Diabetes in Urban Native American Populations - Research Paper Example

? The Patient Protection and Affordable Care Act - Urban Native Americans with Diabetes - Promoting Health and Disease Prevention as a Primary Resource Name: Class: Date: 07/11/11 Table of Contents Diabetes in Urban Native American Populations 2 Introduction 2 The Patient Protection and Affordable Care Act 3 Diabetes 4 Causes of Diabetes 4 Native American Communities & Diabetes 5 The Urban Environment 7 Applicability of the Legal Statutes 7 Analysis of Health Care Need 8 Access to Health Care Facilities 8 Access to Health Insurance & Medical Programs 8 Treatment 9 Prevention 9 Community & Personal Education Initiatives 10 Health Care Policy Analysis 10 According to Logest (2006), Health Policy "consists of decisions (laws, rules, judicial decisions) made within government structures (executive, legislative, judicial branches) that direct the actions, behaviors, and decisions pertaining to health and its determinants". (Mason, 2007, p.50) As the Patient Protection and Affordable Care Act represents the largest reform in health policy in over 50 years, the specific impact needs to be understood for each individual, group, and institution in the sector. Native Americans receive certain benefits under public law that are intended to improve historical conditions related to discrimination and poverty in communities, and these policies can be made more effective by informed implementation. 10 11 Funding for Treatment 11 Funding for Prevention 11 Funding for Education 12 Recommendation to the Institute of Medicine 2010 13 Policy Implementation 13 Policy Implementation Goals 14 The Role of Nursing in Policy Implementation 14 Diabetes Treatment & Long Term Care 15 Conclusion 15 The Use of Public Resources in Health Care 16 The Need to Address Minority Issues Related to Ethnic Discrimination 16 Nursing through Educated Care-giving 17 References 18 Appendix 20 Diabetes in Urban Native American Populations Introduction The loss of the traditional Native American lifestyle has led to an increase in the prevalence of diabetes in Indian people across America. As Dorothy Gohdes wrote in “Diabetes in North American Indians and Alaska Natives” (1995), “The epidemic of non-insulin-dependent diabetes mellitus (NIDDM) in Native American communities has occurred primarily during the second half of this century. Although NIDDM has a genetic component, with rates highest in full-blooded Native Americans, the incidence and prevalence of the disease have increased dramatically as traditional lifestyles have been abandoned in favor of westernization, with accompanying increases in body weight and diminished physical activity.” (Gohdes, 1995, p.1) The problem of diabetes in Native American urban populations is one that has been recognized and studied by a wide range of government organizations as a priority in public health care policy. The reasons for this include the fact that Native Americans are statistically in the lower range of socio-economic status in society, often lacking official health care insurance or the means to pay for it for themselves or their children. “More than 67% of Native families live below the federal poverty line.”(Seva, 2011, para. 1) The Patient Protection and Affordable Care Act includes numerous clauses and exceptions that are written specifically for the health care needs of Native Americans living outside of traditional reservations. Additionally, the Act provides for specific policies to be implemented with regard to diabetes treatment. (U.S. Senate, 2011, p.63) According to the Henry J. Kaiser Family Foundation, The Patient Protection and Affordable Care Act “reauthorize(s) and amend(s) the Indian Health Care Improvement Act. (Effective upon enactment)” (The Henry J. Kaiser Family Foundation, 2011, p.13) This essay is a policy review of the Patient Protection and Affordable Care Act that will focus specifically on the issues related to diabetes in Native American communities in urban areas, suggesting approaches in treatment, prevention, and education that can work within public policy requirements for the health care of individuals in these communities. The Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act established the requirement for individuals to maintain minimum essential health care insurance coverage or face a mandated government fine. This clause is found in ‘Subtitle F—Shared Responsibility for Health Care: Part I – Individual Responsibility - Sec. 1501 & Sec. 5000A’ and represents one of the main applications of the legislation. (U.S. Senate, 2011, p.65) The Patient Protection and Affordable Care Act also states that “exemptions from the penalty will be made for those who cannot afford coverage, taxpayers with income below the filing threshold, members of Indian tribes, those who have received a hardship waiver and those who were not covered for a period of less than three months during the year.” (U.S. Senate, 2011, p.13) The Patient Protection and Affordable Care Act as written requires a policy analysis for the specific application to Native American individuals, as their status, eligibility for special benefits, and exemptions from health care insurance requirements may vary with the degree of formal association that the individual has with a recognized Native American Indian Tribe, Reservation, or place of residence. This paper will contain a literature review related to the policy implementation of The Patient