HEALTH CARE REFORM: IT’S IMPACT ON TRIBES AND

INDIAN PEOPLE

Problem DefinitionIt appears our health care problem has been defined as high rates of uninsured that have increased every year for two decades.

Health Care Reform attempts to reduce the rate of uninsurance for the legally resident population and begin the discussion on how to be healthier at lower cost.

It turns out that AIANs have the highest rates of uninsurance in the nation.

So, on the face of it HC Insurance Reform seems like a good thing! Another good idea for Indian people!

Definition of IndianIt has become very imprecise, but it is more important than ever-as we always knew it would be with universal health care. Who is eligible and what are you eligible for?

For most Americans the question is what type of coverage are they eligible to receive? Employer paid, Medicaid, Exchange, Medicare.

There are many special provisions for Indians and the legislation uses many terms, sometimes tribal member, some times urban Indian, sometimes simply Indian to say who is eligible for protection from cost sharing, ability to use IHS and Tribal health programs, waiver of penalty from individual mandate, and others.

Definition of IndianNCAI has adopted a resolution supporting a broad definition that includes anyone considered an Indian by federal agencies like BIA, IHS, or Interior or HHS depts.

It is the definition promulgated by Centers for Medicare and Medicaid in reference to who does not have to pay cost sharing for the Medicaid and CHIP programs.

Census: Respondent can answer Alaska Native or American Indian (but could be from Latin America). They can designate principal tribe, but large percentage do not. Respondent can also answer AIAN in combination with other races-and millions do answer it this way. 3,151,284 alone 4,960,643 in combination (see next slide).

• The two added together (alone and in combination) are typically added together and used for most statistics, but it is important to know which is being used.

State Current Population Survey

2009 Estimate AI/ANs (Alone)

Current Population Survey 2009 Estimate AI/ANs

(In Combination)

Alone as a % of Alone or

In Combination

New Mexico 195,403 215,605 91% South Dakota 68,976 76,205 91% North Dakota 36,258 40,740 89% Arizona 320,587 366,954 87% Montana 62,873 74,399 85% Alaska 106,398 126,999 84% Wyoming 14,118 18,692 76% Utah 39,289 53,679 73% Oklahoma 296,182 415,371 71% Minnesota 66,640 95,130 70% Wisconsin 57,060 82,335 69% Idaho 23,986 36,464 66% Nevada 39,588 60,283 66% Washington 117,121 188,071 62% Colorado 62,231 102,451 61% California 447,424 739,964 60% New York 110,304 194,714 57% Oregon 59,665 104,143 57% Michigan 62,485 128,335 49% Massachusetts 20,812 45,653 46% 20 State total 2,207,400 3,166,187 70% US Total 3,151,284  4,960,643 64% 

2009 Population Estimates for American Indians and Alaska Natives (Current Population Survey)

2009 Rate of Uninsurance (29%) for Various Population Groups AIAN (alone)

  Total Margin of Error

Number Uninsured Error Percentage

Uninsured Error

Total Civilian Noninstitutionalized Population

301,472,074 +/-23,096 45,664,741 +/-237,829 15.10% +/-0.1

White Alone 226,131,614 +/-141,061 30,109,971 +/-182,749 13.30% +/-0.1

Black or African American Alone 36,724,621 +/-56,489 6,664,427 +/-60,703 18.10% +/-0.2

American Indian and Alaska Native Alone 2,393,821 +/-30,791 698,681 +/-18, error

692 29% +/-0.7

United States S2701. Health Insurance Coverage Status  Data Set: 2009American Community Survey, 1-year estimates

AIAN Alone or In Combination compared to All races Health Insurance Coverage 2009

HEALTH INSURANCE COVERAGE US all races Error AI/AN Alone or in

combination Error

Civilian Population* 301,472,074 23,096 3,697,232 31,575

With private health insurance coverage 67.4% 0.1 48.0% 0.6

With public health coverage 28.5% 0.1 35.6% 0.6

No health insurance coverage 15.1% 0.1 24.3% 0.5

Total uninsured 45,522,283   898,427 0.6

Source: S0201: Selected Population Profile in the United States Data Set: 2009 American Community Survey 1-Year Estimates Survey: American Community Survey Population Group: American Indian alone or in any combination

