Amid the continuing health care debate in Washington, Native Americans throughout the country are bracing for major cuts to their insurance coverage. Under the Republican health care legislation just voted down in the US Senate, nearly 6 percent of the Native population, or 300,000 individuals, would lose access to health care coverage. In addition, government health agencies that serve Native Americans and Alaska Natives face ongoing budget cuts of up to $300 million.
Prior to the Affordable Care Act (ACA), all tribal members were eligible to receive free health care through the Indian Health Services (IHS), the US government agency operated by tribal and federal leaders, financed through the Indian Health Care Improvement Act of 1976. However, the IHS has been severely underfunded throughout its entire existence, resulting in care that is insufficient at best and appalling at worst.
Serving roughly half the total Native American population, including both tribal and non-tribal members, the IHS has received only 30 to 50 percent of the funding required to maintain adequate services, staffing, and programs.
As a result, medical facilities struggle to serve their 2.2 million patients. Many facilities are unable to provide comprehensive services, especially preventive care, public health programs, and dental work. Unsafe and poor conditions—such as outdated buildings, unqualified staff, and difficulty scheduling appointments—have been reported in the hospitals and service units spread across 36 states. An inspection of IHS facilities in South Dakota last year found life-threatening conditions, such as neglect of patients in emergency rooms, lost medical records, and sanitation equipment that had been broken for months.
Additionally, IHS overwhelmingly focuses its services on those who live on tribal and rural lands. Of the 3.7 million tribal members who are eligible to receive IHS services, only one-fifth of members live in these areas as opposed to urban areas. This means that health services are largely inaccessible to the urban majority. As a result, IHS spends only $24 per capita on health services for the urban Native population—less than 1 percent of its overall funding.
With some of the most deplorable living conditions in the United States, Native Americans face severe health issues that have long gone untreated by the government-sponsored Indian health system. Disparities in rates of mortality, preventable illnesses and diseases, drug and alcohol addiction, and life expectancy are staggering.
According to the US Department of Health and Human Services, Native Americans are 6 times more likely to die from tuberculosis, 4.8 times more likely to die from chronic liver disease, and 3 times more likely to die from diabetes than the general US population. Over 40 percent of young Native children are either overweight or obese, and by their teenage years Type 2 diabetes rates are three times the national average. Suicide has become the leading cause of death for Native men between the ages of 17 and 24, and among the general Native population over half suffer from trauma and mental health issues.
These urgent health issues were purportedly addressed by Obamacare through opening up the private health insurance market to tribal members. Rather than provide adequate funding to the IHS, directing resources toward programs and services that address Native American populations, the ACA attempted to expand Native Americans’ health care through Medicaid and private subsidized plans. Roughly 100,000 enrolled in Medicaid, with smaller numbers enrolling through employer-provided or private insurance.
Even though many American Indians and Alaska Natives were exempt from mandatory enrollment, revisions to the ACA sought to penalize 400,000 people who could not prove their tribal membership. This forced Native Americans into the private health system, while integrating private funding into the IHS budget.
Obamacare proponents hailed the expansion of third-party insurers as a progressive step for Native health. Yet the destruction of social welfare programs and the turn towards private insurance markets will likely add to the pool of 1.5 million American Indians and Alaska Natives who are still uninsured.
Robert, a working-class resident of Albuquerque, New Mexico and member of the Cherokee tribe, spoke with WSWS reporters about his experiences with IHS and the Obamacare market. Having gone without health insurance for over seven years, he wasn’t able to receive adequate care for his chronic conditions and immediate medical needs through IHS. A couple of trips to a private doctor on top of medications resulted in thousands of dollars in bills that he could not pay.
With the start of Obamacare, Robert signed up for coverage on the ACA marketplace using government subsidies. The combination of IHS and federal benefits helped him gain a health insurance plan at roughly $80/month.
Asked what it would mean if the subsidies and budgets were cut for Native American health programs, he said, “I’m sort of lucky because I have that fall-back [on IHS]. But at the same time, I know it’s a rough system that you don’t want to have to deal with exclusively, unless you have to.”
“They’ll take care of you for serious things,” Robert said. “But for not-so-serious things that could lead to serious things, you’re going to have a lot of trouble getting them taken care of. And something as simple as keeping teeth in your head is like a real fight.”
“That’s part of why I did what I did with buying insurance,” he added. “So for me I’d be extremely concerned about it, and I actually do believe they would take it away. I have full faith they will screw it up as best they can.”
Under either Obamacare or any bipartisan scheme to “fix” the ACA, Native Americans are likely to see their costs soar and benefits dry up as the criteria for subsidies narrow, or they lose coverage altogether. The Center for Budget and Policy Priorities estimated that the latest versions of the Senate Republicans’ health care legislation would have cut 300,000 Native Americans from Medicaid and other federal plans.
Meanwhile, there are no efforts to increase direct funding to the Indian Health Services, even from IHS officials themselves. Budget requests for 2018 reveal at least $57.5 million in cuts, hitting facility maintenance and comprehensive services the hardest. The Trump administration proposes a more aggressive budget cut of $300 million.
While giant insurance and medical corporations accrue mega-profits, Indian Health Services is set to reduce its budget for the second year in a row, despite the growth in third-party revenue from Medicaid, Medicare, and the Department of Veterans Affairs (VA). Across the board, petty-bourgeois officials of the federal, state, and tribal systems have encouraged the turn away from public funding and toward the private market.
The majority of Native American policymakers, administrators, and advocates have maintained their close collaboration with the Democratic Party. These individuals have taken the option of full IHS funding completely off the table, and instead are focused on how to channel funding to the agency through the private market and the deteriorating Medicaid, Medicare, and VA programs. Though the funding from third-party insurers has brought in $1.5 billion over the past seven years, it is only a fraction of the $15 billion required to meet the health needs of Native Americans. This is a dead-end solution.
Keeping pace with the political establishment as a whole, Native leaders have moved further to the right in recent years. The only two Native American members of Congress, Reps. Tom Cole and Markwayne Mullin of Oklahoma, both Republicans, have enthusiastically supported their party’s health care legislation under the guise of increasing “consumer choice.” Leading policymakers in South Dakota and the Sioux Nation tribes have attacked Obamacare by arguing that tribal governments should not be required to provide their employees with health insurance, arguing funds should be directed toward private, economic development projects instead.
Whether taking a conservative or “liberal” approach, the Native American elite are unable to present a solution to the dire conditions facing American Indians and Alaska Natives, precisely because their social position is bound up with the maintenance of capitalism and the private, for-profit health care system in the US. A solution to the health care crisis facing Native Americans is not to be found in Indian Health Services, Obamacare, or a bipartisan deal to “fix” the ACA. Native Americans as part of the working class as a whole must advance a strategy, independent of the Democrats and Republicans, that takes the health care industry out of private hands and establishes socialized medicine.