Health Care Reform: Measuring its impact12 States with Large Indian Populations

CALIFORNIA

American Indians & Alaska Natives

Based on Data and Analysis from the American Community Survey by the California Rural Indian Health Board

July 2, 2012

Review of new data from the 2008-2010 American Community Survey onrates of insurance and income distr ibuti onfor Alaska Nati ves & American Indians

1 2 S TAT E A C A A I A N D ATA P R O J E C T A C A /A I A N 1 2

Example:how to use data for state level impact

analysis

Your state______1st step: How many AIANs are there?

1. ____AIAN alone-not typically used, but relevant 2. ______AIAN alone and in combination - most commonly used

2nd step: What is rate of private and public insurance? 1. _____have private insurance (employer and individual) 2. ______of ____ have private insurance (repeat for public)

3rd step: What is number and rate of uninsured? 1. _____uninsured ( _____) in ____state for AIAN alone and in

combination and____% for AIAN alone.

When we say rate, we typically mean percentage-this standardizes a measure for comparison between states with various AIAN populations

Using data for planning 4th step: Determine distribution across 3 income categories.

A. __ under 138% of poverty, B. __138 to 400%, C. ___over 400%

California Rural Indian Health Board developed estimates of distribution of income across these categories. This project utilizes that database and compiles relevant categories for analysis.

5th step: Use estimates to provide information needed for planning outreach and education, workforce, facilities, budgets.

6th step: Remember these are estimates, check with reality as it becomes known, make no assumptions, remember error rates.

Compare your state to other states so you can adopt, but adapt best practices appropriately.

If most of your states’ Indian population is in category A (like South Dakota)-you may focus on Medicaid, if it is B you would focus on

exchange and if C you have to convince high earners to purchase care.

How many AIANs will remain uninsured in 2014 – 2019?

It is a behavioral question how many will remain uninsured in 2014-2019, but this presentation describes the basic components of the insurance equation for AIANs:

What is the state’s AIAN population’s current insurance status?

What is the income level of the AIAN population?

Is IHS available as an alternative to health insurance?

Will some tribes be able to sponsor (pay for) insurance offered in the health insurance exchanges?

Nationally: 2,352,932 or 48% w/ Private Insurance; 1,692,375 or 35% w/ Medicaid or Medicare; and 1,157,179 or 24% uninsured

2010 Census official US population:

5,220,579 AIAN alone & in comb. (alone & multiple races incl. 300,000+ foreign born who self report as AIAN)

2,932,248 alone (single race reported as AIAN)

ACS has the best state level estimates of income & insurance2010 ACS estimates:

4.9 million AIAN alone & in comb. of whom 4,676,933 were born in United States

Census: Decennial and Annual & American Community Survey

California’s AIANs

• A n e s ti m a t e d 1 3 2 , 0 0 0 ( ~ 2 0 % ) A I A N s a r e u n i n s u r e d i n C a l i f o r n i a• N e a r l y 5 5 , 0 0 0 o f t h e u n i n s u r e d a r e u n d e r 1 3 8 % o f p o v e r t y a n d

u n d o u b t e d l y w i l l b e e l i g i b l e f o r M e d i c a i d i n 2 0 1 4• A n o t h e r 6 0 , 0 0 0 a r e b e t w e e n 1 3 8 % a n d 4 0 0 % o f p o v e r t y a n d l i k e l y

e l i g i b l e f o r s u b s i d i e s t o p u r c h a s e h e a l t h i n s u r a n c e t h r o u g h t h e e x c h a n g e

C a l i f o r n i a A m e r i c a n I n d i a n s f a c e t h e n a ti o n ’s h i g h e s t c o s t o f l i v i n g t h a t i s n o t f a c t o r e d i n t o d e t e r m i n i n g e l i g i b i l i t y. T h e y a r e h i g h e r i n c o m e , b u t m a y h a v e l e s s d i s c r e ti o n a r y i n c o m e t h a n A I A N s i n o t h e r s t a t e s . R e v i s i o n s t o t h e A C A s h o u l d r e fl e c t c o s t o f l i v i n g d i ff e r e n c e s .

