October 2003, Vol 93, No. 10 | American Journal of Public Health 1634-1636
© 2003 American Public Health Association
Tribal Benefits Counseling Program: Expanding Health Care Opportunities for Tribal Members
Donna Friedsam, MPH,
Gretchen Haug,
Mike Rust, MDiv and
Amy Lake, MS
Donna Friedsam and Amy Lake are with the University of Wisconsin Medical School, Madison. Gretchen Haug is with the Great Lakes Inter-Tribal Council, Lac Du Flambeau, Wis. Mike Rust is with Advocacy and Benefits Counseling for Health, Balsam Lake, Wis.
Correspondence: Requests for reprints should be sent to Donna Friedsam, MPH, Wisconsin Public Health and Health Policy Institute, 760 WARF Bldg, 610 Walnut St, Madison, WI 53726 (e-mail: dafriedsam{at}facstaff.wisc.edu).
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ABSTRACT
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American Indian tribal clinics hired benefits counselors to increase the number of patients with public and private insurance coverage, expand the range of health care options available to tribal members, and increase third-party revenues for tribal clinics. Benefits counselors received intensive training, technical assistance, and evaluation over a 2-year period.
Six tribal clinics participated in the full training program, including follow-up, process evaluation, and outcomes reporting. Participating tribal sites experienced a 78% increase in Medicaid enrollment among pregnant women and children, compared with a 26% enrollment increase statewide during the same period.
Trained benefits counselors on-site at tribal clinics can substantially increase third-party insurance coverage among patients.
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INTRODUCTION
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AMERICAN INDIAN TRIBAL clinics in Wisconsin began hiring benefits counselors in 1998 to assist uninsured patients in gaining access to public and private insurance programs. The Wisconsin Intertribal Managed Care Demonstration Project (WIM Care) provided tribal benefits counselors with intensive training, technical assistance, and evaluation. The tribal benefits counseling program showed quick and effective results. From January 1998 to October 2000, six Wisconsin tribal sites experienced a 78% increase in Healthy Start enrollments (Wisconsin’s Medicaid program for pregnant women and children). On-site trained benefits counselors at tribal clinics substantially increase the number of patients with third-party coverage. Health care options available to tribal members are thus expanded, and this in turn increases the potential for third-party revenues to tribal clinics.
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HIGH RATES OF UNINSURANCE
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American Indians and Alaska Natives continue to have high rates of uninsurance. Nationally, 24% of American Indians/Alaska Natives aged younger than 65 years were uninsured in 1998, compared with 14% of Whites. In Wisconsin, 31% of patients who received care at 9 tribal clinics in Wisconsin from 1994 to 1997 had no record of insurance. Even groups that are often presumed to be eligible for Medicaid and Medicare—children of low-income families and elderly persons—significantly lack coverage. In Wisconsin’s tribal clinics, 21% of children aged younger than 19 years and 15% of seniors aged older than 65 were reported as uninsured.
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BARRIERS TO PUBLIC BENEFITS
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Wisconsin tribal members face several logistical and social barriers to accessing public insurance programs. Interviews with tribal officials uncovered perceived barriers that have been reported elsewhere. Lack of transportation or of work release may prevent patients from going to the tribal or county Office of Economic Support to apply for public benefits. Applicants must gather several pieces of verification regarding financial and family status. Social barriers also deter participation. Many tribal members report feeling that workers at public agencies treat them poorly. They may sense a stigma of welfare and, at nontribal agencies, may perceive cultural discrimination or insensitivity. Some nontribal agency employees may presume that the Indian Health Service takes care of tribal members, and thus they may not advocate in earnest for the applicant.
On the other hand, tribal members may not apply for public assistance because the federal government has a treaty obligation to provide for tribes’ health care. Indeed, the tribal clinic is legally required to provide care free of charge, regardless of a patient’s potential coverage. At the same time, Indian Health Service regulations require clinics to pursue "alternate resources" before using the federal resources.
Federal law since 1990 has required that Federally Qualified Health Centers, a category that came to include tribal clinics, provide "outstationed" Medicaid eligibility workers (i.e., workers available in community locations rather than only in government offices) so that the Medicaid application process is easily accessible to uninsured pregnant women and children. These Medicaid counselors can file program applications on-site at tribal clinics on behalf of the patient. They can also follow up with applicants and assist with complications and financial documentation. Beyond simple "outstationing," benefits counselors at tribal clinics advocate for applicants, helping patients with a broad menu of programs and aggressively appealing denials of coverage.
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TRAINING BENEFITS COUNSELORS
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Wisconsin’s tribal clinic counselors underwent rigorous training over an 18-month period. The training focused on 2 distinct aspects of the program:
• Medicaid outstationing—helping pregnant women and children apply for and gain coverage by Medicaid/Healthy Start and State Children’s Health Insurance Program (SCHIP; called BadgerCare in Wisconsin).
