The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline

Elayne J. Heisler
Analyst in Health Services

On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (ACA; P.L. 111-148). Among its provisions, the ACA reenacts, amends, and permanently reauthorizes the Indian Health Care Improvement Act (IHCIA). IHCIA authorizes many specific Indian Health Service (IHS) activities, sets out the national policy for health services administered to Indians, and sets health condition goals for the IHS service population to reduce “the prevalence and incidence of preventable illnesses among, and unnecessary and premature deaths of, Indians.” The reauthorization of IHCIA in the ACA amends the IHCIA to, among other changes, expand programs that seek to augment the IHS health care workforce, increase the amount and type of services available at facilities funded by the IHS, and increase the number and type of programs that provide behavioral health and substance abuse treatment to American Indians and Alaska Natives.

This report provides a brief overview of IHCIA and summarizes the provisions of the Indian Health Care Improvement Reauthorization and Extension Act of 2009 as reported by the Senate Committee on Indian Affairs and as enacted and amended by Section 10221 of the ACA. Appendix A presents a timeline of the deadlines included in the act. Another report, CRS Report R41152, Indian Health Care: Impact of the Affordable Care Act (ACA), by Elayne J. Heisler, summarizes the major changes made by the ACA to IHCIA and other provisions in the ACA that may affect IHS and American Indian and Alaska Native health and their access to health care.


Date of Report: December 14, 2012
Number of Pages: 47
Order Number: R41630
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Indian Health Care: Impact of the Affordable Care Act (ACA)

Elayne J. Heisler
Analyst in Health Services

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

IHCIA authorizes many IHS programs and services, sets out the national policy for health services administered to Indians, and articulates the federal goal of ensuring the highest possible health status for Indians, including urban Indians. In addition, it authorizes direct collections from Medicare, Medicaid, and other third-party insurers. Prior to the ACA, IHCIA was last reauthorized in FY2000, although programs have received appropriations since that time. The ACA reauthorizes IHCIA and extends authorizations of appropriations for IHCIA programs indefinitely. It amends a number of sections of IHCIA in general, to permit tribal organizations (TOs) and urban Indian organizations (UIOs) to apply for contract and grant programs for which they were not previously eligible; to create new mental health prevention and treatment programs; and to require demonstration projects to construct modular and mobile health facilities in order to expand health services available through IHS, Indian Tribes (ITs), and TOs. It also made several organizational changes to IHS. It requires IHS to establish an Office of Direct Service Tribes to serve tribes that receive their health care and other services directly from IHS as opposed to receiving services through IHS-funded facilities or programs operated by ITs or TOs. In addition, the law requires IHS to develop a plan to establish a new area office to serve tribes in Nevada and requires the Secretary of the Department of Health and Human Services (HHS) to appoint a new IHS Director of HIV/AIDS Prevention and Treatment.

In addition to reauthorizing IHCIA, the ACA includes a number of provisions that may affect American Indians and Alaska Natives who have private insurance coverage or who receive services through SSA health benefit programs. With regard to private insurance coverage, the ACA provides a special enrollment period for American Indians and Alaska Natives who may enroll in private insurance offered through an exchange and exempts certain American Indians and Alaska Natives from the requirement to obtain private insurance coverage. Finally, it excludes tribal health benefits from being counted as gross income for tax purposes. With regard to SSA health benefit programs, the new law permits specified Indian entities to determine Medicaid and CHIP eligibility and extends the period during which IHS, IT, and TO services are reimbursed for all Medicare Part B services, indefinitely, beginning January 1, 2010. Prior to the ACA, authority for these facilities to receive Medicare Part B reimbursements for certain specified services had expired on January 1, 2010.

This report, one of a series of CRS products on the ACA, summarizes some of the key changes made in the reauthorization of IHCIA and summarizes other changes included in the ACA that may affect American Indian and Alaska Native health and health care. Another report, CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline, by Elayne J. Heisler, provides a detailed section-by-section summary of the IHCIA Reauthorization and Extension Act of 2009.


Date of Report: December 14, 2012
Number of Pages: 17
Order Number: R41152
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Medicare: Part B Premiums

Patricia A. Davis
Specialist in Health Care Financing

Medicare is a federal insurance program that pays for covered health care services of most individuals aged 65 and over and certain disabled persons. In 2012, the program is expected to cover 50 million persons (41 million aged and 9 million disabled) at a total cost of $586 billion. Most individuals (or their spouses) who are 65 and older, and have worked in covered employment and paid Medicare payroll taxes for 40 quarters receive premium-free Medicare Part A (Hospital Insurance). Those entitled to Medicare Part A (regardless of whether they are eligible for premium-free Part A), have the option of enrolling in Part B, which covers such things as physician and outpatient services and medical equipment.

Beneficiaries have a seven-month initial enrollment period, but those who enroll in Part B after their initial enrollment period and/or reenroll after a termination of coverage may be subject to a “delayed enrollment penalty” which is equal to a 10% surcharge for each 12 months of delay in enrollment and/or reenrollment. Under certain conditions, select beneficiaries are exempt from the delayed enrollment penalty; these include working individuals (and their spouses) with group coverage, some military retirees, and some international volunteers.

While Part A is financed primarily by payroll taxes paid by current workers, Part B is financed through a combination of beneficiary premiums and federal general revenues. The standard Part B premiums are set to cover 25% of projected per capita Part B program costs for the aged, with federal general revenues accounting for the remaining amount. In general, if projected Part B costs increase or decrease, the premium rises or falls proportionately.

