Indian Country politics and public policy

Commentary by Mark Trahant

Governing without a working majority

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Smiles no more. President Donald J. Trump failed in his pitch to the Republicans who opposed the speaker’s Affordable Care Act replacement.  (Photo via Speaker Ryan’s page.)

 

Mark Trahant / Trahant Reports

President Donald J. Trump’s legislative agenda has crashed. The Republican promise to quickly repeal and replace the Affordable Care Act on Friday failed to win enough votes from conservatives to make it so.

As House Speaker Paul Ryan said in a post-failure news conference: “Obamacare is the law of the land … We’re going to be living with Obamacare for the foreseeable future.”

For his part, President Donald J. Trump (who, of course, says he is not to blame for the loss) told The Washington Post, “the best thing politically is to let Obamacare explode.” He called the law, “totally the property of the Democrats,” and that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

The president and his administration can do a lot to make that happen. The Secretary of Health and Human Services has extraordinary authority under the Affordable Care Act and they can use the power regulation to gunk up Obamacare. There will be many battles ahead on the regulation front. But, and this is the good part, states will have a say in this too. And there is the potential for a few states to engage in experiments that might improve the law. The question here: Is the administration willing to work to improve insurance options for Americans or are they more interested in punishing Democrats? (Yeah, I know, but there is a political upside to answering that question correctly.)

Here’s the thing: There is a crisis in insurance markets. And a bipartisan solution, meaning most Republicans working in partnership with Democrats, is the best way to reach a solution. There are three ways most of us get health insurance: our employers, public insurance such as Medicare and Medicaid, and the individual market when we buy our own insurance policies. Employer-based care is an accident of history (it’s a long story) and has been shrinking for the past fifteen years. Public health insurance has been growing (something the conservatives in Congress really object to because it codifies the notion that health care is a right) and under the Affordable Care Act individual insurance has increased from about 10.6 million people to 15.6 million.

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Much of the current health insurance debate is about that individual market. Even if it is the smallest part of the problem. It’s important to understand, as David Blumenthal and Sara Collins wrote in the Harvard Business Review:

Individual markets were troubled prior to the ACA’s enactment in 2010. One reason was that premiums for these policies were increasing more than 10% a year, on average, while the policies themselves had major deficiencies. They often excluded pre-existing conditions, charged higher premiums for people with health risks and for young women, placed limits on annual and lifetime benefits, or refused to renew policies for individuals who became sick. Many people who tried to buy plans were turned down. In 2010, an estimated 9 million adults who had tried to buy a plan in the individual market over the prior three years reported that they were turned down, charged a higher price, or had a condition excluded from their plan because of their health.

Thus “returning to the status quo ante — before the ACA — is not a viable option for the individual markets.”

The fix does not involve a “great mystery” according to Blumenthal and Collins. It’s simply making certain that more young people buy insurance to help pay for the higher health care costs of older Americans. The bigger the pool, the lower the cost. (Which, I should add, is why single payer works as a public policy.) One part of that solution is to increase the government subsidies so more people will buy in. That’s how the insurance market could work better.

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More money for Indian health

Enough background. Where does Indian Country fit into this matrix? So there is a legal understanding that the Indian health system is federal obligation that stems from the promises made in treaties to provide doctors and nurses to reservation communities. Yet no Democrat nor Republican government has ever (as in ever) proposed fully-funding that Indian health system. Members of Congress often acknowledge the treaty responsibility, but have never followed those words with a budget.

But the Affordable Care Act separates insurance from health care delivery. It basically makes the Indian health system (both the government-operated Indian Health Service facilities, and those run by tribes and tribal organizations) medical care that’s mostly funded by federal appropriations and funded by insurance. Nationally that mix right now is about 80 percent appropriations and 20 percent insurance. But, and this ought to be huge, the insurance side of the equation under the Affordable Care Act is unlimited. That pool of money grows every time an eligible American Indian or Alaska Native signs up for insurance. This makes full-funding of Indian health a possibility. (Even better: Insurance collections remain at the local clinic or hospital. It really is the best kind of funding.)

There are three ways to add money to Indian health now.

First: More American Indians and Alaska Natives can sign up for Medicaid. The fact is there are many more people eligible than have signed up. The Kaiser Family Foundation estimates that nationwide one million American Indians and Alaska Natives lack coverage (depending on the state). Already Medicaid covers more than half of all children but 11 percent of those children remain uninsured.

Second: More American Indians and Alaska Natives can sign up for exchange plans under the Affordable Care Act. This is huge.  According to healthcare.gov “If you get services from an Indian Health Care Provider, you won’t have any out-of-pocket costs like copayments, coinsurance, or deductibles, regardless of your income. (This benefit also applies to Purchased and Referred Care.).” And this benefit has essentially a permanent open enrollment.

Signing up for insurance (including plans from an employer) makes the Indian health system stronger for everyone. It’s the same principle as any insurance, the larger the pool of people who participate, the lower the cost.

Third: It’s time to make the case for Medicaid expansion in state governments that have said no. Now that the Affordable Care Act remains the law of the land there remains unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments such as imposed work rules). It’s a win for Indian Country when a state does this because it increases the number of people eligible for insurance. It’s a win for the state because Indian health patients are a 100 percent federal obligation so the state will be reimbursed by Washington.

Kansas is the latest state to consider expansion. And it’s likely that the Trump/Ryan failure to repeal and replace will push other state legislatures to consider this approach. Indian health patients would benefit from Medicaid expansion in Oklahoma, South Dakota, Texas, Maine, Mississippi, Nebraska, North Carolina, Utah, Idaho, Wisconsin, and Wyoming. A total of 19 states are on this list.

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The dangers for Indian Country ahead

It’s easy to see the defeat of Trump and Ryan’s plan as a huge win. But it is also a warning sign. Make that a flashing red light with sirens. The problem is that Congress is deeply divided and cannot govern.

