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Health Coverage and Care for American Indians and Alaska Natives

Issue Brief
  1. The Bureau of the Census collects data on the major types of American Indian and Alaska Native areas, including:  reservations, land trusts, and tribal statistical areas. Reservations are areas that have been set aside for tribes through treaties, statues, or executive order. Within these territories, tribes have primary governmental authority. Tribes also have primary authority over land trusts, land held in trust by the federal government for a tribe. Land trusts may exist within reservations or off-reservation. Statistical areas are used by the Census Bureau to present data on recognized tribes that do not have a reservation (U.S. Census Bureau, “American Indian and Alaska Native Areas,” Chapter 5 in Geographic Areas Reference Manual  (Washington, DC: November 1994), http://www.census.gov/geo/reference/pdfs/GARM/Ch5GARM.pdf).

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  2. U.S. Census, Map: American Indians and Alaska Natives in the United States (2010), http://www2.census.gov/geo/maps/special/AIANWall2010/AIAN_US_2010.pdf.  

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  3. Office of Minority Health, American Indian/Alaska Native Profile, (September 2012), http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52.

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  4. Ralph Forquera, Seattle Indian Health Board, Urban Indian Health (Kaiser Family Foundation, November 2001), http://www.kff.org/disparities-policy/report/urban-indian-health/.

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  5. Bureau of Indian Affairs, U.S. Department of the Interior, “Indian Entities Recognized and Eligible to Receive Services From the Bureau of Indian Affairs,” Federal Register 77, no. 155 (Friday, August 10, 2012), http://www.bia.gov/cs/groups/public/documents/text/idc-020700.pdf.  The Shinnecock tribe of New York was added as a federally-recognized tribe since the last Federal Register publication.

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  6. Office of Minority Health (September 2012).

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  7. Kaiser Commission on Medicaid and the Uninsured analysis of 2009-2011 ACS data.

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  8. Ibid.

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  9. Charles Harrington, American Indian Entrepreneurship: A Case For Sustainability, Journal of Leadership, Management, and Organizational Studies, Volume 2, Issue 1 (2012) http://www.scientificjournals.org/journals2012/articles/1533.pdf and National Indian Gaming Association, 2009 Economic Impact Report (2009), http://www.indiangaming.org/info/NIGA_2009_Economic_Impact_Report.pdf.

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  10. Kaiser Commission on Medicaid and the Uninsured analysis of the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System Survey Data (BRFSS), 2011.

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  11. For more information about overweight and obesity among AIAN children and adolescents, please see: Leadership for Healthy Communities, Overweight and Obesity Among American Indian and Alaska Native Youths (Robert Wood Johnson Foundation, May 2010), http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/05/overweight-and-obesity-among-american-indian-and-alaska-native-y.html.

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  12. National Center for Injury Prevention and Control, Division of Violence Prevention, Suicide: Facts at a Glance (2012), http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.PDF.

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  13. Indian Health Service, “About IHS, " http://www.ihs.gov/aboutihs/.

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  14. Department of Health and Human Services, Indian Health Service, Fiscal Year 2014 Justification of  Estimates for Appropriations Committees, March 12, 2013, available at: http://www.ihs.gov/BudgetFormulation/documents/FY2014BudgetJustification.pdf

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  15. Indian Health Service, Year 2013 profile, January 2013, available at: http://www.ihs.gov/newsroom/factsheets/ihsyear2013profile/.

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  16. Indian Health Service, Office of Urban Indian Health Programs, Program Information, available at: http://www.ihs.gov/newsroom/factsheets/urbanindianhealthprogram/.

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  17. Ralph Forquera, (Kaiser Family Foundation, November 2001).

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  18. Department of Health and Human Services, Indian Health Service: Fiscal Year 2014 Justification of Estimates for Appropriations Committees (March 12, 2013).

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  19. 42 CFR 136.61.

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  20. Department of Health and Human Services, Indian Health Service: Fiscal Year 2014 (March 12, 2013).

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  21. Edward Fox and Verné Borner, Health Care Coverage and Income of American Indians and Alaska Natives: A Comparative Analysis of 33 States with Indian Health Service Funded Programs, for Tribal Affairs: Centers for Medicare and Medicaid Services, (2012), http://www.crihb.org/files/Health_care_coverage_and_income_of_aians.pdf; Ed Fox, Health Care Reform: Tracking Tribal, Federal, and State Implementation, Tribal Affairs Group, Centers for Medicare and Medicaid Services, (May, 20, 2011) http://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/Downloads/CMSHealthCareReform5202011.pdf; and Government Accountability Office, Indian Health Service, Health Care Services Are Not Always Available to Native Americans, GAO-05-789 (Washington DC: Government Accountability Office, August 2005), http://www.gao.gov/products/GAO-05-789.

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  22. Ibid.

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  23. Tribal Leader Letter, Dr. Roubideaux provides an update on Contract Health Services (CHS) Program increases for referrals for prevention services as a follow-up to the Tribal Leader Letter dated August 2, 2012, Department of Health and Human Services, Indian Health Service, (January 15, 2013), http://www.ihs.gov/newsroom/includes/themes/newihstheme/display_objects/documents/2013_Letters/01-15-2013_DTLL_FollowupCHSPreventionServices.pdf.

