• Medicaid expenditures for AIANs and Medicaid payments to IHPs have increased since 1996 thanks to the cooperation of the Centers for Medicare and Medicaid Services, particularly since development of the encounter rate by the Indian Health Service and the Health Care Financing Administration in 1997. 
  • The Encounter Rate is a simplified, nationally developed, mechanism to set payment rates without requiring each Indian health program to conduct costly annual cost reports.
  • CMS funding has narrowed the gap between IHS funding ($4.5 billion) and the required $12-15 billion (approximate) need to fully fund Indian health programs.
  • In 2008 payments to Indian Health Programs exceed $30 million in 8 states and total Medicaid expenditures for American Indians and Alaska Natives exceeded $100 million in 6 states.
  • CMS revenues increased from 1998-2010, first in the Northwest, Minnesota, and Alaska, followed by Arizona and New Mexico, Oklahoma.  This growth is likely to continue across the nation with Medicaid Expansion.
  • Even with combined IHS and Medicaid spending of upwards of $6-7 billion, $5 billion-$8 billion in unfunded need remains, close to $4 billion of which could be secured by expansion of Medicaid and access to health exchange subsidies.
  • See this 2010 Data Symposium Report that includes presentation on level of Medicaid Payments as Percentage of IHS payments by IHS Area.
  • Urban Institute has developed a model for estimating Medicaid expansion.  
  • The  table provides estimates for AIANs based on the model by using the % of a state's current program AIAN as the basis for estimates.
  • How many AIAN will be newly insured under Medicaid Expansion?
  • Medicaid Participation Rates, what percent of eligibles are enrolled, are very hard to estimate and no good estimate for 'take-up' exists for AIANs.  "Take-up can be defined in several ways, depending on the program and population in question. Generally speaking, it is a participation rate, ranging from 0 to 100%, and measures the fraction of people who are eligible for a program who choose to enroll. Factors that have been shown to impact take-up include the benefits of the program to the intended beneficiaries, information and transaction costs in enrolling, and stigma."
  • It is possible to estimate the maximum, but actual will depend on each state's Medicaid program and the success of outreach and education efforts.
  • 300,000 to 350,000 newly eligible is a good range for upper level estimates.
  • 100,000 to 150,000 of currently eligible, but not enrolled, raise expansion total to about 500,000.
  • Newly eligible refers to Medicaid expansion-usually in 2014, but some states have taken advantage of option to expand childless adults early, such as Washington, Oregon and Minnesota.
  • Currently eligible refers to those who are eligible, but not enrolled in Medicaid.
  • Health Care reform will increase the number of current and newly eligibles as outreach targets all eligibles.  Washington calls currently eligibles the 'welcome mat' eligibles.
  • State Estimates of Medicaid Expansion
  • Will it reach the 20,000 AIANs uninsured and eligible in 2014? 
  • An estimated 10,000 uninsured will be newly eligible for Medicaid in 2014; 
  • perhaps 10,000 are currently eligible, but not enrolled in Medicaid. ACS reports 20,700 AIANs under 139% of FPL are uninsured.
  • CMS estimates 53% of newly enrolled will be males, 47% female.
  •   Medicaid Expansion Oregon

  •   16,000 of uninsured AIANs are under 139% of Poverty. It is very possible that a many are already eligible but not enrolled although Oregon is a leader in outreach and enrollment. It is important to remember that these are 'estimates'.  

  •   Migration (crowd out) from individual (non group) plans to the Exchange ---estimated 2-4,000.
  •   Medicaid Expansion Idaho

  • 4,800 of uninsured AIANs are under 139% of Poverty.  At least 2,500 would be eligible for Medicaid if Idaho approved full expansion.  
  •   Medicaid Expansion Arizona

  •   Medicaid Expansion and American Indians and Alaska Natives

  •   400,000 estimate for newly eligible if ALL states expanded to 138% of FPL.