The same Republican divisions that killed their health reform plan will kill President Trump’s budget (thank you). But it will also make it nearly impossible to pass any kind of budget. As I have written before the best outcome might be a Continuing Resolution, a status quo budget.

An even bigger challenge will be for Congress to pass an increase in the debt ceiling. Secretary of Treasury Steven Mnuchin informed Congress that the United States reached its limit on March 15. The Treasury is now juggling accounts so that the government can continue to pay bills.

Conservatives in Congress (actually, just about every member of Congress) hate this part of governing. But a no vote here has enormous consequences for everyone’s finances. markets. There is an absolute requirement that Congress increase that borrowing authority. It will be a nasty fight.

Of course there is one solution: Create a new coalition of Republicans and Democrats. This works in state legislatures across the country (most recently Alaska). It takes 216 votes to pass legislation in the House so a working body of 22 or so Republicans, plus the 194 Democrats in the House, could accomplish a lot together. But that would mean rethinking the role of party politics. And governing.

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

 

 

Good morning.
No post this morning, but a couple of thoughts before the House vote on the plan to repeal & replace the Affordable Care Act.
President Trump has made this an either, or vote for House members. With the president or not? Are they more worried about a primary from Trump supporters or their own constituents? As I wrote yesterday, Alaska’s Rep. Don Young will be worth watching on that score. This bill is terrible for Alaska. And a “yes” vote will be risky come election time. Or will Trump supporters use this an opportunity to take on Young in the primary?
Second point (and future stories) If this is end of repeal and replace, then the action will shift (as it already has) to the rule making process. Secretary Tom Price has a lot of power to make deals with the states on how ACA is implemented (and for that matter, Medicaid).
Third. It’s really interesting to see the new round of leaks coming from the White House. They were against this whole thing from the beginning, see. Blame is directed to Paul Ryan. (Trump’s news favorite Brietbart even calls this bill RyanCare.) So the question is what does this do to Ryan’s speakership going forward (if he continues in office)? As I wrote the budget divisions ahead are even greater than those that surfaced in the health care policy debate.
That’s it for now. Working on something not-Trump-related for the weekend. — Mark
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Governor Bill Walker and Health and Social Services Commissioner Valerie Davidson announcing the expansion of Medicaid in Alaska in 2016. (Picture from video feed.)

Mark Trahant / Trahant Reports

The story of Alaska and Montana is not front and center in the health care debate in the House today. But it should be.

Montana does not get a vote. (The state does not currently have a member of Congress after former Rep. Ryan Zinke was confirmed as Secretary of the Interior.)

And Alaska ends up with legislation that is by all measures, a raw deal. No state (and no pool of voters) will lose more under the Republican replacement for the Affordable Care Act than Alaska.

Alaska only expanded Medicaid in 2016. But the program has been a success. As Chris Ashenbrenner  wrote in the Anchorage Dispatch News: “Expansion is a bright spot in a dismal Alaska economy. Over 25,000 people now have health coverage at no cost to the state of Alaska. Alaska health care providers have received over $288 million in revenues since it started in September 2015.” One reason for that is the role Medicaid plays in funding the Indian health system. Recent changes (promoted by Alaska Gov. Bill Walker) resulted in “a change to their policy resulting in even more Alaska general fund savings — projected to be over $30 million this year and growing each year.  By 2022, it’s estimated to be over $90 million. This would not have happened without expansion.”

Alaska Health and Social Services Commissioner Valerie “Nurr’araaluk” Davidson recently told a state legislative committee that the American Health Care Act does not save money but shifts costs to the states. would shift the cost of health care to states. “I get nervous every time I hear a member of Congress talk about the great savings to the Medicaid program, because what they’re saying is, it’s a savings to the federal government,” Davidson said on Alaska Public Media. “They’re not saying it’s a savings to states – they’re actually shifting that cost to states, and that’s a problem for Alaska.”

But that’s not the only problem for Alaska. The Republican plan to give taxpayers a flat rate subsidy to purchase individual plans will mean that Alaskans would pay far more for insurance. “That’s because unlike the ACA’s tax credits, the House plan’s tax credits wouldn’t adjust for geographic variation in insurance premiums,” according to the Center for Budget and Policy Priorities. “They’d be the same for a 45-year-old consumer in Alaska, where benchmark health insurance coverage costs $12,600 this year on average, as in New Hampshire, where it costs $3,600.” The total bill: A whopping $10,500 more for a health insurance policy in Alaska.

Watch Rep. Don Young today. Alaska’s only member of Congress will likely demand a special deal from the House leadership. If not, will he still vote for the bill? Young told Alaska Dispatch News that he’s undecided. And on Facebook today, Sen. Lisa Murkowski will brief Alaskans on the legislation.

A poll published by FiveThirtyEight shows that 45% of Alaskans oppose the House bill, and 33 percent strongly oppose the legislation. It’s a similar story in Montana where 43 percent oppose the bill and 31 percent would strongly say no.

Montana, like Alaska, has a short experience with Medicaid expansion. But the numbers are strong. Montana Public Radio reported after seven months the program was nearly double the projected number of people insured. “Recipients have used their benefits to get $75 million worth of health care, 100 percent paid for by the federal government. That’s a big windfall in this state with slightly more than 1 million residents,” Montana Public Radio said.

Medicaid and Medicaid expansion are a critical, and growing, source of funding for the Indian health system.

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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President Donald J. Trump makes a pitch to Republicans who are reluctant votes for the speaker’s Affordable Care Act replacement. The House vote is scheduled for Thursday. (Photo via Speaker Paul Ryan’s official page.)