  Sum of All 20 States

Percentage of Total US

2009 AI/AN Population (Alone) 2,207,400 70.05%

2009 AI/AN Population (In Combination) 3,166,187 63.83%

IHS User Population 2009 1,314,464 87.74%

AI/AN Medicaid Population 2008 Annual Eligibles 615,254 76.29%

AI/AN as percentage of Total Medicaid 2008 .02% to 36% .3% 

2007 AI/AN Medicaid Beneficiaries August, final MSIS. 537,831 85.84%

2008 AI/AN Medicaid Beneficiaries August, final MSIS. 562,643 87.45%

2007 Medicaid Payments for AI/ANs $2,927,670,477 86.44%

2008 Medicaid Payments for AI/ANs $3,350,877,299 86.94%

20 States Totals and Percentage of overall population, and Medicaid enrollment and spending 2007-2008

Alaska 15.23% Idaho 1.55%

New Mexico 9.72% Nevada 1.50%

South Dakota 8.49% Utah 1.41%

Oklahoma 8.03% Minnesota 1.27%

Montana 6.45% Colorado 1.24%

North Dakota 5.61% California 1.21%

Arizona 4.86% Nebraska 1.11%

Wyoming 2.59% Kansas 1.04%

Washington 1.76% Wisconsin 1.01%

Oregon 1.56% Michigan 0.63%

Rank by Percentage of State Population AI/AN (Alone)

20 state study of the Impact of Health Care Reform on Tribes and Indian People

Alaska New Mexico

Arizona New York

California North Dakota

Colorado Oklahoma

Idaho Oregon

Massachusetts South Dakota

Michigan Utah

Minnesota Washington

Montana Wisconsin

Nevada Wyoming

The rate of health insurance coverage varies widely

The uninsurance rate varies from 15% to 42.9% across the 20 study states

Massachusetts 15%, Wisconsin 16.8%

Montana 43% and New Mexico 39% uninsured

If we exclude Children and look at the 18 to 64 year olds the uninsurance rates are very high indeed 18% Mass to 57% in Montana for adults under 65, not eligible for Medicare.

State % UninsuredMontana 42.9%New Mexico 38.7%Idaho 37.8%South Dakota 37.8%Alaska 37.5%Wyoming 35.0%Utah 33.5%Arizona 30.6%Oregon 30.5%Oklahoma 30.2%Nevada 30.1%Colorado 29.4%North Dakota 27.7%Washington 27.1%New York 25.6%Minnesota 23.9%California 23.6%Michigan 20.8%Wisconsin 16.8%Massachusetts 15.1%

S2701 American Community Survey 2009Health Insurance Coverage Status

AI/AN 2009 Percentage Uninsured Alone or in combination AI/ANs All ages: IHS is not considered coverage

STATE

American Community Survey 2009 Non-

institutionalized Estimate AI/ANs (alone)

18 to 64 Popwithout

insurance 18-64

% uninsured 18-64

Montana 64,053 37,224 21,087 56.65%South Dakota 65,745 36,912 18,992 51.45%New Mexico 185,714 113,154 56,275 49.73%Alaska 90,233 55,690 26,387 47.38%Utah 30,404 17,507 7,740 44.21%Wyoming 13,751 8,760 3,847 43.92%Idaho 22,368 13,905 5,770 41.50%Oregon 47,311 29,308 11,578 39.50%Oklahoma 218,483 134,715 52,362 38.87%Nevada 30,682 18,708 6,941 37.10%Arizona 289,547 172,001 63,696 37.03%North Dakota 32,282 21,453 7,411 34.55%Colorado 46,661 33,605 10,991 32.71%New York 62,464 43,055 13,202 30.66%California 287,138 190,448 57,997 30.45%Washington 85,643 55,547 16,892 30.41%Minnesota 53,242 33,947 10,002 29.46%Michigan 48,636 31,496 8,653 27.47%Wisconsin 46,535 28,069 6,068 21.62%Massachusetts 9,635 6,678 1,196 17.91%

