Impact Analysis Based on Estimates from the 2014 1-Year American Community Survey: Released September 17, 2015.
2015
Prepared for Delivery at the National Indian Health Board Annual Consumer Conference, September 23, 2015
1-year 2014 American Community Survey, September 17, 2015
Prepared for Delivery at the National Indian Health Board Annual Consumer Conference, September 23, 2015 2
1-year 2014 American Community Survey, September 17, 2015 2
2014 Health Insurance Coverage of American Indians and Alaska Natives 3
2014 US HEALTH INSURANCE COVERAGE Compared to 2013 3
Uninsured AIANs 2011, 2012, 2013, 2014 and reduction 2013-2014 and 2011-2014 4
Ranking by Largest Percentage decrease in number of uninsured American Indians and Alaska Natives 2013 to 2014*** 5
Uninsured AIANs 2013 Compared to 2012 5
Urban Indians in 9 Large Metropolitan Areas 7
Rate of Uninsured AIANs in Largest Urban Indian Metropolitan Areas 2012 and 2014 7
IHS and Uninsured AIANs 8
Summary and Conclusion 9
Research note: 10
Ed Fox
Director, Health Services
Port Gamble S’Klallam Tribe
360 790-1164
The American Community Survey, conducted by the US Census Bureau, has become the most reliable source of information about income and insurance for the nation’s American Indians and Alaska Natives[1]. Annual releases include 1-year estimates of the previous year’s survey and 3-year and 5-year estimates that allow lower error rates and thus reporting on smaller entities and populations. Only 18 of the 33 states with tribes had AIANs in large enough numbers (65,000) to be included in the 1-year estimate for 2014 survey data. The 1-year estimates do not allow reporting for 15 states like Wyoming or Idaho that have Federally recognized Tribes.
This Brief provides a report on the findings of a preliminary analysis of the September 17, 2015 release of 1-year 2014 estimates from the American Community Survey. It also provides a brief and necessarily tentative analysis for all 18 states in the one-year survey. The analyses for more metropolitan areas and counties will have to wait for the release of five-year data December 10, 2015.[2] The analysis presented here refers to previous one and three-year ACS estimates to put this year’s enrollment gains into proper perspective.
2014 Health Insurance Coverage of American Indians and Alaska Natives
In 2014 the number of uninsured AIANs totaled 955,000, 150,000 fewer than 2013 and 190,000 lower than 2011. The rate of uninsured dropped 3.4% from 21.6% to 18.2%. This compares to a 2.9% drop of the all races rate from 13.3% in 2013 to 10.4% in 2014.[3] The AIAN decline in number uninsured was 16% compared to the all races decline of 22%.
2014 US HEALTH INSURANCE COVERAGE Compared to 2013
2014 / 2013Uninsured AIANs / 955,867 / 1,105,523
Civilian non-institutionalized population / 5,252,019 / 5,118,164
With private health insurance / 49.80% / 48.20%
With public coverage / 40.60% / 38.80%
No health insurance coverage / 18.20% / 21.60%
The impact of the ACA varied greatly between states with some, like Colorado, Washington and Oregon, reducing the number of uninsured AIANs by over 25% to others, like Alaska, seeing no change in the number of uninsured.
The primary factor that explains the wide variation is, not surprisingly, whether or not a state expanded its Medicaid program in 2014.[4]
Uninsured AIANs 2011, 2012, 2013, 2014 and reduction 2013-2014 and 2011-2014
In addition to the one-year change (2013-2014) after the full roll out of the ACA, it is also significant to recognize and examine the change from early expansion of Medicaid. Since these expansions are also part of the ACA the better measure of the success of the ACA is to look at the change in enrollment from 2011 and 2014. The following table shows the greatest decrease in the uninsured in Colorado at a 37% increase. Minnesota, New Mexico, and Oregon all had decreases of over 25%. States with increases of less than 10% included both expansion states, like Washington and Arizona, and non-expansion states like Alaska, Oklahoma, South Dakota and Wisconsin. Washington may have an error in reporting for 2011 as the pattern does not follow the pattern seen in other states. A research note at this end of this brief compares these one-year estimates to three-year ACS estimates (page 8).
