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Medicare Beneficiaries & HMO’s: A Case Study of the Los Angeles Market
Note: This publication is no longer in circulation. However, a few copies may still exist in the Foundation’s internal library that could be xeroxed. Please email order@kff.org if you would like to pursue this option.
Panorama General: Medicare proporciona servicios de salud a casi 39 millones de norteamericanos, incluyendo aproximadamente a 34 millones de ancianos y a 5 millones de discapacitados. La gran mayoria de estas personas cubren sus gastos medicos directamente mediante el programa tradicional de “pago por servicio,” mientras que el 15 porciento restante (mas de 5 millone de beneficiarios) estan cubiertos bajo algun plan de servicio medico contratado con Medicare, principalmente las organizaciones de administracion de la salud (HMO por sus siglas en ingles).
Child Health Facts: National and State Profiles of Coverage
Appendix 2
Medicaid Enhanced Matching Rate Matching Rate Alabama 69.3% 78.5% Alaska 59.8% 71.9% Arizona 65.3% 75.7% Arkansas 72.8% 81.0% California 51.2% 65.9% Colorado 52.0% 66.4% Connecticut 50.0% 65.0% Delaware 50.0% 65.0% District of Columbia 70.0% 79.0% Florida 55.7% 69.0% Georgia 60.8% 72.6% Hawaii 50.0% 65.0% Idaho 69.6% 78.7% Illinois 50.0% 65.0% Indiana 61.4% 73.0% Iowa 63.8% 74.6% Kansas 59.7% 71.8% Kentucky 70.4% 79.3% Louisiana 70.0% 79.0% Maine 66.0% 76.2% Maryland 50.0% 65.0% Massachusetts 50.0% 65.0% Michigan 53.6% 67.5% Minnesota 52.1% 66.5% Mississippi 77.1% 84.0% Missouri 60.7% 72.5% Montana 70.6% 79.4% Nebraska 61.2% 72.8% Nevada 50.0% 65.0% New Hampshire 50.0% 65.0% New Jersey 50.0% 65.0% New Mexico 72.6% 80.8% New York 50.0% 65.0% North Carolina 63.1% 74.2% North Dakota 70.4% 79.3% Ohio 58.1% 70.7% Oklahoma 70.5% 79.4% Oregon 61.5% 73.0% Pennsylvania 53.4% 67.4% Rhode Island 53.2% 67.2% South Carolina 70.2% 79.2% South Dakota 67.8% 77.4% Tennessee 63.4% 74.4% Texas 62.3% 73.6% Utah 72.6% 80.8% Vermont 62.2% 73.5% Virginia 51.5% 66.0% Washington 52.2% 66.5% West Virginia 73.7% 81.6% Wisconsin 58.8% 71.2% Wyoming 63.0% 74.1%
Child Health Facts: National and State Profiles of Coverage
Table A2 Table One Table Two Table Three Table Four Table Five Table Six Table Seven Table Eight Table Nine Table Ten Table Eleven Table Twelve Table Thirteen Table Fourteen Table Fifteen Table Sixteen Table Seventeen Table Eighteen Table Nineteen Table TwentyTable A1 Table A3 Table A4
Child Health Facts: National and State Profiles of Coverage
Nearly 10 million children in the United States lack health insurance coverage and over two-thirds of them or low-income. This databook provides baseline data on how many children are uninsured today and on the extent of Medicaid coverage. It provides astarting point to monitor and assess state efforts to reach and insure more children.
Native Americans and Medicaid:Coverage and Financing Issues
Prepared by Andy Schneider and JoAnn Martinez, The Center on Budget and Policy Priorities for The Kaiser Commission on the Future of Medicaid
December 1997
Table 1: Medicaid Eligibility Thresholds
Pregnant Women, Infants and Children (Effective October 1997) Other Eligibility Categories State Pregnant Women and Infants Children Under Age Six Children Ages Six and Older Upper Age Limit Asset Test Required Supplemental Security Income, 1996 Max. AFDC Payments (7/16/96) Medically Needy, 1996 (Percent of Federal Poverty Level) (Percent of Federal Poverty Level) Alabama 133 133 100 14 No 75 15 N/A Alaska 133 133 100 14 No 75 76 N/A Arizona 140 133 100 14 No 75 32 N/A Arkansas (a) (133) (200) 200 200 17 Yes 75 19 25 California 200 133 100 14 No 75 56 86 Colorado (b) 133 133 100 14 No 75 39 N/A Connecticut 185 185 185 16 No 75 81 71 Delaware 185 133 100 18 No 75 31 N/A District of Columbia N/A N/A N/A N/A No 75 N/A N/A Florida 185 133 100 14 No 75 28 28 Georgia 185 133 100 19 No 75 39 35 Hawaii (c,d) 300 300 300 19 No 67 57 57 Idaho 133 133 100 14 No 75 29 N/A Illinois (c) 133 133 100 14 No 48 35 45 Indiana (c,e) 150 133 100 18 No 73 27 N/A Iowa 185 133 100 14 Yes 75 39 52 Kansas 150 133 100 17 No 75 40 44 Kentucky 185 133 100 14 No 75 49 28 Louisiana 133 133 100 18 No 75 18 N/A Maine 185 133 125 19 No 75 51 42 Maryland (d) 185 185 185 14 No 75 34 40 Massachusetts 185 133 133 17 No 75 52 72 Michigan 185 150 150 16 No 75 45 52 Minnesota (c,d) 275 275 275 20 No 71 49 86 Mississippi 185 133 100 14 No 75 34 N/A Missouri (c) 185 133 100 18 No 71 27 N/A Montana 133 133 100 14 No 75 41 46 Nebraska 150 133 100 14 No 75 34 45 Nevada 133 133 100 14 Yes 75 32 N/A New Hampshire (c) 185 185 185 19 No 74 51 60 New Jersey 185 133 100 14 No 75 41 52 New Mexico 185 185 185 19 No 75 36 N/A New York (f) 185 133 100 14 No 75 61 76 North Carolina (c) 185 133 100 18 No 41 50 34 North Dakota (c) 13 133 100 18 Yes 62 40 47 Ohio (c) 133 133 100 14 No 63 32 N/A Oklahoma 150 133 100 14 Yes 75 28 42 Oregon 133 133 100 19 No 75 43 57 Pennsylvania 185 133 100 14 No 75 39 43 Rhode Island (d) 250 250 250 17 No 75 51 69 South Carolina 185 150 150 18 No 75 18 N/A South Dakota 133 133 100 19 No 75 47 N/A Tennessee (d) 400 400 400 17 No 75 54 23 Texas 185 133 100 14 No 75 17 25 Utah 133 133 100 18 No 75 53 53 Vermont (g) (200) (225) 225 225 17 No 75 59 81 Virginia 133 133 100 19 No 75 22 33 Washington (g) (185) (200) 200 200 19 No 75 50 62 West Virginia 150 133 100 19 No 75 24 27 Wisconsin 185 185 100 14 No 75 48 64 Wyoming 133 133 100 14 No 75 55 N/A
Source: National Governors’ Association.Washington, DC. 1996 and 1997.
N/A Not applicable.
Note: The 1997 Federal poverty guideline for a family of three was $13,330; for Alaska $16,670 and Hawaii $15,330.
(a) In Arkansas pregnant women are covered up to 133 percent and infants are covered up to 200 percent of poverty.
(b) Colorado has dropped the asset test for pregnant women only.
(c) indicates state with a 209 (b) waiver, which permits it have different eligibility criteria for the Supplemental Security Income program.
(d) Hawaii, Maryland, Minnesota, Rhode Island, and Tennessee operate under 1115 waivers. Some populations receive fully
subsidized premiums while others are required to pay a portion of the premium and may have a different benefits package.
(e) Indiana is planning to reinstate the asset test for pregnant women.
(f) Payment standards in New York state vary across counties. The figures shown are for New York City.
(g) In Vermont pregnant women are covered up to 185 percent of poverty and infants are covered to 225 percent of poverty.
In Washington pregnant women are covered up to 185 percent of poverty and infants to 200 percent.
