1. Health Reform 101 National Tribal Health Reform Implementation Summit April 19, 2011 Jennifer Cooper Legislative Director, National Indian Health Board Jcooper@nihb.org

2. Today’s Presentation What Health Care Reform Means for American Indians and Alaska Natives  Reason for Indian specific provisions  Major Indian Specific Provisions  IHCIA 2

3. Indian Health Care in the United States Foundation for Health Care: Based on Treaties  the Federal Trust responsibility and Govt to Govt relationship Health Care: Indian Health Service provides health care to American Indians/Alaska Natives (AI/AN)  Indian Health Service is not insurance – public health delivery system

4. Need for Indian Specific Provisions in Health Reform Because of the Trust Responsibility to provide health care State of the Indian Health Care Delivery System Need for provisions in HCR to assure that: 1)Protects the Indian health delivery system & 2)Maximizes the ability of Individual Indians and I/T/U system to benefit from health care reform.

5. Key Components: Individual Mandate Objective: Require all Americans to acquire some form of health insurance - includes Medicare, Medicaid, CHIP, private insurance. Deadline: January 1, 2014 Enforced through tax penalties.  IRS penalties  Exceptions for hardships, religious reasons and Members of Indian Tribes - included to protect trust responsibilities of Federal government.

6. Key Components: Medicaid Expansion Medicaid Expansion  ALL individuals up to 133% of Federal Poverty Level in 2014.  Estimated to cover additional 16 million people.  Also, cost-sharing for many preventive services will be eliminated.

7. Medicaid - Enrollment and access No Indian specific provisions regarding Medicaid Expansion but There is still lots to do! As much as 60% of uninsured AI/AN are or will be eligible for Medicaid DON’T FORGET – The State must consult with Tribes BEFORE making changes to Medicaid. See, Sec. 5006 of ARRA. Medicaid is a primary source of third party revenue for Indian Health programs.

8. Projected Outcomes For AI/AN, 16% have no insurance and another 16% have only IHS * Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009. Figures may exceed 100% due to rounding. 8

9. Projected Outcomes Uninsured AI/AN are primarily lower-income 9 * Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009

10. Key Component: State Based Insurance Exchanges Marketplace for information on health insurance products offering acceptable coverage. January 1, 2014 Subsidies available for individuals in Exchange.  Subsidies on a sliding scale for individuals up to 400% FPL.

11. Major Provisions: ACA Indian-Specific Exchange Provisions Enrollment: All Indians can enroll on a monthly basis, rather than during annual 2 month period I/T/U Clients: No cost-sharing by AI/AN clients for services provided by IHS, Tribal or urban Indian program, or CHS Cost Sharing: Indians at or below 300% FPL will have no cost- sharing under a plan offered through the Exchange I/T/U Providers: All I/T/U providers are able to bill health plans for reimbursement  The amount is the higher of a) reasonable charges billed or b) highest amount plan would pay to other providers 11

12. Cost Sharing If between 300% and 400% of Federal Poverty Level  Subsidies (through advance tax credits paid directly to plans) are available for all Americans Why Should Indians Be Enrolled in a Plan  Can be used to acquire services that the I/T/U cannot provide  Insurance payments to the I/T/U for services it does provide  Reduces costs to contract health services program

13. Tribally-provided Health Care Benefits New law excludes value of health insurance and services provided to a tribal member by IHS or tribe from individual member’s gross income Exclusion was high priority for Indian Country  IRS had said tribally-provided health insurance was taxable to individual tribal member Effective March 23, 2010 “No inference” on whether such benefits provided prior to enactment are or are not excluded from member’s gross income

14. Payer of Last Resort IHS’s regulation making IHS, tribal programs the payer of last resort  law! Impact: Any other insurance coverage carried by Indian patient is required to pay first  Maximizes authority to collect third-party revenues –Medicare, Medicaid, CHIP, private insurance

15. Reauthorization of the Indian Health Care Improvement Act

16. Indian Health Care Improvement Act (1976 – 2000) Enacted September 30, 1976  Public Law 94-437  US Code citation: 25 USC §§1601-1680 Reauthorized often between 1977-2000  Last reauthorization thru September 30, 2001 (PL 106 – 568)

17. Road to Reauthorization – 2009-2010 2009: New IHCIA reauthorization bills introduced in House and Senate and eventually included in broader health reform bill 2010: Senate version of health reform & IHCIA passed and enacted – ( See Sec. 10221 of Patient Protection and Affordable Care Act which reference to S.1790)  Enacted March 23, 2010  Permanent reauthorization, but can be amended (Sec. 825)  Over 85 new/revised provisions  Authorized programs are subject to annual appropriations

18. The Unfolding Story… Now, the tasks at hand are to –  Ensure that the law is successfully implemented to meet the needs of AI/AN  Work to gain sufficient funding (appropriations) for authorized but-not-yet funded programs 18