• IHS operated health programs serve tribes with very different social and economic characteristics than 638 tribes. 
  • These generalizations are certainly NOT true in many instances and the difference between DST/IHS and self-governance Tribes are narrowing AND more DST are considering contracting or compacting.
  • 1.   Location:  IHS operated programs tend to be more remote than 638 programs with exceptions of Alaska (see below).
  • 2.   Economics:  Tribes still served by IHS are typically poorer due to unfavorable locations for enterprises like gaming that thrive in urban areas where most 638 tribes are located. There are several exceptions to this in states as poor as New Mexico and Arizona.
  • 3.  Size:  Larger tribes are much more likely to be served by IHS with North and South Dakota Tribes, large Minnesota Tribes, Montana tribes, and the Navajo Nation typical of the large tribes being  served by IHS.  Oklahoma's 638 tribes are an exception to the rule with compacted Choctaw and Cherokee.
  • 4.  Cultural-legal perceptions of non-IHS services like health insurance, public and private, view them unfavorably.  While a federal agency is certainly not 'traditional' in the sense that it is Indian, there is a clear correlation between more traditional tribes and antipathy to insurance, public and private.  Alaska is the exception to this rule.  States like Montana, and South Dakota are good examples of it.  They feel, often strongly, that IHS services are the preferred way to honor treaty obligations-in fact they more often have treaties that mention health care services, although some direct service tribes do not have treaties with the federal government.
  • 5. Direct Service tribes have a much higher American Indian alone census population than 638 tribes that are more likely to have members who identify with multiple races. This means more will be exempt from cost sharing in Marketplace plans if under 300% of the Federal Poverty Level.
  • 6.  638 tribal members themselves or close relatives have experience with health insurance, many direct service tribes tribal members do not.  
  • Note:  The majority of tribal members for both do NOT identify with multiple races.  To say it another way, most AIANs, who self-identify to the Census are one race AIANs; over 90% identify with just 1 or 2 races.
  • The Indian Health Care Improvement Act (S. 1790 adopted by reference) has many provisions that will assist both 638 and Direct Service tribes expand services if more resources become available, as expected with implementaion of the ACA.
  • Medicaid expansion 
  • It will have a greater impact for Direct Service Tribes than health exchange plans and subsidies.
  • Medicaid expansion can be easily implemented by Direct Service Tribes when compared to enrolling in health exchange health plans.
  • Medicaid expansion's impact on Direct Service Tribes is likely greater than its impact on 638 (contract and compact) Tribes and the programs they operate.
  • To the extent that Direct Service tribes experience greater poverty, Medicaid expansion will result in more eligible for these programs as Medicaid expands to serve childless single adults. 
  • 638 tribes have fewer patients under 138% of poverty than Direct Service Tribes, but many more who are over 400% of poverty.
  • ​​Many members of Direct Service tribes resent or even refuse to enroll in Medicaid for reasons stated above.  Although many 638 tribes ask direct care patients to enroll in Medicaid upon registration or first visit, by regulation, IHS programs can only invoke the alternate resource rule for referral care to specialists and hospital care.  Some IHS programs with successful outreach and education programs do encourage Medicaid enrollment prior to a CHS referral.
  • Health Insurance Subsidies
  • Between 35% and 40% of tribal members in Direct Service Tribes may be eligible for health insurance subsidies to purchase exchange offered health insurance plans. This is very similar to 638 tribes.
  • Unfortunately, the antipathy toward private insurance combined with the inability of cash-strapped tribes to sponsor health insurance will make take-up rates very low.
  • Indian Health Services does not have clear  legislative authority to use Contract Health Service funds to purchase health insurance as do 638 tribally operated health programs.
  • Conclusion:  Direct Service Tribes and the populations they serve will not benefit from the Affordable Care Act to the same extent as 638 Tribes, they will have fewer enrolled in Medicaid and far fewer enrolled in exchange-offered health insurance plans.  The key to mitigating this less favorable outcome is to identify best practices in Direct Services Tribes for possible adoption (and adaptation) by other Direct Service Tribes and the IHS programs that serve them.
  • The benefits of Medicaid expansion and subsidies for the purchase of health insurance are likely to go unrealized without a full consideration of how the ACA impacts direct service tribes differently than 638 tribes.  Only then can necessary changes in law, outreach and education, and IHS budget considerations be adequately addressed.
  • ​​Direct Service Tribes are in states where respondents indicate they have access to IHS services.
  • ​Unfortunately, they are also states that are less likely to have health insurance exchanges operated by their states and less likely to expand Medicaid to 138% of poverty.
  • Conversely, Direct Service Tribes are more likely to be in states with a federally facilitated exchange or its close relative the state-partnership exchange.  Both of these options mean less consultation with a state's tribes.
  • The reasons for a potential differential impact of ACA implementation are thus not simply legal or legislative, nor are they based on the perceived differences in the performance of 638 programs compared to IHS program performance. 
  • Understanding these seldom discussed differences will be important or direct service tribes will end up in 2014-2019 with:
  • 1. much lower enrollment in exchange-offered health insurance than members of 638 tribes. 
  • 2. moderately less enrollment in Medicaid expansion, but unfortunately many are in states that may not expand Medicaid to 138%.
  • 3. less access to care overall if the IHS budget receives smaller annual increases after the rollout of the ACA in 2014 due to faulty conclusions about how well the ACA meets the needs of direct service tribes
  • States where AIAN "alone" is over 80% of the AIAN "alone and in combination" are also states where a large majority of tribes are Direct Service Tribes (with the notable exception of Alaska).  

