Health Reform 101 National Tribal Health Reform

Implementation Summit April 19, 2011

Jennifer CooperLegislative Director, National Indian Health Board

Jcooper@nihb.org

Today’s Presentation

What Health Care Reform Means for American Indians and Alaska Natives Reason for Indian specific provisions Major Indian Specific Provisions IHCIA

2

Indian Health Care in the United States

Foundation for Health Care: Based on Treaties the Federal Trust responsibility and Govt to Govt relationshipHealth Care: Indian Health Service provides health care to American Indians/Alaska Natives (AI/AN) Indian Health Service is not insurance –

public health delivery system

Need for Indian Specific Provisions in Health Reform

Because of the Trust Responsibility to provide health careState of the Indian Health Care Delivery System

Need for provisions in HCR to assure that: 1) Protects the Indian health delivery system &2) Maximizes the ability of Individual Indians and

I/T/U system to benefit from health care reform.

Key Components: Individual Mandate

Objective: Require all Americans to acquire some form of health insurance - includes Medicare, Medicaid, CHIP, private insurance.Deadline: January 1, 2014Enforced through tax penalties. IRS penalties Exceptions for hardships, religious reasons

and Members of Indian Tribes - included to protect trust responsibilities of Federal government.

Key Components: Medicaid Expansion

Medicaid Expansion ALL individuals up to 133% of Federal

Poverty Level in 2014. Estimated to cover additional 16 million

people. Also, cost-sharing for many preventive

services will be eliminated.

Medicaid - Enrollment and access

No Indian specific provisions regarding Medicaid Expansion but

There is still lots to do! As much as 60% of uninsured AI/AN are or will be eligible for Medicaid

DON’T FORGET – The State must consult with Tribes BEFORE making changes to Medicaid. See, Sec. 5006 of ARRA.

Medicaid is a primary source of third party revenue for Indian Health programs.

Projected Outcomes

For AI/AN, 16% have no insurance and another 16% have only IHS

41%

28%

16%

16%

Source of Health Insurance Coverage for Nonelderly American Indians and Alaska Natives, 2006-2007*

Employer

Medicaid and Other Public

IHS

Uninsured

* Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009. Figures may exceed 100% due to rounding.

8

Projected Outcomes

Uninsured AI/AN are primarily lower-income

9

0

100,000

200,000

300,000

400,000

500,000

600,000

Total = 527,000

231,880 / 44%

73,780 / 14%

57,970 / 11%

126,480 / 24%

36,890 / 7%

Nonelderly American Indians and Alaska Natives Who Are Uninsured or Only Have IHS by Poverty Level, 2006-2007*

400%+

200 - 399%

150 - 199%

100 - 149%

< 100%

* Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009

Key Component: State Based Insurance Exchanges

Marketplace for information on health insurance products offering acceptable coverage. January 1, 2014 Subsidies available for individuals in Exchange. Subsidies on a sliding

scale for individuals up to 400% FPL.

Major Provisions: ACA

Indian-Specific Exchange ProvisionsEnrollment: All Indians can enroll on a monthly basis, rather than during annual 2 month periodI/T/U Clients: No cost-sharing by AI/AN clients for services provided by IHS, Tribal or urban Indian program, or CHSCost Sharing: Indians at or below 300% FPL will have no cost-sharing under a plan offered through the ExchangeI/T/U Providers: All I/T/U providers are able to bill health plans for reimbursement The amount is the higher of a) reasonable charges billed

or b) highest amount plan would pay to other providers

11

Cost Sharing

If between 300% and 400% of Federal Poverty Level Subsidies (through advance tax credits paid

directly to plans) are available for all Americans

Why Should Indians Be Enrolled in a Plan Can be used to acquire services that the I/T/U

cannot provide Insurance payments to the I/T/U for services it

does provide Reduces costs to contract health services

program

Tribally-provided Health Care Benefits

New law excludes value of health insurance and services provided to a tribal member by IHS or tribe from individual member’s gross income

Exclusion was high priority for Indian Country IRS had said tribally-provided health insurance

was taxable to individual tribal memberEffective March 23, 2010“No inference” on whether such benefits provided prior to enactment are or are not excluded from member’s gross income

Payer of Last Resort

IHS’s regulation making IHS, tribal programs the payer of last resort law!Impact: Any other insurance coverage carried by Indian patient is required to pay first Maximizes authority to collect third-party

revenues– Medicare, Medicaid, CHIP, private insurance

Reauthorization of the Indian Health Care Improvement Act

Indian Health Care Improvement Act (1976 –

2000)

Enacted September 30, 1976 Public Law 94-437 US Code citation: 25 USC

§§1601-1680

Reauthorized often between 1977-2000 Last reauthorization thru

September 30, 2001 (PL 106 – 568)

Road to Reauthorization – 2009-2010

2009: New IHCIA reauthorization bills introduced in House and Senate and eventually included in broader health reform bill

2010: Senate version of health reform & IHCIA passed and enacted – (See Sec. 10221 of Patient Protection and Affordable Care Act which reference to S.1790) Enacted March 23, 2010 Permanent reauthorization, but can be amended (Sec. 825) Over 85 new/revised provisions Authorized programs are subject to annual

appropriations

The Unfolding Story…

Now, the tasks at hand are to – Ensure that the law is successfully

implemented to meet the needs of AI/AN Work to gain sufficient funding

(appropriations) for authorized but-not-yet funded programs

18