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markt | Sep 11, 2009 03:03 PM

Will ‘poor old grandma’ redefine this debate?

You hear a lot about grandma now that Congress is back to work on health care reform legislation.

“Poor old grandma” is a reason opponents say they will fight health care reform. Grandma will lose services, her Medicare will be less than it is, and some bureaucrat far away will decide when it’s her time to die.

This is not the first time this debate has surfaced. In the 1960s opponents of Medicare used the phrase “poor old grandma” to warn that the legislation would rob elderly of their Social Security or provide insufficient care. They were wrong, of course. Medicare has probably become the most popular government program ever. These days it’s common to speak as if Medicare is the universal coverage for American elderly. (Medicare is for the elderly and disabled, Medicaid is partnership with the states aimed at some people with low-income.)


And that’s mostly true. Mostly. But Indian Country was largely left out of the original Medicare and Medicaid, plan, a problem that was fixed when President Ford signed the 1976 Indian Health Care Improvement Act into law.

Rick Lavis, a Republican, who was working for Arizona Sen. Paul Fannin, sent a memo to the Ford White House raising the question why it was even necessary to amend the law to include American Indians and Alaskan Natives. Then Lavis answered his own question by saying the act would “permit Indian Medicare and Medicaid beneficiaries to utilize their benefits in IHS facilities, which under present law is disallowed.”

Lavis also argued that the IHS should be reimbursed at 100 percent rates in their facilities because “the federal government has obligations to provide services to Indians. It has not been a state responsibility.” The idea was that Medicare and Medicaid money would be a new source of money for Indian health programs.

Since the original Indian Health Care Improvement Act was signed into law there has been a steady increase in Medicare and Medicaid reimbursement to IHS. A 2008 study by the Government Accountability Office reported $677 million in reimbursement in fiscal year 2007. “However facilities vary greatly in the total reimbursement obtained from these programs. For example, our prior work found that Medicaid reimbursements across 12 IHS-funded facilities ranged from 2 percent to 49 percent of the total direct medical care budgets.”

A 2007 study by the Upper Midwest Rural Health Research Center found a 20-fold difference in the uninsured rate for Native American elders 65 years of age and older compared to the U.S. population of the same age group, or 15 percent versus .07 percent. (Some 6 percent of Native American elderly are eligible for Medicaid rather than Medicare.)

There are several reasons for this high rate of uninsured elderly in Indian Country. At the top of GAO’s list: “Some officials we spoke with reported that some American Indians and Alaskan Natives believe they should not have to apply for Medicare and Medicaid because the federal government has a duty to provide them with health care as a result of treaties.” Other barriers include transportation, language, identification, communication, and even the complicated nature of the forms.

The GAO report said that Medicare still represents an “important means of expanding health care funding” for Indian Country. That remains true because as the American Indian and Alaskan Native elderly population ages it can automatically tap these funds.

But in the larger health care reform there must be a way to better align the Medicare program with the existing Indian health care delivery system.

Medicare is an entitlement program. If you are eligible for services, the money is there. The IHS, on the other hand, is funded by appropriations. This is a good year because the Obama administration proposed a 13 percent increase.

But that very difference – entitlement versus appropriation – is what is driving the health care reform debate. Medicare, at least in theory, has unlimited funding. That theory is about to be tested because in about a year and half when the first baby boomers turn 65 years old and are eligible for Medicare. Then over the next two decades some 77 million boomers will follow – about twice the number that is currently enrolled in Medicare.

One way or another we need to come up with a system-wide reform, one that makes the entire system sustainable. Either that or we will really need to worry about poor old grandma.


            Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at



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