Most Part B participants must pay monthly premiums, which do not vary with a beneficiary’s age, health status or place of residence. However, since 2007, higher-income enrollees pay higher premiums to cover a higher percentage of Part B costs. Premiums of those receiving benefits through Social Security are deducted from their monthly payments. Additionally, certain lowincome beneficiaries may qualify for Medicare cost-sharing and/or premium assistance from Medicaid through a Medicare Savings Program. The Social Security Act includes a provision that holds most Social Security beneficiaries harmless for increases in the Medicare Part B premium; affected beneficiaries’ Part B premiums are reduced to ensure that their Social Security checks do not decline from one year to the next.

Each year, the Centers for Medicare & Medicaid Services (CMS) determines the Medicare Part B premiums for the following year. The standard monthly Part B premium for 2012 is $99.90. Higher-income beneficiaries, currently defined as those with incomes over $85,000 a year, or couples with incomes over $170,000 per year, pay $139.90, $199.80, $259.70, or $319.80 per month, depending on their income levels. 

The 2013 Part B premiums rates were announced in November 2012. The standard 2013 premium will be $104.90 per month, and the higher monthly premium amounts will be $146.90, $209.80, $272.70, or $335.70, depending on income level. The income thresholds will be the same as those in 2012. This CRS report will be updated in early 2013. 

Current issues related to the Part B premium that may come before Congress include the amount of the premium and the rate of increase in recent years (and the potential net impact on Social Security benefits), modifications to the late enrollment penalty, and possible increases in Medicare premiums as a means to reduce federal spending and deficits.


Date of Report: December 12, 2012
Number of Pages: 37
Order Number: R40082
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Abortion Services and Military Medical Facilities

David F. Burrelli
Specialist in Military Manpower Policy

In 1993, President Clinton modified the military policy on providing abortions at military medical facilities. Under the change directed by the President, military medical facilities were allowed to perform abortions if paid for entirely with non-Department of Defense (DOD) funds (i.e., privately funded). Although arguably consistent with statutory language barring the use of Defense Department funds, the President’s policy overturned a former interpretation of existing law barring the availability of these services. On December 1, 1995, H.R. 2126, the FY1996 DOD appropriations act, became law (P.L. 104-61). Included in this law was language barring the use of funds to administer any policy that permits the performance of abortions at any DOD facility except where the life of the mother would be endangered if the fetus were carried to term or where the pregnancy resulted from an act of rape or incest. Language was also included in the FY1996 DOD Authorization Act (P.L. 104-106, February 10, 1996) prohibiting the use of DOD facilities in the performance of abortions. These served to reverse the President’s 1993 policy change. Recent attempts to change or modify these laws have failed.

Over the last three decades, the availability of abortion services at military medical facilities has been subjected to numerous changes and interpretations. Within the last 15 years, Congress has considered numerous amendments to effectuate such changes. Although Congress, in 1992, passed one such amendment to make abortions available at overseas installations, it was vetoed. Abortions are generally not performed at military medical facilities in the continental United States. In addition, few have been performed at these facilities abroad for a number of reasons. First, the U.S. military follows the prevailing laws and rules of foreign countries regarding abortion. Second, the military has had a difficult time finding health care professionals in uniform willing to perform the procedure.

With the enactment of P.L. 104-61 and P.L. 104-106, these questions became moot, because now, neither DOD funds nor facilities may be used to administer any policy that provides for abortions at any DOD facility, except where the life of the mother may be endangered if the fetus were carried to term. Privately funded abortions at military facilities are permitted when the pregnancy was the result of an act of rape or incest.

In 2010, language was added to the Senate version of the FY2011 National Defense Authorization Act that would allow any DOD facilities to perform privately funded abortions. As noted, the military follows local laws and practices to the greatest extent possible. This potential change would not likely have much of an effect outside of the United States since nations that host large numbers of U.S. military personnel maintain legal restrictions on abortions. On September 21, 2010, and December 15, 2010, attempts were made to move this legislation to the Senate floor for a vote. However, due to disagreements over procedures, cloture votes were taken and failed. The House-passed version of this legislation does not contain language pertaining to abortion. The FY2011 National Defense Authorization Act became P.L. 111-383 without the Senate provision allowing military facilities to be used to perform abortions.

In 2011, attempts to expand coverage for cases of rape and incest and allow for privately funded abortion were blocked in the Senate.

Language in the Senate version of the National Defense Authorization Act for FY2013 would expand coverage of government-funded abortions for cases of rape and incest.


Date of Report: December 13, 2012
Number of Pages: 24
Order Number: 95-387
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Family Planning and Abortion: A Compendium

A number of issues relating to abortion, birth control, family planning, and related issues have received – and will likely continue to receive in the foreseeable future – substantial attention from the Executive, Legislative, and Judicial branches of federal and state governments.

This Compendium and its periodic updates is designed to provide continuing coverage of developments relating to topics such as the Family Planning Program (Title X of the Public Health Service Act); state laws relating to parental involvement; religious institutions’ positions on abortion and contraception; international family planning programs and related U.S. foreign aid for family planning; and more.


Date of Report: November 9, 2012
Number of Pages: 158
Order Number: C-12002
Price: $59.95

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