INDIAN HEALTH 

SERVICE

Most American 

Indians and Alaska 

Natives Potentially 

Eligible for Expanded 

Health Coverage, but 

Action Needed to 

Increase Enrollment

Report to Congressional Addressees

September 2013

GAO-13-553

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-13-553, a report to 

congressional addressees

September 2013

INDIAN HEALTH SERVICE 

Most American Indians and Alaska Natives 

Potentially Eligible for Expanded Health Coverage, 

but Action Needed to Increase Enrollment

Why GAO Did This Study

IHS provides care to American Indians 

and Alaska Natives through a system 

of health care facilities. PPACA 

provides states the option to expand 

their Medicaid programs and creates 

new health care coverage options, 

including for American Indians and 

Alaska Natives, beginning in 2014. 

PPACA also requires GAO to study 

IHS’s coordination with public 

programs. In this report, GAO 

(1) estimated the number of American 

Indians and Alaska Natives potentially 

eligible for the expanded and new 

coverage options and (2) reviewed 

efforts by IHS, CMS, states, tribal 

organizations, and facilities to promote 

enrollment of American Indians and 

Alaska Natives in current programs 

and expanded and new coverage 

options, and any challenges 

associated with their enrollment.

To address the objectives, GAO 

(1) analyzed U.S. Census Bureau data 

and (2) interviewed IHS and CMS 

officials and state, facility, and tribal 

officials from three IHS areas with high 

levels of uninsured.

What GAO Recommends

GAO recommends that IHS and CMS 

coordinate to improve communication 

with facility staff and tribal leaders and 

increase outreach; that IHS realign its 

capacity to prepare for increased 

enrollment; and that CMS address 

issues related to sharing members’ 

coverage status with their tribes.

HHS agreed with the recommendation 

to improve communication and 

outreach, but did not agree or disagree 

with the other two recommendations. 

GAO believes preparing for increased 

enrollment and addressing issues 

related to coverage status is important.

What GAO Found

GAO estimates, on the basis of recent U.S. Census Bureau data, that most 

American Indians and Alaska Natives will be potentially eligible for either 

expanded or new coverage options created by the Patient Protection and 

Affordable Care Act (PPACA). These options include expanded eligibility for 

Medicaid—the federal-state program for certain low-income individuals—and 

eligibility for the Health Insurance Exchanges (Exchanges), which are 

marketplaces where health insurance plans can be compared and purchased. 

While it is still unclear which states will opt to expand Medicaid, their decisions 

may affect a large proportion of American Indians and Alaska Natives, as GAO 

estimates that potential new enrollment could include about a quarter of this

population. For example, in the Oklahoma City area—one of the Indian Health 

Service’s (IHS) 12 federally designated service areas—tens of thousands of 

American Indians and Alaska Natives could be affected by the state of 

Oklahoma’s decision not to expand its Medicaid program. For the Exchanges, 

GAO found that more than one-third of American Indians and Alaska Natives are 

potentially eligible for premium tax credits in the Exchanges—which help offset 

the cost of premiums for low-income individuals—and nearly one-third are below 

the income threshold for cost-sharing exemptions, which are limited to enrolled 

members of federally recognized tribes. 

Some efforts have been made by IHS, the Centers for Medicare & Medicaid 

Services (CMS), and three states with high levels of uninsured to facilitate 

Medicaid enrollment through training of facility staff and conducting outreach for 

current public programs. However, uncertainty related to legal and policy 

decisions, lack of capacity building, unfamiliarity with expanded and new 

coverage options, and limited access to information present challenges to 

education and enrollment in expanded and new coverage options. While IHS and 

CMS have reported providing basic training on expanded Medicaid and the 

Exchanges, most of the facilities and tribes GAO interviewed said they received 

little or no information from IHS or CMS, as of February 2013. Many of the 

officials GAO interviewed—from federal agencies, state Medicaid programs, and 

facilities—said they delayed outreach and enrollment activities because of the 

uncertainty related to the Supreme Court decision about PPACA and states’ 

subsequent decisions about expanding Medicaid that were both pending at the 

time of GAO’s review. Although a Supreme Court decision had been issued and 

some state decisions had been made, IHS had not developed a plan to increase 

enrollment and billing capacity to accommodate the hundreds of thousands of 

American Indians and Alaska Natives potentially eligible for expanded and new 

coverage options. IHS officials told GAO, however, that the agency distributed a 

“business plan template” that directs IHS-operated facilities to plan for their 

community outreach and staff training needs in preparation for expanded 

Medicaid and the Exchanges. This plan was to be submitted in May 2013. 

Additionally, some tribes noted that their Medicaid outreach efforts could be more 

targeted and effective if they had information from states about their members’ 

Medicaid coverage status.

View GAO-13-553. For more information, 

contact Kathleen M. King at (202) 512-7114 or 

kingk@gao.gov.
Page i GAO-13-553 Indian Health Service

Letter 1 

Background 9

Most American Indians and Alaska Natives Will Be Potentially 

Eligible for Expanded Medicaid and New Coverage Options; 

States’ Decisions Will Affect Coverage for Many 19

Efforts Have Been Made to Enroll American Indians and Alaska 

Natives in Current Medicaid Programs, but Multiple Barriers 

May Hinder Enrollment in Expanded Medicaid and New 

Coverage Options 29

Conclusions 38

Recommendations for Executive Action 39

Agency Comments and Our Evaluation 40

Appendix I Methodology for Estimating Potential Eligibility for 

American Indians and Alaska Natives in Expanded Health 

Coverage 43

Appendix II Estimates of Potential Medicaid Eligibility for American 

Indians and Alaska Natives, by Indian Health Service (IHS) 

Area 50

Appendix III Potential Eligibility for Expanded Health Coverage in 2014, 

Nationally, by IHS Service Area, and by State 51

Appendix IV Comments from the Department of Health and Human 

Services 64

Appendix V GAO Contact and Staff Acknowledgments 68

Related GAO Products 69

Contents 
Page ii GAO-13-553 Indian Health Service

Tables

Table 1: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for 

Expanded Medicaid in 2014 21

Table 2: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for the 

Basic Health Program Option and for Cost-Sharing and 

Premium Tax Credits under the Health Insurance 

Exchanges 28

Table 3: Estimates of the Number and Percentage of All Races 

Potentially Eligible for Expanded Medicaid in 2014, by 

Indian Health Service (IHS) Service Area 52

Table 4: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for 

Expanded Medicaid in 2014, by State 53

Table 5: Estimates of the Number and Percentage of All Races 

Potentially Eligible for Expanded Medicaid in 2014, by 

State 55

Table 6: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for the 

Basic Health Program Option in 2015, and Cost-Sharing 

Exemptions and Premium Tax Credits under the Health 

Insurance Exchanges in 2014, by Indian Health Service 

(IHS) Service Area 57

Table 7: Estimates of the Number and Percentage of All Races 

Potentially Eligible for the Basic Health Program Option in 

2015 and Premium Tax Credits under the Health Insurance 

Exchanges in 2014, by Indian Health Service (IHS) Service 

Area 58

Table 8: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for the 

Basic Health Program Option in 2015, and Cost-Sharing 

Exemptions and Premium Tax Credits under the Health 

Insurance Exchanges in 2014, by State 59

Table 9: Estimates of the Number and Percentage of All Races 

Potentially Eligible for the Basic Health Program Option in 

2015 and Premium Tax Credits under the Health Insurance

Exchanges in 2014, by State 62
Page iii GAO-13-553 Indian Health Service

Figures

Figure 1: The 12 IHS Service Areas, Shown with Contract Health 

Service Delivery Area (CHSDA) Counties Included in 

Each Area 11

Figure 2: Relationship between American Indians and Alaska 

Natives as Self-Reported to the Census, for IHS Eligibility, 

and for Tribal Membership 13

Figure 3: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for 

Expanded Medicaid in 2014, by IHS Service Area 23

Figure 4: Estimates of the Number and Percentage of American 

Indians and Alaska Natives Potentially Eligible for 

Expanded Medicaid in 2014 for IHS Service Areas and 

Non-IHS Service Areas 25
Page iv GAO-13-553 Indian Health Service

Abbreviations

ACS American Community Survey

CHIP Children’s Health Insurance Program

CHIPRA Children’s Health Insurance Program Reauthorization Act 

 of 2009

CHS Contract Health Services

CHSDA Contract Health Service Delivery Area

CMS Centers for Medicare & Medicaid Services

FPL federal poverty level

HHS Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act

IHS Indian Health Service

IPUMS Integrated Public Use Microdata Series

I/T/U IHS facilities, tribal facilities, and urban Indian health 

 programs

ISDEAA Indian Self-Determination and Education Assistance Act

PPACA Patient Protection and Affordable Care Act

PUMA Public Use Microdata Areas

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United States. The published product may be reproduced and distributed in its entirety 

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Page 1 GAO-13-553 Indian Health Service

441 G St. N.W.

Washington, DC 20548

September 5, 2013

The Indian Health Service (IHS), an agency within the Department of 

Health and Human Services (HHS), is responsible for providing health 

care for approximately 2.1 million American Indians and Alaska Natives 

who are members or descendants of federally recognized tribes.1 IHS 

provides this care through a system of health care facilities (facilities) 

managed by IHS, tribal organizations, or urban Indian health programs. 

However, American Indians and Alaska Natives have experienced longstanding problems accessing needed services, due in part to IHS funding 

constraints.2 Many users of IHS services are also eligible for public 

insurance programs—Medicaid, the Children’s Health Insurance Program 

(CHIP), and Medicare3

—which are overseen by another HHS agency, the 

Centers for Medicare & Medicaid Services (CMS). Enrollment of eligible 

American Indians and Alaska Natives in these public programs can 

improve access to health care by providing them with benefits more 

comprehensive than available through IHS and can also reduce pressure 

on IHS’s budget. In its 2014 budget justification, IHS stated that 

reimbursements from public and private insurance are a significant part of 

IHS and tribal budgets and provide increased access to health services 

for American Indians and Alaska Natives.4

 

1

IHS defines an Indian tribe as any Indian tribe, band, nation, group, Pueblo, or 

community, including any Alaska Native village or Native group, which is federally 

recognized as eligible for the programs and services provided by the United States to 

Indians because of their status as Indians.

While both IHS and CMS have 

conducted outreach in the past to increase enrollment in public insurance 

Individuals are eligible for IHS services if they are considered American Indians and 

Alaska Natives by the community in which they live, as evidenced by factors such as tribal 

membership, enrollment, residence on tax-exempt land, ownership of restricted property, 

active participation in tribal affairs, or other relevant factors. See 42 C.F.R. § 136.12.

2

See GAO, Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans, GAO-05-789 (Washington, D.C.: Aug. 31, 2005). See also the Related 

GAO Products page at the end of this report.

3

Medicaid is a joint federal–state program that finances health insurance coverage for 

certain categories of low-income individuals. CHIP, also a joint federal–state insurance 

program, provides coverage to children whose family income is low, but too high for 

Medicaid. Medicare is the federal health insurance program for individuals age 65 and 

over and for individuals with certain disabilities or end-stage renal disease.

4

Indian Health Service, “Justification of Estimates for Appropriations Committees, Fiscal 

Year 2014” (Rockville, Md., 2013).

 
 

Page 2 GAO-13-553 Indian Health Service

programs, participation of American Indians and Alaska Natives in 

Medicaid and CHIP has been relatively low.5

The Patient Protection and Affordable Care Act (PPACA) expanded or 

created new health care coverage options that may benefit American 

Indians and Alaska Natives.6

• Medicaid eligibility will expand in 2014, in states opting to participate. 

This expansion will apply to Americans with incomes at or below 

138 percent of the federal poverty level (FPL),7 including previously 

ineligible categories such as childless adults.8

 

5

For example, see Genevieve M. Kenney et al., “Who and Where are the Children Yet to 

Enroll in Medicaid and the Children’s Health Insurance Program?” Health Affairs, vol. 29, 

no. 10 (2010).

HHS included in its Action Plan to Eliminate Racial and Ethnic Health Disparities the goal 

of increasing the health insurance coverage rate among racial and ethnic minorities as a 

means of eliminating health disparities.

6

Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and 

Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029. For purposes 

of this report, references to PPACA include the amendments made by the Health Care 

and Education Reconciliation Act of 2010. Unless otherwise noted, we use “expanded and 

new coverage options” to refer to expanded Medicaid and the new coverage options 

created by PPACA, specifically premium tax credits and exemptions from cost-sharing 

available for insurance obtained through Exchanges and the Basic Health Program.

7

PPACA established 133 percent of the FPL as the income limit for expanded Medicaid 

eligibility; however, it also specifies that an income disregard in the amount of 5 percent of 

the FPL be deducted from an individual’s income when determining Medicaid eligibility, 

which effectively raises the eligibility limit for newly eligible Medicaid recipients to 

138 percent of the FPL. See Pub. L. No. 111-148, §§ 2001(a)(1), 2002, 124 Stat. 119, 

271, 279 (2010); Pub. L. No. 111-152, § 1004, 124 Stat. 1029, 1034 (2010) (codified at 

42 U.S.C. § 1396a(a)(10)(A)(i)(VIII) and to be codified at 42 U.S.C. § 1396a(e)(14)(I)).

8

The U.S. Supreme Court ruled in June 2012 that states choosing not to expand Medicaid 

coverage to individuals eligible under PPACA will forgo only the federal matching funds 

associated with such expanded coverage, rather than be subject to a termination of all 

Medicaid federal matching funds. See Nat’l Fed’n of Indep. Bus. v Sebelius,132 S.Ct. 

2566 (2012). 
 

Page 3 GAO-13-553 Indian Health Service

• Health Insurance Exchanges (Exchanges)9 will also be established in 

2014, with enrollment beginning in October 2013. PPACA provides for 

a federal premium tax credit for eligible individuals obtaining 

insurance through the Exchanges with incomes between 100 and 

400 percent of the FPL, and certain American Indians and Alaska 

Natives are also eligible for cost-sharing exemptions if they have 

incomes at or below 300 percent of the FPL.10

• In 2015, states will have the option of implementing the new “Basic 

Health Program,” under which the federal government is to give states 

95 percent of the premium tax credits and cost-sharing subsidies that 

would have been provided if the individuals had been enrolled through 

the Exchanges, to allow the states to provide coverage to certain lowincome residents with incomes between 138 and 200 percent of the 

FPL, who—despite the expansion of Medicaid and establishment of 

Exchanges—might otherwise go uninsured.

 

9

Exchanges are health insurance marketplaces in which individuals and small businesses 

will be able to compare, select, and purchase health coverage from among participating 

carriers. Exchanges are also referred to by HHS as Marketplaces. PPACA directed states 

to establish state-based Exchanges by January 1, 2014. In states electing not to establish 

and operate such an Exchange, PPACA requires the federal government to establish and 

operate an Exchange in the state, referred to as a Federally Facilitated Exchange. Pub. L. 

No. 111-148, §§ 1311(b)(1), 1321(c), 124 Stat. 119, 173, 186 (2010). CMS provided 

states in which a Federally Facilitated Exchange will operate the option to participate in a 

variation of a Federally Facilitated Exchange, called a Partnership Exchange, in which the 

state would assist CMS in carrying out certain Exchange activities.

10American Indians and Alaska Natives who obtain insurance through an Exchange are 

eligible for cost-sharing exemptions if they are members of federally recognized tribes and 

have a household income of not more than 300 percent of the FPL. Pub. L. No. 111-148, 

§ 1402(d)(1), 124 Stat. 119, 222 (2010) (codified at 42 U.S.C. § 18071).

Although PPACA generally requires that individuals obtain health insurance or be subject 

to a federal tax—a requirement often referred to as the individual mandate—American 

Indians and Alaska Natives who are members of federally recognized tribes are statutorily 

exempt. See Pub. L. No. 111-148, §§ 1501(b),10106, 124 Stat. 119, 244, 909 (2010); 

Pub. L. No. 111-152, §§ 1002, 1004, 124 Stat. 1029, 1032, 1034 (2010) (codified at 

26 U.S.C. § 5000A). Additionally, a final rule released June 26, 2013, established 

additional exemptions to the individual mandate under HHS’s authority to establish 

hardship exemptions, including for individuals eligible for IHS services, who are not 

members of federally recognized tribes, and for individuals living in states that chose not 

to expand Medicaid eligibility but who would otherwise qualify for it. 78 Fed. Reg. 39,494

(July 1, 2013).
 

Page 4 GAO-13-553 Indian Health Service

Although reimbursements from Medicaid or insurance obtained through 

an Exchange or Basic Health Program have the potential to alleviate 

some constraints on the IHS budget, eligible individuals must first be 

aware of and enroll in these programs and options, and choose to receive 

care through IHS.11 PPACA required that GAO examine IHS’s 

coordination of health care services provided through other public 

insurance programs.12

1. estimates the number of American Indians and Alaska Natives 

potentially eligible for the expanded and new coverage options and

This report specifically focuses on the expanded 

and new coverage options soon to be available to American Indians and 

Alaska Natives. This report

2. reviews efforts by IHS, CMS, states, tribal organizations, and facilities 

to promote enrollment of American Indians and Alaska Natives in 

current programs and the expanded and new coverage options, and 

any challenges associated with their enrollment.

To estimate the number of American Indians and Alaska Natives 

potentially eligible for the expanded and new coverage options, we 

examined data from the American Community Survey (ACS)13

 

11The availability of more coverage options for American Indians and Alaska Natives could 

alleviate constraints on the IHS budget both by increasing reimbursements for services 

provided by IHS to enrolled individuals and by allowing American Indians and Alaska 

Natives more options for care, potentially resulting in fewer American Indians and Alaska 

Natives seeking care through Indian health facilities.

of the U.S. 

