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Reporting the Outcomes of Native Americans Affected By Arizona’s Medicaid Scam
Alexa Bu
Feb 9
By: Alexa Bu
Photo by ANITA SNOW/ AP Photo
In May 2023, the Arizona government uncovered a state-wide Medicaid fraud targeting Native Americans struggling with alcoholism(Operation Rainbow Bridge, 2023). This led them to suspend Medicaid reimbursements to treatment centers, causing 20% of providers to close or file for bankruptcy leaving tribal members at those centers without treatment options and at risk of homelessness (Bassett, 2023). The outcomes of the majority of the victims of the Medicaid scam were not tracked, leaving the government with insufficient data on how to create targeted treatment for Native Americans with alcoholism (How Arizona’s Medicaid Fraud Crackdown Hurt Native American Patients, 2023). I propose that the Center for Disease Control and Prevention (CDC) work with local initiatives aiming to help the Medicaid scam victims to collect data about the outcomes for those scammed. Such data can be used to inform the government about what resources the Medicaid scam victims need.
Since European colonization first made mass amounts of alcohol available to Native Americans (Beauvais, 1998), they have experienced higher rates of alcoholism than the rest of the US (Alcohol and Drug Abuse Statistics, 2024). Native Americans were exposed to more potent forms of alcohol by European colonizers using it as a medium of trade. This rapid introduction meant large amounts of alcohol suddenly became available to Native Americans before tribes could develop social guidelines around alcohol (Beauvais, 1998). In 2023, 11.6% of Native Americans had an alcohol use disorder within the past year, compared to a country-wide average of 10.2% (American Addiction Centers, 2024). To combat this issue, the Arizona state government created the American Indian Health Program (AIHP), a Medicaid fund that subsidized health care for low-income tribal members (Healy, 2023). Under this program, the Arizona Health Care Cost Containment System (AHCCCS), which oversees Arizona’s Medicaid programs, allowed health clinics to set their own rates and directly bill beneficiaries (Bassett, 2023). The program was intended to expand access to healthcare for Native Americans but was exploited as fake treatment centers and sober living homes in Arizona targeted Native Americans included in the AIHP so they could bill the AHCCCSfor treatments they never delivered upon (Healy, 2023). In fact, Native Americans targeted by fake treatment centers reported that they never spoke to counselors and that workers would look the other way while tribal members drank in rehabilitation centers (Healy, 2023). As a result, an already-vulnerable population was further taken advantage of by fake treatment centers trying to extract money from Arizona’s Medicaid programs.
In 2023, the Medicaid scheme was uncovered, and the AHCCCS terminated contracts with many treatment facilities and suspended Medicaid reimbursements to hundreds of providers (Snow, 2023). In the process of defunding scam treatments, however, legitimate behavioral health providers were left without financial support. As these treatment facilities and sober homes closed, Indigenous people struggling with alcohol abuse have been left at risk of homelessness and now lack the resources needed to treat their alcoholism. For this at-risk population, Arizona established a hotline to connect patients to either treatment, temporary housing, or transportation back to their tribal reservations. However, the AHCCCS has no record of the outcomes for most of the hotline callers. The hotline received 11,400 callers, but the AHCCCS only tracked the outcomes of the 4,100 callers that chose to stay in temporary government housing for six months (How Arizona’s Medicaid Fraud Crackdown Hurt Native American Patients, 2023). Therefore, Arizona has no record of what happened to a majority of those Native Americans scammed by fake treatment centers despite being warned by state housing officials that their crackdown could cause a rise in homelessness (AHCCCS Alerted to ‘predictable’ homeless surge in 2022, 2023). Given there is no data on where tribal members went after leaving the fake treatment centers, it is difficult for the state to make a targeted effort to help this vulnerable population reach sobriety.Collecting data is especially hard in this situation since these Native American victims are considered a hidden population. Hidden populations are hard-to-reach groups of people that researchers have difficulty collecting data on (Liu & Lu, 2018). Since many of the victims are homeless or do not have phones it makes it difficult for researchers to locate and contact them (Bassett, 2023). Without this data, government agencies cannot gauge the amount of tribal members struggling with alcoholism and homelessness or where they’re located. Thus, they don’t know where to focus their policy development.
To fix the underreporting of outcomes for Native American victims, I suggest that the Center for Disease Control and Prevention (CDC) work with Operation Rainbow Bridge to collect data about the outcomes for those scammed. Operation Rainbow Bridge is an effort started by Navajo Nation to help victims get transportation back to their reservation or find other treatment services (Becenti, 2023). They are primarily focused on alleviating the immediate impacts of the treatment center shut-downs rather than collecting data on where tribal members ended up after the shut-downs (Operation Rainbow Bridge, 2023). Therefore, there is an unmet need for data on the outcomes of these tribal members that the government needs in order to create targeted legislation. In 2005, the CDC worked with state and local health departments to create the National HIV Behavioral Surveillance System (NHBS) to collect behavioral data on injecting drug users, another hidden population, to inform HIV prevention programs (Lansky et. al., 2007;United Nations Office on Drugs and Crime, 2014). The NHBS circumvented sampling issues associated with hidden populations by collecting data using respondent-driven sampling (RDS) (Lansky et. al., 2007). RDS starts with a group of people called “seeds,” who are selected by referrals from those who know the population of interest (Lansky et. al., 2007). These seeds start off chain-referral sampling by completing an interview and then recruiting a specified number of people they know who are also part of the population of interest (Lansky et. al., 2007). In this case, seeds can be selected through referrals from Operation Rainbow Bridge which works with already identified victims of the Medicaid scam (Becenti, 2023). The CDC would work with Operation Rainbow Bridge to interview the initial seeds about their life outcomes after the Medicaid scam. Then those seeds would be asked to recruit 3-5 other Native American Medicaid victims to also complete the interview. To further incentivize the data collection, the NHBS compensated participants for their interview and for recruiting other interviewees (Lansky et. al., 2007). This incentive should also be applied to the interviews of Native Americans to ensure that a large enough sample can be collected.
Critics of RDS point out that there is potential bias in the recruitment of participants. Since RDS relies on seeds recruiting their peers, they may only recruit people similar to themselves, skewing the data (Gil et. al., 2010). In this case, if many of the seeds were residents at one rehabilitation center, they would recruit people they met at that center, making that location overrepresented in the data. However, RDS acknowledges and adjusts for that potential bias using statistical analysis. For example, participants may be weighted differently when adjusting for bias (Salganik et. al., 2004).
Collecting this data about the outcomes of those affected by the Medicaid scam is vital because it provides the government with information about what resources need to be allocated to help the affected group. Now that the AIHP Medicaid fund has suspended reimbursements to hundreds of providers forcing many to shut down, Native Americans with alcohol use disorders have reduced access to treatment. Through data collection, conclusions can be drawn about where most victims are located in Arizona and their current sobriety. Then, lawmakers can use that data to determine whether there needs to be more targeted treatment programs in some regions of Arizona and where to allocate funding.
The views expressed in this publication are the authors' own and do not necessarily reflect the position of The Rice Journal of Public Policy, its staff, or its Editorial Board.
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Liu, C., Lu, X. Analyzing hidden populations online: topic, emotion, and social network of HIV-related users in the largest Chinese online community. BMC Med Inform Decis Mak 18, 2 (2018). https://doi.org/10.1186/s12911-017-0579-1
Salganik, M. J., & Heckathorn, D. D. (2004). 5. Sampling and Estimation in Hidden Populations Using Respondent-Driven Sampling. Sociological Methodology, 34(1), 193-240. https://doi.org/10.1111/j.0081-1750.2004.00152.x
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