Tribal health clinics often provide healthcare to tribal members and non-tribal members in their area. The providers can also be the only accessible healthcare option for people in rural communities. The Ko-Kwel Wellness Centers serve Coos Bay and Eugene. The clinics are grappling with looming changes to Medicaid and gaps in funding. Lyric Aquino, an indigenous affairs reporter and Report for America corps member, has covered this issue for Underscore Native News. She joins us with details.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We start today with concerns about the viability of tribal health clinics. These clinics provide health care to tribal members and the general public. In some cases, they are the most accessible healthcare option for people in rural communities. But these clinics, like the Ko-Kwel Wellness Center in Coos Bay, are now grappling with looming cuts to Medicaid on top of long-standing gaps in funding.
Lyric Aquino is an Indigenous affairs reporter and a Report for America corps member. She’s been covering this issue for Underscore Native News, and she joins us now. It’s great to have you on the show.
Lyric Aquino: Thanks, it’s great to be here.
Miller: You started your article by writing about a woman in Coos Bay named Fauna Hill. Who is she?
Aquino: Fauna Hill is an enrolled Coquille tribal member and she’s also the executive director of strategic operations for the Coquille Indian Tribe. She’s also someone who had her life completely changed by the essential care that she received at the Ko-Kwel Wellness Center.
Miller: This is based on something that happened to her 23 years ago when she was working for AmeriCorps. What happened?
Aquino: So in 2002, Fauna was working in Ohio with AmeriCorps, and she was clearing logs to make room for plant growth. She was loading a log into a truck with a colleague, and they were standing behind her, their hand slipped. The log lodged at her head, and she was knocked to the ground. She told everyone she was OK despite having a headache. But in the ensuing days, her pain worsened and developed, and it began to take over her day-to-day life.
Miller: What was her experience with health care after that?
Aquino: So she sought medical help, and per doctor’s instructions, she got an MRI. And it was supposed to be paid for under AmeriCorps’ contract. However, there were some issues, and she ended up footing the bill, and that medical bill followed her for several years. She was trying to receive medical care but couldn’t afford to pay this bill and then became concerned with whether or not she would be able to try to receive medical care because she wasn’t sure how she was going to pay for any of these costs.
Miller: Why did you want to start your article about tribal health clinics with Fauna’s story? How does her story tie into the larger picture of what’s happening right now?
Aquino: So I started off with Hill because I found her story to be compelling. Her story isn’t unique. I feel like we all know someone who’s put off health care because they were scared and couldn’t afford it. But the difference is that Fauna shouldn’t have had to navigate health care the way she did, because she’s entitled to health care through the federal government’s treaty and trust responsibility to Indigenous peoples.
So I feel like it ties into this larger discussion because the federal government is responsible for providing health care to Indigenous people for stealing our lands and our resources. But we constantly see issues and failures from the government, which are regularly impacting the health care that people receive across 574 federally recognized tribes and its citizens, including Hill.
Miller: The system – it’s hard to even call it a system, it seems more disparate and complicated than that – there are a couple different pieces to it. The Indian Health Service [IHS] provides three kinds of health clinics nationwide, or money for three different kinds. So what are these three parts?
Aquino: IHS runs three types of facilities in the ITU system of care. So they have IHS-run facilities, which are fully funded and operated by the Indian Health Service. And then they have tribal health programs, which are partially or fully operated by the tribe and IHS. And then they have urban facilities, which are part of the Urban Indian Health program, and that’s funded through IHS local, state and federal grants and contracts.
Miller: So as you note, these different clinics, they’re either wholly or partially funded through Indian Health Service dollars. And that funding has increased recently – it’s over $8 billion this fiscal year compared to about $7 billion two years before. But what did you hear about that level of funding?
Aquino: So through my reporting, I found that this funding is not nearly enough. Indian Health Services’ national tribal budget formulation workgroup has recommended that the agency receives $73 billion. So realistically, they’re receiving like nine times less than they asked for with $8 billion. These numbers aren’t just goals, they’re not just a hope, they are rooted in real need for resources, for staffing, for services and for programming. So when you have that gap in funding, it’s trickling down and leading to staffing shortages, service limitations, and making health care for many Indigenous peoples difficult to navigate, if they’re even able to receive it.