Census Bureau, which contains information on race, age, income, and 

health insurance coverage, among other variables, for millions of 

households. In order to capture the appropriate family ties and income for 

12See Pub. L. No. 111-148, § 10221, 124 Stat. 119, 935 (2010) (enacting S. 1790, as 

reported by the Committee on Indian Affairs in the Senate in December 2009, into law with 

amendments); S. 1790, 111th Cong. § 199(a) (2009) (codified at 25 U.S.C. § 1680t(a)).

13Like other survey-based sources of health insurance coverage data, the ACS likely 

underestimates the population enrolled in Medicaid and CHIP compared to administrative 

data that includes information on enrollment. Researchers have attempted to estimate the 

magnitude of the underestimation—for example, see Victoria Lynch et al., “Improving the 

Validity of the Medicaid/CHIP Estimates on the American Community Survey: The Role of 

Logical Coverage Edits” (Urban Institute Health Policy Center, 2011). Reporting errors can 

be due to several factors, including reluctance to report public coverage or confusion 

about what type of insurance respondents have. However, research by others shows that 

agency enrollment data may not accurately or consistently capture information on 

enrollees’ race and ethnicity, particularly for American Indians and Alaska Natives.
 

Page 5 GAO-13-553 Indian Health Service

determining program eligibility, we used an augmented version of the 

ACS data prepared by the University of Minnesota Population Center—

the Integrated Public Use Microdata Series (IPUMS).14 We used the most 

recent 3-year data available—2009 through 201115—to provide estimates 

at the national, IHS area,16 and state levels beginning in 2014. For 

expanded Medicaid,17

• potentially eligible, including: (1) all American Indians and Alaska 

Natives at or below 138 percent of the FPL,

we estimated the total number of American Indians 

and Alaska Natives who are

18

 

14Because coverage options often consider family ties in determining program eligibility, 

we used the “health insurance unit,” a variable included in the IPUMS data and considered 

the most accurate unit of analysis for estimating health insurance eligibility using survey 

data. The health insurance unit consists of all individuals residing in a sampled household, 

whose family ties determine them to be eligible for coverage, whereas the definition of a 

family or household in the Census’s nonaugmented data typically includes all related 

members of a household, not all of whom would be eligible for coverage. See State Health 

Access Data Assistance Center, “Defining ‘Family’ for Studies of Health Insurance 

Coverage,” Issue Brief #27 (Minneapolis: University of Minnesota). 

(2) American Indians 

Steven Ruggles et al., Integrated Public Use Microdata Series: Version 5.0, machinereadable database (Minneapolis: University of Minnesota, 2010).

15The 2009-2011 3-year estimates are averages over the pooled 2009-2011 period. At 

least 3 years of ACS data are needed for a reliable sample of most county populations. In 

this report, we do not conduct projections of eligibility on the basis of future income; 

instead, we estimate the number of American Indians and Alaska Natives who would be 

eligible for programs beginning in 2014 on the basis of the most recent data currently 

available. We also do not predict the take-up rate for these programs. As public programs 

generally do not have full take-up, it is likely that not all individuals who are eligible will 

enroll.

16The U.S. Census Bureau reports ACS data in Public Use Microdata Areas (PUMA), 

which aggregates smaller counties or breaks up larger counties into units of 100,000 

individuals to protect anonymity. We created a crosswalk between the counties included in 

IHS areas and the counties included in PUMAs.

17The ACS data groups Medicaid and CHIP together when collecting information about 

Medicaid coverage status. As a result, some individuals eligible for CHIP are combined 

with Medicaid in our analysis. 

We did not include estimates for Medicare in this report because eligibility for this program 

did not change as a result of PPACA. 

18The ACS collects broader income data than will be used to determine eligibility for 

Medicaid, which will be based on Modified Adjusted Gross Income, a measure that 

excludes certain sources of income. See Pub. L. No. 111-148, § 2002, 124 Stat. 119, 279 

(2010); Pub. L. No. 111-152, § 1004, 124 Stat. 1029, 1034 (2010) (to be codified at 

42 U.S.C. § 1396a(e)(14)).
 

Page 6 GAO-13-553 Indian Health Service

and Alaska Natives above 138 of the FPL who were eligible for 

Medicaid in each state,

19 (3) American Indians and Alaska Natives 

who received Supplemental Security Income,

20 and (4) American 

Indians and Alaska Natives who reported in the ACS as being 

enrolled in Medicaid;21

• currently enrolled in Medicaid, meaning individuals who reported in 

the ACS as being currently enrolled; and

• potential new Medicaid enrollees, including individuals who will be 

newly eligible for expanded Medicaid and some who are eligible now 

but did not report to ACS as being currently enrolled.

We also estimated the number of American Indians and Alaska Natives 

potentially eligible for the Basic Health Program option beginning in 2015, 

and income-based cost-sharing exemptions and premium tax credits in 

the Exchanges beginning in 2014.22

 

19Some states offer Medicaid coverage to certain categories of individuals above 

138 percent of the FPL, such as children and pregnant women.

Because the number of IHS eligible 

individuals is likely to be between the number identifying solely as 

American Indian and Alaska Native and the number identifying as 

American Indian and Alaska Native alone or in combination with another 

racial/ethnic group, we present results for both groups to show the range 

20Individuals who qualify for Supplemental Security Income—certain low-income 

individuals who are aged, blind, or disabled—are generally eligible for Medicaid.

21A subset of those who identified as being currently enrolled in Medicaid did not 

otherwise meet our criteria, which could be due to a variety of factors. Considering that 

these individuals reported being enrolled, we included them in our estimates of the 

number potentially eligible.

22For both the income-based cost-sharing exemption and premium tax credit in the 

Exchanges, we estimated the number of American Indians and Alaska Natives between 

138 percent of the FPL and 300 or 400 percent of the FPL, respectively. Although 

individuals at lower incomes may be eligible, for our analysis we excluded individuals from 

these categories who could be potentially eligible for expanded Medicaid. For the incomebased cost-sharing protections, we estimated the number of American Indians and Alaska 

Natives within this income range; however, the subset of those who are also members of 

federally recognized tribes, and therefore eligible under PPACA, is unknown. Individuals 

who already have a minimum level of coverage, as specified by HHS, are ineligible for the 

premium tax credit. The ACS data did not contain a variable that would allow us to identify 

the subset of individuals who fall into the income range for premium tax credits but who 

already have minimum essential coverage. 
 

Page 7 GAO-13-553 Indian Health Service

within which the number who are IHS-eligible is likely to fall.23

To assess the precision of ACS estimates, which are subject to some 

sampling error, we calculated a relative standard error for each estimate. 

Unless otherwise noted, we present estimates that have relative standard 

errors of less than 15 percent. We assessed the reliability of 2009-2011 

ACS data by reviewing documentation and discussing the database with 

knowledgeable officials. After taking these steps we determined the data 

were sufficiently reliable for our purposes. See appendix I for more details 

about our methodology for estimating the number of American Indians 

and Alaska Natives potentially eligible for the expanded and new 

coverage options.

In the 

absence of information on IHS eligibility status of respondents, this 

approach allowed us to present a lower and upper bound for these 

estimates.

To review efforts to promote the enrollment—through training and 

outreach—of American Indians and Alaska Natives in both the current 

programs and expanded and new coverage options, and to identify any 

associated challenges, we examined actions taken by IHS, CMS, states, 

tribal organizations, and facilities. Specifically, we reviewed their recent 

and planned efforts to facilitate enrollment of American Indians and 

Alaska Natives into Medicaid under states’ current Medicaid and CHIP 

programs. We also examined efforts to prepare for the increase in 

American Indians and Alaska Natives eligible for expanded Medicaid or 

the new coverage options, specifically the Exchanges.24

 

23We excluded from our analysis individuals identifying as American Indians and Alaska 

Natives who were foreign-born, as these individuals are generally unlikely to be eligible for 

IHS services.

We also 

consulted our prior work for descriptions of initial outreach initiatives that 

encouraged enrollment in other relatively recent federal programs, such 

as CHIP and the Medicare Part D prescription drug benefit. In addition, 

we examined whether efforts to promote enrollment included an 

emphasis on eligibility for expanded Medicaid and the new coverage 

options, the extent to which IHS has coordinated and communicated with 

other entities in its efforts, and the extent to which IHS has managed its 

24Our review of efforts to promote enrollment in the expanded and new coverage options 

focused on expanded Medicaid and the Exchanges rather than on the Basic Health 

Program. 
 

Page 8 GAO-13-553 Indian Health Service

personnel to prepare for increased enrollment.25 We obtained this 

information through interviews with: IHS headquarters officials; CMS 

officials, including members of its Tribal Affairs Group, Center for 

Medicaid and CHIP Services, and Center for Consumer Information and 

Insurance Oversight; and national associations representing tribal and 

urban Indian health organizations. In addition, we selected a sample of 

three IHS service areas to obtain additional information—Aberdeen, 

Albuquerque, and Billings—on the basis of the percentage of American 

Indians and Alaska Natives in these areas who were uninsured.26 Within 

each, we interviewed officials from the IHS area office, the Medicaid 

program of the state in which the area office is located, and, in the same 

state, an IHS-operated health facility, a tribally operated Indian health 

facility, an urban Indian health program, and a tribal outreach grantee 

who received funds appropriated by the Children’s Health Insurance 

Program Reauthorization Act of 2009 (CHIPRA).27

 

25Federal internal control standards specify that agency management should ensure that 

there are adequate means of timely and effective communication with, and obtaining 

information from, external stakeholders that have significant effect on the agency 

achieving its goals and that an agency should employ many and various means of 

communication, such as policy and procedure manuals and Internet web pages. Federal 

internal control standards also specify that agency management should ensure that proper 

personnel, with the right training, are in place to enable organizational success. See GAO, 

Standards for Internal Control in the Federal Government, 

We conducted these 

interviews from June through August 2012, and obtained updated 

information from these officials in February 2013. We asked officials a 

standard set of open-ended questions and did not independently validate 

their reported experiences. Given the small number of each type of entity 

included in the areas in our sample and our process for selecting them, 

the results from these interviews are not generalizable to all areas.

GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999), and Internal Control Management and Evaluation 

Tool, GAO-01-1008G (Washington, D.C.: Aug. 1, 2001).

26Specifically, we selected the three areas with the highest level of uninsured American 

Indians and Alaska Natives, on the basis of ACS data, that also contained at least one 

entire state and each type of entity we sought to include. The Aberdeen, Albuquerque, 

and Billings area offices are located in South Dakota, New Mexico, and Montana, 

respectively.

27CHIPRA included funding for outreach to increase Medicaid and CHIP enrollment 

among American Indian and Alaska Native children. See Pub. L. No. 111-3, § 201, 

123 Stat. 8, 35 (2009) (codified at 42 U.S.C. § 1397mm). We refer to recipients of these 

funds as CHIPRA tribal outreach grantees.
 

Page 9 GAO-13-553 Indian Health Service

We conducted this performance audit from February 2012 to August 2013 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

The health care coverage options established by PPACA have 

implications for how American Indians and Alaska Natives may receive 

and pay for their future health care needs.

IHS was established as an HHS agency for the purpose of providing, or 

arranging for, health care to American Indians and Alaska Natives—a 

responsibility of the United States established in treaty and law. IHS has 

headquarters based in the Washington, D.C., area, but is organized into 

12 federally designated geographic service areas that cover all or part of 

35 states (see fig. 1).28 IHS provides health care services directly through 

a system of facilities—hospitals, health clinics, and health stations—

operated by IHS (for “direct service” tribes), by tribes or tribal 

organizations themselves,29

 

28The 12 areas are Aberdeen, Alaska, Albuquerque, Bemidji, Billings, California, 

Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson.

or by urban Indian health programs. This 

system is often referred to collectively as “I/T/U.” When health care 

services at IHS or tribally operated facilities, referred to as direct care 

services, are not available, care may be obtained from external providers 

and paid for through IHS’s Contract Health Services (CHS) program. 

However, as we have noted in past reports, IHS is not able to pay for all 

eligible health care services—through direct care services and services 

obtained through the CHS program—leading to an unmet need for health 

29Direct service tribes receive health care directly from IHS, instead of receiving services 

through IHS-funded facilities or programs operated by Indian tribes or tribal organizations. 

Under the Indian Self-Determination and Education Assistance Act, as amended, federally 

recognized Indian tribes can enter into self-determination contracts or self-governance

compacts with the Secretary of Health and Human Services to take over administration of 

IHS programs for Indians previously administered by IHS. See 25 U.S.C. §§ 450f(a), 

458 aaa-4(b)(1). 

Background 

The IHS System
 

Page 10 GAO-13-553 Indian Health Service

care services.30 Additionally, services obtained through the CHS program 

are generally limited to individuals who live on a federally recognized 

Indian reservation or within a designated Contract Health Service Delivery 

Area (CHSDA).31

 

30See 

American Indians and Alaska Natives living outside of 

these areas, which may include many urban Indians, therefore are 

unlikely to be eligible for CHS program services.

GAO-05-789 and GAO, Increased Oversight Needed to Ensure Accuracy of Data 

Used for Estimating Contract Health Service Need, GAO-11-767 (Washington, D.C.: 

Sept. 23, 2011).

31See 42 C.F.R. § 136.23. CHSDAs typically encompass reservation and trust lands—

areas located on or off a reservation, for which the United States holds title in trust for the 

benefit of a tribe or individual Indian—and bordering counties. Patients must also meet 

other eligibility, administrative, and medical priority requirements to have their services 

paid for by the CHS program.
 

Page 11 GAO-13-553 Indian Health Service

Figure 1: The 12 IHS Service Areas, Shown with Contract Health Service Delivery Area (CHSDA) Counties Included in Each 

Area

Note: While CHSDAs, which make up IHS service areas, are typically counties, the city of Elton, 

Louisiana, is also designated as a CHSDA in the Nashville area.
 

Page 12 GAO-13-553 Indian Health Service

In addition to IHS funding, I/T/U facilities can use reimbursements from 

third-party payers for services they provide to patients as an additional 

source of funds, and IHS may not reduce funding to tribally operated 

facilities and urban Indian health programs because of such 

reimbursements.32 For direct care services, I/T/Us are authorized to bill 

third-party payers, including public and private insurance, for care 

provided to enrolled patients. For both tribal and IHS-operated CHS 

programs, any alternate sources of coverage that may be available to a 

patient, including Medicare, Medicaid, CHIP, and private insurance, must 

pay for services before the CHS program, as I/T/Us are generally the 

payers of last resort.33

To be eligible for IHS services, an individual must be closely affiliated with 

an American Indian or Alaska Native community that is federally 

recognized, but not necessarily an official member of a tribe. IHS tracks 

the number of users treated at IHS operated facilities, although the 

number of American Indians and Alaska Natives potentially eligible for 

IHS services is unknown. The Census Bureau produces data on the 

number of individuals identifying as American Indian and Alaska Native 

Increased enrollment in alternative sources of 

coverage among American Indians and Alaska Natives could thus 

increase revenue for I/T/U facilities if these individuals choose to receive 

care through IHS, improving access to care and reducing the level of 

unmet need American Indians and Alaska Natives experience. Increased 

enrollment in alternative sources of coverage may allow American Indians 

and Alaska Natives more options for care, if options exist in their 

community outside the I/T/U system, potentially resulting in fewer 

American Indians and Alaska Natives seeking care through I/T/U 

facilities.

 

32The Indian Health Care Improvement Act authorizes IHS, tribes, and urban Indian 

organizations to collect reimbursement for services provided at I/T/U facilities from thirdparty payers, including Medicare, Medicaid, and private health insurers. See 25 U.S.C. 

§§ 1621e(a), 1621f. IHS is allowed to retain funds collected from these payers without a 

corresponding offset against its appropriations, so that all revenue collected by a facility 

remains with that facility, supplementing its funds. See 25 U.S.C. § 1621(b).

We previously reported that, in fiscal year 2008, IHS reported collecting about $795 million 

from all third-party payers. See GAO, Indian Health Service: Updated Policies and 

Procedures and Increased Oversight Needed for Billings and Collections from Private 

Insurers, GAO-10-42R (Washington, D.C.: Oct. 22, 2009).

33See 25 U.S.C. § 1623(b).
 

Page 13 GAO-13-553 Indian Health Service

alone or in combination with another race.34

Figure 2: Relationship between American Indians and Alaska Natives as SelfReported to the Census, for IHS Eligibility, and for Tribal Membership

In the 2010 Census, 

5.2 million people identified as American Indian and Alaska Native alone 

or in combination with another race (2.9 million as American Indian and 

Alaska Native alone). IHS-eligible individuals are a subset of this 

population. (See fig. 2.)

Note: Figure reflects the general relationship, not actual size, of the populations.

 

34Prior to the 2000 Census, respondents could only select one race. Since the 2000 

Census, the number of individuals identifying as American Indians and Alaska Natives, 

especially in combination with another race, has significantly increased.
 

Page 14 GAO-13-553 Indian Health Service

In 2014, in states opting to participate in Medicaid expansion, eligibility 

will expand to those with incomes at or below 138 percent of the federal 

poverty level (FPL).35 Unlike current Medicaid eligibility rules that require 

an individual to meet both income and categorical requirements—such as 

children and pregnant women—eligibility under expanded Medicaid will 

apply to all individuals, including American Indians and Alaska Natives, at 

or below 138 percent of the FPL, including groups previously not eligible, 

such as childless adults. For those individuals obtaining insurance 

through the Exchanges beginning in 2014, PPACA includes a federal 

premium tax credit for eligible individuals whose incomes are between 

100 and 400 percent of the FPL, and who do not have access to public 

insurance such as Medicaid or CHIP.36 PPACA also includes a number of 

Exchange-related provisions specific to American Indians and Alaska 

Natives, including eliminating cost-sharing, such as deductibles and 

copays, for services provided to certain enrollees at or below 300 percent 

of the FPL, or for services provided by I/T/Us, regardless of the enrollee’s 

income.37

 

35The U.S. Supreme Court ruled in June 2012 that states choosing not to expand 

Medicaid coverage to individuals eligible under PPACA will forgo only the federal 

matching funds associated with such expanded coverage, rather than a termination of all 

Medicaid federal matching funds. See Nat’l Fed’n of Indep. Bus. v Sebelius,132 S.Ct. 

