Coeur d’Alene Tribal Members Receive Needed Health Care Through the Affordable Care Act
Story by Mim Dixon
Photos by Kacy Ross
After her brother ran over her foot with a car nine years ago, Margaret Coffey was left with broken bones and a useless toe. The 50-year-old citizen of the Coeur d’Alene (CDA) Tribe had no insurance and her injury did not meet the priority for Contract Health Services, now called Purchased/Referred Care (PRC).
Nearly six years later, the damaged bones in her foot snapped. “I dropped to the floor in pain,” she recalls. Still, her injury was not considered life threatening, and PRC was unable to pay for treatment. “I lost my temper,” she exclaims. “I can’t walk! Isn’t that a priority?”
The Tribe contacted her in March 2014 to offer her health insurance through Your Health Idaho (YHI), the health insurance marketplace established by the State of Idaho under the Patient Protection and Affordable Care Act (ACA). The CDA Tribal Premium Sponsorship Program paid the portion of the premiums that was not subsidized through federal tax credits.
Finally, Ms. Coffey saw a podiatrist for the first time in July 2014 and she had surgery on her foot. “Through this insurance, I am now a priority,” Ms. Coffey says with satisfaction. She adds, “Life has changed – I feel thankful and hopeful.”
The Coeur d’Alene Tribe has 2,190 enrolled citizens who live on the reservation in northern Idaho and adjacent areas in Washington State. Originally, the Tribe occupied 5 million acres spanning portions of what is now Washington, Idaho and Montana.
Debra Finkbonner works as a cook for a residential men’s drug and alcohol treatment center in Spokane, WA. However, her arthritis was so bad that she had difficulty writing, using a can opener, and standing on her feet all day. Her employer offered health insurance, but she could not afford the co-payments.
As an enrolled Tribal member, Ms. Finkbonner qualifies for insurance with no co-pays or deductibles under ACA. CDA contacted her about their Tribal Premium Sponsorship Program, assisted her to enroll, and paid the portion of the premiums that was not covered by a federal tax credit.
Before she had insurance under ACA, Ms. Finkbonner used her Tribal health clinic, the Benewah Medical Center in Plummer, ID. The Tribe provided rheumatoid arthritis and seizure medications for her. But, they had to limit her visits to specialists because her health problems were not considered the highest priority for the limited funding for PRC. With insurance, Debra can see a neurologist more often. She was recently diagnosed with an early stage of Parkinson’s disease and now she can see the neurologist as recommended every six months for further evaluation.
“If it weren’t for insurance,” Ms. Finkbonner speculates, “I would probably be disabled and not working.”
Help for People whose Needs are Not Priority for CHS
Ms. Coffey, Ms. Finkbonner and other American Indians and Alaska Natives are receiving their care through the Indian health system that is funded by Congress at less than 60 percent of the level of need. While most of their primary care and medications can be provided at clinics operated by Tribes or the Indian Health Service, they often rely on PRC to pay for specialty medical care. Like many Tribes, the CDA relies on a priority system to ration the limited PRC dollars. The top priority is illnesses or injuries that are life-threatening.
A lot of people have medical conditions that cause pain without being life-threatening. Donna Matheson has had rheumatoid arthritis since she was 26 years old. At 58 years old, she is working as a substitute teacher in the public schools and she does not receive any health benefits.
With the assistance of the Tribe, she has insurance through ACA that allows her to have an injection by a neurologist to stop the back pain that causes twitching from her lower back to her toes and has affected her ability to walk, sit and lay down. As an added bonus, insurance through the ACA enabled her to switch to a more effective – and expensive– biologic medicine for her arthritis.
“People are in tears when they get here, and they are in tears when they leave,” says Molly Schnebly, Health Insurance Specialist at the Benewah Medical Center. She hastens to add that those are tears of frustration when they arrive at an ACA health insurance enrollment event, and tears of joy when they have signed up for health insurance.
“We have happy dancing, too,” she adds, “People just break out in a happy dance when they get up from the computer knowing that they are covered for their health care.”
