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entitled 'Indian Health Service: Most American Indians and Alaska 
Natives Potentially Eligible for Expanded Health Coverage, but Action 
Needed to Increase Enrollment' which was released on August 23, 2013. 

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United States Government Accountability Office: 
GAO: 

Report to Congressional Addressees: 

September 2013: 

Indian Health Service: 

Most American Indians and Alaska Natives Potentially Eligible for 
Expanded Health Coverage, but Action Needed to Increase Enrollment: 

GAO-13-553: 

GAO Highlights: 

Highlights of GAO-13-553, a report to congressional addressees. 

Why GAO Did This Study: 

IHS provides care to American Indians and Alaska Natives through a 
system of health care facilities. PPACA provides states the option to 
expand their Medicaid programs and creates new health care coverage 
options, including for American Indians and Alaska Natives, beginning 
in 2014. PPACA also requires GAO to study IHS’s coordination with 
public programs. In this report, GAO (1) estimated the number of 
American Indians and Alaska Natives potentially eligible for the 
expanded and new coverage options; and (2) reviewed efforts by IHS, 
CMS, states, tribal organizations, and facilities to promote 
enrollment of American Indians and Alaska Natives in current programs 
and expanded and new coverage options, and any challenges associated 
with their enrollment. 

To address the objectives, GAO (1) analyzed U.S. Census Bureau data, 
and (2) interviewed IHS and CMS officials, and state, facility, and 
tribal officials from three IHS areas with high levels of uninsured. 

What GAO Found: 

GAO estimates, on the basis of recent U.S. Census Bureau data, that 
most American Indians and Alaska Natives will be potentially eligible 
for either expanded or new coverage options created by the Patient 
Protection and Affordable Care Act (PPACA). These options include 
expanded eligibility for Medicaid—the federal-state program for 
certain low-income individuals—and eligibility for the Health 
Insurance Exchanges (“Exchanges”), which are marketplaces where health 
insurance plans can be compared and purchased. While it is still 
unclear which states will opt to expand Medicaid, their decisions may 
affect a large proportion of American Indians and Alaska Natives, as 
GAO estimates that potential new enrollment could include about a 
quarter of this population. For example, in the Oklahoma City area-—
one of the Indian Health Service’s (IHS) 12 federally designated 
service areas-—tens of thousands of American Indians and Alaska 
Natives could be affected by the state of Oklahoma’s decision not to 
expand its Medicaid program. For the Exchanges, GAO found that more 
than one-third of American Indians and Alaska Natives are potentially 
eligible for premium tax credits in the Exchanges—-which help offset 
the cost of premiums for low-income individuals-—and nearly one-third 
are below the income threshold for cost-sharing exemptions, which are 
limited to enrolled members of federally recognized tribes. 

Some efforts have been made by IHS, the Centers for Medicare & 
Medicaid Services (CMS), and three states with high levels of 
uninsured to facilitate Medicaid enrollment through training of 
facility staff and conducting outreach for current public programs. 
However, uncertainty related to legal and policy decisions, lack of 
capacity building, unfamiliarity with expanded and new coverage 
options, and limited access to information present challenges to 
education and enrollment in expanded and new coverage options. While 
IHS and CMS have reported providing basic training on expanded 
Medicaid and the Exchanges, most of the facilities and tribes GAO 
interviewed said they received little or no information from IHS or 
CMS, as of February 2013. Many of the officials GAO interviewed—-from 
federal agencies, state Medicaid programs, and facilities—-said they 
delayed outreach and enrollment activities due to the uncertainty 
related to the Supreme Court decision about PPACA and states’ 
subsequent decisions about expanding Medicaid that were both pending 
at the time of our review. Although a Supreme Court decision had been 
issued and some state decisions had been made, IHS had not developed a 
plan to increase enrollment and billing capacity to accommodate the 
hundreds of thousands of American Indians and Alaska Natives 
potentially eligible for expanded and new coverage options. IHS 
officials told GAO, however, that the agency distributed a “business 
plan template” that directs IHS-operated facilities to plan for their 
community outreach and staff training needs in preparation for 
expanded Medicaid and the exchanges. This plan was to be submitted in 
May 2013. Additionally, some tribes noted that their Medicaid outreach 
efforts could be more targeted and effective if they had information 
from states about their members’ Medicaid coverage status. 

What GAO Recommends: 

GAO recommends that IHS and CMS coordinate to improve communication 
with facility staff and tribal leaders and increase outreach; that IHS 
realign its capacity to prepare for increased enrollment; and that CMS 
address issues related to sharing members’ coverage status with their 
tribes. 

In commenting on a draft of this report, HHS agreed with one 
recommendation, and neither agreed nor disagreed with the report’s 
other recommendations. HHS also provided technical comments, which GAO 
incorporated as appropriate. 

View [hyperlink, http://www.gao.gov/products/GAO-13-553]. For more 
information, contact Kathleen M. King at (202) 512-7114 or 
kingk@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Most American Indians and Alaska Natives Will Be Potentially Eligible 
for Expanded Medicaid and New Coverage Options; States' Decisions Will 
Affect Coverage for Many: 

Efforts Have Been Made to Enroll American Indians and Alaska Natives 
in Current Medicaid Programs, but Multiple Barriers May Hinder 
Enrollment in Expanded Medicaid and New Coverage Options: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Methodology for Estimating Potential Eligibility for 
American Indians and Alaska Natives in Expanded Health Coverage: 

Appendix II: Estimates of Potential Medicaid Eligibility for American 
Indians and Alaska Natives, by Indian Health Service (IHS) Area: 

Appendix III: Potential Eligibility for Expanded Health Coverage in 
2014, Nationally, by IHS Service Area, and by State: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014: 

Table 2: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for the Basic Health Program 
Option and for Cost-Sharing and Premium Tax Credits under the Health 
Insurance Exchanges Based on Responses to the U.S. Census Bureau's 
2009-2011 American Community Survey (ACS): 

Table 3: Estimates of the Number and Percentage of All Races 
Potentially Eligible for Expanded Medicaid in 2014, by Indian Health 
Service (IHS) Service Area: 

Table 4: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014, 
by State: 

Table 5: Estimates of the Number and Percentage of All Races 
Potentially Eligible for Expanded Medicaid in 2014, by State: 

Table 6: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for the Basic Health Program 
Option in 2015, and Cost-Sharing Exemptions and Premium Tax Credits 
under the Health Insurance Exchanges in 2014, by Indian Health Service 
(IHS) Service Area: 

Table 7: Estimates of the Number and Percentage of All Races 
Potentially Eligible for the Basic Health Program Option in 2015 and 
Premium Tax Credits under the Health Insurance Exchanges in 2014, by 
Indian Health Service (IHS) Service Area: 

Table 8: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for the Basic Health Program 
Option in 2015, and Cost-Sharing Exemptions and Premium Tax Credits 
under the Health Insurance Exchanges in 2014, by State: 

Table 9: Estimates of the Number and Percentage of All Races 
Potentially Eligible for the Basic Health Program Option in 2015 and 
Premium Tax Credits under the Health Insurance Exchanges in 2014, by 
State: 

Figures: 

Figure 1: The 12 IHS Service Areas, Shown with Contract Health Service 
Delivery Area (CHSDA) Counties Included in Each Area: 

Figure 2: Relationship between American Indians and Alaska Natives as 
Self-Reported to the Census, for IHS Eligibility, and for Tribal 
Membership: 

Figure 3: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014, 
by IHS Service Area: 

Figure 4: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014 
for IHS Service Areas and Non-IHS Service Areas: 

Abbreviations: 

ACS: American Community Survey: 

CHIP: Children's Health Insurance Program: 

CHIPRA: Children's Health Insurance Program Reauthorization Act of 
2009: 

CHS: Contract Health Services: 

CHSDA: Contract Health Service Delivery Area: 

CMS: Centers for Medicare & Medicaid Services: 

FPL: federal poverty level: 

HHS: Department of Health and Human Services: 

HIPAA: Health Insurance Portability and Accountability Act: 

IHS: Indian Health Service: 

IPUMS: Integrated Public Use Microdata Series: 

I/T/U: IHS facilities, tribal facilities, and urban Indian health 
programs: 

ISDEAA: Indian Self-Determination and Education Assistance Act: 

PPACA: Patient Protection and Affordable Care Act: 

PUMA: Public Use Microdata Areas: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

September 5, 2013: 

Congressional Addressees: 

The Indian Health Service (IHS), an agency within the Department of 
Health and Human Services (HHS), is responsible for providing health 
care for approximately 2.1 million American Indians and Alaska Natives 
who are members or descendants of federally recognized tribes. 
[Footnote 1] IHS provides this care through a system of health care 
facilities (facilities) managed by IHS, tribal organizations, or 
urban Indian health programs. However, American Indians and Alaska 
Natives have experienced long-standing problems accessing needed 
services, due in part to IHS funding constraints.[Footnote 2] Many 
users of IHS services are also eligible for public insurance programs--
Medicaid, the Children's Health Insurance Program (CHIP), and 
Medicare[Footnote 3]--which are overseen by another HHS agency, the 
Centers for Medicare & Medicaid Services (CMS). Enrollment of eligible 
American Indians and Alaska Natives in these public programs can 
improve access to health care by providing them with benefits more 
comprehensive than available through IHS and can also reduce pressure 
on IHS's budget. In its 2014 budget justification, IHS stated that 
reimbursements from public and private insurance are a significant 
part of IHS and tribal budgets and provide increased access to health 
services for American Indians and Alaska Natives.[Footnote 4] While 
both IHS and CMS have conducted outreach in the past to increase 
enrollment in public insurance programs, participation of American 
Indians and Alaska Natives in Medicaid and CHIP has been relatively 
low.[Footnote 5] 

The Patient Protection and Affordable Care Act (PPACA) expanded or 
created new health care coverage options that may benefit American 
Indians and Alaska Natives.[Footnote 6] 

* Medicaid eligibility will expand in 2014, in states opting to 
participate. This expansion will apply to Americans with incomes at or 
below 138 percent of the federal poverty level (FPL),[Footnote 7] 
including previously ineligible categories such as childless adults. 
[Footnote 8] 

* Health Insurance Exchanges ("Exchanges")[Footnote 9] will also be 
established in 2014, with enrollment beginning in October 2013. PPACA 
provides for a federal premium tax credit for eligible individuals 
obtaining insurance through the Exchanges with incomes between 100 and 
400 percent of the FPL, and certain American Indians and Alaska 
Natives are also eligible for cost-sharing exemptions if they have 
incomes at or below 300 percent of the FPL.[Footnote 10] 

* In 2015, states will have the option of implementing the new "Basic 
Health Program," under which the federal government is to give states 
95 percent of the premium tax credits and cost-sharing subsidies that 
would have been provided if the individuals had been enrolled through 
the Exchanges, to allow the states to provide coverage to certain low-
income residents with incomes between 138 and 200 percent of the FPL, 
who--despite the expansion of Medicaid and establishment of Exchanges--
might otherwise go uninsured. 

Although reimbursements from Medicaid or insurance obtained through an 
Exchange or Basic Health Program have the potential to alleviate some 
constraints on the IHS budget, eligible individuals must first be 
aware of and enroll in these programs and options, and choose to 
receive care through IHS.[Footnote 11] PPACA required that GAO examine 
IHS's coordination of health care services provided through other 
public insurance programs.[Footnote 12] This report specifically 
focuses on the expanded and new coverage options soon to be available 
to American Indians and Alaska Natives. This report: 

1. estimates the number of American Indians and Alaska Natives 
potentially eligible for the expanded and new coverage options; and: 

2. reviews efforts by IHS, CMS, states, tribal organizations, and 
facilities to promote enrollment of American Indians and Alaska 
Natives in current programs and the expanded and new coverage options, 
and any challenges associated with their enrollment. 

To estimate the number of American Indians and Alaska Natives 
potentially eligible for the expanded and new coverage options, we 
examined data from the American Community Survey (ACS)[Footnote 13] of 
the U.S. Census Bureau, which contains information on race, age, 
income, and health insurance coverage, among other variables, for 
millions of households. In order to capture the appropriate family 
ties and income for determining program eligibility, we used an 
augmented version of the ACS data prepared by the University of 
Minnesota Population Center--the Integrated Public Use Microdata 
Series (IPUMS).[Footnote 14] We used the most recent 3-year data 
available--2009 through 2011[Footnote 15]--to provide estimates at the 
national, IHS area,[Footnote 16] and state levels beginning in 2014. 
For expanded Medicaid,[Footnote 17] we estimated the total number of 
American Indians and Alaska Natives who are: 

* potentially eligible, including: (1) all American Indians and Alaska 
Natives at or below 138 percent of the FPL,[Footnote 18] (2) American 
Indians and Alaska Natives above 138 of the FPL who were eligible for 
Medicaid in each state,[Footnote 19] (3) American Indians and Alaska 
Natives who received Supplemental Security Income,[Footnote 20] and 
(4) American Indians and Alaska Natives who reported in the ACS as 
being enrolled in Medicaid;[Footnote 21] 

* currently enrolled in Medicaid, meaning individuals who reported in 
the ACS as being currently enrolled; and: 

* potential new Medicaid enrollees, including individuals who will be 
newly eligible for expanded Medicaid and some who are eligible now but 
did not report to ACS as being currently enrolled. 

We also estimated the number of American Indians and Alaska Natives 
potentially eligible for the Basic Health Program option beginning in 
2015, and income-based cost-sharing exemptions and premium tax credits 
in the Exchanges beginning in 2014.[Footnote 22] Because the number of 
IHS eligible individuals is likely to be between the number 
identifying solely as American Indian and Alaska Native and the number 
identifying as American Indian and Alaska Native alone or in 
combination with another racial/ethnic group, we present results for 
both groups to show the range within which the number who are IHS-
eligible is likely to fall.[Footnote 23] In the absence of information 
on IHS eligibility status of respondents, this approach allowed us to 
present a lower and upper bound for these estimates. 

To assess the precision of ACS estimates, which are subject to some 
sampling error, we calculated a relative standard error for each 
estimate. Unless otherwise noted, we present estimates that have 
relative standard errors of less than 15 percent. We assessed the 
reliability of 2009-2011 ACS data by reviewing documentation and 
discussing the database with knowledgeable officials. After taking 
these steps we determined the data were sufficiently reliable for our 
purposes. See appendix I for more details about our methodology for 
estimating the number of American Indians and Alaska Natives 
potentially eligible for the expanded and new coverage options. 

To review efforts to promote the enrollment--through training and 
outreach--of American Indians and Alaska Natives in both the current 
programs and expanded and new coverage options, and to identify any 
associated challenges, we examined actions taken by IHS, CMS, states, 
tribal organizations, and facilities. Specifically, we reviewed their 
recent and planned efforts to facilitate enrollment of American 
Indians and Alaska Natives into Medicaid under states' current 
Medicaid and CHIP programs. We also examined efforts to prepare for 
the increase in American Indians and Alaska Natives eligible for 
expanded Medicaid or the new coverage options, specifically the 
Exchanges.[Footnote 24] We also consulted our prior work for 
descriptions of initial outreach initiatives that encouraged 
enrollment in other relatively recent federal programs, such as CHIP 
and the Medicare Part D prescription drug benefit. In addition, we 
examined whether efforts to promote enrollment included an emphasis on 
eligibility for expanded Medicaid and the new coverage options, the 
extent to which IHS has coordinated and communicated with other 
entities in its efforts, and the extent to which IHS has managed its 
personnel to prepare for increased enrollment.[Footnote 25] We 
obtained this information through interviews with: IHS headquarters 
officials; CMS officials, including members of its Tribal Affairs 
Group, Center for Medicaid and CHIP Services, and Center for Consumer 
Information and Insurance Oversight; and national associations 
representing tribal and urban Indian health organizations. In 
addition, we selected a sample of three IHS service areas to obtain 
additional information--Aberdeen, Albuquerque, and Billings--on the 
basis of the percentage of American Indians and Alaska Natives in 
these areas who were uninsured.[Footnote 26] Within each, we 
interviewed officials from the IHS area office, the Medicaid program 
of the state in which the area office is located, and, in the same 
state, an IHS-operated health facility, a tribally operated Indian 
health facility, an urban Indian health program, and a tribal outreach 
grantee who received funds appropriated by the Children's Health 
Insurance Program Reauthorization Act of 2009 (CHIPRA).[Footnote 27] 
We conducted these interviews from June through August 2012, and 
obtained updated information from these officials in February 2013. We 
asked officials a standard set of open-ended questions and did not 
independently validate their reported experiences. Given the small 
number of each type of entity included in the areas in our sample and 
our process for selecting them, the results from these interviews are 
not generalizable to all areas. 

We conducted this performance audit from February 2012 to August 2013 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

The health care coverage options established by PPACA have 
implications for how American Indians and Alaska Natives may receive 
and pay for their future health care needs. 

The IHS System: 

IHS was established as an HHS agency for the purpose of providing, or 
arranging for, health care to American Indians and Alaska Natives--a 
responsibility of the United States established in treaty and law. IHS 
has headquarters based in the Washington, D.C., area, but is organized 
into 12 federally designated geographic service areas that cover all 
or part of 35 states (see fig. 1).[Footnote 28] IHS provides health 
care services directly through a system of facilities--hospitals, 
health clinics, and health stations--operated by IHS (for "direct 
service" tribes), by tribes or tribal organizations themselves, 
[Footnote 29] or by urban Indian health programs. This system is often 
referred to collectively as "I/T/U." When health care services at IHS 
or tribally operated facilities, referred to as direct care services, 
are not available, care may be obtained from external providers and 
paid for through IHS's Contract Health Services (CHS) program. 
However, as we have noted in past reports, IHS is not able to pay for 
all eligible health care services--through direct care services and 
services obtained through the CHS program--leading to an unmet need 
for health care services.[Footnote 30] Additionally, services obtained 
through the CHS program are generally limited to individuals who live 
on a federally recognized Indian reservation or within a designated 
Contract Health Service Delivery Area (CHSDA).[Footnote 31] American 
Indians and Alaska Natives living outside of these areas, which may 
include many urban Indians, therefore are unlikely to be eligible for 
CHS program services. 

Figure 1: The 12 IHS Service Areas, Shown with Contract Health Service 
Delivery Area (CHSDA) Counties Included in Each Area: 

[Refer to PDF for image: illustrated U.S. map] 

The 12 IHS Service Areas: 

Nashville; 
Bemidji; 
Oklahoma City; 
Aberdeen; 
Billings; 
Albuquerque; 
Navajo; 
Tucson; 
Phoenix; 
Portland; 
California; 
Alaska. 

Also depicted: 

Counties in both California and Phoenix; 
Counties in both Phoenix and Tucson; 
Counties in both Phoenix and Navajo; 
Counties in both Navajo and Albuquerque. 

Source: GAO analysis of IHS information. 

Note: While CHSDAs, which make up IHS service areas, are typically 
counties, the city of Elton, Louisiana, is also designated as a CHSDA 
in the Nashville area. 

[End of figure] 

In addition to IHS funding, I/T/U facilities can use reimbursements 
from third-party payers for services they provide to patients as an 
additional source of funds, and IHS may not reduce funding to tribally 
operated facilities and urban Indian health programs because of such 
reimbursements.[Footnote 32] For direct care services, I/T/Us are 
authorized to bill third-party payers, including public and private 
insurance, for care provided to enrolled patients. For both tribal and 
IHS-operated CHS programs, any alternate sources of coverage that may 
be available to a patient, including Medicare, Medicaid, CHIP, and 
private insurance, must pay for services before the CHS program, as 
I/T/Us are generally the payers of last resort.[Footnote 33] Increased 
enrollment in alternative sources of coverage among American Indians 
and Alaska Natives could thus increase revenue for I/T/U facilities if 
these individuals choose to receive care through IHS, improving access 
to care and reducing the level of unmet need American Indians and 
Alaska Natives experience. Increased enrollment in alternative sources 
of coverage may allow American Indians and Alaska Natives more options 
for care, if options exist in their community outside the I/T/U 
system, potentially resulting in fewer American Indians and Alaska 
Natives seeking care through I/T/U facilities. 

To be eligible for IHS services, an individual must be closely 
affiliated with an American Indian or Alaska Native community that is 
federally recognized, but not necessarily an official member of a 
tribe. IHS tracks the number of users treated at IHS operated 
facilities, although the number of American Indians and Alaska Natives 
potentially eligible for IHS services is unknown. The Census Bureau 
produces data on the number of individuals identifying as American 
Indian and Alaska Native alone or in combination with another race. 
[Footnote 34] In the 2010 Census, 5.2 million people identified as 
American Indian and Alaska Native alone or in combination with another 
race (2.9 million as American Indian and Alaska Native alone). IHS-
eligible individuals are a subset of this population. (See figure 2.) 

Figure 2: Relationship between American Indians and Alaska Natives as 
Self-Reported to the Census, for IHS Eligibility, and for Tribal 
Membership: 

[Refer to PDF for image: illustration] 

Set: Self-reported to Census; 
Subset: IHS eligible; 
Subset of IHS eligible: Tribal member. 

Source: GAO presentation of information from interviews with IHS 
officials. 

Note: Figure reflects the general relationship, not actual size, of the 
populations. 

[End of figure] 

PPACA Provisions Affecting American Indians and Alaska Natives: 

In 2014, in states opting to participate in Medicaid expansion, 
eligibility will expand to those with incomes at or below 138 percent 
of the federal poverty level (FPL).[Footnote 35] Unlike current 
Medicaid eligibility rules that require an individual to meet both 
income and categorical requirements--such as children and pregnant 
women--eligibility under expanded Medicaid will apply to all 
individuals, including American Indians and Alaska Natives, at or 
below 138 percent of the FPL, including groups previously not 
eligible, such as childless adults. For those individuals obtaining 
insurance through the Exchanges beginning in 2014, PPACA includes a 
federal premium tax credit for eligible individuals whose incomes are 
between 100 and 400 percent of the FPL, and who do not have access to 
public insurance such as Medicaid or CHIP.[Footnote 36] PPACA also 
includes a number of Exchange-related provisions specific to American 
Indians and Alaska Natives, including eliminating cost-sharing, such 
as deductibles and copays, for services provided to certain enrollees 
at or below 300 percent of the FPL, or for services provided by 
I/T/Us, regardless of the enrollee's income.[Footnote 37] 
Additionally, expected to begin in 2015, states may implement the 
Basic Health Program option, under which the federal government is to 
give states 95 percent of the premium tax credits and cost-sharing 
subsidies that would have been provided if the individuals had been 
enrolled in the Exchanges to allow the states to provide coverage for 
individuals, including American Indians and Alaska Natives, with 
incomes between 138 and 200 percent of the FPL. Finally, although 
PPACA generally requires that individuals obtain health insurance or 
be subject to a federal tax--a requirement often referred to as the 
individual mandate--certain American Indians and Alaska Natives are 
statutorily exempt--specifically, those who are members of federally 
recognized tribes.[Footnote 38] In June 2013, after this draft report 
was submitted to the agency for review and comment, HHS released a 
final rule establishing additional exemptions for specified 
individuals under its authority to establish hardship exemptions. The 
final rule included a hardship exemption for American Indians and 
Alaska Natives eligible for services from an Indian health care 
provider who are not members of federally recognized tribes.[Footnote 
39] Without this hardship exemption, American Indians and Alaska 
Natives who were not enrolled in a federally recognized tribe, but who 
were still eligible for IHS services--for example, nonmember 
descendents--would have been subject to the individual mandate. 