Mark Trahant / Trahant Reports

It’s hard to think of a more make or break moment for the Speaker of the House of Representatives than what happens over the next two days. Well, sort of.

The Speaker needs 216 votes to move his health care reform proposal on to the Senate. If he loses, then Paul Ryan will have a difficult time rounding up the votes for the next tough vote (which is supposed to be tax reform).

And, if he wins, that’s the odd part. Then the bill moves to the Senate where the most likely outcome is a major rewrite. And if that works, then it’s back to the House where the same division between conservatives and leadership surface again. In the Republican Party there are three factions: Conservatives, Moderates, and those who fit into either camp but yet are inclined to support leadership. (That would be the majority of members in both the House and Senate).

I think I’ve told this story before, but here goes again, many years ago when I was at The Seattle Post-Intelligencer we had an editorial board meeting with Rep. Jim McDermott. A tough vote was coming up in the House about the war in Iraq. We knew where McDermott stood. His inclination would be to vote no. But, he told us, “I will not do that to my speaker.” A “no” would have undermined Nancy Pelosi.

That’s not the way Congress works now. House conservatives do not fear the consequences of voting against their speaker (even though in the past it’s resulted in loss of committee assignments and the perks). The thing is that they represent districts that are not competitive. So there is little the speaker can do to punish them. (This is not new. These are exactly the same dynamics that resulted in the end of John Boehner’s speakership.)

So the leadership challenge over the next two days is to make sure there are 216 votes to pass the American Health Care Act (after making minor changes). There are only three options: Make sure the votes are there. Pull the bill back and rewrite it again. Or, least likely, lose the vote and use that as a mechanism to try and punish the members who would not play along.

President Trump has his reputation (such that it is) on the line, too. He went to Capitol Hill trying to close the deal. According to Politico: “Trump entered the meeting to loud cheers. ‘We have a chance to do something fantastic, to do something amazing,’ Trump told the lawmakers, according to sources in the room. He later added: ‘Many of you came in on the pledge to repeal and replace Obamacare. I honestly think many of you will lose your seats in 2018 if you don’t get this done.’ ”

Once again, though, the polls show a different story. “A strong plurality of voters think congressional Republicans are moving too quickly to overhaul the nation’s health care system,” according to a new Morning Consult/POLITICO poll. This is the big reveal: The poll shows that Obamacare is more popular than the GOP alternative.

This is not a prescription for winning the next election.

It makes it easier for any member of Congress who votes no to tell voters that they stuck up for their interests, instead of following the speaker’s command.

Today the president will meet with the Congressional Black Caucus. He’s likely to make the case there, too. But Trump will have a tough time getting any votes from Democrats unless this health care bill changes into something quite different. The more I read about the legislation, and the review by the Congressional Budget Office, it’s clear that this bill is more of a Medicaid repeal than a repeal of the Affordable Care Act. That’s where most of the “savings” in the bill is found.

There is a notion in the Republican reform, one that I find deeply troubling, that Medicaid is only another word for welfare. In this logic, people who are “able-bodied” are only gaming the system when they have this insurance. Nonsense. Health care is health care. Period. I think we should be expanding access to basic insurance, and Medicaid is a cost-effective program that works. (A tack I took in a recent piece for Yes! Magazine.) I’d like to see Medicaid expanded, perhaps to 300 percent of the federal poverty level.

Again, back to my Seattle days. We had an editorial board meeting on health care reform and at that time the single largest source of Medicaid “customers” was people who worked at Wal-Mart. Fact is they had access to health insurance but could not afford it. And their incomes were so low that they qualified for Medicaid.

An increase in Medicaid eligibility would be a huge gain for Indian Country. That 300 percent number I cited would cover most of the people who use the Indian Health System. If you then add the people who have employer-based insurance, I would bet you would be awfully close to universal coverage. And that ought to be the goal. (Working or not.)

Of course the House plan goes in the other direction. The New York Times reported today that this bill is so bad that even a straight up repeal of the Affordable Care Act would be better. “Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report,” The Times said. “In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.”

That little nugget is not going to help the Speaker reach 216 votes on Thursday. If there is a vote.

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

Remember the sequester? Ah, the good old days. The new Trump Administration budget is short on details, but clear on direction. And we do know two things. First: If enacted, this budget would shrink the federal government to a much smaller size. Except for the military and the Veterans Administration. And, second, this budget guarantees chaos ahead.

Thursday morning the White House officially released the “skinny budget.” That’s an overall statement about the president’s financial goals for the year. It lists priorities, but provides few details. And this document does even less of that than previous skinny budgets. But the agenda, the direction ahead, would create a very different federal government. There is money available to approve (and pretend to regulate) energy projects, but nothing, really nothing, for public broadcasting, the arts, and the humanities. All told some 19 federal agencies would be eliminated.

This is where I should add: Hold on! Every one of these agencies has a constituency in Congress. You’ll see 535 budget revisions coming soon with members working to restore funding, and in some cases, even increasing the total amount of appropriation. But the overall direction is less. This is the eighth year of a slowing (and perhaps shrinking) federal government.

This is also where chaos kicks in. The political tension that surfaced in Congress over the repeal and replacement of the Affordable Care Act will only magnify in this budget debate. And to pass this budget, Republican leaders will need votes from Democrats. And if there is no agreement, then there could a shutdown of the government that could last much longer than previous episodes. The best case scenario is a continuing resolution that results in cuts, but not as dramatic as those proposed by the White House.

So let’s try to make some sense of the president’s proposal as how it relates to Indian Country.

First throughout the document there is only one reference that include the phrase, “and Tribes.” The Obama administration often added that language to routine grants and programs for states and local governments to make it clear that tribes were eligible partners. No more.

