1. Health Care Reform: Measuring its impact 12 States with Large Indian Populations CALIFORNIA Health Care Reform: Measuring its impact 12 States with Large Indian Populations CALIFORNIA American Indians & Alaska Natives Based on Data and Analysis from the American Community Survey by the California Rural Indian Health Board July 2, 2012 Review of new data from the 2008-2010 American Community Survey on rates of insurance and income distribution for Alaska Natives & American Indians 12 STATE ACA AIAN DATA PROJECT ACA/AIAN 12

2. Example: how to use data for state level impact analysis Your state______ 1 st step: How many AIANs are there?  1. ____AIAN alone-not typically used, but relevant  2. ______AIAN alone and in combination - most commonly used 2 nd step: What is rate of private and public insurance?  1. _____have private insurance (employer and individual)  2. ______of ____ have private insurance (repeat for public) 3 rd step: What is number and rate of uninsured?  1. _____uninsured ( _____) in ____state for AIAN alone and in combination and____% for AIAN alone. When we say rate, we typically mean percentage-this standardizes a measure for comparison between states with various AIAN populations

3. Using data for planning 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. This project utilizes that database and compiles relevant categories for analysis. 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 state to other states so you can adopt, but adapt best practices appropriately. If most of your states’ Indian population is in category A (like South Dakota)-you may focus on Medicaid, if it is B you would focus on exchange and if C you have to convince high earners to purchase care.

4. How many AIANs will remain uninsured in 2014 – 2019? 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 state’s AIAN population’s current insurance status?  What is the income level of the AIAN population?  Is IHS available as an alternative to health insurance?  Will some tribes be able to sponsor (pay for) insurance offered in the health insurance exchanges?

5. Nationally: 2,352,932 or 48% w/ Private Insurance; 1,692,375 or 35% w/ Medicaid or Medicare; and 1,157,179 or 24% uninsured 2010 Census official US population:  5,220,579 AIAN alone & in comb. (alone & multiple races incl. 300,000+ foreign born who self report as AIAN)  2,932,248 alone (single race reported as AIAN) ACS has the best state level estimates of income & insurance 2010 ACS estimates: 4.9 million AIAN alone & in comb. of whom 4,676,933 were born in United States Census: Decennial and Annual American Community Survey Census: Decennial and Annual & American Community Survey

6. California’s AIANs An estimated 132,000 (~20%) AIANs are uninsured in California An estimated 132,000 (~20%) AIANs are uninsured in California Nearly 55,000 of the uninsured are under 138% of poverty and undoubtedly will be eligible for Medicaid in 2014 Nearly 55,000 of the uninsured are under 138% of poverty and undoubtedly will be eligible for Medicaid in 2014 Another 60,000 are between 138% and 400% of poverty and likely eligible for subsidies to purchase health insurance through the exchange Another 60,000 are between 138% and 400% of poverty and likely eligible for subsidies to purchase health insurance through the exchange California American Indians face the nation’s highest cost of living that is not factored into determining eligibility. They are higher income, but may have less discretionary income than AIANs in other states. Revisions to the ACA should reflect cost of living differences.

7. Medicaid 26% Medicare 11% Employer 48% Individual 6% IHS 9% Uninsured 20% California: Uninsured, IHP access to services, & insurance coverage

8. State level impact analysis - California 1 st step: How many AIANs are there? 662,000 estimated AIAN alone & in combination 2 nd step: What is rate of private insurance? 54% 350,000 AIAN alone & in comb. have private insurance 3 rd step: What is number and rate of uninsured? 132,000 (19%) uninsured 4 th step: Determine income distribution of uninsured across 3 income categories.*  42% under 138% of poverty, 55,000  45% 138 to 400%, 60,000  13% over 400%, 17,000  5 th step: Use estimates to provide information needed for planning outreach & education, workforce, facilities, budgets for all. 6 th step: Remember these are estimates, check with reality as it becomes known, make no assumptions, remember error rates. * It is possible, but not easy, to get rates of uninsured for each category. ** Some of the 33% under 138% of poverty are now insured under early expansion bridge waiver for basic health.