Medicaid

26%

Medicare 11%

Employer 48%

Individual

6%

IHS 9%

Uninsured20%

California: Uninsured, IHP access to services, & insurance coverage

State level impact analysis - California

1st step: How many AIANs are there?

662,000 estimated AIAN alone & in combination 2nd step: What is rate of private insurance?

54% 350,000 AIAN alone & in comb. have private insurance 3rd step: What is number and rate of uninsured?

132,000 (19%) uninsured 4th step: Determine income distribution of uninsured across 3 income categories.*

42% under 138% of poverty, 55,000 45% 138 to 400%, 60,000 13% over 400%, 17,000 5th step: Use estimates to provide information needed for planning outreach &

education, workforce, facilities, budgets for all. 6th step: Remember these are estimates, check with reality as it becomes known, make

no assumptions, remember error rates.

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Income Distribution of AIANs

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

35%

40%

45%

31%

40%

40%

38%

41%

25%

20%

17%

28%

over 400

138-400

under 138

Total AIAN

CA

MN

OR

WA

% AIANs under 138% FPL

0% 10% 20% 30% 40% 50% 60%

31%

34%

35%

38%

40%

42%

45%

45%

47%

49%

49%

59%SDNDAKAZMNMTNMORIDWAOKCA

California will have a smaller percentage of AIANs in Medicaid Expansion far fewer than SD, ND, AZ

CAL AIANs have an income distribution closer to all races population than most

states

Arizona

New Mexico

Minnesota

Oklahoma

Oregon

Washington

California

-30% -20% -10% 0% 10% 20% 30% 40%

13%

15%

17%

19%

20%

25%

28%

29%

26%

39%

28%

34%

38%

31%

-16%

-11%

-22%

-9%

-14%

-13%

-3%

DIFFERENCE400%+ all races400% + AIAN

Comparison of % of Al/AN population to All Races with income over 400% of Federal Poverty Level (American Community Survey data 2008-

2010)

Relative Poverty of California’s AIANs far less than other states with large Indian populations

California

Oklahoma

Washington

Oregon

New Mexico

Minnesota

Arizona

-30% -20% -10% 0% 10% 20% 30% 40% 50%

32%

29%

24%

26%

36%

20%

34%

31%

34%

35%

40%

42%

45%

47%

1%

-5%

-11%

-14%

-6%

-25%

-13%

DIFFERENCE0-138% AIAN0-138% ALL RACES

Comparison of % of AI/ANs under 138% of Poverty to All Races under 138%

% Income distribution of Uninsured AIANs in CAL depicts more (45%) in the exchange subsidy range

(138-400%)than states of MN, OR, WA

Uninsured-WA

Uninsured OR

Uninsured MN

Uninsured CA

0% 10% 20% 30% 40% 50% 60%

48%

53%

50%

42%

40%

39%

37%

45%

11%

7%

13%

13%

over 400

138-400

under 138

Income distribution of Uninsured AIANs in CAL

Uninsured-WA

Uninsured OR

Uninsured MN

Uninsured CA

20,743

16,538

10,900

55,576

17,379

12,171

8,039

59,716

4,877

2,295

2,721

16,877

43,000

31,004

21,661

132,169

Total

over 400

138-400

under 138

…CA depicts more (45%) in the exchange subsidy range (138-400%) than states of MN, OR, WA

The American Community Survey

Three-year data2008-2010 surveys pooled data released 10/27/11, w/ add’l releases Dec. ’11

State, County, and Metropolitan Area data for areas w/ ≥ 20,000 AIAN alone & in comb.

Health Insurance data partially available

(most reliable data thus far for AIANs – question on health insurance first asked in 2008, allowing 1st time 3-yr data is avail.)