Because of the definitions used in PPACA to specify eligibility for 
certain benefits, certain groups of American Indians and Alaska 
Natives participating in the Exchanges will not be eligible for 
certain benefits available beginning in 2014 compared to other 
American Indians and Alaska Natives. Specifically, exemption from cost-
sharing such as deductibles and copays, as well as special monthly 
enrollment periods[Footnote 40]--apply to "Indians," a term that is 
defined in PPACA provisions by reference to definitions found in other 
federal statutes that define Indians as members of federally 
recognized tribes.[Footnote 41] Consistent with the PPACA provisions, 
CMS's final rule for the establishment of the Exchanges provided that 
the benefits related to cost-sharing and special enrollment periods 
apply only to members of federally recognized tribes. CMS officials 
involved with the design of the single, streamlined application for 
health insurance--a PPACA requirement--told us that the application 
will include a section of questions specific to American Indians and 
Alaska Natives, including information about membership in a federally 
recognized tribe.[Footnote 42] PPACA also requires establishment of 
application assistance programs,[Footnote 43] which may help American 
Indians and Alaska Natives understand which provisions apply to them. 

Consequently, these benefits may not apply to American Indians and 
Alaska Natives eligible for IHS services who: 

* live in urban locations and use urban Indian health programs, but 
who are not able to obtain tribal enrollment because they do not meet 
residency or other requirements, or are unable to document their 
descent, 

* are affiliated with an Indian tribe but do not meet the tribe's 
minimum blood quantum requirements for enrollment, and: 

* would otherwise be eligible for tribal membership, except for 
certain requirements set by the tribe: for example, some tribes limit 
their membership to adults or base membership on matrilineal descent. 
[Footnote 44] 

We and others have noted in past reports that American Indians and 
Alaska Natives may face challenges in enrolling in Medicaid, CHIP, and 
Medicare.[Footnote 45] According to a CMS-funded research paper, 
American Indians and Alaska Natives, and agencies seeking to enroll 
them in public programs, face unique challenges to enrollment, as well 
as other challenges common to rural populations.[Footnote 46] Some 
challenges described relate to the relationship between the federal 
government and tribes and the treaty agreements and statutes that 
established a responsibility to provide health care--for example, the 
belief by some American Indians and Alaska Natives that such 
responsibility means that tribal members should not have to apply for 
assistance through public programs. This government-to-government 
relationship may also make some tribes hesitant to interact with state-
run programs. Other challenges reported include lack of awareness 
about health care coverage programs generally; limited knowledge of 
benefits and eligibility criteria for programs; significant 
transportation challenges, and language and literacy barriers; the 
complexity of application and renewal processes for health care 
coverage programs; and cultural barriers. According to the same CMS-
funded report, because a large proportion of American Indians and 
Alaska Natives reside in rural areas on reservations with high poverty 
rates and low educational levels, these challenges may be significant 
deterrents to enrollment. 

Prior CMS Outreach and Enrollment Efforts: 

HHS has previously managed successful outreach and enrollment 
campaigns that may provide lessons learned, such as for the CHIP and 
the Medicare Part D prescription drug benefit programs. CHIP was 
established in August 1997 to reduce the number of low-income 
uninsured children in families with incomes too high to qualify for 
Medicaid. Medicare Part D was authorized in 2003 to provide an 
outpatient prescription drug benefit to millions of people already 
enrolled in Medicare.[Footnote 47] As we and others have noted in 
previous reports,[Footnote 48] both programs relied heavily on large-
scale media campaigns to raise awareness among the general public. For 
CHIP, state outreach efforts encompassed multiple marketing approaches 
including multimedia campaigns, direct mailings, toll-free hotlines, 
widespread distribution of applications, and community- and school-
based enrollment campaigns. In promoting Medicare Part D and the 
temporary drug discount card that preceded it, CMS employed a mass-
media campaign comprised of large-scale advertising, direct mail, a 
dedicated website, and a toll-free hotline, as well as one-on-one 
counseling and partnerships with community organizations. Enrollment 
in both CHIP and Medicare Part D was high as the programs began, and 
increased steadily over time.[Footnote 49] 

Despite the gains in CHIP enrollment over the last decade, in 2009 
Congress recognized that some children eligible for CHIP, as well as 
Medicaid, were still not enrolled, and therefore included in CHIPRA 
funds for Medicaid and CHIP outreach targeted at enrollment. Of this 
funding, CHIPRA provided $10 million for the Secretary of Health and 
Human Services to award grants to I/T/Us to conduct outreach and 
enrollment efforts to increase Medicaid and CHIP coverage among 
American Indian and Alaska Native children.[Footnote 50] Most of the 
funding, administered by CMS, was awarded in 2010 to 41 organizations 
in 19 states. 

Most American Indians and Alaska Natives Will Be Potentially Eligible 
for Expanded Medicaid and New Coverage Options; States' Decisions Will 
Affect Coverage for Many: 

We estimate that, beginning in 2014, hundreds of thousands--more than 
half--of American Indians and Alaska Natives will be potentially 
eligible for health care coverage through Medicaid or the Basic Health 
Program, or for cost-sharing exemptions and premium tax credits for 
insurance obtained through the Exchanges. States' decisions whether to 
expand their Medicaid programs may affect coverage for many American 
Indians and Alaska Natives, however. 

More Than Half of American Indians and Alaska Natives Will Be 
Potentially Eligible for Coverage under Expanded Medicaid Depending on 
the Number of Participating States: 

If all states opt to expand their Medicaid programs, we estimate that 
more than half of all American Indians and Alaska Natives will be 
potentially eligible for Medicaid[Footnote 51] in 2014. Excluding 
those already enrolled, potential new enrollment in Medicaid could 
exceed 650,000 out of 2.4 million (27 percent) for those identifying 
as American Indians and Alaska Natives alone, and almost 1.2 million 
out of 4.8 million (25 percent) for those identifying as American 
Indians and Alaska Natives alone or in combination with another race. 
[Footnote 52] Compared to the general population, a significantly 
larger proportion of American Indians and Alaska Natives are 
potentially eligible for expanded Medicaid. Potential new enrollment 
among American Indians and Alaska Natives is also proportionally 
greater than among the general population. (See table 1.) 

Table 1: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014: 

Population group (number): American Indian and Alaska Native alone (2.4 
million from ACS); 
Total potentially eligible number (percent): 1,368,316 (58%); 
Current enrollment[A] number (percent): 718,254 (30%); 
Potential new enrollment[B] number (percent): 650,062 (27%). 

Population group (number): American Indian and Alaska Native alone or 
in combination with another race (4.8 million from ACS); 
Total potentially eligible number (percent): 2,569,410 (54%); 
Current enrollment[A] number (percent): 1,377,924 (29%); 
Potential new enrollment[B] number (percent): 1,191,486 (25%). 

Population group (number): All races (309.2 million from ACS); 
Total potentially eligible number (percent): 115,749,838 (37%); 
Current enrollment[A] number (percent): 53,196,416 (17%); 
Potential new enrollment[B] number (percent): 62,553,422 (20%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend 
to participate, they may opt to do so at a later date. We did not 
predict the number of people who will participate in this program, 
commonly referred to as the take-up rate. 

Because the number of IHS-eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[End of table] 

These estimates reflect all potential new enrollment, including both 
those who may be newly eligible under 2014 eligibility rules and not 
enrolled, as well as individuals currently eligible but not enrolled. 
Nationally, among those identifying as American Indians and Alaska 
Natives alone, about 16 percent will be newly eligible and about 11 
percent are currently eligible but not enrolled.[Footnote 53] Among 
those identifying as American Indians and Alaska Natives alone or in 
combination with another race, about 15 percent will be newly eligible 
and about 10 percent are currently eligible but not enrolled. While 
not all eligible individuals will enroll, the extent to which American 
Indians and Alaska Natives enroll in these programs is unknown. 

The 12 IHS service areas varied widely in the number and proportion of 
American Indians and Alaska Natives potentially eligible for Medicaid 
under 2014 rules and for potential new enrollment. The Oklahoma City 
area--the IHS service area with the largest population of American 
Indians and Alaska Natives--had large numbers and percentages of 
American Indians and Alaska Natives potentially eligible for Medicaid 
and of potential new enrollment.[Footnote 54] The highest percentages 
of individuals potentially eligible for Medicaid were in the Aberdeen 
area for those identifying solely as American Indians and Alaska 
Natives (73 percent), and in the Navajo area for those identifying as 
American Indians and Alaska Natives alone or in combination with 
another race (71 percent). (See figure 3). 

Figure 3: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014, 
by IHS Service Area: 

[Refer to PDF for image: stacked horizontal bar graph] 

American Indian/Alaska Native alone: 

Aberdeen: 
Current enrollment[A]: 55%; 
Potential new enrollment[B]: 45%; 
Number potentially eligible: 43,541. 

Alaska: 
Current enrollment[A]: 48%; 
Potential new enrollment[B]: 52%; 
Number potentially eligible: 35,959. 

Albuquerque: 
Current enrollment[A]: 52%; 
Potential new enrollment[B]: 48%; 
Number potentially eligible: 39,375. 

Bemidji: 
Current enrollment[A]: 59%; 
Potential new enrollment[B]: 41%; 
Number potentially eligible: 30,846. 

Billings: 
Current enrollment[A]: 51%; 
Potential new enrollment[B]: 49%; 
Number potentially eligible: 14,007. 

California: 
Current enrollment[A]: 53%; 
Potential new enrollment[B]: 47%; 
Number potentially eligible: 31,267. 

Nashville: 
Current enrollment[A]: 53%; 
Potential new enrollment[B]: 47%; 
Number potentially eligible: 22,306. 

Navajo: 
Current enrollment[A]: 58%; 
Potential new enrollment[B]: 42%; 
Number potentially eligible: 105,348. 

Oklahoma City: 
Current enrollment[A]: 42%; 
Potential new enrollment[B]: 58%; 
Number potentially eligible: 70,399. 

Phoenix: 
Current enrollment[A]: 52%; 
Potential new enrollment[B]: 48%; 
Number potentially eligible: 72,045. 

Portland: 
Current enrollment[A]: 55%; 
Potential new enrollment[B]: 45%; 
Number potentially eligible: 42,755. 

Tucson: 
Current enrollment[A]: 64%; 
Potential new enrollment[B]: 36%; 
Number potentially eligible: 16,210. 

American Indian/Alaska Native alone or in combination with another 
race: 

Aberdeen: 
Current enrollment[A]: 54%; 
Potential new enrollment[B]: 46%; 
Number potentially eligible: 50,774. 

Alaska: 
Current enrollment[A]: 48%; 
Potential new enrollment[B]: 52%; 
Number potentially eligible: 43,106. 

Albuquerque: 
Current enrollment[A]: 51%; 
Potential new enrollment[B]: 49%; 
Number potentially eligible: 46,984. 

Bemidji: 
Current enrollment[A]: 59%; 
Potential new enrollment[B]: 41%; 
Number potentially eligible: 50,093. 

Billings: 
Current enrollment[A]: 52%; 
Potential new enrollment[B]: 48%; 
Number potentially eligible: 15,623. 

California: 
Current enrollment[A]: 55%; 
Potential new enrollment[B]: 45%; 
Number potentially eligible: 61,468. 

Nashville: 
Current enrollment[A]: 55%; 
Potential new enrollment[B]: 45%; 
Number potentially eligible: 49,581. 

Navajo: 
Current enrollment[A]: 58%; 
Potential new enrollment[B]: 42%; 
Number potentially eligible: 108,384. 

Oklahoma City: 
Current enrollment[A]: 46%; 
Potential new enrollment[B]: 54%; 
Number potentially eligible: 134,940. 

Phoenix: 
Current enrollment[A]: 52%; 
Potential new enrollment[B]: 48%; 
Number potentially eligible: 86,489. 

Portland: 
Current enrollment[A]: 57%; 
Potential new enrollment[B]: 43%; 
Number potentially eligible: 82,777. 

Tucson: 
Current enrollment[A]: 64%; 
Potential new enrollment[B]: 36%; 
Number potentially eligible: 18,014. 

Source: GAO analysis of 2009-2011 American Community Survey (ACS) 
three-year estimates, U.S. Census Bureau. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend 
to participate, they may opt to do so at a later date. We did not 
predict the number of people who will participate in this program, 
commonly referred to as the take-up rate. 

Because the number of IHS-eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[End of figure] 

While many American Indians and Alaska Natives in IHS service areas 
reflected potential new enrollment for Medicaid--we estimate about 
405,000 for American Indian and Alaska Native alone, and about 605,000 
for American Indian and Alaska Native alone or in combination with 
another race--a large number of American Indians and Alaska Natives 
living outside of IHS service areas are also potentially eligible, and 
reflected a large number of potential new enrollees--we estimate about 
245,000 for American Indian and Alaska Native alone, and 587,000 for 
American Indian and Alaska Native alone or in combination with another 
race. (See figure 4.) American Indians and Alaska Natives living 
outside IHS service areas were more likely to identify as American 
Indian or Alaska Native in combination with another race. Individuals 
living outside IHS service areas are less likely to have access to IHS 
or tribal health services. For American Indians and Alaska Natives not 
located in IHS service areas, states' decisions regarding Medicaid 
expansion could affect their coverage options and access to care, 
particularly if those American Indians and Alaska Natives living 
outside IHS service areas are not eligible for services at federally 
or tribally operated facilities, a group which may include many urban 
Indians. Appendix II provides more information on the estimated 
numbers and percentages of American Indians and Alaska Natives 
potentially eligible for expanded Medicaid, by IHS service area. 

Figure 4: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid in 2014 
for IHS Service Areas and Non-IHS Service Areas: 

[Refer to PDF for image: 4 pie-charts and 4 subcharts] 

American Indian/Alaska Native alone (1.4 million potentially eligible): 

IHS service areas: 
Not potentially eligible: 40%; 
Potentially eligible: 60%; 
Of the 850,039 potentially eligible: 
Current enrollment[A]: 32% (445,208); 
Potential new enrollment[B]: 29% (404,830). 

Non-IHS service areas: 
Not potentially eligible: 46%; 
Potentially eligible: 54%; 
Of the 518,276 potentially eligible: 
Current enrollment[A]: 28% (273,045); 
Potential new enrollment[B]: 25% (245,231). 

American Indian/Alaska Native alone or in combination with another race
(2.6 million potentially eligible): 

IHS service areas: 
Not potentially eligible: 43%; 
Potentially eligible: 57%; 
Of the 1.3 million potentially eligible: 
Current enrollment[A]: 30% (685,895); 
Potential new enrollment[B]: 27% (604,964). 

Non-IHS service areas: 
Not potentially eligible: 49%; 
Potentially eligible: 51%; 
Of the 1.3 million potentially eligible: 
Current enrollment[A]: 28% (692,028); 
Potential new enrollment[B]: 23% (586,521). 

Source: GAO analysis of 2009-2011 American Community Survey (ACS) 
three-year estimates, U.S. Census Bureau. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates, 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend to 
participate, they may opt to do so at a later date. We did not predict 
the number of people who will participate in this program, commonly 
referred to as the take-up rate. 

Because the number of IHS-eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who are eligible now, but did 
not report to ACS as being currently enrolled. Percentages of current 
enrollment and potential new enrollment may not add up to the total of 
potentially eligible due to rounding. 

[End of figure] 

Our analysis assumed that all states would opt to participate in the 
expanded Medicaid program; however, some IHS service areas have large 
American Indian and Alaska Native populations located in states that 
may choose not to expand their Medicaid programs. This would limit 
access to Medicaid benefits for those who would be eligible for 
expanded Medicaid, as well as limit I/T/U facilities' ability to 
obtain Medicaid revenue for services provided to these individuals. 
For example, Oklahoma announced in November 2012 that the state would 
not pursue Medicaid expansion. In the state of Oklahoma alone, which 
comprises most of the Oklahoma City IHS service area, we estimate that 
potential new enrollment for Medicaid in 2014 would exceed 76,000 for 
individuals identifying as American Indians and Alaska Natives alone 
and more than 137,000 for those identifying as American Indians and 
Alaska Natives alone or in combination with another race.[Footnote 55] 
According to CMS officials, states have not been given a deadline to 
declare their interest in expanding Medicaid. Some states have 
expressed intent to expand their programs, while others have indicated 
they will not participate.[Footnote 56] See appendix III for state-
level estimates of potential new Medicaid enrollment to understand the 
effect of each state's decision regarding Medicaid expansion. 

About 35 Percent of American Indians and Alaska Natives Are 
Potentially Eligible for One or More Special Provisions under New 
Coverage Options: 

More than one-third of certain American Indians and Alaska Natives may 
also be potentially eligible for premium tax credits for insurance 
obtained through the Exchanges, many of whom would also be eligible 
for cost-sharing protections and, to a lesser extent, the Basic Health 
Program, on the basis of our estimates. Specifically, about 832,000 
American Indians and Alaska Natives who identified as American Indians 
and Alaska Natives alone are potentially eligible for premium tax 
credits, as are 1.7 million who identified as American Indians and 
Alaska Natives alone or in combination with another race. More than 
623,000 American Indians and Alaska Natives who identified as American 
Indians and Alaska Natives alone are within the income range for cost-
sharing exemptions for insurance obtained through the Exchanges, as 
are almost 1.3 million who identified as American Indians and Alaska 
Natives alone or in combination with another race.[Footnote 57] If all 
states decided to run a Basic Health Program,[Footnote 58] we estimate 
that more than 292,000 American Indians and Alaska Natives who 
identified as American Indians and Alaska Natives alone could be 
covered, as well as about 593,000 American Indians and Alaska Natives 
who identified as American Indians and Alaska Natives alone or in 
combination with another race. Unlike potential eligibility for 
Medicaid, the percentages of American Indians and Alaska Natives 
potentially eligible for the Basic Health Program and cost-sharing 
exemptions and premium tax credits for insurance obtained through the 
Exchanges are comparable to the general population at the same income 
levels. (See table 2.) Appendix III provides more information on 
American Indians and Alaska Natives' potential eligibility for public 
programs. 

Table 2: Estimates of the Number and Percentage of American Indians 
and Alaska Natives Potentially Eligible for the Basic Health Program 
Option and for Cost-Sharing and Premium Tax Credits under the Health 
Insurance Exchanges Based on Responses to the U.S. Census Bureau's 
2009-2011 American Community Survey (ACS): 

Population group (number): American Indian and Alaska Native alone (2.4 
million from ACS); 
Basic Health Program option[A] number (percent): 292,599 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 623,890 (26%); 
Exchange premium tax credits[C] number (percent): 831,985 (35%). 

Population group (number): American Indian and Alaska Native alone or 
in combination with another race (4.8 million from ACS); 
Basic Health Program option[A] number (percent): 593,367 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 1,290,362 (27%); 
Exchange premium tax credits[C] number (percent): 1,744,651 (37%). 

Population group (number): All races (309.2 million from ACS); 
Basic Health Program option[A] number (percent): 35,432,727 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 82,560,360 (27%); 
Exchange premium tax credits[C] number (percent): 118,632,279 (38%). 

Source: GAO analysis U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Because the number of IHS-eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

We did not predict the number of people who will participate in these 
new coverage options, commonly referred to as the take-up rate. 

Certain individuals who are eligible for the premium tax credits may 
also be eligible for cost-sharing exemptions. 

[A] Beginning in 2015, states may opt to run a Basic Health Program 
for individuals between 138 and 200 percent of the federal poverty 
level (FPL). These estimates are if all states opt to run a Basic 
Health Program. 

[B] Certain American Indians and Alaska Natives obtaining insurance 
through the Exchanges who are at or below 300 percent of the FPL are 
exempt from cost-sharing, such as deductibles and copays, although our 
estimates reflect only those above 138 percent of the FPL because 
individuals below this level would be potentially eligible for 
expanded Medicaid. While this provision applies only to certain 
American Indians and Alaska Natives and not the general population, we 
provide data here for all races at the same income level for 
comparison. 

[C] Individuals obtaining insurance through the Exchanges who are 
between 100 and 400 percent of the FPL are eligible for premium tax 
credits on a sliding scale, although our estimates reflect only those 
above 138 percent of the FPL because individuals below this level 
would be potentially eligible for expanded Medicaid. Individuals with 
incomes above 138 percent of the FPL who may be eligible for Medicaid 
in a particular state are not eligible for premium tax credits. 

[End of table] 

Efforts Have Been Made to Enroll American Indians and Alaska Natives 
in Current Medicaid Programs, but Multiple Barriers May Hinder 
Enrollment in Expanded Medicaid and New Coverage Options: 

Although efforts have been made by the federal agencies and states we 
interviewed to facilitate Medicaid enrollment through training of 
I/T/U facility staff and conducting outreach for current public 
programs, uncertainty, lack of capacity-building, and limited 
awareness and information present challenges to enrollment in expanded 
Medicaid and new coverage options.[Footnote 59] 

Most Efforts to Promote Enrollment in Current Medicaid Programs Were 
Conducted by I/T/U Facilities and Tribes; Limited Efforts Have Been 
Made regarding Expanded and New Coverage Options: 

IHS, CMS, and the three states we interviewed reported taking some 
steps to train I/T/U facility staff on current program eligibility; 
however, most efforts to facilitate enrollment of individuals in these 
programs have taken place at the tribal or facility level. 

IHS: 

According to IHS officials, the agency has collaborated with CMS to 
develop and disseminate information about program eligibility rules--
mainly on current programs with some limited information on the 
expanded and new coverage options--to I/T/U facilities and tribes 
through letters to tribal leaders, the IHS Director's Blog, regional 
and national tribal consultation meetings, annual business office 
training, and a combined IHS and CMS national training for I/T/Us 
called the National Partnership Conference. However, officials from 
most of the nine facilities and three tribes that we interviewed said 
that they received little or no guidance from IHS regarding expanded 
Medicaid or the Exchanges as of February 2013.[Footnote 60] In 
contrast, federal internal control standards specify that agency 
management should ensure that there are adequate means for timely and 
effective communication with stakeholders that have a significant 
effect on the agency achieving its goals. 

IHS officials told us that the agency does not conduct direct outreach 
to individual IHS users or to American Indian and Alaska Native 
communities at the headquarters level. Rather, direct outreach is 
generally conducted at the facility level by both tribally and 
federally operated facilities. The agency also contracts with other 
organizations to develop and disseminate outreach and educational 
materials. For PPACA-related outreach, the agency provided $1.8 
million in funding to three national tribal organizations--the 
National Indian Health Board, National Congress of American Indians, 
and National Council of Urban Indian Health--over fiscal years 2011 
through 2013 to develop and distribute materials for educating I/T/Us, 
tribes, and American Indian and Alaska Native communities about the 
expanded and new coverage options. These organizations have produced 
educational materials and tools designed to assist I/T/U 
administrators and tribal leaders in understanding PPACA-related 
changes, including Medicaid expansion and the Exchanges. They have 
also produced some training materials; however, additional direct 
outreach materials (such as mass media materials for general 
education, e.g., posters, videos, or mailers) for American Indians and 
Alaska Natives were still being developed and not widely disseminated 
as of April 2013. IHS also reported providing $3.7 million over fiscal 
years 2011 through 2013 to IHS area offices to educate tribes and 
organizations about PPACA, such as through briefing sessions for 
tribal leaders and facility staff. As the implementation of CHIP and 
Medicare Part D demonstrated, an effective outreach effort for 
building awareness of new programs and encouraging enrollment requires 
a large, multipronged effort, including the use of media, direct mail, 
one-on-one counseling, and partnerships with community organizations. 
IHS' efforts, however, do not match the large, multipronged efforts 
launched in advance of CHIP and Medicare Part D. 

