Indian Country politics and public policy

Commentary by Mark Trahant

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The Senate is broken. Sen. Lisa Murkowski (who has already lost a primary only to win a general election) should consider The Alaska Fix for the good of the country. Three senators could put the Senate under new management (like the Alaska House of Representatives). (Senate photo)

Mark Trahant / Trahant Reports

The Senate is broken. Republicans control 52 seats only part of the time. Enough votes to win a majority and pass a judicial nominee. But not enough votes to fix the healthcare legislation sent up by the House. Or, more important, not enough votes to govern. Watch that problem grow on issues ranging from the federal budget to raising the debt limit.

The latest plan is a doomed vote on healthcare. Majority Leader Mitch McConnell told reporters that “as of today we simply do not have 50 senators who can agree on what ought to replace the existing law.” His response is to demand a vote to repeal the Affordable Care Act with a plan to pass a replacement bill later. The old kick-the-can-down-the-road approach. But first a vote — and already at least three senators have said they will oppose a motion to proceed so there will not even be a debate.

The Senate will be on record. And we will know which Republicans are more loyal to their party than the country. Then, the thinking goes, Republican voters could punish those members next election with primary challenges. (Already the White House is shopping for a candidate to run against Arizona Sen. Jeff Flake.)

This is governing in the Trump era. Make that, this is not governing in the Trump era. The twist in this story is that the majority of the Senate wants to work together, find common ground, and move on. The majority in the Senate could pass a budget. A majority in the Senate would raise the debt limit. And, most important, the majority of the Senate would act as a constitutional check on the executive branch.

This is actually what senators say they want. And get this: More than 70 percent of the public want bipartisan cooperation, according to a new Kaiser Family Foundation poll. Even 46 percent of Trump supporters say “they want to see Republicans work with Democrats to improve the Affordable Care Act — statistically tied with the 47% who would rather see Republicans continue working on their own plan to repeal and replace it.”

Meanwhile the White House is blaming Democrats for the failure to get 52 Republican votes. (Logic be damned.) And President Trump’s is again saying just let Obamacare fail (with his management help). He said: “It will be a lot easier. … We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail and then the Democrats are going to come to us.”

Same story from Republican leaders across the board. McConnell has used “working with Democrats” as kind of a threat. The message is GOP loyalty is more important than governing.

Enough.

The Senate could get back on track by picking up a lesson from Alaska: Choose to govern.

The Senate could function again if the majority — Republicans and Democrats — came together to lead. This is how it works in the Alaska House of Representatives; a governing caucus brings together 17 Democrats, 3 Republicans, and 2 independents.

A new Senate independent bloc could work the same way.

It would only take 3 Republicans to make it so. They’d join all of the Senate’s Democrats and independents to run the show. You could start with Senators Lisa Murkowski of Alaska, Susan Collins of Maine, and, since he’s so unpopular at the White House, Jeff Flake from Arizona. Either Murkowski or Collins would make a fine Majority Leader. (Yes, there will be retaliation from Republican loyalists. But even that might not work. Murkowski already knows what it’s like to lose a Republican primary only to win the general election.)

The Senate would be the counterweight to a Trump administration out of control.

This would mean new committee chairs, including Democrats. Imagine Patty Murray in charge of heath care legislation.  Or Bernie Sanders calling the shots on the budget. And Indian Affairs would be chaired by Tom Udall. A new day.

There is precedent. In 2001 the Senate was divided equally among Democrats and Republicans. The leadership went to Republicans because Richard Cheney was Vice President and could cast the deciding vote. But in May 2001 Vermont Sen. James Jeffords switched from Republican to Independent. One Senator flipped control from the Republicans to the Democrats in the middle of a session.

Jeffords’ obituary in The New York Times put it this way: “As chairman of the Education and Labor Committee … he had become frustrated by what he viewed as Republican parsimony.” As the dictionary puts it parsimony is cheap to the point of stinginess. True today. But then, like now, Republicans weren’t serious about governing. So for the good of the country — politics be damned — Jeffords placed the Senate under new management.

It’s time for new management in the Senate.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

 

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Trahant Reports

So the Senate (and therefore the House) plan to repeal the Affordable Care Act, destroy Medicaid as we know it, and shell out billions in tax cuts for the wealthy is no more. Monday night Utah Sen. Mike Lee and Kansas Sen. Jerry Moran said they would vote against even debating the Senate healthcare bill. So it was defeated by unanimous opposition of Democrats, the Senate’s most conservative members, and Republican Maine Sen. Susan Collins who opposed the Medicaid cuts.

“Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” McConnell said. “So, in the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care.”

So plan B, supported by President Donald J. Trump, is a repeal of the Affordable Care Act without a plan to figure out what a replacement looks like. Trump tweeted: “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!”

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But that will not be easy either. The idea of a repeal without a plan is crazy when you’re talking about such a huge chunk of the economy. And many Republican senators have already said so. As I have been writing (often) the problem is that the Republicans do not have a governing majority.  They are split. Hopelessly. They really needed their healthcare bill (something they all campaigned on) as a glue to keep their coalition together. Now it gets tougher.

There are practical problems with a “just repeal” approach too. The Senate language has to be narrowly drafted on fiscal issues in order to meet the test of a budget reconciliation bill. This process is arcane but it eliminates any filibuster by Democrats. It also means there will be no outright repeal (which would require 60 votes to stop the filibuster) just the budget applications of the Affordable Care Act. Complicated, right? The budget the Senate is working off of requires a billion dollars in savings from any repeal.

Even this will be tricky. First there will need to be consensus for a new vote to bring up the House bill. (It’s called a Motion to Proceed.) That measure would be open to amendments, including the repeal provision. (The president must have just been informed about this problem. He tweeted: “The Senate must go to a 51 vote majority instead of current 60 votes. Even parts of full Repeal need 60. 8 Dems control Senate. Crazy!”

That’s just one of the crazy, sticky issues for a repeal amendment (not to mention any other amendment that surfaces). Language that would lift the individual mandate to purchase insurance could also eliminate coverage for pre-existing conditions — and doing that would make health insurance unworkable for the companies. This could cause widespread market panic.

Depending on how it’s written, an outright repeal could impact Indian Country because it could include the Indian Health Care Improvement Act. The Senate and House plans were careful to sidestep that issue. This is a blank slate. A political danger zone.

However the Senate’s political implosion also shows how difficult it will be for the House and Senate to pass a budget, lift the debt ceiling, and get on with other important work.

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The House released its budget plan Tuesday morning and it sets its course for using the reconciliation process too. (In theory: Life is so much easier if you don’t need votes from Democrats.) That budget bill will be marked up on Wednesday and it will be tough to win a majority of Republicans. It has every controversial Trump project included, money for a border wall, cuts to social welfare programs, including Medicare. Some Members don’t like the increases in military spending coupled with sharp budget cuts for domestic programs, more than $200 billion worth. (It will be up to committees to figure out where the cuts would happen.) Other Members think there ought to be more cuts. And to make this process even more complicated, the House budget includes tax provisions. That only makes the task ahead more difficult.

Buckle your seat belts. — Mark Trahant

 

 

 

 

 

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When every senator could be the 50th vote, any one absence means no healthcare bill

Trahant Reports

The Senate healthcare bill looked like it was going to pass on Friday. There were only two public no votes (when three are needed to defeat the measure.) And you can only imagine how much pressure leadership was putting on its members to vote yes for the good of the party. This bill was (and is) a priority for the Republican leadership and the White House.

But over the weekend things changed. Sen. John McCain’s office announced that the senator had surgery for a blot clot over his eye. “Senator McCain received excellent treatment at Mayo Clinic Hospital in Phoenix, and appreciates the tremendous professionalism and care by its doctors and staff. He is in good spirits and recovering comfortably at home with his family. On the advice of his doctors, Senator McCain will be recovering in Arizona next week.”

Now the Senate cannot vote on the healthcare bill. There is no way to get to 50 votes without him. So Majority Leader Mitch McConnell will wait until McCain heals. At least a week.

That means there is a lot more time for the opposition to make its case. On Monday or Tuesday there will be a new Congressional Budget Office score of the bill. And that could be followed by some kind of alternative review from a federal agency. Think fake news but in a government document.

Another Not So Good for the Senate Bill moment was a letter from health insurance companies that said the Cruz amendment is unworkable in any form. The problem is that healthy people will buy cheaper plans leaving those who are already sick to buy the ones preserved from the Affordable Care Act.

State governors also remain opposed to the Senate bill. Vice President Mike Pence attempted to change their minds. He spoke as a former governor who accepted Medicaid Expansion, but now says the Senate bill is all about freedom to redesign health insurance. “And if you take nothing else from what I say today, know that the Senate healthcare bill gives states the freedom to redesign your health insurance markets.  And, most significantly, under this legislation, states across the country will have an unprecedented level of flexibility to reform Medicaid and bring better coverage, better care, and better outcomes to the most vulnerable in your states.”  He argues that the Medicaid reforms will secure “Medicaid for the neediest in our society.  And this bill puts this vital America program on a path to long-term sustainability.”

