Improving Alaska Native access to healthcare is a key result of the Medicaid reform bill now awaiting the governor’s signature.

About 150,000 Alaskans covered under the Alaska Tribal Health Compact will move one step closer to expanded specialized care coverage once Gov. Bill Walker signs Senate Bill 74 into law, as care centers expand in rural areas.

The omnibus healthcare and Medicaid reform bill has been one of the few items to survive a contentious and grueling 2016 legislative session, passing both chambers and only awaiting Walker’s signature to put its dozens of changes into law.

Among the bill’s changes, the most potential cost savings come from shifting more Alaska Native healthcare expenses to federal dollars. This includes a change that allows full federal reimbursement for Native travel and for Native care in non-Tribal facilities.

The policy change in SB 74 would take advantage of the new 100 percent Medicaid reimbursement to Native patients referred to non-Tribal providers.

The Department of Health and Social Services estimates the changes to the Medicaid system in SB 74 would save the state more than $31 million right away in fiscal year 2017 starting July 1.

Those savings are expected to increase to nearly $114 million per year by 2022 as the programmatic reforms are fully implemented.

Like many of the Legislature’s cost-shaving plans, some of SB 74’s changes try to fund more services with federal dollars to reduce state spending.

By far the most of the forecasted savings to be wrung from SB 74 — $29 million in 2017 growing to $97 million in 2022 — would come from getting more Medicaid services for Alaska Natives fully covered by the federal government.

Under federal law, Medicaid provides for 100 percent reimbursement for all Indian Health Services beneficiaries under certain circumstances, but the criteria are often difficult to fulfill for 100 percent coverage.

“It tends to be a rather narrow definition,” said Jon Sherwood, deputy commissioner of the Alaska Department of Health and Social Services.

Under the current system, care provided for IHS beneficiaries in non-Tribal or non-IHS facilities is only eligible for 50 percent reimbursement by Medicaid.

In order to get 100 percent reimbursement, three conditions must be met. The recipient must be an Alaska Native or American Indian, must be treated at an Indian Health Services or tribal facility, and must be Medicaid eligible.

This narrow criteria leaves some kinds of care more difficult for rural and Tribal healthcare recipients to access.

Indian Health Service, or IHS, is an agency within the U.S. Department of Health and Human Services. It provides healthcare for every federally recognized Tribe in the nation.

The Alaska Area Indian Health Services provides healthcare services for just less than 150,000 Alaska Natives and American Indians, according to the Center for Medicaid Studies. There are 228 federally recognized Tribes in the state, each of them incorporated into the Alaska Tribal Health Compact.

There are IHS-funded, Tribally managed hospitals in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome, and Sitka. Statewide, there are 58 Tribal health centers, 160 tribal community health aide clinics and five residential substance abuse treatment centers.

Alaska Native Medical Center in Anchorage is the only statewide IHS facility, and the facility that serves as the focal point for specialty care. Not all, or even most, of these facilities have specialty care or often MRI capability.

An IHS recipient may have hard luck finding a gastroenterologist within the IHS network, and need to be referred outside the Tribal system to find the necessary care.

This puts financial strain on IHS beneficiaries who need specialized care.

On the surface, the change seems like a win-win for providers and recipients. For healthcare recipients, this means increased access to specialist services unavailable in tribal facilities. For providers, it means full reimbursement for care.

To implement the changes, DHSS will have to work with Tribal and non-Tribal healthcare providers to compile lists of recipients to share among them.

“From our perspective,” said Sherwood, “we’re going to have to work with Tribal and non-Tribal providers to make sure the sharing is in place. We’re going to have to develop an adequate tracking system to ensure we have the ability to identity claims that would be eligible.”

The policy change allows rather than commands involvement. Neither the state nor the federal government can force private healthcare providers join the program, so the new system will require a new network of participating providers.

“This is voluntary,” Sherwood said. “The state can’t impose this onto either provider or individual recipients. This has to be a cooperative effort.”

Providence Medical Center, the state’s largest non-Tribal healthcare facility, said it plans to participate in the change, though representatives say it’s too early to discuss any particulars.

IHS changes come during a wave of land and construction agreements for Alaska Native medical centers across the state.

The Yukon-Kuskokwim Health Corp., or YKHC, signed a joint venture agreement with IHS on March 29.

The agreement secured increased funding for additional provider and a new primary care clinic, the 188,000 square foot Dr. Paul John Calricaaraq Project, as well as a remodel of Bethel’s existing 105,000 square foot hospital.

Expanding populations in areas like Bethel make the existing healthcare structures somewhat outdated.

The YKHC hospital in Bethel received about 88,000 patient visits in the early 1990s. The number has nearly doubled to 150,000 by 2015.

This follows an October 2015 grant for the same project. The U.S. Department of Agriculture’s Rural Development agency made a funding commitment for $165 million in low interest loans to YKHC for the Dr. Paul John Calricaaraq Project in October 2015, the most the agency has ever given to an organization nationwide.

At the federal level, Alaska’s congressional delegation is securing Alaska lands for Native health purposes.

On April 27, U.S. Senate Committee on Indian Affairs passed legislation introduced by Alaska U.S. Sens. Lisa Murkowski and Dan Sullivan directing the U.S. Department of Health and Human Services to give property to both the Tanana Tribal Council and Bristol Bay Area Health Corp.

The land transfers allow the Tanana Tribal Council to develop a Community Wellness Center and the Bristol Bay Area Health Corp. to expand a dental clinic.

DJ Summers can be reached at [email protected].