1. Health and Human Services Secretary Sylvia Burwell Port Gamble S’Klallam (PGST) Tribe Report on Implementing the Affordable Care Act August 18, 2014 Health Services Department, Slides 1-12 PGST Slides 13-20 State and National -

2. PGST advocacy to support ACA January 16, 2012 Testimony on Sponsorship to the WA Senate Health and Wellness Committee, Chair Karen Kaiser. January 16, 2012 Testimony February 20, 2012 Testimony on Sponsorship to the WA Senate Health and Wellness Committee, Chair Karen Kaiser. February 20, 2012 Testimony February 4, 2014 Testimony Update on Sponsorship and Medicaid enrollment to WA House Health Committee, Chair Eileen Cody. February 4, 2014 Testimony May 25, 2013 Premium Sponsorship Program approved by Port Gamble S'Klallam Tribal Council November 7, 2013 program enrollment began.

3. Newsletter article ‘Ready for Reform’ initiative October, 2011 Key Points for Health Care Reform Success 1.Staffing 2.Electronic Health Records 3.Eligibility Determination Capacity 4.Sponsor Health Insurance 5.Real time accounting 6.Work with other Tribes and Indian Organizations.

4. Planning Goals and Results Goal (estimated number eligible with goal of 100% 'take up'): 175 Medicaid, 50 Qualified Health Plans. Results: 275 Medicaid (about 175 newly insured); 23 assisted with QHP enrollment 19 sponsored (most PGST tribal members) and assisted others purchase a QHP (not CHS eligible). Average premium just $40 per month, $480 annually. 4 'No' or zero premium. Highest $190 monthly several free. Have we reached all uninsured? No, 100 likely still uninsured, but still eligible for CHS-now with more dollars for more services.

5. Port Gamble S’Klallam Planning Port Gamble S’Klallam Planning

7. Feb 1, 2012 ACA planning meeting to October 30, 2013 Launch Party with State Health Care Authority Staff On October 30, 2013 we had just overcome severe website malfunctions and were beginning to see that it would be easier to enroll in Medicaid than in the past. We began buying insurance (QHPS) on November 7, 2014, fortunately, the website had stabilized.

8. Tribal Premium Sponsorship Port Gamble S'Klallam buys insurances in the exchange for a subset of CHS eligibles who are tax credit eligible and under 300% of FPL. Eligibility for Sponsorship Program ​ 1. Eligible for tax credit in exchange 2. Contract Health (CHS) Eligible 3. Income-139-300% (not 400%)

9. By December 15, 2013 PGST had enrolled 9 into Qualified Health Plans and paid for their insurance PGST also enrolled 79 in Medicaid By the end of January 2014 200 were enrolled in Medicaid and 18 in Qualified Health Plans

10. Port Gamble S’Klallam 28% Increase in Medicaid January to June 2014 compared to 2013 Jan-June.

11. Impact on Contract Health Services / Purchased/Referred Care 1. CHS payments for care in 1st six months of 2014 reduced by almost 50% from $469,241 (2013) to $252,038 (2014). 2. CHS obligations reduced from $488,007 to $341,411; ◦ Less so than payments, in part, because we give out POs for QHP-covered in sponsorship even though we expect the QHP to pay for all these bills.

12. Improvements in 2015 More stable functional website ◦ Families with Indian and non-Indians ◦ Ability to pay promptly and on recurring basis ◦ Simplified exemption from individual mandate for all AIANs (hopefully IRS will take lead role).  Perhaps our VITA(volunteer) Tax preparers can help Contracts with Qualified Health Plans ◦ Currently no fully executed QHP contracts with use of the Indian Addendum  Neither exchange nor Insurance regs require ◦ Still uncertain if we are fully included in networks with Primary Care Provider status  Some evidence that we are, but early in the process

13. Medicaid and QHPs Goal of increasing Medicaid enrollment generally successful for all races in states that expanded Medicaid. In states that provided outreach support, like Washington, it has been successful for American Indians and Alaska Natives. Goal of increasing private insurance(QHPs) enrollment through tax subsidies (tax credits) generally NOT successful for American Indians and Alaska Natives even with outreach support. Medicaid data and Washington state example follows and then an examination of Qualified Health Plans.

14. Oregon and Washington Medicaid Medicaid success with first six month enrollment exceeding estimates (or reaching year two estimates). 10,000 newly insured by Medicaid in Washington 6,000 newly insured by Medicaid in Oregon Source: Health Care Reform: Tracking Tribal, Federal, and State Implementation, Centers for Medicare and Medicaid (2012) MS

15. 10,000 newly insured in Medicaid. In counties with higher access to IHS, take up rates are much higher.

16. 75% of the 10, 000 remaining uninsured live in 10 counties, 40% Seattle Metro Area

17. Unlike Medicaid, that exceeds many estimates, QHP enrollment very low. Determining how many are eligible for tax credits is not easy as there are many variables to consider. For this report eligibles are those ‘uninsured’ who are between 100% and 400% of FPL in non-Expansion states and those between 139% and 400% in Expansion states. Nationally ◦ 3-10% of Eligible AIANs enrolled in a Qualified Health Plan ◦ No state has more than 10% of eligibles enrolled ◦ Only 5 states have between 1000 and 2,000 enrolled. Washington ◦ 1,110 enrolled ◦ 17,000 to 20, 000 eligible

18. QHP enrollment of those eligible for QHP and of those eligible for tax credits Take-up rates in Qualified Health Plans do not follow an easily discernable pattern, but tribes with sponsorship programs seem to have better take-up rates. Port Gamble S’Klallam enrolled 14 of 18 who were tax credit eligible in this report and have now enrolled 21 of 27 tax credit eligible in QHPs. It is too early (we are in 8 th month of implementation) in the process to make any firm conclusions about ultimate success of Qualified Health Plans for AIANs in Washington Tribal Premium Sponsorship does offer a model of enrollment success. Source: WHBE May 2014 Data Report

19. Sources: Centers for Medicare and Medicaid Services, “Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report,” May 1, 2014. HHS/ASPE Emily R. Gee and Arpit Misra, July 16, 2014 Presentation. Washington Health Care Authority August 15 Data Pull; and WA Health Benefits Exchange, April & May 2014 Data Reports Original data analysis developed by Ed Fox is found at AIAN Health Care Reform Website, Ed Fox, 2014 www.edfoxphd.com.www.edfoxphd.com. “How Much Financial Assistance Are People Receiving Under the Affordable Care Act?” Kaiser Family Foundation, March 2014. Health Care Reform: Tracking Tribal, Federal and State Implementation. CMS 2011.

20. 2014 Port Gamble S’Klallam is funded at about 60% (up from 40% in 2009) of the level of Need