, and this new option has been very popular. I think 48 States have picked it up. Now I think we're just missing Arkansas and Wisconsin, if I'm remembering correctly.
Joan Alker: But you're exactly right. This is a kind of optional service that could be on the chopping block. And, as you said, for Medicaid expansion, women of reproductive age, right? It's important that they're covered before they get pregnant
Joan Alker: while they're pregnant and after and after they give birth. So that's where this, you know, comprehensive expansion option. But then for people women over that income level, they're getting this 12 month postpartum in most states. So that is absolutely critical.
Meredith Raimondi: Thank you for elaborating on that as well. When I think this is a good question, and I don't think we've touched on this issue. But can you speak to whether tribes can use or demand consultation as a way to advocate against proposed Medicaid cuts? Maybe, if you can explain what consultation is.
Winn Davis | NIHB: Yeah, so consultation, is
Winn Davis | NIHB: the is the most formal process that tribes engage in the government to government relationship
Winn Davis | NIHB: as a part of the Medicaid program. There are many requirements around completion of tribal consultation.
Winn Davis | NIHB: And States are required when they are making changes to their Medicaid program to do tribal consultation.
Winn Davis | NIHB: They have to complete an assessment on how that will impact tribes, and then they have to complete a tribal consultation process, and then that has to be reported to Cms. As a part of that work.
Winn Davis | NIHB: Tribes also have the opportunity to directly request tribal consultation with Cms. On any particular issue that arises with the program.
Winn Davis | NIHB: In terms of what does this look like in Medicaid cuts? I think
Winn Davis | NIHB: when we're when we're discussing kind of the menu that Congress has before. Right now, consultation, unfortunately, doesn't play a role
Winn Davis | NIHB: in the way that Congress is evaluating these issues. But once Congress has made reforms, those reforms must be implemented both by Cms and then by the States in their Medicaid programs. And once that's happening, tribes have the opportunity to engage in tribal consultation to share the impacts that it will have on their communities, both rural and urban.
Winn Davis | NIHB: and to be able to share that information with them about how they could lose access to care how it would affect the availability of services that they provide, and is a really critical and important piece in the way that this will be implemented. If and when Congress makes a decision on the types of reforms, they're going to pursue.
Meredith Raimondi: Thank you. When
Meredith Raimondi: the next question is, what is the current status of work requirements? And the next question, I'm not sure if we have the answer to, but it's how many people can lose access under work requirements.
Joan Alker: I can jump in on that issue. We've done a a lot of work on. And I think
Joan Alker: when did a great job of underscoring that while I think most people agree that supporting employment is a great goal, a work reporting requirement in Medicaid is not the way to accomplish that goal. A work reporting requirement in Medicaid is only going to accomplish.
Joan Alker: Well, 2 things. Now, I used to say one thing, which is that it is definitely going to result in people losing their health insurance and really not affecting the employment rate. That's what we saw in Arkansas which did implement this work reporting requirement in the 1st Trump administration. Before a court stepped in.
Joan Alker: We saw 18,000 people lose their Medicaid in 3 months, and they were just kind of getting going, so we would expect to see large coverage losses, no impact on employment. And I think the center on budget and policy priorities may have a new paper with some estimates there. So that's a good resource. But more broadly.
Joan Alker: we do have some really kind of shocking information from the State of Georgia, which has a section 1115, Medicaid waiver called Pathways to Coverage. This was Governor Kemp's alternative to Medicaid expansion.
Joan Alker: and it has a work requirement. And what has happened in practice is that almost nobody 5,000 people, which is a drop in the bucket in a state like Georgia, where hundreds of thousands of people would be covered under expansion.
Joan Alker: have actually jumped over all the various hurdles.
Joan Alker: But it's worked really great for a large global consulting firm, Deloitte, which has made millions of dollars off of setting up the it systems, and they got a big contract to do outreach.
Joan Alker: So the vast majority of the funds. The taxpayer dollars has gone to this corporation, and almost nobody has gotten healthcare. So we've seen in Georgia. Like I said, it's effective. It's not effective at supporting work, which is a good goal. It's effective ensuring that people don't access health coverage. They need so that they can work so that they can get on top of their health conditions.
Joan Alker: Unfortunately, here in Georgia, in Georgia, we've seen this sort of shocking waste of taxpayer dollars going to these consultants, and of course lawyers will be involved, too, because there's always litigation around this. So really a very, not the way to go.