Outreach and In-reach
Last year the Benewah Medical Center enrollment team held numerous enrollment events in many different small communities in rural Idaho. Grant funding allowed CDA to pay for advertising in local magazines, sending out mailings, and creating materials. Most important, the grants enabled them to hire an Outreach and Enrollment Specialist and an In-reach Coordinator.
“We needed people who could make this a priority and not an add-on for another job,” explains Gary Leva, CEO of the Benewah Medical Center.
During the open enrollment period from November 2014 until February 2015, the team assisted 1,002 people to enroll in health insurance or Medicaid in both Washington and Idaho. The expert enrollment team had to learn the particulars of each state’s programs. For example, Washington has Medicaid Expansion, but Idaho does not. The two states have different enrollment periods, different websites, and different processes. Other Tribes, state officials, and even librarians look to the CDA team for advice and training.
“We don’t use the word Obamacare,” explains Ms. Schnebly, choosing instead to use the less polarizing term “Affordable Care Act” in their clinic and their outreach materials. According to Ms. Schnebly, after people enroll they say, “This is better than Obamacare!”
Theresa Bessette, the In-reach Coordinator, reviews charts of people the day before their appointments at Benewah Medical Center to see if they have insurance and asks them to set up an appointment to review their options. It turns out that many non-Native people who use the Community Health Center actually have insurance that they have not reported to the clinic, because they are afraid they will pay more for a deductible or co-pay than they would with the sliding-scale fees. Some Tribal citizens also were hesitant to report their insurance because they thought it was “double dipping.”
With the blessing of the CDA Tribal Council and Health Board, the Benewah Medical Center changed their policies and procedures so that everyone who is seeking specialty medical care through PRC must first be screened to see if they qualify for insurance through the Marketplace and the Tribal Premium Sponsorship Program. In addition, Benewah Medical Center provides an independent tax preparer, who sets up appointments for patients in the Tribal Premium Sponsorship Program who received the advanced payment tax credits for their health insurance premiums. CDA also pays any amount on individual taxes that is due (tax reconciliation) as a result of enrolling in health insurance through the Tribal Premium Sponsorship program.
More Resources for Health Care
Mark Ramos loved his job with the Council on Multi-Cultural Affairs in the office of the Mayor of Spokane, Washington. When the city faced a budget shortfall, his position was eliminated and he found himself without health insurance. The Tribal Premium Sponsorship Program allowed him to have health insurance. As a condition of the Tribal Premium Sponsorship Program, he drives about 40 miles from Spokane to the Tribally-operated Benewah Medical Center in Plummer, Idaho, for his primary care. These services are billed to insurance and it increases the amount of resources that are available to add services for everyone in the Tribe. For example, Benewah Medical Center is planning an expansion to include dialysis treatment, outpatient surgery, additional medical specialists, optical and a child care center.
In the first year, the Tribal Premium Sponsorship Program cost CDA about $100,000 for premiums to cover 85 tribal members, an average of $1,176 per person. CDA figures that their investment of $100,000 saved Benewah Medical Center $328,000 in PRC and increased the revenues at the Medical Center by $22,300.
Cindy and Mike Ladeaux know that a single event can have a huge impact on the PRC budget after their family was in a car crash five years ago. The costs for the emergency care, medivac, surgery, and hospital were paid by PRC.
After they received a letter from their Tribal clinic asking them to sign up for insurance through ACA, they met with Ms. Schnebly. “It was easier to do as a couple,” Ms. Ladeaux recalls. “We may have struggled to do it by ourselves.”
“I’m not sure how it works,” Ms. Ladeaux admits. “I just know me and my husband benefit from it.”
Mr. Ladeaux, who has COPD, was recently flown by medivac from the Benewah Medical Center to a hospital where he was admitted to the Intensive Care Unit for pneumonia. This time their insurance paid the cost of the medivac and the hospital care, saving the PRC program significant valuable dollars.
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