Impact of State & Tribal Relations on Data & Indian Health

1. Impact of State & Tribal Relations on Data & Indian Health AI and PH Data Discussions March 15, 2011 Pierre, SD Donald Warne, MD, MPH Oglala Lakota Senior Policy Advisor GPTCHB

2. Overview • American Indian Health Disparities • American Indian Resource Disparities • Role of States in: • Licensure & Certification • Access to Medicaid funding • Access to Block Grant funding • Access to Public Health Initiatives • Strategies for Partnership and Advocacy

3. AMERICAN INDIAN HEALTH POLICY • Do people have a legal right to healthcare in the US? • US Constitution—Commerce Clause (Article I, Section 8)

4. 2009 IHS Expenditures Per Capita and Other Federal Health Care Expenditures Per Capita Per Capita spending in the year for which data are published most recently – see base of each bar. IHSMedical IHSOther 2008 2009 2007 2007 2009 1999 $648 2009 See page 2 notes on reverse for data sources and extrapolation assumptions.

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

6. AI Health Disparities Death rates from preventable diseases among AIs 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

7. AI/AN Cancer Disparities IHS total: 184.1

8. CRC Risk Factors: Non-Traditional Tobacco • Smokers 30-40% more likely to die from colon cancer • Smoking rates in most IHS regions > 40%

9. CRC Risk Factors: Diabetes • Diabetes is associated with a 30% increased risk of colon cancer • 30% of AI/AN over age 55 have diabetes Larsson SC et al JNCI 2005;97:22: 1679-87

10. Diabetes Death Rates (Rate/Per 100,000 Population)

13. Alcohol Related Death Rates (Rate/Per 100,000 Population)

15. Medicaid BH Carveout

16. State of South Dakota Mental Health Medicaid BH Carveout Alcohol & SA

17. South Dakota Medicaid System Title XIX & XXI FundingState Matching $Block Grants (SAMHSA, etc) BH Carve-out DSS DHS Medicaid Mental Health Alcohol & SA Medical Service Providers Community MH Centers Alcohol & SA Treatment Facilities

18. Overview • Role of States in: • Licensure & Certification • Access to Medicaid funding • Access to Block Grant funding • Access to Public Health Initiatives • Strategies for Partnership and Advocacy

19. Overview • Role of States in: • Licensure & Certification • Access to Medicaid funding • Access to Block Grant funding • Access to Public Health Initiatives • Strategies for Partnership and Advocacy

20. Indian Health System 1955-1975 IHS Federal

21. Indian Health System 1975-1985 IHS Federal PL 93-638 Tribal

22. Indian Health System IHS Federal PL 93-638 Tribal AI Healthcare Consumer Medicaid State Health Sector

23. Medicaid Issues continued • States determine Medicaid Plan—even for services covered by 100% FMAP • (e.g. TCM in ND v SD or BH meds in AZ v NM) • States control number of All-Inclusive Rates billed per day (100% FMAP) • (e.g. 3/day in AZ—1/day in SD—changed in 2009!) IHS or Tribal services 100% FMAP State

24. Overview • Role of States in: • Licensure & Certification • Access to Medicaid funding • Access to Block Grant funding • Access to Public Health Initiatives • Strategies for Partnership and Advocacy

25. Access to Block Grant Funding and State Public Health Initiatives • Key HHS agencies (e.g. SAMHSA) distribute funds to the states via Block Grants • States use AI data to acquire Block Grant funding (e.g. suicide rates in SD) • AI communities receive disproportionately less funds than non-Indian communities • PH Initiatives (e.g. Emergency Preparedness) inclusion of tribes varies among states • PH outreach to tribes (e.g. tobacco programs, diabetes programs) varies among states

26. Smoking Disparities by State

27. Traditional Tobacco ≠ Commercial Tobacco Traditional Tobacco Commercial Tobacco

28. Overview • Role of States in: • Licensure & Certification • Access to Medicaid funding • Access to Block Grant funding • Access to Public Health Initiatives • Strategies for Partnership and Advocacy

29. Recommendations • States with federally-recognized tribes should have tribal consultation policies (Medicaid) • Data coordination would benefit both tribes and state—accessing additional resources • Block Grant funding should be linked to reporting requirements and accountability regarding funding reaching tribes (or BG Demonstration Project) • States would benefit from full funding of IHS—decreased Medicaid costs

30. Donald Warne donald.warne@gptchb.org donald.warne@sanfordhealth.org