2566 (2012).

Additionally, expected to begin in 2015, states may implement 

the Basic Health Program option, under which the federal government is 

to give states 95 percent of the premium tax credits and cost-sharing 

subsidies that would have been provided if the individuals had been 

PPACA established 133 percent of the FPL as the income limit for Medicaid eligibility; 

however, it also specifies that an income disregard in the amount of 5 percent of the FPL 

be deducted from an individual’s income when determining Medicaid eligibility, which 

effectively raises the eligibility limit for newly eligible Medicaid recipients to 138 percent of 

the FPL. See Pub. L. No. 111-148, §§ 2001(a), 2002, 124 Stat. 119, 271, 279 (2010); Pub. 

L. No. 111-152, § 1004, 124 Stat. 1029, 1034 (2010) (codified at 42 U.S.C. 

§ 1396a(a)(10)(A)(i)(VIII) and to be codified at 42 U.S.C. § 1396a(e)(14)(I)).

36See Pub. L. No. 111-148, §§1401, 10105(a)-(c), 10108(h), 124 Stat. 119, 213, 906, 914 

(2010); Pub. L. No. 111-152, §§ 1011, 1004, 124 Stat. 1029, 1030, 1034 (2010) (codified 

at 26 U.S.C. § 36B); 26 C.F.R. § 1.36B-2(a)(1). In addition, PPACA provides cost-sharing 

subsidies to certain eligible individuals between 100 and 250 percent of the FPL to assist 

with such expenses as deductibles and copays, as well as limits on the percentage of 

income that health plans can charge enrollees for cost-sharing. See Pub. L. No. 111-148, 

§ 1402(c), 124 Stat. 119, 221 (2010); Pub. L. No. 111-152, § 1001, 124 Stat. 1029, 1039 

(2010) (codified at 42 U.S.C. § 18071).

37See Pub. L. No. 111-148, §1402(d), 124 Stat. 119, 222 (2010) (codified at 42 U.S.C. 

§ 18071).

PPACA Provisions 

Affecting American 

Indians and Alaska Natives
 

Page 15 GAO-13-553 Indian Health Service

enrolled in the Exchanges to allow the states to provide coverage for 

individuals, including American Indians and Alaska Natives, with incomes 

between 138 and 200 percent of the FPL. Finally, although PPACA 

generally requires that individuals obtain health insurance or be subject to 

a federal tax—a requirement often referred to as the individual mandate—

certain American Indians and Alaska Natives are statutorily exempt—

specifically, those who are members of federally recognized tribes.38 In 

June 2013, after our draft report was submitted to the agency for review 

and comment, HHS released a final rule establishing additional 

exemptions for specified individuals under its authority to establish 

hardship exemptions. The final rule included a hardship exemption for 

American Indians and Alaska Natives eligible for services from an Indian 

health care provider who are not members of federally recognized 

tribes.

39

Because of the definitions used in PPACA to specify eligibility for certain 

benefits, some groups of American Indians and Alaska Natives 

participating in the Exchanges will not be eligible for certain benefits 

available beginning in 2014 compared to other American Indians and 

Alaska Natives. Specifically, exemption from cost-sharing such as 

deductibles and copays, as well as special monthly enrollment 

periods

Without this hardship exemption, American Indians and Alaska 

Natives who were not enrolled in a federally recognized tribe but who 

were still eligible for IHS services—for example, nonmember 

descendants—would have been subject to the individual mandate. 

40

 

38See Pub. L. No. 111-148, §§ 1501(b),10106, 124 Stat. 119, 244, 909 (2010); Pub. L. 

No. 111-152, §§ 1002, 1004, 124 Stat. 1029, 1032, 1034 (2010) (codified at 26 U.S.C. 

§ 5000A).

—apply to “Indians,” a term that is defined in PPACA provisions 

by reference to definitions found in other federal statutes that define 

39HHS established hardship exemptions for individuals eligible for IHS services who are 

not members of federally recognized tribes and for individuals living in states that chose 

not to expand Medicaid eligibility but who would otherwise qualify for it. 78 Fed. Reg. 

39,494 (July 1, 2013).

40Under PPACA, eligible American Indians and Alaska Natives may enroll in a different 

Exchange plan each month, in contrast to annual enrollment windows generally applicable 

to other participants. See Pub. L. No. 111-148, § 1311(c)(6)(D), 124 Stat. 119, 175 (2010) 

(codified at 42 U.S.C. § 18031(c)(6)(D)).
 

Page 16 GAO-13-553 Indian Health Service

Indians as members of federally recognized tribes.41 Consistent with the 

PPACA provisions, CMS’s final rule for the establishment of the 

Exchanges provided that the benefits related to cost-sharing and special 

enrollment periods apply only to members of federally recognized tribes. 

CMS officials involved with the design of the single, streamlined 

application for health insurance—a PPACA requirement—told us that the 

application will include a section of questions specific to American Indians 

and Alaska Natives, including information about membership in a 

federally recognized tribe.42 PPACA also requires establishment of 

application assistance programs,43 which may help American Indians and 

Alaska Natives understand which provisions apply to them.

 

41Cost-sharing protections specific to American Indians and Alaska Natives incorporate 

the definition of Indian in section 4(d) of the Indian Self-Determination and Education 

Assistance Act, codified at 25 U.S.C. § 450b(d). The special enrollment period provision 

incorporates the definition of Indian in section 4 of the Indian Health Care Improvement 

Act, codified at 25 U.S.C. § 1603(13). CMS’s final rule for the establishment of the 

Exchanges, published March 27, 2012, stated that the definitions contained in both the 

Indian Self-Determination and Education Assistance Act and the Indian Health Care 

Improvement Act are operationally equivalent and include only individuals who are 

members of federally recognized tribes. See 77 Fed. Reg. 18,310, 18,346. The United 

States recognized 566 tribes as of May 2013. 

In contrast, in the American Recovery and Reinvestment Act in 2009, Congress 

established premium and cost-sharing protections for American Indians and Alaska 

Natives enrolled in Medicaid, without linking them to a specific definition of Indian. See 

Pub. L. No. 111-5, § 5006(a), 123 Stat. 115, 505 (2009) (codified at 42 U.S.C. § 1396o(j)). 

Consequently, CMS’s regulation implementing these protections uses a broader definition 

that includes all American Indians and Alaska Natives who are eligible for IHS services. 

See 75 Fed. Reg. 30,244, 30,247 (May 28, 2010) (amending 42 C.F.R. § 447.50).

42PPACA requires the use of a single, streamlined application for health insurance that 

will include application pathways for Medicaid, CHIP, and the Exchanges. See Pub. L. 

No. 111-148, § 1413, 124 Stat. 119, 233 (2010) (codified at 42 U.S.C. § 18083). In 

April 2013, HHS released the model application to be used in federally operated 

Exchanges, which will also be used by state-operated Exchanges unless the Secretary of 

Health and Human Services grants permission to a state to use its own. The single, 

streamlined application is expected to be available for open enrollment beginning in 

October 2013 for coverage that begins in January 2014.

43See Pub. L. No. 111-148, §§ 1311(d)(4)(K),(i), 10104(h), 124 Stat. 119, 177, 180, 901 

(2010) (codified at 42 U.S.C. § 18031). Application assistance programs are intended to 

help individuals submit the application, compare plans, and complete the enrollment 

process. 
 

Page 17 GAO-13-553 Indian Health Service

Consequently, these benefits may not apply to American Indians and 

Alaska Natives eligible for IHS services who

• live in urban locations and use urban Indian health programs, but who 

are not able to obtain tribal enrollment because they do not meet 

residency or other requirements, or are unable to document their 

descent,

• are affiliated with an Indian tribe but do not meet the tribe’s minimum 

blood quantum requirements for enrollment, and

• would otherwise be eligible for tribal membership, except for certain 

requirements set by the tribe: for example, some tribes limit their 

membership to adults or base membership on matrilineal descent.44

We and others have noted in past reports that American Indians and 

Alaska Natives may face challenges in enrolling in Medicaid, CHIP, and 

Medicare.45 According to a CMS-funded research paper, American 

Indians and Alaska Natives, and agencies seeking to enroll them in public 

programs, face unique challenges to enrollment, as well as other 

challenges common to rural populations.46

 

44Criteria for tribal membership vary by tribe and include such requirements as 

documented descent from an original member, residency on tribal lands, or minimum 

blood quantum levels—that is, the required degree of ancestry from a particular tribe.

Some challenges described 

relate to the relationship between the federal government and tribes and 

the treaty agreements and statutes that established a responsibility to 

provide health care—for example, the belief by some American Indians 

and Alaska Natives that such responsibility means that tribal members 

should not have to apply for assistance through public programs. This 

government-to-government relationship may also make some tribes 

hesitant to interact with state-run programs. Other challenges reported 

include lack of awareness about health care coverage programs 

generally; limited knowledge of benefits and eligibility criteria for 

programs; significant transportation challenges, and language and literacy 

45See GAO, Medicare and Medicaid: CMS and State Efforts to Interact with the Indian 

Health Service and Indian Tribes, GAO-08-724 (Washington, D.C.: July 11, 2008).

46See K. L. Langwell et al., “American Indian and Alaska Native Eligibility and Enrollment 

in Medicaid, SCHIP, and Medicare” (December 2003). This report, commissioned by 

CMS, included extensive analysis of common challenges affecting American Indian and 

Alaska Native participation in public programs.
 

Page 18 GAO-13-553 Indian Health Service

barriers; the complexity of application and renewal processes for health 

care coverage programs; and cultural barriers. According to the same 

CMS-funded report, because a large proportion of American Indians and 

Alaska Natives reside in rural areas on reservations with high poverty 

rates and low educational levels, these challenges may be significant 

deterrents to enrollment.

HHS has previously managed successful outreach and enrollment 

campaigns that may provide lessons learned, such as for the CHIP and 

the Medicare Part D prescription drug benefit programs. CHIP was 

established in August 1997 to reduce the number of low-income 

uninsured children in families with incomes too high to qualify for 

Medicaid. Medicare Part D was authorized in 2003 to provide an 

outpatient prescription drug benefit to millions of people already enrolled 

in Medicare.47 As we and others have noted in previous reports,48 both 

programs relied heavily on large-scale media campaigns to raise 

awareness among the general public. For CHIP, state outreach efforts 

encompassed multiple marketing approaches including multimedia 

campaigns, direct mailings, toll-free hotlines, widespread distribution of 

applications, and community- and school-based enrollment campaigns. In 

promoting Medicare Part D and the temporary drug discount card that 

preceded it, CMS employed a mass-media campaign comprised of largescale advertising, direct mail, a dedicated website, and a toll-free hotline, 

as well as one-on-one counseling and partnerships with community 

organizations. Enrollment in both CHIP and Medicare Part D was high as 

the programs began, and increased steadily over time.49

 

47Medicare Part D took effect in 2006, although it was preceded by a temporary 

prescription drug discount card program beginning in 2004.

48See GAO, Children’s Health Insurance Program: State Implementation Approaches Are 

Evolving, GAO/HEHS-99-65 (Washington, D.C.: May 14, 1999); Medicare: CMS’s 

Beneficiary Education and Outreach Efforts for the Medicare Prescription Drug Discount 

Card and Transitional Assistance Program, GAO-06-139R (Washington, D.C.: Nov. 18, 

2005).

49Enrollment in CHIP exceeded 700,000 in its first year—fiscal year 1998—and continued 

to grow steadily for more than a decade. By the final quarter of fiscal year 2000, all 

50 states and the District of Columbia had implemented CHIP with a total enrollment of 

nearly 2.7 million. By fiscal year 2010, CMS reported CHIP enrollment had reached nearly 

7.7 million. By 2010 nearly 30 million people had enrolled in Medicare Part D.

Prior CMS Outreach and 

Enrollment Efforts
 

Page 19 GAO-13-553 Indian Health Service

Despite the gains in CHIP enrollment over the last decade, in 2009 

Congress recognized that some children eligible for CHIP, as well as 

Medicaid, were still not enrolled, and therefore included in CHIPRA funds 

for Medicaid and CHIP outreach targeted at enrollment. Of this funding, 

CHIPRA provided $10 million for the Secretary of Health and Human 

Services to award grants to I/T/Us to conduct outreach and enrollment 

efforts to increase Medicaid and CHIP coverage among American Indian 

and Alaska Native children.50 Most of the funding, administered by CMS, 

was awarded in 2010 to 41 organizations in 19 states.

We estimate that, beginning in 2014, hundreds of thousands—more than 

half—of American Indians and Alaska Natives will be potentially eligible 

for health care coverage through Medicaid or the Basic Health Program, 

or for cost-sharing exemptions and premium tax credits for insurance 

obtained through the Exchanges. States’ decisions whether to expand 

their Medicaid programs may affect coverage for many American Indians 

and Alaska Natives, however.

 

50See Pub. L. No. 111-3, § 201(a), 123 Stat. 8, 36 (2009) (codified at 42 U.S.C. 

§ 1397mm(b)(2)).

Most American 

Indians and Alaska 

Natives Will Be 

Potentially Eligible 

for Expanded 

Medicaid and New 

Coverage Options; 

States’ Decisions Will 

Affect Coverage for 

Many 
 

Page 20 GAO-13-553 Indian Health Service

If all states opt to expand their Medicaid programs, we estimate that more 

than half of all American Indians and Alaska Natives will be potentially 

eligible for Medicaid51 in 2014. Excluding those already enrolled, potential 

new enrollment in Medicaid could exceed 650,000 out of 2.4 million 

(27 percent) for those identifying as American Indians and Alaska Natives 

alone, and almost 1.2 million out of 4.8 million (25 percent) for those 

identifying as American Indians and Alaska Natives alone or in 

combination with another race.52 Compared to the general population, a 

significantly larger proportion of American Indians and Alaska Natives are 

potentially eligible for expanded Medicaid. Potential new enrollment 

among American Indians and Alaska Natives is also proportionally 

greater than among the general population. (See table 1.)

 

51We estimated the number of American Indians and Alaska Natives potentially eligible for 

Medicaid as individuals who met the criteria for Medicaid eligibility in 2014, which included 

individuals eligible for Medicaid at the expanded income levels in PPACA, as well as 

individuals currently eligible for Medicaid as reported in the ACS.

52Because the number of IHS eligible individuals is likely to be between the number of 

individuals who self-identify as American Indians and Alaska Natives alone and American 

Indians and Alaska Natives alone or in combination, we presented results for both groups 

as the range.

In the 2010 Census, 2.9 million individuals reported as American Indian and Alaska Native 

alone, and 5.2 million reported as American Indian or Alaska Native alone or in 

combination with another race. The ACS estimates are lower, in part, because we 

excluded foreign-born American Indians and Alaska Natives from our analysis of ACS 

data. We present the total population estimate from the ACS to represent the basis for the 

percentages in our analysis throughout this report. These estimates are not meant to 

represent the population in the United States for any year in that period. To obtain the 

population count, researchers should use counts from the most recent Census or 

population estimates from the U.S. Census Bureau’s Population Estimates Program, 

which produces estimates of the population for the United States, its states, counties, 

cities, and towns, as well as for the Commonwealth of Puerto Rico.

More Than Half of 

American Indians and 

Alaska Natives Will Be 

Potentially Eligible for 

Coverage under Expanded 

Medicaid Depending on 

the Number of 

Participating States
 

Page 21 GAO-13-553 Indian Health Service

Table 1: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for Expanded 

Medicaid in 2014

Population group (Number)

Total potentially 

eligible 

number (percent)

Current 

enrollmenta Potential new enrollment

number (percent)

b

American Indian and Alaska Native alone (2.4 million from ACS)

number (percent)

1,368,316 (58) 718,254 (30) 650,062 (27)

American Indian and Alaska Native alone or in combination with 

another race (4.8 million from ACS) 2,569,410 (54) 1,377,924 (29) 1,191,486 (25)

All races (309.2 million from ACS) 115,749,838 (37) 53,196,416 (17) 62,553,422 (20)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

The estimates we present have relative standard errors of less than 15 percent.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

These estimates reflect all potential new enrollment, including both those 

who may be newly eligible under 2014 eligibility rules and not enrolled, as 

well as individuals currently eligible but not enrolled. Nationally, among 

those identifying as American Indians and Alaska Natives alone, about 

16 percent will be newly eligible and about 11 percent are currently 

eligible but not enrolled.

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.

53

 

53Unless otherwise specified, when referring to potential new enrollment we include both 

those who will be newly eligible in 2014 and those who are currently eligible, but not 

enrolled.

Among those identifying as American Indians 

and Alaska Natives alone or in combination with another race, about 

15 percent will be newly eligible and about 10 percent are currently 

eligible but not enrolled. While not all eligible individuals will enroll, the 

extent to which American Indians and Alaska Natives enroll in these

programs is unknown.
 

Page 22 GAO-13-553 Indian Health Service

The 12 IHS service areas varied widely in the number and proportion of 

American Indians and Alaska Natives potentially eligible for Medicaid 

under 2014 rules and for potential new enrollment. The Oklahoma City 

area—the IHS service area with the largest population of American 

Indians and Alaska Natives—had large numbers and percentages of 

American Indians and Alaska Natives potentially eligible for Medicaid and 

of potential new enrollment.54

 

54As with the national level, most of the potential new enrollment among American Indians 

and Alaska Natives in the Oklahoma City area consists of those who will be newly eligible 

for expanded Medicaid.

