1. Health Care Reform: Measuring its impact American Indians & Alaska Natives In 38 Metro Areas with large Indian Populations Review of Latest 2013 and pre-ACA Data from the American Community Survey on rates of insurance and income distribution for Alaska Natives and American Indians

2. S0201: SELECTED POPULATION PROFILE IN THE UNITED STATES ACS 2013 Release 3 year 2011,2012,2013. Uninsured 2011-2013 American Community Survey 3-Year Estimates Total population Not foreign born No health insurance coverage Not foreign born United States5,208,9624,939,57922.40% 1,106,466 Largest 38 Metros 2,076,896 1,894,227 392,937 Phoenix-Mesa-Scottsdale, AZ Metro Area 127,364123,95926.90% 33,345 Los Angeles-Long Beach- Anaheim, CA Metro Area 180,193152,97520.20% 30,901 Tulsa, OK Metro Area128,165127,67523.60% 30,131 Oklahoma City, OK Metro Area101,41697,75224.90% 24,340 New York-Newark-Jersey City, NY-NJ-PA Metro Area 156,276115,28618.40% 21,213 Albuquerque, NM Metro Area62,16261,60928.00% 17,251 Riverside-San Bernardino- Ontario, CA Metro Area 86,56479,85721.50% 17,169 Dallas-Fort Worth-Arlington, TX Metro Area 88,39881,30720.60% 16,749 Seattle-Tacoma-Bellevue, WA Metro Area 88,87184,70119.60% 16,601 Houston-The Woodlands-Sugar Land, TX Metro Area 61,53752,11224.30% 12,663

3.  2010 Census is official census:  5,220,579 AIAN alone and in combination  2013 ACS estimates:  5.2 million AIAN alone and in combination  of which 4.9 million were born in United States.  1,890,000 total AIAN alone and in combination population in 38 largest Metro areas.  Over 60% of all AIAN live in urban areas.  40% of all AIANs live in the 38 metro areas with the largest AIAN population (alone and in combination). Census: Decennial and Annual American Community Survey

4. 2 main components of ACA relate to covering the uninsured  1. Medicaid Expansion  2. Marketplace Private Health Insurance  Tax Credits to buy Qualified Health Plans  Other elements also reform health insurance to expand non-subsidized health insurance such as eliminating – pre-existing conditions-  Premiums are unrelated to health status 4 4

5. Medicaid Enrollment  360,000-400,000 uninsured are eligible and an additional 140,000 if all states expanded Medicaid. 360,000-400,000 uninsured are eligible  Some expansion States report great success and high take-up rates.  Washington: Estimated enrollment 10,000 actual enrollment 10,000-meeting goal for year one.  Oregon: Estimated enrollment 8,000; actual enrollment 9,000  Medicaid is easier because there is a simple definition of Indian and no cost to enroll 5 5

6. The Port Gamble S’Klallam example of Medicaid Payment Increases  Medicaid Payments up 28% 1 st 6 months of 2014 6 6

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8. Premium sponsorship  Sponsorship is typically when someone pays ALL the premium for eligibles (WA requires this)  Federal regulations approve Tribal Premium Sponsorship Federal regulations approve  Tribe pays for the premium of certain eligible patients  Other organizations, entities, including Urban Indian Organizations could sponsor Other organizations 8 8

9. Marketplace enrollment  Currently estimated 460,000 AIANs (both enrolled and descendants) are eligible for tax credits in the 33 states with federally recognized tribes Currently estimated 460,000 AIANs  Of the uninsured subsidy-eligible (100-300% FPL ) AIAN adults 18-64 years old, ACS estimates that 239,000 do not have access to IHS programs-most are likely Urban Indians  HHS reports 48,000 AIANs have enrolled.  10% or less of those eligible have enrolled in QHPs  So, it’s a Hard Sell 9 9

10.  Your Metropolitan Area  1 st step: How many AIANs are there?  1. ____AIAN alone  2. ______AIAN alone and in combination - most commonly used  2 nd step: What is rate of private and public insurance?  1. _____have private insurance  2. ______of ____ have private insurance (repeat for public)  3 rd step: What is number and rate of uninsured?  1. _____uninsured ( _____) in __metro area for AIAN alone and in combination and____% for AIAN alone. Example: how to use data for impact analysis

11.  4 th step: Determine distribution across 3 income categories.  A. __ under 138% of poverty, B. __138 to 400%, C. ___over 400%  California Rural Indian Health Board developed estimates of distribution of income across these categories and one 138-300% for states and metropolitan areas.  5 th step: Use estimates to provide information needed for planning outreach and education, workforce, facilities, budgets.  6 th step: Remember these are estimates, check with reality as it becomes known, make no assumptions, remember error rates.  Compare your area to your state and to other metro areas so you can adopt, but adapt best practices appropriately. Using data for planning

12. It is a behavioral question how many will remain uninsured in 2014-2019, but this presentation describes the basic components of the insurance equation for AIANs:  What is the Metro AIAN population’s current insurance status?  What is the income of the AIAN population- eligibility for Medicaid or Exchange subsidies?  Is IHS available as an acceptable (however inadequate) alternative to health insurance? How many AIANs will remain uninsured in Metro Areas in 2014 – 2019?

