Income Categories and Estimates of Insurance Status and Income

1. Income Categories and Estimates of Insurance Status and Income American Community Survey 2008-2010

2. Income and Insurance estimates relevant to Medicaid Expansion and Exchange Subsidies • Three ACA population categories: 0-138, 138-400, over 400% of federal poverty level. • Under 138% of poverty-AI/ANs are vastly overrepresented and thus many will be eligible for Medicaid. • No asset test • Childless adults covered so 65% of newly eligible will be males. • A % very similar to the general population (40-47%) are in the 138% to 400% of federal poverty level (no cost sharing up to 300%) • A much smaller % of AI/ANs are in the category over 400% of the FPL (13% to 28%) in these 7 states.

3. Lowest ACA poverty category is under 138% of poverty • The following slide displays seven states ranked according to percentage of total Indian population under 138% of poverty • It compares AI/AN population to the all races population • Arizona, Minnesota, New Mexico and Oregon have over 40% of the AIAN population under 138% • Minnesota has by far the greatest relative poverty depravation with a 25% difference in the percentage under 138% of poverty between AIAN and all races. Only North and South Dakota equal this degree of difference between Indian population and the state’s all races pop. • OK and CA are nearly equal to the all races category in the percentage of the population under 138% of the federal poverty level. • These data are consistent with the reported poverty levels depicted in the following table that compares AI/AN income to all races.

6. ACA income category for subsidies 138-400% of FPL • The differential between AIAN and all races is exceedingly small (under 5%) in the seven states despite great variation in the distribution of income between AIANs and total population: The Reason? • The explanation is because so many AIANs are under 138% of FPL not because of similar income distribution. • That said, the subsidies will reach a large number of AI/ANs. • All 7 states are between 40 and 47% of total AIAN population lie in this income category. • Oklahoma has the highest percentage at 47%

9. ACA income category over 400% of Federal Poverty Level • California and Washington have over ¼ their AIAN population over 400% of FPL and thus not eligible for subsidies. • These are states with high cost of living that is not taken into account in determining subsidies. • With the exception of CA and OK the % of the population over 400% differential between AIAN and all races exceeds 10%-In Minnesota 39% of the population is over 400% of poverty compared to just 17% of the AIAN population.

11. Missing Variable: Offers of Employment Sponsored Insurance • There are NO estimates of number of AIANs who will be disqualified from access to subsidies because of access to employer coverage. • AI/AN are subject to the Minimum Coverage Requirement • They are exempt from penalties however. • They are not eligible for charity care if they are not exempt from minimum coverage requirement (many low income are). • If offered coverage that is affordable and meets minimum coverage requirements they are required to accept (and pay for insurance coverage) AND they are not eligible for subsidies in the exchange. This will reduce (perhaps dramatically) the number of currently uninsured AIANs who are eligible for subsidies. • Rather than accept and pay for coverage for themselves or dependents (and therefore will not be eligible for subsidies) AIAN will rely on IHS whenever there is reasonable access to IHS services.

13. References • Health Care Reform, Tracking Tribal, Federal and State Implementation, CMS May 2011 • California Rural Indian Health Board dataset of 2008-2010 American Community Survey. • Health Care Reform: Measuring its impact on the Portland Area’s Uninsured American Indians & Alaska Natives