What does the Affordable Care Act
Mean to You as an AI/AN
Donald Warne, MD, MPH
Oglala Lakota
Senior Policy Consultant
Great Plains Tribal Chairmen’s Health Board
&
Director
Office of Native American Health
Sanford Health
Overview
 Brief overview of PPACA
 Brief overview of Indian Health System
 Impact of PPACA on Indian Health System
 What does this mean to you?
 Jennifer Cooper—Key Components of Insurance
Reform and Consumer Protections
Patient Protection & Affordable Care Act
 PPACA—March 23, 2010, includes IHCIA
 Health Insurance Reform—PEC, Prev Svs, etc
 “Government Takeover of Health Care”
 No Single Payer
 “Obamacare”
 No Public Option
 Individual Mandate
 Employer Mandate
 Impact on AI/ANs?
Who is Insured?
 Private:
– Employed adults and families
– “Health Insurers Post Record Profits”
– Five largest insurers had $12.2B profit in 2009
 Public:
– Elderly—Medicare
– Impoverished—Medicaid, CHIP
– Military Veterans—VA
– AI/AN—Is IHS Insurance?
IHS Areas
Portland
California
Billings
Bemidji
Phoenix
Tucson
Alaska
Aberdeen
Nashville
Navajo
Albuquerque
Oklahoma
10 CMS Regional Offices
AAIHS / AATCHB
INDIAN HEALTH SERVICE
 The Indian Health Service (IHS) is the principal
federal health care provider and health advocate
for Indian people
 Its goal is to assure that comprehensive,
culturally acceptable personal and public health
services are available and accessible to
American Indian and Alaska Native people
CMS Role in Indian Health Care
 Medicare and Medicaid third-party revenue are
increasing portions of Indian health budgets
 Important to bill at service unit level
 CMS is key component of the trust responsibility
 AI/AN Medicare and Medicaid coverage impacts
Contract Health Service (CHS) spending
 Any changes in CMS policies and programs can
make a significant difference in Indian health budgets
and programs
AI Health Disparities
Life Expectancy in Years:
U.S.
AAIHS
Disparity:
Men
74.1
63.5
10.6
Women
79.5
71.0
8.5
Median age at death in SD (2007):
81.0 General Population
59.0 AI Population
Total
76.9
67.3
9.6
AI Health Disparities
Death rates from preventable diseases among
AIs are significantly higher than among nonIndians:




Diabetes 208% greater
Alcoholism 526% greater
Accidents 150% greater
Suicide 60% greater
Indian Health Service. Regional Differences in Indian Health 2002-2003
Diabetes Death Rates
(Rate/Per 100,000 Population)
Alcohol Related Death Rates
(Rate/Per 100,000 Population)
AI/AN Cancer Disparities
IHS total:
184.1
PPACA Role in Indian Health Care
Key Provisions:
No Cost Sharing
Coverage of Preventive Services
Expanding Medicaid Coverage
Expanding FQHCs
I/T/U Delivery System
 IHS only
 Tribal 638 services
 Urban Indian Health Centers
Payer Source
 NAR, CHS only
 On Medicaid
 On Medicare
 Privately Insured
2009 IHS Expenditures Per Capita and Other
Federal Health Care Expenditures Per Capita
-
$10,000
$8,000
Per Capita spending in the year for which data are
published most recently – see base of each bar.
-
$-
2008
2009
2007
Medicare per National Health
Veterans
beneficiary
Expenditures Administration
2007
Medicaid per
enrollee
2009
-
IHS
Medical
1999
$2,696
-
$3,242
$4,817
$2,000
$5,163
-
$6,732
$4,000
-
$6,130
$6,000
$11,018
-
IHS
Other
$648
FEHB Medical
Medical for
Indian Health
Benchmark Federal Prisons
Service
>decade old
2009
See page 2 notes on reverse for data sources and extrapolation assumptions.
4/8/2015
IHS Budget 2008
3,782
700
345
DHHS Budget 2008
~$800 Billion
386
202
28.9
4.1
Indian Health Payer System
IHS
PL 93-638
Federal
Tribal
AI
Healthcare
Consumer
Medicaid
State
Health Sector
Percent High School Graduation
2000 Census
Percent At or Below FPL
2000 Census
Medicaid Considerations
 States determine Medicaid Plan—even for
services covered by 100% FMAP
– (e.g. TCM in ND v SD or BH meds in AZ v NM)
 States control number of All-Inclusive Rates
billed per day (100% FMAP)
– (e.g. 3/day in AZ—1/day in SD—changed!)
100%
FMAP
State
IHS or
Tribal
services
Thank you!
Donald Warne
donald.warne@sanfordhealth.org
SD Medicaid
Next Steps
 Continue Medical Processes
 Expand efforts in BH services coordination
– IHS, Tribal, State, Private Sector, ATR?
 Identify issues in LTC
 Partners in Advocacy
– e.g. Full funding of IHS—more local services—
more access to 100% FMAP payments