Additionally, IHS officials told us that the agency distributed a 
"business plan template" in April 2013. Using this template, IHS 
facilities were expected to submit a business plan to their respective 
Area office director in May 2013. The business plan template, an 
initiative led by the IHS Deputy Director for Field Operations, is 
intended to help facilities identify and plan for their community 
outreach and staff training needs, among other things, in preparation 
for implementation of PPACA.[Footnote 61] Although IHS officials said 
these templates were also shared with tribal facilities and urban 
Indian health programs, only IHS facilities have been directed to 
submit them. IHS headquarters officials told us in April that the Area 
Directors would be responsible for reviewing the plans and at this 
time IHS's headquarters would not conduct any additional review or 
analysis. 

CMS: 

CMS has likewise reported disseminating information to I/T/U 
facilities about program eligibility rules under Medicaid and CHIP, 
and introductory material about the expanded and new coverage options, 
through regional and national training in collaboration with IHS, 
webinars, web-based videos, regular conference calls, and through the 
agency's regional Native American Contacts.[Footnote 62] However, 
officials from most of the nine facilities and three tribes that we 
interviewed said that they received little or no guidance from CMS 
regarding expanded Medicaid or the Exchanges as of February 2013, 
similar to what they reported about a lack of information from IHS. 
[Footnote 63] CMS officials indicated that additional, more-specific 
regional training on Medicaid expansion and the Exchanges would be 
planned after more states made decisions about whether to participate 
in expanded Medicaid or how Exchanges will operate. CMS officials also 
told us that they are planning nationwide training on PPACA-related 
changes, including expanded Medicaid and the Exchanges. The officials 
said this training is intended to include a broader audience than the 
past regional training and will include tribal and community leaders 
in addition to I/T/U facility staff. 

CMS officials described a variety of direct outreach materials the 
agency has developed to educate American Indian and Alaska Native 
communities about current Medicaid and CHIP, including posters, 
brochures, and DVDs, for use by facilities in promoting enrollment in 
current programs. Officials told us that, as part of the agency's 
implementation of provisions regarding expanded Medicaid and the 
Exchanges, its Office of Communications is developing a general 
outreach strategy, which will include an American Indian and Alaska 
Native-specific component led by the CMS Tribal Affairs Group in 
collaboration with IHS. In March 2013, officials told us they planned 
to implement this outreach strategy in the coming months, noting that 
they did not want to launch outreach too early because the application 
to enroll would not be available until October 2013.[Footnote 64] 
Officials also told us that they recently adapted materials developed 
for the general population by the Office of Communications with 
specific information on expanded Medicaid for American Indians and 
Alaska Natives, which were distributed in March 2013 to attendees of 
IHS regional tribal consultation meetings. In May 2013, CMS officials 
told us they recently launched a public website containing materials, 
including brochures, about the Exchanges for the general population, 
and were conducting a national awareness campaign about the Exchanges. 
As of May 2013, CMS was adapting the materials on the website for the 
American Indian and Alaska Native population, which were still under 
internal review.[Footnote 65] In addition, CMS officials told us they 
plan to issue an announcement later this year to provide an additional 
$4 million in funding specifically for tribal outreach for Medicaid 
and CHIP, as authorized by PPACA. The $10 million in CHIPRA tribal 
outreach grants CMS administered to 41 organizations in 2010 resulted 
in nearly 20,000 American Indian and Alaska Native children enrolled 
in the first 2 years of funding.[Footnote 66] Although the grants did 
not include an emphasis on the expanded and new coverage options, one 
CMS official noted that the lessons learned about effective tribal 
outreach through grantees' efforts can be applied to future years. 

States: 

Two of the three states we interviewed conducted training for facility 
staff on their current Medicaid and CHIP programs and all three 
produced outreach materials, although none were engaged in training or 
outreach for expanded Medicaid or the Exchanges as of February 2013. 
Specifically, Montana and New Mexico reported conducting some training 
for I/T/U facilities regarding program eligibility and enrollment 
procedures under current Medicaid and CHIP, but not for expanded 
Medicaid or the Exchanges. These states distributed Medicaid and CHIP 
information to facilities through training, regular meetings with 
business managers and, in Montana, on-site training. Although 
officials in South Dakota indicated the state had not conducted any 
training of its own, the state has provided materials for the IHS area 
office to distribute to facility staff with information on eligibility 
and enrollment procedures. Direct outreach to American Indians and 
Alaska Natives by all three states we spoke with was limited and 
focused on current Medicaid and CHIP programs. Specifically, all three 
states produced and distributed print materials promoting their 
current Medicaid and CHIP programs, such as brochures and posters, and 
New Mexico also conducted radio advertising. Additionally, in Montana, 
the Medicaid program provided reimbursement for outreach activities 
conducted by two tribes.[Footnote 67] None of the three states 
reported conducting any outreach regarding the expanded and new 
coverage options. 

Besides facility training and outreach as a means of facilitating 
enrollment of American Indians and Alaska Natives, officials in all 
three states reported more than one option available for individuals 
to enroll in Medicaid or CHIP. In addition to the option of enrolling 
at local enrollment offices and by mail, individuals could enroll 
online in Montana and by means of e-mail in New Mexico. Additionally, 
New Mexico installed electronic enrollment kiosks in select locations, 
and South Dakota was in the process of implementing kiosks with a 
native language audio format option. Although all the I/T/U facility 
staff we interviewed helped patients with submitting enrollment 
applications, eligibility was generally determined by the Medicaid 
program's local enrollment office; however, in Montana, the state 
entered into an agreement with one tribe to allow the tribe to 
complete the Medicaid determination process itself. Finally, two 
states--Montana and New Mexico--allowed for presumptive eligibility 
for children and pregnant women, in which individuals who appear to be 
eligible can receive covered services while their applications are 
being processed. 

I/T/Us and Tribes: 

All the facilities we interviewed--three IHS-operated, three tribally 
operated, and three urban Indian health programs--reported that they 
routinely screen patients visiting their clinics for potential 
eligibility for Medicaid and CHIP.[Footnote 68] The three tribal 
facilities, three urban Indian health programs, and three CHIPRA 
tribal outreach grantees were also involved in community outreach 
efforts outside of the clinic, including participation at community 
events, such as health fairs, pow wows, school events, and senior-
center meetings. Several facilities and CHIPRA tribal outreach 
grantees reported that incentives, such as gift cards, baby supplies, 
and raffle tickets, were effective tools for generating interest. 
Several facilities and CHIPRA grantees also reported using other 
outreach methods, including radio, TV, newspapers, direct mail, and 
Facebook. Two of the CHIPRA grantees reported using home visits as 
their primary outreach method. In contrast, one of the three IHS-
operated facilities we met with conducted community outreach; the 
other two said they rely on the tribes in their service area to 
conduct outreach. As of February 2013, none of the I/T/U facilities we 
spoke with reported conducting any early outreach regarding the 
expanded and new coverage options. However, in June 2013 IHS officials 
told us that, as part of its business plan template, IHS facilities 
are expected to assess the need for, and describe, their planned 
outreach activities. 

Multiple Barriers, Including Uncertainty and Lack of Capacity 
Building, Hinder Enrollment in Expanded Medicaid and New Coverage 
Options: 

We identified several issues that have presented and continue to 
present challenges to efforts to promote the enrollment of American 
Indians and Alaska Natives in the expanded and new coverage options, 
including legal and policy uncertainties, lack of capacity building, 
unfamiliarity with new and expanded coverage options, and tribes' 
limited access to coverage status information that could help target 
outreach efforts. 

Uncertainty Related to Pending Legal and Policy Decisions: 

Officials we interviewed at federal agencies and I/T/U facilities told 
us when we spoke with them prior to, and immediately following, the 
Supreme Court's decision regarding PPACA that they were waiting for 
the court's decision, and subsequently their states' decisions about 
Medicaid expansion, before developing a plan to launch education and 
enrollment activities. Before the Supreme Court's decision, both IHS 
and CMS headquarters officials noted they were waiting for the 
decision before engaging in more widespread efforts to educate 
facilities and American Indians and Alaska Natives about the expanded 
and new coverage options. Similarly, officials in the Albuquerque 
area--from the area office, New Mexico Medicaid office, and two of the 
three facilities we spoke with in the area--cited the pending Supreme 
Court decision, later released in June 2012, as the reason for little 
or no action taken to that point. Following the Supreme Court's 
decision, we met with officials from the Aberdeen and Billings IHS 
service areas. Officials with the two IHS area offices, the South 
Dakota and Montana state Medicaid offices, and several facilities all 
cited uncertainty regarding their state's pending decision about 
Medicaid expansion as a reason for continued inaction as of the time 
we spoke with them. As of June 2013, New Mexico had opted to 
participate in Medicaid expansion, South Dakota decided not to 
participate, and Montana had not decided.[Footnote 69] 

Lack of Capacity Building: 

I/T/U facilities will likely face increased workload related to 
enrollment in, and reimbursement from, Medicaid and the Exchange 
health plans with the estimated addition of hundreds of thousands of 
American Indians and Alaska Natives into expanded Medicaid and, to a 
lesser extent, the new coverage options under the Exchanges. IHS 
officials told us, however, that the agency has no national plan in 
place to adjust the number of patient benefit coordinators--I/T/U 
staff responsible for identifying program eligibility and assisting 
with enrollment--and billing staff to handle the large number of 
individuals who may seek to enroll in expanded Medicaid and the new 
coverage options. Officials said that increased collections through 
third-party billing from enrollments in public programs may provide 
additional funds to hire such staff, although they also acknowledged 
that such increased capacity would be needed prior to an increase in 
enrollment and collections. Officials told us that facility directors 
will need to maximize existing resources, adding that IHS's ability to 
manage the implementation process at tribally operated facilities and 
urban Indian health programs is limited. To help facility directors 
prepare for the implementation of expanded and new coverage options, 
officials told us in April 2013 that IHS developed a business plan 
template that calls for facilities to assess their current levels of 
public and private insurance, potential enrollment growth, effect on 
staffing levels, the workforce needed for enrollment activities, and 
marketing strategy. According to IHS Headquarters officials, all 
federally operated IHS facilities have been directed to use the 
business plan template to complete and submit their implementation 
plans by May 2013. The lack of a plan to shift staff to help 
facilitate increased enrollment in, and billing for, expanded Medicaid 
and new coverage options could result in some eligible American 
Indians and Alaska Natives remaining unenrolled or some facilities 
unable to bill for services. In contrast, federal internal control 
standards specify that agency management should ensure that proper 
personnel, with the right training, are in place to enable 
organizational success. Officials expressed doubt, however, that the 
demand for expanded Medicaid and the Exchanges would be high when 
enrollment begins. 

Unfamiliarity with Expanded and New Coverage: 

Officials with two of the three CHIPRA tribal outreach grantees with 
whom we met were unaware of Medicaid expansion and creation of the 
Exchanges at the time we first spoke with them, in June through August 
2012, more than 2 years after the enactment of PPACA. As direct 
service tribes, they relied on IHS-operated facilities for most of 
their health care services. The various training options cited by IHS 
and CMS, some of which included content on the expanded and new 
coverage options, were largely targeted to staff from IHS-operated and 
tribally operated facilities, resulting in a potential gap in the level 
of awareness among direct service tribes, which generally do not operate 
their own health care facilities. Additionally, many of the officials 
from the I/T/U facilities we interviewed lacked awareness about eligibility 
for cost-sharing exemptions for insurance obtained through the Exchanges. 
CMS officials told us that they are including language in the brochures 
being developed for this population that will clarify which American Indians 
and Alaska Natives are eligible for cost-sharing exemptions and other 
provisions. 

Limited Access to Information: 

At least one tribal facility or CHIPRA tribal outreach grantee in each of 
the three areas in which we focused our interviews reported a lack of
information on tribal members’ Medicaid enrollment status, which they
said limits their ability to target outreach to nonenrollees and assist
enrolled members with their annual Medicaid renewal applications.
Specifically, they said that they had been unable to receive information 
on members’ coverage status from their states because of restrictions on 
information sharing under the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA). The Privacy Rule promulgated under 
HIPAA permits individually identifiable health information to be shared 
in connection with providing or paying for health care but otherwise 
generally does not permit such information, including coverage status, 
to be shared without individuals’ authorization.[Footnote 70] Entities 
subject to the HIPAA Privacy Rule may, however, share such information 
without obtaining authorization in certain circumstances, such as in 
connection with government agencies providing public benefits.
[Footnote 71] The HIPAA Privacy Rule permits information sharing between 
health care providers and payers such as state Medicaid agencies and 
I/T/Us in connection with providing health care. Direct service tribes 
receive the majority of their primary health care services from IHS. 
In some instances, direct service tribes choose to provide services 
or operate a portion of or a health program pursuant to the Indian 
Self-Determination and Education Assistance Act (ISDEAA). Direct 
service tribes are considered tribal health providers for those 
services or programs operated under an ISDEAA self-determination 
contract or self-governance compact. According to CMS officials, 
in the context of these services or programs, states are thus 
permitted to share information with these tribes on their members’ 
coverage status without authorization. Confusion among states about 
whether they are allowed to share coverage status with tribes, 
particularly with direct service tribes, is an ongoing concern, 
they said, in part because the HHS guidance that clarified the 
permissibility of such sharing is nearly 30 years old and pre-dates 
HIPAA. This confusion limits tribes’ ability to assist their members 
with enrollment. Officials with one direct service tribe told us 
their preferred method for Medicaid outreach is door-to-door home 
visits, although they said the tribe is not able to target those 
efforts due to a lack of information on members’ coverage status, 
which reduces its effectiveness. All three CHIPRA tribal outreach 
grantees we interviewed said that they track the applications they 
submit as part of their outreach and enrollment efforts, although 
two noted that the applications submitted represent a small proportion 
of those eligible to enroll. One CHIPRA tribal grantee noted that 
keeping eligible members enrolled in Medicaid is also a challenge 
because many lack a permanent address or mailbox, and so do not receive 
renewal notices from the state. These challenges may affect HHS’s 
ability to achieve its goal of increasing health insurance coverage 
among racial and ethnic minorities as a means to eliminate health 
disparities.

Conclusions: 

The expansion of Medicaid and new coverage options under PPACA may 
allow many American Indians and Alaska Natives to obtain additional 
health care benefits for which they were not previously eligible. If 
American Indians and Alaska Natives enroll in these programs and 
choose to receive care through IHS, the increase in reimbursements 
from third-party payers may free up resources and help alleviate some 
of the pressures on I/T/U facilities' and CHS budgets that contribute 
to unmet health care needs. Although some uncertainty remains 
regarding which states will opt to participate in Medicaid expansion, 
a significant share of the estimated hundreds of thousands of American 
Indians and Alaska Natives who could be eligible for expanded Medicaid 
are in states that plan to participate. 

I/T/Us are leading current efforts to identify members who may be 
eligible for Medicaid and CHIP and assist with their enrollment 
process, and are poised to continue those efforts in the future. 
However, given the complexities of the eligibility requirements for 
different programs, these efforts can only be successful if facilities 
receive timely and important information from IHS and CMS, including 
specific information about new and expanding coverage options, such as 
eligibility rules, enrollment procedures, and other implementation 
details. The efforts to date to educate American Indians and Alaska 
Natives, and the facilities that serve them, about the coverage 
options available beginning in 2014 do not resemble the successful 
campaigns launched in advance of other recent programs. IHS and CMS 
have limited time to conduct a major outreach campaign before October 
2013, when open enrollment in expanded Medicaid and the Exchanges 
begins. Increased enrollment will clearly lead to an increased 
workload for I/T/U facility staff; however, as of April 2013, IHS does 
not have an effective plan in place to ensure that a sufficient number 
of I/T/U staff are prepared to assist with enrollment and to process 
increased third-party payments. IHS officials told us their business 
plan template is intended to encourage facilities to plan for an 
increase in enrollment in expanded and new coverage options, although 
the effect of this step remains to be seen. 

Recommendations for Executive Action: 

To help ensure successful outreach efforts resulting in significant 
new enrollment, we recommend that the Secretary of Health and Human 
Services direct: 

1. the Director of IHS and the Administrator of CMS to coordinate a 
plan to: 

* improve their communication with facility staff and tribal leaders 
to ensure that information on Medicaid and the Exchanges, including 
detailed information on program eligibility rules and enrollment 
procedures, is being disseminated to all facilities and tribes; and, 

* increase direct outreach to American Indians and Alaska Natives who 
may be eligible for expanded Medicaid and the Exchanges; 

2. the Director of IHS to prepare for the increase in eligibility for 
expanded Medicaid and new coverage options, and the need for 
enrollment assistance and billing capacity, by realigning current 
resources and personnel to increase capacity to assist with these 
efforts; and: 

3. the Administrator of CMS to develop a plan to educate state Medicaid 
agencies about when coverage status information may be shared between 
states and I/T/U facilities and tribes. 

Agency Comments and Our Evaluation: 

We provided a draft of this report for comment to HHS. HHS provided 
written comments, which we summarize below, in which HHS agreed with 
one recommendation and neither agreed nor disagreed with two 
recommendations. The text of HHS's letter is reprinted in appendix IV. 
HHS also provided technical comments, which we incorporated as 
appropriate. 

HHS agreed with our recommendation for CMS and IHS to coordinate a plan 
to improve communications with facility staff and tribal leaders and 
increase direct outreach to American Indians and Alaska Natives who may 
be eligible for expanded Medicaid and the Exchanges. The department noted 
that CMS is working closely with IHS to develop and review outreach 
materials and information dissemination and training strategies. HHS 
also cited a number of activities conducted in 2012 and 2013 intended to 
increase awareness among American Indians and Alaska Natives of expanded 
Medicaid and the Exchanges. In addition, in our draft report, we recommended 
the development of a strategy for educating American Indians and Alaska 
Natives about the effect of PPACA’s definition of Indian on their coverage 
options and obligations. The issuance of HHS’s final rule, which was 
released after our draft report had been submitted to HHS for review and 
comment, lessened the need for this strategy, and we deleted this 
recommendation accordingly. 

HHS did not specify in its response whether it agreed or disagreed with
our two remaining recommendations. In commenting on our recommendation for 
IHS to prepare for the increase in eligibility for expanded Medicaid and 
new coverage options and the need to increase its capacity for enrollment 
assistance and billing, HHS noted that the IHS business plan template is 
intended to serve this purpose. In light of the decentralized nature of 
this approach, we continue to believe that IHS should realign current 
resources and personnel to assist with these efforts. In commenting on 
our recommendation for CMS to develop a plan to educate states about 
sharing coverage information with I/T/Us and tribes, HHS noted that it 
plans to provide information to states as part of its technical 
assistance activities, but that it needed additional clarity about our 
recommendation to fully comment. We had subsequent discussions with HHS 
and CMS regarding this recommendation and revised our report and the 
recommendation to reflect those discussions. 

We are sending copies of this report to the Secretary of Health and 
Human Services and other interested parties. In addition, the report 
is available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of the report. GAO staff who made major contributions to 
this report are listed in appendix V. 

Signed by: 

Kathleen M. King: 
Director, Health Care: 

List of Addressees: 

The Honorable Maria Cantwell: 
Chairwoman: 
The Honorable John Barrasso: 
Vice Chairman: 
Committee on Indian Affairs: 
United States Senate: 

The Honorable Don Young: 
Chairman: 
The Honorable Colleen Hanabusa: 
Ranking Member: 
Subcommittee on Indian and Alaska Native Affairs: 
Committee on Natural Resources: 
House of Representatives: 

The Honorable Tim Johnson: 
United States Senate: 

The Honorable Lisa Murkowski: 
United States Senate: 

The Honorable John Thune: 
United States Senate: 

[End of section] 

Appendix I: Methodology for Estimating Potential Eligibility for 
American Indians and Alaska Natives in Expanded Health Coverage: 

To estimate the number of American Indians and Alaska Natives 
potentially eligible for expanded Medicaid and new coverage options 
that will be available beginning in 2014, we examined data from the 
American Community Survey (ACS) of the U.S. Census Bureau, which 
contains nationwide information on race, age, income, and health 
insurance coverage, and other variables as described below. We used 3 
years of ACS data to make reliable estimates at the state and Indian 
Health Service (IHS) service area levels.[Footnote 72] In order to 
capture the appropriate family ties and income for determining program 
eligibility, we used an augmented version of the ACS data prepared by 
the University of Minnesota Population Center--the Integrated Public 
Use Microdata Series (IPUMS). We used the most recent data available--
2009 through 2011--to provide estimates of American Indians and Alaska 
Natives eligible for coverage in expanded Medicaid,[Footnote 73] the 
Basic Health Program, and income-based cost-sharing exemptions for 
American Indians and Alaska Natives and premium tax credits in the 
Exchanges--at the national, IHS service area, and state levels. 

About the ACS: 

The ACS collects information about age, sex, race, family and 
relationships, income and benefits, health insurance, education, 
veteran status, disabilities, and geographic location, among other 
variables. The ACS initially samples about 3 million addresses each 
year, resulting in about 2 million final interviews for each year's 
survey. For the 2011 survey, a sample of 2.3 million households was 
selected from a sample frame of about 3.5 million. For the 2010 and 
2009 surveys, a sample of 2.1 million households was selected from a 
sample frame of 3.1 million, for each year.[Footnote 74] 

In general, ACS estimates are period estimates that describe the 
average characteristics of population and housing over a period of 
data collection. The 2009-2011 ACS 3-year estimates are averages over 
the period from January 1, 2009 to December 31, 2011, and reflect what 
the average value is over the full period. Because survey data are 
based on a sample of the population, the numbers in the report are not 
the same as those that would be obtained if everyone in the population 
were actually counted. For this reason, the ACS combines data from 
multiple years to produce reliable estimates for small areas--such as 
states--and population groups, such as American Indians and Alaska 
Natives. To produce data for small communities--between 20,000 and 
65,000 individuals--3 years of data collection are pooled to produce 
reliable estimates. 

Estimates from the ACS are subject to some sampling error. To assess 
the precision of these estimates, we calculated a relative standard 
error for each estimate. A relative standard error is calculated by 
dividing the standard error of the estimate by the estimate itself. 
For example, if an estimate has a mean of 100 and a standard error of 
20, the relative standard error would be 20/100, which would be 20 
percent. Estimates with small relative standard errors are considered 
more reliable than estimates with large relative standard errors. A 
small relative standard error is a more precise measurement since 
there is less variance around the mean. Unless otherwise noted, we 
present estimates that have relative standard errors of less than 15 
percent. In addition to sampling errors, nonsampling errors may affect 
the data; however, the Census Bureau takes steps to minimize these 
errors. 

