Indian Health Care: Impact of the Affordable Care Act (ACA)

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Elayne J. Heisler
Analyst in Health Services

OnMarch 23, 2010, President Obama signed into law a comprehensive health carereform bill, the Patient Protection and Affordable Care Act (ACA; P.L.111-148). The law, among other things, reauthorizes the Indian Health CareImprovement Act (P.L. 94-437, IHCIA), which authorizes many programs andservices provided by the Indian Health Service (IHS). In addition, itmakes several changes that may affect American Indians and Alaska Nativesenrolled in and receiving services from the Medicare, Medicaid, and StateChildren’s Health Insurance Program (CHIP)—also called Social Security Act(SSA) health benefit programs, and it includes changes to private healthinsurance that may affect American Indians and Alaska Natives and may affect tribesthat offer private health insurance.

IHCIA authorizes many IHS programs and services, sets out the national policyfor health services administered to Indians, and articulates the federalgoal of ensuring the highest possible health status for Indians, includingurban Indians. In addition, it authorizes direct collections from Medicare,Medicaid, and other third-party insurers. Prior to the ACA, IHCIA was last reauthorizedin FY2000, although programs have received appropriations since that time. The ACAreauthorizes IHCIA and extends authorizations of appropriations for IHCIAprograms indefinitely. It amends a number of sections of IHCIA in general,to permit tribal organizations (TOs) and urban Indian organizations (UIOs)to apply for contract and grant programs for which they were notpreviously eligible; to create new mental health prevention and treatmentprograms; and to require demonstration projects to construct modular andmobile health facilities in order to expand health services availablethrough IHS, Indian Tribes (ITs), and TOs. It also made several organizationalchanges to IHS. It requires IHS to establish an Office of Direct Service Tribesto serve tribes that receive their health care and other services directlyfrom IHS as opposed to receiving services through IHS-funded facilities orprograms operated by ITs or TOs. In addition, the law requires IHS todevelop a plan to establish a new area office to serve tribes in Nevada and requiresthe Secretary of the Department of Health and Human Services (HHS) to appoint anew IHS Director of HIV/AIDS Prevention and Treatment.

In addition to reauthorizing IHCIA, the ACA includes a number of provisionsthat may affect American Indians and Alaska Natives who have privateinsurance coverage or who receive services through SSA health benefitprograms. With regard to private insurance coverage, the ACA provides aspecial enrollment period for American Indians and Alaska Natives who may enrollin private insurance offered through an exchange and exempts certain AmericanIndians and Alaska Natives from the requirement to obtain privateinsurance coverage. Finally, it excludes tribal health benefits from beingcounted as gross income for tax purposes. With regard to SSA healthbenefit programs, the new law permits specified Indian entities to determine Medicaidand CHIP eligibility and extends the period during which IHS, IT, and TOservices are reimbursed for all Medicare Part B services, indefinitely,beginning January 1, 2010. Prior to the ACA, authority for thesefacilities to receive Medicare Part B reimbursements for certain specifiedservices had expired on January 1, 2010.

This report, one of a series of CRS products on the ACA, summarizes some of thekey changes made in the reauthorization of IHCIA and summarizes otherchanges included in the ACA that may affect American Indian and AlaskaNative health and health care. Another report, CRS Report R41630, TheIndian Health Care Improvement Act Reauthorization and Extension as Enactedby the ACA: Detailed Summary and Timeline, by Elayne J. Heisler, provides adetailed section-by-section summary of the IHCIA Reauthorization andExtension Act of 2009.


Date of Report: December 14, 2012
Number of Pages: 17
Order Number: R41152
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