Navajo's take on running its own Medicaid program

By Bill Donovan
Special to the Times

WINDOW ROCK, February 14, 2013

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O ne of the biggest programs that benefits the Navajo people is the Medicaid program, which is why Navajo Nation officials are now setting their sights on the possibility of running it themselves.

With almost one of every three of the tribe's 300,000 plus members eligible to get Medicaid, the Navajo Nation has authorized a feasibility study to look at whether the tribe would one day be able to run the program itself.

Erny Zah, director of communications for the tribe's Office of the President and Vice President, points out that if this becomes a reality, the Navajo Nation would become the first tribe in the country to take the program over from the states, which have been running it since the early 1990s.

The study commissioned by the tribe is currently under review by the U.S. Department of Health and Human Development and is expected to be presented to Congress in late March.

The biggest obstacle facing the tribe may be centered around the program itself, which has been described at times as cumbersome and expensive to operate, given all of the regulations that have to be followed and the paperwork that has to be filed on each case.

To turn the program over to the tribe and to train tribal officials on how to operate it would cost tens of millions of dollars at a time when funds for the program are being cut back in some states.

When asked how the states of New Mexico and Utah feel about the idea of turning over the program to the Navajos, Zah said that's a difficult question to answer.

On one hand, it would eliminate a portion of their responsibility, which would then be turned over to the Navajo Nation. On the other hand, less responsibility usually means less funding for administrative costs, which would have an affect on the state programs.

Larry Curley, executive director of the Division of Health, told the Farmington Daily Times that that the study indicated that if the "Navajo Nation wanted to do it, it could do it."

But would it help or hurt the Navajo people who depend on the program?

That's a question that will probably be addressed by members of Congress in the coming months as they shift through the pros and cons of turning the program over to the Navajos.

Navajo officials have pointed out that one of the reasons the tribe considered taking it over in the first place was hearing complaints from some Navajos that they were having problems meeting requirements set forth by the states.

There were also arguments from the tribe that it would be an easier process overall.

And then there is another factor, said Zah, that deals with tribal sovereignty and the right of the tribe to run programs that benefit its members.

That question may not be an issue, however, since the Obama Administration's Affordable Care Act allows tribes to explore more healthcare options that would allow it to take over their own programs if tribal officials feel it is better in the long run.

Tribes unhappy with NM's choice of Medicaid providers

By Colleen Keane
Special to the Times

ALBUQUERQUE - Even as the Navajo Nation was contemplating starting its own Medicaid program, the New Mexico Human Services Department last week selected four national managed care organizations as health providers for New Mexico's Medicaid - over the objections of some tribal leaders.

Tribes have a vested interest in the Medicaid program because about one-fifth of the eligible population is Native, according to a tribal health official. The Medicaid program provides health and medical services to low-income families. For the Navajo Nation, the Medicaid program affects thousands of tribal members and tribal health facilities.

The selected companies include Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan and United Healthcare Community Plan of New Mexico. Under state contracts, these health insurance companies will share about $4 billion a year.

The selection of the new companies is part of a reform plan called Centennial Care that has not been approved by the federal government.

The main concern tribes have with the plan is the state mandate that all Native Americans have to join one of the selected MCOs. The Navajo Nation opposed the mandate in a June 15 Naa'bik'iyati' Committee tribal council resolution.

Navajo Nation Vice President Rex Lee Jim followed up with a presentation to state legislators telling them that MCOs haven't worked in the past, especially for tribal people living in remote areas of their communities.

"Those MCOs do not reimburse tribal operators in a timely manner and failed to coordinate care," he told the New Mexico Health and Human Services Committee members.

Another concern the Navajo Nation brought to the state's attention is the MCO practice of auto-enrollment. In the past, MCOs assigned Navajo patients living in northern New Mexico to health facilities in southern New Mexico, according to a prepared statement to HSD from the Navajo Nation last April.

Anáábaah Begay of To'hajiilee, N.M. who is in her 80s, knows first hand what it's like to be part of a state-managed MCO.

In a 2011 interview, she said through a Navajo language translator that she wasn't getting needed services like meals-on-wheels, transportation and home renovation that she thought was provided through the program. Her granddaughter Jerrilyn said that Begay was put on a waiting list that was years long.