The results of ACS data analysis are based on self-reported 
information. The Census Bureau applied some logical edits to the data 
to correct for obvious misunderstanding of the questions. All 
respondents to the survey are asked to identify their race, with the 
option to check one or more boxes indicating racial category.[Footnote 
75] We refer to respondents who marked only the "American Indian or 
Alaska Native" response box as the "American Indian and Alaska Native 
alone" population. We refer to respondents who marked both the 
"American Indian and Alaska Native" response box and one or more other 
racial categories as the "American Indian and Alaska Native alone or 
in combination" population. Self-identification as an American Indian 
and Alaska Native in the ACS is not an indication of either being a 
member of a federally recognized tribe or eligibility for IHS 
services. In the absence of ACS data on IHS eligibility, we report our 
results separately for American Indians and Alaska Natives alone, and 
American Indians and Alaska Natives alone or in combination, allowing 
us to provide a lower and upper bound within which the number who are 
actually IHS-eligible is likely to fall. The range we report--of those 
identifying as American Indian and Alaska Native alone and those 
identifying as American Indian and Alaska Native alone or in combination 
with another race--include American Indians and Alaska Natives who are 
members of a federally recognized tribe. We excluded foreign-born American 
Indians and Alaska Natives from our analysis, as these individuals are 
generally unlikely to be eligible for IHS services.[Footnote 76] 

ACS data are reported in Public Use Microdata Areas (PUMA), which 
aggregates smaller counties or breaks up larger counties into units of 
100,000 individuals to protect anonymity. We created a crosswalk 
between the counties included in PUMAs and the counties included in 
each of the 12 geographic areas the Indian Health Service has 
designated for service, called IHS service areas. 

Like other survey-based sources of coverage data--such as the National 
Health Interview Survey--the estimates from ACS data of Medicaid 
coverage are lower than numbers found in program counts by the Centers 
for Medicare & Medicaid Services (CMS), even after logical edits have 
been applied by the Census Bureau. In order to account for a variety 
of scenarios that might contribute to the differences in these 
numbers, one group of researchers has developed an additional set of 
edits--for example, assigning to Medicaid a child for whom no coverage 
was reported when that child has a sibling enrolled in Medicaid. 
[Footnote 77] We did not apply these edits because the publicly 
available data set was sufficient for the purpose of providing an 
approximate range in which the number of IHS-eligible American Indians 
and Alaska Natives could fall. 

Augmented American Community Survey Dataset: 

In order to capture the appropriate family ties and income for 
determining program eligibility, we used an augmented version of the 
ACS data prepared by the University of Minnesota Population Center--
the Integrated Public Use Microdata Series (IPUMS).[Footnote 78] The 
IPUMS dataset constructs a health insurance unit variable that follows 
program eligibility definitions of family eligibility more closely 
than the ACS' household unit. 

Estimating Eligibility for American Indians and Alaska Natives in 
Expanded Medicaid and New Coverage Options: 

The Patient Protection and Affordable Care Act (PPACA) expanded 
Medicaid and created new coverage options. For expanded Medicaid, 
assuming all states opt to participate, we estimated: 

* the total number of American Indians and Alaska Natives who are 
potentially eligible under the eligibility rules beginning in 2014, 
including: (1) all American Indians and Alaska Natives at or below 138 
percent of the federal poverty level (FPL);[Footnote 79] (2) American 
Indians and Alaska Natives above 138 of the FPL who were eligible in 
each state in 2011; (3) American Indians and Alaska Natives who 
received supplemental security income;[Footnote 80] and (4) American 
Indians and Alaska Natives who reported in the ACS as being enrolled 
in Medicaid, but who did not meet the other three criteria;[Footnote 
81] 

* the number of American Indians and Alaska Natives who reported in 
the 2009-2011 ACS as being currently enrolled; and: 

* the number of potential new enrollees, calculated by determining the 
number of individuals who will be potentially eligible for expanded 
Medicaid including some who may be eligible now, but did not report to 
the ACS as being currently enrolled.[Footnote 82] 

To examine the number of American Indians and Alaska Natives who would 
be eligible for other benefits if they were not eligible for Medicaid, 
we also estimated the number of American Indians and Alaska Natives 
potentially eligible for the: 

* Basic Health Program option, if their income was between 138 and 200 
percent of the FPL; 

* income-based cost-sharing exemptions for insurance obtained through 
the Exchanges,[Footnote 83] if their income was between 138 and 300 
percent of the FPL; and: 

* premium tax credits for insurance obtained through the Exchanges, if 
their income was between 138 and 400 percent of the FPL. 

In this report, we do not conduct projections of eligibility based on 
future income; instead, we estimate the number of American Indians and 
Alaska Natives who would be eligible for programs and benefits 
beginning in 2014 based on the most recent data currently available. 
We did not predict the number of people who will participate in these 
programs and benefits, commonly referred to as the take-up rate. As 
public programs generally do not have full take-up, and take-up for 
Medicaid and the Children's Health Insurance Program (CHIP) generally 
tends to be lower for American Indians and Alaska Natives than the 
rest of the population,[Footnote 84] it is likely not all who are 
eligible for Medicaid and new coverage options will enroll. 

Program eligibility among our samples was determined by comparing 
total income of the health insurance unit to the FPL. In order to 
determine whether individuals were eligible for expanded Medicaid or 
new coverage options, we defined two factors needed to compare the 
income to the FPL: (1) the number of people in the family--defined by 
the health insurance unit in our analysis; and (2) the total family 
income, added for all individuals with the same health insurance unit 
identification code. Income was then adjusted to 2011 dollars across 
all 3 years of the survey, in order to determine the poverty level 
status for program eligibility.[Footnote 85] We discussed our approach 
with a Census Bureau senior official, who agreed that our approach 
regarding this analysis was reasonable. 

In conducting our analysis, we considered several other data sources, 
including the Current Population Survey, the National Health Interview 
Survey, and the Medicaid Statistical Information System and the 
Medicaid Analytic Extract. After reviewing these sources, we 
determined that data from the ACS were the most appropriate for our 
analysis for determining the number of individuals potentially 
eligible for these expanded Medicaid and new coverage options based on 
family income and race, and reporting on areas smaller than the state 
level in some cases. This information is not complete or consistently 
collected in the other sources. For example, while data from the 
Medicaid Statistical Information System and the Medicaid Analytic 
Extract include a race variable to identify American Indians and 
Alaska Natives, the states do not consistently collect this 
information. 

[End of section] 

Appendix II: Estimates of Potential Medicaid Eligibility for American 
Indians and Alaska Natives, by Indian Health Service (IHS) Area: 

IHS Service Area: Aberdeen; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 59,645 (73%); 
Current enrollment[A] number (percent): 32,441 (40%); 
Potential new enrollment[B] number (percent): 27,203 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 72,534 (70%); 
Current enrollment[A] number (percent): 39,632 (38%); 
Potential new enrollment[B] number (percent): 32,902 (32%). 

IHS Service Area: Alaska; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 57,078 (62%); 
Current enrollment[A] number (percent): 27,276 (30%); 
Potential new enrollment[B] number (percent): 29,802 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 74,320 (58%); 
Current enrollment[A] number (percent): 35,562 (28%); 
Potential new enrollment[B] number (percent): 38,758 (30%). 

IHS Service Area: Albuquerque; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 61,523 (64%); 
Current enrollment[A] number (percent): 31,363 (33%); 
Potential new enrollment[B] number (percent): 30,161 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 74,578 (63%); 
Current enrollment[A] number (percent): 37,710 (32%); 
Potential new enrollment[B] number (percent): 36,868 (31%). 

IHS Service Area: Bemidji; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 50,568 (61%); 
Current enrollment[A] number (percent): 29,668 (36%); 
Potential new enrollment[B] number (percent): 20,900 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 82,120 (60%); 
Current enrollment[A] number (percent): 48,595 (36%); 
Potential new enrollment[B] number (percent): 33,526 (25%). 

IHS Service Area: Billings; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 22,962 (61%); 
Current enrollment[A] number (percent): 11,711 (31%); 
Potential new enrollment[B] number (percent): 11,251 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 26,935 (58%); 
Current enrollment[A] number (percent): 13,791 (30%); 
Potential new enrollment[B] number (percent): 13,144 (28%). 

IHS Service Area: California; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 58,994 (53%); 
Current enrollment[A] number (percent): 31,218 (28%); 
Potential new enrollment[B] number (percent): 27,776 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 120,525 (51%); 
Current enrollment[A] number (percent): 65,886 (28%); 
Potential new enrollment[B] number (percent): 54,640 (23%). 

IHS Service Area: Nashville; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 42,087 (53%); 
Current enrollment[A] number (percent): 22,155 (28%); 
Potential new enrollment[B] number (percent): 19,932 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 97,217 (52%); 
Current enrollment[A] number (percent): 53,347 (28%); 
Potential new enrollment[B] number (percent): 43,870 (23%). 

IHS Service Area: Navajo; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 146,317 (72%); 
Current enrollment[A] number (percent): 85,197 (42%); 
Potential new enrollment[B] number (percent): 61,120 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 150,533 (71%); 
Current enrollment[A] number (percent): 88,018 (42%); 
Potential new enrollment[B] number (percent): 62,515 (30%). 

IHS Service Area: Oklahoma City; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 135,383 (52%); 
Current enrollment[A] number (percent): 57,261 (22%); 
Potential new enrollment[B] number (percent): 78,121 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 259,501 (53%); 
Current enrollment[A] number (percent): 119,474 (24%); 
Potential new enrollment[B] number (percent): 140,027 (28%). 

IHS Service Area: Phoenix; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 114,589 (62%); 
Current enrollment[A] number (percent): 59,271 (32%); 
Potential new enrollment[B] number (percent): 55,319 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 149,119 (58%); 
Current enrollment[A] number (percent): 77,813 (30%); 
Potential new enrollment[B] number (percent): 71,306 (28%). 

IHS Service Area: Portland; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 77,737 (55%); 
Current enrollment[A] number (percent): 42,807 (30%); 
Potential new enrollment[B] number (percent): 34,930 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 156,182 (53%); 
Current enrollment[A] number (percent): 88,692 (30%); 
Potential new enrollment[B] number (percent): 67,490 (23%). 

IHS Service Area: Tucson; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 23,157 (70%); 
Current enrollment[A] number (percent): 14,841 (45%); 
Potential new enrollment[B] number (percent): 8,316 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 27,294 (65%); 
Current enrollment[A] number (percent): 17,375 (42%); 
Potential new enrollment[B] number (percent): 9,919 (24%). 

IHS Service Area: IHS Service Area Total; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 850,039 (60%); 
Current enrollment[A] number (percent): 445,208 (32%); 
Potential new enrollment[B] number (percent): 404,830 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 1,290,859 (57%); 
Current enrollment[A] number (percent): 685,895 (30%); 
Potential new enrollment[B] number (percent): 604,964 (27%). 

IHS Service Area: Non-IHS Service Areas; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 518,276 (54%); 
Current enrollment[A] number (percent): 273,045 (28%); 
Potential new enrollment[B] number (percent): 245,231 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 1,278,549 (51%); 
Current enrollment[A] number (percent): 692,028 (28%); 
Potential new enrollment[B] number (percent): 586,521 (23%). 

Source: GAO analysis of U.S. Census Bureau data.Notes: Data are from 
2009-2011 American Community Survey (ACS) 3-year estimates. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend 
to participate, they may opt to do so at a later date. We did not 
predict the number of people who will participate in this program, 
commonly referred to as the take-up rate. 

Because the number of IHS eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[End of table] 

[End of section] 

Appendix III: Potential Eligibility for Expanded Health Coverage in 
2014, Nationally, by IHS Service Area, and by State: 

We examined data to provide estimates of the number of American 
Indians and Alaska Natives potentially eligible for expanded 
Medicaid[Footnote 86] and new coverage options that will be available 
beginning in 2014, including the Basic Health Program option and the 
premium tax credits and the exemption from cost-sharing for insurance 
obtained through the Exchanges. We used an augmented version of the 
U.S. Census Bureau's American Community Survey (ACS) 2009-2011 data, 
called the Integrated Public Use Microdata Series. For Medicaid, we 
estimated the total number of American Indians and Alaska Natives who 
are potentially eligible under provisions of PPACA applicable in 2014; 
the number of American Indians and Alaska Natives who reported being 
currently enrolled; and potential new enrollment, calculated by 
determining the number of individuals who will be newly eligible for 
expanded Medicaid and some who may be eligible now, but did not report 
to ACS as being currently enrolled. We also estimated the number of 
American Indian and Alaska Natives potentially eligible for coverage 
in a state that chooses the Basic Health Program option beginning in 
2015, and income-based cost-sharing exemptions and premium tax credits 
for insurance obtained in the Exchanges beginning in 2014. Because the 
number of individuals eligible for services provided by the Indian 
Health Service (IHS) is likely to be between the number identifying as 
American Indian and Alaska Native alone, and the number identifying as 
American Indian and Alaska Native in combination with one or more 
other racial/ethnic groups, we present results for both groups as the 
range. In the absence of precise data, this approach allowed us to 
present a lower and upper bound. 

Tables 3 through 9 present the results of our estimates by IHS service 
area or by state. 

Table 3: Estimates of the Number and Percentage of All Races 
Potentially Eligible for Expanded Medicaid in 2014, by Indian Health 
Service (IHS) Service Area: 

IHS Service Area: Aberdeen; 
Total potentially eligible number (percent): 656,204 (33%); 
Current enrollment[A] number (percent): 282,311 (14%); 
Potential new enrollment[B] number (percent): 373,893 (19%). 

IHS Service Area: Alaska; 
Total potentially eligible number (percent): 239,010 (34%); 
Current enrollment[A] number (percent): 104,497 (15%); 
Potential new enrollment[B] number (percent): 134,513 (19%). 

IHS Service Area: Albuquerque; 
Total potentially eligible number (percent): 1,041,685 (47%); 
Current enrollment[A] number (percent): 481,496 (22%); 
Potential new enrollment[B] number (percent): 560,189 (25%). 

IHS Service Area: Bemidji; 
Total potentially eligible number (percent): 2,408,969 (36%); 
Current enrollment[A] number (percent): 1,154,241 (17%); 
Potential new enrollment[B] number (percent): 1,254,728 (19%). 

IHS Service Area: Billings; 
Total potentially eligible number (percent): 200,454 (33%); 
Current enrollment[A] number (percent): 80,061 (13%); 
Potential new enrollment[B] number (percent): 120,393 (20%). 

IHS Service Area: California; 
Total potentially eligible number (percent): 4,302,079 (41%); 
Current enrollment[A] number (percent): 2,056,411 (20%); 
Potential new enrollment[B] number (percent): 2,245,668 (22%). 

IHS Service Area: Nashville; 
Total potentially eligible number (percent): 8,297,725 (39%); 
Current enrollment[A] number (percent): 3,835,419 (18%); 
Potential new enrollment[B] number (percent): 4,462,307 (21%). 

IHS Service Area: Navajo; 
Total potentially eligible number (percent): 268,851 (53%); 
Current enrollment[A] number (percent): 140,960 (28%); 
Potential new enrollment[B] number (percent): 127,892 (25%). 

IHS Service Area: Oklahoma City; 
Total potentially eligible number (percent): 1,621,849 (41%); 
Current enrollment[A] number (percent): 669,412 (17%); 
Potential new enrollment[B] number (percent): 952,438 (24%). 

IHS Service Area: Phoenix; 
Total potentially eligible number (percent): 3,362,161 (37%); 
Current enrollment[A] number (percent): 1,471,219 (16%); 
Potential new enrollment[B] number (percent): 1,890,942 (21%). 

IHS Service Area: Portland; 
Total potentially eligible number (percent): 3,597,807 (34%); 
Current enrollment[A] number (percent): 1,631,993 (16%); 
Potential new enrollment[B] number (percent): 1,965,814 (19%). 

IHS Service Area: Tucson; 
Total potentially eligible number (percent): 421,364 (42%); 
Current enrollment[A] number (percent): 218,839 (22%); 
Potential new enrollment[B] number (percent): 202,525 (20%). 

IHS Service Area: IHS Service Area Total; 
Total potentially eligible number (percent): 26,418,161 (38%); 
Current enrollment[A] number (percent): 12,126,858 (18%); 
Potential new enrollment[B] number (percent): 14,291,303 (21%). 

IHS Service Area: Non-IHS Service Areas; 
Total potentially eligible number (percent): 89,331,678 (37%); 
Current enrollment[A] number (percent): 41,069,559 (17%); 
Potential new enrollment[B] number (percent): 48,262,119 (20%). 

Source: GAO analysis of U.S. Census Bureau. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend to 
participate, they may opt to do so at a later date. We did not predict 
the number of people who will participate in this program, commonly 
referred to as the take-up rate. 

Because the number of IHS eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

The estimates we present have relative standard errors of less than 15 
percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[End of table] 

Table 4: Estimates of the Number and Percentage of American Indians and 
Alaska Natives Potentially Eligible for Expanded Medicaid in 2014, by 
State: 

State: Alabama; 
American Indian and Alaska Native alone: 
Total 
potentially eligible number (percent): 10,562 (43%); 
Current enrollment[A] number (percent): 4,841 (20%); 
Potential new enrollment[B] number (percent): 5,721 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 25,563 (46%); 
Current enrollment[A] number (percent): 11,340 (21%); 
Potential new enrollment[B] number (percent): 14,223 (26%). 

State: Alaska; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 63,281 (63%); 
Current enrollment[A] number (percent): 30,665 (30%); 
Potential new 
enrollment[B] number (percent): 32,616 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 80,988 (59%); 
Current enrollment[A] number (percent): 39,162 (29%); 
Potential new enrollment[B] number (percent): 41,826 (31%). 

State: Arizona; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 192,553 (68%); 
Current enrollment[A] number (percent): 117,001 (42%); 
Potential new enrollment[B] number (percent): 75,552 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 219,568 (66%); 
Current enrollment[A] number (percent): 133,706 (40%); 
Potential new enrollment[B] number (percent): 85,862 (26%). 

State: Arkansas; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 8,024 (45%); 
Current enrollment[A] number (percent): 4,357 (24%); 
Potential new enrollment[B] number (percent): 3,667 (20%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 22,673 (50%); 
Current enrollment[A] number (percent): 11,955 (26%); 
Potential new enrollment[B] number (percent): 10,718 (23%). 

State: California; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 127,298 (52%); 
Current enrollment[A] number (percent): 70,950 (29%); 
Potential new enrollment[B] number (percent): 56,348 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 298,007 (49%); 
Current enrollment[A] number (percent): 167,835 (28%); 
Potential new enrollment[B] number (percent): 130,172 (22%). 

State: Colorado; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 24,904 (53%); 
Current enrollment[A] number (percent): 12,783 (27%); 
Potential new enrollment[B] number (percent): 12,121 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 51,212 (48%); 
Current enrollment[A] number (percent): 27,597 (26%); 
Potential new enrollment[B] number (percent): 23,615 (22%). 

State: Connecticut; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 3,046[C] (50%); 
Current enrollment[A] number (percent): 2,075[C] (34%)[C]; 
Potential new enrollment[B] number (percent): 971[C] (16%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 12,563 (45%); 
Current enrollment[A] number (percent): 8,081 (29%); 
Potential new enrollment[B] number (percent): 4,482 (16%). 

State: Delaware; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 1,065[C] (50%)[C]; 
Current enrollment[A] number (percent): 0 (0%); 
Potential new enrollment[B] number (percent): 0 (41%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 2,806 (36%); 
Current enrollment[A] number (percent): 1,267[C] (16%)[C]; 
Potential new enrollment[B] number (percent): 1,539[C] (20%)[C]. 

State: District of Columbia; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 701[C] (46%)[C]; 
Current enrollment[A] number (percent): 560[C] (37%)[C]; 
Potential new enrollment[B] number (percent): 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 2,300 (49%); 
Current enrollment[A] number (percent): 1,471[C] (31%); 
Potential new enrollment[B] number (percent): 829[C] (18%)[C]. 

State: Florida; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 25,170 (50%); 
Current enrollment[A] number (percent): 11,915 (24%); 
Potential new enrollment[B] number (percent): 13,255 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 66,478 (49%); 
Current enrollment[A] number (percent): 33,322 (25%); 
Potential new enrollment[B] number (percent): 33,156 (24%). 

State: Georgia; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 8,809 (44%); 
Current enrollment[A] number (percent): 3,469 (17%); 
Potential new enrollment[B] number (percent): 5,340 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 29,052 (44%); 
Current enrollment[A] number (percent): 11,389 (17%); 
Potential new enrollment[B] number (percent): 17,663 (27%). 

State: Hawaii; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 1,258[C] (36%)[C]; 
Current enrollment[A] number (percent): 0 (25%)[C]; 
Potential new enrollment[B] number (percent): 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 18,730 (57%); 
Current enrollment[A] number (percent): 10,853 (33%); 
Potential new enrollment[B] number (percent): 7,877 (24%). 

State: Idaho; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 11,835 (59%); 
Current enrollment[A] number (percent): 5,448 (27%); 
Potential new enrollment[B] number (percent): 6,387 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 19,517 (55%); 
Current enrollment[A] number (percent): 9,266 (26%); 
Potential new enrollment[B] number (percent): 10,251 (29%). 

State: Illinois; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 11,556 (54%); 
Current enrollment[A] number (percent): 5,991 (28%); 
Potential new enrollment[B] number (percent): 5,565 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 35,686 (50%); 
Current enrollment[A] number (percent): 18,336 (26%); 
Potential new enrollment[B] number (percent): 17,350 (24%). 

State: Indiana; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 6,659 (53%); 
Current enrollment[A] number (percent): 2,218 (18%); 
Potential new enrollment[B] number (percent): 4,441 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 26,360 (50%); 
Current enrollment[A] number (percent): 12,298 (24%); 
Potential new enrollment[B] number (percent): 14,062 (27%). 

State: Iowa; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 6,173 (61%); 
Current enrollment[A] number (percent): 3,598[C] (35%); 
Potential new enrollment[B] number (percent): 2,575[C] (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 18,405 (63%); 
Current enrollment[A] number (percent): 12,490 (43%); 
Potential new enrollment[B] number (percent): 5,915 (20%). 

State: Kansas; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 13,150 (56%); 
Current enrollment[A] number (percent): 4,956 (21%); 
Potential new enrollment[B] number (percent): 8,194 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 35,850 (54%); 
Current enrollment[A] number (percent): 16,712 (25%); 
Potential new enrollment[B] number (percent): 19,138 (29%). 

State: Kentucky; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 4,453 (52%); 
Current enrollment[A] number (percent): 2,528[C] (29%); 
Potential new enrollment[B] number (percent): 1,925[C] (22%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 17,484 (57%); 
Current enrollment[A] number (percent): 9,659 (31%); 
Potential new enrollment[B] number (percent): 7,825 (25%). 

State: Louisiana; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 14,057 (57%); 
Current enrollment[A] number (percent): 7,154 (29%); 
Potential new enrollment[B] number (percent): 6,903 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 28,182 (56%); 
Current enrollment[A] number (percent): 14,739 (29%); 
Potential new enrollment[B] number (percent): 13,443 (27%). 