Miller: Where does the rest of the money for these various clinics come from?
Aquino: The rest of this money is made up by federal grants, which were also gutted by the Trump administration, and then third-party reimbursements from Medicare, Medicaid and private insurance companies.
Miller: You noted that Indigenous people are exempt from the work requirements that are now going to need to be met twice a year to remain Medicaid eligible. Does that mean that most of these clinics, existing sources of funding, the ones specifically tied to Medicaid, that they’re going to be safe?
Aquino: It’s unsure right now and that’s what’s really scary. About 30% of Native American and Alaskan Native people younger than 65 are enrolled in Medicaid. In 2023, Medicaid accounted for nearly two-thirds of third-party revenue for the ITU system of care. But many of these health clinics in the ITU system of care, aside from urban facilities, are located in rural areas that have little or no other options for health care. They serve both the rural population and the Indigenous population. So a lot of rural communities, a lot of the residents rely on Medicaid. While Native communities are exempt from work requirements federally, what happens to the non-Natives who aren’t exempt and may potentially lose their Medicaid if they can’t comply?
These facilities relied on these Medicaid reimbursements. So if their rural citizens are losing access to Medicaid, they’re losing those reimbursements. But it’s also not that simple as well. “Native people won’t be affected by the Medicaid cuts” is something that I hear consistently …
Miller: That’s what the administration has said.
Aquino: Yes. They’re exempt from these federal mandates of these work requirements. But Medicaid is up to individual states. Within these guidelines that are set by the states, Native people still might not qualify for Medicaid. So while the federal government is saying, “Your Medicaid won’t be touched,” that’s not necessarily true.
Miller: Can you describe the Ko-Kwel Wellness Center in Coos Bay?
Aquino: The Ko-Kwel Wellness Center in Coos Bay is phenomenal. It was really cool to see it in person. There’s two facilities. There’s one in Eugene, but the one in Coos Bay offers primary care, behavioral health, a dental clinic, a pharmacy, a rehabilitation fitness center and community services.
But what’s really cool is that every detail of this building was planned so carefully. Each section of the building has a color for the service that it corresponds to, so people who are illiterate or struggle with reading can find their way to their appointments without having to feel embarrassed. There are triangles on the wall that are a symbol of wealth for the Coquille Tribe, and they can be found throughout the building just to add a sense of warmth. There are large windows that bring in natural light to make people feel welcome and bring comfort to patients. Even in the opioid treatment center, there’s still natural light. It was designed so people can still receive their health care privately but bring in that natural light to destigmatize these things. And there’s even handmade regalia throughout the center that’s out from their displays to be worn by tribal members for ceremonial dances.
When I was talking to Hill, she said that when she was aiding in the design and development of the facility, that she and her co-workers really wanted patients to know what it meant to be Coquille when you walked through the halls – and that’s something that I learned.
Miller: What might these Medicaid cuts mean to the provision of services at this particular center in Coos Bay?
Aquino: So again, I think what is so concerning is that we are in this wave of uncertainty. It could mean an interruption to their services, which would affect the lives of all of their patients. But when we were talking about what does this actually mean, they were not sure how much funding they are going to lose. Therefore, they were not sure what services are going to be interrupted. And that’s just scary.
Miller: But based on what you heard, both non-tribal and tribal residents could lose some access to care?
Aquino: Yes.
Miller: What is the federal government legally obligated to provide in terms of health care to members of federally recognized tribes – and you mentioned this briefly, but it’s really worth coming back to – based on its treaty and trust responsibilities?
Aquino: The federal trust responsibility is a legal and moral obligation that requires the United States government to protect the lands, resources and rights of American Indian and Alaskan Natives. And that stems from treaty promises of health care and other services. So in 2010, as part of the Patient Protection and Affordable Care Act, they gave specific legislative authority to Congress to appropriate funds specifically for the health care of Indian people. And yet we are seeing these funding needs not being met. They’re required to fund these services.
Miller: Lyric, thanks very much.
Aquino: Thank you.
Miller: Lyric Aquino is an Indigenous affairs reporter for Underscore Native News. She is a Report for America corps member. She wrote a recent article about what Medicaid cuts might mean for tribal health clinics.
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