mmpc - National Indian Health Board

Introduction
The Indian Health Service (IHS) provides only part of the health care needed by the AIAN who rely on the IHS
health care system because of the limited funding appropriated to the agency by the federal budget process.
Funding of the agency has grown in recent years but has not caught up with the growth of the low income AIAN
population, the amount or kinds of specialized care needed, and the increases in health care costs. The IHS
estimates that they provide only 54% of the health care funds needed for the AIAN user population.
The largest and most important alternate resource to IHS for the health care funding of AIAN who rely on the
IHS system is Medicaid. 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 user population of the IHS system. Though the numbers of the user population enrolled in Medicaid and
CHIP has grown substantially over the years, it has been a challenge for IHS and tribally operated health care
facilities accustomed to annual appropriations of federal funds to bill and collect daily claims payments from
state Medicaid programs or private Medicaid managed care plans. Even with Medicaid coverage, it can also be a
challenge for AIAN to obtain the specialty medical care and non-medical services they need from providers
outside the IHS system when they are required.
There has been little reliable data on how much Medicaid funding has grown to cover care the Medicaid enrolled
user population of the IHS system of providers since a household survey of AIAN who rely on the IHS system
was conducted in 1987. While the IHS releases its estimates of total funds gathered from third-parties annually
for the facilities they operate, it is not known how this compares to what is collected at tribally operated
facilities, nor how it breaks down on a per capita basis.
We previously analyzed Medicaid MSIS online data for 2005 on paid claims to IHS system providers on a stateby-state
basis for 2005 (Crouch et al, 2009). That aggregate data could not be used to determine the per capita
funding, or portions of funds spent on IHS system and other providers. The data within states was often from
more than one IHS Area. We then analyzed data extracted from the MSIS data into analytical files for 2004 and
provided estimates of per capita payments for AIAN who had Medicaid (or Medicaid-CHIP) IHS Program claims
in each IHS Area (Crouch et al, 2010). This data could also be compared to per capita payments for AIAN who did
not have such claims and were likely not to have access to the IHS system. It could also be compared to per
capita payments for non-Hispanic Whites living in the same counties. But it could not be determined what the
total number of AIAN Medicaid enrollees who were users of the IHS system. The extent to which there were
AIAN users of the IHS system without Medicaid IHS Program claims paid was an important factor in
determining the potential amounts of funds that IHS system providers might not be collecting.
The data needed to reliably estimate what Medicaid (and Medicaid-CHIP) contribute to cover the health care
costs of AIAN who are users of the IHS system is Medicaid payment data linked to IHS registry data. With such
linked data it is possible to determine how per capita levels of payment for AIAN in the IHS system compare
with those for AIAN not in the system, and to what extent AIAN in the IHS system with Medicaid paid claims do
not have Medicaid IHS Program paid claims. Even more importantly, with Medicaid data linked to IHS registry
data it is possible to determine the fraction of total health care costs of the AIAN user population in the IHS
system is paid by Medicaid and Medicaid-CHIP programs.
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