But, as I said, the governors didn’t see the issue the same way. Democrat and Republican sees the numbers and now that the Senate bill will result in substantial budget cuts lasting more than a generation. (In fact: One of twisted messages from McConnell to moderate Republicans is don’t worry. The cuts down the road will never happen.) This bill would destroy the Medicaid that we have now. Including the money that helps fund the Indian Health system.

Looking for background? Here are recent pieces on the Senate health care bill and its impact on Indian Country: The special deal for Alaska; Lies we’re being told about budget cuts; The impact on jobs in Indian Country; Trump tells tribal leaders Medicaid cuts will be good; and health care policy is a debate worth having (but this is not that.)

 

 

 

 

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Alaska’s Health and Human Services Commissioner Valerie “Nurr’araaluk” Davidson. A report by her agency says Medicaid now covers one in four people in Alaska; nearly half of whom are children. If Medicaid caps are enacted, the “magnitude of the federal cuts are such that they may well affect Alaska’s ability to finance other state priorities such as education and infrastructure.”

Mark Trahant / Trahant Reports

It would be cool, just this once, if the Senate would say, “Indian Country you are so important. So we are adding a special provision to this health care bill that adds big bucks to the Indian Health Service.” Then Senators with significant American Indian or Alaska Native populations would shift their votes from perhaps to yes.

That might sound like a fantasy. But it’s the track that the Alaska delegation is on; senators secured a special deal in the Senate health care plan for their state. Only it’s not about Alaska Natives. And it’s not nearly the same amount of dollars that the state will lose with Medicaid cuts (or, for that matter, in high cost insurance.) But it’s a “victory” of sorts that will be claimed if Sen. Lisa Murkowski eventually votes yes on the Senate bill. (Sen. Dan Sullivan was a likely yes, anyway, although he’s claiming credit too.)

Here’s the deal. The legislation includes a complicated formula to reduce Medicaid spending — except in states with a population density of less than 15 people per square mile. That’s Alaska, Wyoming, North and South Dakota, and Montana. New Mexico just misses but then it’s a Blue state and its senators would likely vote no anyway. And, the exception might be of use to Sen. John Hoeven from North Dakota but, like Sullivan, he probably would vote with leadership anyway.

So really it’s about Alaska — and Murkowski’s vote. She’s a firm maybe. So far three senators have said no (enough to kill the bill) but we won’t know how solid those no votes are until there’s an actual vote. The self-proclaimed no votes are Sen. Susan Collins of Maine, Rand Paul of Kentucky and John McCain of Arizona. (Republicans need 50 votes from their own party.)

The rural exception to the Senate bill adds up to just under $2 billion, according to The New York Times.

But special deal or not, the big picture might be more important to Murkowski.

Alaska is a state where the evidence is strong that the Affordable Care Act and Medicaid Expansion are working. Nearly a quarter of the state’s population is enrolled in Medicaid and the state’s 2015 expansion added more than 34,739 people. Half of the state’s children are insured by Medicaid.

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And, of course, Medicaid is an essential revenue source for the Alaska Native medical system — a system that Murkowski praised just this week at a hearing on the Indian Health Service.

A study done for Alaska’s Department of Health and Human Services — run by Commissioner Valerie “Nurr’araaluk” Davidson — is blunt. It says: To stay under a per capita cap Alaska would be required to cut its Medicaid program spending by $929 million in federal and State dollars between FY 2020 and 2026, with a federal funds loss of $473 million … The magnitude of the federal cuts are such that they may well affect Alaska’s ability to finance other State priorities such as education and infrastructure.”

The report says the cap will not include patients in the Indian Health system, but that Alaska will have to cut back on eligibility to reduce Medicaid spending.

Analysis of the House plan (remember at some point the House and Senate bills would have to be merged and passed again) would cost Alaska $2.8 billion in Medicaid funds between 2020 and 2026.

What’s even more problematic: “Alaska will have to establish its Medicaid budget almost two years before it knows the amount of federal Medicaid funding available for that budget year.” That could result in a “claw back” effect where money has to be returned to the federal treasury after its already spent. The impact of the Senate bill would be quick. The state’s report estimates that within three years a quarter of all Medicaid funding would be eliminated. And, more important, by 2022 95% of expansion enrollees will have lost coverage due to Alaska’s highly seasonal workforce.”