1,730,527 1,082,182 407,087 37.62%

Medicaid very important to all Areas of the IHS

Next three slides show:• 2004 Payments for IHS users paid by Medicaid to IHS programs and other providers for the

same patients• 2004 Payments by Area compared to the IHS alllowance• 2008 Payments for all AIANs by state

IHS Area Beneficiaries Paid to Programs Non-Indian Providers All Payments

Navajo 78,292 $171,017,000 $248,848,000 $419,865,000

Alaska 27,737 $94,216,000 $185,828,000 $280,044,000

Phoenix 27,331 $80,648,000 $128,618,000 $209,266,000

Albuquerque 24,892 $27,102,000 $80,471,000 $107,573,000

Aberdeen 27,873 $37,880,000 $62,287,000 $100,167,000

Oklahoma 31,883 $25,567,000 $69,324,000 $94,891,000

Portland 17,643 $22,925,000 $58,968,000 $81,893,000

Billings 17,703 $29,263,000 $41,105,000 $70,368,000

Tucson 6,155 $18,991,000 $41,045,000 $60,036,000

Bemidji 8,140 $14,018,000 $44,358,000 $58,376,000

California 7,642 $8,324,000 $23,871,000 $32,195,000

Nashville 3,561 $6,898,000 $7,439,000 $14,337,000

Total All Areas 278,852 $536,849,000 $992,162,000 $1,529,011,000

Source: American Indian and Alaska Native Medicaid Program and Policy Data California Rural Indian Health Board March 2010, compiled by Kauffman & Associates, Inc.

James Crouch, Chi Kao, Juan Korenbrot, Carol Korenbro

IHS Area Medicaid Payments for IHS Users

IHS Allowances for Health Care Services

Medicaid as a Percentage of IHS Allowance

TUCSON $60,036,000 38,427,217 156.23%

NAVAJO $419,865,000 307,030,302 136.75%

PHOENIX $209,266,000 221,540,291 94.46%

ALASKA $365,359,945 400,809,060 91.16%

ALBUQUERQUE $107,573,000 121,532,318 88.51%

BILLINGS 70,368,000 134,210,770 52.43%

ABERDEEN $100,167,000 $219,714,752 45.59%

PORTLAND $81,893,000 181,449,609 45.13%

BEMIDJI $58,376,000 131,962,298 44.24%

OKLAHOMA $94,891,000 344,864,621 27.52%

NASHVILLE $14,337,000 93,643,964 15.31%

CALIFORNIA $8,324,000 121,669,195 6.84%

$1,590,455,945 $2,316,854,397

2004 Comparison of IHS Allowances for Health Care Services to Medicaid Payments for AI/ANs

By Area Office of IHS

2008 Eligible's Beneficiaries Paid for AI/ANs

Arizona 80,945 80,861 $366,767,605

New Mexico 57,779 56,952 $78,433,397 Alaska 18,387 18,191 $48,041,436 South Dakota 21,509 21,507 $34,687,828 Oklahoma 33,948 33,940 $30,902,973 Montana 13,715 13,626 $29,922,300 Washington 14,514 14,510 $25,373,420 Minnesota 10,316 10,234 $22,214,646 California 10,693 10,693 $11,460,883 North Dakota 5,234 5,186 $5,984,073 Wyoming 3,483 3,483 $5,746,418 Mississippi 1,957 1,956 $5,114,240 Oregon 2,809 2,778 $4,832,818 Nevada 1,471 1,470 $2,371,104 Idaho 1,800 1,800 $1,905,247 Colorado 458 458 $478,130 Michigan 690 674 $62,003 Massachusetts 4 4 $1,203

279,712 278,323 $681,706,607

Source: CMS MSIS, MAX Database, accessed November, 2010.

