Understanding the 'small p' Politics of Tribal Premium Sponsorship: 
Overcoming the Barriers to Adoption

Understanding the politics of Tribal Premium Sponsorship: Overcoming the Barriers to Adoption January, 2014

by Ed Fox, Health Services Director, Port Gamble S’Klallam Tribe, Little Boston, WA

  • Universal Health Insurance is an idea whose time has come to the United States. While it is not guaranteed it will succeed in its current form (ObamaCare), it's a good bet it will. The failure to stop Obamacare in October, 2013 put one political truism into play; once started an entitlement program is nearly impossible to end.
  • By law, American Indians are not only included, but have special provisions that protect and promote their inclusion.

  • Why is it that most predict extremely low participation of AIANs in Health Marketplaces?
This page explores the conditions or context that shape the 'politics' that are internal to tribes that sometimes promote and sometimes discourage this type of program.
No financial rationale for the benefit of buying insurance can overcome a political context that argues against accessing the new Marketplace(s) but a close look suggests there are no insurmountable political barriers to sponsorship.

  • 'small p 'Politics is simply decisionmaking when more than one person has a legitimate stake in the outcome-any tribal citizen in this case who is not sure about sponsorship.

  • There is no typical tribe, but there are tribes who will find it is easier to say yes to Sponsorship-if you are not one of these tribes EXPECT more POLITICS and that's to be expected as it should be when consensus is harder to reach.

It is easy to say yes to sponsorship at a Tribe where....
The community is well defined by location 
  • Or where most tribal members are distant from health program and buying insurance makes more sense then building multiple health centers.
A large percentage of the community that accesses their health program is a descendent (both enrolled and not enrolled) of the tribe that operates the health program.
A 'small' percentage of the community with access to the health program is from other tribes (both current users and 'potential' users-an important point).
Their community includes mainly (over 50%) Enrolled Tribal Members 
The Descendants (who are not enrolled) who use the tribes' IHS-funded services are mainly members of the tribe (that is, there is not a large number from other tribes)
They are remote from large Urban Indians populations

  • There is no typical Indian health program, but there are IHPs who will find it is very easy to say yes to Sponsorship based on previous insurance experience.  

They have experience buying health insurance 
They reimburse for Medicare A, B, C and/or pay directly for Part D
They have paid premiums for one of the state-funded insurance programs like Basic Health Washington, BadgerCare or MinnesotaCare.
They have experience encouraging tribal members to file taxes, secure their earned income tax credit, and stay up-to-date on reporting 'taxable income' and protecting trust income.
Related to all of the above; the tribe has built the administrative capacity to provide customer service for a program that buys insurance, answers questions about coverage, accesses carriers health plan databases, and troubleshoots the inevitable problems with such a program.
Tribe has experience supporting the concept of 'wrap around' services to pay for 'gaps' in coverage between various types of coverage so all tribal members feel they have essentially the same coverage.
There is a widespread understanding that non-IHS funding is 1/2 or more of the health program budget. The importance of Medicaid funding, for example, is not universally understood by elected tribal leaders.

  • What explains why some tribes decided to buy insurance before Obamacare?  

Is it because they are more economically successful? 
While true that 'poorer',( i.e., fewer resources), tribes are less likely to buy insurance, many do (and sliding scale premiums actually makes it a more favorable return on investment for poorer tribes).
It is not economics that 'stops' a tribe from buying insurance when the return on investment of doing so is positive.
Many did so because of the existence of State Basic Health Programs that offered extremely low cost health insurance (but often stingy benefits packages)
Medicare Part D experience was another chance for tribes to promote insurance and save expenditures that introduced tribes to insurance.
Tribes talk, Health Directors compare, Indian health organizations spread information about success.

  • So what about the politics, the political context, for your program, your Tribe? 
Sorry, you have to fill that in for your Indian health program. And yes, leadership is about overcoming those things that argue against success and leadership finds and supports those things (characteristics, resources) that will promote success.
For some it will mean including 'limits to a sponsorship program' that reflect necessary adjustments to a 'full' sponsorship program to gain political acceptance. 
There are a number of ways to phase-in sponsorship. 
Limit to 200%, put global dollar limit to premium in budget year, buy for those over 50 (although few are uninsured) since the largest subsidies are for the 50 to 64 age group (and largest CHS expenditures), pilot project with limit to number 'sponsored.'  
If there is a positive return on investment, limits do not make economic sense, but they may make political sense. 
And there is always time to start a sponsorship program, only enrolled tribal members can sign up in any month and their non-Indian spouses, non-enrolled children,  but other descendants who are not enrolled tribal members and their families must wait until the next open enrollment period.


•October, 2015 
As the tribe nears the start of YEAR THREE open enrollment Sponsorship is now a routine element of coverage options at the Port Gamble S'Klallam Tribe, a tribe where over 80% of tribal members live on or near reservation, a tribe where most patients are 'enrolled tribal members' who trust their health program's capacity to buy insurance, a tribe remote from urban populations, a tribe with no per capitas, with experience buying health insurance, providing customer service for that insurance, and with an income profile that finds nearly all the uninsured eligible for either Medicaid (400 or so) or Subsidies (25-50) in the exchange---it is easy to say yes to Sponsorship-ObamaCare works here and the tribe has begun to buy Qualified Health Plans for the subset of contract health eligibles who are under 300% of the Federal poverty level.  The remaining uninsured are spouses (50-60 est) of tribal employees and a similar number (50-60) who are likely Medicaid eligible, but not yet enrolled.