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Health Care Reform: It’s Impact on Tribes and Indian People. Problem Definition . It appears our health care problem has been defined as high rates of uninsured that have increased every year for two decades.
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Problem Definition • It appears our health care problem has been defined as high rates of uninsured that have increased every year for two decades. • Health Care Reform attempts to reduce the rate of uninsurance for the legally resident population and begin the discussion on how to be healthier at lower cost. • It turns out that AIANs have the highest rates of uninsurance in the nation. • So, on the face of it HC Insurance Reform seems like a good thing! Another good idea for Indian people!
Definition of Indian • It has become very imprecise, but it is more important than ever-as we always knew it would be with universal health care. Who is eligible and what are you eligible for? • For most Americans the question is what type of coverage are they eligible to receive? Employer paid, Medicaid, Exchange, Medicare. • There are many special provisions for Indians and the legislation uses many terms, sometimes tribal member, some times urban Indian, sometimes simply Indian to say who is eligible for protection from cost sharing, ability to use IHS and Tribal health programs, waiver of penalty from individual mandate, and others.
Definition of Indian • NCAI has adopted a resolution supporting a broad definition that includes anyone considered an Indian by federal agencies like BIA, IHS, or Interior or HHS depts. • It is the definition promulgated by Centers for Medicare and Medicaid in reference to who does not have to pay cost sharing for the Medicaid and CHIP programs. • Census: Respondent can answer Alaska Native or American Indian (but could be from Latin America). They can designate principal tribe, but large percentage do not. Respondent can also answer AIAN in combination with other races-and millions do answer it this way. 3,151,284 alone 4,960,643 in combination (see next slide). • The two added together (alone and in combination) are typically added together and used for most statistics, but it is important to know which is being used.
2009 Population Estimates for American Indians and Alaska Natives (Current Population Survey)
2009 Rate of Uninsurance (29%) for Various Population Groups AIAN (alone)
AIAN Alone or In Combination compared to All racesHealth Insurance Coverage 2009
20 States Totals and Percentage of overall population, and Medicaid enrollment and spending 2007-2008
20 state study of the Impact of Health Care Reform on Tribes and Indian People
The rate of health insurance coverage varies widely • The uninsurance rate varies from 15% to 42.9% across the 20 study states • Massachusetts 15%, Wisconsin 16.8% • Montana 43% and New Mexico 39% uninsured • If we exclude Children and look at the 18 to 64 year olds the uninsurance rates are very high indeed 18% Mass to 57% in Montana for adults under 65, not eligible for Medicare.
AI/AN 2009 Percentage Uninsured Alone or in combination AI/ANsAll ages: IHS is not considered coverage
Medicaid very important to all Areas of the IHS • Next three slides show: • 2004 Payments for IHS users paid by Medicaid to IHS programs and other providers for the same patients • 2004 Payments by Area compared to the IHS alllowance • 2008 Payments for all AIANs by state
2004 Comparison of IHS Allowances for Health Care Services to Medicaid Payments for AI/ANsBy Area Office of IHS
Access to IHS programs for the very poor • Perceived access to IHS-funded services varies widely across the states • These responses are those of AIANs who were uninsured and were under 133% of poverty in response to the question about access to IHS services. • 10% in Utah said they have access compared to 90% in Alaska
Responses of AI/ANs under 133% of Poverty and Uninsured Access to IHS services or Without Access to IHS Coverage Ranked by Access to IHS Coverage as Reported by Respondents to the American Community Survey
Estimating Medicaid Expansion • Medicaid will expand by over 250,000 AIANs in the 20 study states • With aggressive outreach it could top 300,000 • Expansion will vary greatly by state • The second slide shows the range of increase from a high of over 88% in Nevada and 80% in Oregon to just 22% in Arizona with enhanced outreach (only 7% in AZ with standard outreach)
Estimated Medicaid Expansion under three scenarios: Limited Outreach and Enhanced Outreach with 2008 baseline and Enhanced Outreach with 2009 Baseline
Estimating subsidies in Health Insurance Exchanges • 21% of the AIAN population (alone or in combination) is over 400% of the FPL compared to 43% of the white population. Range: 11% SD to 35% CA • 35% of the AIAN population is between 139% and 400% • 37% of the White population is between 139% and 400% • Why is AIAN less in the category 139 to 400% of FPL than white? Answer because 45% of AIANs are under 139% of federal poverty level compared to 20% for whites.
Will AIANs participate in health insurance exchanges? • The lowest income more likely: 139% of poverty to 250% of poverty will have no copays and little or no premiums. • No cost sharing up to 300% of poverty for all AIANs, but it appears premiums will NOT be considered cost sharing. • The premiums from 250% to 400% will be a large disincentive for participation if an AIAN has the alternative to remain uninsured and get care at an IHS funded program.
Health Exchange Participation • Reasons for predicted low participation • Premiums will ranges from $800 per year to $11,000 per year for a family of four. • Since there will be premiums most programs cannot invoke the ‘alternative resource rule’ and require participation in health exchange plans. • There is no mandate for any AIAN to purchase care • AN AIAN can enroll in any month of the year • Enrollees may have to repay subsidy if their income increases-$600 to $3,000 maximum depending on size of family and size of subsidy. • IHS direct service tribes, less likely to pay premiums????
Estimated Number of AI/AN eligible for subsidies under two scenarios:
20 states overall Distribution of Income Comparing AIANs to All Races
Community Health Centers • CHCs could play a large role in health care reform if the take up rate of AIANs in the Health Exchanges is low • In areas without urban programs now new ones could see AIANs with culturally relevant services to the newly insured or uninsured AIAN urban population. • Some CHC requirements will have to change: Reporting, 24 hour coverage, others??
American Indians and Alaska Natives Community Health Centers 2008
Conclusion • The main thrust of health care reform is to reduce the number of uninsured. This promises to be a positive reform if the 30% rate of uninsurance can be reduced to the hoped for 5% rate. • Medicaid expansion is likely to be well received by Tribes and Indian people since it is familiar, provides protection against cost sharing, and a simplified definition of Indian for the purpose of determining eligibility. All Tribes, IHS and Urban programs will aggressively support implementation. • Health Insurance Exchange subsidies also promise to reduce rates of uninsurance, but the impact will vary according to the steps IHS and Tribes take to inform and otherwise provide support for AI/ANs to obtain the health insurance offerings of Exchanges. • Increased health insurance coverage for AI/ANs will raise significant challenges for Indian health programs that will require protective regulations to insure AI/ANs can choose these programs as their medical home, receive fair payment for services rendered, and inclusion in systems that support coordinated care.
