AMERICAN INDIAN AND ALASKA NATIVE … · A Study on the Affordable Care Act Messaging. ... APTC....

AMERICAN INDIAN AND

ALASKA NATIVE

OUTREACH AND EDUCATIONPresented by:

Kristen BitsuieTribal Healthcare Reform Outreach and Education Program AssociateNational Indian Health Board

Mission Statement: Established by the Tribes to advocate as the united voice of federally recognized American Indian

and Alaska Native Tribes, NIHB seeks to reinforce Tribal sovereignty, strengthen Tribal health systems, secure

resources, and build capacity to achieve the highest level of health and well-being for our People

National Indian Health BoardPurpose: To advocate on behalf of all federally recognized American Indian and Alaska Native Tribes to ensure the

fulfillment of the trust responsibility to deliver health and public health services as assured through treaties, and reaffirmed in

legislation, executive orders and Supreme Court cases.

Lisa Elgin -

Manchester Band of

Pomo Indians

NIHB Secretary and

California Area

lisa.elgin@yahoo.com

Andrew Joseph, Jr. -

Confederated Tribes of the

Colville Reservation

NIHB Member-at-Large &

Portland Area

andy.joseph@colvilletribes.com

Charles Headdress - Fort Peck Assiniboine

and Sioux Tribes Billings Area

ckheaddress@yahoo.com

Victoria Kitcheyan – Winnebago Tribe of

Nebraska

NIHB Vice-Chair & Great Plains Area

tori.kitcheyan@winnebagotribe.com

Sam Moose - Mille Lacs Band of Ojibwe

NIHB Treasurer and Bemidji Area

SamuelMoose@FDLREZ.COM

Beverly Cook - St. Regis

Mohawk Tribe

Nashville Area

beverly.cook@srmt-nsn.gov

Marty Wafford - Chickasaw

Nation

Oklahoma City Area

Marty.Wafford@chickasaw.net

Donnie Garcia - Jicarilla

Apache Nation

Albuquerque Area

docsix@hotmail.comRussell Begaye - Navajo Nation

Navajo Area

russellbegaye@gmail.com

Vinton Hawley - Pyramid Lake

Paiute Tribe

NIHB Chair and Phoenix Area

vhawley@plpt.nsn.us

William Smith Jr. -

Valdez Native Tribe

Alaska Area

imeyak@valdezak.net

Sandra Ortega - Tohono

O'odham Nation

Tucson Area

Sandra.Ortega@tonation-nsn.gov

Board Of Directors

Congressional Relations

Caitrin Shuy cshuy@nihb.org

Center of Indian Health Policy and

ResearchJessica Steinberg

Jsteinberg@nihb.org

Public Health Policy and Programs

Carolyn Hornbucklechornbuckle@nihb.org

Finance and Administration

Sheri Pattersonspatterson@nihb.org

Executive Director

Stacy A. Bohlen

Sbohlen@nihb.org

Area Indian Health Boards

National Indian Health BoardOrganizational Chart

Save the DateNIHB Tribal Public Health Summit May 22-24, 2018

Outreach and Education in AI/AN Communities:

A Study on the Affordable Care Act Messaging

Indian Health Background

▪ What is considered a federally recognized Tribe in the U.S.?

A federally recognized tribe is any Indian or Alaska Native Tribe, band, nation, Pueblo, village, or community that the Department of the Interior (DOI) acknowledge as an Indian Tribe, including Alaska Native regional and village corporations.

▪ How many American Indian and Alaska Natives live in the U.S.?

According to the U.S. census there are 5.2 million people in the U.S. who identify themselves as either American Indian and Alaska Native (AI/AN), either alone or in combination with one or more other races. Approximately 2 million receive services from the Indian Health system.

Indian Health Background▪ Federally recognized Tribes and the federal government have a

historical government-to-government relationship based on The U.S. Constitution, treaties, statutes, Supreme Court cases, and Executive Orders.

▪ As part of this unique relationship and trust responsibility, the federal government provides health care, social services, housing, education, and other services to AI/ANs, through federal agencies such as the Department of Health & Human Services (HHS), Department of the Interior, and the Department of Education.

Definition of AI/AN

▪For purposes of the Marketplace, an AI/AN is limited to members of a federally recognized tribe or ANCSA shareholders.