Protection and Affordable Care Act specifically for Native Americans living in urban environments. This will include a discussion of the different applications of the legislation to individuals depending on their socio-economic and Tribal status. The essay will further focus on the area of diabetes treatment by analyzing the specific threat the disease portends for the urban Native American community and the aspects of the Patient Protection and Affordable Care Act that formally references diabetes treatment. Diabetes Causes of Diabetes According to studies conducted with Pima Indians and other tribes, the prevalence of diabetes in Native American individuals is primarily non-insulin-dependent diabetes mellitus (NIDDM), rather than the insulin-dependent variation of the disease. (Gohdes, 1995, p. 684) According to medical health care professionals, the primary causes for this type of diabetes in genetic traits, obesity, lifestyle, and pathogenesis. (Gohdes, 1995, p. 687-8) Source: (Gohdes, 1995, p.687) As the chart above shows, studies suggest that full-blooded Native Americans are more susceptible to NIDDM diabetes than non-Indian or mixed race individuals. According to Gohdes (1995), “a genetic marker linked with insulin resistance, a major factor in the pathogenesis of NIDDM”. (Gohdes, 1995, p. 687) Obesity is accepted as a major determinant for the genetic predisposition to diabetes, as the incidence of the disease predictably increases as the weight of the individual exceeds healthy standards. The Seattle Indian Health Board, in a report from the Urban Indian Health Commission entitled 'Invisible Tribes: Urban Indians and Their Health in a Changing World,' (2008) found that "Depression, diabetes and cardiovascular disease occur at alarming rates and often coexist... Compared to the general U.S. population, American Indians and Alaska Natives have a higher prevalence of diabetes, a greater mortality rate from diabetes and an earlier age of diabetes onset." (Parker, 2009, ‘Findings’) Obesity is related to both genetic and lifestyle factors, including the diet, the amount of exercise, caloric intake, and metabolic rate. For Native Americans, the socio-economic status, education, and traditional values may combine with incidents of depression to make conditions like obesity worse. (Espinosa, 2011, para.6) These factors point to the interrelation of causes in diabetes in the Native American community that must be addressed through health care and policy. Native American Communities & Diabetes Numerous studies show that Native American communities are afflicted disproportionately from mainstream averages in the incidence of diabetes in the population, and this is based in genetic factors, lifestyle decisions, diet, smoking, obesity, and other causes as interrelating factors. The Patient Protection and Affordable Care Act establishes specific policies to address this need, based in the historical, socio-economic, and cultural issues that are specific to Native American communities. The U.S. Census data relating to American Indian people is predominately collected from Native Americans living off of the official reservation areas in the country. The prevalence of concentrated populations of Native Americans in urban areas can be seen in the chart below: Source: (Gohdes, 1995, p.684) From these statistics, the evidence suggests that concentrated populations of Native Americans in particular urban areas are in greater need of treatment related to diabetes than others, and that the health effects of the disease is exacerbated by social factors such as economic status, access to employment-based or public health care insurance, willingness of individuals to approach the health care system for treatments, and other issues that can be addressed through public policy changes and nursing. The Urban Environment The urban environment may represent a restriction of traditional Indian lifestyle which leads to greater degrees of obesity, diabetes, and depression in the Native American population. The concentration of Indian populations in urban areas opens the opportunity for public policy approaches to community treatment. The goal of this will be considered with regards to the treatment, prevention, and education of Native Americans in these urban areas with regard to the policy directives of the Patient Protection and Affordable Care Act. The urban environment should make specialized public education and outreach programs targeted to the Native American community related to the concentration of indigenous populations in each locality. Applicability of the Legal Statutes The Patient Protection and Affordable Care Act establishes new rules for Native American healthcare policy in the terminology of the legislation. For example, in ‘Subtitle K – Protections for American Indians and Alaska Natives’ the law “Prohibits cost-sharing for Indians enrolled in a qualified health benefit plan in the individual market through a State Exchange” and Sec. 2902 provides for the “elimination of sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics.” (U.S. Senate, 2011, pp.21-22) The specifics of health care reform relating to the Native American community thus needs a further, in depth analysis of the impact on urban Native American communities to determine the effect on public funding of institutions, programs, and facilities that assist these people directly. Sections such as Sec. 10336 and Subtitle D—Provisions Relating to Title IV (Sec. 10407) of the Patient Protection and Affordable Care Act specifically reference diabetes, diabetes treatment, and research, leading to the possibility that Native American specific policies can be developed under the framework to further address the problem socially through healthcare. (U.S. Senate, 2011, p. 63) Analysis of Health Care Need Access to Health Care Facilities The socio-economic position of Native Americans shows that over 67% of the families in this community live under the poverty line, making the access to healthcare through insurance a traditional problem that the Patient Protection and Affordable Care Act is intended to address. (Seva, 2011, Web) From this arises the need to educate Native American individuals and families as to what exactly their rights, responsibilities, and cost for treatment is under the new system. Individuals and families who cannot receive healthcare insurance through employment, lacking either a job or benefits, need to be provided with educational services that explain the process of signing up for public medical coverage and the way that insurance can be used to receive regular medical treatment from doctors and hospitals. Access to Health Insurance & Medical Programs The diabetes treatment programs organized under the new terms of the Patient Protection and Affordable Care Act need to assist Native Americans in urban locations initially in working through the paperwork that gets them registered as part of the insurance system. Without the basic understanding of governmental regulations and policies, these individuals will continue to fall through the cracks in public assistance programs and fail to receive the medical treatment that can both save and improve lives. Access can be considered a first step to treatment, something many in these communities are lacking currently. From this comes a need for initiative building and proactive policies in the Native American communities. Treatment Non-insulin-dependent diabetes mellitus (NIDDM) may be treated through medication, surgeries, counseling, and dietary changes. NIDDM often relates to other health issues and diseases such as obesity, heart disease, breathing problems, and mobility issues. “Cardiovascular disease (CVD) and diabetes are prevalent and of major concern for American-Indian communities in the United States. Health professional counseling is effective in increasing patient awareness and inducing lifestyle modification.” (Harwell, et al., 2003, p.1) Treatment for NIDDM may include “smoking cessation, physical activity, and a healthy diet in adult American Indians with and without diabetes”. (Harwell, et al., 2003, p.1) Prevention According to the Harwell study (2003), “Respondents with diabetes, compared to those without, had a significantly higher prevalence of CVD (27% vs 8%); overweight (89% vs 71%); high blood pressure (57% vs 24%); and high cholesterol (44% vs 22%). There were no differences for insufficient physical activity (60% vs 51%) or smoking (34% vs 41%) after adjustment for age, gender, and survey year. Respondents with diabetes, compared to respondents without diabetes, were significantly more likely to report health professional counseling for smoking cessation (83% vs 58%); physical activity (73% vs 37%); and reduced fat consumption (57% vs 24%).” (Harwell, et al., 2003, p.1) From this, healthcare professionals are tasked with developing effective prevention programs for diabetes in Native American communities that address the need for weight reduction, smoking cessation, increased exercise, and dietary improvements as a means of reducing the incidence of diabetes. The best way to do this is through education initiatives, which lead individuals to receive primary care treatment and health counseling from doctors and hospitals directly. Community & Personal Education Initiatives Community education programs can target the larger group with information that is distributed popularly through television advertisements, newspaper ads, the internet, or other sources of publicity. The goal of these education programs is to establish awareness and then to lead to the further provision of assistance through personal primary care. The Native American community needs counseling not only about the disease of diabetes, but also in how to negotiate the bureaucratic landscape to attain insurance coverage and access to treatment. The awareness building programs should lead to a deeper education program where the health issues are discussed and lifestyle changes are introduced. This can occur alongside and as part of primary physician care at clinics, hospitals, and doctor’s offices. Health Care Policy Analysis According to Logest (2006), Health Policy "consists of decisions (laws, rules, judicial decisions) made within government structures (executive, legislative, judicial branches) that direct the actions, behaviors, and decisions pertaining to health and its determinants". (Mason, 2007, p.50) As the Patient Protection and Affordable Care Act represents the largest reform in health policy in over 50 years, the specific impact needs to be understood for each individual, group, and institution in the sector. Native Americans receive certain benefits under public law that are intended to improve historical conditions related to discrimination and poverty in communities, and these policies can be made more effective by informed implementation. Funding for Treatment The Native Americans in urban areas are