The budget does not directly put a number on the Indian Health Service. It only lists IHS as part of the overall budget for the Department of Health and Human Services. That agency “requests $69.0 billion for HHS, a $15.1 billion or 17.9 percent decrease” from the Continuing Resolution level. The first mention in that request includes IHS (that must be good, right?) “The President’s 2018 Budget: Supports direct health care services, such as those delivered by community health centers, Ryan White HIV/AIDS providers, and the Indian Health Service. These safety net providers deliver critical health care services to low-income and vulnerable populations.”

The way this budget will work is that each department will figure out how to make the 18 percent cut (as I said, if it comes to that).

Many have compared this Trump budget to the Reagan-era budgets. I remember how that worked for IHS. The president would drop a number — and Congress would ignore it. Every time. That could happen again.

One interesting increase in the HHS budget is a request for $70 million to prosecute health care fraud. It claims a $5 return for every dollar spent tracking down “fraudulent or improper payments.”

The Department of Interior budget does not provide much information about the Bureau of Indian Affairs. It only says the  budget: “Supports tribal sovereignty and self-determination across Indian Country by focusing on core funding and services to support ongoing tribal government operations. The Budget reduces funding for more recent demonstration projects and initiatives that only serve a few Tribes.” The budget says it will “sustain” funding for programs that bring in revenue from natural resources, including those programs that serve Indian mineral owners.

The budget would eliminate several independent agencies that serve Indian Country, including the Corporation for Public Broadcasting, the Denali Commission, the National Endowment for the Arts, the National Endowment for the Humanities, and the Institute for Museum and Library Services. (Irony: A news release last week asked for tribal applications for next round of grants.)

Many of these agencies will show a number in the budget because that reflects the cost to close the agency. Or as OMB put it “the amount of money that’s necessary for us to unwind our involvement …”

In addition Agriculture would eliminate the Water and Waste Disposal Loan and Grant Program, Commerce would eliminate the Minority Business Development Agency and NOAA grants supporting coastal and marine management. At Energy the budget would eliminate the weatherization program. At HHS, the budget proposes to end Community Services Block Grants as well as the Low Income Home Energy Assistance Program. Homeland Security would sharply curtail or eliminate grants to states and local governments (tribes, I assume). Even Meals on Wheels programs for seniors would be eliminated. 

Another program that is slated for elimination is the Transportation Department’s Essential Air Service for rural airports — including those that serve remote reservation and 60 Alaska Native communities.

The only mention of “and Tribes” in the budget proposal is at the Environmental Protection Agency where the budget will avoid duplication by “concentrating EPA’s enforcement of environmental protection violations on programs that are not delegated to States, while providing oversight to maintain consistency and assistance across State, local, and tribal programs.”

The actual numbers of this budget mean little. They will go up and down. Some of the headlines, such as the elimination of public broadcasting, will survive because of support found in Congress. But it’s important to remember that this is the president’s agenda. This administration is hostile to every program that’s identified. So even if those programs are funded, the agencies will have a difficult task going forward.

Some of this agenda is nonsense. There are two ways to spend money on global warming: Learning about the science and trying to change behavior to lower carbon dioxide emissions. Or money for higher sea walls and community mitigation. This budget cuts the latter. That won’t work for long. When a community is severely impacted by fires or other climate catastrophe, the money will have to follow. Period.

But for now the debate is all about the president’s plan.

As OMB Director Mick Mulvaney said at the White House briefing room on Wednesday: “This is the “America First” budget.  In fact, we wrote it using the President’s own words.  We went through his speeches, we went through articles that have been written about his policies, we talked to him, and we wanted to know what his policies were, and we turned those policies into numbers. So you have an “America First” candidate, you have an “America First” budget.”

Only that’s a budget that means significantly less for the First Americans.

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

A short transparency report.

It’s spring break and I have a plan: Write at least 15,000 words. My next book is in my head and I need to transcribe it on digital paper.

For those who want to follow along: I am opening a new tab on my blog, Disrupt! I’ll post the outline and each chapter as a draft.  (I am still toying with titles.)

I’m trying to capture what’s going on in an age of disruption in Indian Country from viral videos to Standing Rock. And, of course, the election.

So next week I’ll step back from breaking stories — unless something big happens on health care or the budget. (I do however want to build a cool, moving graphic that follows the Indian affairs budget from 1900 on and match it to population. I’ve got the numbers … I am now playing with ideas about how to tell this as a visual story.)

Another internal debate: Should I pitch this book to my agent and commercial publishers or go the route I did for The Last Great Battle. That book did well. And I really liked marketing and distributing it via social media. But it would be nice not to have to worry about any of that, especially if there was an advance involved. Thinking. Thinking.

One more head’s up: I am considering the idea of making the radio version of Trahant Reports a daily feed. There is so much going on right now that having breaking analysis might be helpful. Trahant Reports now is a weekly commentary carried on Native Voice One for tribal stations. Every day would be a huge challenge. But if I am organized, I don’t see why not? (I write every day … so it’s just one more thing to read that work into a microphone.) I need to figure out the revenue model (if there is one), and perhaps see if a foundation or sponsors would support it, and go from there. I am exploring with a colleague the idea of sharing a producer to keep costs down.

Enough transparency. Feedback and ideas are welcome.

Now back to work. Today’s word count is 1830. So far.

— Mark

INDIAN COUNTRY &

The Era of Disruption

(Working Outline)

THEME: Uncertainty

One: What the hell just happened?

Essay explores the forces of disruption from the changing nature of technology to the coming decline in fossil fuels. We are already seeing dramatically changing consumption patterns and a country that may not be able to govern itself. Why is this era of dramatic change is so unsettling? (Hint: It’s not just Donald J. Trump.)

Two: Standing Rock changed everything

The story of Standing Rock and why it matters in a Trump era. After two centuries of destruction, why now, why are tribes refusing to accept environmental sacrifice for the good of the country?