Meredith Raimondi: Thank you for clarifying that, Joan. The next one I missed was earlier, and I apologize. Is, are there contingency plans? If Medicaid cuts are implemented or alternative funding sources available.
Meredith Raimondi: You wanna take that one when.
Winn Davis | NIHB: Yeah.
Winn Davis | NIHB: I think that for many Indian health Service providers, tribal providers, uio providers
Winn Davis | NIHB: there will be, you know, work to identify contingencies. But
Winn Davis | NIHB: I think, as we identified earlier, when you're talking about somewhere between 30 to 60% of a facilities, budget is is
Winn Davis | NIHB: made up by Medicaid dollars.
Winn Davis | NIHB: That's a very difficult that's a very difficult hole to to try and backfill and
Winn Davis | NIHB: as of right. Now, I think it would be very difficult for many facilities to try and figure out how you close that funding gap. And so when we talk about what those consequences look like in terms of reduced staffing, reduced hours
Winn Davis | NIHB: closure facilities even like
Winn Davis | NIHB: those those are are likely to be the outcomes if any Medicaid reforms aren't done in a deliberative way, and they're done in such a way that recognizes the impact on tribal communities to make sure that there is no impact from those types of reforms.
Meredith Raimondi: Thank you when and just to what has underscored. This really was what happened last week when there was an Omb memo issued, and there was a lot of confusion about funding and funding was paused.
Meredith Raimondi: We saw how important and how critical Federal funding is, and the disruption of any Federal funding is going to impact native communities and the health care services that they receive through federally funded programs like the Indian health system.
Winn Davis | NIHB: Yeah. In fact. The the funding pause that we saw last week took many communities back to a time before there was advance appropriation for the Indian Health Service.
Winn Davis | NIHB: where there simply was not access to funding many.
Winn Davis | NIHB: many providers actually, during the last government shutdown that occurred in 2019 before advanced appropriations.
Winn Davis | NIHB: Many, many providers ended up leaving the service, leaving huge gaps in staffing. It's been very difficult to go back and try and fill those gaps. When
Winn Davis | NIHB: services have to be deferred or delayed, it exacerbates chronic conditions. In the case of behavioral health, particularly substance use disorder when there is a lack of funding available and a lack of staffing and services it can lead to to mortality.
Winn Davis | NIHB: And I think when we speak about the the real risk in tribal communities for changes to Medicaid. That's what we are all thinking about. And when we go up and we discuss these issues, that's what we're all highlighting.
Meredith Raimondi: And we just have a few seconds left. But when one thing I forgot to touch on that I do think, is important is the number of elderly folks on Medicaid. So if you could just close up with that.
Meredith Raimondi: that would be great.
Winn Davis | NIHB: Yeah, I think that there I think a lot of folks believe that Medicare does the primary coverage for elders. I think the reality is that in American Indian Alaska, native communities.
Winn Davis | NIHB: being an elder, starts significantly earlier, usually around 50 or 55. And those individuals are not eligible for Medicare until they're in their sixties and
Winn Davis | NIHB: In many communities elders may not
Winn Davis | NIHB: have enrolled at the right time into Medicare, and so, when they do finally enroll into Medicare. There can be a significant penalty that's actually a deterrent to getting enrolled in Medicare.
Winn Davis | NIHB: and folks will stay on Medicaid, and even elders who end up on Medicare frequently meet
Winn Davis | NIHB: the eligibility threshold for income to be what is called dual eligible.
Winn Davis | NIHB: which means that they are covered both by Medicare and by Medicaid
Winn Davis | NIHB: and that population, I think, frequently, is not talked about enough as a part of Medicaid coverage, but Medicaid covers a significant amount of services through programs like home and community based care that are really critical for that group that may not be eligible under medicare services. And so it. It covers a very specific group
Winn Davis | NIHB: for very specific types of services, and it ensures that they continue to have the fullest access to healthcare, even in their golden years.
Winn Davis | NIHB: And so I want to make sure that we're not leaving that group out.
Meredith Raimondi: Thank you for that important clarification. A big part of it is really that. How can? If coverage doesn't start till 65, and the life expectancy is lower than that. How are people even going to reach Medicare age? And so that's really the importance of Medicaid and lifting up all of the Indian health system and supporting native communities.
Meredith Raimondi: So thank you, everyone for joining us today. For this really important discussion, we can all be reached. At. Well, I can be reached at emorymandi@nicui.org. Otherwise just feel free to visit Georgetown's website after this Webinar for additional information.
Meredith Raimondi: Thank you.