Behavioral Health and Tribal Communities

2. Behavioral Health and Tribal Communities Sheila K. Cooper Senior Advisor for Tribal Affairs National Indian Health Board Tribal Health Reform Implementation Summit Washington, DC • April 20, 2011

3. SAMHSA  LEADING CHANGE 3 • Mission: To reduce the impact of substance abuse and mental illness on America’s communities • Roles: • Leadership and Voice • Funding - Service Capacity Development • Information/Communications • Regulation and Standard setting • Practice Improvement • Leading Change - 8 Strategic Initiatives • Tribes, Tribal Communities and AI/ANs

4. HHS STRATEGIC PLANS  SAMHSA STRATEGIC INITIATIVES AIM: Improving the Nation’s Behavioral Health 1 Prevention 2 Trauma and Justice 3 Military Families 4 Recovery Support AIM: Transforming Health Care in America 5 Health Reform 6 Health Information Technology AIM: Achieving Excellence in Operations 7 Data, Outcomes & Quality 8 Public Awareness & Support 4

5. HEALTH REFORM “But if we're going to bring real and lasting change for Native Americans, we need a comprehensive strategy, as I said before.  Part of that strategy is health care.  We know that as long as Native Americans die of illnesses like tuberculosis, alcoholism, diabetes, pneumonia, and influenza at far higher rates than the rest of the population, then we're going to have to do more to address disparities in health care delivery.” 5 ­President Obama

6. HEALTH REFORM IMPACT OF AFFORDABLE CARE ACT More people will have insurance coverage ↑Demand for qualified and well-trained BH professionals Medicaid will play a bigger role in M/SUDs Focus on primary care & coordination with specialty care Major emphasis on home & community-based services; less reliance on institutional care Theme: preventing diseases & promoting wellness Focus on quality rather than quantity of care 6

7. Targeted Provisions in Health Care Reform Culturally and linguistically appropriate explanations of coverage that are clear and transparent Maternal, Infant, and Early Childhood Home Visiting Programs targeted to reduce health disparities in at-risk communities – includes a Tribal set-aside School-based health centers to serve medically underserved children Healthier Community Grants focus on reducing disparities and addressing needs of inadequately served communities and populations 7

8. Specific to AI/AN Individual Mandate Exchanges Medicare Part D Drug Benefit • Members of AI/AN Tribes exempt from the penalties if an individual does not have health insurance coverage; may formally waive the individual mandate requirement • When gaining coverage from state exchange. AI/AN under 300% of FPL do not have co-pays or deductibles (2010: fam 4: $66,000 or $83,000 AN) • Exchanges must provide special monthly enrollment periods for AI/AN • Services from IHS or Tribe/Tribal Org/ Urban Indian Org (T/TO/UIO) do not reduce payments by state exchange plans • Tribe/Tribal Org/ Urban Indian Org (T/TO/UIO) program spending and AIDS Drug Assistance Program spending to count towards out of pocket “Donut Hole” individual spending to meets annual out of pocket threshold (1/11)

9. Specific to AI/AN: Provider Medicaid “express lane” enrollment Medicare Part B Outpatient Payer of Last Resort Education & Outreach on Prevention ACA early visitation moms and kids ACA adolescent abstinence and contraception • Medicaid changes to “assume” Medicaid eligibility if in certain programs or by hospitals is extended IHS and Indian, Tribal and Urban Indian facilities (I/T/U) • Permanently requires Medicare reimbursement for all services furnished by IHS hospitals and clinics • Services by I/T/U providers are payers of last resort ; all other public and private payers must pay first • Indian health providers can receive information disseminated on prevention services and health promotion outreach and education • Sets 3 % set aside funding for I/T/U, tribes preferred • A 5% set aside of $65 million/year for grants to T/TO

10. SAMHSA STRATEGIC INITIATIVEHEALTH REFORM Ensure BH included in all aspects of health reform Support Federal, State, Territorial, and Tribal efforts to develop and implement new provisions under Medicaid and Medicare Finalize/implement parity provisions in MHPAEA and ACA Develop changes in SAMHSA Block Grants to support recovery and resilience and ↑accountability Foster integration of primary and behavioral health care 10

11. 25 percent of American Indians/Alaska Natives live at poverty level 2006: 36 percent of American Indians/Alaska Natives had private health insurance coverage, and 24 percent relied on Medicaid coverage 2007: 33 percent had no health insurance coverage HEALTH REFORM  CHALLENGES 11

12. Percent of persons 12 or older who met criteria for substance abuse or dependence by race/ethnicity: 2009 12 Percent with substance abuse or dependence * *Low precision; no estimate reported Source: 2009 NSDUH

13. Percent of persons 18 or older who met criteria for any mental illness by race/ethnicity: 2009 13 Percent with any mental illness in past year Source: 2009 NSDUH

14. CHANGE IN THE MAKING Self-determination approaches Promising partnership between Tribes and Federal Government Tribal Law and Order Act (TLOA) Affordable Care Act/Health Reform (including Indian Health Care Improvement Act) 14

15. CONTEXT FOR CHANGE Health Reform 15

17. SAMHSA $ & Resources in 2014 Currently 2/3 of SAMHSA’s budget goes to State Block Grants. • Mental Health BG • Substance Abuse Prevention & Treatment BG The question we need to ask is what will SAMHSA $ buy in 2014?

