Overview of the Indian Health System

1
Overview of the Indian Health System

• Melissa Gower
• Group Leader for Health Services
• Cherokee Nation

2
Recognition of Inherent Tribal Powers

• Since time immemorial there has been a Cherokee
  Nation that has exercised the rights of
  self-government on behalf of the Cherokee people
  (Cherokee Nation v. Georgia, 1831)

3
Federal-Tribal Relationship

• The presence of Tribal Governments predates both
  the formation of the U.S. and the State of
  Oklahoma.
• As sovereign nations, Tribal Governments exercise
  powers over their citizens, territory and lands.

4
Federal-Tribal Relationship

• The U.S. and the State of Oklahoma enjoy a
  government-to-government relationship with Tribal
  governments, which is grounded in numerous
  treaties, statutes, court decisions, and
  executive orders
• Because of this government-to-government
  relationship, Tribal citizens have a unique legal
  and political status which is based on Tribal
  citizenship rather than a racial category

5
Codification of the Federal Responsibility to
Provide Health Services to AI/ANs

• Snyder Act of 1921 (P.L. 67-85) general
  authority for the U.S. to expend funds for the
  provision of health care
• Indian Self-Determination and Education
  Assistance Act, aka ISDEA (P.L. 93-638, as
  amended) provides Tribes the option of either
  assuming from the IHS the administration and
  operation of health services and programs in
  their communities, or to remain within the IHS
  administered direct health system

6
Codification of the Federal Responsibility to
Provide Health Services to AI/ANs

• Indian Health Care Improvement Act, aka IHCIA
  (P.L. 94-437, as amended) provides numerous
  reforms to enhance the quantity and quality of
  health services for AI/ANs and to encourage the
  maximum participation of Tribes in the planning
  and management of those services

7
The Indian Health System

• The Indian Health Service (IHS), an agency within
  the Department of Health and Human Services, is
  charged with the Federal Government's obligation
  to provide health services to American Indians
  and Alaska Natives
• Currently, the IHS provides health services to
  approximately 1.9 million American Indians and
  Alaska Natives belonging to over 557 federally
  recognized Tribes in 35 states

8
The Indian Health System

• Services are provided through facilities of the
  IHS, facilities operated by a Tribe or Tribal
  organization authorized by Title I or III of the
  ISDEA, and Urban Indian programs authorized under
  Title V of the IHCIA. Collectively, the
  facilities comprise what is known as the I/T/U

9
Oklahoma City Area IHS

• The Oklahoma City Area (OCA) IHS oversees the
  provision of health services to Tribal citizens
  in Oklahoma, Kansas, and portions of Texas
• Of the 40 facilities throughout the OCA, 26 are
  operated by Tribes, 12 are operated directly by
  the IHS, and 3 clinics are operated in urban
  settings

10
Oklahoma Tribal Population

• 2000 U.S. Census 391,949, 11.4 of total
  population
• Oklahoma Indian Affairs Commission 2004 Tribal
  Survey
• Total enrollment for the 37 federally-recognized
  Tribes in Oklahoma 643,588
• Of the 643,588, 302,007 reside within Oklahoma

11
Cherokee Nation Health System Snapshot

• The 14-county service area of Cherokee Nation
  (CN) includes
• 6 CN clinics
• 2 CN satellite clinics, 1 student/employee
  clinic, and
• 2 Indian Health Service (IHS) operated hospitals
• A CN managed, 20-bed co-educational facility for
  treatment of chemical dependency in AI
  adolescents
• A number of CN field-service sites for auxiliary
  health programs such as WIC, Early Cancer
  Detection and Health Promotion/Disease
  Prevention, and other public health activities
• CN Emergency Medical Services (EMS) accredited by
  Commission on Accreditation of Ambulance Services
• Serves more than 115,000 eligible patients
  throughout the 14-county service area

12
Indian Health Funding

• In the federal appropriations process, IHS
  funding is discretionary, and funding is not
  required to be adjusted to address population
  increases and inflation
• Mandatory programs such as Medicaid and Medicare
  receive annual increases to address population
  growth and inflation

13
Indian Health Funding

• Every single aspect of the IHS is severely under
  funded, resulting in a disproportionately lower
  health status for AI/ANs than the rest of the
  U.S. population evidenced by a life expectancy
  six years less than the rest of the U.S
  population.
• The lower health status is primarily attributable
  to disproportionately high rates of chronic
  diseases that could be greatly reduced if
  sufficient funding was available

14
Indian Health Funding

• In 2003, the per capita personal health care
  expenditures for IHS population totaled 1,914,
  while the per capita amount for the total U.S.
  population totaled 5,085.
• Within the IHS system, funds are distributed
  inequitably. The Oklahoma City Area receives
  only 976 per capita, which is the lowest funded
  area in the system and represents only 44 of the
  actual need according to the Federal Disparity
  Index.

15
Indian Health Funding

• Per capita spending for AI/AN beneficiaries
  receiving care in the IHS is approximately ½ of
  the per capita spending for Medicaid
  beneficiaries and
• One-third the per capita spending for VA
  beneficiaries and
• The federal government spends nearly twice as
  much money for a federal prisoners health care
  than it does for an American Indian or Alaska
  Native.