State: Maine; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 4,456 (64%); 
Current enrollment[A] number (percent): 3,155 (45%); 
Potential new enrollment[B] number (percent): 1,301[C] (19%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 11,681 (59%); 
Current enrollment[A] number (percent): 8,752 (44%); 
Potential new enrollment[B] number (percent): 2,929 (15%). 

State: Maryland; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 6,319 (47%); 
Current enrollment[A] number (percent): 3,438 (26%); 
Potential new enrollment[B] number (percent): 2,881 (21%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 21,954 (46%); 
Current enrollment[A] number (percent): 11,541 (24%); 
Potential new enrollment[B] number (percent): 10,413 (22%). 

State: Massachusetts; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 5,961 (55%); 
Current enrollment[A] number (percent): 4,419[C] (41%); 
Potential new enrollment[B] number (percent): 1,542[C] (14%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 19,639 (49%); 
Current enrollment[A] number (percent): 14,524 (36%); 
Potential new enrollment[B] number (percent): 5,115 (13%). 

State: Michigan; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 27,643 (51%); 
Current enrollment[A] number (percent): 15,941 (30%); 
Potential new enrollment[B] number (percent): 11,702 (22%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 70,867 (52%); 
Current enrollment[A] number (percent): 43,228 (32%); 
Potential new enrollment[B] number (percent): 27,639 (20%). 

State: Minnesota; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 40,838 (71%); 
Current enrollment[A] number (percent): 25,330 (44%); 
Potential new enrollment[B] number (percent): 15,508 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 69,556 (69%); 
Current enrollment[A] number (percent): 40,987 (41%); 
Potential new enrollment[B] number (percent): 28,569 (29%). 

State: Mississippi; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 7,570 (57%); 
Current enrollment[A] number (percent): 3,445 (26%); 
Potential new enrollment[B] number (percent): 4,125 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 15,594 (58%); 
Current enrollment[A] number (percent): 7,215 (27%); 
Potential new enrollment[B] number (percent): 8,379 (31%). 

State: Missouri; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 10,189 (48%); 
Current enrollment[A] number (percent): 5,437 (26%); 
Potential new enrollment[B] number (percent): 4,752 (22%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 40,579 (53%); 
Current enrollment[A] number (percent): 22,139 (29%); 
Potential new enrollment[B] number (percent): 18,440 (24%). 

State: Montana; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 38,330 (61%); 
Current enrollment[A] number (percent): 17,927 (28%); 
Potential new enrollment[B] number (percent): 20,403 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 45,501 (59%); 
Current enrollment[A] number (percent): 21,847 (28%); 
Potential new enrollment[B] number (percent): 23,654 (31%). 

State: Nebraska; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 11,864 (72%); 
Current enrollment[A] number (percent): 6,378 (39%); 
Potential new enrollment[B] number (percent): 5,486 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 20,539 (66%); 
Current enrollment[A] number (percent): 10,885 (35%); 
Potential new enrollment[B] number (percent): 9,654 (31%). 

State: Nevada; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 13,587 (49%); 
Current enrollment[A] number (percent): 5,467 (20%); 
Potential new enrollment[B] number (percent): 8,120 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 22,848 (47%); 
Current enrollment[A] number (percent): 8,951 (18%); 
Potential new enrollment[B] number (percent): 13,897 (28%). 

State: New Hampshire; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 1,040[C] (42%)[C]; 
Current enrollment[A] number (percent): 710[C] (29%)[C]; 
Potential new enrollment[B] number (percent): 330[C] (13%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 3,799 (40%); 
Current enrollment[A] number (percent): 2,144 (23%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 1,655[C] (18%)[C]. 

State: New Jersey; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 7,152 (47%); 
Current enrollment[A] number (percent): 4,185[C] (27%); 
Potential new enrollment[B] number (percent): 2,967[C] (19%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 19,392 (42%); 
Current enrollment[A] number (percent): 11,120 (24%); 
Potential new enrollment[B] number (percent): 8,272 (18%). 

State: New Mexico; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 129,546 (67%); 
Current enrollment[A] number (percent): 62,881 (33%); 
Potential new enrollment[B] number (percent): 66,665 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 143,157 (66%); 
Current enrollment[A] number (percent): 69,878 (32%); 
Potential new enrollment[B] number (percent): 73,279 (34%). 

State: New York; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 28,462 (56%); 
Current enrollment[A] number (percent): 18,170 (36%); 
Potential new enrollment[B] number (percent): 10,292 (20%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 70,009 (52%); 
Current enrollment[A] number (percent): 43,578 (32%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 26,431 (19%). 

State: North Carolina; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 62,131 (58%); 
Current enrollment[A] number (percent): 32,570 (30%); 
Potential new enrollment[B] number (percent): 29,561 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 101,065 (56%); 
Current enrollment[A] number (percent): 53,637 (30%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 47,428 (26%). 

State: North Dakota; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 23,270 (65%); 
Current enrollment[A] number (percent): 10,269 (29%); 
Potential new enrollment[B] number (percent): 13,001 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 26,426 (62%); 
Current enrollment[A] number (percent): 12,213 (28%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 14,213 (33%). 

State: Ohio; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 10,415 (51%); 
Current enrollment[A] number (percent): 4,921 (24%); 
Potential new enrollment[B] number (percent): 5,494 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 46,406 (53%); 
Current enrollment[A] number (percent): 25,775 (29%); 
American Indian and Alaska Native alone 
Potential new enrollment[B] number (percent): 20,631 (24%). 

State: Oklahoma; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 133,291 (52%); 
Current enrollment[A] number (percent): 56,588 (22%); 
Potential new enrollment[B] number (percent): 76,703 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 255,555 (53%); 
Current enrollment[A] number (percent): 117,602 (24%); 
Potential new enrollment[B] number (percent): 137,953 (28%). 

State: Oregon; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 25,305 (53%); 
Current enrollment[A] number (percent): 13,486 (28%); 
Potential new enrollment[B] number (percent): 11,819 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 56,373 (53%); 
Current enrollment[A] number (percent): 30,574 (29%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 25,799 (24%). 

State: Pennsylvania; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 8,150 (54%); 
Current enrollment[A] number (percent): 5,145[C] (34%); 
Potential new enrollment[B] number (percent): 3,005 (20%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 34,372 (52%); 
Current enrollment[A] number (percent): 21,047 (32%); 
Potential new enrollment[B] number (percent): 13,325 (20%). 

State: Rhode Island; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 2,935 (70%); 
Current enrollment[A] number (percent): 1,511[C] (36%)[C]; 
Potential new enrollment[B] number (percent): 1,424[C] (34%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race:
Total potentially eligible number (percent): 7,548 (65%); 
Current enrollment[A] number (percent): 4,673 (40%); 
Potential new enrollment[B] number (percent): 2,875[C] (25%)[C]. 

State: South Carolina; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 7,677 (56%); 
Current enrollment[A] number (percent): 3,982 (29%); 
Potential new enrollment[B] number (percent): 3,695 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 21,109 (55%); 
Current enrollment[A] number (percent): 10,362 (27%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 10,747 (28%). 

State: South Dakota; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 53,691 (75%); 
Current enrollment[A] number (percent): 30,352 (43%); 
Potential new enrollment[B] number (percent): 23,339 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 62,654 (74%); 
Current enrollment[A] number (percent): 35,476 (42%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 27,178 (32%). 

State: Tennessee; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 6,172 (50%); 
Current enrollment[A] number (percent): 3,449[C] (28%); 
Potential new enrollment[B] number (percent): 2,723 (22%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total 
potentially eligible number (percent): 29,278 (54%); 
Current enrollment[A] number (percent): 16,306 (30%); 
Potential new enrollment[B] number (percent): 12,972 (24%). 

State: Texas; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 51,889 (47%); 
Current enrollment[A] number (percent): 25,328 (23%); 
Potential new enrollment[B] number (percent): 26,561 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 111,459 (43%); 
Current enrollment[A] number (percent): 53,347 (20%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 58,112 (22%). 

State: Utah; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 19,053 (62%); 
Current enrollment[A] number (percent): 8,922 (29%); 
Potential new enrollment[B] number (percent): 10,131 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 27,043 (57%); 
Current enrollment[A] number (percent): 12,910 (27%); 
Potential new enrollment[B] number (percent): 14,133 (30%). 

State: Vermont; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 855[C] (44%)[C]; 
Current enrollment[A] number (percent): 518[C] (27%)[C]; 
Potential new enrollment[B] number (percent): 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 3,973 (53%); 
Current enrollment[A] number (percent): 2,528 (34%); 
Potential new enrollment[B] number (percent): 1,445[C] (19%)[C]. 

State: Virginia; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 7,561 (35%); 
Current enrollment[A] number (percent): 2,744[C] (13%)[C]; 
Potential new enrollment[B] number (percent): 4,817 (22%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 25,690 (37%); 
Current enrollment[A] number (percent): 10,690 (15%); 
Potential new enrollment[B] number (percent): 15,000 (22%). 

State: Washington; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 51,029 (56%); 
Current enrollment[A] number (percent): 29,268 (32%); 
Potential new enrollment[B] number (percent): 21,761 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 99,622 (53%); 
Current enrollment[A] number (percent): 58,926 (31%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 40,696 (21%). 

State: West Virginia; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 1,839 (56%); 
Current enrollment[A] number (percent): 1,064[C] (33%)[C]; 
Potential new enrollment[B] number (percent): 775[C] (24%)[C]; 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 12,569 (58%); 
Current enrollment[A] number (percent): 7,376 (34%); 
Potential new enrollment[B] number (percent): 5,193 (24%). 

State: Wisconsin; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 27,041 (56%); 
Current enrollment[A] number (percent): 14,412 (30%); 
Potential new enrollment[B] number (percent): 12,629 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 49,675 (58%); 
Current enrollment[A] number (percent): 29,046 (34%); 
American Indian and Alaska 
Potential new enrollment[B] number (percent): 20,629 (24%). 

State: Wyoming; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 8,501 (63%); 
Current enrollment[A] number (percent): 5,268 (39%); 
Potential new enrollment[B] number (percent): 3,233 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 12,054 (55%); 
Current enrollment[A] number (percent): 7,169 (33%); 
Potential new enrollment[B] number (percent): 4,885 (22%). 

State: Total; 
American Indian and Alaska Native alone: 
Total potentially eligible number (percent): 1,368,316 (58%); 
Current enrollment[A] number (percent): 718,254 (30%); 
Potential new enrollment[B] number (percent): 650,062 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 
Total potentially eligible number (percent): 2,569,410 (54%); 
Current enrollment[A] number (percent): 1,377,924 (29%); 
Potential new enrollment[B] number (percent): 1,191,486 (25%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend to 
participate, they may opt to do so at a later date. We did not predict 
the number of people who will participate in this program, commonly 
referred to as the take-up rate. 

Because the number of IHS eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

Unless otherwise noted, the estimates we present have relative standard 
errors of less than 15 percent. Estimates with relative standard errors 
greater than 30 percent are omitted. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[C] Relative standard error of the estimate is between 15 and 30 
percent. 

[End of table] 

Table 5: Estimates of the Number and Percentage of All Races 
Potentially Eligible for Expanded Medicaid in 2014, by State: 

State: Alabama; 
Total potentially eligible number (percent): 1,955,265 (41%); 
Current enrollment[A] number (percent): 870,108 (18%); 
Potential new enrollment[B] number (percent): 1,085,157 (23%). 

State: Alaska; 
Total potentially eligible number (percent): 247,597 (35%); 
Current enrollment[A] number (percent): 108,671 (15%); 
Potential new enrollment[B] number (percent): 138,926 (20%). 

State: Arizona; 
Total potentially eligible number (percent): 2,544,027 (40%); 
Current enrollment[A] number (percent): 1,286,480 (20%); 
Potential new enrollment[B] number (percent): 1,257,547 (20%). 

State: Arkansas; 
Total potentially eligible number (percent): 1,312,714 (45%); 
Current enrollment[A] number (percent): 611,947 (21%); 
Potential new enrollment[B] number (percent): 700,767 (24%). 

State: California; 
Total potentially eligible number (percent): 15,036,282 (40%); 
Current enrollment[A] number (percent): 7,134,352 (19%); 
Potential new enrollment[B] number (percent): 7,901,930 (21%). 

State: Colorado; 
Total potentially eligible number (percent): 1,577,788 (31%); 
Current enrollment[A] number (percent): 672,433 (13%); 
Potential new enrollment[B] number (percent): 905,355 (18%). 

State: Connecticut; 
Total potentially eligible number (percent): 1,129,058 (32%); 
Current enrollment[A] number (percent): 563,149 (16%); 
Potential new enrollment[B] number (percent): 565,909 (16%). 

State: Delaware; 
Total potentially eligible number (percent): 309,172 (34%); 
Current enrollment[A] number (percent): 169,972 (19%); 
Potential new enrollment[B] number (percent): 139,200 (15%). 

State: District of Columbia; 
Total potentially eligible number (percent): 292,339 (48%); 
Current enrollment[A] number (percent): 155,687 (26%); 
Potential new enrollment[B] number (percent): 136,652 (23%). 

State: Florida; 
Total potentially eligible number (percent): 7,362,867 (39%); 
Current enrollment[A] number (percent): 2,958,596 (16%); 
Potential new enrollment[B] number (percent): 4,404,271 (23%). 

State: Georgia; 
Total potentially eligible number (percent): 3,885,976 (40%); 
Current enrollment[A] number (percent): 1,545,237 (16%); 
Potential new enrollment[B] number (percent): 2,340,739 (24%). 

State: Hawaii; 
Total potentially eligible number (percent): 564,190 (41%); 
Current enrollment[A] number (percent): 203,263 (15%); 
Potential new enrollment[B] number (percent): 360,927 (27%). 

State: Idaho; 
Total potentially eligible number (percent): 560,947 (36%); 
Current enrollment[A] number (percent): 224,590 (14%); 
Potential new enrollment[B] number (percent): 336,357 (21%). 

State: Illinois; 
Total potentially eligible number (percent): 4,624,033 (36%); 
Current enrollment[A] number (percent): 2,265,211 (18%); 
Potential new enrollment[B] number (percent): 2,358,822 (18%). 

State: Indiana; 
Total potentially eligible number (percent): 2,320,838 (36%); 
Current enrollment[A] number (percent): 983,983 (15%); 
Potential new enrollment[B] number (percent): 1,336,855 (21%). 

State: Iowa; 
Total potentially eligible number (percent): 957,367 (31%); 
Current enrollment[A] number (percent): 472,285 (15%); 
Potential new enrollment[B] number (percent): 485,082 (16%). 

State: Kansas; 
Total potentially eligible number (percent): 911,862 (32%); 
Current enrollment[A] number (percent): 364,552 (13%); 
Potential new enrollment[B] number (percent): 547,310 (19%). 

State: Kentucky; 
Total potentially eligible number (percent): 1,762,366 (41%); 
Current enrollment[A] number (percent): 823,531 (19%); 
Potential new enrollment[B] number (percent): 938,835 (22%). 

State: Louisiana; 
Total potentially eligible number (percent): 2,052,868 (45%); 
Current enrollment[A] number (percent): 957,560 (21%); 
Potential new enrollment[B] number (percent): 1,095,308 (24%). 

State: Maine; 
Total potentially eligible number (percent): 482,639 (36%); 
Current enrollment[A] number (percent): 305,920 (23%); 
Potential new enrollment[B] number (percent): 176,719 (13%). 

State: Maryland; 
Total potentially eligible number (percent): 1,946,646 (34%); 
Current enrollment[A] number (percent): 811,217 (14%); 
Potential new enrollment[B] number (percent): 1,135,429 (20%). 

State: Massachusetts; 
Total potentially eligible number (percent): 2,192,026 (33%); 
Current enrollment[A] number (percent): 1,366,120 (21%); 
Potential new enrollment[B] number (percent): 825,906 (13%). 

State: Michigan; 
Total potentially eligible number (percent): 3,721,250 (38%); 
Current enrollment[A] number (percent): 1,901,559 (19%); 
Potential new enrollment[B] number (percent): 1,819,691 (18%). 

State: Minnesota; 
Total potentially eligible number (percent): 1,899,738 (36%); 
Current enrollment[A] number (percent): 768,063 (14%); 
Potential new enrollment[B] number (percent): 1,131,675 (21%). 

State: Mississippi; 
Total potentially eligible number (percent): 1,408,772 (47%); 
Current enrollment[A] number (percent): 693,677 (23%); 
Potential new enrollment[B] number (percent): 715,095 (24%). 

State: Missouri; 
Total potentially eligible number (percent): 2,130,573 (36%); 
Current enrollment[A] number (percent): 909,635 (15%); 
Potential new enrollment[B] number (percent): 1,220,938 (20%). 

State: Montana; 
Total potentially eligible number (percent): 328,487 (33%); 
Current enrollment[A] number (percent): 125,629 (13%); 
Potential new enrollment[B] number (percent): 202,858 (20%). 

State: Nebraska; 
Total potentially eligible number (percent): 609,581 (33%); 
Current enrollment[A] number (percent): 242,969 (13%); 
Potential new enrollment[B] number (percent): 366,612 (20%). 

State: Nevada; 
Total potentially eligible number (percent): 924,095 (34%); 
Current enrollment[A] number (percent): 299,079 (11%); 
Potential new enrollment[B] number (percent): 625,016 (23%). 

State: New Hampshire; 
Total potentially eligible number (percent): 355,591 (27%); 
Current enrollment[A] number (percent): 149,418 (11%); 
Potential new enrollment[B] number (percent): 206,173 (16%). 

State: New Jersey; 
Total potentially eligible number (percent): 2,606,674 (30%); 
Current enrollment[A] number (percent): 1,183,299 (13%); 
Potential new enrollment[B] number (percent): 1,423,375 (16%). 

State: New Mexico; 
Total potentially eligible number (percent): 983,222 (48%); 
Current enrollment[A] number (percent): 472,629 (23%); 
Potential new enrollment[B] number (percent): 510,593 (25%). 

State: New York; 
Total potentially eligible number (percent): 7,393,719 (38%); 
Current enrollment[A] number (percent): 4,200,350 (22%); 
Potential new enrollment[B] number (percent): 3,193,369 (16%). 

State: North Carolina; 
Total potentially eligible number (percent): 3,703,744 (39%); 
Current enrollment[A] number (percent): 1,628,400 (17%); 
Potential new enrollment[B] number (percent): 2,075,344 (22%). 

State: North Dakota; 
Total potentially eligible number (percent): 184,646 (27%); 
Current enrollment[A] number (percent): 66,878 (10%); 
Potential new enrollment[B] number (percent): 117,768 (17%). 

State: Ohio; 
Total potentially eligible number (percent): 4,314,151 (37%); 
Current enrollment[A] number (percent): 1,924,763 (17%); 
Potential new enrollment[B] number (percent): 2,389,388 (21%). 

State: Oklahoma; 
Total potentially eligible number (percent): 1,540,881 (41%); 
Current enrollment[A] number (percent): 641,202 (17%); 
Potential new enrollment[B] number (percent): 899,679 (24%). 

State: Oregon; 
Total potentially eligible number (percent): 1,349,809 (35%); 
Current enrollment[A] number (percent): 579,746 (15%); 
Potential new enrollment[B] number (percent): 770,063 (20%). 

State: Pennsylvania; 
Total potentially eligible number (percent): 4,311,622 (34%); 
Current enrollment[A] number (percent): 2,151,585 (17%); 
Potential new enrollment[B] number (percent): 2,160,037 (17%). 

State: Rhode Island; 
Total potentially eligible number (percent): 416,093 (40%); 
Current enrollment[A] number (percent): 181,819 (17%); 
Potential new enrollment[B] number (percent): 234,274 (22%). 

State: South Carolina; 
Total potentially eligible number (percent): 1,966,415 (42%); 
Current enrollment[A] number (percent): 808,541 (17%); 
Potential new enrollment[B] number (percent): 1,157,874 (25%). 

State: South Dakota; 
Total potentially eligible number (percent): 265,053 (32%); 
Current enrollment[A] number (percent): 117,475 (14%); 
Potential new enrollment[B] number (percent): 147,578 (18%). 

State: Tennessee; 
Total potentially eligible number (percent): 2,518,761 (40%); 
Current enrollment[A] number (percent): 1,208,562 (19%); 
Potential new enrollment[B] number (percent): 1,310,199 (21%). 

State: Texas; 
Total potentially eligible number (percent): 10,189,074 (40%); 
Current enrollment[A] number (percent): 4,221,763 (17%); 
Potential new enrollment[B] number (percent): 5,967,311 (24%). 

State: Utah; 
Total potentially eligible number (percent): 871,846 (31%); 
Current enrollment[A] number (percent): 315,030 (11%); 
Potential new enrollment[B] number (percent): 556,816 (20%). 

State: Vermont; 
Total potentially eligible number (percent): 237,942 (38%); 
Current enrollment[A] number (percent): 146,507 (23%); 
Potential new enrollment[B] number (percent): 91,435 (15%). 

State: Virginia; 
Total potentially eligible number (percent): 2,350,901 (30%); 
Current enrollment[A] number (percent): 879,536 (23%); 
Potential new enrollment[B] number (percent): 1,471,365 (18%). 

State: Washington; 
Total potentially eligible number (percent): 2,301,507 (34%); 
Current enrollment[A] number (percent): 1,093,373 (16%); 
Potential new enrollment[B] number (percent): 1,208,134 (18%). 

State: West Virginia; 
Total potentially eligible number (percent): 753,274 (41%); 
Current enrollment[A] number (percent): 360,572 (19%); 
Potential new enrollment[B] number (percent): 392,702 (21%). 

State: Wisconsin; 
Total potentially eligible number (percent): 1,924,191 (34%); 
Current enrollment[A] number (percent): 998,648 (18%); 
Potential new enrollment[B] number (percent): 925,543 (16%). 

State: Wyoming; 
Total potentially eligible number (percent): 159,359 (28%); 
Current enrollment[A] number (percent): 70,845 (13%); 
Potential new enrollment[B] number (percent): 88,514 (16%). 

State: Total; 
Total potentially eligible number (percent): 115,749,838 (37%); 
Current enrollment[A] number (percent): 53,196,416 (17%); 
Potential new enrollment[B] number (percent): 62,553,422 (20%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Our estimates are based on the assumption of all states opting to 
expand Medicaid. While some states have indicated they do not intend to 
participate, they may opt to do so at a later date. We did not predict 
the number of people who will participate in this program, commonly 
referred to as the take-up rate. 

Unless otherwise noted, the estimates we present have relative standard 
errors of less than 15 percent. 

[A] We use the term "current enrollment" to refer to estimated 
enrollment based on responses to the 2009-2011 ACS. 

[B] We estimated potential new enrollment as those who will be newly 
eligible for expanded Medicaid and some who may be eligible now, but 
did not report to ACS as being currently enrolled. Percentages of 
current enrollment and potential new enrollment may not add up to the 
total of potentially eligible due to rounding. 

