History of the Medicare and Medicaid provisions of the Indian Health Care Improvement Act Centers for Medicare & Medicaid Services – Aberdeen Area Training August 29 – 30, 2007
House Report 94-1026, April 9, 1976 • The House Committee on Interior and Insular Affairs published a report to accompany the IHCIA bill that was eventually enacted into law on October 1, 1976. • The report provides a brief history of Indian health but more importantly includes an explanation of the provisions in the bill and Congressional intent.
House Report 94-1026 • “The most basic human right must be the right to enjoy decent health. Certainly, any effort to fulfill Federal responsibilities to the Indian people must begin with the provision of health services. In fact, health services must be the cornerstone upon which rest all other Federal programs for the benefit of Indians.”
House Report 94-1026 • The House Committee recognized that the responsibility to provide health stems from treaty rights: • “In the early history of our country, the only Federal health services available to Indians were those provided by military physicians assigned to frontier forts and reservations . . . to fulfill treaty promises”
Federal responsibility to provide health care based on treaties • The Federal government entered into close to 400 treaties with Indian Tribes between 1778 and 1871. • Indian Tribes exchanged over 400 million acres of land to the U.S. Government. • Many of the treaties contain provisions which explicitly include promises to provide health care.
Treaty with the Winnebago, September 15, 1832 And the United States further agree to make to the said nation of Winnebago Indians…for the services and attendance of a physician at Prairie du Chien, and of one at Fort Winnebago, each, two hundred dollars per annum.
Treaty with the Oto and Missouri, March 15, 1854, and with the Omaha, March 16, 1864 All which several sums of money shall be paid to the said confederate tribes…for medical purposes [among others].
Agencies responsibility for health care • 1803- Office of Indian Affairs in the War Department. • 1849-Department of the Interior, where office eventually renamed Bureau of Indian Affairs • 1954 - Indian Health Service within the Public Health Service, now within the Dept. of Health and Human Services
Legislation Assigning Federal Responsibility for Health Care Snyder Act of 1921 • First time Congress formulated broad Indian health policy: “direct, supervise and expend such moneys as Congress may from time to time appropriate for the benefit, care and assistance of the Indians…for relief of distress and conservation of health.”
Indian Health Care Improvement Act of 1976 – beyond Snyder • The IHCIA, along with the Snyder Act, serves as the statutory foundation of the government’s responsibilility to provide health care. • The IHCIA clearly acknowledged the legal and moral responsibility for providing the “highest possible health status to Indians…with all the resources necessary to effect that policy.”
“I am signing S. 522, the Indian Health Care Improvement Act. This bill is not without faults, but after personal review I have decided that the well-documented needs for improvement in Indian health manpower, services, and facilities outweigh the defects in the bill. While spending for Indian Health Service activities has grown from $128 million in FY 1970 to $425 million in FY 1977, Indian people still lag behind the American people as a whole in achieving and maintaining good health. I am signing this bill because of my own conviction that our first Americans should not be last in opportunity.” --President Ford’s written statement upon signing the IHCIA, 1976
Health Disparities in 1976 vs. 2006 • Incidence of tuberculosis for AI/ANs is 7.3 times higher than U.S. general population. • In 2006, AI/ANs are 6.5 times more likely to die from tuberculosis. • In 1976, the Report noted prevalence of disease contributes to problems of mental illness, alcoholism, accidents, homicide and suicide. • In 2006, compared to the general populations, AI/ANs are:7.7 times more likely to die from alcoholism; 2.5 times more likely to die from suicide; 2.8 times more likely to die from accidents
Indian health expenditures per capita for general population • In 1976, per capita expenditures for Indian health were 25 percent below capita expenditures for general population. • In 2005, per capita expenditures for Indian health are less than 40% below capital expenditures for the general population.
2005 IHS Expenditures Per Capita Compared to other Federal Health Expenditure Benchmarks $847 Growth Through 2005 $735 $581 $682 $6784 $743 $923 IHS Medical $5670 $4653 $4328 $3842 $2980 $2130 Non-Medical $498 Medicare, 2002 National Health Expenditures, 2003 Medicaid, 2002 FEHB Medical Benchmark, 1999 2005 IHS Expenditures Med. for Fed. Prisons, 1999 Veterans Admin., 2002
House report addresses lack of access of Indians in SSA programs • “The greater incidence of disease . . . is further compounded by the fact that many of our national health programs, designed to assist the general population, are difficult or impossible to apply to Indians. Medicare, Medicaid and social security programs afford little relief.”
