CONTRIBUTORS: ALAN BURKE, MEAGHAN CONLISK, RYAN PARKER, TARA ROBINSON

HAD 553 SPRING 2013

The Hope forNative American Health

Opportunities and Challenges to Improve Health Outcomes through the Affordable Care Act

Snyder Act of 1921

5.2 Million

Why is this important?

As future healthcare administrators, it’s important…

To examine the U.S. healthcare system's attempt and promise to ensure adequate and quality access to care for all Americans.

To better understand these challenges and opportunities to improve Native American health access, costs, quality, and outcomes.

Outline

Overview of American Indian & Alaska Native (AIAN) in U.S.

Basics of Indian Health Services (IHS) & Healthcare Coverage

Basics Cultural & Tribal Implications

Indian Healthcare Improvement Act (IHCIA) of 1976 & Affordable Care Act (ACA) Implications

IHS & ACA programs

Federal Funding Shifts

Impact of the ACA on Costs

Conclusion & Key Conclusions

Indian Health Service (IHS)

Established in 1955 by the Public Health Service (Department of DHHS)

Mission: to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Goal: to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people.

Foundation: to uphold the Federal Government's obligation to promote healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes.

www.ihs.gov/about

IHS Operational Overview

Budget FY 2012 HHS total budget: $822.7 billion IHS budget appropriation:   $4.3 billionhttp://www.hhs.gov/about/budget/fy2012/gdm_cj_fy2012.pdf

Health CoverageRestricted to clinics or hospitals on reservationsRestricted to providers who contract with HISMostly Primary Care Services—some Ancillary and Specialty

Services

Population Served:Members of 566 federally recognized Tribes2 million American Indians and Alaska Natives residing on or near reservations

Annual Patient Services (Tribal and IHS facilities):Inpatient Admissions: 48,575Outpatient visits: 12,772,553Dental Services:   3,736,054

Healthcare Coverage

Healthcare Coverage

Access to Care

Services Hospitals, Clinics,

Ambulatory Care Sites, Dentists, Community Health Centers

IHS Facilities (Reservations or Contracted Facilities)

The Urban Indian Health Programs (UIHP)

Today’s American Indians/Alaska Native

Health Disparities Among AI/AN

AI/AN more likely to die…

• 500% higher from tuberculosis• 519% high from alcoholism• 195% higher from diabetes• 79% higher from suicide• 40% higher risk from AIDS• 20% higher from cervical cancer• 30% higher from prostate cancer

…than their non-AI/AN counterpartshttp://www.indian.senate.gov/news/pressreleases/upload/PPACAforIndianHealthCare2.pdf

Cultural Considerations for Medical Care

Strong links between medicine and religion

The clinician patient relationship must be sympathetic in understanding the patients spirituality, if the patient does not feel this is happening they are not likely to return.

Use of traditional healers restore balance with simple ceremonies with prayers and chants.

Culturally Sensitive Educational Materials

Childhood Obesity/Diabetes

Eagle Book

uses animals to promote healthy eating and exercise choices

promote traditional foods by sustainable ecological approach

Indian Healthcare Improvement Act of 1976

The Indian Healthcare Improvement Act (IHCIA) is the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives

Expired in 2000, but was made permanent as part of the Patient Protection and Affordable Care Act.

http://www.hhs.gov/news/press/2010pres/03/20100326a.html

How does the ACA relate to the IHCIA?

IHCIA 2010 compared to IHCIA 1976 Enhancement of the authority of the IHS Director in

DHHS Reimburses for extended continuum services

(SNF, Hospice, HCBS, NH, etc) Encourages partnership with VA and Dept of Defense Establishes a Community Health Representative program

to train and employ AI/AN to provide health care services Establishes a comprehensive behavioral health,

prevention, and treatment programs for AI/AN

http://www.hhs.gov/news/press/2010pres/03/20100326a.html

How does the ACA relate to the IHCIA?

Continued

Updates current law regarding collection of reimbursements from Medicare, Medicaid, and CHIP

Improvements in Contract Health Services Access to Federal Employees Health Benefits Program Exempt from the penalty for not purchasing health insurance

http://www.hhs.gov/news/press/2010pres/03/20100326a.html

IHS Programs Supported by ACA

Title III (a)(3015) : grants support efforts to collect and aggregate quality and resource measures.

Title III (a)(3501): provides training for quality improvement practices in the delivery of health care services. There are specific provisions for specific language related to cultural competency issues.

Title III (f)(5507): eligible individuals the opportunity to obtain training and education in high demand health care fields.

Secretary must award at least three grants to an eligible entity that is an Indian tribe, tribal organization, college, or university.

http://www.ihs.gov/PublicAffairs/DirCorner/docs/Affordable_Care_Act_Provisions_Summary.pdf

Federal Shifts: IHS Budget Increase

$124 Million (2.9%) Increase for FY ’14 $35 million to help purchase health care from the

private sector through the Contract Health Services program, which is under proposal to be called the Purchased/Referred Care program

$77.3 million to support staffing and operating costs at new and replacement facilities

$5.8 million to fund contract support costs incurred by tribes in managing their own health programs.

http://www.ihs.gov/BudgetFormulation/documents/FY2014BudgetJustification.pdf

Federal Shifts: Medicaid ExpansionFocus on: Indian Country States with Highest Prevalence of AIAN

= Expanding = Not Expanding

Federal Shifts: Increased Healthcare Coverage

How does the ACA effect costs of care to AI/AN?

AI/AN Tribal Consultation Outcomes

Affordable Insurance Exchanges

Tax credits

No Cost-Sharing or Co-Payments

Projected Individual Costs

Lower premiums will cost less if you have an income up to $89,000 for a family of four or $112,000 in Alaska.

No out of pocket costs (copays or deductibles) if AI/AN choose IHS provider in the insurance network

No out of pocket costs with any health care provider if your income is under $67,000 for a family of four.

www.healthcare.gov

Conclusion

Challenges Even though the expansion of payer and insurers are increasing, the AI/AN population

may not have the economic resources to take advantage of the opportunity to access medical care

If certain rural hospitals are unable to meet certain quality or patient metrics, they become in jeopardy of being closed which leaves the population further medically vulnerable

Because states are able to opt-in or –out of the ACA Medicaid Expansion, this leaves the 21% of AI/AN Medicaid recipients further vulnerable to limited medical support systems.

Closing the high prevalence of disease among AIAN will be a major challenge without ability to regulate public health provisions as a result of sovereign autonomy from the U.S. Federal Government

Opportunities Increase in payers and insurer options allow funds to be more readily available Increased programming to create and evaluate effective care to AIAN through the

permanent reauthorization of the IHCIA If hospitals who serve AI/AN are able to meet the quality metrics, they have an

opportunity to receive the government incentives to off-set the uncompensated costs The permanent reauthorization allows for permanent funding in the future