16
The Effect of Under Funding

• Rationing of care, including contract health
  services
• Long waiting periods for appointments
• Reduced hours of operation at many facilities
• Inadequate staffing

17
The Effect of Under Funding

• Diminished health and well-being, as well as
  higher mortality rates than the rest of the
  population
• Overburdened facilities example a
  tribally-operated hospital in Oklahoma was
  designed to accommodate 60,000 outpatient visits
  and last year exceeded 350,000 visits
• Obsolete facilities and equipment
• Needs go unmet

18
Efforts to Address Funding Deficiencies

• While Tribes continue to push for adequate
  funding to carry out the federal governments
  trust responsibility, the reality exists that
  Tribes must provide additional Tribal resources
  in an attempt to meet the health care needs of
  their people. The amount of funding and the
  manner in which funds are allocated for
  healthcare purposes varies among Tribes
• Examples of the utilization of funds include
• Supplementing the IHS Contract Health Services
  (CHS) Program
• Direct Care
• Facility Construction/Expansion
• Leveraging federal resources

19
Efforts to Address Under Funding Maximizing
Third Party Collections

• Over the past several years, Tribes in Oklahoma
  have put forth much effort to stretch limited
  health resources by maximizing third party
  collections such as Medicare, Medicaid, and
  private insurance.
• Increased third party collections have been
  achieved through close collaboration with Tribes
  and the IHS, CMS, OHCA, OID, and private
  insurance providers
• However, barriers exist to increasing
  participation by AI/ANs due to the perception
  that enrollment (and the payment of any premiums,
  co-pays, etc.) in Medicare, Medicaid, and private
  insurance is not necessary because the patient is
  seeking care in an Indian health facility.
• Many Tribes in Oklahoma, as well as IHS operated
  facilities, undertake great effort to ensure
  third party payers are utilized when possible

20
Efforts to Address Under Funding Collaboration

• Tribes recognize the need to partner with local
  health providers, such as municipal hospitals,
  clinics, etc.
• Partnerships have occurred for various purposes
  to reduce the duplication of services, increase
  emergency medical services, and to establish
  specialty care in rural communities
• Many Tribes are supportive of their local
  communities and offer many programs/services that
  do not differentiate between Tribal citizens and
  non-citizens, to the extent allowable by law.
• Tribes are often viewed as valuable community
  partners and offer many unique opportunities due
  to sovereign status, flexibility, etc.

21
Tribal Considerations when Collaborating

• In Oklahoma, I/T/U facilities are paid according
  to what is referred to as the all-inclusive, or
  OMB rate, which is established annually by the
  federal government.
• The flat daily rate per encounter is calculated
  based on various cost factors and eases the
  administrative burden on both the OHCA and the
  I/T/U facilities.
• In HB 2842, language was included authorizing the
  OHCA to develop mechanisms to allow Tribally
  operated facilities that elect to provide
  services to non-AI/ANs to receive reimbursement
  for such services.
• The purpose of the language was to benefit from
  the favorable reimbursement rates through the
  all-inclusive rate.
• However, when considering providing services to
  non-AI/ANs, Tribes must carefully consider any
  potential impacts on individual Tribal health
  systems

22
Tribal Considerations when Collaborating

• Some of the practical considerations a Tribal
  facility must consider include
• Patient load as previously discussed, many
  Tribal facilities do not have the capacity to
  serve the current AI/AN patient load, therefore
  extending services to non-AI/ANs is not a
  practical option
• Applicability of the Federal Tort Claims Act
  (FTCA) Tribes (and its employees) are deemed to
  be employees of the Federal government while
  performing work under ISDEA Compacts. However,
  such FTCA coverage only extends to the provision
  of care to eligible beneficiaries under the ISDEA
  Compact (AI/ANs and in very limited
  circumstances, non-AI/ANs)

23
Tribal Considerations when Collaborating

• Continued
• Federal supply sources In addition to FTCA
  coverage, Tribes can also access federal supply
  sources through ISDEAA Compacts. However,
  federal supply sources can only be accessed when
  providing care to care to eligible beneficiaries
• Federal Scrutiny Given the lack of available
  federal resources for health care and routine
  scrutiny of federal spending involving Tribes,
  the Federal government could view the expanded
  use of the all-inclusive rate negatively and
  remove the authority for Tribal facilities to
  utilize the all-inclusive rate

24
100 Federal Medical Assistance Percentage
(FMAP)

• I/T/U facilities are authorized under federal law
  to be reimbursed at 100 of the federal medical
  assistance percentage (FMAP) when providing
  services to AI/AN Medicaid recipients
• The 100 FMAP reimbursement greatly benefits both
  the State of Oklahoma and the I/T/U because the
  State does not have to fund the state match
  (currently at 32.09) and the I/T/U is able to
  conserve woefully under funded Indian Health
  Service dollars by accessing Medicaid funds
  instead.
• What is the fiscal impact to the State of
  Oklahoma because of the 100 FMAP? For the 2005
  calendar year, nearly 85 million in health
  services was provided to AI/AN Medicaid enrollees
  in I/T/U facilities in Oklahoma. As a result of
  100 FMAP, the State saved over 27 million in
  matching funds during this period

25
Notable Laws/Regulations

• IHS Contract Health Services Payer of Last
  Resort, 42 C.F.R. 136.61
• I/T/U Eligible Beneficiaries Excluded from
  Preexisting Condition Exclusions, 42 U.S.C.
  300gg(c)(1)(F)

26
Questions/Comments?

• Melissa Gower
• melissa-gower_at_cherokee.org
• J.T. Petherick
• jt-petherick_at_cherokee.org
• Rachel McAlvain
• rachel-mcalvain_at_cherokee.org