[End of table] 

Table 6: Estimates of the Number and Percentage of American Indians and 
Alaska Natives Potentially Eligible for the Basic Health Program Option 
in 2015, and Cost-Sharing Exemptions and Premium Tax Credits under the 
Health Insurance Exchanges in 2014, by Indian Health Service (IHS) 
Service Area: 

IHS Service Area: Aberdeen; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 9,014 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 11,397 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 17,605 (21%); 
American Indian and Alaska Native alone or in combination with another 
race: 22,868 (22%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 22,006 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 29,288 (28%). 

IHS Service Area: Alaska; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 11,722 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,056 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 26,142 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 37,133 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 33,459 (37%); 
American Indian and Alaska Native alone or in combination with another 
race: 49,537 (39%). 

IHS Service Area: Albuquerque; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 12,022 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,339 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 25,975 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 31,265 (26%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 35,627 (37%); 
American Indian and Alaska Native alone or in combination with another 
race: 43,109 (36%). 

IHS Service Area: Bemidji; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 9,871 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 17,268 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 21,413 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 36,729 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 29,294 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 49,225 (36%). 

IHS Service Area: Billings; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 4,904 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 6,341 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 9,521 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 12,196 (26%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 12,633 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,334 (35%). 

IHS Service Area: California; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 13,926 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 30,048 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 31,109 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 63,679 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 40,303 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 84,676 (36%). 

IHS Service Area: Nashville; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 9,405 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 22,296 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 21,458 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 51,233 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 28,619 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 70,964 (38%). 

IHS Service Area: Navajo; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 22,347 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 23,436 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 46,410 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 48,303 (23%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 61,006 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 63,905 (30%). 

IHS Service Area: Oklahoma City; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 37,934 (15%); 
American Indian and Alaska Native alone or in combination with another 
race: 73,282 (15%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 79,608 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 153,691 (31%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 106,030 (41%); 
American Indian and Alaska Native alone or in combination with another 
race: 204,569 (42%). 

IHS Service Area: Phoenix; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 23,604 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 32,573 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 46,115 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 66,217 (26%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 60,931 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 88,675 (35%). 

IHS Service Area: Portland; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 17,347 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 36,989 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 39,952 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 80,905 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 52,950 (37%); 
American Indian and Alaska Native alone or in combination with another 
race: 108,541 (37%). 

IHS Service Area: Tucson; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 3,863[D] (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 4,992 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 7,078 (21%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,968 (24%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 8,895 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 12,245 (29%). 

IHS Service Area: IHS Service Area Total; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 175,959 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 289,018 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 372,386 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 614,187 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 491,753 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 821,067 (36%). 

IHS Service Area: Non-IHS Service Areas; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 116,640 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 304,349 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 251,504 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 676,174 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 340,231 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 923,583 (37%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Because the number of IHS eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

Unless otherwise noted, the estimates we present have relative standard 
errors of less than 15 percent. 

We did not predict the number of people who will participate in these 
new coverage options, commonly referred to as the take-up rate. 

Certain individuals who are eligible for the premium tax credits may 
also be eligible for cost-sharing exemptions. 

[A] Beginning in 2015, states may opt to run a Basic Health Program for 
individuals between 138 and 200 percent of the federal poverty level 
(FPL). These estimates are if all states opt to run a Basic Health 
Program. 

[B] Certain American Indians and Alaska Natives obtaining insurance 
through the exchanges who are at or below 300 percent of FPL are exempt 
from cost-sharing, such as deductibles and copays, although our 
estimates reflect only those above 138 percent of FPL because 
individuals below this level would be potentially eligible for expanded 
Medicaid. 

[C] Individuals obtaining insurance through the exchanges who are 
between 100 and 400 percent of FPL are eligible for premium tax credits 
on a sliding scale, although our estimates reflect only those above 138 
percent of FPL because individuals below this level would be 
potentially eligible for expanded Medicaid. Individuals with incomes 
above 138 percent of FPL who may be eligible for Medicaid in a 
particular state are not eligible for premium tax credits. 

[D] Relative standard error of the estimate is between 15 and 30 
percent. 

[End of table] 

Table 7: Estimates of the Number and Percentage of All Races 
Potentially Eligible for the Basic Health Program Option in 2015 and 
Premium Tax Credits under the Health Insurance Exchanges in 2014, by 
Indian Health Service (IHS) Service Area: 

IHS Service Area: Aberdeen; 
Basic Health Program option[A] number (percent): 226,433 (11%); 
Exchange premium tax credits[B] number (percent): 850,311 (43%). 

IHS Service Area: Alaska; 
Basic Health Program option[A] number (percent): 83,373 (12%); 
Exchange premium tax credits[B] number (percent): 311,310 (45%). 

IHS Service Area: Albuquerque; 
Basic Health Program option[A] number (percent): 286,561 (13%); 
Exchange premium tax credits[B] number (percent): 836,492 (38%). 

IHS Service Area: Bemidji; 
Basic Health Program option[A] number (percent): 825,085 (12%); 
Exchange premium tax credits[B] number (percent): 2,906,786 (44%). 

IHS Service Area: Billings; 
Basic Health Program option[A] number (percent): 83,541 (14%); 
Exchange premium tax credits[B] number (percent): 275,478 (45%). 

IHS Service Area: California; 
Basic Health Program option[A] number (percent): 1,256,696 (12%); 
Exchange premium tax credits[B] number (percent): 3,852,121 (37%). 

IHS Service Area: Nashville; 
Basic Health Program option[A] number (percent): 2,430,650 (11%); 
Exchange premium tax credits[B] number (percent): 8,049,301 (38%). 

IHS Service Area: Navajo; 
Basic Health Program option[A] number (percent): 56,095 (11%); 
Exchange premium tax credits[B] number (percent): 184,299 (36%). 

IHS Service Area: Oklahoma City; 
Basic Health Program option[A] number (percent): 521,131 (13%); 
Exchange premium tax credits[B] number (percent): 1,656,550 (42%). 

IHS Service Area: Phoenix; 
Basic Health Program option[A] number (percent): 1,137,368 (13%); 
Exchange premium tax credits[B] number (percent): 3,719,458 (41%). 

IHS Service Area: Portland; 
Basic Health Program option[A] number (percent): 1,173,223 (11%); 
Exchange premium tax credits[B] number (percent): 4,138,184 (39%). 

IHS Service Area: Tucson; 
Basic Health Program option[A] number (percent): 124,460 (12%); 
Exchange premium tax credits[B] number (percent): 393,027 (39%). 

IHS Service Area: IHS Service Area Total; 
Basic Health Program option[A] number (percent): 8,204,617 (12%); 
Exchange premium tax credits[B] number (percent): 27,173,316 (39%). 

IHS Service Area: Non-IHS Service Areas; 
Basic Health Program option[A] number (percent): 27,228,110 (11%); 
Exchange premium tax credits[B] number (percent): 91,458,963 (38%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

The estimates we present have relative standard errors of less than 15 
percent. 

We did not predict the number of people who will participate in these 
new coverage options, commonly referred to as the take-up rate. 

[A] Beginning in 2015, states may opt to run a Basic Health Program for 
individuals between 138 and 200 percent of the federal poverty level 
(FPL). These estimates are if all states opt to run a Basic Health 
Program. 

[B] Individuals obtaining insurance through the exchanges who are 
between 100 and 400 percent of FPL are eligible for premium tax credits 
on a sliding scale, although our estimates reflect only those above 138 
percent of FPL because individuals below this level would be 
potentially eligible for expanded Medicaid. Individuals with incomes 
above 138 percent of FPL who may be eligible for Medicaid in a 
particular state are not eligible for premium tax credits. 

[End of table] 

Table 8: Estimates of the Number and Percentage of American Indians and 
Alaska Natives Potentially Eligible for the Basic Health Program Option 
in 2015, and Cost-Sharing Exemptions and Premium Tax Credits under the 
Health Insurance Exchanges in 2014, by State: 

State: Alabama; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,660 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 6,491 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 7,733 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,240 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 10,025 (41%); 
American Indian and Alaska Native alone or in combination with another 
race: 22,539 (41%). 

State: Alaska; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 12,890 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 17,401 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 28,612 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 39,968 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 36,480 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 52,978 (39%). 

State: Arizona; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 31,967 (11%); 
American Indian and Alaska Native 
alone or in combination with another race: 38,615 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 64,703 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 79,670 (24%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 84,816 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 104,834 (31%). 

State: Arkansas; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,604 (15%); 
American Indian and Alaska Native alone or in combination with another 
race: 6,805 (15%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 6,184 (34%); 
American Indian and Alaska Native alone or in combination with another 
race: 15,250 (33%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 7,870 (44%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,068 (42%). 

State: California; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 29,093 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 69,195 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 64,034 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 151,102 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 86,182 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 208,511 (34%). 

State: Colorado; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 6,418 (14%); 
American Indian and Alaska Native alone or in combination with another 
race: 13,374 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 13,266 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 29,498 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 18,978 (40%); 
American Indian and Alaska Native alone or in combination with another 
race: 41,349 (39%). 

State: Connecticut; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 4,259[D] (15%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 1,373[D] (22%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 7,963 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 2,038[D] (33%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 11,271 (41%). 

State: Delaware; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,391[D] (18%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 0 (20%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 2,494[D] (32%)[D]; 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 605[D] (28%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,191 (41%). 

State: District of Columbia; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 0 (0%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 0 (0%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 964[D] (21%)[D]. 

State: Florida; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 5,786 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 17,745 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 12,287 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 38,037 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 16,664 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 50,996 (38%). 

State: Georgia; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,137[D] (11%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 7,607 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 5,704 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 17,977 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 7,647 (39%); 
American Indian and Alaska Native alone or in combination with another 
race: 24,816 (38%). 

State: Hawaii; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 851[D] (24%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,217[D] (13%)[D];
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 1,167[D] (34%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 9,967 (30%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 1,596[D] (46%); 
American Indian and Alaska Native alone or in combination with another 
race: 13,774 (42%). 

State: Idaho; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,408[D] (12%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,636 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 5,286 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,694 (30%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 6,851 (34%); 
American Indian and Alaska Native alone or in combination with another 
race: 13,603 (38%). 

State: Illinois; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,859[D] (9%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 7,215 (10%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 5,380 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,759 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 7,335 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 26,862 (37%). 

State: Indiana; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,304[D] (10%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 7,428 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,724 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,472 (31%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 5,018 (40%); 
American Indian and Alaska Native alone or in combination with another 
race: 21,028 (40%). 

State: Iowa; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,733[D] (17%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,271[D] (15%)[D]; 
Exchange 
cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,293[D] (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 7,974 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 3,725[D] (37%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,836 (34%). 

State: Kansas; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,854 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 7,416 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 5,957 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 18,181 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 7,924 (34%); 
American Indian and Alaska Native alone or in combination with another 
race: 25,523 (38%). 

State: Kentucky; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,147[D] (13%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,812 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 2,558 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 8,170 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 2,969 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,320 (34%). 

State: Louisiana; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 3,330[D] (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 6,610 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 6,424 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 13,692 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 8,939 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,354 (38%). 

State: Maine; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 2,597[D] (13%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 1,327[D] (19%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 5,448 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 2,031[D] (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 7,297 (37%). 

State: Maryland; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 943[D] (7%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,580 (10%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 2,248[D] (17%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 10,000 (21%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 3,582 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,486 (30%). 

State: Massachusetts; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (9%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,381 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 2,091[D] (19%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 9,781 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 3,075[D] (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 13,954 (35%). 

State: Michigan; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 7,595 (14%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,374 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 14,984 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 38,984 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 20,838 (39%); 
American Indian and Alaska Native alone or in combination with another 
race: 52,479 (39%). 

State: Minnesota; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 6,173 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 12,230 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 13,024 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 24,822 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 17,356 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 33,454 (33%). 

State: Mississippi; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,519[D] (11%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,048[D] (11%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 4,196 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 7,774 (29%); 
[Empty]; Exchange premium tax credits[C] number (percent): American 
Indian and Alaska Native alone: 5,224 (39%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,399 (38%). 

State: Missouri; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,232[D] (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,588 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 6,095 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 21,371 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 8,952 (42%); 
American Indian and Alaska Native alone or in combination with another 
race: 29,171 (38%). 

State: Montana; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 7,685 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,935 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 15,395 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,590 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 20,548 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 26,278 (34%). 

State: Nebraska; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,127[D] (13%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,871 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,787 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 6,806 (22%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 4,879 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,914 (32%). 

State: Nevada; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 4,007 (14%); 
American Indian and Alaska Native alone or in combination with another 
race: 7,051 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 8,045 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,652 (30%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 10,258 (37%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,521 (40%). 

State: New Hampshire; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,126[D] (12%)[D][D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 744[D] (30%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 2,433 (26%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 1,167[D] (47%); 
American Indian and Alaska Native alone or in combination with another 
race: 3,843 (41%). 

State: New Jersey; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,743[D] (11%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,659 (10%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,467 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,298 (22%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 5,003 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 15,864 (34%). 

State: New Mexico; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 23,430 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 26,135 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 49,010 (25%); 
American Indian and Alaska Native alone or in combination with another 
race: 54,552 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 66,114 (34%); 
American Indian and Alaska Native alone or in combination with another 
race: 74,152 (34%). 

State: New York; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 5,287 (10%); 
American Indian and Alaska Native alone or in combination with another 
race: 12,582 (9%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 11,791 (23%); 
American Indian and Alaska Native alone or in combination with another 
race: 32,257 (24%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 16,310 (33%); 
American Indian and Alaska Native alone or in combination with another 
race: 45,518 (33%). 

State: North Carolina; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 14,652 (14%); 
American Indian and Alaska Native alone or in combination with another 
race: 24,716 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 31,077 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 53,298 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 38,279 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 67,203 (37%). 

State: North Dakota; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,280[D] (6%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 2,844[D] (7%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 6,919 (19%); 
American Indian and Alaska Native alone or in combination with another 
race: 8,887 (21%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 9,220 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 11,949 (28%). 

State: Ohio; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 3,143[D] (15%); 
American Indian and Alaska Native alone or in combination with another 
race: 12,599 (14%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 5,917 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 26,947 (31%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 7,889 (38%); 
American Indian and Alaska Native alone or in combination with another 
race: 35,040 (40%). 

State: Oklahoma; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 37,664 (15%); 
American Indian and Alaska Native alone or in combination with another 
race: 72,715 (15%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 79,010 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 152,144 (31%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 105,343 (41%); 
American Indian and Alaska Native alone or in combination with another 
race: 202,414 (42%). 

State: Oregon; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 6,793 (14%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,042 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 14,429 (30%); 
American Indian and Alaska Native alone or in combination with another 
race: 29,427 (28%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 18,543 (39%); 
American Indian and Alaska Native alone or in combination with another 
race: 38,517 (36%). 

State: Pennsylvania; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,385[D] (9%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 8,044 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 2,982 (20%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,712 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 4,848 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 23,976 (36%). 

State: Rhode Island; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,374[D] (12%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 994[D] (24%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 2,207[D] (19%)[D]; 
Exchange premium tax credits[C] number (percent): [Empty]; 
American Indian and Alaska Native alone: 1,356[D] (32%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,254 (28%). 

State: South Carolina; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,622[D] (12%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,306 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,914 (29%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,014 (26%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 5,354 (39%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,325 (37%). 

State: South Dakota; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 7,711 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 9,054 (11%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 13,695 (19%); 
American Indian and Alaska Native alone or in combination with another 
race: 18,354 (22%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 17,285 (24%); 
American Indian and Alaska Native alone or in combination with another 
race: 22,592 (27%). 

State: Tennessee; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 1,628[D] (13%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 6,851 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,447 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 14,646 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 4,916 (40%); 
American Indian and Alaska Native alone or in combination with another 
race: 19,758 (36%). 

State: Texas; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 14,177 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 32,923 (13%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 28,932 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 74,637 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 39,332 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 102,385 (39%). 

State: Utah; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 3,688[D] (12%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 5,941 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 7,384 (24%); 
American Indian and Alaska Native alone or in combination 
with another race: 12,101 (25%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 9,633 (31%); 
American Indian and Alaska Native alone or in combination with another 
race: 16,360 (34%). 

State: Vermont; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,074[D] (14%)[D]; 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 0 (0%); 
American Indian and Alaska Native alone or in combination with another 
race: 2,414 (32%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 948[D] (49%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 4,182 (56%). 

State: Virginia; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 3,126[D] (15%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 8,353 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 6,845 (32%); 
American Indian and Alaska Native alone or in combination with another 
race: 20,087 (29%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 8,835 (41%); 
American Indian and Alaska Native alone or in combination with another 
race: 27,738 (40%). 

State: Washington; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 10,314 (11%); 
American Indian and Alaska Native alone or in combination with another 
race: 22,530 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 24,751 (27%); 
American Indian and Alaska Native alone or in combination with another 
race: 50,392 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 33,322 (36%); 
American Indian and Alaska Native alone or in combination with another 
race: 68,825 (36%). 

State: West Virginia; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 505[D] (15%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 2,555 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 1,114[D] (34%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 5,801 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 1,187[D] (36%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 7,705 (36%). 

State: Wisconsin; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 6,180 (13%); 
American Indian and Alaska Native alone or in combination with another 
race: 10,337 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 13,703 (28%); 
American Indian and Alaska Native alone or in combination with another 
race: 23,254 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 19,231 (40%); 
American Indian and Alaska Native alone or in combination with another 
race: 32,550 (38%). 

State: Wyoming; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 2,272[D] (17%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 3,329 (15%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 3,959[D] (29%)[D]; 
American Indian and Alaska Native alone or in combination with another 
race: 6,701 (31%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 5,075 (38%); 
American Indian and Alaska Native alone or in combination with another 
race: 8,731 (40%). 

State: Total; 
Basic Health Program option[A] number (percent): 
American Indian and Alaska Native alone: 292,599 (12%); 
American Indian and Alaska Native alone or in combination with another 
race: 593,367 (12%); 
Exchange cost-sharing exemptions[B] number (percent): 
American Indian and Alaska Native alone: 623,890 (26%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,290,362 (27%); 
Exchange premium tax credits[C] number (percent): 
American Indian and Alaska Native alone: 831,985 (35%); 
American Indian and Alaska Native alone or in combination with another 
race: 1,744,651 (37%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

Because the number of IHS eligible individuals is likely to be between 
the number of individuals who self-identify as American Indians and 
Alaska Natives alone and American Indians and Alaska Natives alone or 
in combination, we presented results for both groups as the range. We 
excluded foreign-born American Indians and Alaska Natives from our 
analysis. 

Unless otherwise noted, the estimates we present have relative standard 
errors of less than 15 percent. Estimates with relative standard errors 
greater than 30 percent are omitted. 

We did not predict the number of people who will participate in these 
new coverage options, commonly referred to as the take-up rate. 

Certain individuals who are eligible for the premium tax credits may 
also be eligible for cost-sharing exemptions. 

[A] Beginning in 2015, states may opt to run a Basic Health Program for 
individuals between 138 and 200 percent of the federal poverty level 
(FPL). These estimates are if all states opt to run a Basic Health 
Program. 

[B] Certain American Indians and Alaska Natives obtaining insurance 
through the exchanges who are at or below 300 percent of FPL are exempt 
from cost-sharing, such as deductibles and copays, although our 
estimates reflect only those above 138 percent of FPL because 
individuals below this level would be potentially eligible for expanded 
Medicaid. 

[C] Individuals obtaining insurance through the exchanges who are 
between 100 and 400 percent of FPL are eligible for premium tax credits 
on a sliding scale, although our estimates reflect only those above 138 
percent of FPL because individuals below this level would be 
potentially eligible for expanded Medicaid. Individuals with incomes 
above 138 percent of FPL who may be eligible for Medicaid in a 
particular state are not eligible for premium tax credits. 

[D] Relative standard error of the estimate is between 15 and 30 
percent. 

[End of table] 

Table 9: Estimates of the Number and Percentage of All Races 
Potentially Eligible for the Basic Health Program Option in 2015 and 
Premium Tax Credits under the Health Insurance Exchanges in 2014, by 
State: 

State: Alabama; 
Basic Health Program option[A] number (percent): 584,905 (12%); 
Exchange premium tax credits[B] number (percent): 1,854,582 (39%). 

State: Alaska; 
Basic Health Program option[A] number (percent): 85,706 (12%); 
Exchange premium tax credits[B] number (percent): 317,908 (45%). 

State: Arizona; 
Basic Health Program option[A] number (percent): 778,325 (12%); 
Exchange premium tax credits[B] number (percent): 2,521,814 (39%). 

State: Arkansas; 
Basic Health Program option[A] number (percent): 401,989 (14%); 
Exchange premium tax credits[B] number (percent): 1,216,079 (42%). 

State: California; 
Basic Health Program option[A] number (percent): 4,216,442 (11%); 
Exchange premium tax credits[B] number (percent): 12,863,653 (34%). 

State: Colorado; 
Basic Health Program option[A] number (percent): 533,713 (11%); 
Exchange premium tax credits[B] number (percent): 1,916,497 (38%). 

State: Connecticut; 
Basic Health Program option[A] number (percent): 321,598 (9%); 
Exchange premium tax credits[B] number (percent): 1,199,422 (34%). 

State: Delaware; 
Basic Health Program option[A] number (percent): 98,089 (11%); 
Exchange premium tax credits[B] number (percent): 341,818 (38%). 

State: District of Columbia; 
Basic Health Program option[A] number (percent): 46,282 (8%); 
Exchange premium tax credits[B] number (percent): 158,258 (26%). 

State: Florida; 
Basic Health Program option[A] number (percent): 2,392,563 (13%); 
Exchange premium tax credits[B] number (percent): 7,531,421 (40%). 

State: Georgia; 
Basic Health Program option[A] number (percent): 1,121,198 (12%); 
Exchange premium tax credits[B] number (percent): 3,667,884 (38%). 

State: Hawaii; 
Basic Health Program option[A] number (percent): 177,223 (13%); 
Exchange premium tax credits[B] number (percent): 592,985 (44%). 

State: Idaho; 
Basic Health Program option[A] number (percent): 226,044 (14%); 
Exchange premium tax credits[B] number (percent): 719,097 (46%). 

State: Illinois; 
Basic Health Program option[A] number (percent): 1,404,723 (11%); 
Exchange premium tax credits[B] number (percent): 4,802,739 (37%). 

State: Indiana; 
Basic Health Program option[A] number (percent): 813,117 (13%); 
Exchange premium tax credits[B] number (percent): 2,800,941 (43%). 

State: Iowa; 
Basic Health Program option[A] number (percent): 351,300 (12%); 
Exchange premium tax credits[B] number (percent): 1,360,465 (45%). 

State: Kansas; 
Basic Health Program option[A] number (percent): 350,367 (12%); 
Exchange premium tax credits[B] number (percent): 1,212,107 (42%). 

State: Kentucky; 
Basic Health Program option[A] number (percent): 546,772 (13%); 
Exchange premium tax credits[B] number (percent): 1,776,393 (41%). 

State: Louisiana; 
Basic Health Program option[A] number (percent): 524,484 (12%); 
Exchange premium tax credits[B] number (percent): 1,710,480 (38%). 

State: Maine; 
Basic Health Program option[A] number (percent): 171,101 (13%); 
Exchange premium tax credits[B] number (percent): 585,878 (44%). 