So will the rural exception be enough to buy votes? It’s certainly not enough funding to maintain Alaska’s successful Medicaid Expansion.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

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At a Senate appropriations subcommittee hearing Wednesday there was a testy exchange between Sen. Jon Tester, D-Montana, and the acting director of the Indian Health Service Rear Admiral Michael Weahkee (Zuni). Tester asked how money can be taken from the budget without hurting the quality of care or staffing at IHS. The Senate video is here.

Mark Trahant / Trahant Reports

A Senate hearing Wednesday on Indian health illustrates the larger problem exactly: How can you strip millions of dollars from a health care system and get better results?

The answer is you cannot.

But that’s not what the Trump administration testified. And it’s not what the Senate leadership is saying about its health care bill. Or the House for that matter.

So they lie. And it’s a lie that is so bold, so outrageous, that it should not told with a straight face. There is no defense. That’s why doctors, governors, hospitals, patients, economists, policy-makers, anyone willing to tell the truth about the destructive nature of these so-called health plans are in the opposition. A recent USA TODAY/Suffolk University poll shows the support for the Senate plan by only 12 percent making it one of the most unpopular bills ever.

And yet the Senate bill is still on the table. A new bill is out today and a vote could come as soon as next week. President Donald J. Trump told a Christian television show that he would be “very angry” if this bill fails.  “I am sitting in the Oval Office with a pen in hand, waiting for our senators to give it to me,” the president said. “It has to get passed. They have to do it. They have to get together and get it done.”

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I have been writing a lot about the GOP plans in the House and Senate. Three recent pieces: The impact on jobs in Indian Country; Trump tells tribal leaders Medicaid cuts will be good; and health care policy is a debate worth having (but this is not that.) And I still find I have something to say because the Senate and House bills are so harmful to Indian Country.

Let’s start with the hearing on Capitol Hill Wednesday. Rear Admiral Michael Weahkee, the acting director of the Indian Health Service, testified about the agency’s budget to the Senate Appropriations Subcommittee on Interior, Environment and Related Agencies, chaired by Alaska’s Sen. Lisa Murkowski. “I am pleased to provide testimony on the President’s Fiscal Year (FY) 2018 Budget Request for the IHS, which will allow us to maintain and address our agency mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/ANs) to the highest level,” began his written statement. It gets better: “The Budget reflects the Administration’s high priority commitment to Indian Country, protecting direct health care investments and reducing IHS’s overall program level by only 0.9 percent when compared to the Annualized Continuing Resolution, in the context of an 18 percent reduction within the overall HHS discretionary budget.”

In other words we’re cutting the hell out of all budgets — so be happy with your cuts Indian Country.

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So what if the words “maintain” and “raise” don’t fit with the highest level of health care. It’s no secret that Indian Health is already underfunded.

The measure of that shortage that makes the most sense is to compare spending by IHS to what’s spent by the federal government on federal employees. According to the National Congress of American Indians that measure shows IHS funding at about 60 percent of need.

(Of course you could argue that the U.S. health care system is too expensive. But that’s a different conversation. Reform is not even on the table right now. This whole fight is just about money; money for health care or tax cuts.)

The problem with the Senate hearing and a recent Wall Street Journal article on the failure of the Indian Health Service in the Great Plains is that the Indian Health Service is not what it was. It’s no longer just a government health care agency. In fact most of the agency is a funding mechanism for tribal and non-profit health care facilities.  The congressional oversight needs to be re-imagined to fit both of these missions.

The Journal stories highlighted operational issues in South Dakota and Nebraska that demonstrate a tragic failure. (This is the IHS story most of us already know.) And after years of warning the agency has not come up with a strategy to effectively fix its own management.

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“Because this is our IHS. These are our facilities that are supposed to care for our first people,” Sen. Murkowski said. “And the stories that were detailed were shocking.”

But Sen. Murkowski correctly identified the division within IHS. She told Alaska Public Media that Alaska’s Native health facilities are run by tribes, under contract to the IHS, so their problems aren’t the same. True. But that’s more than half of the system. That’s the story that the Journal did not tell (and do the reporting about why tribes and non-profits are able to deliver better care than the agency itself.)

The answer, in part, take us back to the larger Senate debate. The Alaska Native Medical Center has balanced funding: Money from IHS, aggressive third-party billing from private insurance and especially Medicaid as well as foundation grants. This kind of balance ought to be the future (unless Congress says, “well, let’s fund Indian health at 100 percent of need”) for others across Indian Country.

That’s why the narrative of failure is problematic. It’s true that there is a systemic crisis — especially in the Dakotas. So much so that Montana Sen. Steve Daines has even suggested changing the name of IHS to “Indian Health Suffering.” Old story.

