|July 18, 2013
Final ACA policy makes an exemption from the shared responsibility payment available to individuals eligible for IHS services
By B.L. Azure
ST. IGNATIUS — The Affordable Care Act, the comprehensive health care reform law enacted by the President Barack Obama Administration has been bobbing and weaving through the choppy turbid political waters since its implementation in March 2010. It has survived nearly 40 attempts to scuttle the federal law by the quirky right leaning U.S. House of Representatives. However, more importantly it passed the legal muster of the U.S. Supreme Court, that ruled the ACA was constitutional thus the law of the land.
The ACA was enacted in two parts. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
On the plus side for American Indians and Alaska Natives the ACA permanently reauthorizes the Indian Health Care Improvement Act, provides new opportunities for health insurance coverage, eliminates cost sharing such as copays and deductibles, and provides special monthly enrollment periods for members of federally recognized tribes who enroll in health plans offered through the Health Insurance Marketplace.
However there are perceived shortcomings in the ACA when it comes to American Indians. One of the main burrs under the saddle blanket is the “Individual Shared Responsibility” edict that required non-enrolled American Indians — presently being served by the Indian Health Service, Urban Indian clinics and tribal organizations that compact the health care delivery system on Indian reservations — to purchase health insurance. The Confederated Salish and Kootenai Tribes’ Tribal Health and Human Services Department (THHS) fit into the latter category and it serves many descendants of the Salish, Pend d’Oreille and Kootenai people as well as those from other tribes being served by THHS.
Under the ACA, starting January 1, 2014, such a non-enrolled person must be enrolled in a health insurance plan that meets basic minimum standards. The health insurance enrollment period is slated to begin October 1, 1013. If a person does not have the mandatory health insurance coverage they could be required to pay an annual tax assessment of $695 to the Internal Revenue Service.
The Individual shared responsibility requirement takes a limited view of who is an American Indian and it raised a lot of hackles in Indian Country since it would remove up to 480,000 of previously locally identified American Indians from the health care services provided by IHS, Urban Indian clinics and compacting tribal health organizations because they aren’t enrolled in one of the 560 federally recognized Tribal Nations.
According to the 2010 census nearly one-third of the 6.2 million people who self-identify as American Indian or Alaska Native lack health insurance coverage. The Indian Health Service, a division of the U.S. Department of Health and Human Services, is required to serve all patients of Indian ancestry even if they can’t document their federal tribal status, i.e. enrollment.
Needless to say the consternation in Indian Country was palatable and luckily their concerns fell upon the open ears of the Obama Administration.
On June 26th, the Obama Administration through the U.S. Department of Health and Human Services issued a final rule allowing all American Indians and Alaska Natives who are eligible to receive services from an Indian health care provider to receive an exemption from the shared responsibility payment if they do not maintain minimum essential coverage under the ACA.
Prior to development of the final rule, only a portion of the American Indian and Alaska Native population — members of federally recognized tribes — would have access to an exemption from the requirement to maintain minimum essential coverage under the law. The final rule reflects comments and feedback received from Indian Country through rulemaking and the tribal consultation process.
Tribal people won’t have to pay an assessment if they are American Indian or Alaska Native and receive their health care services from an IHS, tribal (THHS), or urban clinic, have very low income and coverage is unaffordable, or for other reasons including your religious beliefs. A person can also apply for a waiver asking not to pay an assessment if they don’t qualify automatically.
“The administration is taking steps to honor our historical commitment to the rights of American Indians and Alaska Natives and ensure that individuals protected under the Indian Health Care Improvement Act benefit from the special provisions in the Affordable Care Act,” said DHHS Secretary Kathleen Sebelius. “Today, we continue to fulfill our responsibility to consult and work with tribal communities.”
It was a semi-sweet morsel to chew on for THHS.
“The bottom line is that tribal descendants are exempt from the Individual shared individual responsibility mandate if they are currently eligible for Indian Health Service,” said THHS Director Kevin Howlett. “The net effect of this is a relief of anxiety that Indian Health Service eligible Indians felt about the tax penalty that would have been imposed upon them if the Department of Health and Human Services had not granted the exemption in the Affordable Care Act.”
Howlett said the downside of the exemption is that tribally managed clinics such as those operated by Tribal Health will not be able to bill the health insurance exchanges for services provided to folks who would’ve been mandated to purchase such coverage. However, he said purchasing of heath care insurance is a good idea since insurance under the provisions of the ACA provides for monetary coverage far beyond the capabilities of IHS.
“We still encourage people eligible to enroll in the exchanges to do so. In all likelihood the cost of the insurance would be minimal,” Howlett said. “People will then have the comfort of knowing that in the event of a catastrophic illness or accident they won’t have to rely on the limited coverage provided by the Indian Health Service but on the comprehensive coverage available through the medical insurance exchanges.”
Howlett reiterated the long known reality of IHS and its funding.
“Indian Health Service is not an insurance program,” Howlett said. “It is subject to the annual appropriations of Congress and that historically only meets 50 percent of the need to provide health care to Indian people.”
The news was welcomed at the headquarters of the Indian Health Service.
“We appreciate our tribal partners who advocated to ensure that all American Indians and Alaska Natives eligible for IHS can receive an exemption from the penalty for not having insurance coverage,” said IHS Director Dr. Yvette Roubideaux.
As a result of this final regulation, all American Indians and Alaska Natives who are eligible to receive services from an Indian health care provider will have access to an exemption from the shared responsibility payment.
The final rule is available by clicking here