State: Maryland; 
Basic Health Program option[A] number (percent): 529,201 (9%); 
Exchange premium tax credits[B] number (percent): 1,929,703 (33%). 

State: Massachusetts; 
Basic Health Program option[A] number (percent): 589,495 (9%); 
Exchange premium tax credits[B] number (percent): 2,204,596 (34%). 

State: Michigan; 
Basic Health Program option[A] number (percent): 1,136,069 (11%); 
Exchange premium tax credits[B] number (percent): 3,974,626 (40%). 

State: Minnesota; 
Basic Health Program option[A] number (percent): 546,341 (10%); 
Exchange premium tax credits[B] number (percent): 2,135,973 (40%). 

State: Mississippi; 
Basic Health Program option[A] number (percent): 367,880 (12%); 
Exchange premium tax credits[B] number (percent): 1,137,216 (38%). 

State: Missouri; 
Basic Health Program option[A] number (percent): 732,846 (12%); 
Exchange premium tax credits[B] number (percent): 2,518,872 (42%). 

State: Montana; 
Basic Health Program option[A] number (percent): 132,167 (13%); 
Exchange premium tax credits[B] number (percent): 444,635 (45%). 

State: Nebraska; 
Basic Health Program option[A] number (percent): 215,875 (12%); 
Exchange premium tax credits[B] number (percent): 807,154 (44%). 

State: Nevada; 
Basic Health Program option[A] number (percent): 350,437 (13%); 
Exchange premium tax credits[B] number (percent): 1,131,112 (42%). 

State: New Hampshire; 
Basic Health Program option[A] number (percent): 132,249 (10%); 
Exchange premium tax credits[B] number (percent): 518,179 (39%). 

State: New Jersey; 
Basic Health Program option[A] number (percent): 807,361 (9%); 
Exchange premium tax credits[B] number (percent): 2,907,472 (33%). 

State: New Mexico; 
Basic Health Program option[A] number (percent): 252,790 (12%); 
Exchange premium tax credits[B] number (percent): 791,781 (38%). 

State: New York; 
Basic Health Program option[A] number (percent): 1,991,643 (10%); 
Exchange premium tax credits[B] number (percent): 6,789,077 (35%). 

State: North Carolina; 
Basic Health Program option[A] number (percent): 1,176,315 (12%); 
Exchange premium tax credits[B] number (percent): 3,799,848 (40%). 

State: North Dakota; 
Basic Health Program option[A] number (percent): 76,515 (11%); 
Exchange premium tax credits[B] number (percent): 295,907 (44%). 

State: Ohio; 
Basic Health Program option[A] number (percent): 1,359,034 (12%); 
Exchange premium tax credits[B] number (percent): 4,752,273 (41%). 

State: Oklahoma; 
Basic Health Program option[A] number (percent): 497,346 (13%); 
Exchange premium tax credits[B] number (percent): 1,576,455 (42%). 

State: Oregon; 
Basic Health Program option[A] number (percent): 476,007 (12%); 
Exchange premium tax credits[B] number (percent): 1,569,424 (41%). 

State: Pennsylvania; 
Basic Health Program option[A] number (percent): 1,453,820 (11%); 
Exchange premium tax credits[B] number (percent): 5,178,832 (41%). 

State: Rhode Island; 
Basic Health Program option[A] number (percent): 115,361 (11%); 
Exchange premium tax credits[B] number (percent): 383,823 (36%). 

State: South Carolina; 
Basic Health Program option[A] number (percent): 566,467 (12%); 
Exchange premium tax credits[B] number (percent): 1,840,598 (40%). 

State: South Dakota; 
Basic Health Program option[A] number (percent): 95,792 (12%); 
Exchange premium tax credits[B] number (percent): 367,951 (45%). 

State: Tennessee; 
Basic Health Program option[A] number (percent): 790,484 (12%); 
Exchange premium tax credits[B] number (percent): 2,599,340 (41%). 

State: Texas; 
Basic Health Program option[A] number (percent): 3,006,362 (12%); 
Exchange premium tax credits[B] number (percent): 9,324,879 (37%). 

State: Utah; 
Basic Health Program option[A] number (percent): 361,150 (13%); 
Exchange premium tax credits[B] number (percent): 1,292,879 (47%). 

State: Vermont; 
Basic Health Program option[A] number (percent): 71,796 (11%); 
Exchange premium tax credits[B] number (percent): 271,785 (43%). 

State: Virginia; 
Basic Health Program option[A] number (percent): 799,384 (10%); 
Exchange premium tax credits[B] number (percent): 2,921,457 (36%). 

State: Washington; 
Basic Health Program option[A] number (percent): 696,422 (10%); 
Exchange premium tax credits[B] number (percent): 2,561,712 (38%). 

State: West Virginia; 
Basic Health Program option[A] number (percent): 235,843 (13%); 
Exchange premium tax credits[B] number (percent): 775,393 (42%). 

State: Wisconsin; 
Basic Health Program option[A] number (percent): 657,266 (12%); 
Exchange premium tax credits[B] number (percent): 2,434,021 (43%). 

State: Wyoming; 
Basic Health Program option[A] number (percent): 67,068 (12%); 
Exchange premium tax credits[B] number (percent): 244,885 (43%). 

State: Total; 
Basic Health Program option[A] number (percent): 35,432,727 (11%); 
Exchange premium tax credits[B] number (percent): 118,632,279 (38%). 

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year 
estimates. 

The estimates we present have relative standard errors of less than 15 
percent. 

We did not predict the number of people who will participate in these 
new coverage options, commonly referred to as the take-up rate. 

[A] Beginning in 2015, states may opt to run a Basic Health Program for 
individuals between 138 and 200 percent of the federal poverty level 
(FPL). These estimates are if all states opt to run a Basic Health 
Program. 

[B] Individuals obtaining insurance through the exchanges who are 
between 100 and 400 percent of FPL are eligible for premium tax credits 
on a sliding scale, although our estimates reflect only those above 138 
percent of FPL because individuals below this level would be 
potentially eligible for expanded Medicaid. Individuals with incomes 
above 138 percent of FPL who may be eligible for Medicaid in a 
particular state are not eligible for premium tax credits. 

[End of table] 

Appendix IV: Comments from the Department of Health and Human Services: 

Department of Health & Human Services: 
Office of The Secretary:
Assistant Secretary for Legislation: 
Washington, DC 20201: 

July 26, 2013: 

Kathleen King: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. King: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled, "Indian Health Service: Most American Indians 
and Alaska Natives Potentially Eligible for Expanded Medicaid and New 
Coverage Options, but Action Needed to Increase Enrollment" (GAO-13-
553). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Indian Health Service: Most American Indians And Alaska Natives 
Potentially Eligible For Expanded Medicaid And New Coverage Options, 
But Action Needed To Increase Enrollment" (GAO-13-553): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

Recommendation: 

To help ensure successful outreach efforts resulting in significant 
new enrollment, GAO recommends that the Secretary of Health and Human 
Services (HHS) direct the Director of IHS and the Administrator of CMS 
coordinate a plan to: 

* Improve their communications with facility staff and tribal leaders 
to ensure that information on Medicaid and the Marketplace, including 
detailed information on program eligibility rules and enrollment 
procedures, is being disseminated to all facilities and tribes; and, 

* Increase direct outreach to American Indians and Alaska Natives who 
may be eligible for expanded Medicaid and the Marketplace, including 
strategy for educating American Indians and Alaska Natives about the 
effect of Patient Protection & Affordable Care Act's (PPACA) 
definition of Indian on their coverage options and obligations. 

HHS Response: 

HHS concurs with this recommendation. CMS' Center for Medicaid and 
CHIP Services, Tribal Affairs, and Center for Consumer Information and 
Insurance Oversight staff are currently working closely with IHS and 
HHS Intergovernmental & External Affairs staff to develop and review 
outreach, education and enrollment materials and information 
dissemination/training strategies. 

HHS is actively engaged in a number of outreach and education 
activities to ensure active participation of American Indian/American 
Native (Al/AN) in the expanded and new coverage options available 
through the Affordable Care Act. CMS has organized a number of All 
Tribes Calls and webinars to disseminate information about the 
Marketplace and the Medicaid expansion. In addition, CMS has issued 
guidance directly to tribal leaders and health directors and has 
participated in a number or tribal consultations. CMS conducted six 
(three in 2012 and three in 2013) face-to-face national tribal 
consultations and 18 regional consultations (11 in 2012 and 7 in 2013) 
to discuss the Marketplace and the Medicaid expansion. Further, as 
part of our ongoing outreach and education efforts, CMS has developed 
AI/AN training materials and fact sheets on Medicare, Medicaid and 
CHIP. Building off these existing outreach materials, CMS has 
developed AI/AN specific outreach materials on the Marketplace and 
Medicaid expansion. These outreach and education activities are 
necessary to ensure the active participation of Al/AN in the new and 
expanded coverage options and ensures that CMS develops culturally 
appropriate policies that consider tribal views. 

As described above, within HHS, CMS's Center for Medicaid and CHIP 
Services, Tribal Affairs, and Center for Consumer Information and 
Insurance Oversight staff is currently working closely with IHS and 
HHS Intergovernmental & External Affairs staff to develop and review 
outreach, education and enrollment materials and information 
dissemination/training strategies, including educating tribal 
communities about the hardship exemption for Indians from the shared 
responsibility payment. 

IHS will continue to work with CMS to move forward to improve 
communication with Area Offices, facility staff and tribal leaders to 
ensure information on Medicaid and exchanges are addressed including 
detailing program eligibility rules and enrollment procedures. IHS 
will increase direct outreach to AVANs who may be eligible for 
expanded Medicaid and the exchanges, including a strategy for 
educating American Indians and Alaska Natives about the effect of the 
Affordable Care Act's definition of Indian on their coverage options 
and obligations. IHS continues to work closely with CMS to review 
rules and regulations related to Affordable Care Act ensuring Al/AN 
coverage options and obligations are addressed. 

Recommendation: 

The Director of IHS to prepare for the increase in eligibility for 
expanded Medicaid and new coverage options, and the need for 
enrollment assistance and billing capacity, but realigning current 
resources and personnel to increase capacity to assist with these 
efforts. 

HHS Response: 

IHS developed the Business Plan Template to ensure that capacity 
building and enrollment activities are maximized at the local level in 
coordination with Headquarters and Area Offices. Local facilities are 
required to develop and implement local implementation plans that 
focus on capacity building activities including staffing needs. 
Leadership at the local level is required to implement these plans and 
to increase resources to support staff and expand duties, as 
necessary. This is a priority for IHS, and Headquarters and the 
respective Areas will monitor the overall implementation process. Each 
IHS operated facility is directed to maximize the full benefit of the 
Affordable Care Act. IHS Headquarters and Areas will continue to work 
with the local levels and move forward on both enrollment activities 
and capacity building at the local facility level. Monitoring this 
process will take place through the performance plan evaluations of 
local leadership by their respective Area Director, with monitoring of 
the Areas by the IHS Deputy Director for Field Operations. 

Recommendation: 

GAO recommends the Administrator of CMS develop a plan to: 

* Educate state Medicaid agencies about when coverage status 
information may be shared between states and I/T/U facilities; and, 

* Provide a means for members of direct service tribes to authorize 
disclosure of information about their coverage status with their 
tribes, such as through the single, streamlined application for health 
insurance, or through application assistance personnel. 

HHS Response: 

The CMS' Center for Medicaid and CHIP Services will include this 
education as part of their State Operations and Technical Assistance 
(SOTA) and other technical assistance calls with states. 

Based on our reading of the report, it appears that the issue of 
directing service tribes to authorize disclosure of information about 
their coverage status with their tribes might be addressed on pages 31 
and 32 of the report, but we would need further clarification of what 
GAO is recommending to fully comment. Otherwise, we suggest the 
recommendation be deleted in its entirety. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Kathleen M. King, (202) 512-7114 or kingk@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Catina Bradley, Assistant 
Director; Lisa Motley; Giao N. Nguyen; Laurie Pachter; Dae Park; Perry 
Parsons; and Monique Williams made key contributions to this report. 

[End of section] 

Related GAO Products: 

Indian Health Service: Capping Payment Rates for Nonhospital Services 
Could Save Millions of Dollars for Contract Health Services. 
[hyperlink, http://www.gao.gov/products/GAO-13-272]. Washington, D.C.: 
April 11, 2013. 

Medicaid Expansion: States' Implementation of the Patient Protection 
and Affordable Care Act. [hyperlink, 
http://www.gao.gov/products/GAO-12-821]. Washington, D.C.: August 1, 
2012. 

Indian Health Service: Action Needed to Ensure Equitable Allocation of 
Resources for the Contract Health Service Program. [hyperlink, 
http://www.gao.gov/products/GAO-12-446]. Washington, D.C.: June 15, 
2012. 

Indian Health Service: Increased Oversight Needed to Ensure Accuracy 
of Data Used for Estimating Contract Health Service Need. [hyperlink, 
http://www.gao.gov/products/GAO-11-767]. Washington, D.C.: September 
23, 2011. 

Indian Health Service: Updated Policies and Procedures and Increased 
Oversight Needed for Billings and Collections from Private Insurers. 
[hyperlink, http://www.gao.gov/products/GAO-10-42R]. Washington, D.C.: 
October 22, 2009. 

Medicare and Medicaid: CMS and State Efforts to Interact with the 
Indian Health Service and Indian Tribes. [hyperlink, 
http://www.gao.gov/products/GAO-08-724]. Washington, D.C.: 
July 11, 2008. 

Indian Health Service: Health Care Services Are Not Always Available 
to Native Americans. [hyperlink, 
http://www.gao.gov/products/GAO-05-789]. Washington, D.C.: August 31, 
2005. 

[End of section] 

Footnotes: 

[1] IHS defines an Indian tribe as any Indian tribe, band, nation, 
group, Pueblo, or community, including any Alaska Native village or 
Native group, which is federally recognized as eligible for the 
programs and services provided by the United States to Indians because 
of their status as Indians. 

Individuals are eligible for IHS services if they are considered 
American Indians and Alaska Natives by the community in which they 
live, as evidenced by factors such as tribal membership, enrollment, 
residence on tax-exempt land, ownership of restricted property, active 
participation in tribal affairs, or other relevant factors. See 42 
C.F.R. § 136.12. 

[2] See GAO, Indian Health Service: Health Care Services Are Not 
Always Available to Native Americans, [hyperlink, 
http://www.gao.gov/products/GAO-05-789] (Washington, D.C.: Aug. 31, 
2005). See also the Related GAO Products page at the end of this 
report. 

[3] Medicaid is a joint federal-state program that finances health 
insurance coverage for certain categories of low-income individuals. 
CHIP, also a joint federal-state insurance program, provides coverage 
to children whose family income is low, but too high for Medicaid. 
Medicare is the federal health insurance program for individuals age 
65 and over and for individuals with certain disabilities or end-stage 
renal disease. 

[4] Indian Health Service, "Justification of Estimates for 
Appropriations Committees, Fiscal Year 2014" (Rockville, Md., 2013). 

[5] For example, see Genevieve M. Kenney et al., "Who and Where are 
the Children Yet to Enroll in Medicaid and the Children's Health 
Insurance Program?" Health Affairs, vol. 29, no. 10 (2010). 

HHS included in its Action Plan to Eliminate Racial and Ethnic Health 
Disparities the goal of increasing the health insurance coverage rate 
among racial and ethnic minorities as a means of eliminating health 
disparities. 

[6] Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the 
Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-
152, 124 Stat. 1029. For purposes of this report, references to PPACA 
include the amendments made by the Health Care and Education 
Reconciliation Act of 2010. Unless otherwise noted, we use "expanded 
and new coverage options" to refer to expanded Medicaid and the new 
coverage options created by PPACA, specifically premium tax credits 
and exemptions from cost-sharing available for insurance obtained 
through Exchanges and the Basic Health Program. 

[7] PPACA established 133 percent of the FPL as the income limit for 
expanded Medicaid eligibility; however, it also specifies that an 
income disregard in the amount of 5 percent of the FPL be deducted 
from an individual's income when determining Medicaid eligibility, 
which effectively raises the eligibility limit for newly eligible 
Medicaid recipients to 138 percent of the FPL. See Pub. L. No. 111-
148, §§ 2001(a)(1), 2002, 124 Stat. 119, 271, 279 (2010); Pub. L. No. 
111-152, § 1004, 124 Stat. 1029, 1034 (2010) (codified at 42 U.S.C. § 
1396a(a)(10)(A)(i)(VIII) and to be codified at 42 U.S.C. § 
1396a(e)(14)(I)). 

[8] The U.S. Supreme Court ruled in June 2012 that states choosing not 
to expand Medicaid coverage to individuals eligible under PPACA will 
forgo only the federal matching funds associated with such expanded 
coverage, rather than be subject to a termination of all Medicaid 
federal matching funds. See Nat'l Fed'n of Indep. Bus. v Sebelius, 132 
S.Ct. 2566 (2012). 

[9] Exchanges are health insurance marketplaces in which individuals 
and small businesses will be able to compare, select, and purchase 
health coverage from among participating carriers. Exchanges are also 
referred to by HHS as Marketplaces. PPACA directed states to 
establish state-based Exchanges by January 1, 2014. In states electing 
not to establish and operate such an Exchange, PPACA requires the 
federal government to establish and operate an Exchange in the state, 
referred to as a Federally Facilitated Exchange. Pub. L. No. 111-148, 
§§ 1311(b)(1), 1321(c), 124 Stat. 119, 173, 186 (2010). CMS provided 
states in which a Federally Facilitated Exchange will operate the 
option to participate in a variation of a Federally Facilitated 
Exchange, called a Partnership Exchange, in which the state would 
assist CMS in carrying out certain Exchange activities. 

[10] American Indians and Alaska Natives who obtain insurance through 
an Exchange are eligible for cost-sharing exemptions if they are 
members of federally recognized tribes and have a household income of 
not more than 300 percent of the FPL. Pub. L. No. 111-148, § 
1402(d)(1), 124 Stat. 119, 222 (2010) (codified at 42 U.S.C. § 18071). 

Although PPACA generally requires that individuals obtain health 
insurance or be subject to a federal tax--a requirement often referred 
to as the individual mandate--American Indians and Alaska Natives who 
are members of federally recognized tribes are statutorily exempt. See 
Pub. L. No. 111-148, §§ 1501(b),10106, 124 Stat. 119, 244, 909 (2010); 
Pub. L. No. 111-152, §§ 1002, 1004, 124 Stat. 1029, 1032, 1034 (2010) 
(codified at 26 U.S.C. § 5000A). Additionally, a Final Rule released 
June 26, 2013, established additional exemptions to the individual 
mandate under HHS's authority to establish hardship exemptions, 
including for individuals eligible for IHS services, who are not 
members of federally recognized tribes, and for individuals living in 
states that chose not to expand Medicaid eligibility but who would 
otherwise qualify for it. 78 Fed. Reg. 39,494 (July 1, 2013). 

[11] The availability of more coverage options for American Indians 
and Alaska Natives could alleviate constraints on the IHS budget both 
by increasing reimbursements for services provided by IHS to enrolled 
individuals and by allowing American Indians and Alaska Natives more 
options for care, potentially resulting in fewer American Indians and 
Alaska Natives seeking care through Indian health facilities. 

[12] See Pub. L. No. 111-148, § 10221, 124 Stat. 119, 935 (2010) 
(enacting S. 1790, as reported by the Committee on Indian Affairs in 
the Senate in December 2009, into law with amendments); S. 1790, 111th 
Cong. § 199(a) (2009) (codified at 25 U.S.C. § 1680t(a)). 

[13] Like other survey-based sources of health insurance coverage 
data, the ACS likely underestimates the population enrolled in 
Medicaid and CHIP compared to administrative data that includes 
information on enrollment. Researchers have attempted to estimate the 
magnitude of the underestimation--for example, see Victoria Lynch et 
al., "Improving the Validity of the Medicaid/CHIP Estimates on the 
American Community Survey: The Role of Logical Coverage Edits" (Urban 
Institute Health Policy Center, 2011). Reporting errors can be due to 
several factors, including reluctance to report public coverage or 
confusion about what type of insurance respondents have. However, 
research by others shows that agency enrollment data may not 
accurately or consistently capture information on enrollees' race and 
ethnicity, particularly for American Indians and Alaska Natives. 

[14] Because coverage options often consider family ties in 
determining program eligibility, we used the "health insurance unit," 
a variable included in the IPUMS data and considered the most accurate 
unit of analysis for estimating health insurance eligibility using 
survey data. The health insurance unit consists of all individuals 
residing in a sampled household, whose family ties determine them to 
be eligible for coverage, whereas the definition of a family or 
household in the Census's nonaugmented data typically includes all 
related members of a household, not all of whom would be eligible for 
coverage. See State Health Access Data Assistance Center, "Defining 
'Family' for Studies of Health Insurance Coverage," Issue Brief #27 
(Minneapolis: University of Minnesota). 

Steven Ruggles et al., Integrated Public Use Microdata Series: Version 
5.0, machine-readable database (Minneapolis: University of 
Minnesota, 2010). 

[15] The 2009-2011 3-year estimates are averages over the pooled 2009-
2011 period. At least 3 years of ACS data are needed for a reliable 
sample of most county populations. In this report, we do not conduct 
projections of eligibility on the basis of future income; instead, we 
estimate the number of American Indians and Alaska Natives who would 
be eligible for programs beginning in 2014 on the basis of the most 
recent data currently available. We also do not predict the take-up 
rate for these programs. As public programs generally do not have full 
take-up, it is likely that not all individuals who are eligible will 
enroll. 

[16] The U.S. Census Bureau reports ACS data in Public Use Microdata 
Areas (PUMA), which aggregates smaller counties or breaks up larger 
counties into units of 100,000 individuals to protect anonymity. We 
created a crosswalk between the counties included in IHS areas and the 
counties included in PUMAs. 

[17] The ACS data groups Medicaid and CHIP together when collecting 
information about Medicaid coverage status. As a result, some 
individuals eligible for CHIP are combined with Medicaid in our 
analysis. 

We did not include estimates for Medicare in this report because 
eligibility for this program did not change as a result of PPACA. 

[18] The ACS collects broader income data than will be used to determine 
eligibility for Medicaid, which will be based on Modified Adjusted Gross 
Income, a measure that excludes certain sources of income. See Pub. L. 
No. 111-148, § 2002, 124 Stat. 119, 279 (2010); Pub. L. No. 111-152, 
§ 1004, 124 Stat. 1029, 1034 (2010) (to be codified at 42 U.S.C. 
§ 1396a(e)(14)). 

[19] Some states offer Medicaid coverage to certain categories of 
individuals above 138 percent of the FPL, such as children and 
pregnant women. 

[20] Individuals who qualify for Supplemental Security Income--certain 
low-income individuals who are aged, blind, or disabled--are generally 
eligible for Medicaid. 

[21] A subset of those who identified as being currently enrolled in 
Medicaid did not otherwise meet our criteria, which could be due to a 
variety of factors. Considering that these individuals reported being 
enrolled, we included them in our estimates of the number potentially 
eligible. 