But that’s why there should also be a narrative of success. I, too, would change the name of IHS, but to the Indian Health System. Because parts of that system are excellent and ought to be a model for health care, period.

And that’s where Medicaid comes into the picture. At the Senate hearing there was frustration because IHS did not provide enough data.

The IHS budget calls for $1.2 billion in third-party billing. Most of that is Medicaid. That will work for next year. But it’s important to remember the House and Senate plans will cap and reduce what is spent on Medicaid. Right now: If a person is eligible, the money  is there. Under the GOP alternative there will be a set amount of some kind. The money will run out.

But IHS officials did not talk about Medicaid much. And Montana Sen. Jon Tester pointed out:  “I think it’s absolutely unbelievable that you can’t separate how much Medicaid has helped your with third-party billing.” This is is what we need to know.

The Indian Health Service operates in both Medicaid and Medicaid expansion states. Remember not every state expanded Medicaid under the Affordable Care Act (To date: Thirty one states and Washington, D.C. are on board). For example: South Dakota did not and North Dakota did. So we ought to have data about how much Medicaid money goes into the system, for what kind of patents, and how it’s used (hint: by law it’s supposed to remain at the local service unit.) We should have similar data for tribal or non-profit facilities. Life-saving data.

The Center for Budget and Policy Priorities released a report earlier this week that highlighted the connection between Medicaid and Indian Health. “The Medicaid expansion has improved access to care for thousands of American Indians and Alaska Natives especially in states with large AI/AN populations including Alaska, Arizona, and New Mexico. It has also provided much-needed revenue to Indian Health Service (IHS) and Tribally operated facilities, allowing them to expand services and hire and retain more staff. Ending Medicaid expansion would jeopardize coverage for these newly insured low-income AI/AN adults, and reduce revenue for IHS and Tribally operated facilities, forcing them to revert to pre-ACA service levels.”

In Montana, a state that recently expanded Medicaid, more than 11,000 American Indians have signed up for the insurance. “At a time when Montana is working in a bipartisan basis to address the suicide epidemic and improving health outcomes for American Indians, D.C. politicians are threatening to take away health insurance for thousands of Americans Indians in Montana,” said Heather Cahoon, State Tribal Policy Analyst for the Montana Budget and Policy Center. “More than 11,000 American Indians in Montana now have access to health insurance through our bi-partisan Medicaid expansion plan, and we can’t afford to go back.”

But going back is on the Senate agenda today. The Republican caucus is counting votes to see if a compromise is possible within their own ranks. The bill will be released, scored by the Congressional Budget Office, and, if Sen. Mitch McConnell gets his way, there will be a vote early next week.

But the facts are this: The Senate bill still strips $700 billion from Medicaid. And that number will grow over time. And the Trump administration is cutting from the already underfunded Indian Health Service budget by 6 percent. Now. That, too, will get worse down the road.

And so there will be many lies flying fast. It’s a health care bill. Or this legislation won’t take away your insurance. Medicaid will be better off. So will the patients. Whatever. The Congressional Budget Office is wrong. Then there’s that forever lie: That United States is meeting its solemn treaty promises to American Indians and Alaska Natives.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

 

 

 

 

 

 

 

 

 

 

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Mark Trahant / Trahant Reports

Last year about now I was pretty much writing all politics all the time. Indian Country had so many good candidates to offer. Interesting resumes. Better ideas. Campaigns that led to a few wins. A few more losses. And that’s life.

This year I am pretty much writing about health care policy all the time. The Republican plans are so bad — and especially for Indian Country — that they ought be dismissed as dangerous nonsense at every opportunity. As I have written before there is a conservative approach to health care. None of the current proposals are that; they are only a destructive force. (More about that after the Senate releases it latest attempt to reach a 50 vote majority.)

Of course there is also a connection between campaign politics and policy. We’re almost a year away from the next House and Senate election and we’re just starting to get a look at the candidates who will be making policy.

And it turns out there is news.

In Oklahoma, Democrats swept two state legislative seats this week in districts where Donald Trump won handily last year.

One of the seats in the Tulsa area had been held by Rep. Dan Kirby, Creek, and a Republican member of the Native American caucus. He resigned in February following allegations of sexual harassment by staff members. Kirby’s seat was won by a retired teacher, Karen Gaddis (who lost to Kirby in November by 12 percentage points). This had been a safe Republican seat.

A state Senate election (also stemming from a sex scandal) was won Tuesday by a Democrat in the Oklahoma City area.

