Slide 1

Diversity of Native Americans in the Southwest and Legal Complexities

National Association of Public Health Statistics National Center for Health Statistics

Annual Conference

June 3, 2013John Molina, MD, JDChief Executive OfficerPhoenix Indian Medical CenterShooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Government to Government

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20122

3Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20123Origins of Health CareThe federal government acknowledged the responsibility of health care for Native Americans with the first treaties of 1784

1830s - expanded health care provided by army physicians to curb smallpox and other infectious diseases among tribes living in the vicinity of military posts4Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20124Responsibility of Health CareFor more than 200 years, the responsibility of health care for American Indians passed from different government branches:Department of WarBureau of Indian Affairs (BIA)Public Health Service (PHS)Indian Health Service (IHS)Source: Indian Health Service, http://www.ihs.gov 5Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20125Source: 2000 U.S. Census

6Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20126

Ak-Chin Indian Community

Cocopah Tribe

Colorado River Indian Tribes

Fort McDowell Yavapai Nation

Fort Mojave Indian Tribe

Gila River Indian Community

Havasupai Tribe

Hopi Tribe

Hualapai Tribe

Kaibab-Paiute Tribe

Navajo NationPascua Yaqui Tribe

Quechan Tribe

San Carlos Apache Tribe

Salt River Pima-Maricopa Indian Community

San Juan Southern Paiute

Tohono Oodham Nation

Tonto Apache Tribe

White Mountain Apache Tribe

Yavapai Apache Nation

Yavapai Prescott Indian Tribe

Zuni Pueblo(Map Courtesy of the Inter Tribal Council of Arizona, Inc.)Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012

8Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 20128

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Role of Language and Culture

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Indian Health Service, Tribally-Operated 638 Facilities and Urban Clinics (I/T/Us)

Indian Health Service (IHS) Federal agency responsible for providing federal health care services to American Indians and Alaska Natives.

Tribal 638 Programs and Facilities Tribes have the option, through contracts, grants, or compacts, to assume some level of responsibility for their own health care programs. These programs are often referred to as 638 programs and facilities (based on the Indian Self-Determination and Education Assistance Act, P.L. 93-638).

Urban Indian Health Programs (UIHP) provide culturally competent, non-duplicative health services to more than 150,000 people annually.

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201211IHS AreasAlbuquerquePortlandBillingsCaliforniaPhoenixOklahomaNashvilleNavajoTucsonAlaskaAberdeenBemidji12Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201212Source: Government of Canada, http://www.aboriginalcanada.gc.ca

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Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201213Patient Protection and Affordable Care Act (Affordable Care Act or ACA)

Signed into law by President Obama on March 23, 2010Largely addresses health insurance reformsImpacts Medicare and MedicaidIncludes the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA)

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012AI/AN Health Care Policy IssueEnsure that under health reform that the treaty rights of tribes and the trust responsibility of the United States government to provide health care to AI/AN are protected and enhance under health reform Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Individual MandateThe law makes nearly all Americans responsible for acquiring or maintaining acceptable health insurance coverage

AI/ANLaw exempts members of the Indian tribes from the tax penalty for failure to obtain acceptable coverage [Sec. 1501(b)]

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Insurance ExchangesLaw calls for states to operate an Exchange to create a marketplace for health insurance products for purchase by uninsured individuals and small businessesAI/ANAt 300% or below FPL can purchase insurance and no cost sharing [Sec. 1402(d)]No cost sharing for any service provided at an I/T/U [Sec. 1402(d)]Can enroll in an Exchange plan on a monthly basis

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Medicaid ExpansionMedicaid will be expanded to cover individuals under age 65 up to 133% of the FPLAI/ANExpansion of eligibility covers Indian people.IHS beneficiary required to enroll in Medicaid in order to be eligible for Contract Health Services

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Express Lane AgenciesA state can rely on a public agency for a finding of eligibility for an income based program to simply and expedite Medicaid and Childrens Health Insurance Program (CHIP) enrollment AI/ANLaw adds I/T/Us to the list of public agencies for the purposes of making eligibility determinations for Medicaid and CHIP [Sec. 2901(c)]

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Tax ExemptionLaw amends the Internal Revenue Code to exclude from a tribal members gross income the value of health benefits provided by an IHS or an Indian tribe or tribal organization to its members [Sec. 9021] Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Payer of Last ResortLaw makes health programs operated by I/T/Us the payer of last resort for persons eligible for services through these programs [Sec. 2901(b)]Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Indian Health Care Improvement ActIHCIA, Pub. L. No. 94-437, 94th cong. (Sept 30, 1976)Key legal authority for the provision of health care to AI/ANFindings of IHCIA Federal health services to maintain and improve the health of the Indians are consonant with and required by the Federal governments historical and unique legal relationship with and resulting in responsibility of the American Indian people.