Table 2: Medicaid Managed Care Enrollment, by State (As of June 1996)
Total Medicaid Enrollment Medicaid Managed Care Managed Care Penetration Approved Medicaid Births, 1995 (b) State Enrollment Total Full-Risk PCCM (a) Full-Risk PCCM 1115 Waiver Number of Medicaid Births Percent of Total Births United States 32,176,785 11,721,807 7,711,275 4,010,532 24 12 19 states 1,213,943 39 Alabama 498,006 56,929 0 56,929 0 11 Yes 27,867 46 Alaska 87,550 0 0 0 0 3,282 32 Arizona 443,302 381,485 381,485 0 86 0 Yes 31,567 44 Arkansas 371,047 143,232 0 143,232 0 39 16,606 47 California 5,415,207 1,141,857 1,141,857 0 21 0 Yes 229,158 42 Colorado 259,949 136,462 71,419 65,043 27 25 17,277 32 Connecticut 311,884 186,837 186,837 0 60 0 10,931 25 Delaware 73,798 57,256 57,256 0 78 0 Yes 3,145 31 District of Columbia 125,000 69,200 37,650 31,550 30 25 n/a n/a Florida 1,538,007 980,371 390,286 590,085 25 38 Yes 79,969 45 Georgia 968,008 309,503 3,363 306,140 0 32 58,680 52 Hawaii 163,000 131,000 131,000 0 80 0 Yes n/a n/a Idaho 84,618 31,049 0 31,049 0 37 6,608 37 Illinois 1,399,372 179,863 179,863 0 13 0 Yes 65,000 35 Indiana 432,558 135,510 51,171 84,339 12 19 32,686 39 Iowa 226,701 93,791 27,293 66,498 12 29 11,892 32 Kansas 192,188 60,863 8,539 52,324 4 27 n/a n/a Kentucky 531,728 282,813 0 282,813 0 53 Yes n/a n/a Louisiana 801,930 44,772 0 44,772 0 6 34,863 53 Maine 157,881 1,316 0 1,316 0 1 n/a n/a Maryland 466,114 274,276 96,666 177,610 21 38 Yes 23,000 32 Massachusetts 654,000 378,183 87,288 290,895 13 44 Yes 17,335 21 Michigan 1,148,115 790,388 288,889 501,499 25 44 43,986 33 Minnesota 477,000 158,449 158,449 0 33 0 Yes 20,645 33 Mississippi 510,226 35,137 0 35,137 0 7 25,184 61 Missouri 637,897 214,896 207,701 7,195 33 1 29,318 42 Montana 79,000 46,891 635 46,256 1 59 4,266 38 Nebraska 144,305 39,651 22,129 17,522 15 12 6,819 29 Nevada 64,712 0 0 0 0 0 6,890 27 New Hampshire 72,158 11,828 11,828 0 16 0 2,099 21 New Jersey 706,812 302,618 302,618 0 43 0 n/a n/a New Mexico 331,808 147,767 0 147,767 0 45 14,276 53 New York 2,750,000 629,093 625,365 3,728 23 0 Yes 103,516 38 North Carolina 818,364 264,272 3,724 260,548 0 32 44,756 44 North Dakota 46,566 25,442 0 25,442 0 55 1,913 23 Ohio 741,910 239,306 239,306 0 32 0 Yes 56,940 40 Oklahoma 333,613 64,631 64,631 0 19 0 Yes 19,103 42 Oregon 383,334 290,479 290,479 0 76 0 Yes 14,865 35 Pennsylvania 1,612,905 852,265 516,299 335,966 32 21 n/a n/a Rhode Island 113,891 71,367 71,367 0 63 0 Yes 4,170 33 South Carolina 390,561 0 0 0 0 0 Yes 21,859 47 South Dakota 62,539 40,636 0 40,636 0 65 3,581 34 Tennessee 1,180,449 1,180,449 1,180,449 0 100 0 Yes 34,639 47 Texas 1,985,550 71,606 23,914 47,692 1 2 151,614 47 Utah 113,000 88,177 75,087 13,090 66 12 12,306 31 Vermont 82,650 0 0 0 0 0 Yes 2,615 39 Virginia 681,313 461,720 258,952 202,768 38 30 n/a n/a Washington 696,658 377,085 377,085 0 54 0 31,978 42 West Virginia 307,503 93,619 0 93,619 0 30 21,158 55 Wisconsin 463,142 147,218 140,395 6,823 30 1 24,025 36 Wyoming 38,956 249 0 249 0 1 2,737 44
Sources: Urban Institute analysis of data from Health Care Financing Administration’s website.
Liska, D et al. “Medicaid Expenditures and Beneficiaries, 1990-1995.” Kaiser Commission on the Future of Medicaid. Washington, DC. 1997.
(a) PCCM refers to primary care case management plans.
Note: Includes managed care for a full-range of acute care services only. Does not include limited service plans such as mental health or dental only plans.
n/a Data not available.
Native Americans and Medicaid: Coverage and Financing IssuesReport Part Four Report One Report Two Report Three
Native Americans and Medicaid:Coverage and Financing Issues
Prepared by Andy Schneider and JoAnn Martinez, The Center on Budget and Policy Priorities for The Kaiser Commission on the Future of Medicaid
December 1997
Table Of ContentsHighlights ii I: Background On Native American Health Care 1 II: Medicaid’s Role For Native Americans 4 1. Medicaid as a Source of Health Coverage 4 2. Medicaid as a Source of Revenue for Hospitals and Clinics 6 3. Medicaid and Managed Care 10 4. Medicaid as Medicare Premium Assistance 14 5. Medicaid as a Source of Long-Term Care Coverage 15 III: Policy Issues For Native Ameircans In Managed Care 16 1. Policy Issues 16 2. Conclusion 18 Endnotes 20 Tables 22 Highlights
There are an estimated 2.3 million Native Americans — American Indians and Alaska Natives — in the U.S. About half of the Native American population lives on or near reservations; the other half resides in other rural areas and in urban areas. The Native American population includes 554 tribes recognized by the federal government as well as other tribes, largely in California, that do not have federal recognition.
Medicaid plays several significant roles for Native Americans. The Medicaid program acts as:
All Native Americans that are members of federally recognized tribes are eligible to receive services from the IHS. Because of high rates of poverty among Native Americans, Medicaid is an important publicly funded health program for Native Americans. In 1996, it is estimated that Medicaid covered nearly 40 percent of the Native American population.
Medicaid as a Source of Revenue
Medicaid is an important source of revenue for Native American health facilities. In fiscal year 1997, IHS and tribally operated facilities were projected to receive $184.3 million in Medicaid reimbursements. This amount is equal to about 10 percent of the $1.8 billion appropriated for IHS and tribally-provided health services that year. Medicaid is an open-ended entitlement program. In contrast, the IHS receives funding through the domestic appropriations which are subject to broad caps over the next five years. As a result, Medicaid payments will become an increasingly important source of funding for many IHS, tribal, and urban programs.
The structure of the Medicaid program provides financial incentives for states to encourage beneficiaries to use tribal health facilities. Medicaid is a matching program under which the federal government contributes money to the states to pay for covered services on behalf of Medicaid beneficiaries. The federal government’s share of these costs ranges from 50 percent in wealthier states to nearly 80 percent in the poorest states. On average, the federal government pays 57 percent of a state’s Medicaid costs. In contrast, the cost of services provided to Medicaid beneficiaries by a hospital, clinic, or other facility of the IHS or by a tribe or tribal organization is matched by the federal government at a 100 percent rate in a Memorandum of Agreement (MOA) between IHS, the Health Care Financing Administration (HCFA), December 19th 1996. Thus, the state is fully reimbursed by the federal government and is not required to contribute any of its own funds toward the cost of care. This provision does not apply to urban Indian programs.
Medicaid and Managed Care
Over the past few years, Medicaid in many states has been shifting from a predominantly fee-for-service program to a program that purchases services from managed care organizations (MCOs) or primary care case management organizations (PCCMs). This shift presents critical policy issues for the IHS, tribal health programs, and urban Indian health programs. Provisions in the Balanced Budget Act of 1997 will accelerate these changes.
Native Americans and Medicaid: Coverage And Financing Issues
Traditionally, Native Americans have relied upon the facilities and programs of the Indian Health Service (IHS) for access to health care. Although the IHS remains the primary source of health care delivery and financing for most Indian tribes, public programs such as Medicare and Medicaid are playing a larger and larger role in the financing of care for Native Americans living on or near reservations as well as those in urban areas. Because of the high incidence of poverty among American Indians and Alaska Natives, Medicaid – the federal-state health care program for low-income people – is of particular importance.