Three: Andrew Jackson would be proud. Really?

The White House is occupied by a “man of the people” along the lines of those in the Jacksonian era.  Adding modern context and strategies to mitigate Donald Trump ranging from market-based solutions to mass disobedience.


THEME: DEMOCRACY IS SO WORTH A TRY

Four: Breaking the 0.37 percent barrier

What would democracy look like if Indian Country’s voices were included?  What if Indian Country had a say in electing the next president? What if candidates had to visit tribal communities and Native urban centers and ask for our vote? What if American Indians and Alaska Natives had sway far beyond the small percentage of voters that our population represents? What if all we had to do to win was to vote?

Forget the question marks. We do have a say, candidates do visit Indian Country and ask for our vote, and we do have more influence than we think. We also don’t vote enough, at least in percentage terms.

Five: The hidden history of why Native Americans lose elections and what to do about it.

Indian Country does too little investment in our own candidates. Oh, sure, we get excited when someone runs. But the money does not follow. And there is no institutional support. On the other hand, far more campaign funds from tribes and tribal enterprises are invested in the status quo.

Six: Democracy is so worth a try

Let’s be clear: The United States is neither a democracy nor a Republic. The system is rigged. That must change. Chapter explores a counterfactual, what if Indian Country were a part of the Electoral College? As well as the idea of appointing Native delegates to Congress.


THEME: POLITICS IS ABOUT POLICY

Seven: White House, the Obama years

President Obama has visited Indian Country and heard first hand people’s concerns. He’s met with tribes in a formal, government to government process. It’s hard to understate his interest in federal Indian policy. A look at the two terms of President Obama and its impact on Indian Country.

Eight: The Treaty Right to health care

Nearly six years ago, on March 23, 2010, President Barack Obama signed into law the Affordable Care Act. The bill also included the permanent authorization of the Indian Health Care Improvement Act. Chapter explores history of Indian health programs, the implementation of the Affordable Care Act, and its potential for better funding for Indian health programs.


Nine: The austerity fight is just beginning

It’s one thing to think about “budget cuts” as an abstract phrase. It’s quite another when basic services are eliminated, steady jobs disappear and young people’s ambitions are blocked because college is no longer affordable. When austerity is a national program, Indian Country is hit first. The challenge is to elect candidates who understand this (and mitigate its impact).


THEME: DISRUPT!


Ten: A global warming manifesto

Indian Country will be the first to be hit by the impacts of global warming. Alaska Native villages will be at risk of flooding. Animal and salmon patterns will change (or even disappear). And tribal people will have to adapt. At least there is a 10,000-year history that could be a planning guide.

Eleven: A million lines of code

Rethinking education in the digital age. Chapter explores what jobs are being created and looks how reservation economies might take advantage. Even on remote reservations or Alaska villages this is the digital Native generation. They have grown up collecting more data on their phones — music, Facebook posts, video and photographs — than any other generation in history. They grow up connected to other Native youth across the country making deep digital friendships with dozens, even hundreds of other Native American youth. That’s new. It’s exponential.


THEME: POLITICAL TACTICS & STRATEGY

Fifteen: Just say, Montana. Alaska. Or look across the country.

Indian Country success stories lead to other success stories. Montana is a great example. Visualize Montana and do some math. At one point this last year there was more than a dozen candidates for federal and state offices. The Montana Dozen is a powerful idea about change.

Alaska’s story is both improbable and historic. The year started with a three-way race for governor. The governor, Sean Parnell, who has been a zealous litigant against Native interests during his time in office. Then a coalition was forged to elect an independent governor, serving with Byron Mallott a Native leader as the Lt. Gov. This is classic coalition politics — chapter looks at what worked.

One more success story is nationwide. Native Americans are in key leadership positions in at least seven state legislatures. That’s impressive — and critical right now because of the types of conversations that will be going back and forth between Washington, D.C., and state capitals about Medicaid, health care and energy policy.

Thirteen: Five lessons from Canada


Canada’s election was one for the history books: A third-place Liberal party won enough seats to form a government; Aboriginal voters cast so many ballots that in some areas they ran out; and across the country people demanded a reversal of a decade of Conservative policies. Aboriginal voters turned out in record numbers, electing ten Native people to Parliament (up from seven).


Sixteen: Indian Country’s Barack Obama


Who will be Indian Country’s Barack Obama? She’s probably already been elected to a state office. And, at  least 73 American Indians, Alaska Natives and Native Hawaiians currently serve in 17 state legislatures. This is important for a couple of reasons. First, if you look at the body of work of these state senators and representatives, you’ll find them advocating for better services, more funding and improving relationships between tribal nations and state governments. Second, state offices are a source of talent for higher elective posts, ranging from Congress to the White House. Remember it was in only 1996 when Barack Obama was elected to the Illinois state Senate.


Seventeen: Voting rights: Protecting the franchise
American elections were often defined by who is not allowed to vote. So in 1880 John Elk presented himself to a county official in Omaha, Nebraska, and attempted to register to vote. The clerk “designedly, corruptly, willfully, and maliciously, did then and there refuse to register this plaintiff, for the sole reason that the plaintiff was an Indian, and therefore not a citizen of the United States, and not therefore entitled to vote.” On the next day Elk went to the polls anyway. The same clerk was a judge and again refused to give Elk a ballot. Eventually the Supreme Court agreed. It basically said that Elk had been born an Indian, therefore was not a citizen, and could not vote. He owed his “immediate allegiance to” his tribe, not the United States, the court said. Congress supposedly fixed that in 1924 when it passed the Citizenship Act. But that was a Washington, D.C. idea – and states continued to deny American Indians and Alaska Natives the right to vote. South Dakota, Idaho, Maine, Mississippi, New Mexico, Utah and Arizona all found legal loopholes to prevent Native Americans from voting until as late as 1962. Today that challenge continues as s0me counties and states make it difficult for Native American voters to exercise their right.