2008 Medicaid Payments to Indian Health Programs for AI/ANs

Access to IHS programs for the very poor

Perceived access to IHS-funded services varies widely across the states

These responses are those of AIANs who were uninsured and were under 133% of poverty in response to the question about access to IHS services.

10% in Utah said they have access compared to 90% in Alaska

2010 Federal Poverty Level

Family Unit 100% 139 250 300 400

1 $ 10,830 $ 15,054 $ 27,075 $ 32,490 $ 43,320

2 $ 14,570 $ 20,252 $ 36,425 $ 43,710 $ 58,280

3 $ 18,310 $ 25,451 $ 45,775 $ 54,930 $ 73,240

4 $ 22,050 $ 30,650 $ 55,125 $ 66,150 $ 88,200

5 $ 25,790 $ 35,848 $ 64,475 $ 77,370 $ 103,160

Alaska

1 $13,530 $ 18,807 $ 33,825 $ 40,590 $ 54,120

2 $18,210 $ 25,312 $ 45,525 $ 54,630 $ 72,840

3 $22,890 $ 31,817 $ 57,225 $ 68,670 $ 91,560

4 $27,570 $ 38,322 $ 68,925 $ 82,710 $ 110,280

5 $32,250 $ 44,828 $ 80,625 $ 96,750 $ 129,000

2004-2009 ACS Household Poverty Level

ColoradoCalifornia

Nevada New York

Arizona Wyoming Oklahoma

MassachusettsMichigan

Washington Utah

Alaska Wisconsin

Idaho Oregon

New Mexico Minnesota

North DakotaMontana

South Dakota

0% 10% 20% 30% 40% 50% 60%

19%23%23%

26%26%

27%28%

30%30%30%

31%32%32%

33%34%34%

37%41%

42%50%

Under 139% of Poverty Level

All Ages Ranked

total no IHS with IHS no IHS with IHS coverage

1 Alaska 15,015 1,401 13,614 9.33% 90.67%2 South Dakota 12,050 1,652 10,398 13.71% 86.29%3 New Mexico 34,238 4,828 29,410 14.10% 85.90%4 Montana 10,175 1,745 8,430 17.15% 82.85%5 North Dakota 8,041 1,408 6,633 17.51% 82.49%6 Arizona 53,022 11,942 41,080 22.52% 77.48%7 Oklahoma 45,332 13,870 31,462 30.60% 69.40%8 Wyoming 1,800 554 1,246 30.78% 69.22%9 Nevada 3,953 2,152 1,801 54.44% 45.56%10 Minnesota 10,596 6,246 4,350 58.95% 41.05%11 Wisconsin 4,765 2,842 1,923 59.64% 40.36%12 Washington 19,884 12,238 7,646 61.55% 38.45%13 Idaho 2,456 1,752 704 71.34% 28.66%14 Colorado 9,839 7,158 2,681 72.75% 27.25%15 New York 12,645 9,926 2,719 78.50% 21.50%16 Michigan 13,317 11,120 2,197 83.50% 16.50%17 Oregon 18,177 15,347 2,830 84.43% 15.57%18 California 40,308 34,763 5,545 86.24% 13.76%19 Utah 3,477 3,151 326 90.62% 9.38%20 Massachusetts 0 0 0 0.00% 0.00%

Source: American Community Survey 2008

Responses of AI/ANs under 133% of Poverty and Uninsured Access to IHS services or Without Access to IHS Coverage

Ranked by Access to IHS Coverage as Reported by Respondents to the American Community Survey

Estimating Medicaid ExpansionMedicaid will expand by over 250,000 AIANs in the 20 study states

With aggressive outreach it could top 300,000

Expansion will vary greatly by state

The second slide shows the range of increase from a high of over 88% in Nevada and 80% in Oregon to just 22% in Arizona with enhanced outreach (only 7% in AZ with standard outreach)

State % of State Medicaid

AI/AN

% increase with 'limited'

outreach (KFF)