Current release does not report Medicaid or Medicare separately, but as public coverage

In addition it includes, for the first time, information on the perception of IHS ‘coverage’ and Income distribution for AIANs:

Questions on the ACS

The health insurance question asks the respondent to give a separate answer for each member of household regarding health insurance coverage, including:1. Employer Sponsored Insurance (ESI)2. Private, paid by individual3. Medicare4. Medicaid 5. Tricare, Health care insure for military and families6. VA, Veteran’s Administration 7. IHS coverage-not used to compute rates of insurance

Question on insurance is ‘point in time’ or ‘current coverage’ not the coverage in the ‘past year’ asked in some surveys.

It is generally believed that Medicaid is underreported.

Limitations of ACS data

Estimates are based on survey samples: do not have calculated error rates to inform the range of

uncertainty in the estimates However, three years of data for Oklahoma have over

10,000 responses and Washington’s data includes more than 6300 responses from self-identified AIANs

As the first set of 3-year estimates, it is relatively new and little research has examined its relative accuracy.Example: there is some evidence that it underestimates Medicaid coverage by a couple points

Uninsured is calculated when a respondent answers:

no to all 6 types of health insurance coverage Note: IHS is not considered coverage

ACS & Urban IndiansArizona, Alaska, California, Oregon,

Oklahoma, Minnesota, New Mexico, and Washington all have very large Urban Indian populations.

ACS has income and insurance data for metropolitan areas in each of these states. In addition, County level, data is available for Arizona, California, Oklahoma, New Mexico, and Washington.

2014 expansion depends on number of AIANs already receiving health care services through…

Or are…

Estimating the impact ofhealth care reform on AIANs

1.Private insurance, many are surprised at how much experience AIANs have with Private Insurance in some states (CA, OK, TX,)

2.Public: Medicaid (800,000), Medicare (200,000)

3.Military, Veteran’s Administration

4.Indian health services

1.Uninsured2.Underinsured, or whose

co-pay/deductibles are too high for current income

FOR THOSE NEW TO INDIAN HEALTH PROGRAMS, PLEASE NOTE:There are many AIANs with access to VA or IHS services who currently have no way to pay for their needed health care services…uninsured, underinsured (or in Indian health programs, hereafter IHPs, who can’t pay for patient referral care due to shortages of CHS funding or shortages of Urban Indian Health Care Program funding).

Metropolitan

California

Uninsured

SubjectUninsured

% Uninsured

Los Angeles-Long Beach-Santa Ana, CA Metro Area 29,825 20.1%

Riverside-San Bernardino-Ontario, CA Metro Area 16,962 19.8%

San Francisco-Oakland-Fremont, CA Metro Area 11,481 19.2%

San Diego-Carlsbad-San Marcos, CA Metro Area 13,311 27.5%

Sacramento--Arden-Arcade--Roseville, CA Metro Area 7,023 14.1%

Fresno, CA Metro Area 4,132 21.1%

Oxnard-Thousand Oaks-Ventura, CA Metro Area 5,107 25.8%

87,840

American Community SurveyHealth Insurance Data:

3-year Estimates for

AIANs Alone & in Combination

(2008-2010)

WyomingMississippi

IowaConnecticut

NebraskaSouth Carolina

IdahoNorth Dakota

MassachusettsUtah

NevadaLouisianaMarylandAlabama

KansasMontana

IllinoisSouth Dakota

WisconsinMinnesota

ColoradoOregonAlaska

MichiganFlorida

New YorkNorth Carolina

WashingtonNew Mexico

TexasArizona

OklahomaCalifornia

21,65128,02529,43429,93732,88337,67137,74942,04642,55446,34550,14451,93256,72357,28562,772

76,60276,62480,11587,49795,886

106,545116,362

134,962139,924146,160

165,562177,861

192,114215,910

287,560334,182

481,777662,031

California Has the Largest Indian population in the United States

20% are members of one of the States 105 federally recognized Tribes or original peoples of California.

