1. Health Care Reform: Measuring its impact American Indians & Alaska Natives In 34 Metro Areas with large Indian Populations February 20, 2012 Review of New Data from the 2008-2010 American Community Survey on rates of insurance and income distribution for Alaska Natives and American Indians

2. Census: Decennial and Annual American Community Survey 2010 Census is official census: 5,220,579 AIAN alone and in combination 2010 ACS estimates: 4.9 million AIAN alone and in combination of which 4,676,933 were born in United States. 1,802,733 total AIAN alone and in combination population in 34 largest Metro areas. 37% of all AIANs live in the 34 metro areas with the largest AIAN population (alone and in combination). Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

3. Overview of AIANs health insurance status in 34 large Metropolitan Areas 1,802,733 total AIAN alone and in combination population. 34 Metropolitan Areas with the largest American Indian and Alaska Native Population (ACS 3 year 2008-2010 data) 1,802,733 Total AIAN population of 34 Metros 54.7% (985,494) have private health insurance (vs. 48% nationally) 30.4% (548,736 )have Medicaid or Medicare (vs. 35% nationally) 22.3% (402,844 )are uninsured (vs. 24% nationally) Nationally: Total AIAN population ACS estimate 4.9 million 48% have Private Insurance (2,352,932) 35% have Medicaid or Medicare (1,692,375 ) 24% are uninsured (1,157,179) Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

4. Example: how to use data for impact analysis Your Mertropolitan Area 1 st step: How many AIANs are there? 1. ____AIAN alone 2. ______AIAN alone and in combination - most commonly used 2 nd step: What is rate of private and public insurance? 1. _____have private insurance 2. ______of ____ have private insurance (repeat for public) 3 rd step: What is number and rate of uninsured? 1. _____uninsured ( _____) in __metro area for AIAN alone and in combination and____% for AIAN alone. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

5. Using data for planning 4 th step: Determine distribution across 3 income categories. A. __ under 138% of poverty, B. __138 to 400%, C. ___over 400% California Rural Indian Health Board developed estimates of distribution of income across these categories and one 138-300% for states and metropolitan areas. 5 th step: Use estimates to provide information needed for planning outreach and education, workforce, facilities, budgets. 6 th step: Remember these are estimates, check with reality as it becomes known, make no assumptions, remember error rates. Compare your area to your state and to other metro areas so you can adopt, but adapt best practices appropriately. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

6. Metropolitan Seattle-Tacoma-Everett 14,948 AIAN* uninsured according to 2008-2010 ACS 0-138% of poverty 31% or 5,996 Uninsured 46% or 8,760 Medicaid 23% or 4,437 Private 14% or 2,719Medicare 138% to 400% 20% or 5,664 Uninsured 25% or 7,171 Medicaid 56% or 15,921 Private 12% or 3,437Medicare ACS 2009 Data for income distribution *AIAN alone and in combination Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

7. Metropolitan Spokane ACS 2009 Data 0-138% of poverty 22% or 1,304 Uninsured 67% or 4,021 Medicaid 18% or 1,066 Private Insufficient data for Medicare 138% to 400% No data Uninsured 37% or 1,582 Medicaid 57% or 2,467 Private 21% or 9,11 Medicare* *Medicare beneficiaries are apparently typically above 138% of poverty Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

8. Metropolitan Portland 12,759 uninsured AIAN* reported by 2008-2010 ACS 0-138% of poverty 34% or 5,721 Uninsured 48% or 7,932 Medicaid 20% or 3,316 Private 5% or 1,814 Medicare 138% to 400% 14% or 2,823 Uninsured 16% or 3,286 Medicaid 69% or 13,992 Private 9% or 1,814 Medicare Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University ACS 2009 Data for income distribution *AIAN alone and in combination

9. The American Community Survey Notes 3-year data (2008-2010 surveys pooled data) released October 27, 2011 State, County and Metropolitan Area data for areas w/ ≥ 20,000 AIAN alone and in combination Health Insurance data partially available: most reliable data thus far first time including 3-year data as question on health insurance first asked in 2008 Current release does not report Medicaid or Medicare separately, but as public coverage IHS ‘coverage’ and Income distribution for AIANs: 3-year data is now available for analysis, but analyses seldom present AIAN data compared to Hispanic, Black or even Asian. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

10. How many AIANs will remain uninsured in Metro Areas in 2014 – 2019? It is a behavioral question how many will remain uninsured in 2014-2019, but this presentation describes the basic components of the insurance equation for AIANs: What is the Metro AIAN population’s current insurance status? What is the income of the AIAN population- eligibility for Medicaid or Exchange subsidies? Is IHS available as an acceptable (however inadequate) alternative to health insurance? Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

11. Questions on the ACS The health insurance question asks the respondent to give a separate answer for each member of household regarding health insurance coverage. 1.Employer Sponsored Insurance (ESI) 2.Private, paid by individual 3.Medicare 4.Medicaid 5.Tricare, Health care insure for military and families 6.VA, Veteran’s Administration 7.IHS coverage-not used to compute rates of insurance Question on insurance is ‘point in time’ or ‘current coverage’ not the coverage in the ‘past year’ asked in some surveys. It is generally believed that Medicaid is underreported. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

