TESTIMONY before U. S. SENATE COMMITTEE on INDIAN AFFAIRS BEMIDJI AREA FIELD SITE HEARING "Health Care Reform for Great Lakes Tribes" MAY 9, 1994 SUBMITTED BY: CAROL MARQUEZ-BAINES, M.P.H. EXECUTIVE DIRECTOR AMERICAN INDIAN HEALTH CARE ASSOCIATION ST. PAUL, MINNESOTA on Indian and members of the Senate Committee I am the Executive Mr. Chairman, Affairs, my name is Carol Marquez-Baines. Director of the American Indian Health Care Association, a national consortium of 34 urban Indian health programs funded in part by Title V of the Indian Health Care Improvement Act, (P.L. 94-437). I thank you for the I have also served recently as a member of the Board of Directors for the Indian Health Board of Minneapolis. opportunity to address some health care policy concerns which affect the urban Indian health programs across the United States, and in particular programs serving Indian people residing in the Bemidji area. Five Title V funded programs are located in metropolitan centers within the Bemidji area, they located in Chicago, Detroit, Green The urban programs serve and Minneapolis. Services Bay, Milwaukee, primarily Indian people from the Bemidji area tribes. offered cover a broad range from comprehensive full time primary Within this care at two sites, limited primary care at two other sites and social service and referral services at one program. area are represented the broad spectrum of services available to Indian people living off the reservation. The clinics located in this region offer services to enrolled tribal members if services are needed when they reside in the aforementioned urbanized areas. POTENTIAL IMPACT OF HEALTH CARE REFORM: from the actual plan, respite reimbursement through Medicaid, care reform. Minnesota, The Bemidji area encompasses states which have assumed leadership in the implementation of the health not already in place Michigan, Wisconsin and Illinois have some type of Health Care proposal planned for implementation if While tribal programs may have some (Minnesota and Michigan). those receiving significant a source the President's budget heavily relies upon to supplement the loss of funds to the IHS severe disadvantage if not segment of the budget, will be at a allowed to participate as Essential Community Providers in the The President's recent meeting with negotiations of each plan. tribal leaders reaffirms the recognition of the tribes as sovereign This action increases pressure on the states to governments. include or open dialogue with the tribes to insure health care services to members of the tribe living on and off the reservation. Some may believe that the Indian Health Service is autonomous, the urban programs are perhaps the most vulnerable component of the President's proposed health care system for Indian people. The Indian Health Service, Tribal Health programs, and Urban Indian of the none However, Health programs, referred to as the I/T/U system comprise health care delivery for all Indian people. components provide complete coverage for all eligible recipients. Health care reform has placed a great challenge before the urban American Indian Health Care Association 83-756 - 94-3 Indian health care programs. While IHS and the tribal health programs may not be immediately affected by local and state plans, urban Indian health centers are already experiencing the impact. These efforts have grown and been sustained through the clinics' ability to generate revenues from 50%-60% of their patient populations covered by Medicaid. The remaining patient population is uninsured. In general, less than 5% of patients using the UIHPS carry health insurance, (AIHCA, 1993). Considering the various state plans, currently 16 states have submitted Medicaid waivers to HCFA to restrict "freedom of choice" by Medicaid recipients. It is fully anticipated that half of the states will propose similar waivers before the end of this calendar year. This information is given to promote the understanding of the vulnerability of the majority of the urban Indian health programs. In Michigan, the urban clinic has lost the capacity to bill for services of Indian patients seeking care if they are covered by Medicaid, these Indian patients have been reassigned to another clinic. In other states, demonstration programs are already underway and are reassigning Indian patients to other community health providers. In many instances the customary provider of care has been overlooked in the process of assignment. Frustrated by long delays for appointments or insensitive care, Indian people return to the urban Indian health clinics to obtain care. This loyalty is not rewarded by reimbursement for services rendered. UNIVERSAL ACCESS: It is assumed that health care reform, especially the concept of universal access, will solve the urban Indian health access issue. A recent study documents this is not the case. A 1989 report by the Royal Commission on Health and Health Costs for British Columbia, Canada found that in spite of decades of universal access to the Canadian health system, First Nations people in British Columbia were not participating at the rate of other citizens. The study found disproportionately high rates of disease similar to those found among Indians in the United States. In response, the Province of British Columbia has established two urban Health centers in Vancouver and Prince George. These programs are modelled after the Seattle Indian Health Board and the Indian Health Board of Minneapolis, members of the Association. This study recognizes a need for off-reserve (reservation) First Nations people to obtain targeted health care services. Universal access to care has not been