Medicaid plays several different roles of significance to Native Americans. Medicaid is an insurance program, offering coverage for physician, hospital, and other basic health care services to eligible Indians, especially families with children. It is a source of revenue for IHS and tribally-operated clinics and hospitals that deliver those basic services. Through its purchase of managed care products, Medicaid is reshaping the health care delivery system for many Native Americans and other underserved low-income populations. Medicaid also assists low-income elderly and disabled Indians who are eligible for Medicare in meeting their premium and cost-sharing obligations. Finally, Medicaid offers coverage for nursing home care and other long-term care services needed by frail elderly and disabled Native Americans.
This Policy Brief provides an overview of Medicaid from the standpoint of Native Americans with an emphasis on Medicaid as an insurance program and a purchaser of managed care. This Brief supplements other Policy Briefs and background materials on Medicaid issued by the Commission.1 It incorporates the changes to Medicaid made by the Balanced Budget Act of 1997.2 This Policy Brief focuses on those federal policies common to all state Medicaid programs and does not review the details of any particular state program. Because Medicaid is administered by states within broad federal guidelines, Medicaid programs vary significantly from state to state with respect to benefits, eligibility, provider payment, and administration. However, the information contained in this Policy Brief is the starting point for understanding the Medicaid program in any particular state.
I: Background On Native American Health Care
There are an estimated 2.3 million Native Americans – American Indians and Alaska Natives – in the U.S. About half of the Native American population lives on or near reservations; the other half resides in other rural areas and in urban areas. The Native American population includes 554 tribes recognized by the federal government as well as other tribes, largely in California, that for various reasons do not have federal recognition. The federally recognized tribes vary in size from less than 100 to more than 100,000 members. The economic status of these tribes varies substantially; some are wealthy, but many face conditions of high unemployment and high rates of poverty. Indians in urban areas, who are frequently not enrolled members of federally-recognized tribes, are often unemployed.
The driving force for many of the health status and health coverage problems facing Native Americans as a whole is poverty. Not all Indians are poor, but a very large proportion of them are. U.S. Census data indicate that in 1996, 30.9% of Native Americans as a whole had family incomes below the poverty line, in comparison with 13.8% for the U.S. population as a whole.
The health status of Native Americans is significantly lower than that of the rest of the U.S. population. 3 According to the Indian Health Service (IHS) of the Department of Health and Human Services, the age-adjusted mortality rate for American Indians and Alaska Natives residing in the areas served by the IHS was 594.1 (per 100,000 population) for calendar years 1991-1993, compared to a rate of 504.2 for the entire U.S. population in 1992. ,4 In some IHS areas, the rate is double that of the total U.S. population. For instance, in the South Dakota, North Dakota, Nebraska and Iowa area the rate for calendar years 1991-1993 was 1,045.9.
Although there are significant variations from area to area, Native Americans as a whole have higher rates of death and injury caused by accidents and violence (including suicide and homicide) than the U.S. population generally. For the same 1991-1993 period, the IHS service area population had an accident mortality rate of 83.4 (per 100,000 population), compared with a rate of 29.4 for the entire U.S. population in 1992. Many of these deaths are related to the high incidence of alcohol abuse in a number Indian communities. Native Americans have higher rates of mortality from alcoholism than the U.S. population generally. The alcoholism mortality rate for the IHS service area population was 38.4 (per 100,000 population) over the 1991-1993 period compared to a rate of 6.8 among the entire U.S. population in 1992. Finally, the incidence of diabetes among Native Americans is significantly higher than that among the U.S. population generally. The diabetes mellitus mortality rate for the IHS service area population was 31.7 (per 100,000 population) over the 1991-1993 period, in comparison with the rate of 11.9 among the entire U.S. population in 1992.
The agency responsible for providing or paying for the provision of health services to most American Indians and Alaska Natives is the Indian Health Service (IHS). The IHS estimates its 1996 patient population – i.e., those eligible for health care services provided through or paid by the IHS – at 1.4 million Native Americans, most of whom live on reservations. This represents about three-fifths of the 2.3 million Native Americans in the U.S. Eligibility for IHS care is determined under federal statute and regulation and depends largely (but not exclusively) upon membership in a federally-recognized tribe and residence on or near a reservation. Federal recognition of a tribe is generally predicated on treaty or federal statute or both.
The IHS delivers care directly to Indians who meet IHS eligibility criteria through 40 hospitals, 64 health centers, 5 school health centers, and 50 smaller health stations located in 17 states. The IHS also makes arrangements, through contracts or “compacts,” directly with Indian tribes to deliver care to their own members. Currently tribes operate 9 hospitals, 116 outpatient health centers, 5 school health centers, 56 smaller health stations, and 171 Alaska village clinics under these arrangements. Finally the IHS funds 34 urban Indian programs ranging from outreach and referral programs to outpatient health clinics. Specialized and/or expensive diagnostic and treatment services that the IHS (or tribes) cannot offer directly through their own facilities in a particular area may, subject to the availability of funds, be purchased from non-IHS (or non-tribal) providers on a fee-for-service basis through the “contract health services” (CHS) program. Urban Indian programs do not have access to CHS funds.
In 1997, 57.2 percent of the $1.8 billion appropriated to IHS for services was spent on IHS direct operations, 41.5 percent was spent on tribally-operated hospitals and clinics, and 1.4 percent was spent on urban Indian programs. Of the $1.1 billion appropriated to IHS for direct services, $235 million, or 22 percent, took the form of contract health services purchased from non-IHS providers. The comparable CHS figure for tribal providers was $133.4 million, or 18 percent of the total $750 million in fiscal year 1997 appropriations allocated to tribal providers.
II: Medicaid’s Role For Native Americans
Medicaid as a Source of Health Coverage
In part because of high rates of poverty and unemployment, Native Americans are less likely than other Americans to have employer-sponsored or other types of private health insurance coverage. In addition, Native Americans are less likely to be enrolled in public health insurance programs like Medicare and Medicaid. According to U.S. Census data for 1996, 18.1 percent of Native Americans had no health insurance while 47.7 percent had private insurance, 39 percent were enrolled in Medicaid, 10.1 percent were enrolled in Medicare, and 4.1 percent were covered through the Civilian Health and Medical Programs of the Uniformed Services (CHAMPUS).5 The IHS data base indicates that, as of August 12, 1997, of the 1,784,000 individuals registered as IHS patients, 466,000, or 26 percent, were eligible for Medicaid.6
Nationally, Medicaid is the second largest health insurance program after Medicare. The Congressional Budget Office estimates that in 1998 Medicaid will cover 44 million individuals, half of whom are children. Each of these individuals is entitled to have payment made on his or her behalf for covered services received from participating hospitals, physicians, and other providers. Medicaid benefit packages vary from state to state, but they all include physician services; laboratory and x-ray services; inpatient and outpatient hospital services; early and periodic screening, diagnostic, and treatment (EPSDT) services for children; and services provided by federally qualified health centers (FQHCs).
Individual Entitlement
Individuals who meet Medicaid eligibility standards are entitled to coverage. This applies to Native Americans as it does to other American citizens. Historically, some state and local officials viewed the health coverage of American Indians and Alaska Natives as exclusively a federal responsibility and sought to exclude Native Americans from Medicaid coverage.7 Although Medicaid is administered and financed in part by the states, Native Americans who meet the Medicaid eligibility requirements of the state in which they reside are, as a matter of law,8 entitled to Medicaid coverage.9 This is true whether a Native American lives on or near a reservation or in an urban area, and whether or not a Native American is eligible for IHS services.10
Eligibility Requirements
To qualify for Medicaid in any particular state, an individual must be a resident of that state. In addition, regardless of the state in which an individual resides, an individual must meet both categorical eligibility requirements and financial eligibility requirements. Categorical eligibility requirements relate to the age or characteristics of an individual: children, pregnant women, elderly, and disabled are among the categories of individuals that may qualify for Medicaid. Financial eligibility requirements relate to the amount of income or assets an individual is permitted to have (standards), and how those amounts are calculated (methodologies). Individuals who do not meet the categorical requirements – for example, non-elderly adults who are not disabled and do not have children – may not qualify for Medicaid no matter how poor they are. There are exceptions to this general rule. Some states cover poor single adults under “section 1115” demonstration waivers granted by the Secretary of Health and Human Services. 11
States have flexibility within broad federal guidelines to establish eligibility rules for their Medicaid programs, but there are certain groups of individuals that any state receiving federal Medicaid matching funds must cover. For example:
Table 1 shows the Medicaid income eligibility thresholds in effect in each state as of October, 1997, for pregnant women, children, and aged and disabled individuals. These data, which were made available by the National Governors’ Association, describe the thresholds as a percentage of the federal poverty level.
