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Tribal representatives concerned about Medicaid overhaul

6 August 2011 Written by:

Human Services Department (HSD) Cabinet Secretary Sidonie “Sidney” Squier got a skeptical reception at her meeting Wednesday with representatives from eight New Mexico Indian tribes, several of whom voiced concern that her agency’s Medicaid overhaul would create new barriers to American Indians’ access to health care.

The tribes should have a substantive role in the Medicaid restructuring process, several tribal representatives said.

State law requires HSD and other agencies to consult with the tribes before changing policies affecting their members.

But Wednesday’s three-hour meeting at the Indian Pueblo Cultural Center in Albuquerque — HSD’s only scheduled Medicaid consultation with the tribes — was held during a week of seasonal Pueblo ceremonies and on the same day as a state redistricting consultation with tribal officials.

As a result, only eight of the state’s 22 tribes were officially represented at the meeting.

“There are some challenges and I think even you will admit to get all the governors in one place on the same day is difficult, because they are so busy,” Squier said.

“I think, unfortunately, we wish we had more of the (tribes’) governors here but it’s the time of year when we have ceremonies going on,” acknowledged Department of Indian Affairs Cabinet Secretary Arthur P. Allison, who also attended the meeting.

Tribal representatives and members of the audience expressed concern that they had not been included earlier and more substantively in the process, and that additional meetings had not been scheduled.

“We are troubled by the lack of tribal consultations and request continuing consultation be included in any proposed changes,” said former Zuni Pueblo governor Norman Cooeyate.

Squier told Veritas New Mexico immediately before the meeting there “could” be additional meetings with tribal officials, if needed.

“I think we’ll have an opportunity to get together again as we put it out so you can comment on it,” Squier subsequently said at the meeting. “Nothing’s set in stone. If there is something you don’t like, then you’ll have the opportunity to object.”

Despite agreeing before the meeting to answer reporters’ questions after the meeting, Squier and Kennicott left the building immediately after the meeting had concluded.

As of Friday evening, they had not responded to e-mailed questions about the meeting, submitted Wednesday afternoon by Veritas NM.


N.M. Medicaid program ‘in jeopardy’

The state’s $3.9 billion Medicaid program provides health insurance to people with disabilities or low incomes, and their children. About a quarter of that cost is paid by the state; the rest is paid by the federal government.

Federal health care reform has placed N.M.’s Medicaid system “in jeopardy,” Squier said.

“We believe we’ll have 130,000 to 137,000 more people on New Mexico’s Medicaid rolls in 2014″ (when the federal health reform law takes effect), Squier said.

Those newly-insured patients will cost between $300 million and $660 million, Squier claimed.

“We don’t have $300 to $660 million,” she said.


Talk of co-pays to discourage ER visits ignores economic realities, critics say

Part of HSD’s envisioned Medicaid overhaul includes cost controls, such as patient fees or co-pays to encourage “responsible” use of health care resources, state Medicaid Director Julie Weinberg said.

“Research tells us everyone uses health resources more wisely if they have some responsibility for the cost of care,” Weinberg said. “What (can) Native Americans do to take for responsibility for their own health?”

“We’re looking for ways to increase everybody’s responsibility … using a combination of rewards and co-pays,” Weinberg said.

One of HSD’s proposed co-pays would be a patient fee to discourage unnecessary and costly visits to hospital emergency rooms.

But that suggestion frustrated tribal representatives and members, who said HSD officials do not understand the economic and health care access realities faced by Native Americans.

“It’s critical that you understand efforts to increase cost sharing are unacceptable under treaty,” said Paul Pino, of the Pueblo of Laguna’s health committee. “Due to the lack of available medical care, American Indians shouldn’t be penalized for using emergency room services.”

One Acoma tribal member echoed that concern, and took exception to talk about Native Americans taking “responsibility” for the cost of their health care.

“When the U.S. took our land away, they promised us health, education and welfare,” she said to loud applause from the audience. “You show us responsibility. (…) You’re tellin’ us to be responsible for part of our cost for healthcare. But we cannot even do that. These people who are cutting Medicaid, how much do they make in one month? We can’t even get to the next town without putting half our money into gas for the car.”


