While this type of health care coverage may be provided by state or federal government, the federal government is the primary provider of this coverage (e.g., Medicare, Indian Heath Service, Tricare, and Veteran Administration). The federal government provides coverage for two primary groups: individuals for whom the federal government has assumed the responsibility of providing care (e.g., federally recognized tribal nations and veterans), and individuals who are unable to purchase health insurance through the private sector (e.g., the poor and medically indigent). There are programs, such as AHCCCS and KidsCare, which are administered by the State of Arizona, but receive funding support from both the state and federal government.
AHCCCS: In 1965, the U.S. Congress enacted the Medicaid program (Title XIX of the Social Security Act), a federal and state financed program to pay for health services for the categorically needy and the medically needy. The categorically needy are those who receive public assistance from the Aid to Families with Dependent Children (AFDC) program (now called Temporary Assistance for Needy Families, or TANF), and aged, blind and disabled recipients of Supplemental Security Income (SSI). The medically needy are those who have enough money to live on, but not enough to pay for medical care. During the 1981 Arizona Legislative Session, Arizona Health Care Cost Containment System (AHCCCS) was designated as the state’s Medicaid program, and services began on October 1, 1982. All AHCCCS beneficiaries receive health care from contracted managed care plans. AHCCCS provides general medical services to the low-income, indigent and disabled population.
There were 824,575 persons enrolled in AHCCCS (acute care) on December 1, 2002. During 1998–2002, the AHCCCS acute care membership rose 105% from 402,013 in 1998.[4] The increase can be attributed primarily to the expansion of eligibility for the acute care program from 34% for the Federal Poverty Level (FPL) to 100% in 2001. Another factor that cotributed to the rise in AHCCCS enrollment was the increase in unemployment rates. Approximately 24% of the state’s population lived in the 13 rural counties, but 33% of the total AHCCCS enrollees were located in those counties in 2002. During the five years, there were greater percentages of increase in the two urban counties (113%) than the 13 rural counties (rural-urban – 108% and rural-rural – 86%). Table 1 shows the five-year enrollment trends.
KidsCare: The State Children’s Health Insurance Program (SCHIP), enacted by Congress as part of the Balanced Budget Act (BBA) of 1997, provides states with $20.3 billion over five years to expand insurance programs for children under the age of 19. The Arizona SCHIP allotment is $114 million annually. Rather than just expand the AHCCCS (Medicaid) program, Arizona implemented a separate state SCHIP program called KidsCare in November 1998. In this program, health care can be provided to children under the age of 19 through AHCCCS health plans, direct service, sliding-fee-scale clinics, or IHS/self determination tribal facilities for tribal members who elect that option.
KidsCare is a joint federal/state program for children under 19 who are not Medicaid eligible, and are in households below the 200% FPL. In 2002, there were 49,985 children enrolled in KidsCare.[5] Twenty-five percent (12,409) of the children were living in the 13 rural counties (see Table 2). On January 1, 2003, eligible parents of children enrolled in KidsCare, with household incomes up to 100% FPL, were added to the program.
The AHCCCS website provides detailed description and enrollment information of all the programs it administers: http://www.ahcccs.state.az.us/site .
Medicare: In July 1965, Medicare was enacted into law. The nation’s largest federally financed health insurance program, it provides health insurance to people aged 65 and over (34,679,267 – 86%), those who have permanent kidney failure, and certain people with disabilities (5,809,611 – 14%).6 In 2002, $267 billion was spent for health care on behalf of Medicare enrollees.[2]
In 2002, there were 708,210 persons enrolled in Medicare in Arizona, of whom 613,648 (86.6%) were 65 years of age or older and the remainder were disabled persons.[6] Twenty-eight percent (169,142) of the Medicare seniors were living in the 13 rural counties.[6] (See Table 3) Of these, 96% of the seniors purchased Supplemental Medicare Insurance (Medicare Part B).
Other Federal Programs: The Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders.[7] The IHS is the principal federal health care provider and health advocate for Indian people.
The Indian Health Service is organized into twelve regional areas covering the contiguous 48 states and Alaska. The Phoenix, Tucson and Navajo Area Offices are the core of IHS administration and management in Arizona. The Navajo Area IHS Office, located in Window Rock, administers numerous clinics, health centers, and hospitals to 201,583 members of the Navajo Nation, which encompasses northern Arizona in addition to western New Mexico and southern Utah.[7] The Tucson IHS Office works with the Tohono O’odham Nation and the Pascua Yaqui Tribe to provide care to 4000+ members.[7] The Phoenix Area IHS Office oversees the delivery of health care to approximately 105,000 Indian people.[7]
Tricare, implemented i 1994 by the Department of Defense (DOD), is the triple option health benefits program for the seven uniformed services: Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration. There were 124,217 enrollees in Tricare in 2000.[8] The three types of health care coverage programs available under Tricare are: 1) Tricare Prime, an HMO type system with a point-of-service option and no deductible; 2) Tricare Standard, an indemnity plan with an annual deductible where the beneficiary pays a percentage of total charges for medical care; and 3) Tricare Extra, a PPO-type program that allows beneficiaries access to a network of providers, and after the annual deductible is met, the beneficiary pays only 5% of the cost of care.[9] Tricare also offers a dental program, which is a voluntary, comprehensive program offered to family members of all active duty personnel and to selected reserve members and their families. Retirees and their families are eligible for a retiree dental program.
The Veterans Affairs provides coverage for retired, disabled, and otherwise qualified veterans of previous U.S. military service. Of the 509,009 veterans in Arizona in 2000, 16.7% received care from the VA system.[10] Most veterans using the VA health care system are older, retired men with long-term care problems: multiple and chronic physical and emotional illnesses. Although the VA operates a system of both hospitals and outpatient clinics, most health care is provided by the hospital system.
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