Eighteen: Making elections cool


Winter Challenge was a viral video that swept across Indian Country and First Nations. It was a simple: Jump in a cold body of water or snow and then challenge your friends to do the same. And their friends. And their friends’ friends. Until the numbers are huge. What if elections were the same? The prospects are exciting.

Nineteen: One day soon … the road to the White House will be red, brown, black and young


The changing demographics that make up America. The most important thing to know: American Indians and Alaska Natives are a fast growing population that will be a part of many winning political coalitions.


Closing essay.  The end of the United States.

What happens to tribes without the United States? What’s a transition look like? Start with the retelling of a 10,000-year history. Native people in North America have made the shifted from hunting mammoth to buffalo. From living off salmon during the ice age to rebuilding salmon habitat and stock even in the era of global warming.

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Sen. Lisa Murkowski says Alaska should have the option to keep Medicaid expansion under any Affordable Care Act replacement. Three Republican members of the Senate have said as much. Republicans only have three votes to spare to pass the measure. (Senate photo)

Mark Trahant / Trahant Reports

I wrote a couple of days ago that the House bill doesn’t mention a word about the Indian Health Care Improvement Act. True enough. Because, it turns out, the proposed replacement for Affordable Care Act is not a complete repeal. The current law would remain in tact.

“The two proposed bills do not repeal the ACA. They leave in place the ACA’s titles affecting Medicare, quality of care, program integrity, biosimilars, workforce reform, the Indian Health Service—indeed virtually all of the ACA except for its insurance affordability provisions, individual and employer mandates, taxes, and Medicaid reforms,” writes Timothy Jost in the journal Health Affairs.

This idea is important. Instead of a repeal, the Republican leadership took the framework of the Affordable Care Act. Then the House authors wrote adjustments to Medicaid spending, the way the bill is paid for, how people get help to buy insurance, and along the way added a few gold coins for insurance company executives. (Compare the bills here in this Kaiser Family Foundation graphic.)

I like the way Jim Roberts described the process on his Facebook page: “Take the ACA, tear out the pages that have been repealed, and see what’s left on the table. Its pretty easy to figure out. Its like cutting the face of an ex-spouse out of the family photos! The entire family photo is still intact and everyone knows who that cutout is. Its Obamacare … You can cut Obama out of the picture, but guess what people, He’s still there!” Jim Roberts is a Senior Executive Liaison for Intergovernmental Affairs at Alaska Native Tribal Health Consortium and a long time expert analyst on how health care policy impacts Indian Country.

So this is the problem I have writing about the bill. Do you go into detail about how bad it is? I could easily type 10,000 words just on Medicaid. Or is it better to focus on the politics, because the odds of this package becoming law are slim. That’s where I headed.

Here is the short version of the politics: Two committees have moved the legislation forward through the House. The House Budget Committee will consider the bill before it goes to the full House for a vote. Then, if the House has enough votes, on to the Senate for consideration.

The Republican Party is divided by serious differences of opinions about health care reform and the nature of government. Conservatives do not believe that health care is a right. They see it as an individual responsibility (Or say they do. If they really believed that, we’d get rid of the employer-based system that insures most people. But that’s another story). This group wants Planned Parenthood defunded. It doesn’t even like the idea of insuring family planning of any kind.

On the other side of the divide are practical Republicans who represent states that have made progress insuring more people because of Medicaid expansion. This group of legislators, mostly in the Senate, see this bill as a way to flip the cost of health care to the states. (Or allow conservative states to do nothing.) The House plan would keep Medicaid running sort of as is between now and 2020 and then turn it into a capped program.

The National Indian Health Board says the House bill would keep in place the 100 percent federal reimbursement to states for American Indians and Alaska Natives patients who use the Indian health system.

One huge problem with capping Medicaid cost is that it works backwards: Because when Medicaid is most needed, such as during a recession, then states have less money available to spend on health care. So people would not get the help they need, when they most need it.

Alaska Sen. Lisa Murkowski spoke at the state legislature about Medicaid last month. According to the Alaska Dispatch News, she said Medicaid strengthened Alaska’s Native health care system and reduced the number of uninsured people visiting emergency rooms. “So as long as this Legislature wants to keep the expansion, Alaska should have that option,” Murkowski said. “So I will not vote to repeal it.” At least three Senators have said they would vote no unless Medicaid is protected.  And Republicans cannot lose more than three votes in the Senate for the bill to pass. (According to a new report by the Center for Budget and Policy Priorities Alaska would lose the most under the House plan for tax credits, a whopping $10,243.)

Another deal breaker for many members is the nearly unified opposition from the medical establishment. The American Medical Association “is concerned with the proposed rollback of Medicaid expansions, which have been highly successful in providing coverage for lower income individuals. The AMA is also concerned that changes to Medicaid could limit states’ ability to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction.”

The challenge paying for opioid treatment will be a factor because it’s a crisis in so many communities across the country. The House plan leaves this up to the states. Without funding.

Nonetheless President Donald J. Trump is trying to make his first deal. And he is working it hard. He’s trying to get conservatives to support his deal despite their philosophical misgivings. But if the president gives any more ground, then more moderates will be “no” votes. Trump’s strategy seems to be daring conservatives to vote no. He will demand a party-line vote and say, basically, this is the best deal conservatives are going to get. It’s also why the president and House Speaker Paul Ryan are trying to move fast. Every day they wait, the opposition has more resources to counter that strategy.

Here is what to watch for in the days ahead. Will conservative interest groups such as Heritage Action, Club for Growth, and Americans for Prosperity, “score” the vote? That’s a record that groups use to rate how conservative are members of Congress. Going against this vote could mean less money, support in primary elections, and less conservative street cred.