9. Income Distribution of AIANs

10. % AIANs under 138% FPL California will have a smaller percentage of AIANs in Medicaid Expansion far fewer than SD, ND, AZ

11. CAL AIANs have an income distribution closer to all races population than most states Comparison of % of Al/AN population to All Races with income over 400% of Federal Poverty Level (American Community Survey data 2008-2010)

12. Relative Poverty of California’s AIANs far less than other states with large Indian populations Comparison of % of AI/ANs under 138% of Poverty to All Races under 138%

13. % Income distribution of Uninsured AIANs in CAL depicts more (45%) in the exchange subsidy range (138-400%) than states of MN, OR, WA

14. Income distribution of Uninsured AIANs in CAL …CA depicts more (45%) in the exchange subsidy range (138-400%) than states of MN, OR, WA

15. The American Community Survey The American Community Survey Three-year data 2008-2010 surveys pooled data released 10/27/11, w/ add’l releases Dec. ’11  State, County, and Metropolitan Area data for areas w/ ≥ 20,000 AIAN alone & in comb.  Health Insurance data partially available (most reliable data thus far for AIANs – question on health insurance first asked in 2008, allowing 1 st time 3-yr data is avail.)  Current release does not report Medicaid or Medicare separately, but as public coverage  In addition it includes, for the first time, information on the perception of IHS ‘coverage’ and Income distribution for AIANs:

16. Questions on the ACS The health insurance question asks the respondent to give a separate answer for each member of household regarding health insurance coverage, including: 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. It is generally believed that Medicaid is underreported.

17. Limitations of ACS data Estimates are based on survey samples:  do not have calculated error rates to inform the range of uncertainty in the estimates  However, three years of data for Oklahoma have over 10,000 responses and Washington’s data includes more than 6300 responses from self-identified AIANs As the first set of 3-year estimates, it is relatively new and little research has examined its relative accuracy. Example: there is some evidence that it underestimates Medicaid coverage by a couple points Uninsured is calculated when a respondent answers:  no to all 6 types of health insurance coverage  Note: IHS is not considered coverage

18. ACS & Urban Indians Arizona, Alaska, California, Oregon, Oklahoma, Minnesota, New Mexico, and Washington all have very large Urban Indian populations. ACS has income and insurance data for metropolitan areas in each of these states. In addition, County level, data is available for Arizona, California, Oklahoma, New Mexico, and Washington.

19. 2014 expansion depends on number of AIANs already receiving health care services through… Or are… Estimating the impact of health care reform on AIANs 1. Private insurance, many are surprised at how much experience AIANs have with Private Insurance in some states (CA, OK, TX,) 2. Public: Medicaid (800,000), Medicare (200,000) 3. Military, Veteran’s Administration 4. Indian health services 1. Uninsured 2. Underinsured, or whose co- pay/deductibles are too high for current income FOR THOSE NEW TO INDIAN HEALTH PROGRAMS, PLEASE NOTE: There are many AIANs with access to VA or IHS services who currently have no way to pay for their needed health care services…uninsured, underinsured (or in Indian health programs, hereafter IHPs, who can’t pay for patient referral care due to shortages of CHS funding or shortages of Urban Indian Health Care Program funding).

20. Metropolitan California Uninsured SubjectUninsured % Uninsured Los Angeles-Long Beach-Santa Ana, CA Metro Area 29,82520.1% Riverside-San Bernardino-Ontario, CA Metro Area 16,96219.8% San Francisco-Oakland-Fremont, CA Metro Area 11,48119.2% San Diego-Carlsbad-San Marcos, CA Metro Area 13,31127.5% Sacramento--Arden-Arcade--Roseville, CA Metro Area 7,02314.1% Fresno, CA Metro Area 4,13221.1% Oxnard-Thousand Oaks-Ventura, CA Metro Area 5,10725.8% 87,840