live predominately under the poverty line and suffer unemployment at higher levels than the general population. This causes a crisis in access to healthcare through the lack of insurance. The Patient Protection and Affordable Care Act intends to provide universal healthcare coverage in America through a combination of public and private insurance programs. Thus, Native Americans need first and foremost a clear, universal, and easy to understand education program that informs them of their rights and responsibilities for healthcare insurance under the new law. After the dynamics of the legislation are understood in individual application, the Native American people and their families can be enrolled in the appropriate public or private insurance program that provides for their needs. It is technically only after this step is established that the Native American individuals can receive effective treatment in institutions for diabetes. The medical side-effects and interrelated diseases that occur in association with diabetes can also be treated by medical professionals only if this initial step of bureaucratic enrollment is completed. Therefore, the primary aspect relating to healthcare access and the effective treatment of diabetes can only be established when the Native American people individually understand their rights and responsibilities for insurance under the Patient Protection and Affordable Care Act. Funding for Prevention Funding for prevention that acts in the sphere of public assistance programs can take many forms and need to be specifically designed by healthcare professionals in existing institutions to meet the social need for treatment. Prevention can be proactive on the individual level through counseling in a way that is tailored to the needs of the individual or group to be most effective. Counseling supplements medication and primary care in a way that makes lifestyle changes sustainable and through that providing wellness effects that enhance the effect of medications. Prevention concerns can target dietary issues, exercise, lifestyle, smoking, and other issues that interrelate with the causes of diabetes to offer a solution that improves the quality of life. The funding for these programs can be built locally in institutions through resources made available in the Patient Protection and Affordable Care Act. Funding for Education Education is a key aspect of prevention in diabetes and it occurs in a public service role through the building of popular awareness about the disease and also through personal counseling services that are a part of primary healthcare. For example, Sec. 10408 of the Patient Protection and Affordable Care Act provides for “Grants for small businesses to provide comprehensive workplace wellness programs,” and “Authorizes an appropriation of $200 million to give employees of small businesses access to comprehensive workplace wellness programs”. (U.S. Senate, 2011, p.64) Local institutions focusing in Native American health advocacy need to build on these funding sources to build education programs that: 1) Explain the healthcare changes to Indian people, 2) Assists them in managing the bureaucratic registration to become fully insured, 3) Provides primary healthcare treatment, 4) Organizes education and prevention programs. By working within public funding mandates and building innovative outreach, treatment, and education programs, the healthcare establishment can more effectively address the needs of Native Americans related to diabetes. These factors should be presented as a recommendation to the Institute of Medicine as part of a task force that seeks to alleviate the historical epidemic of diabetes in Native American communities nationally. Recommendation to the Institute of Medicine 2010 Policy Implementation The use of activism in policy as a means to promote compassionate intervention for public health needs is an important part of nursing training. Nurses must understand their role as patient advocates and their specialized knowledge of the sector to communicate publicly the need to address health issues that other sectors of government may not recognize officially in policy. The Native American diabetes problem is just one example of this, where there are many needs socially, yet a detailed policy analysis can lead to the more effective use of public resources in institutions. For example, “The Institute of Medicine report, ‘The Future of Nursing: Leading Change, Advancing Health’, is a thorough examination of the nursing workforce... The eight recommendations offered in the report are centered on four main issues: Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and information infrastructure.” (IOM Report, 2010, Section.2) From this there is a greater responsibility to use the knowledge and understanding of healthcare and human needs acquired through nursing to a more beneficial and efficient social policy related to healthcare treatment, prevention, and education. Minority groups such as Native Americans may not have the education, resources, economic capability, or awareness to self-enroll in beneficial treatment programs for diabetes and other health problems. In these instances, nurses can act as advocates who assist in developing public policies in hospitals, clinics, and other institutions which addresses these public health needs more efficiently through existing resources and budgets. Policy Implementation Goals The goal of the Patient Protection