Native Americans and Medicaid: Coverage and Financing IssuesReport Part One Report Two Report Three Report Four
Native Americans and Medicaid:Coverage and Financing Issues
Medicaid and Welfare
Until 1996, families with children who received cash assistance under the Aid to Families with Dependent Children (AFDC) program were automatically entitled to Medicaid coverage. The welfare law enacted that year, Public Law 104-193, repealed the AFDC program and created a Temporary Assistance for Needy Families (TANF) block grant to the states. The 1996 welfare law also severed the automatic eligibility linkage between welfare and Medicaid. States may now use different eligibility rules for families under their welfare block grant programs than they use under Medicaid. At a minimum, states must maintain their Medicaid eligibility standards for families with dependent children at the level of those in effect as of July 16, 1996, under the state’s AFDC program.
In states that choose to use different eligibility rules for mothers and children under the welfare block grant than they do under Medicaid, low-income families who qualify for cash or other assistance under the welfare block grant may no longer automatically qualify for Medicaid. Instead, they may have to file a separate application for Medicaid benefits, perhaps in a different location. In such cases, there is a risk that eligible individuals, especially children, will not be enrolled in Medicaid due to logistical and administrative barriers.
Under the welfare law, tribes may elect to receive federal (but not necessarily state) welfare block grant dollars directly to operate their own “tribal family assistance” program separately from that of the state in which their members reside. However under Medicaid law, tribes are not expressly authorized to administer their own Medicaid programs. As a legal matter, it is possible that a tribe could, with cooperation from the state in which it is located and the approval of the Secretary of HHS, operate its own Medicaid program under a demonstration waiver under section 1115 of the Social Security Act. The legal issues are by no means clear, the technical issues are formidable, and no such waiver has been granted.
Medicaid and Resource Testing
Financial eligibility criteria for Medicaid generally include resource as well as income requirements. For example, disabled and elderly individuals who seek to qualify for Medicaid on the basis of receipt of SSI benefits must have countable resources of less than $2,000 ($4,000 for a couple). Similarly, families who seek to qualify for Medicaid coverage on the basis that they meet the eligibility requirements for AFDC in effect in a state as of July 16, 1996, must have countable resources of less than $1,000. Not all resources are countable; for example, a home of any value is excluded from the calculation of an individual’s resources. States have the option, with respect to certain eligibility groups, to liberalize these resource requirements or to discard them altogether. Many states have chosen to apply only an income test in determining the Medicaid eligibility of children with incomes at or below the poverty line.
Resource tests pose some unique issues for American Indians and Alaska Natives. Certain income-producing property, such as pick-up trucks and fishing boats, can disqualify an individual for Medicaid. Similarly, non-trust land which an individual owns may result in denial of Medicaid eligibility due to excess resources. States have the flexibility under federal Medicaid law to reduce or eliminate these barriers to eligibility by using less restrictive methodologies for counting resources. For example, a coastal state could choose to disregard the first $75,000 dollars in equity value of a boat used to produce income during the fishing season.
Coordination of Medicaid and IHS Coverage
Native Americans who are eligible for health care through the IHS are also entitled to Medicaid coverage if they meet the categorical and financial eligibility requirements of the Medicaid program in the state in which they reside. In cases in which an individual is eligible for both Medicaid and IHS services, and a service (such as hospital care) is covered both by Medicaid and by the IHS, the Medicaid program is required to pay for the service. Where a Medicaid beneficiary receives a service provided by the IHS that is not included in the Medicaid benefits package in that state – for example, non-emergency dental care for adults – the IHS, as the residual program, has the responsibility to pay.
Medicaid as a Source of Revenue for Hospitals and Clinics
The IHS is an appropriated program rather than an entitlement program. That is to say, the federal funding for all the IHS, tribally-operated, and urban Indian programs are appropriated in advance each year in fixed amounts. These annually appropriated amounts are then allocated among the different geographic areas and tribes served by the IHS.
Because no individual American Indian or Alaska Native is entitled to any particular health care service from the IHS, when the funding for a given year has been consumed, the provision or purchase of services must be postponed until the next fiscal year when new appropriations become available. This is particularly evident in the case of contract health (CHS) services, for which waiting lists for non-emergency services are not uncommon in many areas. In contrast, Medicaid is an entitlement program, under which the federal government matches, on an open-ended basis, all state expenditures for covered services on behalf of eligible individuals. In the case of Native American beneficiaries, the federal matching rate is generally 100 percent. Unlike the federal funding for the IHS, federal Medicaid matching funds are not subject to annual appropriations limits.
Under the Balanced Budget Act, growth in federal spending on appropriated programs such as the IHS is tightly constrained for the next five years by across-the-board “caps.” Because the IHS will have to compete for funding with the National Institutes of Health, the Head Start program, and all other domestic programs subject to these appropriations “caps,” IHS funding is not likely to grow nearly as fast as federal spending on entitlement programs like Medicaid, which are projected to grow at around 7 percent per year. As a result, revenues from Medicaid are likely to become increasingly important to many IHS, tribal, and urban programs to help relieve appropriated funding limitations over the next few years.12
Medicaid is already an important source of revenue for IHS hospitals and clinics as well as for tribally operated facilities and urban Indian health programs. In fiscal year 1997, IHS and tribally operated facilities were projected to receive $184.3 million in Medicaid reimbursements, compared with the $1.806 billion appropriated for IHS and tribally-provided health services that year.
The Medicaid program is in transition. Historically, like other health insurers, Medicaid paid for covered care on a fee-for-service basis. Today, most states are encouraging or requiring Medicaid beneficiaries to enroll in managed care in order to receive covered services. Again, there is much variation among the states. Some have enrolled virtually all of their Medicaid beneficiaries in managed care; others have just begun this process. Hospitals, clinics, and other providers – whether or not operated by the IHS or tribes – may face significantly different participation and reimbursement rules when they serve a Medicaid beneficiary on a fee-for-service basis than when they serve a Medicaid managed care enrollee.
Participation in Medicaid by IHS Facilities and Tribal Health Programs
State Medicaid agencies are responsible for establishing and maintaining health standards for public or private facilities in which Medicaid beneficiaries receive care or services. Under federal regulations, a facility owned or leased by the IHS, whether operated by the IHS or by a tribe or tribal organization, is entitled to participate in Medicaid and receive payment for covered services delivered to Medicaid beneficiaries if it meets the requirements and standards generally applicable to the type of facility (e.g., hospital, clinic) under the state Medicaid program. IHS owned or leased facilities are not required to be licensed by the state in order to participate in Medicaid; however, they are required to meet the applicable standards for licensure.
Under the December 19, 1996 Memorandum of Understanding (MOA) between the IHS and the Health Care Financing Administration (HCFA), these same participation rules apply to “638” facilities owned or operated by tribes. These “638” facilities are operated by tribes or tribal organizations under contracts, grants, or compacts under the Indian Self-Determination and Education Assistance Act, Public Law 93-638. Thus, “638” facilities are not required to obtain a state license in order to participate in Medicaid, but they must meet all applicable standards for licensure.
100 Percent Federal Matching for Covered Services Provided by IHS and Tribal Programs
Medicaid has special rules for the financing of covered services provided to Native Americans. In general, Medicaid is a federal-state matching program under which the federal government contributes toward the costs states incur in paying for covered services on behalf of eligible individuals. The federal government’s share of these costs ranges from 50 percent in more affluent states to 80 percent in the poorest states; on average, the federal government pays 57 percent of the cost of Medicaid benefits.
However, a higher federal matching rate applies in the case of services provided by IHS or tribal facilities. Under section 1905(b) of the Social Security Act, the cost of services provided to Medicaid beneficiaries by a hospital, clinic, or other facility of the IHS, whether operated by the IHS or by a tribe or tribal organization, is matched by the federal government at a 100 percent rate. In these cases, the state is reimbursed fully by the federal government and is not required to contribute any of its own funds toward the cost of care. In addition, under a December 19, 1996, Memorandum of Agreement (MOA) between the IHS and the Health Care Financing Administration (HCFA), this same 100 percent federal matching rate also applies to the cost of any covered services furnished on or after July 11, 1996, to Medicaid-eligible American Indians or Alaska Natives by any tribal facility operating under a “638” agreement by grant, contract, or compact. The cost of covered services provided by tribal facilities to Medicaid beneficiaries who are not Native Americans will continue to be matched by the federal government at each state’s regular matching rate.