Concern Medicaid overhaul may discourage Native American enrollment

HSD officials repeatedly raised the issue of Native Americans “opting out” or “opting in” to the state Medicaid program, raising concerns among some tribal representatives that new barriers may be created to discourage Native American enrollment in the state Medicaid program.

“We need to see what exactly you’re alluding to when you raise opt-out,” Zia Pueblo councilor and Center for Native American Health Policy Director Ken Lucero told Squier.

For many tribal members, the only alternative to Medicaid is the federal Indian Health Service (IHS), Lucero and others noted.

“We rely heavily on Medicaid because the Indian Health Service is failing,” one audience member said.

“The lack of adequate federal funding for IHS has helped create disparities in health care,” Cooeyate said.

The leading killers of Pueblo elders, for example, are cancer and heart disease — yet the IHS has no oncologists or cardiologists in the state.

Most IHS patients with chronic diseases are referred to hospitals in Albuquerque, creating delays in care, patients and physicians have told Veritas NM.

“We have to tell patients, you cannot get the surgery you need for five months because we have to get authorization,” one IHS employee said at Wednesday’s meeting.

“IHS, that’s the one we rely one,” Sec. Allison said. “I’m sorry we didn’t bring them to the table today.”

Allison’s mother died at an IHS hospital of an untreated bacterial infection in her leg, he said.

“It woke me up to ask what IHS is really about,” he said.


‘No plan in place’

Squier repeatedly denied that a plan has already been drafted for the Medicaid overhaul.

“It seems premature to be responding to questions,” Lucero told Squier. “It does sound like there is (already) a plan.”

“It’s really important if you have such a plant that you present –”Lucero started to say at one point in the meeting.

But Squier interrupted him.

“We do not,” she interjected. “We don’t.”

But after the meeting, Lucero told Veritas NM he found that unlikely.

“It’s too big a program not to have put some preliminary work in already,” Lucero said. “There has to be some model they have in mind.”


State to seek global waiver, more flexibility

HSD is contracted to pay $1.7 million for contractor Alicia Smith & Associates to plan the state’s Medicaid system overhaul and prepare a “global waiver” application for the federal Centers for Medicare & Medicaid Services, which Squier said would free the state of burdensome federal oversight.

New Mexico is demographically unique and is not best served by one-size-fits-all federal “cookie-cutter” regulations, Squier said.

The global waiver application will be submitted by late 2012, spokesman Matt Kennicott has said.

A global waiver would consolidate the state’s various existing Medicaid waivers, such as those for the Behavioral Health Collaborative and Coordination of Long Term Services (CoLTS) program, into a single, better-coordinated program, increasing the state’s flexibility, Squier said.

“We want to rebid MCO (Managed Care Organization) contracts, from seven to three or four,” she said. “We want to reduce the number of MCOs.”

Several tribal members expressed support for consolidation, particularly of behavioral and other health care.

But asked at one point for HSD’s system evaluation study of the current Medicaid program, Squier deferred to Smith, and Smith indicated a formal evaluation has not been done.

“I don’t know that there’s a research paper per se, but a lot of states are using this (global waiver) approach,” Smith said.


Urgency questioned

Several tribal officials questioned the urgency to revamp Medicaid, noting that under the federal health care reform law, more than 90 percent of the cost of expanding the program to cover the uninsured will be paid by the federal government.

“It’s ironic we’re talking about all the costs the state pays out for Medicaid,” a Taos Pueblo member said. “The truth is, we’re a poor state. What do you expect?”

Squier thanked the audience and tribal representatives for a “wonderfully civil” discussion.

Wednesday’s HSD consultation with tribal officials was the last of several frequently contentious public meetings Squier held around the state in July and August.

The meetings were scheduled after lawmakers and others criticized the agency’s secretive approach to the Medicaid overhaul, and after questions were raised about the legality of revamping the Medicaid program without consulting the tribes. HSD quietly went out to bid in March to have a contractor plan the overhaul, and Squier has rejected calls by lawmakers and others to establish a public task force to plan the Medicaid restructuring.

Alicia Smith has been told by HSD not to answer news media questions, she has told Veritas NM.

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