and Affordable Care Act is for universal access to healthcare, and the Native American urban communities are among the worst nationally in receiving access to treatment. Therefore, the initial stages of the policy implementation must focus on enrollment and inclusion of discriminated against people into the public system of healthcare and the social safety net. The Native Americans need to be educated and informed of their legal rights and responsibilities with regard to heath care insurance and treatment. The costs must be clearly explained, as well as the assistance programs available. Following enrollment, more effective counseling, treatment, prevention, and primary care direction can be established under the insurance system. (Espinosa, 2011, para.1) The Role of Nursing in Policy Implementation The unique understanding of nurses can be better used institutionally and publicly to meet existing health care needs and crisis situations such as the epidemic of obesity and diabetes in urban Native American communities. The social organization of institutions such as clinics, hospitals, and treatment centers can be facilitated by nurses who are aware of the legal aspects of the Patient Protection and Affordable Care Act in addition to their primary care responsibilities. This leads towards an activist and engaged nursing system that can proactively address social problems through existing organizations by using knowledge and experience in a compassionate way. (IOM Report, 2010, para.1) Diabetes Treatment & Long Term Care The importance of a combined approach to treatment, education, prevention, and primary care in diabetes health care can lead to a more positive improvement in individuals than simply medication. (Parker, 2009, ‘Recommendations’) The support of the institution such as clinic or hospital needs to include more information and education services related to lifestyle and wellness, as diet and exercise are often more important than other factors in alleviating this medical problem over the long term. Diabetes can lead to further problems in cardio-vascular disease, breathing, amputations, and loss of daily functionalities which can dramatically diminish the possibilities and quality of life of individuals. Because of this, a balanced treatment program focusing on counseling, education, and primary care can be developed within institutions as an effective treatment plan tailored specifically to Native American’s identity and social needs. Conclusion The Patient Protection and Affordable Care Act is a dramatic and powerful change in U.S. public health policy, but it is bound to result in public misunderstanding of its clauses and requirements. Native Americans form a community that suffers from historical discrimination including marginalization in employment, politics, and education. The needs of this community for health care may exceed the actual ability of the group to manage the bureaucratic requirements of the Patient Protection and Affordable Care Act. Because of this, hospitals, clinics, and other institutions need to build unique programs that assist the Native American community in urban areas to form treatment facilities for diseases like diabetes that combine education, counseling, and prevention with primary care. (Parker, 2009, ‘Recommendations’) The Use of Public Resources in Health Care Public resources in institutional budgets as provided for by the Patient Protection and Affordable Care Act need to be organized more efficiently to meet the needs of Native Americans in urban communities suffering from diabetes. (U.S. Senate, 2011, p.63) Nurses have an advantage of unique knowledge of the health care establishment and day to day operations of facilities. The nurses know the patients needs from direct relationship with the people, and this knowledge needs to be put to greater use in organizing public resources in hospitals, clinics, and other facilities. Public health care resources need to specifically target marginalized or excluded communities like the Native Americans, and also to address the inequalities inherent in poverty, unemployment, and racial discrimination. The Need to Address Minority Issues Related to Ethnic Discrimination The historical issues related to the Native Americans gives this group a specially protected status in U.S. law that has been continued in the Patient Protection and Affordable Care Act in Subtitle K. (U.S. Senate, 2011, p.21) Nurses, doctors, and health care professionals need to understand the dynamics of this situation socially, and how it has led to the endemic problems of unemployment, poverty, obesity, alcoholism, and diabetes. By understanding both the social history of minority groups and their special health care needs, the health care system can provide services more effectively that targets these groups and alleviates the suffering through primary care, prevention, education, and treatment programs in diabetes. Nursing through Educated Care-giving The ability of nurses to make a difference in the administration of institutions, budgets, and public policy is determined by the education and ability to see both macro and micro social issues as they found in the daily lives of individuals. Those health care practitioners with higher concentrations of Native Americans in their community will be tasked with building social assistance programs that alleviate the suffering of diseased people through the application of medical knowledge. This can occur