Estimated Population AIAN alone and in combination

South DakotaMontana

New MexicoArizonaAlaska

NebraskaNorth Dakota

WyomingNorth Carolina

IdahoMinnesota

IowaMississippiOklahoma

UtahOregon

WisconsinLouisiana

South CarolinaFlorida

WashingtonNew YorkCaliforniaColoradoMichigan

TexasNevadaKansas

AlabamaConnecticut

IllinoisMassachusetts

Maryland

22.40%28.20%

30.00%32.80%

36.30%37.50%38.00%

43.70%44.90%45.20%45.60%46.70%47.70%47.70%48.20%48.60%48.80%49.30%50.20%50.50%51.30%

53.60%54.40%54.70%54.90%55.20%55.30%56.00%

57.80%60.00%

61.60%61.70%

63.50%

Percentage of AIANs covered by Private Insurance

WyomingNebraska

MississippiIowa

North DakotaIdaho

South DakotaConnecticut

South CarolinaMontana

UtahLouisiana

MassachusettsNevada

AlabamaKansas

MarylandWisconsinMinnesota

IllinoisAlaska

OregonColorado

New MexicoFlorida

MichiganNorth Carolina

New YorkWashington

ArizonaTexas

OklahomaCalifornia

9,235 11,828 13,037 13,179 15,433 16,415 17,188 17,233 18,178 21,061 21,672 24,967 25,750 26,870

32,545 33,493 35,228

41,136 42,581 46,048 47,960

55,087 56,394

63,681 71,776 74,971 77,046

86,848 96,119

107,140 154,922

225,433 349,881

Slightly less than half of all AIANs are covered by private insurance (48%), under 2.5 million.

Just over half (54%) of CA AIANs have private insurance

AIANs covered by Private Insurance

NevadaTexas

MarylandColorado

KansasOklahoma

FloridaMississippi

IllinoisAlabamaOregon

CaliforniaConnecticut

AlaskaSouth Carolina

IdahoNew Mexico

New YorkWashington

LouisianaNorth Dakota

North CarolinaUtah

MontanaWisconsinWyomingMichigan

IowaNebraska

MinnesotaMassachusetts

ArizonaSouth Dakota

25.80%26.70%

28.90%30.00%

32.10%32.10%32.20%32.40%32.70%33.50%33.70%33.80%33.90%34.00%34.60%35.20%35.40%35.60%35.80%36.60%36.70%

38.10%38.40%39.00%

40.30%40.30%40.40%40.70%41.30%42.10%42.80%43.10%

46.10%

There are no good estimates of ‘take up’ rates and one should not infer that a high percentage on this chart implies high take up rate.

% receiving Public Insurance (Medicare and Medicaid)

ConnecticutIowa

MississippiWyomingNebraska

IdahoMassachusetts

AlabamaSouth Carolina

North DakotaLouisiana

NevadaMaryland

UtahKansasIllinois

MontanaSouth Dakota

MinnesotaColorado

AlaskaWisconsin

OregonFlorida

MichiganNew York

North CarolinaNew MexicoWashington

ArizonaTexas

OklahomaCalifornia

9,219 9,454 9,675 9,742 11,292 11,767 14,190 14,527 14,630 15,839 17,117 17,784 18,807 18,929 20,156

24,445 26,588

31,230 32,870 33,094 35,276 36,332

45,679 45,766 47,249

61,733 65,892

77,903 80,193

94,400 115,911

190,460 192,949

Number of AIANs with Public Insurance

The October 27, 2011 release of 3-year ACS data combined Medicaid, CHIP and Medicare. Medicaid/CHIP and Medicare will be reported separately in later releases.

Insurance status of AIANs varies greatly

fromNon-Indians across the

nation and across individual states.

Massachusetts

Illinois

Maryland

Wisconsin

Alabama

Kansas

Colorado

Louisiana

South Carolina

Texas

Florida

Oklahoma

Wyoming

Arizona

Mississippi

South Dakota

New Mexico

6.60%14.20%14.30%

15.60%16.10%

19.30%19.30%19.70%19.80%19.80%

21.00%21.30%22.00%23.00%23.20%23.90%23.90%

26.10%26.10%26.20%26.50%27.30%27.70%28.20%28.70%28.90%29.20%30.00%30.70%

35.60%36.80%37.60%

39.20%

Percentage of Uninsured AIANs

Respondents are asked if they have IHS coverage,

but it is not considered ‘insurance’ coverage. That

is, if respondent only answers IHS they are

considered uninsured.