Ranking by Largest Percentage decrease in number of uninsured American Indians and Alaska Natives 2013 to 2014***
Uninsured AIANs 2013 Compared to 2012
Evidence of the early expansion can be seen by comparing 2012 with 2013 enrollment. The following table shows modest, but significant increases in some states and a loss of insurance in others.
Oregon signed up 56,000 to its Medicaid program in the first two weeks of October 2013, lowering the state’s uninsurance rate by 10%.[5] This is largely due to automatically enrolling Basic Food recipients in Medicaid. This early success makes the 2013 to 2014 increase understated for Oregon. Arizona also increased its AIAN Medicaid enrollment by over 9% thanks to an uncompensated care waiver that restored some of the enrollment lost in previous years’ Medicaid cutbacks.
Urban Indians in 9 Large Metropolitan Areas
There is limited information regarding Urban Indians in the September 17, 2015 release of data, but what information there is shows a wide variation between nine metropolitan areas. The number of uninsured is in decline (above chart), but the uninsurance rate is staggeringly high in nearly every metro area (chart below).
Rate of Uninsured AIANs in Largest Urban Indian Metropolitan Areas 2012 and 2014
Metropolitan Area / 2012 / 2014 / 12-14 change / % reductionDallas Fort Worth / 22.00% / 18.10% / -3.90% / -18%
Los Angeles-Long Beach-Santa Ana, CA Metro Area / 19.20% / 17.00% / -2.20% / -11%
New York-Northern New Jersey-Long Island / 18.20% / 13.80% / -4.40% / -24%
Oklahoma City, OK Metro Area / 24.80% / 19.10% / -5.70% / -23%
Phoenix-Mesa-Glendale, AZ Metro Area / 27.80% / 25.20% / -2.60% / -9%
Riverside-San Bernardino-Ontario, CA Metro Area / 24.00% / 16.70% / -7.30% / -30%
San Francisco / 17.10% / 8.40% / -8.70% / -51%
Seattle-Tacoma-Bellevue, WA Metro Area / 22.70% / 15.90% / -6.80% / -30%
Tulsa, OK Metro Area / 24.30% / 22.80% / -1.50% / -6%
Diverse cities such as San Francisco, Oklahoma City, Seattle, and Riverside and San Bernardino, California increased enrollment and reduced the number of insured by over 20%. All of the other metro areas were less than a 10% increase and 2 had a real decline in the number insured. Unlike states variation, the variation in enrollment success does not directly vary with whether or not the metro area is in an expansion state. Some California cities did not enjoy enrollment gains (or reductions in number of uninsured) and some did. Likewise for Oklahoma’s two metro areas; since California expanded Medicaid and Oklahoma did not there is clearly more than Medicaid expansion that explains the variation.
IHS and Uninsured AIANs
The American Community Survey contains one ‘coverage’ question that asks if the respondent feels they have access to Indian Health Service. The table below ranks states by the percentage of the uninsured AIANs who have access to IHS. Seven states: Alaska, South and North Dakota, Montana, New Mexico, Oklahoma, and Arizona all have an estimated 70% or higher percentage of their uninsured reporting access to IHS. Eleven states have between 30% and 56% of their population reporting they have access to IHS; including one, Arkansas that has no Indian Health Service programs in the state.
Summary and Conclusion
There is both evidence of success and lack of success in the goal of the ACA to reduce the number of uninsured American Indians and Alaska Natives in the recent ACS release of estimates of insurance of AIANs. Not all states had reports, but of those 18 that did it is clear that Medicaid Expansion is key to lowering the number of uninsured. Some states had significant reductions, but many others did not. Urban Indians living in metropolitan areas did not follow the same pattern with some metro areas in the same state-increasing enrollment by over 20% and some showing little gain in enrollment. Further analysis of insurance coverage will be possible with the release of ACS 5-year data. It is likely that an analysis of the variation between states and metro areas can point to the need to share best practices and provide greater support to reduce these wide variations in insurance coverage gains. Support in some states will be mainly to Tribes, but in many others to non-tribal efforts to reach the uninsured. Support for Medicaid expansion is the most critical need, but so too is support for whatever proved successful in those states with the greatest gains.