KAI estimated

2019 increase 'limited' scenario

% increase with enhance

outreach estimate

KAI estimate using 2008

baseline enhanced scenario

KAI estimate using 2009 as

baseline

Alaska 35.61% 38.50% 16,561 53.90% 23,186 26,911Arizona 10.62% 7.70% 11,904 22.40% 34,631 34,631California 0.38% 20.10% 8,085 29.90% 12,027 12,628Colorado 0.84% 47.70% 2,218 60.60% 2,817 2,958Idaho 2.23% 39.40% 1,867 53.10% 2,516 2,556Mass. 0.20% 2.00% 55 5.20% 144 151Michigan 0.50% 30.20% 2,805 40.16% 3,730 3,917Minnesota 3.48% 32.90% 8,987 45.60% 12,456 13,955Montana 21.72% 54.50% 13,119 75.00% 18,053 19,547Nevada 1.41% 61.70% 2,145 88.60% 3,080 3,234New Mexico 13.09% 28.30% 18,566 39.40% 25,848 40,256New York 0.045% 6.00% 1,350 16.00% 3,601 3,781North Dakota 21.29% 44.00% 6,500 61.00% 9,012 9,462Oklahoma 12.35% 51.20% 45,487 67.40% 59,879 65,082Oregon 2.19% 60.60% 6,814 79.60% 8,950 8,955South Dakota 33.09% 25.90% 10,515 34.60% 14,048 14,231Utah 2.76% 56.10% 4,509 72.80% 5,851 6,143Washington 2.51% 25.20% 7,357 33.60% 9,810 10,300Wisconsin 1.57% 20.80% 3,228 28.00% 4,345 4,562Wyoming 6.14% 40.00% 1,918 53.60% 2,570 3,416

173,989 256,552 286,677

Estimated Medicaid Expansion under three scenarios: Limited Outreach and Enhanced Outreach with 2008 baseline and Enhanced Outreach with 2009 Baseline

State % of State Medicaid AI/AN

% increase with 'limited'

outreach (KFF)

KAI estimated 2019 increase

'limited' scenario

% increase with enhance outreach

estimate

KAI estimate using 2008

baseline enhanced scenario

KAI estimate using 2009 as

baseline

Nevada 1.41% 61.70% 2,145 88.60% 3,080 3,234Oregon 2.19% 60.60% 6,814 79.60% 8,950 8,955Montana 21.72% 54.50% 13,119 75.00% 18,053 19,547Utah 2.76% 56.10% 4,509 72.80% 5,851 6,143Oklahoma 12.35% 51.20% 45,487 67.40% 59,879 65,082North Dakota 21.29% 44.00% 6,500 61.00% 9,012 9,462Colorado 0.84% 47.70% 2,218 60.60% 2,817 2,958Alaska 35.61% 38.50% 16,561 53.90% 23,186 26,911Wyoming 6.14% 40.00% 1,918 53.60% 2,570 3,416Idaho 2.23% 39.40% 1,867 53.10% 2,516 2,556Minnesota 3.48% 32.90% 8,987 45.60% 12,456 13,955Michigan 0.50% 30.20% 2,805 40.16% 3,730 3,917New Mexico 13.09% 28.30% 18,566 39.40% 25,848 40,256South Dakota 33.09% 25.90% 10,515 34.60% 14,048 14,231Washington 2.51% 25.20% 7,357 33.60% 9,810 10,300California 0.38% 20.10% 8,085 29.90% 12,027 12,628Wisconsin 1.57% 20.80% 3,228 28.00% 4,345 4,562Arizona 10.62% 7.70% 11,904 22.40% 34,631 34,631New York 0.05% 6.00% 1,350 16.00% 3,601 3,781Massachusetts 0.20% 2.00% 55 5.20% 144 151

173,989 256,552 286,677

Estimating subsidies in Health Insurance Exchanges

• 21% of the AIAN population (alone or in combination) is over 400% of the FPL compared to 43% of the white population. Range: 11% SD to 35% CA

• 35% of the AIAN population is between 139% and 400%

• 37% of the White population is between 139% and 400%

• Why is AIAN less in the category 139 to 400% of FPL than white? Answer because 45% of AIANs are under 139% of federal poverty level compared to 20% for whites.

