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:

• Dual Eligibles. These are elderly or disabled individuals who are eligible for both Medicare and Medicaid benefits. State Medicaid programs are required to pay on behalf of these individuals the entire Medicare Part B monthly premium as well as Medicare deductibles and co-insurance requirements. Dual eligibles are also entitled to coverage of nursing home care, prescription drugs, and other Medicaid benefits that are not covered by Medicare.
• QMBs. Qualified Medicare beneficiaries, or QMBs, are Medicare beneficiaries who are not also eligible for Medicaid benefits but who have incomes at or below 100 percent of the poverty line ($7,890 for an individual, $9,870 for a couple in 1997) and countable resources no greater than $4,000. Like dual eligibles, QMBs are entitled to have payment made by Medicaid on their behalf for the entire Medicare Part B monthly premium as well as Medicare deductibles and co-insurance requirements. Unlike dual eligibles, QMBs are not eligible for full Medicaid benefits and are not entitled to Medicaid coverage of nursing home care or prescription drugs.
• SLIMBs. Specified Low-income Medicare Beneficiaries, or SLIMBs, are Medicare beneficiaries with income between 100 and 120 percent of the poverty line (up to $9,468 for an individual and $12,732 for a couple) and countable resources no greater than $4,000. SLIMBs are entitled to have payment made on their behalf by state Medicaid programs for the cost of the monthly Medicare Part B premium. Unlike QMBs, SLIMBs are not entitled to Medicaid payment of their Medicare deductible or coinsurance requirements. Unlike dual eligibles, SLIMBs are not entitled to Medicaid payment of nursing home care, prescription drugs, or other services that Medicaid covers.

  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:

• Preserving Choice for Medicaid-Eligible Native Americans. The Balanced Budget Act of 1997 overrides the right to freedom of choice of provider for most Medicaid beneficiaries by giving the states express authority to require Medicaid beneficiaries to enroll in MCOs or PCCMs. However, states under this authority may only force eligible American Indians and Alaska Natives to enroll in MCOs or PCCMs if these managed care entities are operated by the IHS, by a “638” tribe, or by an urban Indian organization. The purpose of this limitation on state flexibility is not so much to assure that Native American Medicaid beneficiaries have choice of providers; they will generally have a choice because IHS and tribal providers cannot refuse to treat Indians who are eligible for their services. Instead, the purpose of this provision is to assure that, when these beneficiaries obtain care from IHS or tribal providers, the providers, rather than MCOs or PCCMs unaffiliated with the IHS or the tribes, receive Medicaid reimbursement for the covered services they deliver. The provision does not bar Medicaid-eligible Indians from voluntarily enrolling in an MCO or PCCM that is not affiliated with the IHS or a tribe.

  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.

• Protecting IHS, Tribal, and Urban Indian Providers. Medicaid revenues can make the difference between a financially viable hospital or health clinic and a facility that must reduce the services it offers or close altogether. To the extent that Medicaid-eligible Indians enroll (or under waivers are enrolled by the state) in MCOs or PCCMs, the funding to pay for the provision of covered services to these patients will flow to the MCO or PCCM. Unless the IHS or tribal or urban Indian facility is affiliated with the MCO, either as an owner or as a subcontractor, or unless the facility has an arrangement with the state under which it will be reimbursed for treating Indian MCO enrollees who go “out of network,” the facility will lose some or all of the Medicaid revenues associated with these patients. The loss of these revenues can in turn undermine the capacity of the facility to deliver quality care to the Indian population that it is responsible for serving as well as any non-Indian patients it undertakes to serve.

  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.

• Program Data. To date, the transition toward managed care has led to a decline in the quality of Medicaid program data available to the federal government and the tribes, among others.¹⁹ However, this transition has the potential of significantly improving the data available to tribes, to the IHS, and to federal and state policy-makers regarding the impact of Medicaid coverage on the use of health services by, and the health status of, Native Americans. To realize this potential, however, current reporting requirements will need to be significantly strengthened. Currently, neither the IHS nor the Health Care Financing Administration (HCFA) have reliable data on how many American Indians or Alaska Natives in each state are enrolled in Medicaid; how many of these individuals are enrolled in a Medicaid MCO or PCCM; and the average cost of covering these beneficiaries through fee-for-service or through managed care. As a condition of receipt of federal Medicaid funds, states could be required to report this data on a quarterly basis, broken down by category (non-disabled child under 19, disabled individual, aged individual, and non-disabled, non-elderly adult). In addition, MCOs or PCCMs contracting with state Medicaid programs should be required to report to the State Medicaid agencies encounter data with respect to Native American enrollees, including encounter data sufficient to monitor compliance with the early and periodic screening, diagnostic, and treatment (EPSDT) program for children. The State Medicaid agencies, in turn, should make this information (without individual patient identifiers) available to tribes and IHS available on request.

