The debate over health care reform in the United States is framed by the question of who has health insurance and who does not, and the primary goal of recent health care reforms has been to increase Americans’ access to health insurance. Despite having a legal right to health care as part of longstanding treaties and laws, many American Indians and Alaska Natives still lack access to health coverage.
Since the Snyder Act of 1921 which later became known as the – indian citizenship act of 1924…
So the simple answer to why this topic is about Beyond protecting the sovereign rights of AIANs, disease prevalence is a key driver for the conversation of access to this population group.
ALAN OTHER: heart disease Cancer unintentional injuries stroke Obesity chronic renal failure mental health issues
TARA The Affordable Care Act benefits American Indians and Alaska Natives because they will have more choices for their healthcare. If they have access to IHS, they can still go to IHS because the law makes IHS permanent. If they want to enroll in Medicaid, more people will qualify based on income. If they want to purchase health insurance, it will be more affordable and prices will be lower because of new Affordable Insurance Exchanges. If they work for a tribe or tribal program, they may have access to the FEHB. Expanded Third Party Funding Updates current law regarding collection of reimbursements Contract Health Services – funds used for direct care (substance abuse treatment, inpatient hospitalization, etc.) outside of IHS and tribal health care facilities or supplementation of alternate resources (Medicare or private insurance). Prior to reauthorization funds ran out quickly. It is used as a payor of last resort and was utilized often by those who lacked insurance. With more AI covered by some form of health insurance, more contract health dollars will be available. Federal Employees Health Benefits Program – Beginning in 2012, Indian tribes and tribal organizations (those carrying out programs under the Indian Self Determination and Education Assistance Act and Title V of IHCIA) had the option to purchase federal health insurance for employees that is used by over 8 million federal civilian employees. This allows for access to insurance with potentially more comprehensive coverage. Exempt From Penalty – exempt from the individual responsibility payment for not complying with the requirement to maintain essential insurance coverage.
MEAGHAN IHS reports on the quality of care it provides patients for the Government Performance and Results Act (GPRA), which is the same as the VA, DHHS, etc. In 2012 IHS reported on 21 GPRA and three other clinical performance measures. The report went to the Office of Management and Budget (OMB) and Congress. Title III (a)(3015) authorizes the Secretary to award grants and contracts to eligible entities to support efforts to collect and aggregate quality and resource measures. IHA and tribal health programs are eligible entities. Title III (a)(3501) provides grants to identify, develop, evaluate, disseminate, and provide training for quality improvement practices in the delivery of health care services . Qualifying entities include Federal IHS programs and health programs operated by tribes. There are specific provisions for specific language related to cultural competency issues . Title III (f)(5507) HHS Secretary and Dept of Labor Secretary are able to award demonstration projects designed to give eligible individuals the opportunity to obtain training and education in high demand health care fields . Secretary must award at least three grants to an eligible entity that is an Indian tribe, tribal organization, college, or university. http://www.ihs.gov/PublicAffairs/DirCorner/docs/Affordable_Care_Act_Provisions_Summary.pdf
The Medicaid expansion is particularly critical for those Native Americans who do not have easy access to an Indian Health Service (IHS) or tribally-run facility. Most IHS facilities are located in reservations, making them inaccessible to those who reside outside reservations. In 2009, an estimated 43 percent of American Indians and Alaska Natives lived outside of areas served by the HIS
TARA U.S. Government – increase budget to $4.42 billion ($116 million increase from 2012 budget)
AI/AN ARE A MEDICALLY, SOCIALLY ISOLATED AND VULNERABLE POLUATION WHOSE SPECIFIC MEDICAL CARE WILL BE AFFECTED BY THE ACA, POTENTIALLY IN POSITIVE WAYS: Challenges: Even though the expansion of payer and insurers are increasing, the AI/AN population may not have the economic resources to take advantage of the opportunity to access medical care If certain rural hospitals are unable to meet certain quality or patient metrics, they become in jeopardy of being closed which leaves the population further medically vulnerable Because states are able to opt-in or –out of the ACA Medicaid Expansion, this leaves the 21% of AI/AN Medicaid recipients further vulnerable to limited medical support systems. Opportunities:- -Increase in payers and insurer options allow funds to be more readily available -INCREASED PROGRAMING TO CREATE AND EVALUATE EFFECTIVE CARE TO AI/AN THROUGH THE IHCIA Reauthorization -If hospitals who serve AI/AN are able to meet the quality metrics, they have an opportunity to receive the government incentives to off-set the uncompensated costs -The permanent reauthorization allows for permanent funding in the future
CONTRIBUTORS: ALAN BURKE, MEAGHAN CONLISK, RYAN
PARKER, TARA ROBINSON
HAD 553 SPRING 2013
The Hope for
Native American Health
Opportunities and Challenges to Improve Health Outcomes
through the Affordable Care Act
Why is this important?
As future healthcare administrators, it’s important…
To examine the U.S. healthcare system's attempt
and promise to ensure adequate and quality access to
care for all Americans.
To better understand these challenges and
opportunities to improve Native American health
access, costs, quality, and outcomes.
Overview of American Indian & Alaska Native (AIAN) in U.S.