▪For purposes of Medicaid and CHIP, an AI/AN is a member of a federally recognized Tribe, an Alaska Native Claims Settlement Act (ANCSA) corporation shareholder or any individual eligible to receive services from IHS.

The ACA for Indian Country

▪Permanently reauthorizes the Indian Health Care Improvement Act (IHCIA)

▪Strengthens the Indian Health Service (IHS)

▪Authorizes the expansion of Medicaid in states

▪Enhances third-party revenue

Marketplace Explained

APTC

ACA Timeline • Patient Protection and Affordable Care Act is signed into law

• Indian Health Care Improvement ActMarch 23, 2010

• CMS announces Navigator program funding Opportunity AnnouncementApril 9, 2013

• CMS release notice of funding to Navigator organizationsAugust 15, 2013

• State and Federal Exchange launched

• Healthcare.gov website goes liveOctober 1, 2013

• First Open Enrollment PeriodOctober 1, 2013-March 31, 2014

• Second Open Enrollment Period

• NIHB ACA Study CommencesNovember 1, 2014-February 15, 2015

• Third Open Enrollment PeriodNovember 1, 2015-January 31, 2016

• Fourth Open Enrollment PeriodNovember 1, 2016-January 31, 2017

ACA Positive Impact

Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2017 Website. http://www.edfoxphd.com/

473,000

Purpose of Study

To investigate the effectiveness of activities widely known as outreach and education on the Patient Protection and Affordable Care Act in Tribal communities at a key time in health care reform.

Marketplace Study Design

▪ Participants recruited from large conferences

▪ Used flyers or approached attendees

▪ Groups of 3 or interviews

▪ Transcription used for analysis

▪ Incentivized with door prizes or gift cards

▪ Qualitative versus Quantitative!

Image source: https://www.ihs.gov/foodhandler/images/areas.jpg

CMS/ITU TrainingRapid City, SD

December 2014

NIHB ACA O&E TrainingTucson, AZ

February 2015

ANA Native American Grantees ConferenceSanta Fe, NM

February 2015

-Native American Child & Family Conference-American Indian Higher Education Consortium annual conference

Albuquerque, NMMarch 2015

NIHB Tribal Public Health SummitPalm Springs, CA

April 2015

Tribal Epidemiology Center Tribal Public Health ConferenceTulsa, OK

April 2015

Gender

(More Female) Age

30 - 55

Race (Self Identified)

American IndianAlaska Native

Demographics

Marketplace Study Limitations

•Lack of demographic information

•Lack of consistent questioning from moderators

•Transcript errors

•Qualitative versus Quantitative

Marketplace Study Design Assessing the messaging around the ACA and Marketplace

1. What messages/advertisements/announcements have you heard about signing up for insurance through the Affordable Care Act?

2. Where did you receive this information from?3. What sources/messages do you feel are the most

trustworthy?4. What sources/messages do you feel are the least

trustworthy?5. What suggestions do you have for future messages

regarding insurance enrollment?

Results Commercials No

communication or

advertisement seen

Newspaper

Newsletters to

community

Tribal Email

Signs in hospitalsFamily

members –parents,

elders, aunts, uncles

Radio

Word of mouth

Benefits coordinators

Workplace

Pamphlets

What kinds of communication or advertisement have you seen regarding the Affordable Care Act? Respondents stated:

Results What sources or messages do you feel are the most trustworthy? Respondents stated:

Information From IHS Clinic

Family Partnership Coordinators

Newspapers Healthcare Providers

Head Start Programs

Social Media Commercials on TV

Tribal Leaders

Brochures Person to Person Engagement

Internet Parents

Results What sources or messages do you feel are the least trustworthy? Respondents stated:

Television Word of Mouth Social Media A person with no relationship to you

Politicized Sources News Media People going door to door

Telemarketing

Pamphlet Flier

Overlap of Trust

Most

•Television

•Word of Mouth

•Social Media

•Brochure/Flier/Pamphlet

Least

•Television

•Word of Mouth

•Social Media

•Brochure/Flier/Pamphlet

Clear Trust

▪Tribal leaders

▪Newspapers

▪Parents

▪Healthcare providers

▪Family Partnership Coordinators

▪ Information from IHS Clinics

▪Head Start programs

On this slide you will see the sources of information that NIHB has defined as having “clear trust” with participants.

The underlined points are directly related to the work of Outreach and Education

Results What suggestions do you have for future messages regarding insurance enrollment?