Meanwhile Rep. Tom Cole, R-Oklahoma, has introduced a just-in-case bill to reauthorize the Indian Health Care Improvement Act. That measure will be ready in case Congress repeals the Affordable Care Act outright (which is what the conservatives argue is the back-up plan).

Stay tuned.

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

There’s a  bad joke that goes like this: What’s your plan to pay for the high cost of health care? No worries. I’ll win the Powerball.

Except the new Republican plan to repeal and replace the Affordable Care Act ends that option (and somehow takes it seriously). There are detailed instructions to prevent lottery winners from getting Medicaid coverage. That probably fixes a huge problem that we never heard about before.

It’s funny that the House Repeal and Replace plan (The American Health Care Act) includes several pages on that non-problem while the draft doesn’t even get around to mentioning the Indian Health Care Improvement Act.

But don’t get too worked up about this miss. Here are the three things you need to know about the House plan.

First: This plan is an urgent call for American Indians and Alaska Natives to sign up for Medicaid, children’s health insurance, or the Exchange Plans. This plan makes it clear that there is time to sign up as an act of defiance and that adds new money to the Indian health system.

Second: There will be fewer people covered under the House plan. We won’t know the numbers until it’s scored by the Congressional Budget Office. But it’s clear fewer people will be covered. And to top it off the plan will cost older Americans more. A lot more. Insurance companies would be allowed to charge older people five times as much as young people. (And to make that more odd: Older people are a GOP constituency.) There is no requirement that people carry insurance, but if there is a lapse in coverage, the cost goes up.

Third: The politics are a lot like President Trump’s election plan. Tick off everybody. Create chaos and hope there are enough votes left to win. I don’t think so. Conservatives already don’t like the provision to include tax credits. And state governments aren’t happy with a punt on Medicaid expansion (keep it until 2020 and then cut the heck out of program). And to top it off, the White House comment is at best only mild support. This plan is politically dead. A plan that looks so much like Obamacare is going to be really difficult to sell as change. It keeps, for example, the essential health benefits package, including family planning and maternity benefits. Yet at the same time it ends funding for Planned Parenthood. That means two very different constituent groups will be opposed. Finally the tax credits are complicated and unfair. They are based mostly on age. So someone under 30 gets a credit of $2,000 while someone who’s 60 or older could get $4,000. Once again that’s contradictory logic. Take from old people. Then give something back. Good politics? We shall see.

I just don’t see how this plan — or anything like it — gets out of the House of Representatives. Let alone become the law. So don’t get too excited. You’re better off buying a Powerball ticket. — Mark Trahant

 

 

 

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Updated interactive version of this graphic, here.  (Trahant Reports)

Native American Republicans include two elected members of Congress; a dozen serving in seven state legislatures

Mark Trahant / Trahant Reports

Indian Country cannot afford to close the door to Republicans in Congress and in state legislatures, especially those Native Americans who have been elected to office and serve as Republicans.

There are two tribal citizens serving in Congress: Representatives Tom Cole, a member of the Chickasaw Nation, and Markwayne Mullin, a member of the Cherokee Nation.

There are at least at least a dozen Native American Republicans serving in state legislatures (compared to 51 Democrats) in seven states. That list includes Alaska Sen. Lyman Hoffmana Democrat, but he caucuses with the Republican majority and now serves as a chair of several committees and sub-committees. Hoffman is Yup’ik. In the Alaska House, Rep. Charisse Millett, Inupiaq, is now her party’s minority leader.

Not all the elected Native American Republicans make tribal issues any sort of priority. Minnesota Rep. Steve Green, for example, does not include tribal membership in his biography or in his campaign literature. Yet his district includes the White Earth Nation.

However most of the Native American Republicans who are elected to office also engage in Native policy issues before state legislatures, including support for enhancing tribal languages, teaching Native history, expanding or limiting tribal jurisdiction, voting rights, and, soon, state measures to shape the next version of health care reform.

One shared trait of the Native Americans who are elected as Republicans is support for fossil fuel energy development. “As a local elected official, I am outraged that Indian Country is prevented from harnessing our own energy resources by ever-increasing regulations,” New Mexico State Representative Sharon Clachischillage said in a Native Americans for Trump promotion. “The Trump Administration will ease restrictions on American energy reserves worth trillions of dollars. Together we will block the bureaucrats holding Native American businesses back and bring new jobs into our communities.”

But even the idea of energy development gets more complicated in Indian Country.  As Sen. Hoffman reports on his biography page: “Every Alaskan deserves affordable energy. As a resource rich state (oil, gas, wind, and tidal), our state should and could, harness all of this energy to benefit all of its citizens. I pledge to continue to work towards reducing the high cost of energy in rural Alaska.” Anyone who’s purchased gas in a village — topping $6 a gallon in Hoffman’s home in Bethel — gets that.

But many of these same communities, especially in rural Alaska, are at the global warming frontline and more money will soon be required to build sea walls, fight more fires, or even relocate entire villages. In his biography, Hoffman only cites the opportunity. “Our backyard is changing opening new ventures, with the thawing of the tundra and the melting of the Arctic ice,” he writes. “It is my intent and my responsibility as your state Senator, to ensure our region participates …”

Then not every Republican even goes that far. Montana Sen. Jason Small, Northern Cheyenne, ran for office against Sharon Stewart-Peregoy, a Crow, to spur reinvestment in coal. Small recently wrote in The Billings Gazette: “Thirty million dollars a year in lost royalties, hundreds of direct jobs lost, thousands of families out of work and out of options, entire towns destroyed, statewide economic ripples, and over $1 trillion dollars in stranded assets, not necessarily because of market forces, but directly attributable to a political agenda. That is what we face in the current and unprecedented assault on reason and Montana’s economy in what has been dubbed ‘the War on Coal.’”

