Cathleen E. Willging, Pacific Institute for Research and Evaluation

1
Impact of Behavioral Health System Transformation
on Native Americans Implications for the
Patient Protection and Affordable Care Act

• Cathleen E. Willging, Pacific Institute for
  Research and Evaluation
• Jessica Goodkind, University of New Mexico
• Gwendolyn Packard, Raincloud Local Collaborative
• Gwendolyn Saul, University of New Mexico

Prepared for the Navajo Nation Human Research
Review Board Conference November 15, 2011, Window
Rock, Arizona Funded by the National Institute
of Mental Health and the Substance Abuse and
Mental Health Services Administration (R01
MH76084 K01 MH074816)
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Learning Objectives

• Identify lessons learned based on qualitative
  research on behavioral health reform in New
  Mexico
• Describe factors related to rural and Native
  American communities that states should consider
  when planning and implementing behavioral health
  reform
• Describe factors related to rural and Native
  American communities that the federal government
  should consider when planning and implementing
  national health reform
• Understand the implications of national health
  reform for Native American communities

3
Health Care and Native Americans

• The federal government is legally obligated to
  provide health services to members of federally
  recognized tribes
• Indian Health Service (IHS) and 638 tribal
  facilities are underfunded
• For the IHS user population, the per capita
  health care expenditure is 2,741 vs. 6,909 for
  the U.S. population
• Native Americans have long been deprived of
  access to state-funded services, such as
  Medicaid, based on assumptions that IHS will
  handle all their health care needs
• Native Americans have also been reluctant to sign
  up for these services (e.g., stigma, burdensome
  enrollment processes, fluctuating eligibility,
  and belief that signing up will hurt IHS)

4
New Mexico Context

• New Mexico (NM) is 1, 2, and 3 in death due to
  alcohol, drugs, and suicide
• Native American and Latino peoples comprise about
  53 of the population
• Native Americans suffer from behavioral health
  care disparities more than any other ethnic group
  in NM
• The state is largely rural and economically
  disadvantaged

5
Behavioral Health Reform in New Mexico

• New Mexico revamped its public behavioral health
  system in 2005. This comprehensive reform was
  distinguished by
• Managed care approach
• Emphasis on making services responsive to the
  specific needs of Native American communities, as
  well as rural populations
• Invitation for Native Americans to provide input
  into state-funded behavioral health care

6
National Health Reform The PPACA

• The most ambitious health reform in the U.S.
  since the 1960s
• By 2014, the reform will afford health coverage
  to 32 million previously uninsured individuals
  through expansion of the Medicaid rolls and newly
  created health insurance exchanges
• An exchange is an organized marketplace that
  offers a choice of health plans, has common rules
  regarding offering and pricing, and provides
  information so people can select a plan that best
  meets their needs
• Federal subsides will defray the costs of
  participation
• For Native Americans, PPACA includes provisions
  for
• Special monthly enrollment periods
• No cost-sharing (at or below 300 of poverty
  level)
• No penalty for failure to carry minimum coverage

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How will the PPACA Impact
Native Americans?

• PPACA will provide Native Americans with more
  health care choices and better access to
  affordable insurance and government-sponsored
  coverage, e.g., exchanges, Medicare, Medicaid,
  and the Childrens Health Insurance Program
• Reauthorizes the Indian Health Care Improvement
  Act, which includes specific provisions for
• Shoring up or modernizing IHS/tribally-run
  programs
• New and expanded mental health and substance use
  treatment and prevention programs for Native
  Americans
• Development of workforce shortage demonstration
  projects
• Tribes to assume management of their own health
  care programs and build/expand them through third
  party revenues

8
What are the Similarities between the PPACA and
Behavioral Health Reform in New Mexico?

• Both reforms are intended to
• Maximize access to care and enhance quality
• Increase use of evidence-based treatment
• Improve efficient use of public funds
• Improve services for Native American people

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PPACA Implications for Rural New Mexico

• Rural areas have not received much attention
  under PPACA
• Congressional hearings did not focus on the
  potential impact on rural behavioral health care
• No targeted funding for community-based
  behavioral health care in rural communities
• Providers in rural areas, where the bulk of New
  Mexicos Native American population resides, will
  face pressures of
• Increased demand for services from the newly
  insured
• Mental health and substance use treatment parity
  requirements in Medicaid
• Expanding behavioral health service portfolios

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Lessons Learned from the New Mexico Reform
Pertinent to the PPACA

• Rural Context Matters!
• Stereotypes and Myths Abound at All Levels
• Outreach to Clients and Their Families Is
  Essential
• Strengthen State-Tribal Interface to Facilitate
  Collaboration
• Native American Stakeholders Need to Know Their
  Input Matters!
• Facilitate Smooth Transitions
• Acknowledge Limitations of Evidence-Based
  Practices
• Evaluate, Evaluate, Evaluate!