Begay also found it difficult to get services because the MCO providers didn't speak Navajo and much of the company information was online and she didn't have access to the Internet.

Gap in services

It's this kind of gap in Medicaid services that has given MCO's a bad name in Indian country.

"If the (MCO mandate) passes, you and everybody else who is eligible for Medicaid; your elders, your little ones will be forced to be enrolled into an MCO where there is good, bad and otherwise and mostly what we have been able to assess is that it would be bad for our people to be forced to join an MCO," said Joe Garcia, former National Congress of American Indians Chairman and Ohkay Owingeh Tribal Councilman.

Garcia was one of about 30 tribal leaders and health advocates who gathered together about the same time Friday.

They were at the state legislature to show their opposition to the state's MCO mandate by supporting Rep. Roger Madalena's (D-Dist. 65) bill, HB 376.

If passed, HB 376 would give Native American Medicaid recipients the right to choose between one of the state MCOs or a fee-for-service provider.

"I think the major thing here is that we want to give the Native Americans a choice," said Anthony Yepa, the Director of the Kewa Pueblo Health Corporation.

Sen. John Pinto (D-Dist. 3) Chair of the Indian and Cultural Affairs Committee, said he would back up Madalena's bill on the Senate side, because of the alarming health disparities impacting Native Americans.

"It will help Native people," he said adding that he is in support of community-based programs.

"This is what I dream about. They (the Navajo people) would be better taken care of and live a longer life," he said.

Tribes want more role

To provide community-based services, tribal leaders and advocates told HSD representatives in public hearings last year that they want a significant role in delivering Medicaid services.

But, the state failed to hold meaningful consultations to work out the operational nuts and bolts, according to Garcia.

"The bottom line is that the state of New Mexico has not done its part in meeting with the tribes. They have really not collaborated with the tribes," he told the group meeting with Madalena last Friday.

"There's going to be a lot of money made by MCOs on behalf of us as Native Americans," Yepa said, adding that these funds could help to develop tribally-controlled programs.

From the $4 billion Medicaid annual budget, the state receives full 100 percent payment from the federal government for Native Americans, Yepa explained. For other New Mexicans, the state pays about a 30 percent match.

Yepa said that tribal health facilities like the one at the Kewa Pueblo can provide better services than ones administered by national MCO's, because they are in the community and staff speak the tribal language.

"The state says that the MCO will be in charge of the care coordination and how they implement services in the community. All we are saying is that let us do that locally. We know our own people best. We can do it better," he said.

Navajo facilities underfunded

On the New Mexico side of the Navajo Nation, Navajo health facilities include Indian Health Service units, tribally controlled programs, and hospitals, but all of them are underfunded and need Medicaid dollars, according to the Nation's April 22 position paper to HSD.

In the June 15 Council resolution, the Nation urged the state to require MCOs to contract directly with the Indian Health Services, tribal and 638 tribal organizations for a pilot project.

A statement on the HSD Web site says that MCOs will be required to make their best efforts to contract with tribal health facilities.

But, without substantive tribal consultation, Yepa said that tribes are in the dark on how that's going to happen.

"We are still waiting for the details," he said.

Madalena said that the national MCO middle-man really isn't needed when it comes to New Mexico's sovereign tribes.

"The tribal governments in their own sovereignty can take care of (themselves). We don't need to be required to enter into any kind of managed care. We can form ourselves into our own managed care group for the benefit of our own Indian people. I'm hoping my legislation will head in that direction," he said.

Tribal leaders and advocates met for a second time with the Centers for Medicaid and Medicare Services on Jan. 23 to present their concerns directly to the federal agency that approves state Medicaid changes, according to a report by the Native American Health Care Alliance.

Quela Robinson, staff attorney for the New Mexico Center on Law and Poverty, said that there isn't any set time for the CMS to approve the state's plan. Centennial Care is scheduled to go into effect January of 2014.

Meanwhile, the Navajo Nation is reviewing a feasibility study from the federal government that, according to Navajo Nation Health Department Director Larry Curley, indicates that the Nation could manage its own Medicaid program, in which case it would not need to deal with the state at all.

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