[22] For both the income-based cost-sharing exemption and premium tax 
credit in the Exchanges, we estimated the number of American Indians 
and Alaska Natives between 138 percent of the FPL and 300 or 400 
percent of the FPL, respectively. Although individuals at lower 
incomes may be eligible, for our analysis we excluded individuals from 
these categories who could be potentially eligible for expanded 
Medicaid. For the income-based cost-sharing protections, we estimated 
the number of American Indians and Alaska Natives within this income 
range; however, the subset of those who are also members of federally 
recognized tribes, and therefore eligible under PPACA, is unknown. 
Individuals who already have a minimum level of coverage, as specified 
by HHS, are ineligible for the premium tax credit. The ACS data did 
not contain a variable that would allow us to identify the subset of 
individuals who fall into the income range for premium tax credits, 
but who already have minimum essential coverage. 

[23] We excluded from our analysis individuals identifying as American 
Indians and Alaska Natives who were foreign-born, as these individuals 
are generally unlikely to be eligible for IHS services. 

[24] Our review of efforts to promote enrollment in the expanded and 
new coverage options focused on expanded Medicaid and the Exchanges 
rather than on the Basic Health Program. 

[25] Federal internal control standards specify that agency management 
should ensure that there are adequate means of timely and effective 
communication with, and obtaining information from, external 
stakeholders that have significant effect on the agency achieving its 
goals and that an agency should employ many and various means of 
communication, such as policy and procedure manuals and Internet web 
pages. Federal internal control standards also specify that agency 
management should ensure that proper personnel, with the right 
training, are in place to enable organizational success. See GAO, 
Standards for Internal Control in the Federal Government, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: 
November 1999), and Internal Control Management and Evaluation Tool, 
[hyperlink, http://www.gao.gov/products/GAO-01-1008G] (Washington, 
D.C.: Aug. 1, 2001). 

[26] Specifically, we selected the three areas with the highest level 
of uninsured American Indians and Alaska Natives, on the basis of ACS 
data, that also contained at least one entire state and each type of 
entity we sought to include. The Aberdeen, Albuquerque, and Billings 
area offices are located in South Dakota, New Mexico, and Montana, 
respectively. 

[27] CHIPRA included funding for outreach to increase Medicaid and 
CHIP enrollment among American Indian and Alaska Native children. See 
Pub. L. No. 111-3, § 201, 123 Stat. 8, 35 (2009) (codified at 42 
U.S.C. § 1397mm). We refer to recipients of these funds as CHIPRA 
tribal outreach grantees. 

[28] The 12 areas are Aberdeen, Alaska, Albuquerque, Bemidji, 
Billings, California, Nashville, Navajo, Oklahoma City, Phoenix, 
Portland, and Tucson. 

[29] Direct service tribes receive health care directly from IHS, 
instead of receiving services through IHS-funded facilities or 
programs operated by Indian tribes or tribal organizations. Under the 
Indian Self-Determination and Education Assistance Act, as amended, 
federally recognized Indian tribes can enter into self-determination 
contracts or self-governance compacts with the Secretary of Health and 
Human Services to take over administration of IHS programs for Indians 
previously administered by IHS. See 25 U.S.C. §§ 450f(a), 458 aaa-
4(b)(1). 

[30] See [hyperlink, http://www.gao.gov/products/GAO-05-789] and GAO, 
Increased Oversight Needed to Ensure Accuracy of Data Used for 
Estimating Contract Health Service Need, [hyperlink, 
http://www.gao.gov/products/GAO-11-767] (Washington, D.C.: Sept. 23, 
2011). 

[31] See 42 C.F.R. § 136.23. CHSDAs typically encompass reservation 
and trust lands--areas located on or off a reservation, for which the 
United States holds title in trust for the benefit of a tribe or 
individual Indian--and bordering counties. Patients must also meet 
other eligibility, administrative, and medical priority requirements 
to have their services paid for by the CHS program. 

[32] The Indian Health Care Improvement Act authorizes IHS, tribes, 
and urban Indian organizations to collect reimbursement for services 
provided at I/T/U facilities from third-party payers, including 
Medicare, Medicaid, and private health insurers. See 25 U.S.C. §§ 
1621e(a), 1621f. IHS is allowed to retain funds collected from these 
payers without a corresponding offset against its appropriations, so 
that all revenue collected by a facility remains with that facility, 
supplementing its funds. See 25 U.S.C. § 1621(b). 

We previously reported that, in fiscal year 2008, IHS reported 
collecting about $795 million from all third-party payers. See GAO, 
Indian Health Service: Updated Policies and Procedures and Increased 
Oversight Needed for Billings and Collections from Private Insurers, 
[hyperlink, http://www.gao.gov/products/GAO-10-42R] (Washington, D.C.: 
Oct. 22, 2009). 

[33] See 25 U.S.C. § 1623(b). 

[34] Prior to the 2000 Census, respondents could only select one race. 
Since the 2000 Census, the number of individuals identifying as 
American Indians and Alaska Natives, especially in combination with 
another race, has significantly increased. 

[35] The U.S. Supreme Court ruled in June 2012 that states choosing 
not to expand Medicaid coverage to individuals eligible under PPACA 
will forgo only the federal matching funds associated with such 
expanded coverage, rather than a termination of all Medicaid federal 
matching funds. See Nat'l Fed'n of Indep. Bus. v Sebelius, 132 S.Ct. 
2566 (2012). 

PPACA established 133 percent of the FPL as the income limit for 
Medicaid eligibility; however, it also specifies that an income 
disregard in the amount of 5 percent of the FPL be deducted from an 
individual's income when determining Medicaid eligibility, which 
effectively raises the eligibility limit for newly eligible Medicaid 
recipients to 138 percent of the FPL. See Pub. L. No. 111-148, §§ 
2001(a), 2002, 124 Stat. 119, 271, 279 (2010); Pub. L. No. 111-152, § 
1004, 124 Stat. 1029, 1034 (2010) (codified at 42 U.S.C. § 
1396a(a)(10)(A)(i)(VIII) and to be codified at 42 U.S.C. § 
1396a(e)(14)(I)). 

[36] See Pub. L. No. 111-148, §§1401, 10105(a)-(c), 10108(h), 124 
Stat. 119, 213, 906, 914 (2010); Pub. L. No. 111-152, §§ 1011, 1004, 
124 Stat. 1029, 1030, 1034 (2010) (codified at 26 U.S.C. § 36B); 26 
C.F.R. § 1.36B-2(a)(1). In addition, PPACA provides cost-sharing 
subsidies to certain eligible individuals between 100 and 250 percent 
of the FPL to assist with such expenses as deductibles and copays, as 
well as limits on the percentage of income that health plans can 
charge enrollees for cost-sharing. See Pub. L. No. 111-148, § 1402(c), 
124 Stat. 119, 221 (2010); Pub. L. No. 111-152, § 1001, 124 Stat. 
1029, 1039 (2010) (codified at 42 U.S.C. § 18071). 

[37] See Pub. L. No. 111-148, §1402(d), 124 Stat. 119, 222 (2010) 
(codified at 42 U.S.C. § 18071). 

[38] See Pub. L. No. 111-148, §§ 1501(b),10106, 124 Stat. 119, 244, 
909 (2010); Pub. L. No. 111-152, §§ 1002, 1004, 124 Stat. 1029, 1032, 
1034 (2010) (codified at 26 U.S.C. § 5000A). Additionally, a Proposed 
Rule published February 1, 2013, proposes that individuals living in 
states that chose not to expand Medicaid eligibility but who would 
otherwise qualify for it be exempt from the individual mandate. 78 
Fed. Reg. 7348 (Feb. 1, 2013). 

[39] HHS established hardship exemptions for individuals eligible for 
IHS services who are not members of federally recognized tribes and 
for individuals living in states that chose not to expand Medicaid 
eligibility but who would otherwise qualify for it. 78 Fed. Reg. 
39,494 (July 1, 2013). 

[40] Under PPACA, eligible American Indians and Alaska Natives may 
enroll in a different Exchange plan each month, in contrast to annual 
enrollment windows generally applicable to other participants. See 
Pub. L. No. 111-148, § 1311(c)(6)(D), 124 Stat. 119, 175 (2010) 
(codified at 42 U.S.C. § 18031(c)(6)(D)). 

[41] Cost-sharing protections specific to American Indians and Alaska 
Natives incorporate the definition of Indian in section 4(d) of the 
Indian Self-Determination and Education Assistance Act, codified at 25 
U.S.C. § 450b(d). The special enrollment period provision incorporates 
the definition of Indian in section 4 of the Indian Health Care 
Improvement Act, codified at 25 U.S.C. § 1603(13). CMS's final rule 
for the establishment of the Exchanges, published March 27, 2012, 
stated that the definitions contained in both the Indian Self-
Determination and Education Assistance Act and the Indian Health Care 
Improvement Act are operationally equivalent and include only 
individuals who are members of federally recognized tribes. See 77 
Fed. Reg. 18,310, 18,346. The United States recognized 566 tribes as 
of May 2013. 

In contrast, in the American Recovery and Reinvestment Act in 2009, 
Congress established premium and cost-sharing protections for American 
Indians and Alaska Natives enrolled in Medicaid, without linking them 
to a specific definition of Indian. See Pub. L. No. 111-5, § 5006(a), 
123 Stat. 115, 505 (2009) (codified at 42 U.S.C. § 1396o(j)). 
Consequently, CMS's regulation implementing these protections uses a 
broader definition that includes all American Indians and Alaska 
Natives who are eligible for IHS services. See 75 Fed. Reg. 30,244, 
30,247 (May 28, 2010) (amending 42 C.F.R. § 447.50). 

[42] PPACA requires the use of a single, streamlined application for 
health insurance that will include application pathways for Medicaid, 
CHIP, and the Exchanges. See Pub. L. No. 111-148, § 1413, 124 Stat. 
119, 233 (2010) (codified at 42 U.S.C. § 18083). In April 2013, HHS 
released the model application to be used in federally operated 
Exchanges, which will also be used by state-operated Exchanges unless 
the Secretary of Health and Human Services grants permission to a 
state to use its own. The single, streamlined application is expected 
to be available for open enrollment beginning in October 2013 for 
coverage that begins in January 2014. 

[43] See Pub. L. No. 111-148, §§ 1311(d)(4)(K),(i), 10104(h), 124 
Stat. 119, 177, 180, 901 (2010) (codified at 42 U.S.C. § 18031). 
Application assistance programs are intended to help individuals 
submit the application, compare plans, and complete the enrollment 
process. 

[44] Criteria for tribal membership vary by tribe and include such 
requirements as documented descent from an original member, residency 
on tribal lands, or minimum blood quantum levels--that is, the 
required degree of ancestry from a particular tribe. 

[45] See GAO, Medicare and Medicaid: CMS and State Efforts to Interact 
with the Indian Health Service and Indian Tribes, [hyperlink, 
http://www.gao.gov/products/GAO-08-724] (Washington, D.C.: July 11, 
2008). 

[46] See K. L. Langwell et al., "American Indian and Alaska Native 
Eligibility and Enrollment in Medicaid, SCHIP, and Medicare" 
(Washington, D.C., December 2003). This report, commissioned by CMS, 
included extensive analysis of common challenges affecting American 
Indian and Alaska Native participation in public programs. 

[47] Medicare Part D took effect in 2006, although it was preceded by 
a temporary prescription drug discount card program beginning in 2004. 

[48] See GAO, Children's Health Insurance Program: State 
Implementation Approaches Are Evolving, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-99-65] (Washington, D.C.: May 14, 
1999); Medicare: CMS's Beneficiary Education and Outreach Efforts for 
the Medicare Prescription Drug Discount Card and Transitional 
Assistance Program, [hyperlink, 
http://www.gao.gov/products/GAO-06-139R] (Washington, D.C.: Nov. 18, 
2005). 

[49] Enrollment in CHIP exceeded 700,000 in its first year--fiscal 
year 1998--and continued to grow steadily for more than a decade. By 
the final quarter of fiscal year 2000, all 50 states and the District 
of Columbia had implemented CHIP with a total enrollment of nearly 2.7 
million. By fiscal year 2010, CMS reported CHIP enrollment had reached 
nearly 7.7 million. By 2010 nearly 30 million people had enrolled in 
Medicare Part D. 

[50] See Pub. L. No. 111-3, § 201(a), 123 Stat. 8, 36 (2009) (codified 
at 42 U.S.C. § 1397mm(b)(2)). 

[51] We estimated the number of American Indians and Alaska Natives 
potentially eligible for Medicaid as individuals who met the criteria 
for Medicaid eligibility in 2014, which included individuals eligible 
for Medicaid at the expanded income levels in PPACA, as well as 
individuals currently eligible for Medicaid as reported in the ACS. 

[52] Because the number of IHS eligible individuals is likely to be 
between the number of individuals who self-identify as American 
Indians and Alaska Natives alone and American Indians and Alaska 
Natives alone or in combination, we presented results for both groups 
as the range. 

In the 2010 Census, 2.9 million individuals reported as American 
Indian and Alaska Native alone, and 5.2 million reported as American 
Indian or Alaska Native alone or in combination with another race. The 
ACS estimates are lower, in part, because we excluded foreign-born 
American Indians and Alaska Natives from our analysis of ACS data. We 
present the total population estimate from the ACS to represent the 
basis for the percentages in our analysis throughout this report. 
These estimates are not meant to represent the population in the 
United States for any year in that period. To obtain the population 
count, researchers should use counts from the most recent Census or 
population estimates from the U.S. Census Bureau's Population 
Estimates Program, which produces estimates of the population for the 
United States, its states, counties, cities, and towns, as well as for 
the Commonwealth of Puerto Rico. 

[53] Unless otherwise specified, when referring to potential new 
enrollment we include both those who will be newly eligible in 2014 
and those who are currently eligible, but not enrolled. 

[54] As with the national level, most of the potential new enrollment 
among American Indians and Alaska Natives in the Oklahoma City area 
consists of those who will be newly eligible for expanded Medicaid. 

[55] As with the national level, most of the potential new enrollment 
among American Indians and Alaska Natives in the Oklahoma City area 
consists of those who will be newly eligible for expanded Medicaid, 
but includes some who may be currently eligible but not enrolled. 

[56] As of June 14, 2013, the Advisory Board Company's online Daily 
Briefing noted that the governors of 26 states and the District of 
Columbia announced they will participate in Medicaid expansion, 1 
state is considering participating, 13 states announced they will not 
participate, 6 states are considering not participating, and 4 states 
are planning or proposing to increase coverage through other means. 
See [hyperlink http://www.advisory.com/Daily-
Briefing/2012/11/09/MedicaidMap], downloaded August 5, 2013. 

While some states have indicated they do not intend to participate, 
they may opt to do so at a later date. 

[57] Some American Indians and Alaska Natives may not be members of 
federally recognized tribes, a requirement of eligibility for the cost-
sharing exemptions. 

[58] As of May 2013, HHS had not issued any rules regarding the Basic 
Health Program option, but announced in February 2013 that the program 
would begin in 2015, rather than 2014 as originally planned. 

[59] Our review of the efforts to promote enrollment in expanded and 
new coverage options focused on expanded Medicaid and the Exchanges 
rather than on the Basic Health Program. 

[60] IHS officials also noted that IHS collaborated with CMS to 
develop regulations on the expanded and new coverage options. Although 
some of these documents were not finalized until after our site 
visits, when we followed up with the facilities and tribes in February 
2013, most confirmed at that time that they still had received little 
or no guidance from IHS. 

[61] Additional components of the IHS business plan template include 
assessing the potential for growth in third-party billing and 
determining the effect on CHS programs, and other assessments to help 
prepare facilities for expanded and new coverage options. 

[62] Native American Contacts are CMS staff based in the agency's 10 
regional offices who serve as a resource to tribes and I/T/U 
facilities for questions about Medicaid, CHIP, and Medicare. 

[63] According to HHS, travel restrictions and budget cuts in recent 
years have impeded CMS's ability to provide the typical level of in-
person training for I/T/U facilities. 

[64] A six month initial open enrollment period for the Exchanges is 
expected to begin October 2013 for the coverage that begins in January 
2014. 

[65] In May 2013, CMS officials told us that the website about the 
Exchanges, at marketplace.cms.gov, would be relaunched once the 
materials targeted to the American Indian and Alaska Native population 
had been approved. 

[66] CMS reported that grantees enrolled, or in some cases reenrolled, 
19,602 American Indian and Alaska Native children through the second 
year of the 3-year grant period (April 16, 2010, to April 15, 2013); 
however, data were reported for only 35 of the 41 grantees. According 
to the CMS official we spoke with, certain data-reliability issues 
that prevented complete reporting in the first and second year were 
being addressed, and data for the third year would be available in 
2014. 

[67] Members of the Tribal Technical Advisory Group, a body that 
advises CMS on American Indian and Alaska Native issues, told us that 
the cost associated with Medicaid outreach is not affordable for many 
tribes and that few states provide reimbursement, although states' 
interest in the practice may be increasing. According to CMS 
officials, in addition to Montana, California's Medicaid program has 
also been approved to allow Medicaid matching for tribal outreach 
activities, plans for Washington and Alaska were pending, and three 
other states had expressed interest. Such reimbursement will assist 
those tribes for whom outreach activities may not otherwise be 
affordable. 

[68] In addition to community outreach, one tribal facility conducted 
targeted "cold calls" to tribal members turning 65 to set up a clinic 
visit, at which Medicare eligibility would be determined, and screened 
high-cost CHS users for eligibility for the state or federal high-risk 
insurance pool, private coverage through a spouse, or possible 
Medicaid or Medicare eligibility through disability status. 

[69] South Dakota announced in December 2012 that it would not 
participate in Medicaid expansion; New Mexico announced in January 
2013 that it will participate; and, as of May 2013, Montana's Governor 
supported Medicaid expansion, but its legislature had not yet enacted 
a plan to expand it. 

[70] See 45 C.F.R. § 164.502. The HIPAA Privacy Rule prescribes 
requirements and standards for protecting individually identifiable 
health information. An individual's insurance status is considered 
individually identifiable health information and is protected from 
unauthorized disclosure under the HIPAA Privacy Rule. See 45 C.F.R. § 
160.103. Disclosure of protected health information for purposes of 
treatment, payment, or health care operations is generally permitted. 
See 45 C.F.R. § 164.506. 

[71] Under the HIPAA Privacy Rule, a government agency administering a 
government program providing public benefits, such as a state Medicaid 
agency, may disclose individually identifiable health information 
relating to the program to another government agency administering a 
government program providing public benefits, such as IHS and tribal 
health facilities, if the programs serve the same or similar 
populations and the disclosure of the information is necessary to 
coordinate, or to improve the administration and management of, the 
programs. See 45 C.F.R. § 164.512(k)(6)(ii). 

[72] IHS coordinates care in 12 geographic areas in 35 states. The 
areas are Aberdeen, Alaska, Albuquerque, Bemidji, Billings, 
California, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and 
Tucson. 

[73] The ACS data groups Medicaid and the Children's Health Insurance 
Program (CHIP) together when collecting information about Medicaid 
coverage status. As a result, some individuals eligible for CHIP are 
combined with Medicaid in our analysis. 

[74] Information for the ACS was collected from housing units as well 
as group quarters, which include college dormitories, correctional 
facilities, and nursing facilities. 

[75] Specifically, the ACS questionnaire asks respondents to indicate 
their race by marking one or more selections among a number of racial 
categories, including white, black/African American, American Indian 
or Alaska Native, several options for Asian American and Pacific 
Islander, or "some other race," with the option to fill in the name of 
an unlisted race. The ACS asks respondents a separate question about 
their Hispanic origin. Because Hispanic origin is not treated as a 
racial category, some individuals who identify solely as American 
Indian and Alaska Native may also identify as being of Hispanic origin. 

[76] We included native-born American Indians and Alaska Natives if 
they reported being born in the United States or its territories, or 
if they were born abroad to a parent or parents who were U.S. 
citizens. We excluded foreign-born American Indians and Alaska Natives 
if they reported being a naturalized citizen, or not a citizen. While 
American nationality is not a criterion for receiving IHS services, 
and several American Indian and Alaska Native tribes straddle the 
Canadian and Mexican borders, we aimed to include tribes that would be 
eligible for IHS services rather than tribes from, for example, South 
or Central America. Individuals from these tribes may report being 
American Indian or Alaska Native on the ACS. 

[77] See Victoria Lynch et al., "Improving the Validity of the 
Medicaid/CHIP Estimates on the American Community Survey: The Role of 
Logical Coverage Edits" (Urban Institute Health Policy Center: Sept. 
27, 2011). The researchers developed 16 additional edits applied to 
responses from children and 6 additional edits applied to responses 
from nonelderly adults, which when applied, resulting in a 3.5 and 0.8 
percent increase in their Medicaid/CHIP estimates, respectively. 

[78] Steven Ruggles et al., Integrated Public Use Microdata Series: 
Version 5.0, machine-readable database (Minneapolis, MN: University of 
Minnesota, 2010). 

[79] The FPL is another name for the poverty guidelines issued 
annually in the Federal Register by the Department of Health and Human 
Services. The FPL is a simplified version of the national poverty 
thresholds used for counting the number of people in poverty, and is 
used mainly for administrative purposes, such as determining 
eligibility for program participation. 

[80] All states provide Medicaid eligibility based on disability 
status. In 39 states and the District of Columbia, recipients of 
supplemental security income are eligible for Medicaid, while 11 
states apply their own eligibility criteria for Medicaid eligibility 
based on their own measures of disability status. Because these states 
allow Medicaid eligibility based on some measure of disability status, 
we did not exclude them. 

[81] About 7.2 percent of those who identified as being currently 
enrolled in Medicaid did not otherwise meet our criteria--that is, 
they did not report income below the levels we used to estimate 
eligibility for Medicaid or report receiving supplemental security 
income. This could be due to a variety of factors, such as: a 
difference between state Medicaid eligibility rules during the survey 
response time frame (2009-2011) and the year reflected in the state-
specific limits we applied to the data (2011); a difference in how 
income is defined in the ACS, in contrast to how income is applied for 
Medicaid eligibility, which excludes certain income sources; or a 
difference in how individuals reported income and family structure 
when applying for Medicaid compared to how they reported income and 
family structure to the ACS. 

[82] We also estimated at the national level the proportion of 
potential new enrollees who were newly eligible under 2014 eligibility 
rules, which does not include those American Indians and Alaska 
Natives who are currently eligible but unenrolled. 

[83] American Indians and Alaska Natives who are members of federally 
recognized tribes are also eligible for cost-sharing exemptions for 
services are obtained through Indian health facilities, regardless of 
income. Because the ACS data does not include a variable for tribal 
enrollment status, we were unable to estimate the number of 
individuals who may be eligible for these services. 

[84] See Genevieve M. Kenney et al., "Who and Where are the Children 
Yet to Enroll in Medicaid and the Children's Health Insurance 
Program?" Health Affairs, vol. 29, no. 10 (2010). 

[85] For 2011, the FPL for a family of four was $22,350 in the lower 
48 states and the District of Columbia, $27,940 in Alaska, and $25,710 
in Hawaii. 

[86] The ACS data groups Medicaid and CHIP together when collecting 
information about Medicaid coverage status. As a result, some 
individuals eligible for CHIP are combined with Medicaid in our 
analysis. 

[End of section] 

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