• Family health benefits counseling—helping individuals and families get access to any public or private insurance coverage for which they may be eligible.
The training began with an introductory "shadowing" experience, in which trainees observed client interviews conducted by experienced counselors. Tribal benefits counselors then received individual training on-site at their own clinic. Other staff members were trained in how to integrate the benefits counseling into regular clinic operations. Seminars focused on insurance, Indian Health Service funding, and Medicaid law and regulation. Ongoing technical assistance includes regular policy and procedure updates and telephone access to expert consultation for problem cases. Tribal benefits counselors themselves convene regularly for case conferencing and troubleshooting.
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DISCUSSION AND EVALUATION
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Six participating tribes showed a 78% increase in Medicaid/Healthy Start enrollments compared with a 26% increase statewide. These same tribes showed an increase in SCHIP/BadgerCare enrollment that is on par with the statewide rate. This occurred despite ongoing disputes between tribes and the state of Wisconsin regarding the applicability of premium cost-sharing to American Indians. While other variables certainly contributed to the increased enrollments, comparisons with statewide rates suggest that the benefits counseling itself is having a substantial impact.
The early success of this program in Wisconsin suggests the potential for replication elsewhere. Program initiation requires up-front resources for hiring counselors, which may then be funded through Medicaid as part of mandatory outstationing services for patients at Federally Qualified Health Centers. Once in place, such outstationing should pay for itself through increased third-party revenues brought to the clinic.
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NEXT STEPS
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Tribal clinics, through benefits counseling, are able to conserve their limited resources to care for more uninsured patients. Many factors contribute to the success of the tribal benefits counseling program. A complete training program and ongoing technical support helped anchor the benefits counselors. Counselors’ presence in the clinics give uninsured patients easy access to them and their services. Benefits counselors’ ability to submit Medicaid/Healthy Start and SCHIP/BadgerCare applications directly to county offices on behalf of clients eliminates transportation and logistic barriers. Benefits counselors help patients gather all necessary documents and follow up with applicants and agencies. Most of the benefits counselors are tribal members or long-time members of the tribal communities. This appears to bolster patients’ acceptance of counselor services.
The tribal benefits program has shown early success and much potential. A significant number of tribal members remain uninsured and may yet be eligible for public benefits. Beyond categorically eligible patients, many others may gain eligibility through Medicaid spend-down provisions. As the tribal benefits counseling program matures, it will expand its services to include more complex cases that continue to show up among the uninsured.
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KEY FINDINGS
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- Tribal clinics, through benefits counseling, are able to conserve their limited resources to care for more uninsured patients.
- Benefits counselors’ ability to submit Medicaid and SCHIP applications directly to county offices on behalf of clients eliminates logistical barriers.
- Six participating tribes showed a 78% increase in Medicaid/Healthy Start enrollments compared with a 26% increase statewide.
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Acknowledgments
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The research for this report was supported by grants from the Robert Wood Johnson Foundation.
The following Wisconsin Tribal Health Directors participated in WIM Care projects and contributed substantially to the work: Mary Bigboy of Bad River Chippewa, Linda Helmich of Forest County Potawatomi, Don Smith of Lac Courte Oreilles Chippewa, Robin Carufel of Lac du Flambeau Chippewa, Jerry Waukau of Menominee, Deanna Bauman of Oneida, Patricia Deragon of Red Cliff Chippewa, Phillis Lowe of St. Croix Chippewa, Judy Anaya of Sokaogon Chippewa, and Joann Schedler, of Stockbridge-Munsee. The authors also gratefully acknowledge the major contributions of Glen Safford and his staff at the Great Lakes Inter-Tribal Council.
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Footnotes
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Contributors
D. Friedsam, the director of WIM Care, is the principal author G. Haug and M. Rust collected, analyzed, and interpreted the data. A. Lake managed and coordinated the benefits counseling project and drafted earlier versions.
Peer Reviewed
Accepted for publication March 28, 2003.
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References
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1. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and Ethnic Disparities in Access to Health Insurance and Health Care. Los Angeles, Calif: UCLA Center for Health Policy Research and Kaiser Family Foundation; April 2000.
2. Dixon M, Roubideaux Y. Promises to Keep: Public Health Policy for American Indians and Alaska Natives in the 21st Century. Washington, DC: American Public Health Association; 2001: 61–87.
3. Schneider A, Martinez J. Native Americans and Medicaid: Coverage and Financing Issues. Washington, DC: Kaiser Family Foundation; 1997.
Copyright © 2003 by the American Public Health Association
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ABSTRACT
INTRODUCTION