This 100 percent federal matching rate removes any financial disincentive a state might otherwise face in paying for covered services provided to Native American Medicaid beneficiaries by IHS or tribal providers, because a state does not have to commit any of its own funds. The 100 percent match also provides a financial incentive for states to encourage Native American beneficiaries to use IHS and tribal providers. If these beneficiaries receive covered Medicaid services from providers other than IHS or tribally-run hospitals or clinics, the state would have to contribute the same share of the cost that it is required to match in the case of any Medicaid beneficiaries who are not Native Americans. Note that, because Medicaid is an entitlement program, there is no annual appropriations limit on the 100 percent matching funds for covered services provided by IHS or “638” tribal facilities to Indian beneficiaries.
The December 19, 1996 MOA does not extend to urban Indian health programs. Thus, the cost of covered services provided by urban Indian health programs to Medicaid beneficiaries will continue to be matched at each state’s regular matching rate, whether or not those beneficiaries are Native Americans. A central purpose of the MOA is, by its own terms, “to encourage tribal self-determination in program operation and facility ownership,” as well as “to address state financing concerns.” While 100 percent federal financing for covered services provided by urban Indian health programs would clearly address state financing concerns, it does not apply to tribal self-determination. Whatever the merits of this policy rationale, the effect is clearly to leave the urban Indian health programs in a Medicaid provider category that is less favorable from the states’ standpoint than the category in which the MOA places tribally owned or operated facilities.
Note that the special 100 percent federal matching rate applies only to state expenditures for services covered by the state’s Medicaid program. The services which a state Medicaid program covers are sometimes not as broad in scope as the services which an IHS or tribally-operated hospital or clinic delivers. For example, tribally-run facilities may provide preventive dental care or orthodontic services to Indians who are eligible for Medicaid. Under Medicaid law, states have the option as to whether to cover these particular services for adults, and many have chosen not to do so. In these states, the “638” clinic would not receive Medicaid payment for such dental visits by eligible adults, and the state would therefore not receive any federal matching funds for such costs.
Fee-for-Service Reimbursement Rates
In general, states have broad discretion in establishing payment rates to hospitals, clinics, and other providers that participate in Medicaid on a fee-for-service basis. States are generally not required to pay these providers for the costs of delivering care to Medicaid beneficiaries. However, special reimbursement rules apply with respect to facilities operated by the IHS. Minimum payment standards also apply to Federally-qualified health centers (FQHCs), which include “638” tribally-operated facilities and urban Indian programs.
In many states, tribally-operated “638” facilities do not bill their Medicaid programs using the 100 percent of reasonable cost rate, even though they are FQHCs and are entitled under federal Medicaid law to do so. Instead, they use the federally-specified or “global” rate. The reasons for billing using the federally-specified rate include more frequent updates and the absence of an annual retrospective audit. The FQHC protection remains important to these facilities, however, because it guarantees that the ambulatory services they provide are included in their state Medicaid program’s benefits package.
Medicaid and Managed Care
Over the past few years, Medicaid in many states has been shifting from a predominantly fee-for-service program to a program that purchases services from managed care organizations (MCOs) or primary care case management organizations (PCCMs), or both, on a prepaid, capitated basis. MCOs are managed care plans that are fully capitated or “full risk” – that is, they assume financial risk for providing covered inpatient hospital, physician, and other services to their enrollees. In contrast, PCCMs are typically not capitated; they provide covered primary care services and manage access to specialist and hospital care for their enrollees in exchange for a monthly management fee and do not assume financial risk for providing inpatient hospital care.
As there is variation among IHS areas and tribes, so there is variation among state Medicaid programs with respect to the use of managed care. Table 2, which is based on HCFA data analyzed by the Urban Institute, shows Medicaid managed care enrollment by state as of June, 1996. Because the data do not distinguish Native American beneficiaries from other Medicaid beneficiaries, it is not possible to draw any conclusions about enrollment by Native American beneficiaries in managed care. The data do, however, show that some states with large Native American populations such as Idaho, Montana, New Mexico, North Carolina, North Dakota, and South Dakota, enrolled none of their Medicaid beneficiaries in full-risk MCOs but relied exclusively on PCCMs. Other states with large Native American populations, such as California, Minnesota, New York, Oklahoma, Washington, and Wisconsin enrolled significant proportions of their Medicaid populations in full-risk MCOs and enrolled almost none of their beneficiaries in PCCMs. Alaska did not enroll any Medicaid beneficiaries in managed care; Arizona and Oregon enrolled most of their Medicaid beneficiaries in full risk plans.
This shift to managed care is likely to accelerate as the result of wide-ranging changes in Medicaid law contained in the Balanced Budget Act of 1997, P.L. 105-33, enacted in August, 1997. Many issues regarding the implementation of these changes remain unresolved. However, the following points seem clear:
Strategic Choices for Native American Health Facilities
The first of these options may in many cases prove impractical due to the unavailability of start-up capital for information systems, reserve funds, and planning and marketing costs; legal issues relating to the assumption of risk by IHS-operated programs; and state licensure requirements. Some of the issues that arise in the context of developing an MCO do not come up for IHS facilities seeking to establish PCCMs. In either case, the first option will often give the IHS facility the best protection against market forces that may otherwise result in the erosion of its patient base and fiscal stability over the long run.15 Of course, participation in Medicaid as an MCO is not an absolute guarantee of survival for a hospital or clinic. There are other reasons why a provider’s Medicaid revenues would decline, including loss of eligibility by beneficiaries due to income fluctuations and changes in state Medicaid eligibility standards.
IHS facilities that are able to establish their own MCO or PCCM are not guaranteed a contract with a state Medicaid program even if they meet the state’s solvency, quality, and other requirements. That is because states are not under federal law required to contract with every qualified MCO or PCCM; instead, states can limit the number of contracting MCOs or PCCMs to two in urban areas and to one in rural areas. Unless they receive a waiver from the Secretary of HHS, however, states can not require Medicaid-eligible Indians to enroll in any MCO or PCCM that is not an IHS- or tribally-operated program. Where a state contracts with an MCO, the state must pay capitation rates that are set on an “actuarially sound” basis whether or not the MCO is operated by the IHS.
Medicaid MCOs may, but are not required to, contract with IHS facilities for the provision of hospital or other services. If an MCO chooses to contract with an IHS facility, it is not required to pay the specified federal reimbursement rate for services rendered to MCO enrollees, and it is not required to pay the IHS facility at the same rate it pays non-IHS providers for the same services.
In those states that have adopted federally-specified rates for IHS facilities, those IHS facilities that remain unaffiliated with MCOs or PCCMs are eligible for payment at such rates for covered inpatient and outpatient services provided to Medicaid-eligible Indian beneficiaries who are not enrolled in MCOs. Where an IHS hospital provides emergency care to a Medicaid-eligible MCO enrollee (whether or not that enrollee is a Native American), the MCO must reimburse the hospital for the care if a “prudent layperson” would have sought emergency care under the same circumstances. Note that if a Medicaid-eligible Indian is enrolled in an MCO or PCCM that is not operated by the IHS but continues to use the IHS facility as a source of health care without a referral from the MCO, the MCO is not obligated to pay for nonemergency services provided by the IHS facility to its enrollee, unless state regulations require the MCO to pay. The IHS facility will not be able to bill the state Medicaid program directly because the MCO has assumed financial responsibility for the beneficiary’s care.
In these circumstances, the IHS facility has two basic options for protecting itself against using its own resources to pay for nonemergency care for Indian MCO beneficiaries. One option is to affiliate with the MCO as a participating provider. The MCO is under no federal law obligation to affiliate with the IHS facility or to do so on reasonable terms, however. The other option is for the state Medicaid agency to include in its contracts with MCOs a provision allowing Indian enrollees to go “out of plan” to receive care from IHS facilities without a referral from the MCO. This contract provision could potentially be structured so that the federal government, through its 100 percent matching for state expenditures, reimburses the IHS facility for the costs of this care, holding the beneficiaries and the MCO harmless for such costs.
Under the Balanced Budget Act, MCOs that subcontract with FQHCs must pay an FQHC at the same level and amount which they would pay any other provider for the same services. In addition, the Act requires state Medicaid programs to pay each subcontracting FQHC the difference between the payment it receives from the MCO and the payment it would receive under fee-for-service Medicaid (i.e., 100 percent of cost phasing down to 70 percent of cost by 2003). These protections expire on October 1, 2003.