  • This suggests that there is a positive correlation between AIANs who are multi-race and 638 tribes and a correlation between AIANs who report they are single race AIANs and Direct Service Tribes.
  • Direct Service Tribes are more often located in states where majority of Respondents indicate they have access to IHS-funded health services -Alaska is an exception to that.
  • Within states their locations are more often rural
  • Uninsured rates are typically higher than the state-wide average for AIANs

  • It is very likely that Direct Service Tribes will enroll a larger percentage of their patients (and active users) in Medicaid than Self-Governance Tribes.
  • Direct Service tribes have more eligible for Medicaid and fewer for Marketplace plans, with notable exceptions for Direct Service Tribes with strong economies.
  • IHS has promoted Medicaid enrollment activities with support for increases in health benefits counselors, training, and regular reporting.
  • Oregon and Washington Direct Service Tribes are reporting new enrollment success  (March 1, 2014).
  • By 2016 Direct Service Tribes have narrowed the gap with self-governance programs with some reporting 75% increase in Medicaid payments in 2015 over 2014.


The impact of the Affordable Care Act on Direct Services Tribes and the health programs operated by the Indian Health Service 
  • An estimated 34% (122,615) of Uninsured adult AIANs between 133 to 300% of poverty say they have ‘access to IHS’
  • 80% (97,000) of these IHS access, adult uninsured AIANs live in just 9 states; states that are nearly all predominately IHS Direct Service Tribes / IHS programs.
  • Within these 9 states, 74% of all 18-64 year old uninsured say they have access to IHS.
Alaska
  • In most characteristics Alaska has social and economic characteristics more similar to direct services tribes 
  • remoteness, 
  • poverty, 
  • Less private insurance,
  • Greater access to IHS, 
  • More often single race ---Alaska Native
  • Direct Service Programs can use Medicaid collections to purchase health insurance in the Marketplace for Qualified Health Plans, but cannot use CHS funds unless the tribe has contracted the CHS program.
  • Can underfunded programs AFFORD to wait to start sponsorship?  Wouldn't it be a good idea to have insurance in August and September when the CHEF fund is depleted?
  • Nearly all DST program will wait until 2014 when tribes and IHS will have better information about how sponsorship is working in a number of Tribes in Washington State, Minnesota and perhaps Oregon, and Oklahoma.
  • Some programs are considering a first-year program for the 35% of the AIAN uninsured in families under 200% of federal poverty level ($28K, 38K, 48K, 1, 2, 3 person family).
  • If program limited to 200% FPL annual premiums would not exceed $1,000 per person for enrolled tribal members buying bronze plan (no cost sharing for those enrolled)---
  • 4 dollars would be returned for each 1 dollar spent on insurance.
  • If a program were limited to annual premium of $550 or less most elders (over 50) under 200% FPL would qualify.
  • A limit of $1000 annual premium per person and all enrolled tribal members under 200% would be covered.  Use return on investment to fund expansion to cover non-enrolled descendents at the same level for fairness and raise income level in expansion.
Suggested Citation: Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2016 Website.
Free and unlimited use granted with citation (suggested citation above).
edfox_phd@yahoo.com