through public education programs, private counseling groups, primary health care facilities, medical treatment, and prevention programs. (NACA, 2011, ‘Goals’) With a complex disease like diabetes, these programs must balance the lifestyle changes required to treat the disease with medication and advanced treatments that are covered by the insurance system as reformed in the Patient Protection and Affordable Care Act. References Espinosa, Mark (2011). Native American Health Center: Diabetes, Alcohol, and Depression in a Displaced Community. San Francisco Medical Society. Retrieved from http://www.sfms.org/AM/Template.cfm?Section=Home&CONTENTID=2243&TEMPLATE=/CM/HTMLDisplay.cfm&SECTION=Article_Archives Gohdes, Dorothy (1995). Diabetes in North American Indians and Alaska Natives. Chapter 34 in "Diabetes in America," National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from http://ndic.circlesolutions.com/dm/pubs/america/pdf/chapter34.pdf Kramer, B J (1992). Health and aging of urban American Indians. West J Med. 1992 September; 157(3): 281–285. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1011277/ Harwell, Todd S and Kelly Moore, Janet M McDowall, Steven D Helgerson, & Dorothy Gohdes (2003). Cardiovascular risk factors in Montana American Indians with and without diabetes. American Journal of Preventive Medicine Volume 24, Issue 3 , Pages 265-269, April 2003. Retrieved from http://www.ajpmonline.org/article/S0749-3797(02)00640-2/abstract Mason, D.J., Leavitt, J.K., & Chaffee, M.W. (2007). Policy & politics in nursing and health care (fifth edition), St. Louis: Elsevier. The Henry J. Kaiser Family Foundation (2011). Implementation Timeline. Health Reform Source. Retrieved from http://healthreform.kff.org/timeline.aspx The Henry J. Kaiser Family Foundation (2011). Summary of Coverage Provisions in the Patient Protection and Affordable Care Act. FOCUS on Health Reform. Retrieved from http://www.kff.org/healthreform/upload/8023-R.pdf The Henry J. Kaiser Family Foundation (2011). Summary of New Health Reform Law. FOCUS on Health Reform. Retrieved from http://www.kff.org/healthreform/upload/8061.pdf IOM Report (2010). The Future of Nursing: Leading Change, Advancing Health. Robert Wood Johnson Foundation. Retrieved from http://thefutureofnursing.org/IOM-Report NACA (2011). Harmony Through Health Diabetes Program. Native Americans for Community Action, Inc.. Retrieved from http://www.nacainc.org/subjects/programs/diabetes-program/diabetes-program.htm Parker, Susan G. (2009). Urban American Indians Have High Levels of Depression, Diabetes and Cardiovascular Disease, Study Shows. Robert Wood Johnson Foundation (RWJF). Retrieved from http://www.nacainc.org/subjects/programs/diabetes-program/diabetes-program.htm SEVA (2011). Intertribal Friendship House Living Native 2010: Reconnecting with Our Mother Earth. Seva Foundation. Retrieved from http://www.seva.org/site/PageServer?pagename=programs_NA_Project_3 U.S. Senate (2011). Affordable Care Act - Section?by?Section Analysis with Changes Made by Title X and Reconciliation. Retrieved from http://dpc.senate.gov/healthreformbill/healthbill96.pdf Appendix Subtitle F—Shared Responsibility for Health Care Part I – Individual Responsibility Sec. 1501. Requirement to maintain minimum essential coverage. Contains findings of Congress related to the individual responsibility requirement, which are amended by Section 10106. Sec. 5000A. Requirement to maintain minimum essential coverage. Requires individuals to maintain minimum essential coverage beginning in 2014. As amended by Section 1002 of the Reconciliation Act, failure to maintain coverage will result in a penalty of the greater of $95 or one percent of income in 2014, $325 or two percent of income in 2015 and $695 or 2.5 percent of income in 2016, up to a cap of the national average bronze plan premium. Families will pay half the amount for children up to a cap of $2,250 for the entire family. After 2016, dollar amounts will increase by the annual cost of living adjustment. Exceptions to the individual responsibility requirement to maintain minimum essential coverage are made for religious objectors, individuals not lawfully present, and incarcerated individuals. Exemptions from the penalty will be made for those who cannot afford coverage, taxpayers with income below the filing threshold, members of Indian tribes, those who have received a hardship waiver and those who were not covered for a period of less than three months during the year. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Subtitle K – Protections for American Indians and Alaska Natives Sec. 2901. Special rules relating to Indians. Prohibits cost-sharing for Indians enrolled in a qualified health benefit plan in the individual market through a State Exchange. Also, facilities operated by the Indian Health Service (IHS) and Indian, Tribal, and Urban Indian facilities 22 (I/T/Us) would be added to the list of agencies that could serve as an “Express Lane” agency able to determine Medicaid and CHIP eligibility. Sec. 2902. Elimination of sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics. Removes the sunset provision, allowing IHS and I/T/U services to continue to be reimbursed by Medicare Part B. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 2953. Personal responsibility education. Provides $75 million per year through FY2014 for Personal Responsibility Education grants to States for programs to educate adolescents on both abstinence and contraception for prevention of teenage pregnancy and sexually transmitted infections, including HIV/AIDS. Funding is also available for 1) innovative teen pregnancy prevention strategies and services to high-risk, vulnerable, and culturally under-represented populations, 2) allotments to Indian tribes and tribal organizations, and 3) research and evaluation, training, and technical assistance. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under part D. Allows drugs provided to beneficiaries by AIDS Drug Assistance Programs or the Indian Health Service to count toward the annual out-of-pocket threshold. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. Integrated Data Repository. Requires CMS to include in the integrated data repository (IDR) claims and payment data from the following programs: Medicare (Parts A, B, C, and D), Medicaid, CHIP, health-related programs administered by the Departments of Veterans Affairs (VA) and Defense (DOD), the Social Security Administration, and the Indian Health Service (IHS). +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 9021. Exclusion of health benefits provided by Indian tribal governments. Provides an exclusion from gross income for the value of specified Indian tribal health benefits. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Part III – Indian Health Care Improvement Sec. 10221. Indian health care improvement. Authorizes appropriations for the Indian Health Care Improvement Act, including programs to increase the Indian health care workforce, new programs for innovative care delivery models, behavioral health care services, new services for health promotion and disease prevention, efforts to improve access to health care services, construction of Indian health facilities, and an Indian youth suicide prevention grant program. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 10334. Minority health. Codifies the Office of Minority Health at the Department of Health and Human Services (HHS) and a network of minority health offices located within HHS. Elevates the National Center on Minority Health and Health Disparities at the National Institutes of Health from a Center to an Institute. The Offices of Minority Health will monitor health, health care trends, and quality of care among minority patients and evaluate the success of minority health programs and initiatives. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality dialysis services. Directs the Comptroller General to submit to Congress, within one year of enactment, a study on the impact on Medicare beneficiary access to high-quality dialysis services of the end stage renal disease prospective payment system. Subtitle D—Provisions Relating to Title IV Sec. 10407. Better diabetes care. Directs the Secretary of HHS to develop a national report card on diabetes to be updated every two years. Directs the Secretary to work with health professionals and States to improve data collection related to diabetes and other chronic diseases. Provides for an Institute of Medicine study on the impact of diabetes on medical care. Sec. 10408. Grants for small businesses to provide comprehensive workplace wellness programs. Authorizes an appropriation of $200 million to give employees of small businesses access to comprehensive workplace wellness programs. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Subtitle E – Provisions Relating to Title V Sec. 10501. Amendments to Title V. (d) Loan repayment for faculty at schools that train physician assistants. Includes faculty at schools for physician assistants as eligible or faculty loan repayment within the workforce diversity program. (g) National diabetes prevention program. Establishes a national diabetes prevention program at the CDC. State, local, and tribal public health departments and non-profit entities can use funds for community-based prevention activities, training and outreach, and evaluation. (l) Rural physician training grants. Authorizes grants for medical schools to establish programs that recruit students from underserved rural areas who have a desire to practice in their hometowns. Programs would provide students with specialized training in rural 65 health issues, and assist them in finding residencies that specialize in training doctors for practice in underserved rural communities. (m)(1) Preventive medicine and public health training grant program. Amends and reauthorizes section 768 of the Public Health Service Act, the preventive medicine and public health residency program. (n)(1) National Health Service Corps improvements. Improves the National Health Service Corps program by increasing the loan repayment amount, allowing for half-time service, and allowing for teaching to count for up to 20 percent of the Corps service commitment. Sec. 10502. Infrastructure to expand access to care. Provides funding to HHS for construction or debt service on hospital construction costs for a new health facility meeting certain criteria. Sec. 10503. Community Health Centers and National Health Service Corps Fund. Establishes a Community Health Centers and National Health Service Corps Fund. The fund will create an expanded and sustained national investment in community health centers under section 330 of the Public Health Service Act and the National Health Service Corps. As amended by Section 2303 of the Reconciliation Act, increases mandatory funding for community health centers to $11 billion over five years (FY2011-2015). Read More