mmpc - National Indian Health Board

Summary
T
he Indian Health Service (IHS) provides only part of the health care needed by the American Indians and
Alaska Natives (AIAN) who rely on the IHS health care system because of the limited funding
appropriated to the agency by the federal budget. The largest alternate resource to IHS for the health
care funding of AIAN who rely on the IHS health care system is Medicaid. Medicaid pays for care received
not only at the IHS and tribally operated health care facilities, but from other providers when specialized or
emergency care is needed. The federal Medicaid program pays 100% of state Medicaid claims from IHS health
care system providers for IHS funded services provided to AIAN (IHS Program claims). Together with its
companion program, the Children’s Health Insurance Program (CHIP), Medicaid has grown to provide a
substantial but largely unknown fraction of the coverage of health care for the AIAN who use the IHS system.
The first objective of this report to determine whether Medicaid (including the Medicaid portion of CHIP not
operated by states alone) pays as much for the personal health care services of AIAN who rely on the IHS system
of health care providers (IHS AIAN) as it does for other Medicaid recipients. If the per capita amounts paid for
the IHS AIAN are comparable to those of others, then a basic measure of health care equity for AIAN served by
the IHS system has been achieved. If not then efforts are needed to achieve equity.
A second objective is to determine whether there are any Areas of the IHS health care delivery system, or
subgroups of AIAN who rely on the IHS system that do not have Medicaid payment levels as high as those of
other AIAN subgroups served by the IHS System. Where the payment levels for IHS AIAN are not as high as
those of others in an Area, it can be because IHS AIAN have more difficulties obtaining Medicaid paid care, or
because the state and IHS system provider need to work more closely to see that Medicaid claims are filed and
paid successfully. If IHS system providers do not file and collect claims for services provided to Medicaid
enrolled AIAN they serve, they are in effect substituting IHS funding for Medicaid funding of health care costs. In
this report, analyzing only the Medicaid data of the counties of the IHS Areas allows comparison of payments
across IHS Areas and using Medicaid data that has been linked with IHS registry data allows examination of
AIAN subgroups served by the IHS System.
A third objective of this report is to determine what fraction of the personal health care costs of the AIAN user
population of the IHS system is actually provided by Medicaid payments. The IHS has current data on the
Medicaid collections of the IHS and tribal facilities that they operate, but not the tribal facilities operated by
tribes. About one-third of the IHS system facilities are tribally-operated facilities. The IHS estimates that about
25% of the per capita costs of health care needed by AIAN they serve is paid by third-parties including Medicaid,
Medicare and private insurance. The AIAN survey data on which this calculation is based is now more than 20
years old, however. Medicaid payment data provides a way to update the Medicaid portion of the third-party
payment fraction. In addition it offers a way to estimate how much this Medicaid fraction varies across IHS
Areas. Determination of the fraction is critical because the IHS estimates that it provides only about 54% of the
per capita costs of health care needed by AIAN they serve. The extent to which the 25% fraction is too high,
underestimates the remaining unmet health care need of the AIAN, the extent to which the 25% fraction is too
low overestimates the unmet health care need. The IHS allocates new federal funds it receives to the IHS and
tribally-operated facilities based on its calculated estimates of the unmet health care need of the AIAN served by
the facilities.
To achieve the first two objectives, after excluding longterm care and institutionalized Medicaid recipients the
per capita payments for six different types of Medicaid recipients of the remaining medical, behavioral health