The other option that tribally-owned or operated facilities may have that IHS facilities may not have is the legal capacity to assume financial risk, which is a prerequisite to becoming an MCO. In many cases, “638” facilities have a legal structure that allows them, under state law, to bear risk. Whether, as a practical matter, they have the necessary capital and technical capacity to do so, and whether it makes strategic sense for them to do so, will of course vary from case to case.
The Balanced Budget Act prohibits states from mandating the enrollment of urban Indian Medicaid beneficiaries in MCOs or PCCMs unless the MCO or PCCM is an urban Indian health program. This in theory gives urban Indian programs the ability to negotiate exclusive enrollment agreements with state Medicaid programs. However, because urban Indian programs are generally small in scale, it is unlikely that many of them will be able to qualify as MCOs or PCCMs for this purpose. In most cases, the only practical option is likely to be subcontracting with one or more Medicaid MCOs or PCCMs. Because this subcontracting is optional with the MCO or PCCM, there is no assurance that urban Indian health programs will be allowed to affiliate with the MCO or PCCM at all, much less on terms that are favorable to the urban Indian organization.
Native Americans and Medicaid: Coverage and Financing IssuesReport Part Two Report One Report Three Report Four
Native Americans and Medicaid:Coverage and Financing Issues
Medicaid as Medicare Premium Assistance
The Medicare program provides health insurance coverage for the nation’s elderly and disabled.16 To enroll in Medicare Part B, which offers coverage for physician and other outpatient care, individuals must be 65 or older or must be disabled, and must pay a monthly premium. This monthly premium, which is generally deducted from an individual’s Social Security check, is $43.80 per month in 1997. The Balanced Budget Act of 1997 raises the Part B premium to $67.00 per month by 2002. To protect low-income Medicare beneficiaries against these monthly premium costs, all state Medicaid programs are required to pay the entire Part B premium amounts on behalf of certain groups of Medicare beneficiaries, including Native American Medicare beneficiaries:
Under the Balanced Budget Act of 1997, states are required to pay some or all of the Medicare Part B premium on behalf of Medicare beneficiaries with incomes between 120 and 135 percent of the poverty line. A fixed amount of federal funding for this premium assistance is provided to each state for each of the next 5 years; no state is required to contribute any of its own funding. Unlike SLIMBs, these individuals are not entitled to premium assistance; states are required only to select individuals from qualified applicants on a first-come, first-served basis, up to the amount of federal funding available. Because the statute does not require that states notify near-poor Medicare beneficiaries of their potential eligibility for this assistance, the IHS and the tribes will, as a practical matter, frequently be the only source of information about this benefit for Native American Medicare beneficiaries.
Medicaid as a Source of Long-Term Care Coverage
Medicaid is the nation’s single largest purchaser of nursing home care. More than half of all nursing home revenues come from Medicaid. The program also covers a wide range of home- and community-based (HCBS) services for frail elderly and chronically ill disabled individuals who are at risk of nursing home care. The transition to managed care that is occurring in Medicaid’s purchase of acute care services has generally not reached the long-term care sector. Most Medicaid nursing home and HCBS services are still paid for on a fee-for-service basis.
Because nursing home care costs on average $40,000 per year, the availability of Medicaid coverage for nursing home and other long-term care services is a major source of financial protection for low- and moderate-income families. It is particularly important to Native American families because few IHS or tribally-operated facilities offer comprehensive long-term care services.17 Yet it is precisely the high cost of these services that has lead many states to impose restrictive income and resource eligibility requirements on elderly and disabled individuals and their spouses. In addition, federal law requires that states seek to recover the costs of Medicaid nursing home care from the estates of deceased beneficiaries and authorizes the states to impose liens in certain circumstances in order to carry out such recoveries. These restrictive eligibility and estate recovery rules have reportedly discouraged many otherwise eligible Native Americans from establishing eligibility for Medicaid nursing home coverage.
III: Policy Issues For Native Ameircans In Managed Care
Policy Issues
The Medicaid program’s historic shift from fee-for-service to managed care presents critical policy issues for the IHS, for tribes and their health programs, and for urban Indian health programs. Because state Medicaid programs differ from one another, and because local circumstances vary considerably, these issues will take different forms in different communities. Many of the issues raised by Medicaid’s shift to managed care are not unique to eligible Native Americans but affect all Medicaid beneficiaries.18 There are, however, some issues unique to Native Americans that are also common to all state Medicaid programs:
For many Native American Medicaid beneficiaries, the issue of choice of provider is more theoretical than practical, especially in sparsely-populated rural areas with few physicians or clinics or hospitals. Medicaid coverage that allows beneficiaries to choose from among all participating providers means little in underserved areas that have few providers of any kind, much less providers that participate in Medicaid. The movement toward Medicaid managed care has the potential to improve these circumstances and give Native American beneficiaries more choices. For example, if states opt to enroll all rural Medicaid beneficiaries in one MCO or PCCM, the resulting Medicaid market could potentially attract established, reputable managed care firms and give them an incentive to bring primary care physicians and other providers into these areas in order to be able to offer the necessary provider networks.
However, the availability of more provider choices for Native American beneficiaries has potentially adverse consequences for traditional Native American delivery systems, whether operated by the IHS or by “638” tribes. If significant numbers of Native American beneficiaries elect to enroll in an MCO or PCCM unaffiliated with the IHS or a tribal facility, the Medicaid revenues of the IHS or tribal facilities will likely decline, undermining their capacity to deliver quality care to their remaining patients. The current law provision – prohibiting states from enrolling Indian beneficiaries in MCOs or PCCMs that are not operated by the IHS or tribal “638” contractors – is not a sufficient protection against this result. If the MCO or PCCM with which the state contracts does not in turn contract with the IHS or tribally-operated facilities in the area, the Indian beneficiaries who do not choose to enroll in the MCO or PCCM would continue to receive care on a fee-for-service basis from the IHS or tribal facility. This would tend to isolate both the Indian beneficiaries and the IHS or tribal facilities from the Medicaid patients and providers in the rest of the area – not necessarily a desirable outcome. This result could be avoided if MCOs or PCCMs that receive the Medicaid franchise for the rural area were required to allow any IHS or tribally-operated facility in the area meeting the entity’s quality standards to participate – if the facility so chooses – on terms at least as favorable as those offered to other facilities. In addition, the Secretary of HHS should consider not granting waivers that would allow states to require Native American beneficiaries to enroll in MCOs or PCCMs that have not incorporated IHS or tribal facilities into their provider networks.
The federal government has a strong interest in the financial viability of IHS, tribal, and urban Indian health care providers. These providers enable the federal government to discharge in part its legal obligation to cover the cost of basic health care to Native Americans and to promote tribal self-determination. In addition, these providers are frequently the only practical source of health care for Indians and other Americans living in underserved rural areas. Because the federal government, on average, pays 57 percent of the cost of the Medicaid program, it also has an interest in assuring that Medicaid payment policies support rather than undercut the IHS, tribal, and urban health care programs that it funds with appropriated dollars.
State Medicaid programs have a strong financial incentive to facilitate the use of IHS or “638” tribally-operated health facilities by Medicaid beneficiaries who are Native Americans. As noted above, under federal statute and a HCFA-IHS Memorandum of Agreement (MOA), the federal matching rate for state expenditures in such cases is 100 percent; the state is not required to contribute any of its own funds. However, if the beneficiary receives covered services from a non-IHS or non-tribal provider, the state must assume between 20 and 50 percent of the cost. If states are aware of their financial interest and take advantage of it, they will be seeking to work with IHS and tribal providers to maximize the use of those facilities by Native American beneficiaries, and the Medicaid revenues associated with those beneficiaries should improve the fiscal position of those facilities.
The need to sustain an IHS and tribally-run health care infrastructure has a number of policy implications. It means that Medicaid fee-for-service payments made directly to Indian hospitals and clinics must be adequate to cover the costs of care. (The recent amendment phasing out cost-based payments to federally-qualified health centers (FQHCs) runs counter to this). Similarly, Medicaid payments to MCOs should be conditioned on the affiliation of MCOs with IHS, tribal, and urban health care programs that meet the MCO’s quality standards. State payment rates to MCOs for eligible Native American enrollees should be adequate to enable the MCOs to pay subcontracting programs their costs of treating Indian beneficiaries, and the MCOs should be required to pay the subcontractors at an adequate level in a timely fashion. Finally, the federal government (through the IHS or through a tribally-accountable entity subcontracting with the IHS) should make start-up capital and technical assistance available to tribal programs (or IHS facilities) that seek to become MCOs or PCCMs and contract with their state Medicaid programs to enroll Medicaid beneficiaries residing in their service areas.
