When he learns that signing up for Medicaid will mean he can visit a nearby hospital in Española instead of traveling to Santa Fe for urgent care, the Native American man sits back in his chair, eyebrows arched. Then he smiles.
"Cool! Oh, that's good," the gray-haired, middle-aged man from Ohkay Owingeh Pueblo says.
He explains he's never had health insurance. His entire life he's visited clinics and hospitals staffed by the federal Indian Health Service (IHS) agency — a system of care for Native Americans whose director and others say is perennially underfunded. The federal government spends less per capita on health care for Native Americans than it does inmates.
Resulting problems in the IHS system, which is similar to the federal health care system for military veterans, include rationing of care when funding for the fiscal year runs out, long waiting lists and denials of referrals to specialty care that leave many Natives with delayed care and medical debt.
By helping them sign up for the newly expanded Medicaid program or private insurance through a virtual marketplace, the Affordable Care Act, commonly known as Obamacare, aims to better the health care situation for Native Americans and others. Some are newly eligible for Medicaid, which, for Native Americans, is a chance to sidestep long waiting lists in the IHS system with funding from another government-run program. For those who make too much money to qualify for Medicaid, Obamacare offers the virtual marketplace to find private insurance at a lower cost.
Across a small conference table from the gray-haired man, health guide Erik Lujan, who is tasked with helping people sign up for Medicaid or a private insurance plan, is typing away. The man qualifies for Medicaid, so Lujan is helping him enroll during the meeting at the Ohkay Owingeh Indian Pueblo tribal office near Española. (Several of Lujan's clients agreed to let a reporter sit in on the process in mid-December on the condition that New Mexico In Depth not use their names.)
Since the IHS clinic eight miles away, at Santa Clara Pueblo, was closed by flooding in September, the Ohkay Owingeh man had to travel to the Santa Fe Indian Hospital instead. Living off $400 a month in unemployment insurance — money he also uses to help his folks — it's not easy to scrape together gas money for the approximately 60 mile round trip, he says.
The man still has medical bills from when the IHS referred him to Christus St. Vincent Hospital in Santa Fe and, he says, refused to cover the cost of treatment for a cut to his head suffered during a fall.
It falls to guides like Lujan to convince Native Americans that, with new options offered through Obamacare, delayed care and personal medical debt can be a thing of the past.
Under Obamacare, Native Americans who meet certain income criteria cannot be charged copays or deductibles, and once they have Medicaid or private insurance, IHS referrals shouldn't be a problem, he explains.
Like Lujan, each health guide carries Wi-Fi-equipped laptops and portable scanners that allow them to help Natives apply for Exchange or Medicaid insurance electronically from kitchen tables or senior centers from Shiprock to Mescalero. Where there's no local Internet access, paper forms can be filled in by hand and scanned.
After about an hour of helping the gray-haired man with his Medicaid application, Lujan feeds the man's photo ID through a portable scanner, sending it to the state's Human Services Department. The application is complete.
Before standing, the man invites Lujan, whose family is from the Taos and Ohkay Owingeh pueblos, to his family home for the upcoming Turtle Dance, an annual community feast. The two compare notes about which of their families' young men would be dancing in the Dec. 26 event.
Lujan was recently certified as a health guide, one of 29 working for a nonprofit the state hired to help Native Americans sign up for the state's marketplace, known as the Health Insurance Exchange. Obamacare requires that guides help people apply for Medicaid if they don't have annual incomes high enough to pay for an Exchange policy (less than 138 percent of the federal poverty level — more than $15,856 for an individual or more than $32,499 for a family of four).
So Lujan spends much of his time helping people at the Ohkay Owingeh, Taos and Tesuque pueblos apply for the newly-expanded Medicaid public insurance program as part of his job with Native American Professional Parent Resources, an Albuquerque nonprofit whose mission is to help support healthy Native American children and families.
Obamacare will 'transform Indian health'
Obamacare, the biggest change to Indian health care in generations, "is going to transform Indian health," says Roxane Spruce Bly, the director of health care and education outreach for Native American Professional Parent Resources. Her nonprofit's task is to shift attitudes about health care among Native Americans who have long relied on the problem-plagued IHS and are sometimes jaded when it comes to the federal government's efforts to meet its mandate to provide Native Americans with health care.
Having insurance should hasten Natives' access to medical specialists, improving outcomes and costs for patients. And signing up Native Americans, who represent 10 percent of the state's population, for plans through the health exchange will also help keep rates lower for everybody — Natives and non-Natives alike — so long as young, healthy Natives sign up. That's because higher enrollment numbers lead to lower rates, says Bly, who is from Laguna Pueblo.
Nascent outreach efforts began in October. A call-center system for scheduling appointments and tracking contacts is ready to go, Bly says. The state expects the nonprofit to make contact with 9,200 non-Navajo Natives statewide by this summer — including 2,260 they plan to help enroll for coverage. Guides have already completed more than 8,600 "outreach encounters," leading to 593 Medicaid applications filed and 81 Native people enrolling in the Exchange, Bly says.
Ninety miles to the south of Ohkay Owingeh, where Lujan works, health guide Sonny Weahkee is approaching Native Americans along Albuquerque's Central Avenue near the University of New Mexico. The clear mid-December sky is cobalt blue, and the air is chilly.
"Hello, hello!" he calls, a pamphlet at the ready as he approaches a young Navajo woman pushing a baby stroller covered with a blanket. "Are you Native?"
When Weahkee, who is part Cochiti and part Navajo, talks with people about insurance options, he hands them a large glossy postcard showing income levels that qualify people for Exchange or Medicaid insurance. Some people look initially skeptical. A few gaze downward or into the distance as Weahkee talks. But whether out of courtesy or budding interest, that day each potential client is soon following along as Weahkee points to numbers on the postcard, racing through his pitch.