21. American Community Survey Health Insurance Data: 3-year Estimates for AIANs Alone & in Combination (2008-2010)

22. Estimated Population AIAN alone and in combination

23. Percentage of AIANs covered by Private Insurance

24. Slightly less than half of all AIANs are covered by private insurance (48%), under 2.5 million. Just over half (54%) of CA AIANs have private insurance AIANs covered by Private Insurance

25. There are no good estimates of ‘take up’ rates and one should not infer that a high percentage on this chart implies high take up rate. % receiving Public Insurance (Medicare and Medicaid)

26. The October 27, 2011 release of 3-year ACS data combined Medicaid, CHIP and Medicare. Medicaid/CHIP and Medicare will be reported separately in later releases.

27. Insurance status of AIANs varies greatly from Non-Indians across the nation and across individual states.

28. Respondents are asked if they have IHS coverage, but it is not considered ‘insurance’ coverage. That is, if respondent only answers IHS they are considered uninsured. Medicare and Medicaid, however, are counted as insurance coverage. 20% California uninsurance rate is ~½ that of New Mexico, but is over 3 times that of Massachusetts.

29. Expect revisions to estimates There is a great deal of uncertainty in estimates of newly insured through Medicaid expansion. There is even greater uncertainty in the number of AIANs who are likely to be newly insured in the health insurance exchange offered plans in 2014.

30. Overall Assessment: California Impact factors of Health Care Reform in California: 1. Large AIAN population (largest in the nation) thus will experience greater impact 2. Many CA AIANs do not have access to Indian Health Services (only ~20% have access, low compared to other states w/ large AIAN populations) 3. ~130,000 CA AIANs are uninsured w/ > 87, 000 AIANs living in larger urban centers 4. Lack of a cost of living adjustment in determining either income or eligibility will likely result in fewer CA AIANs eligible for Medicaid Expansion than most states 1. More uninsured CA AIANs are over 400% of poverty than under 138% of poverty 2. Many CA AIANs above 400% of poverty (particularly in Metropolitan Areas) cannot afford insurance due the high cost of living

31. Overall Assessment: California Continued Impact factors of Health Care Reform in California: 5. Large number of CA AIANs w/ up to 400% poverty will be eligible for: 1. subsidies for the CA Exchange and the waiver of cost sharing (those up to 300% of poverty), but 2. very few will have tribal sponsors since 80% are from tribes from out of state. 6. Will need to consider gathering information not currently known about Employer sponsored insurance, tribal participation in sponsoring insurance, essential community providers, essential benefits, and a possible basic health plan.

32. Overall Assessment: California Continued Impact factors of Health Care Reform in California: No effective mandate, no penalties for AIANs who do not obtain insurance.  Reluctance to accept subsidies if income varies due to seasonal income from fishing or other subsistence activity if reconciliation results in a tax bill.  Inability of many tribes to afford sponsorship of tribal members.  Urban Indians often do not have access to tribal resources for sponsorship and have a higher cost of living. Many will likely have 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 in 2014 if they remain uninsured and Urban Indian Health Programs are not funded to provide uncompensated care for AIANs.

33. Income Distribution for AIANs Income distribution relevant to health care reform Source of Income Distribution Data is from published and unpublished data from the California Rural Indian Health Board Additional analysis and recompilation into insurance and income tables for 12 states by Ed Fox and Verné Boerner. 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

34. References 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) 2008,2009, 2010, 3 year 2008-2010. American Community Survey accessed through Factfinder2 for 3 year reports for years 2008, 2009, 2010.Factfinder2 Agency for Healthcare Research and Quality (AHRQ), Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey-Insurance Component (MEPS- IC). Table II.A.2 (2009), available at http://www.meps.ahrq.gov/mepsweb/data_stats/summ_tables/insr/state/series_ 2/2009/tiia2. pdf Reports based on the Current Population Survey do not include reports on AIANs due to the small sample size. This was even true for the State of California’s recent Employee Benefit Research Institute estimates (in California Health Almanac; California’s Uninsured, December 2011) for race/ethnicity based on the CPS--- despite the largest in the nation AIAN population of over 800,000 in 2010.