Conclusion
In the coming years, the IHS, Medicaid, and state welfare programs will continue to evolve in response to changes in the economy, changes in the health care system, and changes in budgetary and regulatory policy at the state and federal level. These changes will have profound implications for tribes and their health care programs and, ultimately, for the health status of Native Americans. In all likelihood, these changes will intensify the challenges described in this Policy Brief and create new ones. It is crucial that these developments be carefully monitored to identify problems as they arise and to give the tribes and the IHS the information they need to improve the access of Native Americans to quality health care services.
1. See Medicaid Facts: Medicaid Program at a Glance, November 1997; Medicaid Facts: Medicaid and Managed Care, November 1997; Medicaid Facts: Medicaid’s Role for Children, November 1997; Policy Brief: Restructuring Medicaid — Key Elements and Issues in Section 1115 Demonstration Waivers, May 1997.
2. For a general overview of these provisions, see Andy Schneider, Overview of Medicaid Provisions in the Balanced Budget Act of 1997, P.L. 105-33, Center on Budget and Policy Priorities, September 3, 1997, http://www.cbpp.org.
3. See Kaiser Family Foundation, A Forum on the Implications of Changes in the Health Care Environment for Native American Health Care (1997).
4. U.S. Department of Health and Human Services, Indian Health Service, Regional Differences in Indian Health 1996.
5. These figures were reached by a CBPP analysis of unpublished data from March 1997 CPS, Bureau of the Census. The percentages sum to more than 100 percent because some Native Americans had multiple sources of insurance coverage.
6. Indian Health Service, IHS Medicare and Medicaid Eligibility Data Current as of August 12, 1997, compiled September 23, 1997.
7. At its Winter, 1996 meeting, the National Governors’ Association adopted the following policy: “States do not have treaty-based trust responsibilities to provide health care to Native American peoples and, consequently, have no proper role in the financial support or operation of Indian Health Service facilities.”
8. “Indians and other native Americans are entitled under the Fifth and Fourteenth Amendments to the Constitution of the United States, and title VI of the Civil Rights Act for 1964, to equal access to State, local, and Federal programs to which other citizens are entitled.” Department of Health, Education and Welfare (HEW), Memorandum of Agreement, January 7, 1975.
9. In a case involving a dispute over the entitlement of Indians living off the reservation to federal benefits, the Supreme Court in Morton v. Ruiz, 415 U.S. 199 (1974) recognized that “[an Indian thus is entitled to social security and state welfare benefits equally with other citizens of the State.” Id. at 209, n. 11 (citing State ex rel. Williams v. Kamp, 106 Mont. 444, 449, 78 P.2d 585, 587 (1938); U.S. Dept. of the Interior, Federal Indian Law 287, 516 (1958)).
10. In Morton, the Supreme Court also noted that “[a]ny Indian, whether living on a reservation or elsewhere, may be eligible for benefits under the various social security programs in which his State participates and no limitation may be placed on social security benefits because of an Indian claimant’s residence on a reservation.” Morton, 415 U.S. at 209.
11. Under section 1115 of the Social Security Act, the Secretary of Health and Human Services is authorized to waive many of the requirements of federal Medicaid law to enable states to receive federal Medicaid matching funds for carrying out demonstration projects that in the Secretary’s judgment, “is likely to assist in promoting the objectives of [the Medicaid program].” See Kaiser Medicaid Commission Policy Brief, Medicaid: Key Elements and Issues in Section 1115 Demonstration Waivers (May 1997).
12. Peter J. Cunningham, “Health Care Utilization, Expenditures, and Insurance Coverage for American Indians and Alaska Natives Eligible for the Indian Health Service,” Changing Numbers, Changing Needs: American Indian Demography and Public Health, National Research Council, 1996, at 291.
13. A further complication occurs if an MCO or PCCM is not owned or operated by the IHS or by a tribe or tribal organization, but subcontracts with IHS or tribal facilities or programs to deliver services covered under Medicaid risk contract with the state. It is not clear if the capitation payments to the MCO on behalf of Indian beneficiaries are subject to 100 percent matching if the beneficiary uses the IHS or tribal subcontractor.
14. This and the following examples of current arrangements are described in Mim Dixon, Case Studies of Managed Care in Indian Health, National Indian Health Board. February, 1997. pp. 28-40.
15. See Sara Rosenbaum and Ann Zuvekas, Integrating Indian Health Programs into Medicaid Managed Care Systems: A Round Table Sponsored by the Indian Health Service, Final Summary Report, April 25, 1996.
16. For an overview of Medicare, see Harriet Komisar, James A. Reuter, Judith Feder, and Patricia Neuman, Medicare Chart Book, The Kaiser Medicare Policy Project, June, 1997. For a study of issues affecting low-income Medicare beneficiaries, see Patricia B. Nemore, Variations in State Medicaid Buy-in Practices for Low-Income Medicare Beneficiaries, Henry J. Kaiser Family Foundation, November, 1997. For a summary of these issues, see Medicaid’s Financial Protections for Medicare’s Poor and Near-Poor, Henry J. Kaiser Family Foundation, November 1997.
17. Indian Health Service. National Resource Directory for American Indian and Alaska Native Elders. June 1996.
18. For more information on Medicaid and managed care, see Medicaid Facts: Medicaid and Managed Care, Kaiser Commission on the Future of Medicaid, November 1997. Schneider, et al, Background Paper: Medicaid and Managed Care, Henry J. Kaiser Family Foundation, December 1997.
19. David Liska et al., Medicaid Expenditures and Beneficiaries, National and State Profiles and Trends, 1990-1995, Kaiser Commission on the Future of Medicaid, November, 1997, Authors’ Note, p. xiii. Return to top
Native Americans and Medicaid: Coverage and Financing IssuesReport Part Three Report One Report Two Report Four
Teenage Sexual and Reproductive Behavior in the United States
The Changing Face of Teen Sexual Activity and Unplanned Pregnancy
Over the past two decades, the pregnancy rate among sexually experienced teenage girls aged 15-19 has declined by 19%, indicating that many are doing a better job at using contraception. But, because the percentage of teens who have had sex has been steadily increasing at the same time, in real terms, the problem of teen pregnancy is getting worse. In addition, as of the late 1980s, a higher proportion of teenage girls who get pregnant are giving birth and, over the last three decades, dramatically fewer are getting married when they become teen mothers, resulting in more children in households with single teen mothers.
Sexual Activity
Contraceptive Use
Sexually Transmitted Diseases (STDs)
Teenage Pregnancy
Sources of Data:
The data in this fact sheet are from research conducted by the Kaiser Family Foundation, The Alan Guttmacher Institute, the National Center for Health Statistics, and/or were published in Family Planning Perspectives.
For More Information:
Kaiser Family Foundation Survey on Teens and Sex: What They Say Teens Today Need to Know, And Who They Listen To,1996.
Centers for Disease Control and Prevention.
Sex and America’s Teenagers, The Alan Guttmacher Institute, 1994.
Testing Positive: Sexually Transmitted Disease and the Public Health Response, The Alan Guttmacher Institute, 1993.
The Entertainment Media as “Sex Educators?”
And, Other Ways Teens Learn About Sex, Contraception, STDs, and AIDS
June 24, 1996
What Sources Do Teenagers Rely on for Information About Sex and Birth Control?
According to a 1996 Kaiser Family Foundation Survey of teens, teens say they currently get information about sex and birth control from a variety of sources including: their parents (72%); teachers, school nurses, or sex education classes (69%); their friends (other than boy/girlfriends) (60%); and the media, such as TV shows or movies (53%) and magazines (39%).
What Media Are Teens Exposed To?
In today’s “information age,” teens are bombarded with information from many media sources. Television and music are among those most popular with teens. According to one study, the average teen spends more time watching television than doing any other activity besides sleeping (Davies, 1993). As teens get older, however, they show a growing preference for music over TV (Arnett, 1992; Larson, Kubey, & Colletti, 1989). In one focus group study, 11-15 year-olds listened to music four hours a day as a primary activity (not including as background music), compared to three hours a day of watching TV (Liming, 1987). The Kaiser Teen Survey also found that seventy percent of teenage girls say they “regularly” read magazines, particularly those targeted to them such as Seventeen, YM, and Teen.