The highest percentages of individuals 

potentially eligible for Medicaid were in the Aberdeen area for those 

identifying solely as American Indians and Alaska Natives (73 percent), 

and in the Navajo area for those identifying as American Indians and 

Alaska Natives alone or in combination with another race (71 percent). 

(See fig. 3).
 

Page 23 GAO-13-553 Indian Health Service

Figure 3: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for Expanded 

Medicaid in 2014, by IHS Service Area

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

The estimates we present have relative standard errors of less than 15 percent. 

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.
 

Page 24 GAO-13-553 Indian Health Service

While many American Indians and Alaska Natives in IHS service areas 

reflected potential new enrollment for Medicaid—we estimate about 

405,000 for American Indian and Alaska Native alone, and about 605,000 

for American Indian and Alaska Native alone or in combination with 

another race—a large number of American Indians and Alaska Natives 

living outside of IHS service areas are also potentially eligible, and 

reflected a large number of potential new enrollees—we estimate about 

245,000 for American Indian and Alaska Native alone, and 587,000 for 

American Indian and Alaska Native alone or in combination with another 

race. (See fig. 4.) American Indians and Alaska Natives living outside IHS 

service areas were more likely to identify as American Indian or Alaska 

Native in combination with another race. Individuals living outside IHS 

service areas are less likely to have access to IHS or tribal health 

services. For American Indians and Alaska Natives not located in IHS 

service areas, states’ decisions regarding Medicaid expansion could 

affect their coverage options and access to care, particularly if those 

American Indians and Alaska Natives living outside IHS service areas are 

not eligible for services at federally or tribally operated facilities, a group 

which may include many urban Indians. Appendix II provides more 

information on the estimated numbers and percentages of American 

Indians and Alaska Natives potentially eligible for expanded Medicaid, by 

IHS service area.
 

Page 25 GAO-13-553 Indian Health Service

Figure 4: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for Expanded 

Medicaid in 2014 for IHS Service Areas and Non-IHS Service Areas

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

The estimates we present have relative standard errors of less than 15 percent.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who are eligible now, but did not report to ACS as being currently enrolled. Percentages of 

current enrollment and potential new enrollment may not add up to the total of potentially eligible due 

to rounding.
 

Page 26 GAO-13-553 Indian Health Service

Our analysis assumed that all states would opt to participate in the 

expanded Medicaid program; however, some IHS service areas have 

large American Indian and Alaska Native populations located in states 

that may choose not to expand their Medicaid programs. This would limit 

access to Medicaid benefits for those who would be eligible for expanded 

Medicaid, as well as limit I/T/U facilities’ ability to obtain Medicaid revenue 

for services provided to these individuals. For example, Oklahoma 

announced in November 2012 that the state would not pursue Medicaid 

expansion. In the state of Oklahoma alone, which comprises most of the 

Oklahoma City IHS service area, we estimate that potential new 

enrollment for Medicaid in 2014 would exceed 76,000 for individuals 

identifying as American Indians and Alaska Natives alone and more than 

137,000 for those identifying as American Indians and Alaska Natives 

alone or in combination with another race.55 According to CMS officials, 

states have not been given a deadline to declare their interest in 

expanding Medicaid. Some states have expressed intent to expand their 

programs, while others have indicated they will not participate.56 See 

appendix III for state-level estimates of potential new Medicaid enrollment 

to understand the effect of each state's decision regarding Medicaid 

expansion.

 

55As with the national level, most of the potential new enrollment among American Indians 

and Alaska Natives in the Oklahoma City area consists of those who will be newly eligible 

for expanded Medicaid, but includes some who may be currently eligible but not enrolled.

56As of June 14, 2013, the Advisory Board Company’s online Daily Briefing noted that the 

governors of 26 states and the District of Columbia announced they will participate in 

Medicaid expansion, 1 state is considering participating, 13 states announced they will not 

participate, 6 states are considering not participating, and 4 states are planning or 

proposing to increase coverage through other means. See http://www.advisory.com/DailyBriefing/2012/11/09/MedicaidMap, downloaded August 19, 2013.

While some states have indicated they do not intend to participate, they may opt to do so 

at a later date.
 

Page 27 GAO-13-553 Indian Health Service

More than one-third of certain American Indians and Alaska Natives may 

also be potentially eligible for premium tax credits for insurance obtained 

through the Exchanges, many of whom would also be eligible for costsharing protections and, to a lesser extent, the Basic Health Program, on 

the basis of our estimates. Specifically, about 832,000 American Indians 

and Alaska Natives who identified as American Indians and Alaska 

Natives alone are potentially eligible for premium tax credits, as are 

1.7 million who identified as American Indians and Alaska Natives alone 

or in combination with another race. More than 623,000 American Indians 

and Alaska Natives who identified as American Indians and Alaska 

Natives alone are within the income range for cost-sharing exemptions for 

insurance obtained through the Exchanges, as are almost 1.3 million who 

identified as American Indians and Alaska Natives alone or in 

combination with another race.57 If all states decided to run a Basic 

Health Program,58 we estimate that more than 292,000 American Indians 

and Alaska Natives who identified as American Indians and Alaska 

Natives alone could be covered, as well as about 593,000 American 

Indians and Alaska Natives who identified as American Indians and 

Alaska Natives alone or in combination with another race. Unlike potential 

eligibility for Medicaid, the percentages of American Indians and Alaska 

Natives potentially eligible for the Basic Health Program and cost-sharing 

exemptions and premium tax credits for insurance obtained through the 

Exchanges are comparable to the general population at the same income 

levels. (See table 2.) Appendix III provides more information on American 

Indians and Alaska Natives’ potential eligibility for public programs.

 

57Some American Indians and Alaska Natives may not be members of federally 

recognized tribes, a requirement of eligibility for the cost-sharing exemptions. 

58As of May 2013, HHS had not issued any rules regarding the Basic Health Program 

option, but announced in February 2013 that the program would begin in 2015, rather than 

2014 as originally planned. 

About 35 Percent of 

American Indians and 

Alaska Natives Are 

Potentially Eligible for One 

or More Special Provisions 

under New Coverage 

Options 
 

Page 28 GAO-13-553 Indian Health Service

Table 2: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for the Basic 

Health Program Option and for Cost-Sharing and Premium Tax Credits under the Health Insurance Exchanges

Population group (Number)

Basic Health 

Program optiona Exchange costsharing exemptions

number (percent)

b Exchange premium 

tax credits

number (percent)

c

American Indian and Alaska Native alone (2.4 million from ACS)

number (percent)

292,599(12) 623,890(26) 831,985(35)

American Indian and Alaska Native alone or in combination with 

another race (4.8 million from ACS) 593,367(12) 1,290,362(27) 1,744,651(37)

All races (309.2 million from ACS) 35,432,727(11) 82,560,360(27) 118,632,279(38)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

The estimates we present have relative standard errors of less than 15 percent.

We did not predict the number of people who will participate in these new coverage options, 

commonly referred to as the take-up rate.

Certain individuals who are eligible for the premium tax credits may also be eligible for cost-sharing 

exemptions.

a

Beginning in 2015, states may opt to run a Basic Health Program for individuals between 138 and 

200 percent of the federal poverty level (FPL). These estimates are if all states opt to run a Basic 

Health Program.

b

Certain American Indians and Alaska Natives obtaining insurance through the Exchanges who are at 

or below 300 percent of the FPL are exempt from cost-sharing, such as deductibles and copays, 

although our estimates reflect only those above 138 percent of the FPL because individuals below 

this level would be potentially eligible for expanded Medicaid. While this provision applies only to 

certain American Indians and Alaska Natives and not the general population, we provide data here for 

all races at the same income level for comparison.

c

Individuals obtaining insurance through the Exchanges who are between 100 and 400 percent of the 

FPL are eligible for premium tax credits on a sliding scale, although our estimates reflect only those 

above 138 percent of the FPL because individuals below this level would be potentially eligible for 

expanded Medicaid. Individuals with incomes above 138 percent of the FPL who may be eligible for 

Medicaid in a particular state are not eligible for premium tax credits.
 

Page 29 GAO-13-553 Indian Health Service

Although efforts have been made by the federal agencies and states we 

interviewed to facilitate Medicaid enrollment through training of I/T/U 

facility staff and conducting outreach for current public programs, 

uncertainty, lack of capacity-building, and limited awareness and 

information present challenges to enrollment in expanded Medicaid and 

new coverage options.59

IHS, CMS, and the three states we interviewed reported taking some 

steps to train I/T/U facility staff on current program eligibility; however, 

most efforts to facilitate enrollment of individuals in these programs have 

taken place at the tribal or facility level.

According to IHS officials, the agency has collaborated with CMS to 

develop and disseminate information about program eligibility rules—

mainly on current programs with some limited information on the 

expanded and new coverage options—to I/T/U facilities and tribes 

through letters to tribal leaders, the IHS Director’s Blog, regional and 

national tribal consultation meetings, annual business office training, and 

a combined IHS and CMS national training for I/T/Us called the National 

Partnership Conference. However, officials from most of the nine facilities 

 

59Our review of the efforts to promote enrollment in expanded and new coverage options 

focused on expanded Medicaid and the Exchanges rather than on the Basic Health 

Program. 

Efforts Have Been 

Made to Enroll 

American Indians and 

Alaska Natives in 

Current Medicaid 

Programs, but 

Multiple Barriers May 

Hinder Enrollment in 

Expanded Medicaid 

and New Coverage 

Options 

Most Efforts to Promote 

Enrollment in Current 

Medicaid Programs Were 

Conducted by I/T/U 

Facilities and Tribes; 

Limited Efforts Have Been 

Made regarding Expanded 

and New Coverage Options

IHS
 

Page 30 GAO-13-553 Indian Health Service

and three tribes that we interviewed said that they received little or no 

guidance from IHS regarding expanded Medicaid or the Exchanges as of 

February 2013.60

IHS officials told us that the agency does not conduct direct outreach to 

individual IHS users or to American Indian and Alaska Native 

communities at the headquarters level. Rather, direct outreach is 

generally conducted at the facility level by both tribally and federally 

operated facilities. The agency also contracts with other organizations to 

develop and disseminate outreach and educational materials. For 

PPACA-related outreach, the agency provided $1.8 million in funding to 

three national tribal organizations—the National Indian Health Board, 

National Congress of American Indians, and National Council of Urban

Indian Health—over fiscal years 2011 through 2013 to develop and 

distribute materials for educating I/T/Us, tribes, and American Indian and 

Alaska Native communities about the expanded and new coverage 

options. These organizations have produced educational materials and 

tools designed to assist I/T/U administrators and tribal leaders in 

understanding PPACA-related changes, including Medicaid expansion 

and the Exchanges. They have also produced some training materials; 

however, additional direct outreach materials (such as mass media 

materials for general education, e.g., posters, videos, or mailers) for 

American Indians and Alaska Natives were still being developed and not 

widely disseminated as of April 2013. IHS also reported providing 

$3.7 million over fiscal years 2011 through 2013 to IHS area offices to 

educate tribes and organizations about PPACA, such as through briefing 

sessions for tribal leaders and facility staff. As the implementation of 

CHIP and Medicare Part D demonstrated, an effective outreach effort for 

building awareness of new programs and encouraging enrollment 

requires a large, multipronged effort, including the use of media, direct 

mail, one-on-one counseling, and partnerships with community 

In contrast, federal internal control standards specify 

that agency management should ensure that there are adequate means 

for timely and effective communication with stakeholders that have a 

significant effect on the agency achieving its goals.

 

60IHS officials also noted that IHS collaborated with CMS to develop regulations on the 

expanded and new coverage options. Although some of these documents were not 

finalized until after our site visits, when we followed up with the facilities and tribes in 

February 2013, most confirmed at that time that they still had received little or no guidance 

from IHS.
 

Page 31 GAO-13-553 Indian Health Service

organizations. IHS’s efforts, however, do not match the large, 

multipronged efforts launched in advance of CHIP and Medicare Part D.

Additionally, IHS officials told us that the agency distributed a “business 

plan template” in April 2013. Using this template, IHS facilities were 

expected to submit a business plan to their respective area office director 

in May 2013. The business plan template, an initiative led by the IHS 

Deputy Director for Field Operations, is intended to help facilities identify 

and plan for their community outreach and staff training needs, among 

other things, in preparation for implementation of PPACA.61

CMS has likewise reported disseminating information to I/T/U facilities 

about program eligibility rules under Medicaid and CHIP, and introductory 

material about the expanded and new coverage options, through regional 

and national training in collaboration with IHS, webinars, web-based 

videos, regular conference calls, and through the agency’s regional 

Native American Contacts.

Although IHS 

officials said these templates were also shared with tribal facilities and 

urban Indian health programs, only IHS facilities have been directed to 

submit them. IHS headquarters officials told us in April that the area 

directors would be responsible for reviewing the plans and at this time 

IHS’s headquarters would not conduct any additional review or analysis.

62 However, officials from most of the nine 

facilities and three tribes that we interviewed said that they received little 

or no guidance from CMS regarding expanded Medicaid or the 

Exchanges as of February 2013, similar to what they reported about a 

lack of information from IHS.63

 

61Additional components of the IHS business plan template include assessing the 

potential for growth in third-party billing and determining the effect on CHS programs, and 

other assessments to help prepare facilities for expanded and new coverage options.

CMS officials indicated that additional, 

more-specific regional training on Medicaid expansion and the Exchanges 

would be planned after more states made decisions about whether to 

participate in expanded Medicaid or how Exchanges will operate. CMS 

officials also told us that they are planning nationwide training on PPACArelated changes, including expanded Medicaid and the Exchanges. The 

62Native American Contacts are CMS staff based in the agency’s 10 regional offices who 

serve as a resource to tribes and I/T/U facilities for questions about Medicaid, CHIP, and 

Medicare.

63According to HHS, travel restrictions and budget cuts in recent years have impeded 

CMS’s ability to provide the typical level of in-person training for I/T/U facilities. 

CMS
 

Page 32 GAO-13-553 Indian Health Service

officials said this training is intended to include a broader audience than 

the past regional training and will include tribal and community leaders in 

addition to I/T/U facility staff.

CMS officials described a variety of direct outreach materials the agency 

has developed to educate American Indian and Alaska Native 

communities about current Medicaid and CHIP, including posters, 

brochures, and DVDs, for use by facilities in promoting enrollment in 

current programs. Officials told us that, as part of the agency’s 

implementation of provisions regarding expanded Medicaid and the 

Exchanges, its Office of Communications is developing a general 

outreach strategy, which will include an American Indian and Alaska 

Native–specific component led by the CMS Tribal Affairs Group in 

collaboration with IHS. In March 2013, officials told us they planned to 

implement this outreach strategy in the coming months, noting that they 

did not want to launch outreach too early because the application to enroll 

would not be available until October 2013.64 Officials also told us that they 

recently adapted materials developed for the general population by the 

Office of Communications with specific information on expanded Medicaid 

for American Indians and Alaska Natives, which were distributed in March 

2013 to attendees of IHS regional tribal consultation meetings. In May 

2013, CMS officials told us they recently launched a public website 

containing materials, including brochures, about the Exchanges for the 

general population, and were conducting a national awareness campaign 

about the Exchanges. As of May 2013, CMS was adapting the materials 

on the website for the American Indian and Alaska Native population, 

which were still under internal review.65

 

64A 6-month initial open enrollment period for the Exchanges is expected to begin October 

2013 for the coverage that begins in January 2014.

In addition, CMS officials told us 

they plan to issue an announcement later this year to provide an 

additional $4 million in funding specifically for tribal outreach for Medicaid 

and CHIP, as authorized by PPACA. The $10 million in CHIPRA tribal 

outreach grants CMS administered to 41 organizations in 2010 resulted in 

nearly 20,000 American Indian and Alaska Native children enrolled in the 

65In May 2013, CMS officials told us that the website about the Exchanges, at 

marketplace.cms.gov, would be relaunched once the materials targeted to the American 

Indian and Alaska Native population had been approved. 
 

Page 33 GAO-13-553 Indian Health Service

first 2 years of funding.66

Two of the three states we interviewed conducted training for facility staff 

on their current Medicaid and CHIP programs and all three produced 

outreach materials, although none were engaged in training or outreach 

for expanded Medicaid or the Exchanges as of February 2013. 

Specifically, Montana and New Mexico reported conducting some training 

for I/T/U facilities regarding program eligibility and enrollment procedures 

under current Medicaid and CHIP, but not for expanded Medicaid or the 

Exchanges. These states distributed Medicaid and CHIP information to 

facilities through training, regular meetings with business managers and, 

in Montana, on-site training. Although officials in South Dakota indicated 

the state had not conducted any training of its own, the state has provided 

materials for the IHS area office to distribute to facility staff with 

information on eligibility and enrollment procedures. Direct outreach to 

American Indians and Alaska Natives by all three states we spoke with 

was limited and focused on current Medicaid and CHIP programs. 

Specifically, all three states produced and distributed print materials 

promoting their current Medicaid and CHIP programs, such as brochures 

and posters, and New Mexico also conducted radio advertising. 

Additionally, in Montana, the Medicaid program provided reimbursement 

for outreach activities conducted by two tribes.

Although the grants did not include an emphasis 

on the expanded and new coverage options, one CMS official noted that 

the lessons learned about effective tribal outreach through grantees’ 

efforts can be applied to future years.

67

 

66CMS reported that grantees enrolled, or in some cases reenrolled, 19,602 American 

Indian and Alaska Native children through the second year of the 3-year grant period 

(April 16, 2010, to April 15, 2013); however, data were reported for only 35 of the 

41 grantees. According to the CMS official we spoke with, certain data-reliability issues 

that prevented complete reporting in the first and second year were being addressed, and 

data for the third year would be available in 2014.

None of the three states 

reported conducting any outreach regarding the expanded and new 

coverage options.