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.

Endnotes

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

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.

Teen Sex, Contraception and Pregnancy

• Fact Sheet: Teen Sex, Contraception and Pregnancy

• Resource List: Covering Mental Health: A Resource Guide for Reporters and Editors

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%

Return to top

Child Health Facts: National and State Profiles of Coverage

Report Chart Pack

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.

• Report

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

^{return to reference}

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

^{return to reference}

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.

Return to top

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:

• An insurance program covering physician, hospital, and other basic health care services for eligible Native Americans, especially families with children;
• A source of revenue for Indian Health Services (IHS) and tribally-operated clinics and hospitals;
• A purchaser of managed care products;
• A source of financial assistance for low-income elderly and disabled Native Americans to meet Medicare premium and cost-sharing obligations; and
• A source of coverage for nursing home care and other long-term care services for frail elderly and disabled Native Americans.

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.

• Mandatory Beneficiary Enrollment in Managed Care. Under the Balanced Budget Act, states have the authority to require most Medicaid beneficiaries to enroll in MCOs or PCCMs. States can only require Native Americans in Medicaid to receive services through an MCO or PCCM if the MCO or PCCM is the IHS, a tribally operated program, or an urban Indian health program. States do not have authority to require Medicaid-eligible Native Americans to enroll in MCOs that are not operated by the IHS, a tribe, or an urban Indian organization. States do have the authority to require such enrollment under “section 1115” demonstration waivers or under “section 1915(b)” program waivers. Native Americans, who are eligible for Medicaid, have the choice of enrolling in any participating, Medicaid MCO operating in their area.
• Capitation Payments under Medicaid Managed Care. The December 1996 MOA does not expressly address payments to MCOs. Presumably, the 100 percent federal matching rate is payable to MCOs or PCCMs operated by the IHS or tribes. This interpretation would be consistent with the clear policy for fee-for-service arrangements.
• Strategic Choices for Native American Health Facilities. Managed care dramatically affects the strategic choices available to Native American health facilities.
  • IHS facilities can establish their own MCO or PCCM and seek to contract with the state to enroll Indian and non-Indian Medicaid beneficiaries; subcontract with a private MCO or PCCM and provide services to the Indian and non-Indian enrollees of that MCO or PCCM; or continue to be reimbursed by Medicaid on a fee-for-service basis and remain unaffiliated with any Medicaid MCO or PCCM.
  • Tribally owned and operated services face similar choices with two important differences. If they are also a Federally Qualified Health Center (FQHC), then they have additional financial protections until 2003. Second, they may be able to assume financial risk, allowing them the option of becoming an MCO.
  • Because urban Indian facilities are historically underfunded and do not benefit from the 100 percent matching rate, they face considerably greater challenges in adapting to the managed care environment. Their most viable option is to attempt to subcontract with an MCO or PCCM although there are no guarantees that this approach will be successful.

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:

• with respect to children, states must at a minimum cover all infants up to age one (and pregnant women) with family incomes at or below 133 percent of the poverty level ($17,729 per year for a family of three in 1997), all children under age six with family income at or below 133 percent of the federal poverty line, and all children under age 14 with family income below 100 percent of the federal poverty line ($13,330 per year for a family of three in 1997). Many states have elected to set higher Medicaid eligibility thresholds for children under regular Medicaid law or under demonstration waivers.
• with respect to elderly and disabled individuals, states must at a minimum cover those individuals receiving benefits under the Supplemental Security Income (SSI) program. The exception to this rule is that states may use eligibility standards that were in effect in 1972 in determining eligibility for elderly or disabled individuals; 11 states have opted to do so.

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.