Then market forces will be a test of this notion. Can pro-coal Republicans legislate the revival of the coal industry? Small argued in the piece that “carbon capture and combined cycle technology can solve the global climate challenge posed in part by the world’s more than 7,000 coal-fired power plants.” Coal prices did surge after Trump’s election, at one point topping $110 per metric ton, but have since declined to about $83.50 per ton. Since the election at least one major power plant, the Navajo Generating Station near Page, has been marked for closure in two years. The Arizona utilities that own the generating station say that the low cost of natural gas is their primary reason for closing the plant. That in two words, market forces.

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Waiting for Congress

Most state legislatures are waiting for Congress before taking action before another round of healthcare reform at the state level. And that’s a debate that is still hot. There are three distinct points of view about repealing and replacing the Affordable Care Act (or Obamacare). The plan by the House leadership (which has not been released yet) is supposed to be designed around tax credits instead of the insurance subsidies that are in the current law. Several of the most conservative members of the House and Senate see that as a new entitlement and have signaled their opposition. A third group of Republican moderates have been working with state governors to preserve Medicaid expansion because that insures some 22 million people (including more than $800 million for the Indian health system).

Rep. Cole is a likely supporter of the plan that emerges from House leadership. That includes a repeal of the Affordable Care Act as well as the Medicaid expansion. He recently told Native America Calling that Oklahoma did not choose to expand Medicaid and that made the system unequal.

However Cole said what ever plan emerges he said the Indian Health Care Improvement Act is a “bedrock” legal authority that must remain. “This legislation was included … purely as ‘vote bait’ to secure Democratic votes and has nothing to do with” the Affordable Care Act,” Cole said. “It is vital and ensures that Native Americans have quality health care available to them and their families. There is no controversy here – it sets the national policy for many programs and services provided by the Indian Health Service.”

A few weeks ago the repeal of the Affordable Care Act seemed like a sure thing. And now? The next week or two could answer that question. And the course that’s picked will have a huge impact on the Indian health system. 

And, over that same time frame, Native American Republicans will be asked to take a stand about deep budget cuts across federal agencies. Several news agencies have reported that the Office of Management and Budget is calling for a $1.3 billion cut at the Interior Department. Interior Secretary Ryan Zinke employees that he did look at the budget and is not happy about it, according to Energy & Environment News. “We’re going to fight about it,” Zinke said, “and I think I’m going to win at the end of the day.” E & E News reported that Zinke would engage in a major reorganization of the department, one that focuses the agency on the next one hundred years (including the promotion of tribal sovereignty).

It’s easy to find the issues where Native American Democrats and Republicans disagree. Indeed it would be simple for me to shape every column as doom and gloom, the logic of “Oh, what is that Trump going to do next?” But that won’t help the policy debates that are so important to Indian Country. But that idea discounts how much agreement there is out there — even in this hyper-partisan climate. It was Rep. Cole who helped champion the reauthorization of the Violence Against Women Act in 2013, including the provisions for tribal jurisdiction over non-Indians. Tribes still have a lot of work to do to implement that law. Deborah Parker, former vice chair of the Tulalip Tribes, and a key supporter of the act, said tribes should get their law and order codes ready now to comply with the law. Too few tribes have taken that step and VAWA will again require reauthorization in 2018 so Indian Country has to present its strongest case for this Congress.

One example of a Native American issue that cuts across party lines is unfolding in Wyoming. The Indian Education for All, House Bill 76, would require the state’s schools to educate all children about the history and economic contributions by the Eastern Shoshone and Northern Arapaho Tribes.

Sen. Affie Ellis was just elected in November and is a co-sponsor of the legislation. She’s a Navajo who grew up in Wyoming and she told the Casper Star-Tribune that Native American students sometimes are threatened by verbal abuse during sports trips across the state. “It’s a really important first step to understanding each other a little bit better,” she told The Star-Tribune. “It’s a brief idea, and I think it’s a fitting one.”

At the recent Conservative Political Action Conference, or CPAC, Ellis spoke at a panel titled, “Rising Stars in the Conservative Movement.” Back in Wyoming her appearance generated both praise and criticism. The newspaper Planet Jackson Hole asked the question if Ellis was a “sane Republican alternative” to Trumpism? The paper quoted Ellis saying:  “I think our country needs so desperately some thought and some well researched responses …  There’s so many times when it’s easy to name call and have these cute hashtags that stick but we have to have strong facts and start communicating those facts in a very effective way. I think the hard part is the devil in the details of policy you’re working on doesn’t fit into small hashtags. Maybe we just need long hashtags.”

I don’t know about longer hashtags. The one I use,  #NativePolicy, is short. But we certainly need more thoughtful, complex policy debates.

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


In a few days we will see what kind of federal budgets actually surface. Right now there is a lot of posturing going on: 
— From the Trump White House that wants to shrink government dramatically.
— From agencies that want to keep as much of the funding as they have now.
— And from states. Remember state budgets must balance. So slow down of some kind (even if it’s a result of less federal funding) will have to be made up with new program cuts and taxes.


I am trying to think through how to tell this as a story for Indian Country. 
What are the impacts? How many people will lose their jobs? What’s the implication for, say, salmon when the NOAA budget is cut dramatically. Or the EPA budget for ongoing projects on tribal lands?
I am starting with a spreadsheet, a history of BIA spending.
https://dhttps://docs.google.com/spreadsheets/d/1QoPydklTVAyJlumD5fFO4RLsvJMwvPR551fa-Fp2FTo/edit?usp=sharingocs.google.com/spreadsheets/d/1QoPydklTVAyJlumD5fFO4RLsvJMwvPR551fa-Fp2FTo/edit?usp=sharing
#KeepUp
#NativePolicy

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