The Role of Medicare and the Indian Health Service for American Indians and Alaska Natives: Health, Access and Coverage
Report
Kaiser Family Foundation analysis of the 2013 ACS finds that the median age of the AIAN population is 30 and the median age of the U.S. population is 37. Regarding life-expectancy, the Census Bureau estimates that non-Hispanic Blacks and people who identify as American Indian or Alaska Native alone or in combination with another race have a life expectancy of 78 years for women and 72 years for men compared with 81 years and 77 years respectively in the general U.S. population. http://www.census.gov/prod/2014pubs/p25-1140.pdf
U.S. Census Bureau, “An Aging Nation: The Older Population in the United States”, Current Population Reports, May 2014. Available at: http://www.census.gov/prod/2014pubs/p25-1140.pdf.
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). 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.
Office of Minority Health, American Indian/Alaska Native Profile, (September 2012), http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52.
Ralph Forquera, Seattle Indian Health Board, Urban Indian Health (Kaiser Family Foundation, November 2001), http://www.kff.org/disparities-policy/report/urban-indian-health/.
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; Office of Minority Health, “Profile: American Indian/Alaskan Native”, available at: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62 (September 2014).
Legal obligation under which the United States “has charged itself with moral obligations of the highest responsibility and trust” toward Indian tribes (Seminole Nation v. United States, 1942). http://www.bia.gov/FAQs/
See 42 CFR 136.12. Also, in some cases, eligibility criteria for access to I/T/U services can be expanded to include others, particularly in the Urban Indian Health Program. See the “Indian Health Manual” for more details. Available at: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p2c1#2-1.2.
The Current Population Survey (CPS) estimates that 9.5% of people age 65+ were living below 100% of poverty in 2013. Available at: http://www.census.gov/hhes/www/cpstables/032014/pov/pov01_100.htm.
S. Artiga, R. Arguello, P. Duckett, “Health Coverage and Care for American Indians and Alaska Natives” Kaiser Family Foundation, . October 2013; available at: https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-american-indians-and-alaska-natives/. American Psychiatric Association Office of Minority and National Affairs; available at: http://www.integration.samhsa.gov/workforce/mental_health_disparities_american_indian_and_alaskan_natives.pdf.
Harriet Komisar and Judy Feder, “Transforming Care for Medicare Beneficiaries with Chronic Conditions and Long-term Care Needs: Coordinating Care Across All Services,” October 2011.
Kaiser Family Foundation, Medicare Chartbook, 2010, https://www.kff.org/medicare/report/medicare-chartbook-2010/.
In Alaska, health care funded by IHS is provided to shareholders in the Alaska Native Claims Settlement Act (ANCSA) regional and village corporations.
Department of Health and Human Services, “Indian Health Service: Fiscal Year 2015 Justification of Estimates for Appropriations
Committees,” February, 2014; available here: http://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY2015CongressionalJustification.pdf.
Department of Health and Human Services, Indian Health Service: Fiscal Year 2015 Justification of Estimates for Appropriations Committees, (February, 2014).
Approximately 100,000 American Indians utilize 23 Title V Urban Indian health programs and are not able to access hospitals, health clinics, or contract health services administered by IHS and tribal health programs due to their inability to meet IHS eligibility criteria or residency outside of IHS and tribal service areas. More information on Urban Indian health programs can be found here: http://www.ihs.gov/urban/index.cfm?module=dsp_urban_programs.
In addition to medical care, the IHS provides other services, including sanitation and public health functions.
A 2005-2007 national survey of long term care for older American Indians and Alaskan Natives found that only 15 percent of tribes had nursing home services and 16 percent had assisted living services available for elders. See AHRQ Health Care Innovations, Exchange American Indian Nation-Owned Skilled Nursing Facility Provides Culturally Responsible Services, Leading to High Patient Satisfaction and Low Staff Turnover, https://innovations.ahrq.gov/profiles/american-indian-nation%E2%80%93owned-skilled-nursing-facility-provides-culturally-responsive. Another study, focused solely on palliative care services for American Indians and Alaska natives in New Mexico, found that from 1999-2003, only 2.3% of Medicare patients at two IHS hospitals were enrolled in hospice when they died. This compared to a state average of 30.8%. Although some of this difference might result from cultural attitudes about death and dying, the researcher concluded that lack of access was also a significant factor. Domer, Timothy and Judith Kaur, Palliative Practice in Indian Health, South Dakota Medicine, 2008. Spec No.:36-40.
Funding allocations are described in the “All Purpose Table” (pg. 15) and “FY 2014 Crosswalk” (pg. 22) of the
See: 42 CFR 136.61
These estimates of third-party collections are based on the 2015 IHS Congressional Budget Justification and does not convey any otherwise unreported revenues.
S. Artiga, R. Arguello, P. Duckett, “Health Coverage and Care for American Indians and Alaska Natives” Kaiser Family Foundation, . October 2013; available at: https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-american-indians-and-alaska-natives/. 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.
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.
Testimony of Darrin Old Coyote, Crow Tribe of Indians-Apsaalooke Nation, Senate Committee on Indian Affairs, Field Hearing on the Indian Health Service: Ensuring the HIS is living up to its Trust Responsibility, May 27, 2014.
Ralph Forquera, Seattle Indian Health Board, Urban Indian Health (Kaiser Family Foundation, November 2001),
http://www.kff.org/disparities-policy/report/urban-indian-health/.
