Oregon Tribes Turn to Cover Oregon to Offset Health Service Cuts

Oregon’s nine tribes struck a deal with Cover Oregon for increased private insurance access, but it remains to be seen if all private insurers will contract with Indian health providers.
The Lund Report

August 7, 2013 — The federal sequestration has bore down hard on the Indian Health Service, but now Indian health providers are angling to use the Affordable Care Act to expand access to private health insurers through Cover Oregon and help these beleaguered providers remain solvent.

Healthcare has been a right guaranteed to Indian tribes since the federal government took away most of their land in the 19th century. But the Indian Health Service, set up to provide for them, has been chronically under-funded, often only able to cover basic and emergency care.

The deep and capricious cuts of federal sequestration, which President Obama signed in August 2011 to avoid the House Republicans’ threat of a default on the country’s debt obligations, has further devastated the system. While Medicare and Medicaid have been exempt from the budget cuts that took effect in March 2013, the Indian Health Service has not.

In Oregon, it’s been a $15 million loss, out of a budget of about $290 million, forcing some tribes to reduce service hours, pare back non-essential care and cut employees, according to Jim Roberts of the Northwest-Portland Area Indian Health Board. “For some of our tribes … you don’t receive care unless you have a life or limb test of services.”

But as the federal government starves Indian healthcare in one arena, it boosts it in another.

Since many Indians rely on the health service, they are the largest group per capita in Oregon to be otherwise uninsured, at 28 percent, and American Indians might benefit more from the Affordable Care Act than any other race.

Roberts said next year, 84 percent of Oregon’s 110,000 American Indians will either qualify for the Oregon Health Plan expansion or subsidies to purchase private insurance through Cover Oregon, if their employers don’t offer them coverage.

Cover Oregon has given $280,000 to the tribes to pay for administrative staff to promote awareness among American Indians of the exchange and the expanded Oregon Health Plan.

Roberts’ wants all of the state’s Indian health providers to be accepted by all qualified health plans on Cover Oregon, which would ensure both access to American Indians and a revenue source for the providers. “Our Indian people are going to want to continue to see their tribal providers as their primary health providers,” Roberts said.

Historic Barriers to Private Market

Because of historic shortfalls in funding, tribal members who could afford it have long sought additional insurance either through their employer or on the private market. But often those private insurers wouldn’t offer contracts to their tribal health providers, so any reimbursement has fallen back on the Indian Health Service.

Even if an American Indian patient just needs a referral to a specialist for something insurance covers but not the health service, they have to see a second primary care provider if their private carrier doesn’t recognize their tribal provider.

The launch of Oregon’s health insurance exchange, Cover Oregon, has given a new opportunity for Indian health providers to seek contracts and reimbursement for private carriers. The insurance exchanged worked with Oregon’s nine recognized Indian tribes to craft the “Indian Addendum,” which is a streamlined template that insurance carriers must use if they contract with federally recognized Indian health providers for qualified health plans.

In southern Oregon, the Cow Creek Health & Wellness Center is attempting to use the Indian Addendum to sign contracts with all the Cover Oregon insurance carriers who serve the area.

“The sequestration took away our funding, and we’re having to go after other types of resources,” said Dr. Sharon Stanphill, the director of the clinic for the Cow Creek Band of Umpqua Tribe of Indians, which has locations in Roseburg and Canyonville.

Roberts said the Indian Addendum seeks to address a number of barriers to private insurers contracting with tribal health providers. Since the clinics are regulated by the federal government, many of their health professionals are not licensed in Oregon. The clinics don’t have state malpractice insurance because the U.S. attorney defends the Indian Health Service and its affiliates in federal courts against any liability.

Indian Provider Contracts Optional

Roberts told The Lund Report that he was now lukewarm about the addendum because there’s still no requirement that insurance carriers actually offer contracts to his providers.

“Without a requirement to contract it may not … be used,” he said.

But Rachel Oh of Cover Oregon said mandating contracts for Indian health providers in the exchange’s qualified health plans would not have gotten the outcome that Roberts wanted. She said such a mandate does not guarantee insurers offer fair contracts. If forced, Oh told The Lund Report that the carriers might float a contract worth only $1.

While not binding, Oh believes the Indian Addendum will make it easier for Indian health providers to get contracts than ever before. “It’s a tool that carriers use to quickly offer a contract.”

She said the document has been so well received that the Obama administration has copied it for use with Indian health providers in other states.

Regardless if private insurance carriers contract with the providers, American Indians will receive a few benefits on Cover Oregon that non-Indians don’t get, including the right to enroll at any time and zero cost-sharing for those with incomes below 300 percent of poverty.

“Time will tell if contracts are offered to Indian programs, and if they are not, Cover Oregon will hopefully recognize that QHP networks are inadequate to meet the needs of Indian people and do something about it,” Roberts said.  “We won’t know this until it plays out and likely at least for a year.”

Clinic Wants Non-Indians

Stanphill was much more optimistic than Roberts. “Without this, we had trouble getting contracts. Now we think it will be easier.”

She said they have previously signed contracts with carriers such as Regence BlueCross BlueShield, but others like ODS, now Moda Health, have not offered them one. She said they were currently in talks with Atrio Health Plan and Moda Health for contracts with the Indian Addendum.

A representative from Moda Health did not respond to The Lund Report’s request for comment.

Stanphill said the sequestration could not have come at a worse time, as the Cow Creek Band of Umpqua Tribe of Indians just opened a second clinic in Canyonville, 25 miles south of its main clinic in Roseburg.

The clinics have three primary care doctors, three nurse practitioners, a staff psychiatrist and two mental health therapists. Stanphill said the Cow Creeks had not been hit as hard as other tribes, and they have managed to avert layoffs.

Stanphill said she’d like to expand service at both clinics to non-Indians, which Cover Oregon could make possible. Indian Health Service funding will remain volatile, and greater private insurance acceptance would increase access to non-Indians while boosting the clinic’s bottom line, she added. The clinic already serves non-Indians with Regence health insurance as well as tribal employees and non-Indian spouses.

“If they live right in our backyard, it would be nice to serve members of our community,” Stanphill said.

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