Basics of Indian Health Services (IHS) & Healthcare Coverage
Basics Cultural & Tribal Implications
Indian Healthcare Improvement Act (IHCIA) of 1976 &
Affordable Care Act (ACA) Implications
IHS & ACA programs
Federal Funding Shifts
Impact of the ACA on Costs
Conclusion & Key Conclusions
Indian Health Service (IHS)
Established in 1955 by the Public Health Service (Department of DHHS)
Mission: to raise the physical, mental, social, and spiritual health of
American Indians and Alaska Natives to the highest level.
Goal: to assure that comprehensive, culturally acceptable personal and
public health services are available and accessible to American Indian
and Alaska Native people.
Foundation: to uphold the Federal Government's obligation to promote
healthy American Indian and Alaska Native people, communities, and
cultures and to honor and protect the inherent sovereign rights of Tribes.
IHS Operational Overview
Budget FY 2012
HHS total budget: $822.7 billion
IHS budget appropriation: $4.3 billion
Restricted to clinics or hospitals on reservations
Restricted to providers who contract with HIS
Mostly Primary Care Services—some Ancillary and Specialty Services
Members of 566 federally recognized Tribes
2 million American Indians and Alaska Natives residing on or near reservations
Annual Patient Services (Tribal and IHS facilities):
Inpatient Admissions: 48,575
Outpatient visits: 12,772,553
Dental Services: 3,736,054
Access to Care
Ambulatory Care Sites,
(Reservations or Contracted Facilities)
The Urban Indian Health
Health Disparities Among AI/AN
AI/AN more likely to die…
• 500% higher from tuberculosis
• 519% high from alcoholism
• 195% higher from diabetes
• 79% higher from suicide
• 40% higher risk from AIDS
• 20% higher from cervical cancer
• 30% higher from prostate cancer
…than their non-AI/AN counterparts
Cultural Considerations for Medical Care
Strong links between medicine and religion
The clinician patient relationship must be
sympathetic in understanding the patients
spirituality, if the patient does not feel this is
happening they are not likely to return.
Use of traditional healers restore balance with
simple ceremonies with prayers and chants.
Culturally Sensitive Educational Materials
uses animals to promote healthy eating and exercise choices
promote traditional foods by sustainable ecological approach
Indian Healthcare Improvement Act of 1976
The Indian Healthcare Improvement Act (IHCIA) is
the cornerstone legal authority for the provision of
health care to American Indians and Alaska Natives
Expired in 2000, but was made permanent as part
of the Patient Protection and Affordable Care Act.
How does the ACA relate to the IHCIA?
IHCIA 2010 compared to IHCIA 1976
Enhancement of the authority of the IHS Director in DHHS
Reimburses for extended continuum services
(SNF, Hospice, HCBS, NH, etc)
Encourages partnership with VA and Dept of Defense
Establishes a Community Health Representative program to
train and employ AI/AN to provide health care services
Establishes a comprehensive behavioral health, prevention,
and treatment programs for AI/AN
How does the ACA relate to the IHCIA?
Updates current law regarding collection of reimbursements
from Medicare, Medicaid, and CHIP
Improvements in Contract Health Services
Access to Federal Employees Health Benefits Program
Exempt from the penalty for not purchasing health insurance
IHS Programs Supported by ACA
Title III (a)(3015) : grants support efforts to collect and
aggregate quality and resource measures.
Title III (a)(3501): provides training for quality improvement
practices in the delivery of health care services. There are specific
provisions for specific language related to cultural competency
Title III (f)(5507): eligible individuals the opportunity to
obtain training and education in high demand health care fields.
Secretary must award at least three grants to an eligible entity
that is an Indian tribe, tribal organization, college, or university.
Federal Shifts: IHS Budget Increase
$124 Million (2.9%) Increase for FY ’14
$35 million to help purchase health care from the
private sector through the Contract Health Services
program, which is under proposal to be called the
Purchased/Referred Care program
$77.3 million to support staffing and operating costs at
new and replacement facilities
$5.8 million to fund contract support costs incurred by
tribes in managing their own health programs.
Federal Shifts: Medicaid Expansion
Focus on: Indian Country States with Highest Prevalence of AIAN
= Expanding = Not Expanding
How does the ACA effect costs of
care to AI/AN?
AI/AN Tribal Consultation Outcomes
Affordable Insurance Exchanges
No Cost-Sharing or Co-Payments
Projected Individual Costs
Lower premiums will cost less if you have an income up to
$89,000 for a family of four or $112,000 in Alaska.
No out of pocket costs (copays or deductibles) if AI/AN choose
IHS provider in the insurance network
No out of pocket costs with any health care provider if your
income is under $67,000 for a family of four.
Even though the expansion of payer and insurers are increasing, the AI/AN population may
not have the economic resources to take advantage of the opportunity to access medical
If certain rural hospitals are unable to meet certain quality or patient metrics, they become
in jeopardy of being closed which leaves the population further medically vulnerable
Because states are able to opt-in or –out of the ACA Medicaid Expansion, this leaves the
21% of AI/AN Medicaid recipients further vulnerable to limited medical support systems.
Closing the high prevalence of disease among AIAN will be a major challenge without
ability to regulate public health provisions as a result of sovereign autonomy from the U.S.
Increase in payers and insurer options allow funds to be more readily available
Increased programming to create and evaluate effective care to AIAN through the
permanent reauthorization of the IHCIA
If hospitals who serve AI/AN are able to meet the quality metrics, they have an opportunity
to receive the government incentives to off-set the uncompensated costs
The permanent reauthorization allows for permanent funding in the future