1. Swinomish Indian Tribal Community Affordable Care Act Considerations  Tribal Health Director has responsibilities to : Present Tribal Specific Cost-Benefit Analysis Be well informed on State Insurance Exchange Develop alternate premium support options

2. Swinomish Indian Tribal Community Affordable Care Act Considerations  Tribal Health Directors should recognize that Cost-Benefit Analysis is just the start of the technical process  Policy Development process is a dynamic process of Health Policy/Economics/Politics

3. Location of Reservations in the State of Washington

4. Swinomish Indian Tribal Community Affordable Care Act Considerations  An Initial Question is what is the Source of Premium Support costs- Federal dollars or Tribal Hard Dollars The answer affects who the Tribe will politically/legally consider providing support for-ie CHS eligibles or Tribal members only or “creaming” of high cost users Another question is where a Council looks at coverage for Tribal members is : In CHSDA only or all members both inside and outside CHSDA

5. Swinomish Indian Tribal Community Affordable Care Act Considerations  Tribal Provision of Premium Support provides individuals Coverage and Choice ie, with Insurance a member could use it anywhere unless the Tribe institutes some kind of Premium Support limitation This raises the whole question of “Choice” as a Philosophy or Policy Question for the Tribe

6. Swinomish Indian Tribal Community Affordable Care Act Considerations  Individual Patient Choice has implications  Tribal Geography and Proximity to Alternate Services affect Patient Choices  Where Alternate Service Providers exist the Tribe is further “incentivized” to Compete by Improving Quality  Additional questions for Administrators re Tribal Clinic contracting with ACO’s, PPO networks, etc..

7. Swinomish Indian Tribal Community Affordable Care Act Considerations  Medicaid Expansion, CHIP and Insurance Premium Support provide new potential sources of revenue for Clinic and significant reductions in CHS –Both net benefits to the Tribe  Medicaid Expansion will provide the largest net benefit even with relatively small population in poverty-mainly single adult males  Premium Support will provide the largest net benefit for those under 200% of Federal Poverty Level Income

8. Swinomish Indian Tribal Community Affordable Care Act Considerations  Swinomish will likely provide significant Premium Support Return on Investment is likely >$2.00/$1.00 invested  Politics will likely push us to use of Tribal Hard Dollars for Premium Support for Tribal Enrolled Members  Patient Choice has historically been the philosophy at SITC  Continuing with that Choice Philosophy means we must continue our focus on Improving Patient Care and Quality Improvement to “incentivize” use of the Tribal Clinic

9. Swinomish Indian Tribal Community Affordable Care Act Considerations Thanks for Listening! Every Tribe has significant internal work to do to make the most of the Affordable Care Act Contact Information: John Stephens Programs Administrator Swinomish Indian Tribal Community jstephens@swinomish.nsn.us