67Members of the Tribal Technical Advisory Group, a body that advises CMS on American 

Indian and Alaska Native issues, told us that the cost associated with Medicaid outreach is 

not affordable for many tribes and that few states provide reimbursement, although states’ 

interest in the practice may be increasing. According to CMS officials, in addition to 

Montana, California’s Medicaid program has also been approved to allow Medicaid 

matching for tribal outreach activities, plans for Washington and Alaska were pending, and 

three other states had expressed interest. Such reimbursement will assist those tribes for 

whom outreach activities may not otherwise be affordable.

States
 

Page 34 GAO-13-553 Indian Health Service

Besides facility training and outreach as a means of facilitating enrollment 

of American Indians and Alaska Natives, officials in all three states 

reported more than one option available for individuals to enroll in 

Medicaid or CHIP. In addition to the option of enrolling at local enrollment 

offices and by mail, individuals could enroll online in Montana and by 

means of e-mail in New Mexico. Additionally, New Mexico installed 

electronic enrollment kiosks in select locations, and South Dakota was in 

the process of implementing kiosks with a native language audio format 

option. Although all the I/T/U facility staff we interviewed helped patients 

with submitting enrollment applications, eligibility was generally 

determined by the Medicaid program’s local enrollment office; however, in 

Montana, the state entered into an agreement with one tribe to allow the 

tribe to complete the Medicaid determination process itself. Finally, two 

states—Montana and New Mexico—allowed for presumptive eligibility for 

children and pregnant women, in which individuals who appear to be 

eligible can receive covered services while their applications are being 

processed.

All the facilities we interviewed—three IHS-operated, three tribally 

operated, and three urban Indian health programs—reported that they 

routinely screen patients visiting their clinics for potential eligibility for 

Medicaid and CHIP.68

 

68In addition to community outreach, one tribal facility conducted targeted “cold calls” to 

tribal members turning 65 to set up a clinic visit, at which Medicare eligibility would be 

determined, and screened high-cost CHS users for eligibility for the state or federal highrisk insurance pool, private coverage through a spouse, or possible Medicaid or Medicare 

eligibility through disability status.

The three tribal facilities, three urban Indian health 

programs, and three CHIPRA tribal outreach grantees were also involved 

in community outreach efforts outside of the clinic, including participation 

at community events, such as health fairs, pow wows, school events, and 

senior-center meetings. Several facilities and CHIPRA tribal outreach 

grantees reported that incentives, such as gift cards, baby supplies, and 

raffle tickets, were effective tools for generating interest. Several facilities 

and CHIPRA grantees also reported using other outreach methods, 

including radio, TV, newspapers, direct mail, and Facebook. Two of the 

CHIPRA grantees reported using home visits as their primary outreach 

method. In contrast, one of the three IHS-operated facilities we met with 

conducted community outreach; the other two said they rely on the tribes 

in their service area to conduct outreach. As of February 2013, none of 

the I/T/U facilities we spoke with reported conducting any early outreach 

I/T/Us and Tribes
 

Page 35 GAO-13-553 Indian Health Service

regarding the expanded and new coverage options. However, in June

2013 IHS officials told us that, as part of its business plan template, IHS 

facilities are expected to assess the need for, and describe, their planned 

outreach activities.

We identified several issues that have presented and continue to present 

challenges to efforts to promote the enrollment of American Indians and 

Alaska Natives in the expanded and new coverage options, including 

legal and policy uncertainties, lack of capacity building, unfamiliarity with 

new and expanded coverage options, and tribes’ limited access to 

coverage status information that could help target outreach efforts.

Officials we interviewed at federal agencies and I/T/U facilities told us 

when we spoke with them prior to, and immediately following, the 

Supreme Court’s decision regarding PPACA that they were waiting for the 

court’s decision, and subsequently their states’ decisions about Medicaid 

expansion, before developing a plan to launch education and enrollment 

activities. Before the Supreme Court’s decision, both IHS and CMS 

headquarters officials noted they were waiting for the decision before 

engaging in more widespread efforts to educate facilities and American 

Indians and Alaska Natives about the expanded and new coverage 

options. Similarly, officials in the Albuquerque area—from the area office, 

New Mexico Medicaid office, and two of the three facilities we spoke with 

in the area—cited the pending Supreme Court decision, later released in 

June 2012, as the reason for little or no action taken to that point. 

Following the Supreme Court’s decision, we met with officials from the 

Aberdeen and Billings IHS service areas. Officials with the two IHS area 

offices, the South Dakota and Montana state Medicaid offices, and 

several facilities all cited uncertainty regarding their state’s pending 

decision about Medicaid expansion as a reason for continued inaction as 

of the time we spoke with them. As of June 2013, New Mexico had opted 

to participate in Medicaid expansion, South Dakota decided not to 

participate, and Montana had not decided.69

 

69South Dakota announced in December 2012 that it would not participate in Medicaid 

expansion; New Mexico announced in January 2013 that it will participate; and, as of June

2013, Montana’s Governor supported Medicaid expansion, but its legislature had not yet 

enacted a plan to expand it.

Multiple Barriers, 

Including Uncertainty and 

Lack of Capacity Building, 

Hinder Enrollment in 

Expanded Medicaid and 

New Coverage Options

Uncertainty Related to Pending 

Legal and Policy Decisions 
 

Page 36 GAO-13-553 Indian Health Service

I/T/U facilities will likely face increased workload related to enrollment in, 

and reimbursement from, Medicaid and the Exchange health plans with 

the estimated addition of hundreds of thousands of American Indians and 

Alaska Natives into expanded Medicaid and, to a lesser extent, the new 

coverage options under the Exchanges. IHS officials told us, however, 

that the agency has no national plan in place to adjust the number of 

patient benefit coordinators—I/T/U staff responsible for identifying 

program eligibility and assisting with enrollment—and billing staff to 

handle the large number of individuals who may seek to enroll in 

expanded Medicaid and the new coverage options. Officials said that 

increased collections through third-party billing from enrollments in public 

programs may provide additional funds to hire such staff, although they 

also acknowledged that such increased capacity would be needed prior to 

an increase in enrollment and collections. Officials told us that facility 

directors will need to maximize existing resources, adding that IHS’s 

ability to manage the implementation process at tribally operated facilities 

and urban Indian health programs is limited. To help facility directors 

prepare for the implementation of expanded and new coverage options, 

officials told us in April 2013 that IHS developed a business plan template 

that calls for facilities to assess their current levels of public and private 

insurance, potential enrollment growth, effect on staffing levels, the 

workforce needed for enrollment activities, and marketing strategy. 

According to IHS Headquarters officials, all federally operated IHS 

facilities have been directed to use the business plan template to 

complete and submit their implementation plans by May 2013. The lack of 

a plan to shift staff to help facilitate increased enrollment in, and billing 

for, expanded Medicaid and new coverage options could result in some 

eligible American Indians and Alaska Natives remaining unenrolled or 

some facilities unable to bill for services. In contrast, federal internal 

control standards specify that agency management should ensure that 

proper personnel, with the right training, are in place to enable 

organizational success. Officials expressed doubt, however, that the 

demand for expanded Medicaid and the Exchanges would be high when 

enrollment begins.

Officials with two of the three CHIPRA tribal outreach grantees with whom 

we met were unaware of Medicaid expansion and creation of the 

Exchanges at the time we first spoke with them, in June through August 

2012, more than 2 years after the enactment of PPACA. As direct service 

tribes, they relied on IHS-operated facilities for most of their health care 

services. The various training options cited by IHS and CMS, some of 

which included content on the expanded and new coverage options, were 

largely targeted to staff from IHS-operated and tribally operated facilities, 

Lack of Capacity Building

Unfamiliarity with Expanded 

and New Coverage 
 

Page 37 GAO-13-553 Indian Health Service

resulting in a potential gap in the level of awareness among direct service 

tribes, which generally do not operate their own health care facilities. 

Additionally, many of the officials from the I/T/U facilities we interviewed 

lacked awareness about eligibility for cost-sharing exemptions for 

insurance obtained through the Exchanges. CMS officials told us that 

they are including language in the brochures being developed for this 

population that will clarify which American Indians and Alaska Natives are 

eligible for cost-sharing exemptions and other provisions.

At least one tribal facility or CHIPRA tribal outreach grantee in each of the 

three areas in which we focused our interviews reported a lack of 

information on tribal members’ Medicaid enrollment status, which they 

said limits their ability to target outreach to nonenrollees and assist 

enrolled members with their annual Medicaid renewal applications. 

Specifically, they said that they had been unable to receive information on 

members’ coverage status from their states because of restrictions on 

information sharing under the Health Insurance Portability and 

Accountability Act of 1996 (HIPAA). The Privacy Rule promulgated under 

HIPAA permits individually identifiable health information to be shared in 

connection with providing or paying for health care but otherwise 

generally does not permit such information, including coverage status, to 

be shared without individuals’ authorization.70 Entities subject to the 

HIPAA Privacy Rule may, however, share such information without 

obtaining authorization in certain circumstances, such as in connection 

with government agencies providing public benefits.71

 

70See 45 C.F.R. § 164.502. The HIPAA Privacy Rule prescribes requirements and 

standards for protecting individually identifiable health information. An individual’s 

insurance status is considered individually identifiable health information and is protected 

from unauthorized disclosure under the HIPAA Privacy Rule. See 45 C.F.R. § 160.103. 

Disclosure of protected health information for purposes of treatment, payment, or health 

care operations is generally permitted. See 45 C.F.R. § 164.506.

The HIPAA Privacy 

Rule permits information sharing between health care providers and 

payers such as state Medicaid agencies and I/T/Us in connection with 

providing health care. Direct service tribes receive the majority of their 

71Under the HIPAA Privacy Rule, a government agency administering a government 

program providing public benefits, such as a state Medicaid agency, may disclose 

individually identifiable health information relating to the program to another government 

agency administering a government program providing public benefits, such as IHS and 

tribal health facilities, if the programs serve the same or similar populations and the 

disclosure of the information is necessary to coordinate, or to improve the administration 

and management of, the programs. See 45 C.F.R. § 164.512(k)(6)(ii).

Limited Access to Information
 

Page 38 GAO-13-553 Indian Health Service

primary health care services from IHS. In some instances, direct service 

tribes choose to provide services or operate a portion of or a health 

program pursuant to the Indian Self-Determination and Education 

Assistance Act (ISDEAA). Direct service tribes are considered tribal 

health providers for those services or programs operated under an 

ISDEAA self-determination contract or self-governance compact. 

According to CMS officials, in the context of these services or programs, 

states are thus permitted to share information with these tribes on their 

members’ coverage status without authorization. Confusion among states 

about whether they are allowed to share coverage status with tribes, 

particularly with direct service tribes, is an ongoing concern, they said, in 

part because the HHS guidance that clarified the permissibility of such 

sharing is nearly 30 years old and pre-dates HIPAA. This confusion limits 

tribes’ ability to assist their members with enrollment. Officials with one 

direct service tribe told us their preferred method for Medicaid outreach is 

door-to-door home visits, although they said the tribe is not able to target 

those efforts due to a lack of information on members’ coverage status, 

which reduces its effectiveness. All three CHIPRA tribal outreach 

grantees we interviewed said that they track the applications they submit 

as part of their outreach and enrollment efforts, although two noted that 

the applications submitted represent a small proportion of those eligible to 

enroll. One CHIPRA tribal grantee noted that keeping eligible members 

enrolled in Medicaid is also a challenge because many lack a permanent 

address or mailbox, and so do not receive renewal notices from the state. 

These challenges may affect HHS’s ability to achieve its goal of 

increasing health insurance coverage among racial and ethnic minorities 

as a means to eliminate health disparities.

The expansion of Medicaid and new coverage options under PPACA may 

allow many American Indians and Alaska Natives to obtain additional 

health care benefits for which they were not previously eligible. If 

American Indians and Alaska Natives enroll in these programs and 

choose to receive care through IHS, the increase in reimbursements from 

third-party payers may free up resources and help alleviate some of the 

pressures on I/T/U facilities’ and CHS budgets that contribute to unmet 

health care needs. Although some uncertainty remains regarding which 

states will opt to participate in Medicaid expansion, a significant share of 

the estimated hundreds of thousands of American Indians and Alaska 

Natives who could be eligible for expanded Medicaid are in states that 

plan to participate.

Conclusions 
 

Page 39 GAO-13-553 Indian Health Service

I/T/Us are leading current efforts to identify members who may be eligible 

for Medicaid and CHIP and assist with their enrollment process, and are 

poised to continue those efforts in the future. However, given the 

complexities of the eligibility requirements for different programs, these 

efforts can only be successful if facilities receive timely and important 

information from IHS and CMS, including specific information about new 

and expanding coverage options, such as eligibility rules, enrollment 

procedures, and other implementation details. The efforts to date to 

educate American Indians and Alaska Natives, and the facilities that 

serve them, about the coverage options available beginning in 2014 do 

not resemble the successful campaigns launched in advance of other 

recent programs. IHS and CMS have limited time to conduct a major 

outreach campaign before October 2013, when open enrollment in 

expanded Medicaid and the Exchanges begins. Increased enrollment will 

clearly lead to an increased workload for I/T/U facility staff; however, as of 

April 2013, IHS does not have an effective plan in place to ensure that a 

sufficient number of I/T/U staff are prepared to assist with enrollment and 

to process increased third-party payments. IHS officials told us their 

business plan template is intended to encourage facilities to plan for an 

increase in enrollment in expanded and new coverage options, although 

the effect of this step remains to be seen.

To help ensure successful outreach efforts resulting in significant new 

enrollment, we recommend that the Secretary of Health and Human 

Services direct

1. the Director of IHS and the Administrator of CMS to coordinate a plan 

to

• improve their communication with facility staff and tribal leaders to 

ensure that information on Medicaid and the Exchanges, including 

detailed information on program eligibility rules and enrollment 

procedures, is being disseminated to all facilities and tribes and

• increase direct outreach to American Indians and Alaska Natives 

who may be eligible for expanded Medicaid and the Exchanges; 

2. the Director of IHS to prepare for the increase in eligibility for 

expanded Medicaid and new coverage options, and the need for 

enrollment assistance and billing capacity, by realigning current 

resources and personnel to increase capacity to assist with these 

efforts; and

Recommendations for 

Executive Action
 

Page 40 GAO-13-553 Indian Health Service

3. the Administrator of CMS to develop a plan to educate state Medicaid 

agencies about when coverage status information may be shared 

between states and I/T/U facilities and tribes.

We provided a draft of this report for comment to HHS. HHS provided 

written comments, which we summarize below, in which HHS agreed with 

one recommendation and neither agreed nor disagreed with two 

recommendations. HHS’s letter is reprinted in appendix IV. HHS also 

provided technical comments, which we incorporated as appropriate.

HHS agreed with our recommendation for CMS and IHS to coordinate a 

plan to improve communications with facility staff and tribal leaders and 

increase direct outreach to American Indians and Alaska Natives who 

may be eligible for expanded Medicaid and the Exchanges. The 

department noted that CMS is working closely with IHS to develop and 

review outreach materials and information dissemination and training 

strategies. HHS also cited a number of activities conducted in 2012 and 

2013 intended to increase awareness among American Indians and 

Alaska Natives of expanded Medicaid and the Exchanges. In addition, in 

our draft report, we recommended the development of a strategy for 

educating American Indians and Alaska Natives about the effect of 

PPACA’s definition of Indian on their coverage options and obligations. 

The issuance of HHS’s final rule, which was released after our draft report 

had been submitted to HHS for review and comment, lessened the need 

for this strategy, and we deleted this recommendation accordingly.

HHS did not specify in its response whether it agreed or disagreed with 

our two remaining recommendations. In commenting on our 

recommendation for IHS to prepare for the increase in eligibility for 

expanded Medicaid and new coverage options and the need to increase

its capacity for enrollment assistance and billing, HHS noted that the IHS 

business plan template is intended to serve this purpose. In light of the 

decentralized nature of this approach, we continue to believe that IHS 

should realign current resources and personnel to assist with these 

efforts. In commenting on our recommendation for CMS to develop a plan 

to educate states about sharing coverage information with I/T/Us and 

tribes, HHS noted that it plans to provide information to states as part of 

its technical assistance activities, but that it needed additional clarity 

about our recommendation to fully comment. We had subsequent 

discussions with HHS and CMS regarding this recommendation and 

revised our report and the recommendation to reflect those discussions.

Agency Comments

and Our Evaluation
 

Page 41 GAO-13-553 Indian Health Service

We are sending copies of this report to the Secretary of Health and 

Human Services and other interested parties. In addition, the report is 

available at no charge on the GAO website at http//www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of the report. GAO staff who made major contributions to this report are 

listed in appendix V.

Kathleen M. King 

Director, Health Care
Page 42 GAO-13-553 Indian Health Service

List of Addressees

The Honorable Maria Cantwell

Chairwoman

The Honorable John Barrasso

Vice Chairman

Committee on Indian Affairs

United States Senate

The Honorable Don Young

Chairman

The Honorable Colleen Hanabusa

Ranking Member

Subcommittee on Indian and Alaska Native Affairs

Committee on Natural Resources

House of Representatives

The Honorable Tim Johnson

United States Senate

The Honorable Lisa Murkowski

United States Senate

The Honorable John Thune

United States Senate
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 43 GAO-13-553 Indian Health Service

To estimate the number of American Indians and Alaska Natives 

potentially eligible for expanded Medicaid and new coverage options that 

will be available beginning in 2014, we examined data from the American 

Community Survey (ACS) of the U.S. Census Bureau, which contains 

nationwide information on race, age, income, and health insurance 

coverage, and other variables as described below. We used 3 years of 

ACS data to make reliable estimates at the state and Indian Health 

Service (IHS) service area levels.1 In order to capture the appropriate 

family ties and income for determining program eligibility, we used an 

augmented version of the ACS data prepared by the University of 

Minnesota Population Center—the Integrated Public Use Microdata 

Series (IPUMS). We used the most recent data available—2009 through 

2011—to provide estimates of American Indians and Alaska Natives 

eligible for coverage in expanded Medicaid,2 the Basic Health Program, 

and income-based cost-sharing exemptions for American Indians and 

Alaska Natives and premium tax credits in the Exchanges—at the 

national, IHS service area, and state levels.