  •   Payments for AIANs Medicaid Services Exceeded $4 billion in 2010 with about 50% for IHS users.
  • The Business Case for Medicaid Expansion
  • ​Should your Health Program or tribe invest in the staffing for enhanced outreach and enrollment and the maintenance of an active Medicaid expansion program?  
  •     From a financial perspective, yes.
  • Does the new revenue to your program AND the cost savings to your Contract Health Services (CHS) program for payments to specialists and hospitals provide a positive return on investment?  Yes, it does.
  • There are modest planning and operational issues with Medicaid expansion (small compared to exchange health plans issues) and revenue increases will cover this cost.  Council approval to 'expand' is not necessary but in the first year or two of health care reform there may be a need to increase the budget for your outreach effort and enrollment staff if you want to assist enrollment using the new web portals like CoverOregon and Healthplanfinder.
  • Are there other considerations beyond the dollars and cents bottom line?  Yes, e.g., Impact on trust responsibility, stigma of means-tested program to receive health care services, threat of decreased medicaid dollars in the future, and problems resulting from Medicaid reform as states develop coordinated care programs and managed care plans (and now Qualified Health Plans) continue to ignore the existence of Indian health programs or insist on terms these programs cannot meet.
  • The federal government should realize that the funding planned for Medicaid and Health Insurance Marketplace subsidies could go directly to the IHS budget to fully fund IHS--Or allow tribes to redirect these dollars to their P. L.93-638 Title V compacts.
  • Medicaid revenue is not guaranteed to increase every year.
  • Medicaid had become an important component of overall revenues by 2004 (see chart), but by 2009 growth had leveled off in several areas. 
  • Health Care Reform is largely about....
  • Covering uninsured (although 'crowd out' of private plans likely too) American Indians and Alaska Natives in:
  • 1. MEDICAID and in;
  • 2. QUALIFIED HEALTH PLANS purchased in the Exchange Marketplaces.
  • Since the number/ percentage of uninsured under 139% of poverty is nearly the same as the number between 139% and 400% of poverty in most states, one could say the 'potential coverage of the uninsured' in Medicaid and Health Insurance Exchange plans is the same in most states, but the likely coverage expansion is far greater for Medicaid expansion.
  • Many Tribes will succeed with Medicaid expansion without much planning with current process to enroll those eligible for Medicaid--- and this is the case in both IHS and Tribal and Urban health programs.  Every person eligible, but not enrolled costs your program thousands.
  • Modified Adjusted Gross Income (MAGI) for those under 138%
  • Oregon Study findings:  MAGI may represent actual income in only 27% of under 138% population (study respondents).
  • 52% did not file income taxes
  • For another 52% of filers, MAGI did not reflect current income
These presentations include data on % of those under 139% of poverty who are uninsured.
See January 2014 CMS Rules on Cost Sharing exemption. All who have ever received CHS services and others will be exempt from Medicaid Cost Sharing.
Medicaid Rule:
An Indian who is eligible to receive or has received an item or service furnished by an Indian health care provider or through referral under contract health services is exempt from premiums. Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services are exempt from all cost sharing.
See August 2013 Medicaid Expansion report at Kaiser Family Foundation with Urban Institute for benefit of 50 state and District  expansion
  • The Problem (s) that Health Care Reform attempts to address are:
  • 1.  the high rate of uninsured (48 to 50 million) and 
  • 3 key income groups for American Indians & Alaska Natives: 
  • 0-139% wlll be eligible for Medicaid in states chosing to expand.
  • 300% of poverty upper threshold for no cost sharing for AIANs
  • 100%-400% will be eligible for subsidies in states NOT expanding Medicaid

  • Note: If under 100% of poverty, not eligible for subsidy (UI report) in states that don't expand Medicaid to 138% of poverty.  Millions live in states where eligibility ranges from 17% of poverty to 100% of poverty.

  • GAO 9-13 report estimates 115 million potentially eligible for Medicaid on January 2014 with 55 million currently enrolled.
Medicaid Expansion Estimates 
2013 NIHB report on Medicaid Expansion and AIANs in 33 states, by Ed Fox & Verne Boerner
Medicaid Expansion, if adopted in your state (33 +DC 34, in 2016), is easier than Marketplace because enrollment efforts will result in a YES you are Eligible for Medicaid for more AIANs.  Year round enrollment, improved online applications, mean most applications and nearly all recertifications will be easily completed. Retroactive eligibility allows tribes to cover high cost cases.
Enrollment August 2014
Uninsured AIANs in Non-Expansion States
Medicaid: 1999 to 2012 Payments for Services for American Indians and Alaska Natives---States, compiled by Ed Fox
2013 Estimate (Pre ACA): 517,000 AIANs are uninsured and under 139% of FPL and about 500,000 between 139 and 400% according to American Community Survey
DataSet(s) selected: 2009-2013
Source: ACS 5-Year Estimates  
Go to this webpage for latest enrollment and other reports on ACA.
Urban Institute (2015) Estimates 400,000 reduction in uninsured.
Suggested Citation: Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2016 Website.
Suggested Citation: Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2017 Website.
Free and unlimited use granted with citation.
  • $4.7 Billion Medicaid Payments for all AIANs in 2012 -CMS Jan-7-2016 report.
  • Not all are Indian health program patients
  • $5,649 per capita for AIANs (2012)
  • Where does this data come from?
Click here for copy of the December 19, 1996 MOA that established the encounter rate for Medicaid services paid to Indian health programs (not extended to Urban Programs).
Medicaid Expansion:  217,000 increase 2013-2015
Key elements of Increases in Medicaid Enrollment, aka Medicaid Expansion
1. Support for Outreach and Enrollment
2. Effective Website enrollment
3. One year eligibility, Easy annual renewal
4. Childless adults eligible
5. No requirement to provide AIAN tribal documentation  
6.  Expansion of income threshold to 138% of FPL
Medicaid Expansion and Qualified Health Plan Calculator that gives state and tribal estimates (Note state estimate follows the tribal estimate)
Health Care Reform No longer updated as of January 2018