18. Proposed Block Grant Changes Responding to a Changing Environment • Health Reform and Parity • Coordination with primary care • Prevention • CMS and State Medicaid Programs • Strategic Initiatives

19. Proposed Block Grant Changes • Impact on State Authorities • States will play an important role in design and implementation of HR • States should be more strategic in purchasing services • States will need to think more broadly than the populations they serve through BG • States will need to design/collaboratively plan for health information systems

20. Proposed Block Grant Changes • Will need to form or enhance their strategic partnerships • Will need to focus more on recovery services • Redesign their systems to be more accountable for improving the experience of care and for the health of their population

21. Proposed Block Grant Changes • Assessment and Plan Section (MHBG and SAPTBG) • Framework—population based planning (required and new groups) • Planning Steps: • Assessment of systems strengths and needs • Gaps analysis • Prioritizing planning activities • Developing objectives, strategies and performance indicators

22. Proposed Block Grant Changes • Other Areas • How do they pay for services • What do they spend their BG dollars on? • Supports to Individuals to Direct Their Services • Data and information technology • Quality improvement • Consultation with Tribes • Service management strategies

23. Proposed Block Grant Changes • State Dashboards and Incentives • Suicide Prevention • TA Needs • Involvement of Individuals and families • Use of technology • Support of State Partners • BH Advisory Council • Planning requirements now in funding agreements and assurances

24. FRN – SAMHSA Block GrantFY 2012 -2013 Application Federal Register Notice – published April 11. 2011 http://edocket.access.gpo.gov/2011/pdf/2011-8520.pdf Send comments to Summer King summer.king@samhsa.hhs.gov

25. PROPOSED FOR FY 2012: BEHAVIORAL HEALTH – TRIBAL PREVENTION GRANT (BH-TPG) Proposed new discretionary grant program in the President’s 2012 Budget ($50 million) Authorized from the Prevention and Public Health Fund and appropriated by the Affordable Care Act (ACA) FOCUS ON PREVENTION OF SUBSTANCE ABUSE AND SUICIDE Non-competitive application process; every 3 yrs & annual reporting All federally-recognized tribes eligible to receive funding Formula to be determined after consultation with Tribal leaders Likely a base amount with additional $ depending on population and need SAMHSA will coordinate with IHS to implement community-based prevention strategies that complement the clinical services provided by IHS-funded providers 25

26. BH-TPG FORMULA CONSIDERATIONS Scenario #1 w/base amount of $50,000 At 100 percent request = total base allocation of $28,250,000 Additional $21,750,000 to be distributed (Formula TBD) Scenario # 2 w/base amount of $50,000 At 75 percent request = total base allocation of $21,150,000 Additional $28,850,000 to be distributed (Formula TBD) Scenario #3 w/base amount of $35,000 At 100 percent request = total base allocation of $19,775,000 Additional $30,225,000 to be distributed (Formula TBD) Scenario #4 w/base amount of $35,000 At 75 percent request = total base allocation of $14,805,000 Additional $35,195,000 to be distributed (Formula TBD) 26

27. If less than 100 percent apply do we increase base so base and additional amounts are relatively equal? What criteria should be used for calculating the formula for the non-base portion of the funding? If SAMHSA does not receive full amount requested, how should funding be distributed? BH-TPG FORMULA CONSIDERATIONS 27

28. 2010 SAMHSA HIGHLIGHTS Six 2010 Tribal Govt to Govt Consultation Sessions Themes: address substance abuse & suicide; make funding easier Two 2010 Tribal Justice, Safety, and Wellness (TJSW) Consultation Sessions with DOJ Office of Justice Programs December 2010 with DOJ and BIA/BIE re Tribal Law and Order Act (TLOA) SAMHSA – TTAC Meetings February 2010 & June 2010 - included introductions, overview of new administration, and updates on SAMHSA Strategic Initiatives, consultation topics, and increased access to funding September 2010 – SAMHSA/IHS “Dear Tribal Leader” Clarifying roles and responsibilities with a list of collaboration activities First in a series of updates to Tribes 28

29. Raising Awareness about Behavioral Health in Tribal Communities

30. Direct inquiries to: Sheila K. Cooper Senior Advisor for Tribal Affairs Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, Maryland 20850 sheila.cooper@samhsa.hhs.gov 240.276.2005 SAMHSA Tribal Affairs 30

31. People Stay focused on the goal Tribal people; culturally appropriate approaches Partnership Cannot do it alone Tribal leaders; AI/NA organizations Performance Make a measurable difference Outcomes defined by AI/AN culture www.samhsa.gov SAMHSA PRINCIPLES 31