House Report addresses lack of access of AI/AN to Medicare and Medicaid programs • “Since most Indians reside on remote reservations, access to services supported by either Medicare or Medicaid is severely limited. In most cases, the only available health delivery system is that of the Indian Health Service, yet the IHS, as a Federal facility, cannot, under existing law, receive payments from Medicare or reimbursements for services provided under Medicaid.”
IHCIA provided the necessary funds and authorities to improve AI/AN access • By enacting title IV of the IHCIA, Congress addressed the problem of access by providing authority to Indian health hospitals to receive reimbursement for services rendered to Medicare and Medicaid patients. • Section 401 provides authority for reimbursement for Medicare services provided in hospitals and skilled nursing facilities. • Section 402 provides authority for reimbursement for Medicaid services.
Federal government, not States, primarily responsible for health care • Section 402 provides 100% Federal matching funds for services provided to any Indian in an IHS facility. • In providing for 100% Federal match, the Committee noted that it would be unfair and inequitable to burden a State Medicaid program with costs, primarily the responsibility of the Federal government.
Medicare & Medicaid reimbursements to meet accreditation standards • The Committee required that the Medicare and Medicaid revenues be used for meeting standards and conditions of participation in Medicare and Medicaid. • A special fund was created to track the reimbursements and by law, 80% of the reimbursements are forwarded to the local service units to meet accreditation standards. • In 2004, this provision was amended to make permanent the direct billing authority for Tribes operating programs in IHS facilities. • Under this authority, Tribes are able to bill and receive reimbursements directly without having to go through the “special fund.”
Creation of the All inclusive rate • The Committee also intended that the IHS cooperate with the Medicare and Medicaid programs in providing the cost data for calculating reimbursements. • Based on this language, the “All-inclusive rate” or OMB rate was developed based on cost reports developed by the IHS, in collaboration with CMS, and approved by OMB, and are currently published on an annual basis in the Federal Register.
M/M reimbursement are to supplement not supplant IHS appropriations • The Committee intended that any Medicare and Medicaid funds received by the IHS program be used to supplement – and not supplant – current IHS appropriations. • The Committee firmly expected that funds from Medicare and Medicaid will be used to expand and improve current services and to not substitute for present expenditures.
House Committee on use of Medicare and Medicaid reimbursements • The Committee intended the Department to report annually on the use of additional funds available to IHS because of the Medicare and Medicaid reimbursements. • In 2006, the IHS reported $625 million in revenues -- represent almost 25% of the IHS operating budget of a $4.1 billion budget. • In direct contradiction to Congressional intent, the revenues are factored in formulating the Administration’s annual budget justification.
SSA amendments in IHCIA reauthorization • If enacted, the provisions in the IHCIA reauthorization bills will expand on current Medicare and Medicaid authorities. • Reimbursement for Medicare and Medicaid services will not be restricted only to services provided in a facility. • I/T/Us will be provided greater flexibility to participate in any Medicaid managed care plans established by the State.
IHCIA reauthorization provisions eliminate barriers to participation • Many of the provisions in title IV will eliminate barriers to participation in Medicaid: • AI/ANs who utilize the Indian health system, will be exempt from cost sharing requirements under Medicaid and SCHIP. • Indian trust property will be exempt from consideration of Medicaid eligibility criteria and exempt from Medicaid estate recovery rules. • Tribal enrollment cards will serve as sufficient proof of documentation of U.S. citizenship for Medicaid eligibility purposes.
Over 30 years ago, in signing the IHCIA into law, President Ford went against veto advice from his administration in HHS, OMB and opposition from his own party in Congress.
IHCIA in this 110th Congress • On September 12th, the Senate Finance Committee is expected to mark up S.1200, the Senate IHCIA reauthorization bill. • The Finance Committee has jurisdiction over the Medicare, Medicaid and SCHIP provisions. • Once the Finance Committee reports out the bill, it can be brought to the Senate Floor for a vote. • The House Committee on Energy & Commerce is expected to mark up the bill in September.
For more information, please contact: Kitty Marx, Legislative Director, National Indian Health Board firstname.lastname@example.org