The ACS collects information about age, sex, race, family and 

relationships, income and benefits, health insurance, education, veteran 

status, disabilities, and geographic location, among other variables. The 

ACS initially samples about 3 million addresses each year, resulting in 

about 2 million final interviews for each year’s survey. For the 2011 

survey, a sample of 2.3 million households was selected from a sample 

frame of about 3.5 million. For the 2010 and 2009 surveys, a sample of 

2.1 million households was selected from a sample frame of 3.1 million, 

for each year.3

 

1

IHS coordinates care in 12 geographic areas in 35 states. The areas are Aberdeen, 

Alaska, Albuquerque, Bemidji, Billings, California, Nashville, Navajo, Oklahoma City, 

Phoenix, Portland, and Tucson.

2

The ACS data groups Medicaid and the Children’s Health Insurance Program (CHIP) 

together when collecting information about Medicaid coverage status. As a result, some 

individuals eligible for CHIP are combined with Medicaid in our analysis.

3

Information for the ACS was collected from housing units as well as group quarters, 

which include college dormitories, correctional facilities, and nursing facilities.

Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

About the ACS
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 44 GAO-13-553 Indian Health Service

In general, ACS estimates are period estimates that describe the average 

characteristics of population and housing over a period of data collection. 

The 2009-2011 ACS 3-year estimates are averages over the period from 

January 1, 2009 to December 31, 2011, and reflect what the average 

value is over the full period. Because survey data are based on a sample 

of the population, the numbers in the report are not the same as those 

that would be obtained if everyone in the population were actually 

counted. For this reason, the ACS combines data from multiple years to 

produce reliable estimates for small areas—such as states—and 

population groups, such as American Indians and Alaska Natives. To 

produce data for small communities—between 20,000 and 65,000 

individuals—3 years of data collection are pooled to produce reliable 

estimates.

Estimates from the ACS are subject to some sampling error. To assess 

the precision of these estimates, we calculated a relative standard error 

for each estimate. A relative standard error is calculated by dividing the 

standard error of the estimate by the estimate itself. For example, if an 

estimate has a mean of 100 and a standard error of 20, the relative 

standard error would be 20/100, which would be 20 percent. Estimates 

with small relative standard errors are considered more reliable than 

estimates with large relative standard errors. A small relative standard 

error is a more precise measurement since there is less variance around 

the mean. Unless otherwise noted, we present estimates that have 

relative standard errors of less than 15 percent. In addition to sampling 

errors, nonsampling errors may affect the data; however, the Census 

Bureau takes steps to minimize these errors.

The results of ACS data analysis are based on self-reported information. 

The Census Bureau applied some logical edits to the data to correct for 

obvious misunderstanding of the questions. All respondents to the survey 

are asked to identify their race, with the option to check one or more 

boxes indicating racial category.4

 

4

Specifically, the ACS questionnaire asks respondents to indicate their race by marking 

one or more selections among a number of racial categories, including white, 

black/African American, American Indian or Alaska Native, several options for Asian 

American and Pacific Islander, or “some other race,” with the option to fill in the name of 

an unlisted race. The ACS asks respondents a separate question about their Hispanic 

origin. Because Hispanic origin is not treated as a racial category, some individuals who 

identify solely as American Indian and Alaska Native may also identify as being of 

Hispanic origin.

We refer to respondents who marked 
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 45 GAO-13-553 Indian Health Service

only the “American Indian or Alaska Native” response box as the 

“American Indian and Alaska Native alone” population. We refer to 

respondents who marked both the “American Indian and Alaska Native” 

response box and one or more other racial categories as the “American 

Indian and Alaska Native alone or in combination” population. Selfidentification as an American Indian and Alaska Native in the ACS is not 

an indication of either being a member of a federally recognized tribe or 

eligibility for IHS services. In the absence of ACS data on IHS eligibility, 

we report our results separately for American Indians and Alaska Natives 

alone, and American Indians and Alaska Natives alone or in combination, 

allowing us to provide a lower and upper bound within which the number 

who are actually IHS-eligible is likely to fall. The range we report—of 

those identifying as American Indian and Alaska Native alone and those 

identifying as American Indian and Alaska Native alone or in combination 

with another race—include American Indians and Alaska Natives who are 

members of a federally recognized tribe. We excluded foreign-born 

American Indians and Alaska Natives from our analysis, as these 

individuals are generally unlikely to be eligible for IHS services.5

ACS data are reported in Public Use Microdata Areas (PUMA), which 

aggregates smaller counties or breaks up larger counties into units of 

100,000 individuals to protect anonymity. We created a crosswalk 

between the counties included in PUMAs and the counties included in 

each of the 12 geographic areas the Indian Health Service has 

designated for service, called IHS service areas.

Like other survey-based sources of coverage data—such as the National 

Health Interview Survey—the estimates from ACS data of Medicaid 

coverage are lower than numbers found in program counts by the 

Centers for Medicare & Medicaid Services (CMS), even after logical edits 

have been applied by the Census Bureau. In order to account for a 

variety of scenarios that might contribute to the differences in these 

 

5

We included native-born American Indians and Alaska Natives if they reported being 

born in the United States or its territories, or if they were born abroad to a parent or 

parents who were U.S. citizens. We excluded foreign-born American Indians and Alaska 

Natives if they reported being a naturalized citizen, or not a citizen. While American 

nationality is not a criterion for receiving IHS services, and several American Indian and 

Alaska Native tribes straddle the Canadian and Mexican borders, we aimed to include 

tribes that would be eligible for IHS services rather than tribes from, for example, South or 

Central America. Individuals from these tribes may report being American Indian or Alaska 

Native on the ACS.
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 46 GAO-13-553 Indian Health Service

numbers, one group of researchers has developed an additional set of 

edits—for example, assigning to Medicaid a child for whom no coverage 

was reported when that child has a sibling enrolled in Medicaid.6 We did 

not apply these edits because the publicly available data set was 

sufficient for the purpose of providing an approximate range in which the 

number of IHS-eligible American Indians and Alaska Natives could fall.

In order to capture the appropriate family ties and income for determining 

program eligibility, we used an augmented version of the ACS data 

prepared by the University of Minnesota Population Center—the 

Integrated Public Use Microdata Series (IPUMS).7 The IPUMS dataset 

constructs a health insurance unit variable that follows program eligibility 

definitions of family eligibility more closely than the ACS’ household unit.

The Patient Protection and Affordable Care Act (PPACA) expanded 

Medicaid and created new coverage options. For expanded Medicaid, 

assuming all states opt to participate, we estimated

• the total number of American Indians and Alaska Natives who are 

potentially eligible under the eligibility rules beginning in 2014, 

including: (1) all American Indians and Alaska Natives at or below 

138 percent of the federal poverty level (FPL);8

 

6

See Victoria Lynch et al., “Improving the Validity of the Medicaid/CHIP Estimates on the 

American Community Survey: The Role of Logical Coverage Edits” (Urban Institute Health 

Policy Center: Sept. 27, 2011). The researchers developed 16 additional edits applied to 

responses from children and 6 additional edits applied to responses from nonelderly 

adults, which when applied, resulting in a 3.5 and 0.8 percent increase in their 

Medicaid/CHIP estimates, respectively.

(2) American Indians 

and Alaska Natives above 138 of the FPL who were eligible in each 

state in 2011; (3) American Indians and Alaska Natives who received 

7

Steven Ruggles et al., Integrated Public Use Microdata Series: Version 5.0, machinereadable database (Minneapolis: University of Minnesota, 2010).

8

The FPL is another name for the poverty guidelines issued annually in the Federal 

Register by the Department of Health and Human Services. The FPL is a simplified 

version of the national poverty thresholds used for counting the number of people in 

poverty, and is used mainly for administrative purposes, such as determining eligibility for 

program participation.

Augmented American 

Community Survey 

Dataset 

Estimating Eligibility 

for American Indians 

and Alaska Natives in 

Expanded Medicaid 

and New Coverage 

Options 
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 47 GAO-13-553 Indian Health Service

supplemental security income;9 and (4) American Indians and Alaska 

Natives who reported in the ACS as being enrolled in Medicaid, but 

who did not meet the other three criteria;

10

• the number of American Indians and Alaska Natives who reported in 

the 2009-2011 ACS as being currently enrolled; and

• the number of potential new enrollees, calculated by determining the 

number of individuals who will be potentially eligible for expanded 

Medicaid including some who may be eligible now, but did not report 

to the ACS as being currently enrolled.11

To examine the number of American Indians and Alaska Natives who 

would be eligible for other benefits if they were not eligible for Medicaid, 

we also estimated the number of American Indians and Alaska Natives 

potentially eligible for the

 

• Basic Health Program option, if their income was between 138 and

200 percent of the FPL;

 

9

All states provide Medicaid eligibility based on disability status. In 39 states and the 

District of Columbia, recipients of supplemental security income are eligible for Medicaid, 

while 11 states apply their own eligibility criteria for Medicaid eligibility based on their own 

measures of disability status. Because these states allow Medicaid eligibility based on 

some measure of disability status, we did not exclude them.

10About 7.2 percent of those who identified as being currently enrolled in Medicaid did not 

otherwise meet our criteria—that is, they did not report income below the levels we used 

to estimate eligibility for Medicaid or report receiving supplemental security income. This 

could be due to a variety of factors, such as: a difference between state Medicaid eligibility 

rules during the survey response time frame (2009-2011) and the year reflected in the 

state-specific limits we applied to the data (2011); a difference in how income is defined in 

the ACS, in contrast to how income is applied for Medicaid eligibility, which excludes 

certain income sources; or a difference in how individuals reported income and family 

structure when applying for Medicaid compared to how they reported income and family 

structure to the ACS.

11We also estimated at the national level the proportion of potential new enrollees who 

were newly eligible under 2014 eligibility rules, which does not include those American 

Indians and Alaska Natives who are currently eligible but unenrolled. 
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 48 GAO-13-553 Indian Health Service

• income-based cost-sharing exemptions for insurance obtained 

through the Exchanges,12 if their income was between 138 and 

300 percent of the FPL; and

• premium tax credits for insurance obtained through the Exchanges, if 

their income was between 138 and 400 percent of the FPL.

In this report, we do not conduct projections of eligibility based on future 

income; instead, we estimate the number of American Indians and Alaska 

Natives who would be eligible for programs and benefits beginning in 

2014 based on the most recent data currently available. We did not 

predict the number of people who will participate in these programs and 

benefits, commonly referred to as the take-up rate. As public programs 

generally do not have full take-up, and take-up for Medicaid and the 

Children’s Health Insurance Program (CHIP) generally tends to be lower 

for American Indians and Alaska Natives than the rest of the population,13

Program eligibility among our samples was determined by comparing 

total income of the health insurance unit to the FPL. In order to determine 

whether individuals were eligible for expanded Medicaid or new coverage 

options, we defined two factors needed to compare the income to the 

FPL: (1) the number of people in the family—defined by the health 

insurance unit in our analysis; and (2) the total family income, added for 

all individuals with the same health insurance unit identification code. 

Income was then adjusted to 2011 dollars across all 3 years of the 

survey, in order to determine the poverty level status for program 

eligibility.

it is likely not all who are eligible for Medicaid and new coverage options 

will enroll.

14

 

12American Indians and Alaska Natives who are members of federally recognized tribes 

are also eligible for cost-sharing exemptions for services are obtained through Indian 

health facilities, regardless of income. Because the ACS data do not include a variable for 

tribal enrollment status, we were unable to estimate the number of individuals who may be 

eligible for these services. 

We discussed our approach with a Census Bureau senior 

13See Genevieve M. Kenney et al., “Who and Where are the Children Yet to Enroll in 

Medicaid and the Children’s Health Insurance Program?” Health Affairs, vol. 29, no. 10 

(2010).

14For 2011, the FPL for a family of four was $22,350 in the lower 48 states and the District 

of Columbia, $27,940 in Alaska, and $25,710 in Hawaii.
Appendix I: Methodology for Estimating 

Potential Eligibility for American Indians and 

Alaska Natives in Expanded Health Coverage

Page 49 GAO-13-553 Indian Health Service

official, who agreed that our approach regarding this analysis was 

reasonable.

In conducting our analysis, we considered several other data sources, 

including the Current Population Survey, the National Health Interview 

Survey, and the Medicaid Statistical Information System and the Medicaid 

Analytic Extract. After reviewing these sources, we determined that data 

from the ACS were the most appropriate for our analysis for determining 

the number of individuals potentially eligible for these expanded Medicaid 

and new coverage options based on family income and race, and

reporting on areas smaller than the state level in some cases. This 

information is not complete or consistently collected in the other sources. 

For example, while data from the Medicaid Statistical Information System 

and the Medicaid Analytic Extract include a race variable to identify 

American Indians and Alaska Natives, the states do not consistently 

collect this information.
Appendix II: Estimates of Potential Medicaid 

Eligibility for American Indians and Alaska 

Natives, by Indian Health Service (IHS) Area

Page 50 GAO-13-553 Indian Health Service

American Indian and Alaska Native alone

American Indian and Alaska Native alone or in 

combination with another race

IHS Service Area

Total potentially 

eligible 

number

(percent)

Current 

enrollmenta Potential new enrollment

number 

(percent)

b

number

(percent)

Total potentially 

eligible 

number

(percent)

Current 

enrollmenta Potential new enrollment

number 

(percent)

b

Aberdeen

number 

(percent)

59,645 (73) 32,441 (40) 27,203 (33) 72,534 (70) 39,632 (38) 32,902 (32)

Alaska 57,078 (62) 27,276 (30) 29,802 (33) 74,320 (58) 35,562 (28) 38,758 (30)

Albuquerque 61,523 (64) 31,363 (33) 30,161 (31) 74,578 (63) 37,710 (32) 36,868 (31)

Bemidji 50,568 (61) 29,668 (36) 20,900 (25) 82,120 (60) 48,595 (36) 33,526 (25)

Billings 22,962 (61) 11,711 (31) 11,251 (30) 26,935 (58) 13,791 (30) 13,144 (28)

California 58,994 (53) 31,218 (28) 27,776 (25) 120,525 (51) 65,886 (28) 54,640 (23)

Nashville 42,087 (53) 22,155 (28) 19,932 (25) 97,217 (52) 53,347 (28) 43,870 (23)

Navajo 146,317 (72) 85,197 (42) 61,120 (30) 150,533 (71) 88,018 (42) 62,515 (30)

Oklahoma City 135,383 (52) 57,261 (22) 78,121 (30) 259,501 (53) 119,474 (24) 140,027 (28)

Phoenix 114,589 (62) 59,271 (32) 55,319 (30) 149,119 (58) 77,813 (30) 71,306 (28)

Portland 77,737 (55) 42,807 (30) 34,930 (25) 156,182 (53) 88,692 (30) 67,490 (23)

Tucson 23,157 (70) 14,841 (45) 8,316 (25) 27,294 (65) 17,375 (42) 9,919 (24)

IHS service area total 850,039 (60) 445,208 (32) 404,830 (29) 1,290,859 (57) 685,895 (30) 604,964 (27)

Non-IHS service areas 518,276 (54) 273,045 (28) 245,231 (25) 1,278,549 (51) 692,028 (28) 586,521 (23)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

The estimates we present have relative standard errors of less than 15 percent.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

Appendix II: Estimates of Potential Medicaid 

Eligibility for American Indians and Alaska 

Natives, by Indian Health Service (IHS) Area 

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 51 GAO-13-553 Indian Health Service

We examined data to provide estimates of the number of American 

Indians and Alaska Natives potentially eligible for expanded Medicaid1

Tables 3 through 9 present the results of our estimates by IHS service 

area or by state.

and new coverage options that will be available beginning in 2014, 

including the Basic Health Program option and the premium tax credits 

and the exemption from cost-sharing for insurance obtained through the 

Exchanges. We used an augmented version of the U.S. Census Bureau’s 

American Community Survey (ACS) 2009-2011 data, called the 

Integrated Public Use Microdata Series. For Medicaid, we estimated the 

total number of American Indians and Alaska Natives who are potentially 

eligible under provisions of PPACA applicable in 2014; the number of 

American Indians and Alaska Natives who reported being currently 

enrolled; and potential new enrollment, calculated by determining the 

number of individuals who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being 

currently enrolled. We also estimated the number of American Indian and 

Alaska Natives potentially eligible for coverage in a state that chooses the 

Basic Health Program option beginning in 2015, and income-based costsharing exemptions and premium tax credits for insurance obtained in the 

Exchanges beginning in 2014. Because the number of individuals eligible 

for services provided by the Indian Health Service (IHS) is likely to be 

between the number identifying as American Indian and Alaska Native 

alone, and the number identifying as American Indian and Alaska Native 

in combination with one or more other racial/ethnic groups, we present 

results for both groups as the range. In the absence of precise data, this 

approach allowed us to present a lower and upper bound.

 

1

The ACS data groups Medicaid and CHIP together when collecting information about 

Medicaid coverage status. As a result, some individuals eligible for CHIP are combined 

with Medicaid in our analysis.