Oklahoma is one of the most Republican states in the country. So it’s huge to see such a significant shift in a special election. (Unless, that is, it’s just those sex scandals and not the Trump factor.)

One person who ought to be especially concerned by these two election results: Rep. Markwayne Mullins.

Mullins won 70 percent of the vote in his third re-election bid in 2016. Mullins, a member of the Cherokee Nation, first ran in the Tea Party-inspired wave in 2012. He ran against too much government, a repeal of Obamacare, and a silly promise to limit his time in office to three terms.

Now he’s running for his fourth term and some prominent conservatives are unhappy. Former Sen. Tom Coburn told Oklahoma’s KFAQ radio that it was sad because this “nice young man … has drunk the Kool-Aid in Washington.”

It’s funny and prescient. Mullins ads said: “A Rancher. A Businessman. Not a politician.” Mullins can hardly say that now. It’s like the great line in the movie “The Candidate” when young Bill McKay is elected governor and his father (who was a governor) tells him: “Bud, you’re a politician.”

Even the story changed. In his early ads, Mullin talks about term limits as an answer to the problem of being an insider in Washington. But in his video explaining why he’s running again, Mullin said — after much prayer — that he’s changing his mind for family reasons. “I’m not hiding from that because we did say we’re going to serve six years, and it was out of true concerns,” he said. But that’s ok now. The family is doing great.

And, like every politician before him, the voters really need him. Just him. Especially during this era of Donald Trump (that is … if the era even lasts until the next election).

Mullin has been the congressional voice for the Trump version of a Native American policy. He praised the Dakota Access Pipeline project and was critical of tribal leaders for opposing it at a hearing in February. “What do you consider meaningful conversations between government-to-government?” Mullins asked Chad Harrison from Standing Rock. His reply was great: “An actual dialogue, perhaps.”

But while Mullin complained about the power of Standing Rock to slow down the Dakota Access Pipeline, he says he’s all for increased powers of tribes to develop such energy projects. The president should “provide tribes with the resources they need in order to best decide how their land should be developed,” he said. How. Not if.

Then perhaps that gets to the actual dialogue part. Or lack thereof.

Mullin supports the House health care bill that would wreck the Indian health system. Then Mullin does not see it that way. In a May Q & A published by the Miami News-Record he said flat out that Republican plans will not hurt the Indian Health Service. “The American Health Care Act (AHCA), which the House passed on May 4th to repeal and replace Obamacare, makes no changes to Indian Health Services (IHS). In addition, the spending bill passed to fund the government through September funds IHS at a rate of $5 billion – an increase of $232 million from last year’s levels. I anticipate the native people of Oklahoma will welcome both of these things.”

Excuse me. But as I’ve been reporting (often) Medicaid is a significant funding stream for Indian health. And the House bill (and its Senate twin) destroy that whole infrastructure.

He told his constituents that no one who has health care will lose it because of the Republican plans. He said emergency rooms cannot turn people away. Seriously. That’s a health care plan? Mullin told the Tulsa World: “We think the federal government is going to solve all of our problems, but let me ask you, how is (that) going?”

That explains a lot. Mullin was against the Violence Against Women Act (which will need to be reauthorized by Congress next year) including the provisions that recognize tribal judicial authority.

Back to politics. If there is a voter groundswell of Trump opposition — even in Oklahoma — then Mullin’s re-election race could become interesting. The right candidate could push him on the left while Coburn and other conservatives will question his integrity from the right.

But who will challenge him? I’d like to see a candidate from one of the tribes. Oklahoma’s 2nd Congressional District is 17 percent Native American and it’s 65 percent rural. That’s two constituent groups that will be deeply impacted by Republican health care plans. There is an issue to run on here. (Not to mention that Coburn, who once held this seat, will campaign against Mullin. And the Trump chaos.)

We’re a little more than a year away from the next election. So this is the time to sort out who’s running from Indian Country, who should be running, and to pass on those candidates who regularly vote against Indian Country. I’d add Mullin to that last list.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

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I am not sure of the exact year. It probably happened around 1996. That’s when the Indian Health Service became the single largest employer in Indian Country.

This makes sense when you think about it: Indian health was once a small (unappreciated) division of the Bureau of Indian Affairs. But by 1996 the agency’s budget was larger than the BIA’s — and there were likely more workers. The administration estimates that next year the BIA will have some 6,770 full-time employees (a decrease of 241) while the Indian Health Service will have more than 15,119 employees (including 1,928 uniformed Public Health Service officers).