Return to top

Native Americans and Medicaid: Coverage and Financing IssuesReport Part One Report Two Report Three 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

• The proportion of 15- 19-year-old girls who are sexually active rose from 47% in 1982 to 55% in 1990.
• Fifty-six percent of teenage girls and 73% of teenage boys today have had sexual intercourse by their18th birthday. In the early 1970s, 35% of girls and 55% of boys had had sex by that age.
• Most very young teenage boys and girls have not had intercourse — 84% of 13-year-olds, 77% of 14-year-olds and 70% of 15-year-olds.
• While the likelihood of having intercourse increases steadily with age, 1 in 5 teenagers do not have intercourse during their teenage years.
• Seven in 10 girls who had sex before age 14 and 6 in 10 of those who had sex before age 15 report having sex involuntarily.
• Most teenagers begin having intercourse in their mid-to-late teens, about 8 years before they marry.
• Among the most common reasons teens have sex, according to 55% of teens, is that “they think they’re ready.”
• Six out of ten teenage girls say another reason why teen girls may have sex is because a boyfriend is pressuring them.

Contraceptive Use

• Five out of ten (48%) teens say they use birth control “all the time,” an additional 24% say they use it “most of the time,” and 15% say they use it “sometimes.” Only 11% of sexually active teens say they never use birth control, approximately the same percentage as sexually active adults who don’t.
• The contraceptive most frequently used by teens is the condom (44%), followed by birth control pills (40%). One-quarter of the teenagers who use the pill also use the condom.
• Two-thirds of teenagers use some contraceptive method — usually a condom — the first time they have intercourse.
• Teenage girls’ birth control use at first intercourse rose from 48% to 65% during the 1980s, almost entirely because of a doubling in condom use (from 23% to 48%).
• A sexually active teenage girl using no contraception over one year has a 90% chance of becoming pregnant.

Sexually Transmitted Diseases (STDs)

• Three million teenagers — about 1 in 4 sexually experienced teenagers — acquire an STD every year.
• In a single act of unprotected sex with an infected partner, a woman has a 1% risk of acquiring HIV, a 30% risk of getting genital herpes, and a 50% chance of contracting gonorrhea.
• Chlamydia is more common among teenagers than among older men and women; in some studies, up to 30% of sexually active teenage girls and 10% of teenage boys tested for STDs have been found to have chlamydia.
• Teenagers have higher rates of gonorrhea than sexually active men and women aged 20-44. In some studies, up to 15% of sexually active teenage girls have been found to be infected with HPV, the virus that causes genital warts, many with a strain of this virus linked with cervical cancer.
• By the end of 1995, there were more than 2,300 teenagers known to have AIDS.
• Teens are worried about getting AIDS or other STDs. Four out of ten teens say they worry at least some about getting AIDS someday or another STD.

Teenage Pregnancy

• About one million teenage girls — 11% of all girls aged 15-19 (112 per 1,000) and 20% of those who have had sexual intercourse (204 per 1,000) — become pregnant each year.
• Eighty-five percent of teenage pregnancies are unplanned, accounting for one-quarter of all unplanned pregnancies each year.
• Fifty-four percent of teenage pregnancies each year (960,000 in 1992) end in birth (most of which are unplanned); about one-third end in abortion (32%) and the rest in miscarriage (14%).
• Among sexually experienced teenagers, about 16% of 14-year-olds, 17% of 15- 17-year-olds and 23% of 18- 19-year-olds become pregnant each year.
• Teenage pregnancy rates are much higher in the United States than in many other developed countries — twice as high as in England and Wales, France and Canada; and 9 times as high as in the Netherlands or Japan.
• Of all births to U.S. women, 13% are to teenagers.
• Twenty percent of U.S. abortions each year are to teenagers.
• A majority of teens (55%) say when teens have unplanned pregnancies, it’s “often” a result of having sex when drunk or on drugs. Forty-six percent say it’s “often” because teens have sex when they don’t have birth control with them.

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:

• Following a summit of soap opera producers and writers which highlighted the lack of portrayals of the consequences of sexual behavior on soap operas two years ago, three top-rated daytime dramas, “General Hospital,” “One Life to Live,” and “The Bold and the Beautiful,” adopted story lines on teen pregnancy and HIV/AIDS (Olson, 1994).

• MEE (Motivational Educational Entertainment) Productions produced an educational video targeted at inner city youth “at risk” of dropping out of school. The program uses high profile rap artists including KRS One, Public Enemy, and Black Sheep, along with interviews with teens, to encourage youth to stay in school and graduate.
• “ER,” a popular Prime Time drama, has focused several episodes on issues related to teen sexuality and reproductive health. One episode dealt with a 14 year old girl who had a positive pregnancy test and didn’t want her mother to know the results. Another episode showed “Dr. Ross” awkwardly dealing with a gay high school athlete.

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.