Appendix III: Potential Eligibility for 

Expanded Health Coverage in 2014, 

Nationally, by IHS Service Area, and by State 
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 52 GAO-13-553 Indian Health Service

Table 3: Estimates of the Number and Percentage of All Races Potentially Eligible 

for Expanded Medicaid in 2014, by Indian Health Service (IHS) Service Area

IHS Service Area

Total potentially 

eligible 

number (percent)

Current 

enrollmenta Potential new 

enrollment

number (percent)

b

Aberdeen

number (percent)

656,204 (33) 282,311 (14) 373,893 (19)

Alaska 239,010 (34) 104,497 (15) 134,513 (19)

Albuquerque 1,041,685 (47) 481,496 (22) 560,189 (25)

Bemidji 2,408,969 (36) 1,154,241 (17) 1,254,728 (19)

Billings 200,454 (33) 80,061 (13) 120,393 (20)

California 4,302,079 (41) 2,056,411 (20) 2,245,668 (22)

Nashville 8,297,725 (39) 3,835,419 (18) 4,462,307 (21)

Navajo 268,851 (53) 140,960 (28) 127,892 (25)

Oklahoma City 1,621,849 (41) 669,412 (17) 952,438 (24)

Phoenix 3,362,161 (37) 1,471,219 (16) 1,890,942 (21)

Portland 3,597,807 (34) 1,631,993 (16) 1,965,814 (19)

Tucson 421,364 (42) 218,839 (22) 202,525 (20)

IHS service area total 26,418,161 (38) 12,126,858 (18) 14,291,303 (21)

Non-IHS service areas 89,331,678 (37) 41,069,559 (17) 48,262,119 (20)

Source: GAO analysis of U.S. Census Bureau data. 

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates.

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

The estimates we present have relative standard errors of less than 15 percent.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 53 GAO-13-553 Indian Health Service

Table 4: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for Expanded 

Medicaid in 2014, by State

American Indian and Alaska Native alone

American Indian and Alaska Native alone or in 

combination with another race

State 

Total potentially 

eligible 

number

(percent)

Current 

enrollmenta Potential new enrollment

number 

(percent)

b

number 

(percent)

Total potentially 

eligible 

number 

(percent)

Current 

enrollmenta Potential new enrollment

number

(percent)

b 

Alabama

number 

(percent)

10,562 (43) 4,841 (20) 5,721 (24) 25,563 (46) 11,340 (21) 14,223 (26)

Alaska 63,281 (63) 30,665 (30) 32,616 (32) 80,988 (59) 39,162 (29) 41,826 (31)

Arizona 192,553 (68) 117,001 (42) 75,552 (27) 219,568 (66) 133,706 (40) 85,862 (26)

Arkansas 8,024 (45) 4,357 (24) 3,667 (20) 22,673 (50) 11,955 (26) 10,718 (23)

California 127,298 (52) 70,950 (29) 56,348 (23) 298,007 (49) 167,835 (28) 130,172 (22)

Colorado 24,904 (53) 12,783 (27) 12,121 (26) 51,212 (48) 27,597 (26) 23,615 (22)

Connecticut 3,046c (50) 2,075c (34) 971 c c (16)c 12,563 (45) 8,081 (29) 4,482 (16)

Delaware 1,065c (50) — (—) c — (41)c 2,806 (36) 1,267c (16) 1,539 c c (20)

District of Columbia

c

701c (46) 560 c c (37) — (—) c 2,300 (49) 1,471c (31) 829c (18)

Florida

c

25,170 (50) 11,915 (24) 13,255 (27) 66,478 (49) 33,322 (25) 33,156 (24)

Georgia 8,809 (44) 3,469 (17) 5,340 (27) 29,052 (44) 11,389 (17) 17,663 (27)

Hawaii 1,258c (36) — (25) c — (—) c 18,730 (57) 10,853 (33) 7,877 (24)

Idaho 11,835 (59) 5,448 (27) 6,387 (32) 19,517 (55) 9,266 (26) 10,251 (29)

Illinois 11,556 (54) 5,991 (28) 5,565 (26) 35,686 (50) 18,336 (26) 17,350 (24)

Indiana 6,659 (53) 2,218 (18) 4,441 (35) 26,360 (50) 12,298 (24) 14,062 (27)

Iowa 6,173 (61) 3,598c (35) 2,575c (25) 18,405 (63) 12,490 (43) 5,915 (20)

Kansas 13,150 (56) 4,956 (21) 8,194 (35) 35,850 (54) 16,712 (25) 19,138 (29)

Kentucky 4,453 (52) 2,528c (29) 1,925c (22)c 17,484 (57) 9,659 (31) 7,825 (25)

Louisiana 14,057 (57) 7,154 (29) 6,903 (28) 28,182 (56) 14,739 (29) 13,443 (27)

Maine 4,456 (64) 3,155 (45) 1,301c (19)c 11,681 (59) 8,752 (44) 2,929 (15)

Maryland 6,319 (47) 3,438 (26) 2,881 (21) 21,954 (46) 11,541 (24) 10,413 (22)

Massachusetts 5,961 (55) 4,419c (41) 1,542c (14)c 19,639 (49) 14,524 (36) 5,115 (13)

Michigan 27,643 (51) 15,941 (30) 11,702 (22) 70,867 (52) 43,228 (32) 27,639 (20)

Minnesota 40,838 (71) 25,330 (44) 15,508 (27) 69,556 (69) 40,987 (41) 28,569 (29)

Mississippi 7,570 (57) 3,445 (26) 4,125 (31) 15,594 (58) 7,215 (27) 8,379 (31)

Missouri 10,189 (48) 5,437 (26) 4,752 (22) 40,579 (53) 22,139 (29) 18,440 (24)

Montana 38,330 (61) 17,927 (28) 20,403 (32) 45,501 (59) 21,847 (28) 23,654 (31)

Nebraska 11,864 (72) 6,378 (39) 5,486 (33) 20,539 (66) 10,885 (35) 9,654 (31)

Nevada 13,587 (49) 5,467 (20) 8,120 (29) 22,848 (47) 8,951 (18) 13,897 (28)

New Hampshire 1,040c (42) 710 c c (29) 330 c c (13)c 3,799 (40) 2,144 (23) 1,655c (18)

New Jersey

c

7,152 (47) 4,185c (27) 2,967c (19)c 19,392 (42) 11,120 (24) 8,272 (18)
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 54 GAO-13-553 Indian Health Service

American Indian and Alaska Native alone

American Indian and Alaska Native alone or in 

combination with another race

State 

Total potentially 

eligible 

number

(percent)

Current 

enrollmenta Potential new enrollment

number 

(percent)

b

number 

(percent)

Total potentially 

eligible 

number 

(percent)

Current 

enrollmenta Potential new enrollment

number

(percent)

b 

New Mexico

number 

(percent)

129,546 (67) 62,881 (33) 66,665 (35) 143,157 (66) 69,878 (32) 73,279 (34)

New York 28,462 (56) 18,170 (36) 10,292 (20) 70,009 (52) 43,578 (32) 26,431 (19)

North Carolina 62,131 (58) 32,570 (30) 29,561 (27) 101,065 (56) 53,637 (30) 47,428 (26)

North Dakota 23,270 (65) 10,269 (29) 13,001 (36) 26,426 (62) 12,213 (28) 14,213 (33)

Ohio 10,415 (51) 4,921 (24) 5,494 (27) 46,406 (53) 25,775 (29) 20,631 (24)

Oklahoma 133,291 (52) 56,588 (22) 76,703 (30) 255,555 (53) 117,602 (24) 137,953 (28)

Oregon 25,305 (53) 13,486 (28) 11,819 (25) 56,373 (53) 30,574 (29) 25,799 (24)

Pennsylvania 8,150 (54) 5,145c (34) 3,005 (20) 34,372 (52) 21,047 (32) 13,325 (20)

Rhode Island 2,935 (70) 1,511c (36) 1,424 c c (34)c 7,548 (65) 4,673 (40) 2,875c (25)

South Carolina

c

7,677 (56) 3,982 (29) 3,695 (27) 21,109 (55) 10,362 (27) 10,747 (28)

South Dakota 53,691 (75) 30,352 (43) 23,339 (33) 62,654 (74) 35,476 (42) 27,178 (32)

Tennessee 6,172 (50) 3,449c (28) 2,723 (22)c 29,278 (54) 16,306 (30) 12,972 (24)

Texas 51,889 (47) 25,328 (23) 26,561 (24) 111,459 (43) 53,347 (20) 58,112 (22)

Utah 19,053 (62) 8,922 (29) 10,131 (33) 27,043 (57) 12,910 (27) 14,133 (30)

Vermont 855c (44) 518 c c (27) — (—) c 3,973 (53) 2,528 (34) 1,445c (19)

Virginia

c

7,561 (35) 2,744c (13) 4,817 (22) c 25,690 (37) 10,690 (15) 15,000 (22)

Washington 51,029 (56) 29,268 (32) 21,761 (24) 99,622 (53) 58,926 (31) 40,696 (21)

West Virginia 1,839 (56) 1,064c (33) 775 c c (24)c 12,569 (58) 7,376 (34) 5,193 (24)

Wisconsin 27,041 (56) 14,412 (30) 12,629 (26) 49,675 (58) 29,046 (34) 20,629 (24)

Wyoming 8,501 (63) 5,268 (39) 3,233 (24) 12,054 (55) 7,169 (33) 4,885 (22)

Total 1,368,316 (58) 718,254 (30) 650,062 (27) 2,569,410 (54) 1,377,924 (29) 1,191,486 (25)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

Unless otherwise noted, the estimates we present have relative standard errors of less than 

15 percent. Estimates with relative standard errors greater than 30 percent are omitted.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 55 GAO-13-553 Indian Health Service

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.

c

Table 5: Estimates of the Number and Percentage of All Races Potentially Eligible 

for Expanded Medicaid in 2014, by State

Relative standard error of the estimate is between 15 and 30 percent.

State 

Total potentially 

eligible 

number (percent)

Current enrollmenta Potential new enrollment

number (percent)

b

Alabama

number (percent)

1,955,265 (41) 870,108 (18) 1,085,157 (23)

Alaska 247,597 (35) 108,671 (15) 138,926 (20)

Arizona 2,544,027 (40) 1,286,480 (20) 1,257,547 (20)

Arkansas 1,312,714 (45) 611,947 (21) 700,767 (24)

California 15,036,282 (40) 7,134,352 (19) 7,901,930 (21)

Colorado 1,577,788 (31) 672,433 (13) 905,355 (18)

Connecticut 1,129,058 (32) 563,149 (16) 565,909 (16)

Delaware 309,172 (34) 169,972 (19) 139,200 (15)

District of Columbia 292,339 (48) 155,687 (26) 136,652 (23)

Florida 7,362,867 (39) 2,958,596 (16) 4,404,271 (23)

Georgia 3,885,976 (40) 1,545,237 (16) 2,340,739 (24)

Hawaii 564,190 (41) 203,263 (15) 360,927 (27)

Idaho 560,947 (36) 224,590 (14) 336,357 (21)

Illinois 4,624,033 (36) 2,265,211 (18) 2,358,822 (18)

Indiana 2,320,838 (36) 983,983 (15) 1,336,855 (21)

Iowa 957,367 (31) 472,285 (15) 485,082 (16)

Kansas 911,862 (32) 364,552 (13) 547,310 (19)

Kentucky 1,762,366 (41) 823,531 (19) 938,835 (22)

Louisiana 2,052,868 (45) 957,560 (21) 1,095,308 (24)

Maine 482,639 (36) 305,920 (23) 176,719 (13)

Maryland 1,946,646 (34) 811,217 (14) 1,135,429 (20)

Massachusetts 2,192,026 (33) 1,366,120 (21) 825,906 (13)

Michigan 3,721,250 (38) 1,901,559 (19) 1,819,691 (18)

Minnesota 1,899,738 (36) 768,063 (14) 1,131,675 (21)

Mississippi 1,408,772 (47) 693,677 (23) 715,095 (24)

Missouri 2,130,573 (36) 909,635 (15) 1,220,938 (20)

Montana 328,487 (33) 125,629 (13) 202,858 (20)

Nebraska 609,581 (33) 242,969 (13) 366,612 (20)

Nevada 924,095 (34) 299,079 (11) 625,016 (23)

New Hampshire 355,591 (27) 149,418 (11) 206,173 (16)
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 56 GAO-13-553 Indian Health Service

State 

Total potentially 

eligible 

number (percent)

Current enrollmenta Potential new 

enrollment

number (percent)

b

New Jersey

number (percent)

2,606,674 (30) 1,183,299 (13) 1,423,375 (16)

New Mexico 983,222 (48) 472,629 (23) 510,593 (25)

New York 7,393,719 (38) 4,200,350 (22) 3,193,369 (16)

North Carolina 3,703,744 (39) 1,628,400 (17) 2,075,344 (22)

North Dakota 184,646 (27) 66,878 (10) 117,768 (17)

Ohio 4,314,151 (37) 1,924,763 (17) 2,389,388 (21)

Oklahoma 1,540,881 (41) 641,202 (17) 899,679 (24)

Oregon 1,349,809 (35) 579,746 (15) 770,063 (20)

Pennsylvania 4,311,622 (34) 2,151,585 (17) 2,160,037 (17)

Rhode Island 416,093 (40) 181,819 (17) 234,274 (22)

South Carolina 1,966,415 (42) 808,541 (17) 1,157,874 (25)

South Dakota 265,053 (32) 117,475 (14) 147,578 (18)

Tennessee 2,518,761 (40) 1,208,562 (19) 1,310,199 (21)

Texas 10,189,074 (40) 4,221,763 (17) 5,967,311 (24)

Utah 871,846 (31) 315,030 (11) 556,816 (20)

Vermont 237,942 (38) 146,507 (23) 91,435 (15)

Virginia 2,350,901 (30) 879,536 (23) 1,471,365 (18)

Washington 2,301,507 (34) 1,093,373 (16) 1,208,134 (18)

West Virginia 753,274 (41) 360,572 (19) 392,702 (21)

Wisconsin 1,924,191 (34) 998,648 (18) 925,543 (16)

Wyoming 159,359 (28) 70,845 (13) 88,514 (16)

Total 115,749,838 (37) 53,196,416 (17) 62,553,422 (20)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Our estimates are based on the assumption of all states opting to expand Medicaid. While some 

states have indicated they do not intend to participate, they may opt to do so at a later date. We did 

not predict the number of people who will participate in this program, commonly referred to as the 

take-up rate.

Unless otherwise noted, the estimates we present have relative standard errors of less than 

15 percent.

a

We use the term “current enrollment” to refer to estimated enrollment based on responses to the 

2009-2011 ACS.

b

We estimated potential new enrollment as those who will be newly eligible for expanded Medicaid 

and some who may be eligible now, but did not report to ACS as being currently enrolled. 

Percentages of current enrollment and potential new enrollment may not add up to the total of 

potentially eligible due to rounding.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 57 GAO-13-553 Indian Health Service

Table 6: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for the Basic 

Health Program Option in 2015, and Cost-Sharing Exemptions and Premium Tax Credits under the Health Insurance 

Exchanges in 2014, by Indian Health Service (IHS) Service Area

Basic Health Program optiona

number (percent)

Exchange cost-sharing 

exemptionsb 

number (percent)

Exchange premium tax creditsc

IHS Service 

Area

number (percent)

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

Aberdeen 9,014 (11) 11,397 (11) 17,605 (21) 22,868 (22) 22,006 (27) 29,288 (28)

Alaska 11,722 (13) 16,056 (13) 26,142 (29) 37,133 (29) 33,459 (37) 49,537 (39)

Albuquerque 12,022 (12) 14,339 (12) 25,975 (27) 31,265 (26) 35,627 (37) 43,109 (36)

Bemidji 9,871 (12) 17,268 (13) 21,413 (26) 36,729 (27) 29,294 (35) 49,225 (36)

Billings 4,904 (13) 6,341 (14) 9,521 (25) 12,196 (26) 12,633 (33) 16,334 (35)

California 13,926 (12) 30,048 (13) 31,109 (28) 63,679 (27) 40,303 (36) 84,676 (36)

Nashville 9,405 (12) 22,296 (12) 21,458 (27) 51,233 (27) 28,619 (36) 70,964 (38)

Navajo 22,347 (11) 23,436 (11) 46,410 (23) 48,303 (23) 61,006 (30) 63,905 (30)

Oklahoma City 37,934 (15) 73,282 (15) 79,608 (31) 153,691 (31) 106,030 (41) 204,569 (42)

Phoenix 23,604 (13) 32,573 (13) 46,115 (25) 66,217 (26) 60,931 (33) 88,675 (35)

Portland 17,347 (12) 36,989 (12) 39,952 (28) 80,905 (27) 52,950 (37) 108,541 (37)

Tucson 3,863d (12) 4,992 (12) 7,078 (21) 9,968 (24) 8,895 (27) 12,245 (29)

IHS service 

area total 175,959 (13) 289,018 (13) 372,386 (27) 614,187 (27) 491,753 (35) 821,067 (36)

Non-IHS 

service areas 116,640 (12) 304,349 (12) 251,504 (26) 676,174 (27) 340,231 (35) 923,583 (37)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

Unless otherwise noted, the estimates we present have relative standard errors of less than 

15 percent.

We did not predict the number of people who will participate in these new coverage options, 

commonly referred to as the take-up rate.

Certain individuals who are eligible for the premium tax credits may also be eligible for cost-sharing 

exemptions.

a

Beginning in 2015, states may opt to run a Basic Health Program for individuals between 138 and 

200 percent of the federal poverty level (FPL). These estimates are if all states opt to run a Basic 

Health Program.

b

Certain American Indians and Alaska Natives obtaining insurance through the Exchanges who are at 

or below 300 percent of the FPL are exempt from cost-sharing, such as deductibles and copays, 

although our estimates reflect only those above 138 percent of the FPL because individuals below 

this level would be potentially eligible for expanded Medicaid.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 58 GAO-13-553 Indian Health Service

c

Individuals obtaining insurance through the Exchanges who are between 100 and 400 percent of the 

FPL are eligible for premium tax credits on a sliding scale, although our estimates reflect only those 

above 138 percent of the FPL because individuals below this level would be potentially eligible for 

expanded Medicaid. Individuals with incomes above 138 percent of the FPL who may be eligible for 

Medicaid in a particular state are not eligible for premium tax credits.

d

Table 7: Estimates of the Number and Percentage of All Races Potentially Eligible 

for the Basic Health Program Option in 2015 and Premium Tax Credits under the 

Health Insurance Exchanges in 2014, by Indian Health Service (IHS) Service Area

Relative standard error of the estimate is between 15 and 30 percent.