Percentage of AIANs over 400% of poverty

ColoradoCalifornia

MassachusettsNevada

New YorkArizona

Wyoming Washington

MichiganUtah

Alaska WisconsinOklahoma

New Mexico Minnesota

Oregon Idaho

North DakotaMontana

South Dakota

0% 5% 10% 15% 20% 25% 30% 35% 40%

35%34%

33%28%28%

28%28%

26%24%24%

22%21%

21%19%

19%18%

17%15%

15%11%

Health Exchange Subsidy Population

MassachusettsSouth Dakota

Montana California

North DakotaWashington

MinnesotaUtah

Wyoming Michigan

New Mexico Alaska

ColoradoNew York

Arizona Wisconsin

Oregon Nevada

Idaho Oklahoma

0% 10% 20% 30% 40% 50% 60%

37%39%

43%43%

44%44%44%45%45%45%46%46%46%46%47%47%

48%49%50%

51%

139-400 % of Poverty AIAN Households

Will AIANs participate in health insurance exchanges?

The lowest income more likely: 139% of poverty to 250% of poverty will have no copays and little or no premiums.

No cost sharing up to 300% of poverty for all AIANs, but it appears premiums will NOT be considered cost sharing.

The premiums from 250% to 400% will be a large disincentive for participation if an AIAN has the alternative to remain uninsured and get care at an IHS funded program.

Health Exchange Participation• Reasons for predicted low participation

• Premiums will ranges from $800 per year to $11,000 per year for a family of four.

• Since there will be premiums most programs cannot invoke the ‘alternative resource rule’ and require participation in health exchange plans.

• There is no mandate for any AIAN to purchase care

• AN AIAN can enroll in any month of the year

• Enrollees may have to repay subsidy if their income increases-$600 to $3,000 maximum depending on size of family and size of subsidy.

IHS direct service tribes, less likely to pay premiums????

State Families USA

estimate of total eligible for subsidies

% of State AI/AN 2009 (in

combination)

AI/ANs based on % of

Population  AI/AN

Median income adjustment

Adjusted estimate with a factor for

difference in household income

Alaska 72,000 17.30% 12,456 36.07% 16,949Arizona 597,100 5.50% 32,841 37.30% 45,090California 3,473,000 1.90% 65,987 22.32% 80,716Colorado 493,900 2.00% 9,878 27.65% 12,610Idaho 201,400 2.30% 4,632 24.79% 5,780Massachusetts 416000 0.68% 2,835 39.83% 3,964Michigan 468,200 1.27% 5,927 25.04% 7,411Minnesota 117,500 1.80% 2,115 42.69% 3,018Montana 287,400 7.50% 21,555 38.07% 29,761Nevada 211,200 2.20% 4,646 19.75% 5,563New Mexico 211200 10.50% 22,176 25.99% 27,939New York 1,600,000 0.98% 15,666 31.36% 20,579North Dakota 74,300 6.20% 4,607 41.45% 6,517Oklahoma 381,500 10.80% 41,202 16.99% 48,203Oregon 444,400 2.60% 11,554 29.87% 15,006South Dakota 92,800 9.20% 8,538 45.03% 12,383Utah 321,700 1.90% 6,112 36.55% 8,346Washington 597,100 2.70% 16,122 29.96% 20,952Wisconsin 476,900 1.40% 6,677 29.12% 8,621Wyoming 59,000 3.40% 2,006 24.14% 2,490      297,532   381,898

Source of Income adjustment 2005-2009 American Community Survey, 5 year estimate of income

Estimated Number of AI/AN eligible for subsidies under two scenarios:

 State AI/AN income as % of All races median inc. AI/AN income 2009 All races income 2009