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Overview of Qualitative Study RE New Mexico
Behavioral Health Reform (2006-2010)

• 300 semi-structured interviews with a purposive
  sample of Native American community leaders,
  providers, clients with serious mental illness,
  and family members (n169)
• Ethnographic observations in public forums
  focused on reform-related issues (600 hrs)
• Ethnographic observations in Navajo-serving
  clinical institutions (200 hrs)
• Statewide survey of mental health agencies
• Document review

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To Assess Relevance of the New Mexico Behavioral
Health Reform to PPACA

• Document review (focusing on 2009 to present)
• National Native American organizations (e.g.,
  National Indian Health Board, National Congress
  of American Indians)
• Foundations (e.g., Henry J. Kaiser Foundation,
  Robert Wood Johnson Foundation)
• Federal government websites (e.g., Congressional
  Research Service, Indian Health Services, Office
  of Minority Health, White House, etc.)
• State government websites (e.g., NM, AZ, OK,
  etc.)

13
Rural Context Matters!

• Greater access problems than in urban areas
  (e.g., logistical challenges, turnover, and
  workforce shortages)
• Native Americans are disproportionately impacted
  by these challenges
• Our study found that McKinley and San Juan
  Counties, home to the largest numbers of Native
  Americans in New Mexico, have the fewest number
  of providers per population with serious mental
  illness (almost 88 providers for an estimated
  8,295 people)
• Insufficient numbers of licensed clinicians
  created problems for tribes interested in billing
  under Medicaid
• Demand for behavioral health professionals will
  increase under PPACA
• Native American programs must be provided with
  resources to recruit and retain professionals,
  and to enhance the current workforce, i.e.,
  increase training opportunities and create
  incentives for providers to pursue
  education/licensure

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Rural Context Matters!

• Rural behavioral health agencies have fewer
  resources than their urban counterparts, which
  can make it hard to adjust to the demands of
  comprehensive nationwide reform
• Less advanced informational technology (IT)
  systems
• Remote location of many tribal behavioral health
  programs contributes to serious IT system
  disparities
• Under the NM reform, few of these programs had
  computer infrastructure to enroll clients or
  process claims to receive payment for services
  rendered
• For national reform, it is recommended that
  Native American programs not be penalized for a
  lack of IT technology (National Indian Health
  Board, 2009)

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Stereotypes and Myths Abound at all Levels

• Those big shots up there in Santa Fe think
  that IHS, 638 programs and the BIA Bureau of
  Indian Affairs can take care of the needs of all
  the Native Americans in the state of New Mexico.
  Thats a myth. Its been a myth for years.
  -Native American community leader, 2009
• One state staff said to me, Oh, you guys get
  free health care. What are you bellyaching
  about? -Native American community leader, 2009
• Such stereotypes and myths may gain traction,
  given that Native Americans are excluded from
  certain provisions of PPACA, i.e., individual
  mandate and copays (if income does not exceed
  300 of poverty level)
• Other emergent myths will also need to be
  challenged

16
Outreach to Clients and their Families is
Essential

• 96 (n110) of Native American clients and family
  members in our study were unaware that a
  behavioral health reform was taking place in NM
• Only 6 (n5) of the Native American clients and
  no family members took part in Local
  Collaboratives (state-initiated community
  stakeholder groups convened to address behavioral
  health system change within their local areas)
• This means that Native American clients and
  family probably had limited knowledge and
  opportunity to advocate for behavioral health
  needs under the NM reform

17
Outreach to Clients and their Families is
Essential

• Aggressive outreach, education, and marketing
  regarding health care reform, and specifically
  the Native American-specific provisions, needs to
  take place (also see Bernalillo County
  Off-Reservation Native American Health Commission
  and Raincloud Local Collaborative, 2011)
• Such efforts are key to addressing local concerns
  about PPACA, informing people with serious mental
  illness of their rights and services available to
  them, and facilitating enrollment in Medicaid,
  insurance exchanges, and other reform programs
• Such efforts will also enhance the likelihood
  that clients and families may become involved in
  planning and community input processes related to
  implementation of PPACA

18
PPACA Presents Ample Opportunities for States and
Tribes to Collaborate

• Under PPACA, states will become more involved in
  both public and private insurance markets,
  playing critical decision-making roles in
• Eligibility determination
• Oversight of Medicaid expansion
• Operation of health insurance exchanges
• Development of community-based navigation systems
  