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  24. Kaiser Commission on Medicaid and the Uninsured Analysis of 2009-2011 American Community Survey data.

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  25. Ibid.

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  26. Kathryn Langwell, et al., American Indian and Alaska Native Eligibility and Enrollment in Medicaid, SCHIP, and Medicare, Individual Case Studies for Ten States, Centers for Medicare and Medicaid Services (December 2003), http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/langwell_2003_5.pdf and New Mexico Human Services Department, Barriers to Obtaining Health Insurance Among Native Americans in New Mexico, (January 2006), http://www.insurenewmexico.state.nm.us/Inm/Native%20American%20Health%20FINAL%20REPORT%20(2-3-06).pdf.

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  27. See 42 CFR 447.50 (b).

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  28. Robin Rudowitz, Financing Medicaid Coverage Under Health Reform: What is in the Law and the New FMAP Rules (Kaiser Commission on Medicaid and the Uninsured, May 2013), http://www.kff.org/health-reform/issue-brief/financing-medicaid-coverage-under-health-reform-the-role-of-the-federal-government-and-states/.

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  29. Section 1905(b) of the Social Security Act (third sentence).

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  30. While state Medicaid programs have broad discretion to set payment rates to providers, state Medicaid programs must cover services furnished by FQHCs and they are required to pay for those services using a Prospective Payment System (PPS) methodology (Sections 1902(a)(15) and 1902(bb) of the Social Security Act). Under federal law, tribally-operated clinics are considered FQHCs, as are urban Indian health programs that deliver primary care services (Section 1905(l)(2)(A) of the Social Security Act). Tribal clinics and urban Indian health programs that are designated as FQHCs may elect to be paid at the “all-inclusive rate” (AIR) for outpatient visits throughout the IHS system rather than the PPS rate. The Medicare and Medicaid AIR is negotiated between IHS and CMS and is published annually in the Federal Register. (78 Fed. Reg. 22890-22891 (April 17, 2013)).

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  31. Robin Rudowitz and Andy Schneider, The Nuts and Bolts of Making Medicaid Policy Changes: An Overview and a Look at the Deficit Reduction Act (Kaiser Commission on Medicaid and the Uninsured, August 2006), http://www.kff.org/medicaid/issue-brief/the-nuts-and-bolts-of-making-medicaid/.

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  32. U.S. Department of Health and Human Services, U.S. Department of Health and Human Services Tribal Consultation Policy (December 12, 2010), http://www.hhs.gov/iea/tribal/tribalconsultation/hhs-consultation-policy.pdf.

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  33. 42 CFR 431.408(b); State Health Official Letter #12-001 (April 27, 2012), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SHO-12-001.pdf.

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  34. State Medicaid Director Letter #12-001 (July 10, 2012), http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-001.pdf.

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  35. Section 1902(a)(73) of the Social Security Act; State Medicaid Director Letter, ARRA Protections for Indians in Medicaid and CHIP (SMDL #10-001) (January 22,2010), http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10001.PDF.

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  36. Some “expansion states” that have already expanded coverage to parents and childless adults will receive a phased-in increase in their matching rate for childless adults so that it will equal the rate available for newly-eligible adults by 2019.

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  37. Samantha Artiga, MaryBeth Musumeci, and Robin Rudowitz, Medicaid Eligibility, Enrollment Simplification, and Coordination under the Affordable Care Act: A Summary of CMS’s March 23, 2012 Final Rule (Kaiser Commission on Medicaid and the Uninsured, December 2012), http://www.kff.org/medicaid/upload/8391.pdf.

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  38. KCMU Analysis of the 2009-2011 ACS.

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  39. 45 CFR 155.350 and 45 CFR 155.420(d)(8).

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  40. Section 5000A(f)(1)(A)(ii) of the Internal Revenue Code, as added by section 1501 of the Patient Protection and Affordable Care Act, P.L. 111-148.

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  41. 45 CFR 155.605(g)(6),78 Fed. Reg.39524-39525 (July 1, 2013) http://www.gpo.gov/fdsys/pkg/FR-2013-07-01/pdf/2013-15530.pdf#page=2.

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  42. Office of Management and Budget, OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013 (March 1, 2013), http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/fy13ombjcsequestrationreport.pdf and Yvette Roubideaux, Indian Health Service Update for National Congress of American Indians Annual Convention (Indian Health Services, March 6, 2013), http://www.ihs.gov/newsroom/includes/themes/newihstheme/display_objects/documents/2013_Speeches/NCAI_March2013.pdf.

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Appendices
  1. Thomas Betlach, Medicaid Director, 1115 Medicaid Demonstration Waiver Amendment Request: Medical Home for American Indians (Arizona Health Care Cost Containment System, November 9, 2012), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/az-hccc-pa.pdf.

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  2. Centers for Medicare & Medicaid Services, Special Terms and Conditions, Arizona Health Care Cost Containment System, Medicaid Section 1115 Demonstration, (Amended April 6, 2012), http://www.azahcccs.gov/applicants/Downloads/KidsCareII/AZ_%201115_April2012Amend_STCs_FINAL.pdf.

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  3. Centers for Medicare& Medicaid Services, Special Terms and Conditions, California Bridge to Reform Demonstration, (Amended April 3, 2013), http://www.dhcs.ca.gov/provgovpart/Documents/11-W-001939SpecialTermsandConditions.pdf .

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