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What Medicaid Expansion Could Mean for Oklahoma's Native American Tribes

WahZhaZhi Health Center employees test patients for COVID-19 in a drive-thru set-up in Pawhuska, Okla.

Next week, people will head to the ballot box to vote on whether Oklahoma will expand Medicaid through State Question 802. Lenzy Krehbiel-Burton with Oklahoma Engaged explores the impact expanding Medicaid could have on tribes.

Seth Griffith Hotvedt is the first to admit it has been a hot minute since he has been to the dentist.

“Dentists are expensive,” he said. “Most of us can’t afford it if we’re living paycheck to paycheck.”

Hotvedt has a full-time job in Information Technology but has had to put off getting his eyes and teeth checked because of the costs. The handful of places covered by his employer’s health care plan are still out of his price range thanks to the co-pays.

A citizen of the Cherokee Nation, the Oklahoma City resident is among the more than 200,000 estimated people who would be eligible for Medicaid if State Question 802 passes.

“I’m paying $120 out of my paycheck for health care,” he said. “It’s bonkers and I can’t even use it until June. They said I can only go to a few or a couple of places in OKC.”

There is a common saying in Indian Country: don’t get sick after June. That’s because IHS, or Indian Health Service - the primary health care provider for many Native Americans and Alaska Natives, gets a fixed amount of money from Congress every year and when it’s gone, it’s gone.

As part of its trust relationship, the federal government is required to offer health care to tribal citizens. But, IHS is a health care provider, not an insurance policy.

“If we relied only on Indian Health Services funds, I would only have about $1,800 per capita to spend on our patients," Shawn Terry, the Muscogee (Creek) Nation’s Secretary of Heath. said. "Because we can bill third party like Medicare and Medicaid, we almost double that.”

Across its nine health care facilities in eastern Oklahoma, the Muscogee (Creek) Nation serves about 45,000 people. Only 25 percent have private insurance. The rest rely on Medicaid, Medicare or have no insurance at all.

Oklahoma Health Care Authority data shows that Indigenous people account for almost 20 percent of all participants in the state's Medicaid programs. And Indigenous people account for 15 percent of all uninsured Oklahomans.

“It’s an interesting dynamic,” Terry said. “Our highest Medicaid mix is probably in Coweta and Sapulpa. Many times patients that are closer to the metropolitan areas, they have choices on which doctors they want to go to. Whereas in the more rural sites, those patients don’t always have an option on where to go to. We may be the only provider in town.”

Expanding Medicaid coverage would have a huge impact on the Creek Nation's health service ⁠— about $9 million to be exact. That's equal to six weeks of revenue.

“Obviously every time we can grow our third party revenue, it allows us to hire more people, add more equipment, add more services or contract for more services if we have to send a patient to Tulsa,” Terry said. “Ultimately, it’s a win for everyone.”

The Citizen Potawatomi Nation is another tribe that is closely watching State Question 802. Nearly half of the patients at its two Shawnee clinics don't have insurance and the tribe only receives $1,500 per patient from IHS.

In a written statement, John “Rocky” Barrett, the tribe’s chairman, said Medicaid expansion would allow the tribe to put more money towards health care, including access to specialty providers.

Any costs tied to Medicaid visits to IHS facilities are completely covered by the federal government.

When the federal government is determining funding for IHS, any reimbursement dollars from private insurance or Medicaid are used to further stretch that budget. In fiscal year 2019, Congress appropriated $5.8 billion to IHS to cover everything, including payroll and facility costs. An additional $1.15 billion came in from third party billing, including reimbursement for more than 724,000 Medicaid patients.

On average, IHS is federally funded at $4,078 per patient nationwide. By comparison, according to a 2018 study published by the Government Accountability Office, the average federal funding for Medicaid is $8,109 per patient.

Meanwhile, Hotvedt will be watching the vote outcome as well.

“Being able to seek out health care would be a lot better. I know Medicaid is accepted in a lot of places with certain kinds of work benefits and stuff like that,” he said.

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