Differences between Direct Service Tribes and 638 Tribes 1. Location: IHS operated programs tend to be more remote than 638 programs with exceptions like Arizona Tribes and the exception of the Alaska 638 Compacts 2. Economics: Direct Service Tribes are far more often poorer due to unfavorable locations for enterprises like gaming that thrive in urban areas where most 638 tribes are located exceptions include New Mexico and Arizona 3. Size: Larger tribes are much more likely to be served by IHS, Oklahoma's tribes are an exception to the rule, with North and South Dakota Tribes, large Minnesota Tribes, Montana tribes, and the Navajo typical of the large tribes being more often served by IHS.

Differences between Direct Service Tribes and 638 Tribes 4. Cultural-legal perceptions of non-IHS services like health insurance, public and private, view them unfavorably. While a federal agency is certainly not 'traditional' in the sense that it is Indian, there is a clear correlation between more traditional tribes, support for IHS and antipathy to insurance, public and private. Alaska is the exception to this rule. States like Montana, and South Dakota are good examples of it. They feel, often strongly, that IHS services are the preferred way to honor treaty obligations-in fact they more often have treaties that mention health care services, although some direct service tribes do not have treaties with the federal government.

Differences between Direct Service Tribes and 638 Tribes 5. Direct Service tribes have a much higher American Indian alone census population than 638 tribes that are more likely to have members who identify with multiple races. Alaska is an exception to this. Over 85% of AIANs in North Dakota, South Dakota, Montana Arizona, New Mexico are “Indian Alone” much higher than the national average of 50% indicating one race only. 638 tribal members themselves or close relatives have experience with health insurance, many direct service tribes tribal members do not. Note: The majority of AIANs do not identify with 3 or more races. To say it another way about 50% of AIAN, who self-identify to the Census are one race AIANs; over 90% identify with just 1 or 2 races.

The impact of health care reform on Direct Service Tribes will vary greatly from 638, tribally operated programs. The Affordable Care Act has no special provisions to make sure Indian Health Service operated programs (Direct Service Programs) are able to access it's two main expansion programs, Medicaid and Subsidies to purchase Health Insurance Exchange health plans.

Medicaid Expansion To the extent that Direct Service tribes experience greater poverty, and they do, Medicaid expansion will result in more eligible for these programs as Medicaid expands to serve childless single adults up to 139% of poverty. Medicaid expansion can be easily implemented by Direct Service Tribes when compared to enrolling in health exchange health plans. Medicaid Expansion will have a greater impact for Direct Service Tribes than health exchange plans and subsidies. Medicaid expansion's impact on Direct Service Tribes is likely greater than its impact on 638 (contract and compact) Tribes and the programs they operate.

Health Insurance Subsidies Between 35% and 40% of tribal members in Direct Service Tribes may be eligible for health insurance subsidies to purchase exchange offered health insurance plans. This is very similar to 638 tribes. 1. Unfortunately, the antipathy toward private insurance combined with the inability of cash-strapped tribes to sponsor health insurance will make take-up rates very low. 2. Indian Health Services does not have clear legislative authority to use Contract Health Service funds to purchase health insurance as do 638 tribally operated health programs.

Without affirmative actions: Direct Service Tribes will have: 1. much lower enrollment in exchange-offered health insurance than members of 638 tribes. 2. moderately less enrollment in Medicaid expansion in states expanding Medicaid, but unfortunately more Direct Service Tribes are in states that may not expand Medicaid to 138%. 3. less access to care overall if the IHS budget receives smaller annual increases after the rollout of the ACA in 2014 due to faulty conclusions about how well the ACA meets the needs of direct service tribes

Conclusion Direct Service Tribes and the populations they serve will not benefit from the Affordable Care Act to the same extent as 638 Tribes, they will have fewer enrolled in Medicaid and far fewer enrolled in exchange-offered health insurance plans. The key to mitigating this less favorable outcome is to identify best practices in Direct Services Tribes for possible adoption (and adaptation) by other Direct Service Tribes and the IHS programs that serve them. For example, Contract the CHS Program in order to pay premiums and reimburse incidentals.