A sign for the Oneida Community Health Center in Hobart, Wis. | Photo by Jason Kerzinski for Wisconsin Examiner

Wisconsin state Sen. Eric Wimberger (R-Oconto) and Rep. Joy Goeben (R-Hobart) heard concerns about potential Medicaid cuts and gambling at a listening session Monday in Oneida, Wis. 

A woman at the session said her son receives Medicaid through the Katie Beckett program, which serves children under 19 who live at home and have certain health care needs. She said that “with the $880 billion that is going to be reduced in the federal budget, it is without a doubt going to impact Medicaid in our state.” 

A budget proposal approved by the House in late February requires lawmakers to cut spending to offset tax breaks, likely requiring Medicaid cuts, KFF Health News reported. The committee that oversees spending on Medicaid and Medicare is instructed to cut $880 billion over the next decade.

The Congressional Budget Office found House Republicans’ budget goals would require cuts to Medicaid, CBS News reported on March 6. 

The woman said she’s wondering what’s happening in the state budget to “plan for these shortcomings that are going to be coming from the federal level.” 

“I don’t know on the federal side, what’s going on there,” Wimberger said. “…I can’t imagine that we’d let any sort of tragedy happen to people who—if there’s a cut of any kind, so we’ll have to adjust to it.”

Medicaid is funded by both federal and state governments. Proposals that would reduce the amount of money paid by the federal government would not require states to pay more to make up the difference, and most states will not likely increase their health care spending, according to an opinion article by the president of the health policy research and news outlet KFF.  

Wimberger is a member of the state Legislature’s Joint Committee on Finance, which is responsible for reviewing state appropriations and revenues. The committee will hold listening sessions on April 2 in Kaukauna, April 4 in West Allis, April 28 in Hayward and April 29 in Wausau.

Oneida Nation requests anti-gambling efforts, grant funding

Brandon Stevens, the vice-chairman of the Oneida Nation in northeast Wisconsin, spoke at the listening session. One topic discussed was online and in-person gambling. 

In Wisconsin, tribes have the exclusive right to operate Class III games, through compacts with the state. Class III includes banking card games, electronic games of chance, including slot machines and, generally, high-stakes, casino-style games. 

Tana Aguirre from the Oneida Nation’s intergovernmental affairs and communications office sent the Examiner a statement that covers a few of the tribe’s budget priorities. 

The Oneida Nation is requesting an increase in funding to help address illegal/unregulated gambling activities, according to Aguirre. The tribe requests compliance and/or enforcement measures “to help deal with illegal gambling machines and practices throughout Wisconsin.” 

“We’re paying a premium for exclusivity through the gaming compact [between the tribe and the state]. It’s basically a violation of the compact if they’re allowed to game at a particular level,” Stevens said. 

Aguirre said the Oneida Nation and other tribes want to see increased funding for a tribal elderly transportation grant program. The grant gives the state’s 11 federally recognized tribes financial assistance for transportation services for tribal elders on and off the reservation. 

The Oneida Nation also wants funding to go toward an intergovernmental training program, Aguirre said. 

The program “is meant to enhance the skill set and understanding between state and tribal officials.” It aims to promote the different governments engaging in “meaningful and productive” consultations and discussions. 

Aguirre said that for the items included in his email, the tribe is requesting that funding come from Oneida Nation gaming revenue that the state of Wisconsin receives.

Tribes submit gaming-related payments to the state. A variety of state programs receive state funding from tribal payments, such as gaming regulation in the Department of Administration and law enforcement in the Department of Justice. Gaming revenue has been put toward tribal family services grants, a tribal law enforcement grant program and other programs. 

Oneida Community Health Center in Hobart, Wisconsin. | Photo by Jason Kerzinski for Wisconsin Examiner

As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.

That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.

“It would be a tremendous hit,” she said.

The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.

But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.

Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.

Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.

“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.

Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.

During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.

The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.

Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.

James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.

American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News.

A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.

The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.

HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.

Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.

“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.

State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.

Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.

President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.

The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.

The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.

Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.

“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.

Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.

The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.

“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”

This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.