1. AIANs in Medicaid and QHPs: Ed Fox, Director, Health Services, Port Gamble S’Klallam Tribe May 20, 2014 American Indian and Alaska Native Enrollment in Medicaid and Qualified Health Plans at the End of 2014 Open Enrollment

2. Key Questions for Analysis of Qualified Health Plans: Washington State Example How many AIANs are eligible for Marketplace Plans? 20,000 to 25,000? Some are eligible for exchange plans, but not eligible for tax credits How many are eligible for tax credits? 17,000 to 20,000 Of those eligible for tax credits how many are under 300% of FPL? In Washington, Children under 300% of FPL are not eligible for tax credits (CHIP/Medicaid eligible) About 15-17,000 eligible for tax credits are under 300% How many uninsured AIANs under 300% of FPL are not eligible for tax credits because spouse has insurance through employer –no estimate-about 50 at the Port Gamble S’Klallam Tribe would be eligible if the tribe ended coverage for spouses. This is true for many AIAN families where a spouse is a tribal employees How many have individual or group plans that do not meet minimum coverage (MEC). 5,000-7,000 have individual plans that they can drop and access tax credits So we do not know how many are eligible for tax credits with any precision, but about 17,000 to 20,000 is a good estimate that can be revised with experience.

3. Idaho(134%) and Washington exceeded QHP enrollment goals (111%), Oregon lagged with 73% of projected. Urban Institute, May 2014

4. Medicaid and QHPs Goal of increasing Medicaid enrollment generally successful for all races in states that expanded Medicaid. In states that provided outreach support, like Washington, it has been successful for American Indians and Alaska Natives. Goal of increasing private insurance(QHPs) enrollment through tax subsidies (tax credits) generally NOT successful for American Indians and Alaska Natives even with outreach support. Medicaid data and Washington state example follows and then an examination of Qualified Health Plans.

5. Medicaid Expansion a great success for all races in NW: Oregon highest at 43.7 (now 50%) and Washington in top ten at 22.6% 43.7% 22.6% 20,000 eligible uninsured Many more are income eligible, but have some type of insurance Take-up rate note; we can’t easily determine how many insured will choose Medicaid

6. 10,000 newly insured in Medicaid. In counties with higher access to IHS, take up rates are much higher.

7. 75% of the 10, 000 remaining uninsured live in 10 counties

8. Unlike Medicaid, that exceeds many estimates, QHP enrollment very low. Determining how many are eligible for tax credits is not easy as there are many variables to consider. For this report eligibles are those ‘uninsured’ who are between 100% and 400% of FPL in non-Expansion states and those between 139% and 400% in Expansion states. Nationally 3% of Eligible AIANs enrolled in a Qualified Health Plan No state has more than 10% of eligibles enrolled Only 5 states have between 1000 and 2,000 enrolled. Washington 1,110 enrolled 17,000 to 20, 000 eligible

9. Washington has 5 th highest enrollment in Qualified Health Plans; est. 6% of those eligible for tax credits.

10. Washington ranks 3 rd in value of tax credits by AIANs

12. Most AIANs enrolled in QHPs are from tribes outside Washington 429 report membership in Washington State Tribes 681 from tribes outside Washington The majority of Washington AIANs are not members of WA tribes, but the exact number is not known-195,000 AIANs and about 70,000 are members of WA tribes. 151 are Alaska Natives enrolled in qualified health plans (more Alaska Natives enrolled in WA than in Alaska -115-) The members of the Alaska Native Tribal Health Consortium has begun a pilot program to sponsor up to 1,000. ½ of all Alaska Natives who live outside WA are Alaska Natives –over 5,000. 65% of AIANs in Washington report that they do not have ‘access to IHS-paid services’ ---for them health insurance is a good option.

13. Highest enrollment: Large Tribes Tulalip, Colville, Yakama, Cowlitz had highest enrollment in Qualified Health Plans All were in Priority One in 2013; all expect to be in 2014. Beyond the obvious; the reasons are unclear…. 1. All are large tribes (thus more eligible) and 2. Many tribal members and descendants do not live on reservation so insurance is a good option. 3. All these tribes experienced health care rationing in 2013 and were on priority one during the year…. meaning care only for ‘life or limb.’ Some tribal members likely decide buying health insurance is a good option. 5. None of the tribes with highest enrollment had a tribal premium sponsorship program-a surprise.

14. QHP enrollment of those eligible for QHP and of those eligible for tax credits Take-up rates in Qualified Health Plans do not follow an easily discernable pattern, but tribes with sponsorship programs seem to have better take-up rates. Port Gamble S’Klallam enrolled 14 of 18 who were tax credit eligible in this report and have now enrolled 21 of 27 tax credit eligible in QHPs. It is too early (we are in 8 th month of implementation) in the process to make any firm conclusions about ultimate success of Qualified Health Plans for AIANs in Washington Tribal Premium Sponsorship does offer a model of enrollment success. Source: WHBE May 2014 Data Report

15. Sources: Centers for Medicare and Medicaid Services, “Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report,” May 1, 2014. Washington Health Care Authority, April 30, 2014 Medicaid Data Report. Washington Health Benefits Exchange, May 2014 Data Report Washington Health Benefits Exchange, April 2014 Data Report Original data analysis developed by Ed Fox is found at AIAN Health Care Reform Website, Ed Fox, 2014 www.edfoxphd.com.www.edfoxphd.com. “How Much Financial Assistance Are People Receiving Under the Affordable Care Act?” Kaiser Family Foundation, March 2014.