"This shows your health insurance options," Weahkee says, the opening of a rapid narrative that conveys a surprising amount of information in a matter of seconds. He concludes his rap by handing the pamphlet over and pointing out a phone number people can call for help getting insurance.
"Share it with people back home," he urges.
The young Navajo woman fills out a card with her contact information and gives Weahkee a knuckle-bump before turning to the Anglo reporter documenting Weahkee's work and offering a formal handshake goodbye.
"Face-to-face is the most important thing" with Natives, Weahkee says while approaching a short-haired teen skateboarding outside UNM's Zimmerman Library. "That's the kicker: face-to-face."
Under the IHS system, things can be especially difficult for the thousands of urban Natives living in Albuquerque and other cities who are members of out-of-state tribes. IHS regulations require them to schedule non-emergency clinic appointments back home.
Like many people on the university campus, the short-haired teen, Anthony Jiron, a Navajo, is what insurance policy experts call a "young invincible" — healthy and young enough not to have yet given much thought to Obamacare, he admits with a laugh, a baseball cap pulled low over his eyes, as Weahkee makes his pitch.
Convincing "young invincibles" like Jiron to sign up for health insurance can be a challenge, but it's crucial to the success of the Exchange. For the marketplace to prove sustainable, healthy people must sign up to share risk with those who utilize health-care resources more frequently.
Jiron promises with a shy grin that he'll take the informational pamphlet home to discuss with his family. Weahkee says that's common.
"That's the cool thing: They'll always take it back to grandma," he said. "If you talk to the grandma she will make sure the information gets out."
Getting past the 'triage' stage
Native American Professional Parent Resources, the nonprofit responsible for helping Native Americans sign up for the state's marketplace, now has agreements with all 19 Indian Pueblo tribes and some intertribal organizations. It is finalizing contracts with the Jicarilla and Mescalero Apache nations, and has begun talks with the Navajo Nation about that tribe's outreach plans.
Initially, the nonprofit was hired to conduct outreach only among non-Navajo Native Americans, but it has since been asked to work with Navajo Nation officials to help develop outreach plans there as well. An estimated 16,800 Navajos in New Mexico are eligible for Exchange policies. The Exchange has already produced Diné-language radio and TV public service ads for Navajo people.
Problems with the federal healthcare.gov website have been a challenge, Bly acknowledges, as have been less-publicized problems with the state's software platform for sharing eligibility and enrollment information between the Medicaid and Exchange databases. The federal system was beset by errors and delays in the days following its October 2013 rollout, leading to postponed registration deadlines and confusion among consumers nationwide.
Many Medicaid applications submitted online at the federal Exchange website late in 2013 reportedly went missing, meaning that many who applied for Medicaid before January will likely need to apply again. And information transferred from the federal website to the state did not always include enough information for the state to determine eligibility.
Those challenges are causing a two-month wait, Bly notes.
For the time being, health guides have been doing "initial screenings, like triage," Bly says, helping Natives apply separately to Medicaid or the Exchange for eligibility determinations.
For generations, IHS was the federal government's way of making good on treaty obligations to provide health care to tribal members. But with the agency's funding estimated to be far short of actual need, "don't get sick after June" is a common refrain in Indian Country. The new funding year begins each October.
IHS' frequent inability to pay for specialty care leads to missed appointments or personal medical debt. That has left many Natives ambivalent, or downright hostile, toward the agency. "Those sons of bitches," interjected one young Navajo man in Albuquerque when Weahkee mentioned IHS.
IHS is not a self-contained, comprehensive health system like many private insurance plans such as Presbyterian and Lovelace, and it is not a form of health insurance like Medicaid. Patients are frequently referred out of the IHS system to contract medical services if specialty care is needed. But because of limited funding, IHS clinics frequently pay only for referrals related to immediately life-threatening conditions or illnesses.
About half the people Lujan has helped apply for Medicaid at Ohkay Owingeh reported medical debt due to IHS payment denials, he says. Fear of debt, poor treatment at medical facilities and transportation problems explain why many Natives forego care, Lujan says.
But thanks to bad memories about copays and high deductibles, some Natives have a dim view of private health insurance as well. Eldon, a Navajo student at UNM who would not share his last name, talked with Weahkee about having a panic attack that "at the time seemed like a heart attack" while dealing with his mother's death.
He was living in Farmington at the time and drove to the nearest hospital for tests. Because he went to a non-IHS hospital, he says the agency refused to pay his bill. This is a frequent issue: For a non-IHS hospital bill to be covered by the agency, the patient must alert the IHS to the visit within 72 hours of hospitalization.
Eldon had private health insurance through his job in the oil fields. But he said his insurer paid little of his bill, leaving him to pay $10,000 on his own. He says he was lucky to have a job and the ability to pay the debt over time.
Weahkee tries to convince Eldon during a conversation in the UNM Student Union Building that such experiences will soon be a thing of the past. Natives who meet certain income criteria cannot be charged copays or deductibles. Coupled with the tax credits available to all Americans, that means many Natives will pay little or nothing for insurance policies purchased on the Exchange, Weahkee says.
And unlike others, Native Americans will have more flexibility when it comes to enrollment. They can sign up with the Exchange each month, instead of once a year. That provision is intended to reduce gaps in coverage for those whose incomes hover around the threshold between Medicaid and Exchange eligibilities and was included in Obamacare to comply with the federal mandate to provide tribal members with access to health care.
Eldon is polite but noncommittal. He is currently insured through his wife's job, he says. But he assures Weahkee that he'll share what he's heard with family members back home.