Big numbers, right? But that reflects what is happening with health care generally. Google “region’s top employers” and it’s common to see clinics, hospital systems, and university medical centers as any region’s largest employer.

“Employment of healthcare occupations is projected to grow 19 percent from 2014 to 2024, much faster than the average for all occupations, adding about 2.3 million new jobs,” reports the Bureau of Labor Statistics. “Healthcare occupations will add more jobs than any other group of occupations. This growth is expected due to an aging population and because federal health insurance reform should increase the number of individuals who have access to health insurance.”

But here’s the thing: Many of these health care jobs are dismissed as “low wage.” The BLS calls these health care support jobs and the median income (or half pay more and half pay less) as $27,910 which is lower than the median annual wage for all occupations in the economy. The list of support jobs would include Community Health Representatives (long a staple in Indian Country), medical record keeping and coding jobs, as well as different kinds of medical technicians. But what’s considered low wage in the general population, and in cities, can be a good gig in a rural, tribal community.

Alaska is a prime example. More than half of Medicaid spending serves rural constituents, three times more than the national average. Medicaid covers two-thirds of all American Indian and Alaska Native children and more than one in four, or 28%, of American Indian and Alaska Native adults. The Urban Institute estimates that the kind of block grants found in the Senate’s Better Care Reconciliation Act would cost the state $590 million in federal funding — a number that would decline even sharper after 2025. The job losses would be substantial.

This is another reason why the House and Senate plans to roll back the Affordable Care Act (and the destruction of Medicaid as part of the deal) are so important to the Indian health system. The Senate plan especially reverses decades of Medicaid growth. That’s no good for patients (as I have reported before here and here) but it also will cost Indian Country jobs.

Medicaid directly accounts for 24 percent of IHS’ workforce, but even that is short of the kinds of jobs that serve tribal communities. It does not include school-based programs. Or those private companies that bill Medicaid for transportation of patients or other patient services. Same story for jobs that stem from medical coding, accounting and third-party billing services.

Across the country, Medicaid is a major job creator for women, supporting at least 3 million direct jobs.  According to a report by the National Women’s Law Center: “When Medicaid pays for a health service—a visit with a health professional, a laboratory test, a hospital stay, a home health visit—this payment supports the facility, agency, or medical practice that delivers the service, and the individuals who provide this care receive compensation as well. Women’s high participation in the health care industry, which employs more than 22.8% of all women in the workforce, means that Medicaid disproportionately creates jobs for women.”

I don’t have a breakdown for these jobs in Indian Country, but from personal experience I would bet the numbers are similar if not higher.

Senate debate begins again next week

The Senate, of course, still does not have consensus about a bill to replace the Affordable Care Act. Majority Leader Mitch McConnell suggested this week that Republicans might need to try another direction because “no action is not an alternative.” The Associated Press quoted the senator saying: “If my side is unable to agree on an adequate replacement, then some kind of action with regard to private health insurance markets must occur.” That plan would require votes from Democrats and would likely include a compromise.

Other senators, including Paul Rand, have proposed repealing all of the Affordable Care Act without a replacement, basically putting that off for another day. That would be particularly troubling for Indian Country because a full repeal would likely include the Indian Health Care Improvement Act. But that, too, is complicated by Senate rules. A full repeal would need 60 votes unless that legislation was framed narrowly around budget issues.

But Republican leaders have not given up. The new story they are telling is that 22 million people would “choose” to not carry health insurance. It’s a freedom thing. But that does not square with the destruction of Medicaid. And the jobs that public insurance program has created.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

Sponsors

Mark Trahant / Trahant Reports

This will be a short pitch. (Then back to regular programming.) I am looking for a few financial supporters of Trahant Reports. Well, at least, for the radio version of my commentary. Trahant Reports is a combination of my blog and a weekly commentary carried on Native Voice One. 

My goal is to write about serious policy issues that impact Indian Country. In the era of President Donald J. Trump that mission is more important than ever (and my readership numbers reflect that.)

Traffic for the blog continues to grow. A piece last week on Medicaid, for example, had some 20,000 views on Facebook, hundreds of shares, and my regular reach on Twitter now exceeds 210,000 accounts.  Apple News is another growing vehicle for Trahant Reports: People subscribe on their iPhones and see my latest work immediately.  And, most important, on top of all that, most of my readership is through other media that carry Trahant Reports as part of their report. My idea is to keep the content free (although I should mention that a couple of news organizations send a check anyway. And I am grateful for that.) A shout out to all those who share my work on social media. You have no idea how important that simple act is to spreading the word. Two interesting elements here: First, the more serious the story — such as a deep-dive on Medicaid — the bigger my readership numbers. Second, readers are fond of my early idea white boards. As soon as they are posted, folks send me follow-up ideas or suggestions.  This is cool because it’s really interactive.