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012History of the IHCIASnyder Act of 1921 federal funds for health services to AI/AN

Indian Self Determination Act and Education Assistance Act of 1975, Pub. L. No. 93-638, 88 Stat. 2203 (1975), codified as 25 U.S.C. 450a-450n, and as amended in scattered sections of 25 U.S.C., 42, and 50 U.S.C. Tribes to govern their own health care and education programs.Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012History of IHCIAIHCIA enacted in 1976 due to many IHS facilities being inadequate, outdated, inefficient, and undermanned, and to implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation in those programs. Pub. L. No 94-437, 90 Stat. 400, 94th cong. (Sept. 30, 1976); Ariz. Health Care Cost Containment Sys. v. McClellan, 508 F.3d 1243, 1246 (9th Cr. 2007) Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012History of IHCIA1990s Draft amendments to IHCIA2000 IHCIA expired but extended to 2001Since 2001 Congress held only hearings on various proposals but enacted no substantive changes to IHCIA until the ACAPermanent reauthorization of IHCIA signed into law under the Patient Protection and Affordable Care Act, H.R. 3590, Pub. L. No 111-148, 111th Cong. (2010)

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Statement by the President: Reauthorization of the IHCIA

In addition to reducing our deficit, making health care affordable for tens of millions of Americans, and enacting some of the toughest insurance reforms in history, this bill also permanently reauthorizes the Indian Health Care Improvement Act, which was first approved by Congress in 1976. As a Senator, I co-sponsored this Act back in 2007 because I believe it is unacceptable that Native American communities still face gaping health care disparities. Our responsibility to provide health services to American Indians and Alaska Natives derives from the nation-to-nation relationship between the federal and tribal governments. And today, with this bill, we have taken a critical step in fulfilling that responsibility by modernizing the Indian health care system and improving access to health care for American Indians and Alaska Natives.

(This statement is available at http://www.whitehouse.gov/the-press-office/statement-president-reauthorization-indian-health-care-improvement-act)Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Key Provisions of IHCIAEnhancement of the authorities of the IHS Director, including the responsibility to facilitate advocacy and promote consultation on matters relating to Indian health within the Department of Health and Human Services. Provides authorization for hospice, assisted living, long-term, and home- and community-based care. Extends the ability to recover costs from third parties to tribally operated facilities. Updates current law regarding collection of reimbursements from Medicare, Medicaid, and CHIP (Childrens Health Insurance Program) by Indian health facilities. Allows tribes and tribal organizations to purchase health benefits coverage for IHS beneficiaries. Authorizes IHS to enter into arrangements with the Departments of Veterans Affairs and Defense to share medical facilities and services. Allows a tribe or tribal organization carrying out a program under the Indian Self-Determination and Education Assistance Act and an urban Indian organization carrying out a program under Title V of IHCIA to purchase coverage for its employees from the Federal Employees Health Benefits Program. Authorizes the establishment of a Community Health Representative program for urban Indian organizations to train and employ Indians to provide health care services. Directs the IHS to establish comprehensive behavioral health, prevention, and treatment programs for Indians.

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Challenges: Health DisparitiesDeath rates from preventable diseases among AI/ANs are significantly higher than among non-Indians:

Diabetes 208% greaterAlcoholism 526% greaterAccidents 150% greaterSuicide 60% greaterIndian Health Service. Regional Differences in Indian Health 2002-200328Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201228Challenges: Cultural Environment AI/AN populations are diverse, with more than 560 separate tribes and hundreds of languages.There are individual and tribal variations in values and degrees of acculturation to American society.Cultural information that is known on one specific tribe/community is not necessarily applicable to another.Hodge, F., Weinmann, S., and Roubideaux, Y., Recruitment of American Indians and Alaska Natives Into Clinical Trials, Ann Epidemiology 2000;10:S41-S48.29Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201229Centers for Medicare and Medicaid (CMS)The Medicare and Medicaid programs were signed into law on July 30, 1965.A component of the Department of Health and Human Services (DHHS) administers:MedicareMedicaidState Children's Health Insurance Program (SCHIP) Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Arizona Health Care Cost Containment System (AHCCCS)Medicaid is a federal-state partnership designed by Congress in 1965 to provide health care for low income women, children, the elderly and disabledAHCCCS covers acute, long term care, and behavioral health servicesAHCCCS covers over 1.3 million Medicaid & CHIP membersAHCCCS purchases health care coverage through managed care organizations to cover the general populationThe Fee-for-Service Program covers AI/ANs and Emergency Services for qualified immigrants

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012American Indians and Alaska Natives in ArizonaArizona population: 6,266,318277,732 American Indians/Alaska Natives

AHCCCS members: 1,082,593117,440 AI/AN AHCCCS members

Source: U.S. Census Bureau, 2010 American Community Survey

Source: AHCCCS, October 2010 5 %11 %Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012AHCCCS Enrollment ChoicesNative American AHCCCS members have the option to enroll in an acute managed care health plan (e.g., APIPA, Mercy Care) or to select the American Indian Health Program (AIHP)

AIHP members may switch between a managed care plan and AIHP at any time by notifying AHCCCS

Native American AHCCCS Health Plan members may receive services at an IHS or 638 facilityShooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 201233AIHP Members

Health Plan Enrollees27%IHS/AHCCCS Fee-for-Service73%OffReservation58%On Reservation42%Source: AHCCCS, October 2010Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012AIHP Presenting Issues

Developmental disorders, including reading and language disordersDiabetesChronic renal failureAcute upper respiratory disordersPneumoniaObstetricsCellulitis and abscess of legCesarean deliveryObstetrical complicationsAbnormality in fetal heart rate/rhythmSource: AHCCCS Claims Data, 2007Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Policy Issues For Native Health

Preserving Choice for Medicaid-Eligible Native Americans.Protecting IHS, Tribal, and Urban Indian Providers Enhanced Program Data. The transition toward managed care has led to a decline in the quality of Medicaid program data available to the federal government and the tribes, among others.Financial Incentives for states to facilitate use of the I/T/Us.I/T/U collaborations and partnerships with non-IHS facilities for patients to receive coordinated care. Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012Wopila mitiwaheQuestions/Comments?

John Molina, MD, JD (Yaqui/San Carlos Apache)Chief Executive OfficerPhoenix Indian Medical CenterE-mail: John.Molina@ihs.gov

Shooting for the North Star: Our Journey from Good to GreatMinneapolis, MN June 3rd June 7th, 2012