South Dakota 54.97% $ 24,640 $ 44,828 Minnesota 57.31% $ 32,669 $ 57,007 North Dakota 58.55% $ 26,429 $ 45,140 Massachusetts 60.17% $ 38,808 $ 64,496 Montana 61.93% $ 26,685 $ 43,089 Arizona 62.70% $ 31,537 $ 50,296 Utah 63.45% $ 35,306 $ 55,642 Alaska 63.93% $ 41,322 $ 64,635 New York 68.64% $ 37,911 $ 55,233 Washington 70.04% $ 39,493 $ 56,384 Oregon 70.13% $ 34,385 $ 49,033 Wisconsin 70.88% $ 36,552 $ 51,569 Colorado 72.35% $ 40,675 $ 56,222 New Mexico 74.01% $ 31,634 $ 42,742 Michigan 74.96% $ 36,505 $ 48,700 Idaho 75.21% $ 34,733 $ 46,183 Wyoming 75.86% $ 39,440 $ 51,990 California 77.68% $ 46,912 $ 60,392 Nevada 80.25% $ 44,608 $ 55,585 Oklahoma 83.01% $ 34,748 $ 41,861

Source: 2005-2009 ACS Survey 5 year estimate 

Rank by AI/AN % of All races 2009 median income

20 states overall Distribution of Income Comparing AIANs to All Races

to 139%

139 to 250%

250 to 400%

400% and above

0% 5% 10% 15% 20% 25% 30% 35%

31%

23%

22%

23%

28%

21%

19%

32%

20 states all races20 states AIANs

Minnesota AIANs compared to All Races

to 139%

139 to 250%

250 to 400%

400% and above

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

37%

25%

19%

19%

19%

18%

22%

41%

MinnesotaMinnesota AIAN

Oregon AIANs compared to all races

to 139%

139 to 250%

250 to 400%

400% and above

0% 5% 10% 15% 20% 25% 30% 35%

34%

26%

22%

18%

24%

22%

21%

33%

Oregon Oregon AIAN

Arizona AI ANs compared to All Races

to 139%

139 to 250%

250 to 400%

400% and above

0% 5% 10% 15% 20% 25% 30% 35%

26%

24%

23%

28%

32%

17%

19%

30%

Arizona Arizona AIAN

Community Health Centers

CHCs could play a large role in health care reform if the take up rate of AIANs in the Health Exchanges is low

In areas without urban programs now new ones could see AIANs with culturally relevant services to the newly insured or uninsured AIAN urban population.

Some CHC requirements will have to change: Reporting, 24 hour coverage, others??

State Total all races 2008 AI AN PercentageAI AN

Alaska 81,109 29,311  36.14%

Arizona 356,094 18,712  California 2,521,822 24,412 0.97%Colorado 419,514 2,967 0.71%Idaho 108,756 3,420 3.14%Minnesota 154,030 8,064 5.24%Montana 84,760 4,744 5.60%Nevada No data  n/a n/a New Mexico 259,073 14,354 5.54%North Dakota 26,144 1,249 4.78%Oklahoma 101,954 3,676 3.61%Oregon 240,486 4,811 2.00%South Dakota 55,526 10,056 18.11%Utah 105,551 10,647 10.09%Washington 664,795 14,538 2.19%Wisconsin 196,227 2,445 1.25%

Wyoming 20,207 438 2.17%

Totals 5,396,048 124,533 2.31%

American Indians and Alaska Natives Community Health Centers 2008

ConclusionThe main thrust of health care reform is to reduce the number of uninsured. This promises to be a positive reform if the 30% rate of uninsurance can be reduced to the hoped for 5% rate.

• Medicaid expansion is likely to be well received by Tribes and Indian people since it is familiar, provides protection against cost sharing, and a simplified definition of Indian for the purpose of determining eligibility. All Tribes, IHS and Urban programs will aggressively support implementation.

• Health Insurance Exchange subsidies also promise to reduce rates of uninsurance, but the impact will vary according to the steps IHS and Tribes take to inform and otherwise provide support for AI/ANs to obtain the health insurance offerings of Exchanges.

• Increased health insurance coverage for AI/ANs will raise significant challenges for Indian health programs that will require protective regulations to insure AI/ANs can choose these programs as their medical home, receive fair payment for services rendered, and inclusion in systems that support coordinated care.