So that’s the blog report.

Trahant Reports on Native Voice One is in its third year. We started as an audio web post,  then last year made the programming available to stations directly. Every Monday a new three-minute commentary is made available for tribal and community radio stations. It’s also found on iTunes and Soundcloud. I also produce special reports that are 30-minutes in length. (There is a special coming up soon on Native women running for elective offices).

This is where sponsors come in. I am looking for underwriters to help pay for this programming. Major sponsors will get a credit at the end of a show (as well as many thanks on social media).

July is my fundraising month. So I’ll make this pitch. Sponsor Trahant Reports on the radio. Thank you. Ok, now it’s back to work. I have too many stories in my head to spend much time on the financial end of this operation. I’d much rather be writing and reporting. But I figure if I don’t ask … then the answer is already no. So there, done. Pitch complete. Drop me a line if you’re interested in being an underwriter. Email: mntrahant@mac.com

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President Donald J. Trump meets with tribal leaders for Energy Week. He calls the Medicaid cuts will be great for everybody. (White House photo via YouTube.)

Senate bill ‘mostly dead,’ but will it revive after break?

Mark Trahant / Trahant Reports

The Senate’s health care bill is “mostly dead.” But that’s not the same as all dead. And this holiday weekend will decide either the legislation has a second life or if there is a better way to proceed.

Republican Senate Majority Leader Mitch McConnell is planning another shot at health care reform (excuse me, a plan to cut taxes and roll back Medicaid) this week producing yet another draft of the health care bill. Meanwhile Senators (as well as members of the House) will break and return to their home districts. This is where the people have a chance to weigh in with a “hell, no!” The Senate bill may be the most unpopular piece of legislation ever, currently earning support of between 12 and 17 percent depending on which poll you read. To borrow the TSA phrase, if you see someone (as in a member of Congress) say something.

Consider this: Medicaid is popular across the board. A poll by Kaiser Health News illustrates this point. It shows that some three-fourths of Americans view Medicaid favorably. (But the poll also points out that most Americans don’t know that both GOP bills would cut deeply into the popular program.) Even Republicans think Medicaid works.

For the past few weeks I have been writing post after post about how bad this approach to health care — I mean, tax cuts — is as a policy. The problem is basic. Many Republicans do not believe health care is a right. So it’s their mission to roll back government. But not every Republican believes that. Some see the effectiveness of programs such as Medicaid and see it’s rollback as unconscionable. (Previous: Health care deserves policy debate.)

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Recent polling from Kaiser Family Foundation shows support for Medicaid across the political spectrum.

 

At a meeting with tribal leaders at The White House, President Donald J. Trump was asked about cutting Medicaid. His answer: “It’s going to great.  This will be great for everybody.”

Read “great” as “clueless.” But the president did say it was going to be difficult to get the votes, “it’s very tough …  I think we’re going to get at least very close, and I think we’re going to get it over the line. ”

We shall see. Mostly dead or all dead? And an all dead GOP health care bill could deliver a miracle.

This is the moment where McConnell will pull out his checkbook. He will be trying to win *cough* buy * cough* support from senators with sweet deals for the folks back home. If that doesn’t work, McConnell said he might be forced to work with Democrats on legislation. Imagine that! A Congress that works with both parties.

This is what really ought to happen. The Affordable Care Act has problems that need to be fixed. But it’s in specific areas, such as the individual insurance market, and a bipartisan approach would actually yield the best results.

But more important the only way that Congress governs again is for leadership to recognize that they cannot govern with Republican votes alone because they don’t have enough votes. There is a split within the Republican Party on the very question of health care as a right, let alone specifics about how much to cut and where.  And that same division plays out on just about every major public policy issue.

But a few Republicans working with Democrats do constitute a majority in both Houses. A lot could get done. The Congress could pass a budget. Raise the debt limit (averting another crisis) and do the jobs that we the people hired them to do. That would take a miracle right? But we can always hope and the first step is an all dead Republican health care bill.

How long will it take for this process to unfold? This will only happen when congressional leaders run out of options and see working with Democrats as the only path forward. This will take time because as Miracle Max said in The Princess Bride: “You rush a miracle man, you get rotten miracles.”

We don’t need another rotten miracle.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

 

 

 

 

 

 

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