Ed Fox, Director, Health Services Department
Port Gamble S’Klallam Tribe
Updated tables at: http:// www.edfoxphd.com/ACS-2015-Release-of-2014-estimates.html .
Research note:
2014 Medicaid Claims Datafor Washington State Medicaid
The State of Washington paid about $114 million for AIANs Medicaid health care services in 2014. $62 million was paid directly to Tribal and IHS programs. $50 million was paid to outside providers and for Medicaid eligible services.
Source: WA Health Care Authority, September 2015 Data Pull of 2014 payments/claims matching Provider ID for those served in IHS-funded programs to payments for those same patients outside IHS funded-programs. Note: Preliminary Data.
Claim type / IHS & Tribal / Urban / All Other / TotalProfessional / $ 50,512,587 / $ 497,818 / $ 14,968,180 / $ 65,978,586
Pharmacy / $ 4,236,317 / $ 35,855 / $ 8,056,619 / $ 12,328,792
Outpatient Hospital / $ - / $ - / $ 11,406,833 / $ 11,406,833
Inpatient Hospital / $ - / $ - / $ 9,739,738 / $ 9,739,738
Dental / $ 6,471,508 / $ 30,207 / $ 2,043,986 / $ 8,545,703
DME, Non-DME, & Supplies / $ 156,960 / $ - / $ 1,748,758 / $ 1,905,718
EPSDT / $ 1,088,228 / $ 3,782 / $ 273,473 / $ 1,365,484
Nursing Facility / $ 154,855 / $ - / $ 1,107,253 / $ 1,262,108
Medicare Part B Crossover / $ 312,347 / $ - / $ 132,384 / $ 444,732
Ambulatory Surgical Center / $ - / $ - / $ 250,050 / $ 250,050
Medicare Part A Crossover / $ - / $ 179 / $ 226,105 / $ 226,284
Kidney Center / $ - / $ - / $ 201,990 / $ 201,990
Home Health / $ - / $ - / $ 76,685 / $ 76,685
Hospice / $ - / $ - / $ 59,457 / $ 59,457
Total / $ 62,932,802 / $ 567,841 / $ 50,291,511 / $ 113,792,160
Washington state estimates using 3-year ACS survey estimates show the greater reliability of three-year estimates over the one-year estimate reported in this brief. The December 10, 2015 release of 5-year US Census data will allow the reporting of more reliable data for 2014 (3-year estimates now replaced by 5- year estimates).
Washington State AIAN rate and population uninsured 2010,2011, 2012, 2013: source 3-year ACS surveyAIAN pop / % Uninsured / Number Uninsured
2013 / 197,933 / 22% / 42,556
2012 / 193,327 / 21% / 40,599
2011 / 189,107 / 21% / 38,767
2010 / 187,367 / 21% / 39,909
Compare / ACS 3-yr / Vs. 1 year
2014 / n/a / 33,401
2013 / 42,556 / 47,187
2012 / 40,599 / 43,918
2011 / 38,767 / 35,949
2010 / 39,909 / n/a
1
[1] Unlike most US Census and State reports, this brief does not report the number of ‘single race’ AIAN ‘alone’ population that has little meaning for an analysis of the impact of the ACA on AIANs. It reports on AIAN ‘alone and in combination.’
[2] See http://www.census.gov/programs-surveys/acs/ for schedule of releases.
[3] Health Insurance Coverage in the United States: 2014, US Census, September 2015.
[4] For listing of states that have or are planning to expand Medicaid see http://www.commonwealthfund.org/interactives-and-data/maps-and-data/medicaid-expansion-map .
[5] http://www.washingtonpost.com/news/wonkblog/wp/2013/10/17/obamacare-just-cut-oregons-uninsured-rate-by-10-percent/ .