1. 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

2. 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

3. 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?

4. 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?

6. IHS Areas Albuquerque PortlandBillings California Phoenix Oklahoma Nashville Navajo Tucson Alaska AberdeenBemidji

7. 10 CMS Regional Offices

8. AAIHS / AATCHB

9. 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

10. 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

11. AI Health Disparities Life Expectancy in Years: MenWomenTotal U.S. 74.1 79.5 76.9 AAIHS63.5 71.0 67.3 Disparity:10.6 8.5 9.6 Median age at death in SD (2007): 81.0 General Population 59.0 AI Population

12. AI Health Disparities Death rates from preventable diseases among AIs are significantly higher than among non- Indians:  Diabetes 208% greater  Alcoholism 526% greater  Accidents 150% greater  Suicide 60% greater Indian Health Service. Regional Differences in Indian Health 2002-2003

13. Diabetes Death Rates (Rate/Per 100,000 Population)

14. Alcohol Related Death Rates (Rate/Per 100,000 Population)

15. AI/AN Cancer Disparities IHS total: 184.1

16. 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

17. 4/28/2015 2009 IHS Expenditures Per Capita and Other Federal Health Care Expenditures Per Capita 20092009200719992008 Per Capita spending in the year for which data are published most recently – see base of each bar. $648 IHS Medical IHS Other See page 2 notes on reverse for data sources and extrapolation assumptions. 2007 2009

18. IHS Budget 2008 3,782 700 345

19. DHHS Budget 2008 ~$800 Billion 386 202 28.9 4.1

20. IHSFederal PL 93-638 Tribal MedicaidState AIHealthcareConsumer Indian Health Payer System Health Sector

21. Percent High School Graduation 2000 Census

22. Percent At or Below FPL 2000 Census

23.  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!) Medicaid Considerations 100% FMAP IHS or Tribal services State

24. Thank you! Donald Warne donald.warne@sanfordhealth.org

25. 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