▪ Need all tribes identified and listed▪ Connect directly with tribal community▪ Incentives to enroll: food, shirts, small gifts▪ Visual aids▪ Tribal navigator▪ Kiosk at clinic▪ Native American call-in helpline▪ Engage elders▪ Convey community benefit▪ Collaborate with other government programs▪ Connect at pow wows▪ Community events▪ Ceremonies

Best PracticesMoving forward with these lessons Outreach and Education in Tribal communities should involve a multi-prongedapproach.

•Short PSAs or announcements specifically for ITU clinic waiting rooms, etc

Television

•Regular and clear social media in partnership with other visible Native organizations

Social Media

•Maintain strong presence at in person enrollment events, pow wows, and fairs. Speaking with Elders

Word of Mouth

•15, 30 Second ads on Tribally run or local stationsRadio

•A variety of hand outs, posters for around clinics, local native imagery and in multiple languages

Posters, Brochures, Fliers

Tribal Days of Action: A Model▪ In person training

▪ Tribal leaders▪ Parents▪ Information from IHS Clinics▪ Family Partnership Coordinators▪ Healthcare providers

▪ Community enrollment events▪ Tribal leaders▪ Parents▪ Information from IHS Clinics▪ Family Partnership Coordinators▪ Healthcare providers

▪ Advertising and marketing▪ Tribal leaders▪ Newspapers▪ Parents▪ Information from IHS Clinics▪ Family Partnership Coordinators

Role of the Assister

Third Party Billing, Preservation of

PRC Money, Continuity of Care, 100% FMAP…etcCommunity

Members

Coverage

•Patient Benefits Coordinators

•Patient Benefits Advocates

•Certified Application Counselors

•Outreach and Education Specialists

•Navigators

•Medicaid Office Employees

•SHIP Counselors

CMS AI/AN Outreach and Education Materials

➢Tribal Specific Brochures➢Tribal Specific Fact Sheets ➢Customizable Fliers➢AI/AN Targeted PSAs ➢Radio PSA’s in English and 5 Native Languages➢Youtube PSA’s in English and 5 Native Languages

All Materials free to order and ship directly to you. https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/CMS-Tribal-Products.html

CMS Tribal Native American Contact

Who to contact for more information in your area on CMS programs: https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/NACTAGlistJanuary2017.pdf

NATIONAL INDIAN HEALTH BOARD

OUTREACH AND EDUCATION

The National Indian Health Board (NIHB) has begun a Story Banking campaign to collect inspirational stories about how American Indian and Alaska Native (AI/AN) individuals are achieving and sustaining health through the variety of health coverage options available.

• Health Insurance Marketplace (Helathcare.gov)• Medicaid• Medicare • Children’s Health Insurance Program (CHIP) • Private Insurance

Story Banking Campaign

Importance of Story Banking:Highlighting the importance of all health insurance coverages for AI/ANs, such as Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP) is vital to the role that NIHB plays in advocating for the health and wellness of AI/ANs.

• Advocacy Work• Story Telling • Recording History• Celebrating specific areas

Story Banking Campaign

ExampleWhile Shirley’s family was on a camping trip celebrating Easter at Seneca Lake on the San Carlos Apache Reservation on Saturday, April 16, 2017, her niece was involved in a tragic car accident in Phoenix, Arizona. She’s 29 years old and single with no children. While she was a passenger, a car hit them T-bone on her side of the vehicle. The impact was so severe that her intestine was detached from her colon and the first responders had to use the Jaws of Life to cut through the metal to have her removed from the vehicle.

ExampleShe was taken to the trauma center at Maricopa Medical Center in Phoenix, Arizona. She suffered both broken arms with a compound fracture to her right arm, 5 fractured ribs, fractured sternum, fractured pelvis and tail bone, and the back of her neck separated. Her niece went through 6 surgeries to mend all of her broken bones. Because this young woman was on the Medicaid (AHCCCS) health insurance under the Medicaid expansion program, her medical bills will paid in full. She was transferred to a Skilled Nursing Facility where she will recover and go through physical therapy. The Purchase Referred Care (PRC) funds under the Indian Health Service have been conserved because the young woman in this case was on the Medicaid Program.