To What Extent Do These Media Deal With Sex and Related Issues, Such as Contraception, STDs, and AIDS?
A study that looked at TV shows most popular among those under 17 during the 1992-1993 broadcast season found that one in four interactions among characters per episode conveyed a sexual message. In three weeks of programming studied, only two of the ten shows included messages about sexual responsibility (Ward, 1995). Two Kaiser Family Foundation studies also found high rates of sexual references and incidents with few mentions of adverse consequences in soap operas and TV talk shows. (Comparatively fewer studies have been done of print media coverage of sexuality issues, although the Kaiser Family Foundation currently has a study underway to look at the coverage in special interest magazines, such as those targeted to women, men, and teens).
Do the Media Have an Impact on Teenagers’ Attitudes and Behaviors Toward Sex?
One of the issues at the crux of the debate over sex in the media is to what extent the media affects teens’ attitudes and behaviors related to sex. After reviewing the existing research about impact of the media on behavior, Jane Brown and Jeanne Steele at the School of Journalism and Mass Communications at the University of North Carolina at Chapel Hill, both experts on the media and sexuality, concluded that in response to the question of whether the media might affect teens’ sexual behaviors, the answer is a “qualified yes.” “Qualified” because research on the effects of sex in the media is sparse and because it is very difficult to document the effects of media on people’s behavior. However, based on what is known about the effects of sexual media content, along with the larger body of research on the effect of the media on violence and anti-social behavior, they found that entertainment media do play an important role in shaping American youths’ sexual beliefs, attitudes, and behaviors. (From a study prepared for the Kaiser Family Foundation entitled Sex and Mass Media).
In the Kaiser Teen Survey, three-quarters of teens say they think portrayals of teen sex on television and in the movies is one of several possible factors affecting teen sexual activity. There is also evidence that the media can be used effectively to increase awareness and knowledge about reproductive and sexual health issues and possibly to change behavior toward reducing unplanned pregnancy and HIV and other STD infection rates.
What Teenage Pregnancy and STD Prevention Approaches Appear to Have Had a Positive Effect on Risk-Taking Behavior?
Many wide-ranging attempts have been made to affect teenage sexual and reproductive behavior but many of these programs have not been rigorously evaluated. Although numerous studies have attempted to measure the effectiveness of teenage pregnancy intervention programs, scientific research has not yet provided definitive answers about their success. However, much has been learned from the experiences of the few pregnancy prevention programs that have been designed and implemented with a rigorous, scientific evaluation component. A recent review by The Alan Guttmacher Institute of the impact of five rigorously evaluated adolescent pregnancy prevention programs shows that some intervention programs are successful in helping teenagers delay intercourse, and improving contraceptive use among teenagers who are sexually active. Furthermore, some programs can effectively combine an emphasis on delaying sexual activity with education regarding contraception. The most effective programs appear to be those that combine innovative, comprehensive sexuality education; skills for making decisions about having intercourse and for communicating with partners; and access to family planning services. Measuring the impact of community programs on sexual behavior and pregnancy rates is very difficult for several reasons including the lack of information on rates of sexual activity and birth control use at the local level.
What is “Entertainment-Education”? And, How is it Being Used?
International reproductive health organizations have long used mass media entertainment for educational purposes in some developing countries. Entertainment-education involves presenting educational content in entertaining formats with the primary goal of increasing knowledge. Mass media’s pervasiveness allows it to reach a large number of people, sending messages repeatedly in a variety of forms. Television soap operas/dramas and films are widely used in entertainment-education. Radio is also used widely because of its relatively low production cost, accessability and extensive reach. However, assessing the impact of such programs is complex — usually done with pre- and post-intervention surveys; comparison of exposed and non-exposed groups; and tracking of clinic data. Though it is unclear whether entertainment-education changes behavior, it has been proven to be an effective way to increase knowledge and awareness about an issue. Evaluations have demonstrated positive results in terms of increased knowledge about HIV transmission and the need for family planning, and increases in visits to local family planning clinics. Setting up such programs is easier outside the U.S. for a number of reasons, including less competition on the airways.
Here in the United States, there have also been some recent efforts by individuals within the entertainment industry to improve the way in which sex and its possible consequences are portrayed. A significant difference is that these efforts involve changes made to programming that is meant to be entertaining, and not meant specifically to be educational. A few examples of such efforts include:
What is the “V-Chip”? And, What Role are Government and Others Likely to Have in Addressing the Media’s Portrayal of Sex and Related Issues?
After much debate and numerous revisions, a telecommunications bill (S 652) was enacted by Congress on February 8, 1996. While the legislation focuses on de-regulation to promote competition among cable television and telephone services, it also introduces restrictions on sexual and violent content on television and the Internet. The law mandates a ratings system that would use a “V-chip” or equivalent technology to allow parents to screen out material they do not want their children to watch. Under this new law, the V-chip must be installed in all new TV sets with screens larger than 13 inches, as of January 1998. The law also mandates that a federally designed, voluntary ratings system be implemented by February 1997 if a satisfactory ratings system isn’t already in place — giving the entertainment industry a year to set up its own rating system. Since talks began March 1, the industry has agreed that each entertainment program will be rated by its distributor (the network or independent station carrying the program) and guidelines will be put in place to ensure consistency across networks.
Several issues surrounding the ratings system remain unresolved, particularly in regard to the forms ratings will take, and the logistical challenges of rating all relevant programming. For example, excluding news and sports programs which won’t be rated, the industry would need to rate an overwhelming 100,000 hours of programming per year — as compared to the 1,200 hours of film the Motion Picture Association of America rates each year. Some believe using a letter or number rating system may prove to be impractical and think a content description would be more effective. Another suggestion is that a single rating be assigned to each series for an entire season, while assigning different ratings to especially “objectionable” episodes. The biggest challenge may be defining the ratings for particular actions or behaviors and differentiating jokes from “responsible” discussions of topics such as teen pregnancy.
Is Contraceptive Product Advertising Restricted in the U.S.?
Although there are no laws or government regulations prohibiting contraceptive advertising in the United States, several major obstacles hinder contraceptive advertising, including: some FDA restrictions on prescription drug advertising, inconsistent efforts by advertisers, and fear of public disapproval and reprisal. While the public supports advertising of family planning methods, the minority opinion has prevailed in the decisions that broadcast media, and to some degree, print media have made regarding contraceptive advertising policies.
Television and radio. The broadcast media have historically resisted the advertising of contraceptive products, and through its National Association of Broadcasters until 1982 had a code on programming and advertising. Although the television networks ABC, CBS, FOX and NBC continue to reject contraceptive advertising, all networks have relaxed their ban on condom advertising in public service announcements as long as those commercials emphasize the prevention of disease and not pregnancy prevention.
Newspapers and Magazines. The print media do not face the same sort of industry selfregulation as the broadcast media. Yet, until the 1980s, magazines and newspapers also resisted contraceptive advertisements seemingly due to perceived public disapproval of such advertising. Magazines now generally are open to contraceptive advertising, with the women’s magazines taking the lead. Newspapers, however, generally will not give space to public service advertising and only recently (in the wake of the AIDS epidemic) have accepted advertisements that promote condoms for disease prevention.
The Advertisers. Commercial companies, particularly the condom manufacturers, have attempted to conduct advertising campaigns. The campaigns for prescription contraceptives, however, have been limited efforts, directed mostly to the print media.
The Public. In one of the few studies of public attitudes toward contraceptive advertising on television conducted by Louis Harris and Associates in the late 1980s, it was shown that a majority of Americans believe that television stations should be permitted to advertise contraceptive products. In fact, the study found that there was more support for contraceptive advertising (53% in favor) than there was for beer and wine advertising (45% in favor). Eight of 10 Americans believed that advertising on television would encourage more teenagers to use contraceptives, and more than three-quarters of all adults felt that if teenagers saw television stars they admire use birth control, that they would be more likely to use it themselves. Seven of 10 people said that they would not be offended by contraceptive advertising. In a parallel study, Harris and Associates surveyed 259 television station managers about the same issue. Seven of 10 station managers believed that commercials for contraceptives would offend many people; however, more than seven of 10 also said that stations should air these commercials if they do not cause offense.