Key Questions for Analysis of Qualified Health Plan Enrollment.

1. AIANs in Medicaid and QHPs: DRAFT Ed Fox, Director, Health Services, Port Gamble S’KlallamTribe August, 2014 American Indian and Alaska Native Enrollment in Medicaid and Qualified Health Plans (with Washington State as an example), Summer 2014

2. Key Questions for Analysis of Qualified Health Plan Enrollment. • How many AIANs are eligible for Marketplace Plans? • Well over 500,000 of the 1.2 million uninsured nationwide • Some are eligible for exchange plans, but not eligible for tax credits • How many are eligible for tax credits (under 400% FPL) ? • Most AIANs are (500,000) with over 460,000 in the 33 states with federally recognized tribes • Of those eligible for tax credits how many are under 300% of FPL? • 377,000 eligible for tax credits are under 300% • How many uninsured AIANs under 300% of FPL are not eligible for tax credits because spouse has insurance through employer. This reduces the number (377,000) estimate. • How many have individual or group plans that do not meet minimum coverage (MEC).

3. Qualified Health Plans • Take-up rate expected to be lower than general population • 1. Negatively related to ‘access to IHS-paid services’ more access lower take-up • 2. Positively related to ‘enhanced outreach and education’ • 3. Complicated by Website ‘glitches’ • 4. Premium Sponsorship not widespread-not clear that it is solution to low take-up.

4. Idaho(134%) and Washington exceeded QHP enrollment goals (111%), Oregon lagged with 73% of projected. Urban Institute, May 2014

5. Est. Number AIANs eligible for tax credits

6. Est. 55,000 AIANs have selected QHPs with 48,000 AIANs in FFM states and over 5,000 state exchanges. Not all state exchanges have reported AIANs California, 4,300 Wash, 1,100 NY, 425

8. Medicaid • Take-up rate expected to be much higher than for QHPs • 1. No premiums, no cost share • 2. Much simpler Indian status determination (self-attest). • 3. Positive upward spiral as more funds become available • 4. Complicated by Website ‘glitches’ and by ‘access’ to specialists

9. Key Questions for Analysis of Qualified Health Plans: Washington State Example • How many AIANs are eligible for Marketplace Plans? • 20,000 to 25,000? • Some are eligible for exchange plans, but not eligible for tax credits • How many are eligible for tax credits? • 17,000 to 20,000 • Of those eligible for tax credits how many are under 300% of FPL? • In Washington, Children under 300% of FPL are not eligible for tax credits (CHIP/Medicaid eligible) • About 15-17,000 eligible for tax credits are under 300% • How many uninsured AIANs under 300% of FPL are not eligible for tax credits because spouse has insurance through employer –no estimate-about 50 at the Port Gamble S’Klallam Tribe would be eligible if the tribe ended coverage for spouses. • This is true for many AIAN families where a spouse is a tribal employees • How many have individual or group plans that do not meet minimum coverage (MEC). • 5,000-7,000 have individual plans that they can drop and access tax credits • So we do not know how many are eligible for tax credits with any precision, but about 17,000 to 20,000 is a good estimate that can be revised with experience.

10. Medicaid and QHPs • Goal of increasing Medicaid enrollment generally successful for all races in states that expanded Medicaid. • In states that provided outreach support, like Washington, it has been successful for American Indians and Alaska Natives. • Goal of increasing private insurance(QHPs) enrollment through tax subsidies (tax credits) generally NOT successful for American Indians and Alaska Natives even with outreach support. • Medicaid data and Washington state example follows and then an examination of Qualified Health Plans.

11. Medicaid Expansion a great success for all races in NW: Oregon highest increase at 52% and Washington 35% WA has about 20,000 eligible uninsured; more are income eligible, but have insurance. Take-up rate note; we can’t easily determine how many insured will choose Medicaid

12. 10,000 newly insured in Medicaid. In counties with higher access to IHS, take up rates are much higher.

13. 75% of the 10, 000 remaining uninsured live in 10 counties, 40% Seattle Metro Area

14. Unlike Medicaid, that exceeds many estimates, QHP enrollment very low. • Determining how many are eligible for tax credits is not easy as there are many variables to consider. • For this report eligibles are those ‘uninsured’ who are between 100% and 400% of FPL in non-Expansion states and those between 139% and 400% in Expansion states. • Nationally • 3% of Eligible AIANs enrolled in a Qualified Health Plan • No state has more than 10% of eligibles enrolled • Only 5 states have between 1000 and 2,000 enrolled. • Washington • 1,110 enrolled • 17,000 to 20, 000 eligible

15. Most AIANs enrolled in QHPs are from tribes outside Washington • 429 report membership in Washington State Tribes • 681 from tribes outside Washington • The majority of Washington AIANs are not members of WA tribes, but the exact number is not known-195,000 AIANs and about 70,000 are members of WA tribes. • 151 are Alaska Natives enrolled in qualified health plans • The members of the Alaska Native Tribal Health Consortium has begun a pilot program to sponsor up to 1,000. • ½ of all Alaska Natives who live outside Alaska live in Washington over 5,000. • 65% of AIANs in Washington report that they do not have ‘access to IHS-paid services’ ---for them health insurance is a good option since they can’t get comprehensive health care at IHS funded clinics.

16. Highest enrollment: Large Tribes • Tulalip, Colville, Yakama, Cowlitz had highest enrollment in Qualified Health Plans • All were in Priority One in 2013; all expect to be in 2014. • Beyond the obvious; the reasons are unclear…. • 1. All are large tribes (thus more eligible) and • 2. Many tribal members and descendants do not live on reservation so insurance is a good option. • 3. All these tribes experienced health care rationing in 2013 and were on priority one during the year…. meaning care only for ‘life or limb.’ • Some tribal members likely decide buying health insurance is a good option. • 5. None of the tribes with highest enrollment had a tribal premium sponsorship program-a surprise.

17. QHP enrollment of those eligible for QHP and of those eligible for tax credits • Take-up rates in Qualified Health Plans do not follow an easily discernable pattern, but tribes with sponsorship programs seem to have better take-up rates. • Port Gamble S’Klallam enrolled 14 of 18 who were tax credit eligible in this report and have now enrolled 21 of 27 tax credit eligible in QHPs. • It is too early (we are in 8th month of implementation) in the process to make any firm conclusions about ultimate success of Qualified Health Plans for AIANs in Washington • Tribal Premium Sponsorship does offer a model of enrollment success. Source: WHBE May 2014 Data Report

18. Sources: • Centers for Medicare and Medicaid Services, “Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report,” May 1, 2014. • HHS/ASPE Emily R. Gee and ArpitMisra, July 16, 2014 Presentation. • Washington Health Benefits Exchange, April & May 2014 Data Reports • Original data analysis developed by Ed Fox is found at AIAN Health Care Reform Website, Ed Fox, 2014 www.edfoxphd.com . • “How Much Financial Assistance Are People Receiving Under the Affordable Care Act?” Kaiser Family Foundation, March 2014.