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ACA Could Be a Boon for American Indians, but Enrollment Challenges Remain

New health coverage opportunities through the Affordable Care Act could help reduce health disparities among the American Indian and Alaska Native population and garner more funding for tribal health care providers.

But getting AI/AN individuals to enroll in coverage can be a challenge.

The population faces several obstacles to signing up for ACA coverage, including a lack of information and a lack of resources, such as an Internet connection.

State of the AI/AN Population

According to 2010 census figures, about 5.2 million U.S. residents identified as AI/AN, either alone or in combination with one or more other races. Of those, 2.9 million identified as AI/AN alone.

California has the largest portion — 14% — of U.S. residents identifying as AI/AN, either alone or in combination. In California, the census data show that 723,225 residents identify as AI/AN, either alone or in combination — a more than 15% jump from a decade earlier.

AI/AN individuals face many health disparities. For example, the population experiences higher mortality rates than other racial groups for chronic liver disease and cirrhosis (4.7 times higher than the average across all races) and diabetes (2.8 times higher). In addition, lifespans for AI/AN individuals are 4.2 years shorter than the national average across all races.

Many Receive Care Through IHS

Nationwide, the Indian Health Service provides care to about 2.2 million AI/AN individuals across 35 states.

IHS operates under a fixed $4.6 billion annual budget and employs a total of 15,370 workers, including 2,480 nurses, 750 physicians, 700 pharmacists, 670 engineers/sanitarians, 200 physician assistants/nurse practitioners and 280 dentists. The health system operates 12 area offices and 170 IHS and tribally managed service units. In addition, there are 33 urban programs that provide community health services, primary health care and other services.

Meanwhile, the Indian Self-Determination and Education Assistance Act provides tribes the option of assuming control and management of programs previously administered by the federal government. More than half of the IHS appropriation currently is administered by tribes, mainly through self-determination contracts or self-governance compacts.

Tribal- and IHS-run facilities perform 44,677 inpatient admissions and more than 13 million outpatient visits annually.

How the ACA Can Benefit the AI/AN Population

The ACA included the permanent reauthorization of the Indian Health Care Improvement Act, the “cornerstone legal authority for the provision of health care to American Indians and Alaska Natives,” according to the Indian Health Service. Before the law’s passage, the IHCIA had not been reauthorized in 10 years.

According to IHS, the reauthorization under the ACA extended current laws related to the IHCIA and also facilitated new programs and services, such as:

  • Allowing tribal organizations to buy health coverage for IHS beneficiaries, as well as to purchase health coverage for workers via the Federal Employees Health Benefit Program;
  • Authorizing assisted-living, community-based, home-, hospice and long-term care;
  • Authorizing IHS to make agreements with the departments of Veterans Affairs and Defense to share health care facilities and services;
  • Calling for the creation of a Community Health Representative program to train American Indians to provide medical services;
  • Directing IHS to offer comprehensive behavioral health, preventive care and treatment programs;
  • Extending tribal-operating facilities’ rights to recover costs from third parties;
  • Granting the IHS director enhanced authorities; and
  • Updating laws regarding Indian health facilities’ ability to collect reimbursements from Medicaid, Medicare and the Children’s Health Insurance Program.

The ACA also allows AI/AN individuals to sign up for insurance through the law’s exchanges at any time, rather than only during open enrollment periods, and they can change plans up to one time each month. In addition, members of that population are exempt from the ACA’s individual mandate.

The more AI/AN individuals who sign up for coverage, the more revenue tribal health providers that treat those patients can receive, DHCS told California Healthline. In fact, IHS officials say the law already has resulted in $49 million in additional revenue last year because of patients gaining insurance.

Getting AI/AN Individuals To Sign Up

While no cumulative enrollment estimates are available to determine just how many in the AI/AN population have taken advantage of ACA coverage, Covered California spokesperson James Scullary told California Healthline that:

  • Nearly 2,500 signed up for coverage through Covered California during the exchange’s first open enrollment period; and
  • Nearly 1,300 signed up during the exchange’s second open enrollment period.

However, that number could be higher, as an HHS report found that 31 of every 100 ACA enrollment applications omitted race information.

Meanwhile, Medi-Cal enrollment among American Indians increased by more than 46% from December 2013 (before the ACA went into effect) to December 2014, according to DHCS.

However, AI/AN is one of many groups that face particular challenges to signing up for ACA coverage. For instance, a study earlier this year found that just 40.5% of American Indians and Alaska Natives had access to the Internet at their homes and just under 64% had email addresses, which are required to sign up for health coverage online through the ACA’s exchanges.

The study, by the Alliance for a Just Society, also found that many Native Americans and Alaska Natives were unaware of the services and support available to them to obtain health care. For instance, just 52.6% of that population knew which services were included in their health coverage and just 20% had been informed about financial support for low-income individuals.

Meanwhile, Scullary said that a big challenge for the AI/NA population and other communities is unfamiliarity with the law. Another challenge is AI/NA individuals not understanding what benefits under the law might apply to them.

According to Scullary, Covered California has worked directly with the California Rural Indian Health Board to reach out to the AI/AN community, as well as held tribal advisory work groups. Scullary said, “Our outreach focuses on introducing people to this new era of health care, explaining the various coverage options and helping them find the best option for themselves and their family.”

Around the Nation

Repealing the ‘Cadillac Tax.’ Sens. Martin Heinrich (D-N.M.) and Dean Heller (R-Nev.) have introduced bipartisan legislation to repeal the Affordable Care Act’s so-called “Cadillac Tax” provision.

Trouble getting in. The federal government has said it will look into ways to help cooperative health plans gain stronger footing in the health insurance market, as they face tough competition from larger, private health plans

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