Indian Health Service: Most American Indians and Alaska Natives Potentially Eligible for Expanded Health Coverage, but Action Needed to Increase Enrollment
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 because of 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 GAO's 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.
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.
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.
HHS agreed with the recommendation to improve communication and outreach, but did not agree or disagree with the other two recommendations. GAO believes preparing for increased enrollment and addressing issues related to coverage status is important.
Recommendations for Executive Action
|Department of Health and Human Services||To help ensure successful outreach efforts resulting in significant new enrollment, the Secretary of Health and Human Services should direct the Director of IHS and the Administrator of CMS to coordinate a plan to (1) 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 (2) increase direct outreach to American Indians and Alaska Natives who may be eligible for expanded Medicaid and the Exchanges.||
IHS and CMS provided evidence to support both agencies efforts to ensure successful outreach, including developing and reviewing outreach, education and enrollment materials and information dissemination/training strategies. For example, CMS organized 26 All Tribes Calls and webinars in FY 2015. Additionally, CMS held 12 trainings on or near Indian reservations with over 1,000 total participants in FY 2015. Similarly, IHS increased its direct outreach to American Indians and Alaska Natives eligible for expanded Medicaid and the Marketplace, including providing education on the effect of ACA's definition of Indian on their coverage options and obligations.
|Department of Health and Human Services||To help ensure successful outreach efforts resulting in significant new enrollment, the Secretary of Health and Human Services should direct 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.||
Since this report was issued, IHS has realigned resources and personnel in an effort to address increased eligibility for expanded Medicaid and new coverage options, and the need for enrollment assistance and billing capacity. Specifically, IHS increased its spending on business office operations to increase overall capacity and efficiencies in order to meet the increased workload resulting from the passage of the Affordable Care Act (ACA) and its major coverage provisions. In addition, IHS required every IHS facility to have a designated point of contact who would serve as a subject matter expert on ACA matters. In addition, facilities were required to have at least one certified or trained application counselor to directly assist and educate patients with health care coverage options available through the Marketplace. The IHS Areas report their compliance with this requirement through monthly reports.
|Department of Health and Human Services||To help ensure successful outreach efforts resulting in significant new enrollment, the Secretary of Health and Human Services should direct the Administrator of CMS to develop a plan to educate state Medicaid agencies about when coverage status information may be shared between states and IHS facilities, tribal facilities, and urban Indian health programs (I/T/U) facilities and tribes.||
In January 2017, CMS officials reported that the agency had implemented a plan to educate state Medicaid agencies about when coverage status information may be shared between states and I/T/U facilities on a case by case basis because of variation in how this information is shared from state to state. In September 2018, CMS provided documentation of the information that it sent to state Medicaid agencies to inform them of their options for sharing this information.