Medicare and Medicaid, however, are counted as insurance coverage.

20% California uninsurance rate is

~½ that of New Mexico, but is over

3 times that of Massachusetts.

Expect revisions to estimates

There is a great deal of uncertainty in estimates of newly insured through Medicaid expansion.

There is even greater uncertainty in the number of AIANs who are likely to be newly insured in the health insurance exchange offered plans in 2014.

Overall Assessment: CaliforniaImpact factors of Health Care Reform in California:

1. Large AIAN population (largest in the nation) thus will experience greater impact

2. Many CA AIANs do not have access to Indian Health Services (only ~20% have access, low compared to other states w/ large AIAN populations)

3. ~130,000 CA AIANs are uninsured w/ > 87, 000 AIANs living in larger urban centers

4. Lack of a cost of living adjustment in determining either income or eligibility will likely result in fewer CA AIANs eligible for Medicaid Expansion than most states

1. More uninsured CA AIANs are over 400% of poverty than under 138% of poverty2. Many CA AIANs above 400% of poverty (particularly in

Metropolitan Areas) cannot afford insurance due the high cost of living

Overall Assessment:California Continued

Impact factors of Health Care Reform in California:

5. Large number of CA AIANs w/ up to 400% poverty will be eligible for:

1. subsidies for the CA Exchange and the waiver of cost sharing (those up to 300% of poverty), but

2. very few will have tribal sponsors since 80% are from tribes from out of state.

6. Will need to consider gathering information not currently known about Employer sponsored insurance, tribal participation in sponsoring insurance, essential community

providers, essential benefits, and a possible basic

health plan.

Overall Assessment:California Continued

Impact factors of Health Care Reform in California:

No effective mandate, no penalties for AIANs who do not obtain insurance.

Reluctance to accept subsidies if income varies due to seasonal income from fishing or other subsistence activity if reconciliation results in a tax bill.

Inability of many tribes to afford sponsorship of tribal members.

Urban Indians often do not have access to tribal resources for sponsorship and have a higher cost of living. Many will likely have inadequate income for health exchange plans, and urban programs will need increased funding to serve their needs.

Tribes located in urban areas will not be able to serve Urban Indians in 2014 if they remain uninsured and Urban Indian Health Programs are

not funded to provide uncompensated care for AIANs.

Income Distribution for AIANs

Income distribution relevant to health care reform Source of Income Distribution Data is from

published and unpublished data from the California Rural Indian Health Board

Additional analysis and recompilation into insurance and income tables for 12 states by Ed Fox and Verné Boerner.

Uninsured American Indians and Alaska Natives with Incomes 133% to 300% of Poverty: Data for Health Insurance Exchange Outreach, 2011, California Rural Indian Health Board

References Uninsured American Indians and Alaska Natives with Incomes 133% to 300% of

Poverty: Data for Health Insurance Exchange Outreach, 2011, California Rural Indian Health Board

Centers for Medicare and Medicaid: Health Care Reform: Health Care Reform: Tracking Tribal, Federal, and State Implementation

U.S. Census Bureau. American Community Survey (ACS) 2008,2009, 2010, 3 year 2008-2010. American Community Survey accessed through Factfinder2 for 3 year reports for years 2008, 2009, 2010.

Agency for Healthcare Research and Quality (AHRQ), Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey-Insurance Component (MEPS-IC). Table II.A.2 (2009), available at http://www.meps.ahrq.gov/mepsweb/data_stats/summ_tables/insr/state/series_2/2009/tiia2. pdf

Reports based on the Current Population Survey do not include reports on AIANs due to the small sample size. This was even true for the State of California’s recent Employee Benefit Research Institute estimates (in California Health Almanac; California’s Uninsured, December 2011) for race/ethnicity based on the CPS---despite the largest in the nation AIAN population of over 800,000 in 2010.