The Challenges of Medicaid Managed Care for Native Americans

"Until 1996, families and children who received cash assistance under Aid to Families with Dependent Children (AFDC) program were automatically entitled to Medicaid coverage" (Schneider and Martinez, 1997). The report further states that Native Americans who are eligible for health care coverage through the Indian Health Service (IHS) may be entitled to Medicaid coverage if they meet the state categorical and financial eligibility requirements. In a recent fact sheet, the Kaiser Family Foundation (2000) notes that Medicaid and other public programs are the primary source of health insurance coverage for 25% of American Indians and Alaska Natives (AI/AN) in contrast to 9% white or Anglo-Americans. Schneider and Martinez (1997) discuss the significant roles Medicaid plays in health care delivery to American Indians and Alaska Natives, including insurance coverage, revenue source to providers of care, and purchaser of managed care products, to name only a few. Given the significant role of Medicaid in health care delivery to American Indians and Alaska Natives, policy changes in the past few years have had a significant impact on access for both tribal and urban Indians.

This essay reviews the managed or restricted reimbursement of health care services to Medicaid-eligible beneficiaries in Indian country. Managed health care is the managing of fiscal resources to ensure cost-effective health care service delivery. Groups of health care providers who participate in managed care systems all too often find that managed care programs compensate profit-minded managers who restrict access by patients to health care services. Thus, the process of implementing managed care while maintaining adequate health care services may fall foul of treaty obligations to American Indian tribes to provide health care services to American Indians and Alaska Natives (Rolin 1998). This contradiction continues even in light of U.S. Surgeon General Satcher's statement that AI/AN health status ranks among the poorest of all groups in the nation (Satcher 2000). Further erosion of the current level of funding for health care services does not allow the Indian Health Service (IHS) to meet its goal of increasing the health status of AI/AN people to a level comparable with that of the general population. This goal is not only a major justification for the existence of IHS, but is also a goal of the Healthy People 2010 Initiative. This paper examines key challenges facing the Indian Health Service, tribes, and urban Indian communities as services are provided with diminished resources in a managed care environment.

Treaty Obligations and the Provision of Health Care Services

The American Indian and Alaska Native tribes, unlike any other ethnic minority in the United States, possess a unique relationship with the federal government. (Kunitz 1999). The Indian Health Care Improvement Act is under reauthorization; the amendments include funding of tribal and urban Indian health programs to maintain and improve the health of the Indians consonant with and required by the federal government's historical and unique legal relationship, as reflected in the Constitution, treaties, federal statutes and the course of dealings between Indian tribes and the United States resulting in government to government and trust responsibility and obligations to the American Indian people. This relationship underscores the need for and importance of health care delivery to the more than five hundred tribes and estimated 1.4 million American Indians residing in the United States.

In his 1999 congressional testimony on American Indian/Alaska Native unmet health needs, Rolin (1999) restates Senator Inouye's 1993 statement that American Indians purchased the first prepaid health care plan when treaties were exchanged for millions of acres of land. Kunitz expanded on this point by his mention of the historical conflict between the federal role of trustee for American Indian rights and resources and pressures from non-Indian constituents, especially those in the western states that coveted access and ownership to these lands (Kunitz 1999). Additionally...