13. The health insurance question asks the respondent to give a separate answer for each member of household regarding health insurance coverage. 1.Employer Sponsored Insurance (ESI) 2.Private, paid by individual 3.Medicare 4.Medicaid 5.Tricare, Health care insure for military and families 6.VA, Veteran’s Administration 7.IHS coverage-not used to compute rates of insurance  Question on insurance is ‘point in time’ or ‘current coverage’ not the coverage in the ‘past year’ asked in some surveys. Questions on the ACS 3-year data (2011-2012-2013 surveys pooled data) released State, County and Metropolitan Area data for areas w/ ≥ 20,000 AIAN alone and in combination

14. ACS question on insurance coverage

15.  Estimates are based on survey samples:  do not have calculated error rates to inform the range of uncertainty in the estimates  three years of data for Washington include more than 6308 responses from self-identified AIANs, over 12,000 for Oklahoma.  As the first set of 3-year estimates, it is relatively new and little research has examined its relative accuracy.  Uninsured is calculated when a respondent answers:  no to all 6 types of health insurance coverage  also, IHS is not considered coverage Limitations of ACS data

17. Estimated Uninsured AIAN in 34 largest Urban Indian Metropolitan Population 402,844 total uninsured for all 34

21. There is a great deal of uncertainty in estimates of newly insured through Medicaid expansion and even greater uncertainty in the number of AIANs who are likely to be newly insured in the health insurance exchange offered plans in 2014.  No effective mandate, no penalties for AIANs who do not obtain insurance.  Reluctance to accept subsidies if income varies due to seasonal income if reconciliation results in a tax bill.  Urban Indians will often not have access to tribal resources for sponsorship, will have higher cost of living, but inadequate income for health exchange plans, and urban programs will need increased funding to serve their needs.  Tribes located in urban areas will not be able to serve Urban Indians if they remain uninsured and Urban Indian Health Programs are not funded to provide uncompensated care for AIANs.  Community Health Center funding has been cut from level authorized and appropriated in the Affordable Care Act. Expect revisions to estimates

22. The impact of Health Care Reform on Urban Indians in Metro Areas 1.Great variation between Metropolitan Areas in health insurance status with some metros exceeded all-races private insurance rates (Dallas, Houston, Los Angeles). 2.AIANs are not subject to minimum coverage requirement’s penalties (no effective mandate) thus fewer will buy insurance. 3.Will involve many AIANs who do not have access to Indian Health Services funded services for care if they choose not to purchase insurance. 4.Urban Indian Health Programs already unable to provide health care for their Urban Indian Communities will only benefits from ACA if AIANs enroll in Medicaid or Exchange Offered health plans 5.Will involve over 400,000 AIANs who are uninsured and living in the nation’s 38 largest urban Indian Metros. 6.Exchange will involve a large number who will be eligible for subsidies and waiver of cost sharing (100 to 300% of poverty). Overall Assessment

23.  Uninsured American Indians and Alaska Natives with Incomes 133% to 300% of Poverty: Data for Health Insurance Exchange Outreach, 2011, California Rural Indian Health Board  Centers for Medicare and Medicaid: Health Care Reform: Health Care Reform: Tracking Tribal, Federal, and State Implementation Centers for Medicare and Medicaid: Health Care Reform: Health Care Reform: Tracking Tribal, Federal, and State Implementation  U.S. Census Bureau. American Community Survey (ACS) 2011,2012,2013, 3 year 2011-2013. American Community Survey accessed through Factfinder2.Factfinder2  Reports based on the Current Population Survey do not include reports on AIANs due to the small sample size. Original data analysis developed by Ed Fox is found at AIAN Health Care Reform Website, Ed Fox, 2014 www.edfoxphd.com. www.edfoxphd.com.  Health Care Reform: Tracking Tribal, Federal and State Implementation. CMS 2011, Ed Fox.  Reports by author on Insurance and American Indians and Alaska Natives Reports by author References

24. Tools for Sponsorship Program Development  National Indian Health Board National Indian Health Board  Tribal Self-Governance Tribal Self-Governance  Tribal Premium Sponsorship for NW Tribes Tribal Premium Sponsorship  AIANs and Health Care Reform, SponsorshipSponsorship  Native ExchangeNative Exchange  Tribalhealthcare.org Tribalhealthcare.org  Marketplace Calculator Marketplace Calculator  State level website information  Alaska Alaska  Washington Washington 24

25. Toolkit  Income Chart Income Chart  Eligibility Eligibility  Tax Reconciliation Tax Reconciliation  Cost Sharing Reductions Cost Sharing  Cost Benefit Calculator and Cost-Benefit Discussion Cost Benefit Calculator Cost-Benefit Discussion  Urban Indian Sponsorship Urban Indian Sponsorship  Direct Service Tribes Direct Service Tribes  Sample Sponsorship Policies (2014 version) Sample Sponsorship Policies (2014 version) 25