IHS Service Area

Basic Health 

Program optiona Exchange premium tax credits

number (percent)

b

Aberdeen

number (percent)

226,433 (11) 850,311 (43)

Alaska 83,373 (12) 311,310 (45)

Albuquerque 286,561 (13) 836,492 (38)

Bemidji 825,085 (12) 2,906,786 (44)

Billings 83,541 (14) 275,478 (45)

California 1,256,696 (12) 3,852,121 (37)

Nashville 2,430,650 (11) 8,049,301 (38)

Navajo 56,095 (11) 184,299 (36)

Oklahoma City 521,131 (13) 1,656,550 (42)

Phoenix 1,137,368 (13) 3,719,458 (41)

Portland 1,173,223 (11) 4,138,184 (39)

Tucson 124,460 (12) 393,027 (39)

IHS service area total 8,204,617 (12) 27,173,316 (39)

Non-IHS service areas 27,228,110 (11) 91,458,963 (38)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

The estimates we present have relative standard errors of less than 15 percent.

We did not predict the number of people who will participate in these new coverage options, 

commonly referred to as the take-up rate.

a

Beginning in 2015, states may opt to run a Basic Health Program for individuals between 138 and 

200 percent of the federal poverty level (FPL). These estimates are if all states opt to run a Basic

Health Program.

b

Individuals obtaining insurance through the Exchanges who are between 100 and 400 percent of the 

FPL are eligible for premium tax credits on a sliding scale, although our estimates reflect only those 

above 138 percent of the FPL because individuals below this level would be potentially eligible for 

expanded Medicaid. Individuals with incomes above 138 percent of the FPL who may be eligible for 

Medicaid in a particular state are not eligible for premium tax credits.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 59 GAO-13-553 Indian Health Service

Table 8: Estimates of the Number and Percentage of American Indians and Alaska Natives Potentially Eligible for the Basic 

Health Program Option in 2015, and Cost-Sharing Exemptions and Premium Tax Credits under the Health Insurance 

Exchanges in 2014, by State

Basic Health Program optiona 

number (percent)

Exchange cost-sharing 

exemptionsb 

number (percent)

Exchange premium tax creditsc 

State 

number (percent)

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

Alabama 2,660 (11) 6,491 (12) 7,733 (32) 16,240 (29) 10,025 (41) 22,539 (41)

Alaska 12,890 (13) 17,401 (13) 28,612 (28) 39,968 (29) 36,480 (36) 52,978 (39)

Arizona 31,967 (11) 38,615 (12) 64,703 (23) 79,670 (24) 84,816 (30) 104,834 (31)

Arkansas 2,604 (15) 6,805 (15) 6,184 (34) 15,250 (33) 7,870 (44) 19,068 (42)

California 29,093 (12) 69,195 (11) 64,034 (26) 151,102 (25) 86,182 (35) 208,511 (34)

Colorado 6,418 (14) 13,374 (13) 13,266 (28) 29,498 (28) 18,978 (40) 41,349 (39)

Connecticut — (—) 4,259d (15) 1,373d (22) 7,963 (29) d 2,038d (33) 11,271 (41) d

Delaware — (—) 1,391d (18)d — (20) 2,494 d d (32)d 605d (28) 3,191 (41) d

District of Columbia — (—) — (—) — (—) — (—) — (—) 964d (21)

Florida

d

5,786 (12) 17,745 (13) 12,287 (25) 38,037 (28) 16,664 (33) 50,996 (38)

Georgia 2,137d (11) 7,607 (12) d 5,704 (29) 17,977 (27) 7,647 (39) 24,816 (38)

Hawaii 851d (24) 4,217 d d (13)d 1,167d (34) 9,967 (30) d 1,596d (46) 13,774 (42)

Idaho 2,408d (12) 4,636 (13) d 5,286 (26) 10,694 (30) 6,851 (34) 13,603 (38)

Illinois 1,859d (9) 7,215 (10) d 5,380 (25) 19,759 (28) 7,335 (35) 26,862 (37)

Indiana 1,304d (10) 7,428 (14) d 3,724 (29) 16,472 (31) 5,018 (40) 21,028 (40)

Iowa 1,733d (17) 4,271 d d (15)d 3,293d (32) 7,974 (27) 3,725d (37) 9,836 (34)

Kansas 2,854 (12) 7,416 (11) 5,957 (25) 18,181 (27) 7,924 (34) 25,523 (38)

Kentucky 1,147d (13) 3,812 (12) d 2,558 (30) 8,170 (27) 2,969 (35) 10,320 (34)

Louisiana 3,330d (13) 6,610 (13) 6,424 (26) 13,692 (27) 8,939 (36) 19,354 (38)

Maine — (—) 2,597d (13)d 1,327d (19) 5,448 (28) d 2,031d (29) 7,297 (37)

Maryland 943d (7) 4,580 (10) d 2,248d (17) 10,000 (21) d 3,582 (27) 14,486 (30)

Massachusetts — (9) 4,381 (11) d 2,091d (19) 9,781 (25) d 3,075d (28) 13,954 (35)

Michigan 7,595 (14) 19,374 (14) 14,984 (28) 38,984 (29) 20,838 (39) 52,479 (39)

Minnesota 6,173 (11) 12,230 (12) 13,024 (23) 24,822 (25) 17,356 (30) 33,454 (33)

Mississippi 1,519d (11) 3,048 d d (11)d 4,196 (31) 7,774 (29) 5,224 (39) 10,399 (38)

Missouri 2,232d (11) 9,588 (13) 6,095 (29) 21,371 (28) 8,952 (42) 29,171 (38)

Montana 7,685 (12) 9,935 (13) 15,395 (24) 19,590 (25) 20,548 (33) 26,278 (34)

Nebraska 2,127d (13) 3,871 (13) d 3,787 (23) 6,806 (22) 4,879 (30) 9,914 (32)

Nevada 4,007 (14) 7,051 (14) 8,045 (29) 14,652 (30) 10,258 (37) 19,521 (40)
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 60 GAO-13-553 Indian Health Service

Basic Health Program optiona 

number (percent)

Exchange cost-sharing 

exemptionsb 

number (percent)

Exchange premium tax creditsc 

State 

number (percent)

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

American 

Indian and 

Alaska 

Native alone

American Indian 

and Alaska 

Native alone or in 

combination with 

another race

New Hampshire — (—) 1,126d (12)d 744d (30) 2,433 (26) d 1,167d (47) 3,843 (41)

New Jersey 1,743d (11) 4,659 (10) d 3,467 (23) 10,298 (22) 5,003 (33) 15,864 (34)

New Mexico 23,430 (12) 26,135 (12) 49,010 (25) 54,552 (25) 66,114 (34) 74,152 (34)

New York 5,287 (10) 12,582 (9) 11,791 (23) 32,257 (24) 16,310 (33) 45,518 (33)

North Carolina 14,652 (14) 24,716 (14) 31,077 (29) 53,298 (29) 38,279 (36) 67,203 (37)

North Dakota 2,280d (6) 2,844 d d (7)d 6,919 (19) 8,887 (21) 9,220 (26) 11,949 (28)

Ohio 3,143d (15) 12,599 (14) 5,917 (29) 26,947 (31) 7,889 (38) 35,040 (40)

Oklahoma 37,664 (15) 72,715 (15) 79,010 (31) 152,144 (31) 105,343 (41) 202,414 (42)

Oregon 6,793 (14) 14,042 (13) 14,429 (30) 29,427 (28) 18,543 (39) 38,517 (36)

Pennsylvania 1,385d (9) 8,044 (12) d 2,982 (20) 16,712 (25) 4,848 (32) 23,976 (36)

Rhode Island — (—) 1,374d (12)d 994d (24) 2,207 d d (19)d 1,356d (32) 3,254 (28) d

South Carolina 1,622d (12) 4,306 (11) d 3,914 (29) 10,014 (26) 5,354 (39) 14,325 (37)

South Dakota 7,711 (11) 9,054 (11) 13,695 (19) 18,354 (22) 17,285 (24) 22,592 (27)

Tennessee 1,628d (13) 6,851 (13) d 3,447 (28) 14,646 (27) 4,916 (40) 19,758 (36)

Texas 14,177 (13) 32,923 (13) 28,932 (26) 74,637 (29) 39,332 (36) 102,385 (39)

Utah 3,688d (12) 5,941 (12) d 7,384 (24) 12,101 (25) 9,633 (31) 16,360 (34)

Vermont — (—) 1,074d (14)d — (—) 2,414 (32) 948d (49) 4,182 (56) d

Virginia 3,126d (15) 8,353 (12) d 6,845 (32) 20,087 (29) 8,835 (41) 27,738 (40)

Washington 10,314 (11) 22,530 (12) 24,751 (27) 50,392 (27) 33,322 (36) 68,825 (36)

West Virginia 505d (15) 2,555 (12) d 1,114d (34) 5,801 (27) d 1,187d (36) 7,705 (36) d

Wisconsin 6,180 (13) 10,337 (12) 13,703 (28) 23,254 (27) 19,231 (40) 32,550 (38)

Wyoming 2,272d (17) 3,329 (15) d 3,959d (29) 6,701 (31) d 5,075 (38) 8,731 (40)

Total 292,599 (12) 593,367 (12) 623,890 (26) 1,290,362 (27) 831,985 (35) 1,744,651 (37)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates. 

Because the number of IHS-eligible individuals is likely to be between the number of individuals who 

self-identify as American Indians and Alaska Natives alone and American Indians and Alaska Natives 

alone or in combination, we presented results for both groups as the range. We excluded foreign-born 

American Indians and Alaska Natives from our analysis.

Unless otherwise noted, the estimates we present have relative standard errors of less than 

15 percent. Estimates with relative standard errors greater than 30 percent are omitted.

We did not predict the number of people who will participate in these new coverage options, 

commonly referred to as the take-up rate.

Certain individuals who are eligible for the premium tax credits may also be eligible for cost-sharing 

exemptions.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 61 GAO-13-553 Indian Health Service

a

Beginning in 2015, states may opt to run a Basic Health Program for individuals between 138 and 

200 percent of the federal poverty level (FPL). These estimates are if all states opt to run a Basic 

Health Program.

b

Certain American Indians and Alaska Natives obtaining insurance through the Exchanges who are at 

or below 300 percent of the FPL are exempt from cost-sharing, such as deductibles and copays, 

although our estimates reflect only those above 138 percent of the FPL because individuals below 

this level would be potentially eligible for expanded Medicaid.

c

Individuals obtaining insurance through the Exchanges who are between 100 and 400 percent of the 

FPL are eligible for premium tax credits on a sliding scale, although our estimates reflect only those 

above 138 percent of the FPL because individuals below this level would be potentially eligible for 

expanded Medicaid. Individuals with incomes above 138 percent of the FPL who may be eligible for 

Medicaid in a particular state are not eligible for premium tax credits.

d

Relative standard error of the estimate is between 15 and 30 percent.
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 62 GAO-13-553 Indian Health Service

Table 9: Estimates of the Number and Percentage of All Races Potentially Eligible 

for the Basic Health Program Option in 2015 and Premium Tax Credits under the 

Health Insurance Exchanges in 2014, by State

State 

Basic Health Program optiona Exchange premium tax credits

number (percent)

b

Alabama

number (percent)

584,905 (12) 1,854,582 (39)

Alaska 85,706 (12) 317,908 (45)

Arizona 778,325 (12) 2,521,814 (39)

Arkansas 401,989 (14) 1,216,079 (42)

California 4,216,442 (11) 12,863,653 (34)

Colorado 533,713 (11) 1,916,497 (38)

Connecticut 321,598 (9) 1,199,422 (34)

Delaware 98,089 (11) 341,818 (38)

District of Columbia 46,282 (8) 158,258 (26)

Florida 2,392,563 (13) 7,531,421 (40)

Georgia 1,121,198 (12) 3,667,884 (38)

Hawaii 177,223 (13) 592,985 (44)

Idaho 226,044 (14) 719,097 (46)

Illinois 1,404,723 (11) 4,802,739 (37)

Indiana 813,117 (13) 2,800,941 (43)

Iowa 351,300 (12) 1,360,465 (45)

Kansas 350,367 (12) 1,212,107 (42)

Kentucky 546,772 (13) 1,776,393 (41)

Louisiana 524,484 (12) 1,710,480 (38)

Maine 171,101 (13) 585,878 (44)

Maryland 529,201 (9) 1,929,703 (33)

Massachusetts 589,495 (9) 2,204,596 (34)

Michigan 1,136,069 (11) 3,974,626 (40)

Minnesota 546,341 (10) 2,135,973 (40)

Mississippi 367,880 (12) 1,137,216 (38)

Missouri 732,846 (12) 2,518,872 (42)

Montana 132,167 (13) 444,635 (45)

Nebraska 215,875 (12) 807,154 (44)

Nevada 350,437 (13) 1,131,112 (42)

New Hampshire 132,249 (10) 518,179 (39)

New Jersey 807,361 (9) 2,907,472 (33)

New Mexico 252,790 (12) 791,781 (38)

New York 1,991,643 (10) 6,789,077 (35)
Appendix III: Potential Eligibility for Expanded 

Health Coverage in 2014, Nationally, by IHS 

Service Area, and by State

Page 63 GAO-13-553 Indian Health Service

State 

Basic Health Program optiona Exchange premium tax credits

number (percent)

b

North Carolina

number (percent)

1,176,315 (12) 3,799,848 (40)

North Dakota 76,515 (11) 295,907 (44)

Ohio 1,359,034 (12) 4,752,273 (41)

Oklahoma 497,346 (13) 1,576,455 (42)

Oregon 476,007 (12) 1,569,424 (41)

Pennsylvania 1,453,820 (11) 5,178,832 (41)

Rhode Island 115,361 (11) 383,823 (36)

South Carolina 566,467 (12) 1,840,598 (40)

South Dakota 95,792 (12) 367,951 (45)

Tennessee 790,484 (12) 2,599,340 (41)

Texas 3,006,362 (12) 9,324,879 (37)

Utah 361,150 (13) 1,292,879 (47)

Vermont 71,796 (11) 271,785 (43)

Virginia 799,384 (10) 2,921,457 (36)

Washington 696,422 (10) 2,561,712 (38)

West Virginia 235,843 (13) 775,393 (42)

Wisconsin 657,266 (12) 2,434,021 (43)

Wyoming 67,068 (12) 244,885 (43)

Total 35,432,727 (11) 118,632,279 (38)

Source: GAO analysis of U.S. Census Bureau data.

Notes: Data are from 2009-2011 American Community Survey (ACS) 3-year estimates.

The estimates we present have relative standard errors of less than 15 percent.

We did not predict the number of people who will participate in these new coverage options, 

commonly referred to as the take-up rate.

a

Beginning in 2015, states may opt to run a Basic Health Program for individuals between 138 and 

200 percent of the federal poverty level (FPL). These estimates are if all states opt to run a Basic 

Health Program.

b

Individuals obtaining insurance through the Exchanges who are between 100 and 400 percent of the 

FPL are eligible for premium tax credits on a sliding scale, although our estimates reflect only those 

above 138 percent of the FPL because individuals below this level would be potentially eligible for 

expanded Medicaid. Individuals with incomes above 138 percent of the FPL who may be eligible for 

Medicaid in a particular state are not eligible for premium tax credits.
Appendix IV: Comments from the Department 

of Health and Human Services

Page 64 GAO-13-553 Indian Health Service

Appendix IV: Comments from the 

Department of Health and Human Services
Appendix IV: Comments from the Department 

of Health and Human Services

Page 65 GAO-13-553 Indian Health Service
Appendix IV: Comments from the Department 

of Health and Human Services

Page 66 GAO-13-553 Indian Health Service
Appendix IV: Comments from the Department 

of Health and Human Services

Page 67 GAO-13-553 Indian Health Service
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 68 GAO-13-553 Indian Health Service

Kathleen M. King, (202) 512-7114 or kingk@gao.gov

In addition to the contact named above, Catina Bradley, Assistant 

Director; Lisa Motley; Giao N. Nguyen; Laurie Pachter; Dae Park; 

Perry Parsons; and Monique Williams made key contributions to this 

report.

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 
Related GAO Products

Page 69 GAO-13-553 Indian Health Service

Indian Health Service: Capping Payment Rates for Nonhospital Services 

Could Save Millions of Dollars for Contract Health Services. GAO-13-272. 

Washington, D.C.: April 11, 2013.

Medicaid Expansion: States’ Implementation of the Patient Protection and 

Affordable Care Act. GAO-12-821. Washington, D.C.: August 1, 2012.

Indian Health Service: Action Needed to Ensure Equitable Allocation of 

Resources for the Contract Health Service Program. GAO-12-446. 

Washington, D.C.: June 15, 2012.

Indian Health Service: Increased Oversight Needed to Ensure Accuracy 

of Data Used for Estimating Contract Health Service Need. GAO-11-767. 

Washington, D.C.: September 23, 2011.

Indian Health Service: Updated Policies and Procedures and Increased 

Oversight Needed for Billings and Collections from Private Insurers. 

GAO-10-42R. Washington, D.C.: October 22, 2009.

Medicare and Medicaid: CMS and State Efforts to Interact with the Indian 

Health Service and Indian Tribes. GAO-08-724. Washington, D.C.: 

July 11, 2008.

Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans. GAO-05-789. Washington, D.C.: August 31, 2005.

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