Will ‘poor old grandma’ redefine this debate?
You hear a lot about grandma now that Congress is back to
work on health care reform legislation.
“Poor old grandma” is a reason opponents say they will fight
health care reform. Grandma will lose services, her Medicare will be less than
it is, and some bureaucrat far away will decide when it’s her time to die.
This is not the first time this debate has surfaced. In the
1960s opponents of Medicare used the phrase “poor old grandma” to warn that the
legislation would rob elderly of their Social Security or provide insufficient
care. They were wrong, of course. Medicare has probably become the most popular
government program ever. These days it’s common to speak as if Medicare is the
universal coverage for American elderly. (Medicare is for the elderly and
disabled, Medicaid is partnership with the states aimed at some people with
low-income.)
And that’s mostly true. Mostly. But Indian Country was largely
left out of the original Medicare and
Medicaid, plan, a problem that was fixed when President Ford signed
the 1976 Indian Health Care Improvement Act into law.
Rick Lavis, a Republican, who was working for Arizona Sen.
Paul Fannin, sent a memo to the Ford White House raising the question why it
was even necessary to amend the law to include American Indians and Alaskan
Natives. Then Lavis answered his own question by saying the act would “permit Indian
Medicare and Medicaid beneficiaries to utilize their benefits in IHS
facilities, which under present law is disallowed.”
Lavis also argued that the IHS should be reimbursed at 100
percent rates in their facilities because “the federal government has obligations
to provide services to Indians. It has not been a state responsibility.” The
idea was that Medicare and Medicaid money would be a new source of money for
Indian health programs.
Since the original Indian Health Care Improvement Act was
signed into law there has been a steady increase in Medicare and Medicaid
reimbursement to IHS. A 2008 study by the Government Accountability Office
reported $677 million in reimbursement in fiscal year 2007. “However facilities
vary greatly in the total reimbursement obtained from these programs. For
example, our prior work found that Medicaid reimbursements across 12 IHS-funded
facilities ranged from 2 percent to 49 percent of the total direct medical care
budgets.”
A 2007 study
by the Upper Midwest Rural Health Research Center found a 20-fold
difference in the uninsured rate for Native American elders 65 years of age and
older compared to the U.S. population of the same age group, or 15 percent
versus .07 percent. (Some 6 percent of Native American elderly are eligible for
Medicaid rather than Medicare.)
There are several reasons for this high rate of uninsured
elderly in Indian Country. At the top of GAO’s list: “Some officials we spoke
with reported that some American Indians and Alaskan Natives believe they
should not have to apply for Medicare and Medicaid because the federal
government has a duty to provide them with health care as a result of
treaties.” Other barriers include transportation, language, identification,
communication, and even the complicated nature of the forms.
The GAO report said that Medicare still represents an
“important means of expanding health care funding” for Indian Country. That
remains true because as the American Indian and Alaskan Native elderly
population ages it can automatically tap these funds.
But in the larger health care reform there must be a way to
better align the Medicare program with the existing Indian health care delivery
system.
Medicare is an entitlement program. If you are eligible for
services, the money is there. The IHS, on the other hand, is funded by
appropriations. This is a good year because the Obama administration proposed a
13 percent increase.
But that very difference – entitlement versus appropriation
– is what is driving the health care reform debate. Medicare, at least in
theory, has unlimited funding. That theory is about to be tested because in
about a year and half
when the first baby boomers turn 65 years old and are eligible for
Medicare. Then over the next two decades some 77 million boomers will follow –
about twice the number that is currently enrolled in Medicare.
One way or another we need to come up with a system-wide
reform, one that makes the entire system sustainable. Either that or we will
really need to worry about poor old grandma.
Mark Trahant is the former editor of the editorial page for the Seattle
Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend
the next year examining the Indian Health Service and its relevance to the
national health reform debate. He is a member of Idaho’s Shoshone-Bannock
Tribes. Comment at www.marktrahant.com
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