1. CONTRIBUTORS: ALAN BURKE, MEAGHAN CONLISK, RYAN
PARKER, TARA ROBINSON
HAD 553 SPRING 2013
The Hope for
Native American Health
Opportunities and Challenges to Improve Health Outcomes
through the Affordable Care Act

2. Snyder Act of 1921

3. 5.2 Million

4. Why is this important?
As future healthcare administrators, it’s important…
 To examine the U.S. healthcare system's attempt
and promise to ensure adequate and quality access to
care for all Americans.
 To better understand these challenges and
opportunities to improve Native American health
access, costs, quality, and outcomes.

5. Outline
 Overview of American Indian & Alaska Native (AIAN) in U.S.
 Basics of Indian Health Services (IHS) & Healthcare Coverage
 Basics Cultural & Tribal Implications
 Indian Healthcare Improvement Act (IHCIA) of 1976 &
Affordable Care Act (ACA) Implications
 IHS & ACA programs
 Federal Funding Shifts
 Impact of the ACA on Costs
 Conclusion & Key Conclusions

6. Indian Health Service (IHS)
 Established in 1955 by the Public Health Service (Department of DHHS)
 Mission: to raise the physical, mental, social, and spiritual health of
American Indians and Alaska Natives to the highest level.
 Goal: to assure that comprehensive, culturally acceptable personal and
public health services are available and accessible to American Indian
and Alaska Native people.
 Foundation: to uphold the Federal Government's obligation to promote
healthy American Indian and Alaska Native people, communities, and
cultures and to honor and protect the inherent sovereign rights of Tribes.
www.ihs.gov/about

7. IHS Operational Overview
Budget FY 2012
HHS total budget: $822.7 billion
IHS budget appropriation: $4.3 billion
http://www.hhs.gov/about/budget/fy2012/gdm_cj_fy2012.pdf
Health Coverage
Restricted to clinics or hospitals on reservations
Restricted to providers who contract with HIS
Mostly Primary Care Services—some Ancillary and Specialty Services
Population Served:
Members of 566 federally recognized Tribes
2 million American Indians and Alaska Natives residing on or near reservations
Annual Patient Services (Tribal and IHS facilities):
Inpatient Admissions: 48,575
Outpatient visits: 12,772,553
Dental Services: 3,736,054

9. Healthcare Coverage

10. Healthcare Coverage

11. Access to Care
Services
 Hospitals, Clinics,
Ambulatory Care Sites,
Dentists, Community
Health Centers
 IHS Facilities
(Reservations or Contracted Facilities)
 The Urban Indian Health
Programs (UIHP)

12. Today’s American Indians/Alaska Native

13. Health Disparities Among AI/AN
AI/AN more likely to die…
• 500% higher from tuberculosis
• 519% high from alcoholism
• 195% higher from diabetes
• 79% higher from suicide
• 40% higher risk from AIDS
• 20% higher from cervical cancer
• 30% higher from prostate cancer
…than their non-AI/AN counterparts
http://www.indian.senate.gov/news/pressreleases/upload/PPACAforIndianHealthCare2.pdf

14. Cultural Considerations for Medical Care
Strong links between medicine and religion
The clinician patient relationship must be
sympathetic in understanding the patients
spirituality, if the patient does not feel this is
happening they are not likely to return.
Use of traditional healers restore balance with
simple ceremonies with prayers and chants.

15. Culturally Sensitive Educational Materials
Childhood Obesity/Diabetes
 Eagle Book
 uses animals to promote healthy eating and exercise choices
 promote traditional foods by sustainable ecological approach

16. Indian Healthcare Improvement Act of 1976
The Indian Healthcare Improvement Act (IHCIA) is
the cornerstone legal authority for the provision of
health care to American Indians and Alaska Natives
Expired in 2000, but was made permanent as part
of the Patient Protection and Affordable Care Act.
http://www.hhs.gov/news/press/2010pres/03/20100326a.html

17. How does the ACA relate to the IHCIA?
IHCIA 2010 compared to IHCIA 1976
 Enhancement of the authority of the IHS Director in DHHS
 Reimburses for extended continuum services
(SNF, Hospice, HCBS, NH, etc)
 Encourages partnership with VA and Dept of Defense
 Establishes a Community Health Representative program to
train and employ AI/AN to provide health care services
 Establishes a comprehensive behavioral health, prevention,
and treatment programs for AI/AN
http://www.hhs.gov/news/press/2010pres/03/20100326a.html

18. How does the ACA relate to the IHCIA?
Continued
 Updates current law regarding collection of reimbursements
from Medicare, Medicaid, and CHIP
 Improvements in Contract Health Services
 Access to Federal Employees Health Benefits Program
 Exempt from the penalty for not purchasing health insurance
http://www.hhs.gov/news/press/2010pres/03/20100326a.html

19. IHS Programs Supported by ACA
Title III (a)(3015) : grants support efforts to collect and
aggregate quality and resource measures.
Title III (a)(3501): provides training for quality improvement
practices in the delivery of health care services. There are specific
provisions for specific language related to cultural competency
issues.
Title III (f)(5507): eligible individuals the opportunity to
obtain training and education in high demand health care fields.
Secretary must award at least three grants to an eligible entity
that is an Indian tribe, tribal organization, college, or university.
http://www.ihs.gov/PublicAffairs/DirCorner/docs/Affordable_Care_Act_Provisions_Summary.pdf

20. Federal Shifts: IHS Budget Increase
$124 Million (2.9%) Increase for FY ’14
 $35 million to help purchase health care from the
private sector through the Contract Health Services
program, which is under proposal to be called the
Purchased/Referred Care program
 $77.3 million to support staffing and operating costs at
new and replacement facilities
 $5.8 million to fund contract support costs incurred by
tribes in managing their own health programs.
http://www.ihs.gov/BudgetFormulation/documents/FY2014BudgetJustification.pdf

21. Federal Shifts: Medicaid Expansion
Focus on: Indian Country States with Highest Prevalence of AIAN
= Expanding = Not Expanding

22. Federal Shifts: Increased Healthcare Coverage

23. How does the ACA effect costs of
care to AI/AN?
AI/AN Tribal Consultation Outcomes
 Affordable Insurance Exchanges
 Tax credits
 No Cost-Sharing or Co-Payments

24. Projected Individual Costs
Lower premiums will cost less if you have an income up to
$89,000 for a family of four or $112,000 in Alaska.
No out of pocket costs (copays or deductibles) if AI/AN choose
IHS provider in the insurance network
No out of pocket costs with any health care provider if your
income is under $67,000 for a family of four.
 www.healthcare.gov

25. Conclusion
Challenges
 Even though the expansion of payer and insurers are increasing, the AI/AN population may
not have the economic resources to take advantage of the opportunity to access medical
care
 If certain rural hospitals are unable to meet certain quality or patient metrics, they become
in jeopardy of being closed which leaves the population further medically vulnerable
 Because states are able to opt-in or –out of the ACA Medicaid Expansion, this leaves the
21% of AI/AN Medicaid recipients further vulnerable to limited medical support systems.
 Closing the high prevalence of disease among AIAN will be a major challenge without
ability to regulate public health provisions as a result of sovereign autonomy from the U.S.
Federal Government
Opportunities
 Increase in payers and insurer options allow funds to be more readily available
 Increased programming to create and evaluate effective care to AIAN through the
permanent reauthorization of the IHCIA
 If hospitals who serve AI/AN are able to meet the quality metrics, they have an opportunity
to receive the government incentives to off-set the uncompensated costs
 The permanent reauthorization allows for permanent funding in the future