John Molina, MD, JD Chief Executive Officer Phoenix Indian Medical Center

1. Diversity of Native Americans in the Southwest and Legal ComplexitiesNational Association of Public Health Statistics National Center for Health StatisticsAnnual Conference June 3, 2013 John Molina, MD, JD Chief Executive Officer Phoenix Indian Medical Center

2. Government to Government

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4. Origins of Health Care The federal government acknowledged the responsibility of health care for Native Americans with the first treaties of 1784 1830’s - expanded health care provided by army physicians to curb smallpox and other infectious diseases among tribes living in the vicinity of military posts 4

5. Responsibility of Health Care For more than 200 years, the responsibility of health care for American Indians passed from different government branches: Department of War Bureau of Indian Affairs (BIA) Public Health Service (PHS) Indian Health Service (IHS) Source: Indian Health Service, http://www.ihs.gov 5

6. Source: 2000 U.S. Census 6

7. Ak-Chin Indian Community Cocopah Tribe Colorado River Indian Tribes Fort McDowell Yavapai Nation Fort Mojave Indian Tribe Gila River Indian Community Havasupai Tribe Hopi Tribe Hualapai Tribe Kaibab-Paiute Tribe Navajo Nation Pascua Yaqui Tribe Quechan Tribe San Carlos Apache Tribe Salt River Pima-Maricopa Indian Community San Juan Southern Paiute Tohono O’odham Nation Tonto Apache Tribe White Mountain Apache Tribe Yavapai Apache Nation Yavapai Prescott Indian Tribe Zuni Pueblo (Map Courtesy of the Inter Tribal Council of Arizona, Inc.)

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11. Indian Health Service, Tribally-Operated 638 Facilities and Urban Clinics (I/T/Us) Indian Health Service (IHS) – Federal agency responsible for providing federal health care services to American Indians and Alaska Natives. Tribal “638” Programs and Facilities – Tribes have the option, through contracts, grants, or compacts, to assume some level of responsibility for their own health care programs. These programs are often referred to as “638” programs and facilities (based on the Indian Self-Determination and Education Assistance Act, P.L. 93-638). Urban Indian Health Programs (UIHP) provide culturally competent, non-duplicative health services to more than 150,000 people annually.

12. IHS Areas Portland Billings California Phoenix Nashville Tucson Navajo Oklahoma Alaska Albuquerque Aberdeen Bemidji 12

13. 13 Source: Government of Canada, http://www.aboriginalcanada.gc.ca

14. Patient Protection and Affordable Care Act (Affordable Care Act or ACA) • Signed into law by President Obama on March 23, 2010 • Largely addresses health insurance reforms • Impacts Medicare and Medicaid • Includes the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA)

15. AI/AN Health Care Policy Issue • Ensure that under health reform that the treaty rights of tribes and the trust responsibility of the United States government to provide health care to AI/AN are protected and enhance under health reform

16. Individual Mandate • The law makes nearly all Americans responsible for acquiring or maintaining acceptable health insurance coverage • AI/AN • Law exempts members of the Indian tribes from the tax penalty for failure to obtain acceptable coverage [Sec. 1501(b)]

17. Insurance Exchanges • Law calls for states to operate an Exchange to create a “marketplace” for health insurance products for purchase by uninsured individuals and small businesses • AI/AN • At 300% or below FPL can purchase insurance and no cost sharing [Sec. 1402(d)] • No cost sharing for any service provided at an I/T/U [Sec. 1402(d)] • Can enroll in an Exchange plan on a monthly basis

18. Medicaid Expansion • Medicaid will be expanded to cover individuals under age 65 up to 133% of the FPL • AI/AN • Expansion of eligibility covers Indian people. • IHS beneficiary required to enroll in Medicaid in order to be eligible for Contract Health Services

19. “Express Lane Agencies” • A state can rely on a public agency for a finding of eligibility for an income based program to simply and expedite Medicaid and Children’s Health Insurance Program (CHIP) enrollment • AI/AN • Law adds I/T/Us to the list of public agencies for the purposes of making eligibility determinations for Medicaid and CHIP [Sec. 2901(c)]

20. Tax Exemption • Law amends the Internal Revenue Code to exclude from a tribal member’s gross income the value of health benefits provided by an IHS or an Indian tribe or tribal organization to its members [Sec. 9021]

21. Payer of Last Resort • Law makes health programs operated by I/T/Us the payer of last resort for persons eligible for services through these programs [Sec. 2901(b)]

22. Indian Health Care Improvement Act • IHCIA, Pub. L. No. 94-437, 94th cong. (Sept 30, 1976) • Key legal authority for the provision of health care to AI/AN • Findings of IHCIA “ Federal health services to maintain and improve the health of the Indians are consonant with and required by the Federal government’s historical and unique legal relationship with and resulting in responsibility of the American Indian people.”

23. History of the IHCIA • Snyder Act of 1921 – federal funds for health services to AI/AN • Indian Self Determination Act and Education Assistance Act of 1975, Pub. L. No. 93-638, 88 Stat. 2203 (1975), codified as 25 U.S.C. §§ 450a-450n, and as amended in scattered sections of 25 U.S.C., 42, and 50 U.S.C. – Tribes to govern their own health care and education programs.