REQUESTING INPUT

•Constantly looking to see what of outreach materials is needed

• Training materials for AI/AN

NIHB TOOLKIT

•Enrollment Assister

•Youth

•Medicare

ENROLLMENT ASSISTER TOOLKIT

ACA YOUTH TOOLKIT

YOUTH TOOLKIT: ACA Brochure (outside)

YOUTH TOOLKIT: ACA Brochure (inside)

YOUTH TOOLKIT: ACA Poster

YOUTH TOOLKIT: ACA Video

YOUTH TOOLKIT: Posters

ELDER’S TOOLKIT: Brochure (outside)

ELDER’S TOOLKIT: Brochure (inside)

ELDERS TOOLKIT: Bingo Game

ELDER’S TOOLKIT: Video

NIHB OUTREACH & EDUCATION

•Goal

•Stimulate and maintain conversations about outreach and education in Tribal communities

•Create a forum for innovation and idea sharing in Tribal Outreach and Education

• Inform participants of the importance of Tribal Outreach and Education

NIHB OUTREACH & EDUCATION:FEEDBACK

• Highlights• Understanding and framing the federal trust responsibilities and Indian

health system at large to AI/AN consumers

• Being informed and updated on changes in Tribal/non-Tribal health reform, assistance to understand changes, impacts, and message at the community level

• Customer Service/Sales Training to work with community members for end goals of enrollment, retention, and education (Hard and Soft skills)

• In Person Training as integral to understanding concepts and working with Tribal communities, particularly rural

• Having a trusted, knowledgeable resource to better understanding above concepts and technical assistance

UPDATES

Updates• March 6, 2018 2018 Federal Poverty Level Standards Release• The updated standards are available on Medicaid.gov at

https://www.medicaid.gov/medicaid/eligibility/medicaid-enrollees/index.html.

• The informational bulletin can be accessed on Medicaid.gov at https://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html.

• February 21, 2018: 1095-A forms mailed to consumers from the Marketplace.

• February 9, 2018: Children's Health Insurance Program (CHIP), which provides health coverage to nine million children and their families was renewed by Congress for 10 more years.

Exemption update

55

Under the current law, most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee. Exemptions are granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances.

IMPORTANT NEWS: Individual Mandate Penalty Will Be

Eliminated in 2019

• The tax reform bill, signed at the end of 2017, eliminated the individual mandate penalty, beginning in 2019.

• Individuals will no longer be penalized for failing to obtain acceptable health insurance coverage for 2019 and beyond.

• Individual mandate penalties can still apply for 2017 and 2018.• However, AI/ANs are exempt from the individual mandate and can still claim it on

their tax returns.

WHAT DOES THIS MEAN?• Without the mandate, many healthy people may opt out of getting insurance.• The number of uninsured Americans could increase by 13 million in 2027 according to

the Congressional Budget Office.• As a result, Premiums on the individual market are expected to increase about 10% a

year over the next decade.• Individual States may enact their own state-individual mandates for insurance

coverage in order to reduce failing risk pools.• Tribes must remain vigilant about actions in their states to enact an individual

mandate and ensure that any legislation also exempts IHS Beneficiaries.

IMPORTANT DATESDecember 20, 2017 – The Tax Cuts and Jobs Act of 2017 passed both the Senate and House of Representatives.December 22, 2017 – The Tax Cuts and Jobs Act of 2017 was signed into law by President Trump.2019 Tax Year – Individual mandate penalties will be reduced to zero.

Exemption update cont.

Resources• Arizona• University of Arizona, Center for Rural Health’s Az CRH Navigator

Consortiumhttp://crh.arizona.edu/programs/navigator

• Arizona Alliance for Community Health Centershttps://www.aachc.org/resources/resources-aca/

•New Mexico• beWellnm• https://bewellnm.com/native-americans

• Colorado• Connect for Health Colorado • http://connectforhealthco.com/get-started/individuals-families/native-

americans/

Resources cont.

•CMS Assister newsletter• https://marketplace.cms.gov/technical-assistance-

resources/assister-newsletters.html

•National Indian Health Board, Tribal Health Reform Resource Center• https://www.nihb.org/tribalhealthreform/

• Indian Health Service• https://www.ihs.gov/aca/• Email IHS if you Health Insurance questions:

acainformation@ihs.gov

Thank You Kristen Bitsuie

Tribal Healthcare Reform Outreach and Education Program Associate

National Indian Health Board Email: kbitsuie@nihb.org

Direct: 202-507-4084Fax: 202-507-4071