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.
As listed in current guidance for Medicare Advantage network adequacy: http://www.cms.gov/Medicare/Medicare-Advantage/MedicareAdvantageApps/Downloads/CY2015_MA_HSD_Network_Criteria_Guidance.pdf
The Qualified Medicare Beneficiary (QMB) program pays the Medicare B premiums plus deductibles and, in some instances, coinsurance. (It will also pay the Part A premium in the case of an individual who is subject to such premium because that person does not qualify on the basis of work history but is instead buying into Part A.) The Special Low Income Beneficiary (SLMB) and Qualifying Individual (QI) programs pay Medicare Part B premiums for qualified individuals. Each type of program considers the individual's (or couple's) resources and the specific program for which the individual qualifies is based on their income. Applications and eligibility determinations are handled through each state’s Medicaid program.
Low income beneficiaries who are not full duals also may be eligible for Part D premium cost sharing assistance, with the maximum amount of assistance available to those below 135% of the federal poverty level and with resources (in 2014) between $8,660 - $13,440 ($13,750 - $26,860 if married).
Per telephone conversation between CMS staff and Health Policy Alternatives, September 5, 2014.
Government Accountability Office, Medicare and Medicaid. CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes, July 2008, GAO-08-724.
A. Zaslavsky, J. Ayanian, L. Zaborski, The Validity of Race and Ethnicity in Enrollment Data for Medicare Beneficiaries, Health Services Research (June 2012), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349013/ ; California Rural Indian Health Board, Medicare Statistics for American Indians and Alaska Natives, Centers for Medicare and Medicaid Services American Indian and Alaska Native Data Project (2012); D. Waldo, Accuracy and Bias of Race/Ethnicity Codes in the Medicare Enrollment Database, Health Care Financing Review (Winter 2004-2005), https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04-05winterpg61.pdf; S. Arday, D. Arday, S. Monroe, J. Zhang, HCFA's racial and ethnic data: current accuracy and recent improvements, Health Care Financing Review (2000).
The relationships between the Medicare program and the IHS, as well as between Medicare and the facilities and providers operated by the tribes, tribal organizations or urban Indian organizations, are regulated under the Indian Health Care Improvement Act of 1975 and the Indian Self Determination and Education Assistance Act of 1976.
Indian Health Service facility that treats a Medicare beneficiary who is enrolled in Medicare Parts C and D bills the plan/plan sponsors for Medicare reimbursement. http://www.ihs.gov/businessoffice/ROM/Part2/ROM_P2_5.pdf
GAO, Indian Health Service: Most American Indians and Alaska Natives Potentially Eligible for Expanded Health Coverage, but Action Needed to Increase Enrollment, GAO-13-553 (September 2013).
Ibid.
See: http://www.gpo.gov/fdsys/pkg/FR-2014-12-05/html/2014-28508.htm
See “Purchased/Referred Care” section of the Department of Health and Human Services, Indian Health Service: Fiscal Year 2015 Justification of Estimates for Appropriations Committees, (February, 2014).
Government Accountability Office, Medicare and Medicaid CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes, GAO-08-724 (July 2008); 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 ; California Rural Indian Health Board, Medicare Statistics for American Indians and Alaska Natives, Centers for Medicare and Medicaid Services American Indian and Alaska Native Data Project (2012); 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.
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.
GAO, Indian Health Service: Most American Indians and Alaska Natives Potentially Eligible for Expanded Health Coverage, but Action Needed to Increase Enrollment, GAO-13-553 (September 2013).
California Rural Indian Health Board, Medicare Statistics for American Indians and Alaska Natives, Centers for Medicare and Medicaid Services American Indian and Alaska Native Data Project (2012).
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.
A. Zaslavsky, J. Ayanian, L. Zaborski, The Validity of Race and Ethnicity in Enrollment Data for Medicare Beneficiaries, Health Services Research (June 2012), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349013/ ; California Rural Indian Health Board, Medicare Statistics for American Indians and Alaska Natives, Centers for Medicare and Medicaid Services American Indian and Alaska Native Data Project (2012); D. Waldo, Accuracy and Bias of Race/Ethnicity Codes in the Medicare Enrollment Database, Health Care Financing Review (Winter 2004-2005), https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04-05winterpg61.pdf; S. Arday, D. Arday, S. Monroe, J. Zhang, HCFA's racial and ethnic data: current accuracy and recent improvements, Health Care Financing Review (2000).
J. O’Connell et al, Centers for American Indian and Alaskan Native Health, Colorado School of Public Health, University of Colorado, Denver, Medicare Enrollment, Health Status, Service Use and Payment Data for American Indians & Alaskan Natives, Centers for Medicare & Medicaid Services Tribal Technical Advisory Group, American Indian & Alaskan Native Data Project (February 2014).
California Rural Indian Health Board, Medicare Statistics for American Indians and Alaska Natives, Centers for Medicare and Medicaid Services American Indian and Alaska Native Data Project (2012).
Ibid.
Ibid.
J. O’Connell et al, Centers for American Indian and Alaskan Native Health, Colorado School of Public Health, University of Colorado, Denver, Medicare Enrollment, Health Status, Service Use and Payment Data for American Indians & Alaskan Natives, Centers for Medicare & Medicaid Services Tribal Technical Advisory Group, American Indian & Alaskan Native Data Project (February 2014).