24. History of IHCIA • IHCIA enacted in 1976 due to many IHS facilities being “inadequate, outdated, inefficient, and undermanned,” and to “implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation in those programs.” Pub. L. No 94-437, 90 Stat. 400, 94th cong. (Sept. 30, 1976); Ariz. Health Care Cost Containment Sys. v. McClellan, 508 F.3d 1243, 1246 (9th Cr. 2007)

25. History of IHCIA • 1990’s – Draft amendments to IHCIA • 2000 – IHCIA expired but extended to 2001 • Since 2001 Congress held only hearings on various proposals but enacted no substantive changes to IHCIA until the ACA • Permanent reauthorization of IHCIA signed into law under the Patient Protection and Affordable Care Act, H.R. 3590, Pub. L. No 111-148, 111th Cong. (2010)

26. Statement by the President: Reauthorization of the IHCIA • “In addition to reducing our deficit, making health care affordable for tens of millions of Americans, and enacting some of the toughest insurance reforms in history, this bill also permanently reauthorizes the Indian Health Care Improvement Act, which was first approved by Congress in 1976.   As a Senator, I co-sponsored this Act back in 2007 because I believe it is unacceptable that Native American communities still face gaping health care disparities.  Our responsibility to provide health services to American Indians and Alaska Natives derives from the nation-to-nation relationship between the federal and tribal governments.  And today, with this bill, we have taken a critical step in fulfilling that responsibility by modernizing the Indian health care system and improving access to health care for American Indians and Alaska Natives.”  (This statement is available at http://www.whitehouse.gov/the-press-office/statement-president-reauthorization-indian-health-care-improvement-act)

27. Key Provisions of IHCIA • Enhancement of the authorities of the IHS Director, including the responsibility to facilitate advocacy and promote consultation on matters relating to Indian health within the Department of Health and Human Services. • Provides authorization for hospice, assisted living, long-term, and home- and community-based care. • Extends the ability to recover costs from third parties to tribally operated facilities. • Updates current law regarding collection of reimbursements from Medicare, Medicaid, and CHIP (Children’s Health Insurance Program) by Indian health facilities. • Allows tribes and tribal organizations to purchase health benefits coverage for IHS beneficiaries. • Authorizes IHS to enter into arrangements with the Departments of Veterans Affairs and Defense to share medical facilities and services. • Allows a tribe or tribal organization carrying out a program under the Indian Self-Determination and Education Assistance Act and an urban Indian organization carrying out a program under Title V of IHCIA to purchase coverage for its employees from the Federal Employees Health Benefits Program. • Authorizes the establishment of a Community Health Representative program for urban Indian organizations to train and employ Indians to provide health care services. • Directs the IHS to establish comprehensive behavioral health, prevention, and treatment programs for Indians.

28. Challenges: Health Disparities Death rates from preventable diseases among AI/ANs are significantly higher than among non-Indians: Diabetes 208% greater Alcoholism 526% greater Accidents 150% greater Suicide 60% greater Indian Health Service. Regional Differences in Indian Health 2002-2003 28

29. Challenges: Cultural Environment AI/AN populations are diverse, with more than 560 separate tribes and hundreds of languages. There are individual and tribal variations in values and degrees of acculturation to American society. Cultural information that is known on one specific tribe/community is not necessarily applicable to another. Hodge, F., Weinmann, S., and Roubideaux, Y., Recruitment of American Indians and Alaska Natives Into Clinical Trials, Ann Epidemiology 2000;10:S41-S48. 29

30. Centers for Medicare and Medicaid (CMS) • The Medicare and Medicaid programs were signed into law on July 30, 1965. • A component of the Department of Health and Human Services (DHHS) administers: • Medicare • Medicaid • State Children's Health Insurance Program (SCHIP)

31. Arizona Health Care Cost Containment System (AHCCCS) • Medicaid is a federal-state partnership designed by Congress in 1965 to provide health care for low income women, children, the elderly and disabled • AHCCCS covers acute, long term care, and behavioral health services • AHCCCS covers over 1.3 million Medicaid & CHIP members • AHCCCS purchases health care coverage through managed care organizations to cover the general population • The Fee-for-Service Program covers AI/ANs and Emergency Services for qualified immigrants

32. American Indians and Alaska Natives in Arizona Arizona population: 6,266,318 277,732 American Indians/Alaska Natives Source: AHCCCS, October 2010 • AHCCCS members: 1,082,593 • 117,440 AI/AN AHCCCS members 11 % 5 % Source: U.S. Census Bureau, 2010 American Community Survey

33. AHCCCS Enrollment Choices • Native American AHCCCS members have the option to enroll in an acute managed care health plan (e.g., APIPA, Mercy Care) or to select the American Indian Health Program (AIHP) • AIHP members may switch between a managed care plan and AIHP at any time by notifying AHCCCS • Native American AHCCCS Health Plan members may receive services at an IHS or 638 facility

34. AIHP Members Source: AHCCCS, October 2010 IHS/AHCCCS Fee-for-Service 73% Health Plan Enrollees 27% On Reservation 42% Off Reservation 58%

35. AIHP Presenting Issues • Developmental disorders, including reading and language disorders • Diabetes • Chronic renal failure • Acute upper respiratory disorders • Pneumonia • Obstetrics • Cellulitis and abscess of leg • Cesarean delivery • Obstetrical complications • Abnormality in fetal heart rate/rhythm Source: AHCCCS Claims Data, 2007

36. Policy Issues For Native Health • Preserving Choice for Medicaid-Eligible Native Americans. • Protecting IHS, Tribal, and Urban Indian Providers • Enhanced Program Data. The transition toward managed care has led to a decline in the quality of Medicaid program data available to the federal government and the tribes, among others. • Financial Incentives for states to facilitate use of the I/T/U’s. • I/T/U collaborations and partnerships with non-IHS facilities for patients to receive coordinated care.

37. Wopila mi’tiwahe’ Questions/Comments? John Molina, MD, JD (Yaqui/San Carlos Apache) Chief Executive Officer Phoenix Indian Medical Center E-mail: John.Molina@ihs.gov