12. ACS question on insurance coverage Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

13. Limitations of ACS data Estimates are based on survey samples: do not have calculated error rates to inform the range of uncertainty in the estimates three years of data for Washington include more than 6308 responses from self-identified AIANs As the first set of 3-year estimates, it is relatively new and little research has examined its relative accuracy. Example: there is some evidence that it underestimates Medicaid coverage by a couple points Uninsured is calculated when a respondent answers: no to all 6 types of health insurance coverage also, IHS is not considered coverage Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

14. Estimating impact of health care reform on AIANs 2014 expansion depends on number of AIANs already receiving health care services through… 1.Private insurance, many are surprised at how much experience AIANs have with Private Insurance in some states (CA, OK, TX,) 2.Public: Medicaid (800,000), Medicare(200,000) 3.Military, Veteran’s Administration 4.Indian health services Or are… 1.Uninsured 2.Underinsured, or whose co-pay/deductibles are too high for current income FOR THOSE NEW TO INDIAN HEALTH PROGRAMS, PLEASE NOTE: There are many AIANs with access to VA or IHS services who currently have no way to pay for their needed health care services…uninsured, underinsured (or in Indian health programs, hereafter IHPs, who can’t pay for patient referral care due to shortages of CHS funding or shortages of Urban Indian Health Care Program funding). Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

15. American Community Survey Health Insurance Data: 3-year Estimates for American Indians & Alaska Natives Alone and in Combination (2008-2010) Following 5 Tables were created from October 27, 2011 Census release of public data, with error rates calculated, via the Census Factfinder. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

16. ACS insurance coverage tables for American Indians and Alaska Natives Alone and in Combination The following six slides on insurance coverage (that include reporting for Medicaid and Medicare and IHS separately were compiled from PUMS raw data released December, 2011, with percentage calculation for American Indians and Alaska Natives with no error rate calculation (by Ed Fox). Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

18. Estimated Uninsured AIAN in 34 largest Urban Indian Metropolitan Population 402,844 total uninsured for all 34 Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

22. Expect revisions to estimates There is a great deal of uncertainty in estimates of newly insured through Medicaid expansion and even greater uncertainty in the number of AIANs who are likely to be newly insured in the health insurance exchange offered plans in 2014. No effective mandate, no penalties for AIANs who do not obtain insurance. Reluctance to accept subsidies if income varies due to seasonal income from fishing or other subsistence activity if reconciliation results in a tax bill. Urban Indians will often not have access to tribal resources for sponsorship, will have higher cost of living, but inadequate income for health exchange plans, and urban programs will need increased funding to serve their needs. Tribes located in urban areas will not be able to serve Urban Indians in 2014 if they remain uninsured and Urban Indian Health Programs are not funded to provide uncompensated care for AIANs. Community Health Center funding has been cut from level authorized and appropriated in the Affordable Care Act twice (latest February, 2012 release of President’s Proposed Budget for 2014). Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

23. Overall Assessment The impact of Health Care Reform in Metro Areas 1.Great variation between Metropolitan Areas in health insurance status with some metros exceeded all-races (Dallas, Houston, Los Angeles) private insurance rates. 2.AIANs are not subject to minimum coverage requirement’s penalities (no effective mandate) thus fewer will buy insurance. 3.Will involve many AIANs who do not have access to Indian Health Services funded services for care if they choose not to purchase insurance. 4.Urban Indian Health Programs already unable to provide health care for their Urban Indian Communities will only benefits from ACA if AIANs enroll in Medicaid or Exchange Offered health plans 5.Will involve over 400,000 AIANs who are uninsured and living in the nation’s 34 largest urban Indian Metros. 6.Exchange will involve a large number who will be eligible for subsidies and waiver of cost sharing (up to 300% of poverty). Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University

24. References Uninsured American Indians and Alaska Natives with Incomes 133% to 300% of Poverty: Data for Health Insurance Exchange Outreach, 2011, California Rural Indian Health Board Centers for Medicare and Medicaid: Health Care Reform: Health Care Reform: Tracking Tribal, Federal, and State Implementation Centers for Medicare and Medicaid: Health Care Reform: Health Care Reform: Tracking Tribal, Federal, and State Implementation U.S. Census Bureau. American Community Survey (ACS) 2008,2009, 2010, 3 year 2008-2010. American Community Survey accessed through Factfinder2 for 3 year reports for years 2008, 2009, 2010. Factfinder2 Agency for Healthcare Research and Quality (AHRQ), Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey- Insurance Component (MEPS-IC). Table II.A.2 (2009), available at http://www.meps.ahrq.gov/mepsweb/data_stats/summ_tables/insr/sta te/series_2/2009/tiia2. pdf Reports based on the Current Population Survey do not include reports on AIANs due to the small sample size. This was even true for the State of California’s recent Employee Benefit Research Institute estimates (in California Health Almanac; California’s Uninsured, December 2011) for race/ethnicity based on the CPS---despite the largest in the nation AIAN population of over 800,000 in 2010. Ed Fox, Port Gamble S'Klallam Tribe and Verne Boerner, Oregon Health Sciences University