equitably available to native people. In 1976, Title V of the Indian Health Care Improvement Act was passed, this set the course for the eventual improvement of health care status of Indian people living off-reservation. While this act resulted in the establishment of almost 40 urban Indian health programs at one point in time, the result of inadequate funding has American Indian Health Care Association diminished that effort to 34 clinics existing today. The current funding level of Title V programs supported by the Indian Health Service is 22% of need according to IHS 1994 estimates. FUNDING REQUIREMENTS: Indian Health Service funding levels in 1994 support approximately 22% of the level of effort requested of the urban programs and an estimated 49% of service need for the IHS and tribally operated facilities. Budget projections to allow programs to fulfill 100% of patient need would require an estimated $92.1 million. This figure does not include the 12 million dollars requested for facility improvements/upgrades identified in the "IHS Deep Look Survey", (1993), to bring all of the urban programs up to local facility standards. Nor does this budget recommendation reflect the staffing and service upgrades required of urban programs to implement the conditions of the "Federally Qualified Health Center" regulations, federal statute which allows for full cost reimbursement for services to medicaid participants, which now includes urban Indian health programs thanks to congressional action last year. JUSTIFICATION: Historically, Indian people moved to the cities as part of the relocation policies of the sixties, however, this trend towards urbanization continues today. According to the 1990 census, well over one-half of our population live off reservation, mostly in urbanized areas. The health status of this population is not clearly documented except through reports which have been submitted by the American Indian Health Care Association to the Indian Health Service. In a recent report leading causes of morbidity are comparable to those of patients seeking care in IHS or tribal clinics. Presently, eight of the 34 urban programs funded under Title V, including the two demonstration projects in Oklahoma, provide comprehensive primary care services. Twelve of the programs provide limited primary care services, and fourteen sites provide community health services through health education, prevention, outreach and information and referral programs. the As part of the proposed IHS/Tribal/Urban system of delivery identified in the President's plan for national health care reform, the urban Indian health programs play a critical link in delivery of primary care services and serve as a conduit to secondary and tertiary care sources. However, this critical link will be broken without strengthening the link through staffing, services, and facilities upgrades. It will be impossible for most clinics to participate in the state and federal health care reform American Indian Health Care Association plans. Therefore, the American Indian Health Care Association requests $28,420,000 in appropriations for fiscal year 1995. This request represents an increase of seven million dollars over the 1994 Title V appropriation of $21,536,297.00. This increase is summarized in the attached chart. Included in this request is a $200,000 set aside for the American Indian Health Care Association to assist the urban Indian health programs in analyzing and preparing data to help local programs formulate their decisions with regard to health care reform. These efforts are closely coordinated with the efforts of the Urban Branch of the Indian Health Service. In addition to the data collection capacity of the AIHCA, members have requested that we provide assistance parallel to that offered by the National Indian Health Board to the tribes. The funding requested is an investment in fulfilling the requirements of the Indian Health Care Improvement Act and prior legislation which stated health care services would be provided for all Indian people. It must be recognized that within the past two weeks President Clinton has reaffirmed the sovereignty of tribes. There is a need for states to respect the government to government relationship when making plans to provide health care services to their respective residents. We must not forget that Indian people living in urban areas still retain their status as tribal members. The health status of American Indians, including urban Indians remains far below that of other Americans. Census data continues to document the trend of Indian people moving to urbanized areas. The British Columbia study reaffirms the continuing need to provide culturally competent services to Indian people since universal access was not fully achieved until targeted services were developed for the off-reserve population. Therefore it is important to continue the services provided to Indian people under Title V at a level that will allow for development of capacity to participate in health care reform initiatives at the state and federal levels. Mr. Chairman, the transition from the present level of service to those required under health care reform place a great burden on urban Indian health programs. The demand continues and in many sites patients have been turned away due to lack of funds. In addition to the level of IHS funding, other sources such as local or states revenues are diminishing for many of the clinics due to budget limitations. You and your colleagues have long recognized the needs of the population, we ask that you continue your support of this effort. Thank you. American Indian Health Care Association |