• States will need to consult Native American
  constituents about such matters
• Opportunities for state-tribal collaboration also
  include outreach and education workforce
  development and federal grants to bring in new
  monies, programs, and services to Native American
  communities

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Strengthen State-Tribal Interface to Facilitate
Collaboration

• Tribes are not simply another interest group
  (National Indian Health Board, n.d.)
• Tribes need to be consulted early in planning and
  consistently in implementation of programs
  impacting their communities
• In New Mexico, the majority of Native American
  stakeholders in our study were disappointed with
  consultation processes under behavioral health
  reform
• State officials need to become more knowledgeable
  about
• Tribal health care systems
• What it means for tribes to be sovereign nations

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Strengthen State-Tribal Interface to Facilitate
Collaboration

• Out of fairness to the governors senior pueblo
  officials here, you should come visit us. You
  pose a lot of questions to us. I feel I need my
  experts to add information to what I say. Ive
  been dealing with federal, state government for a
  long time and Im not interested in being a
  checkmark yes, we consulted for four hours. My
  problem is the uniqueness of tribes in terms of
  way of life, culture and traditions. Were all
  different. We sit here for this four-hour
  consultation but I feel its not enough time. For
  me to be a sovereign leader of a pueblo nation,
  to be given ten minutes to speak is
  disrespectful. You should come to our pueblo to
  speak with me and my experts
• -Native American community leader, 2010

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Native American Stakeholders Need to Know Their
Input Matters!

• States (as well as the federal government) must
  affirm the insights and labors of Native American
  stakeholders involved in reform efforts,
  demonstrating how their input makes a difference
  in terms of both planning and implementation
• When the behavioral health reform first
  started, Native Americans got the idea that we
  were gonna be at the table finally. Thats still
  our hope. Were still voicing our opinion. As to
  the reality of what our opinion means or is heard
  or what happens with it after that, I have no
  idea.
• -Native American community leader, 2009

22
Facilitate Smooth Transitions

• There are still a lot of unanswered questions
  about how national reform will play out in the
  provider world
• The NM reform was marked by a series of chaotic
  transitions, because key administrative
  processes were not defined at the outset and
  because policies and procedures were constantly
  changing these transitions created stress for
  Native American and non-Native American providers
  alike
• Providers need to be educated early on about
  PPACA provisions related to Native Americans and
  consulted to ensure the fit of implementation
  strategies
• Providers also require resources to help with
  implementation

23
Acknowledge Limitations of Evidence-Based
Practices

• Native American providers in our study were less
  likely to support evidence-based practices (EBPs)
  for behavioral health
• They argued that these EBPs generally lacked
  empirical data on efficacy and effectiveness
  among Native American people (as well as rural
  populations)
• They resented suggestions that EBPs needed
  tweaking to ensure their cultural
  appropriateness
• Several providers also admitted they were
  unlikely to implement EBPs if mandated to do so
  by the state I have a problem with outside
  funders saying we need to use evidence-based
  approaches Clinical director (2008)

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Acknowledge Limitations of Evidence-Based
Practices

• Under the NM reform, resources to adapt,
  implement, and evaluate EBPs for Native American
  contexts were limited
• Native American stakeholders also argued that
  practice-based evidence, largely referring to
  traditional healing modalities, must be
  considered on par with EBPs, but did not feel
  that much movement had been made on this front
• Given the increased attention to mental health
  and substance use service delivery for Native
  Americans under PPACA, tribes and states may have
  increased opportunities to more concertedly
  address the integration of EBPs and traditional
  healing modalities within behavioral health care
  contexts
• Tribes and states should strive for parity in
  reimbursement for traditional healing modalities
  and western treatments.

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Evaluate, Evaluate, Evaluate!

• The NM reform would have benefitted from ongoing
  system-wide evaluation emphasizing process,
  outcomes, and participant points of view
• Real-time evaluation of national reform offers
  several advantages to state, federal, and tribal
  governments
• Keep governments in touch with the lived
  experiences of direct service providers, staff,
  clients and families
• Identify and address unforeseen issues and
  adverse events
• It is especially important to monitor how Native
  American clients with serious mental illness will
  be impacted by PPACA provisions implemented by
  states, e.g., Medicaid expansions and insurance
  exchanges
• Tribes should be provided with resources to
  create and maintain their own comprehensive data
  collection systems so they can take the lead in
  monitoring these and other impacts

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For Further Information

• Cathleen E. Willging, PhD
• Pacific Institute for Research and Evaluation
• Behavioral Health Research Center of the
  Southwest
• 612 Encino Place, NE
• Albuquerque, NM 87102
• E-mail cwillging_at_bhrcs.org
• Phone [phone]
• Website www.pire.org or www.bhrcs.org