We live in odd times. Congress is moving forward with promised legislation that will roll back much of the health care reform enacted during the past eight years. The Trump administration is issuing regulations to do the same. The key here is that President Donald J. Trump and Republicans in Congress have the votes (mostly). But in state capitals there are real debates about public policy. What happens next will be determined by lots of people working together.
The future of the Affordable Care Act is a case in point. Republicans in Congress are eager to ditch the law, but coming up with a replacement or even a fix is a much more difficult task. This is one issue where there are not enough votes in Congress to do anything. Yet.
But in state capitals there is an understanding that a wholesale repeal of the law could be a financial disaster for states that have already expanded Medicaid. So many Republicans at the state level, such as Ohio Gov. John Kaisch, are pushing back. He recently told CNN that that any repeal without addressing Medicaid expansion is a “very, very bad idea.”
But several of the states prefer a real solution, one that doesn’t grab as many headlines, yet would be practical. And that is to continue with current law and then Secretary of Health and Human Services Tom Price would grant states many more waivers to design the programs the way they want.
This makes more sense than a block grant because it keeps in place the idea that if people are eligible for Medicaid, then it will be funded. Under a block grant scenario, it’s likely the total amount would be capped and people who currently get insurance could lose that. (Perhaps the most difficult problem is this: How do you protect the states that expanded Medicaid and still add funding to those states that said no?)
This is a huge issue for Indian Country because Medicaid could cover even more of the people who currently use the Indian health system. (Best of all: Money from insurance is supposed to stay at the local healthcare facility.) States also come out ahead with American Indian and Alaska Native clients because the federal government is obligated to pick up the tab. It’s a 100 percent federal “match.”
This is one of those issues that divide Republicans, especially in Congress. The members who are listening to states understand the problem: What happens when you take away people’s health insurance? The answer is not good. And it’s even life or death for some people because without insurance there will be no medical care for ongoing issues.
This week in Washington state there was a victory for health care reform in Indian Country. The Legislature passed, and Gov. Jay Inslee, signed into law, a measure that opens up the practice of dental health therapy.
Dental health therapists are mid-level providers. They work under the supervision of a dentist and offer routine and preventive services, like dental exams; provide fillings; clean teeth; placing sealants; and perform simple tooth extractions. This law is important because it opens up Medicaid funding to pay for dental care. And it expands access making it much easier for patients to get appointments.
“We have one dentist to see more than 6,000 patients on the Colville Indian Reservation,” said Mel Tonasket, vice-chairman of the Colville Confederated Tribes. “This law will help us hire a dental therapist to make sure our people are getting the oral health care they need.”
Most experts in health care reform argue for increasing value in health care by lowering costs and at the same time improving quality. This is that.
This oral health reform was started a decade ago by Alaska Native Tribal Health Consortium. According to The Kellogg Foundation: Since then “45,000 Alaska Natives now have access to dental care and the dental health aide program has generated 76 full time jobs with a net economic effect of $9.7 million, one-third of which is spent in rural Alaska. Now, as a way to replicate the same dramatic oral healthcare improvements in Alaskan villages, i.e., reduced caries disease, healthier teeth and patient satisfaction with culturally competent care given by home-grown providers, tribes are blazing a trail to bring dental therapy to the lower 48 states as a high-quality, cost-effective strategy to reduce dental care shortages. Washington State is on the leading edge of this movement.”
This is a great example of the principle of lead, follow, or get the hell out of the way. A year ago Swinomish President Brian Cladoosby announced that the tribe was using its sovereign powers to hire a dental health therapist in contradiction to federal and state law. The case was clear that the tribe had the authority even while raising questions about Medicaid funding or licensing. (The American Dental Association was successful getting language into the Affordable Care Act that required state action.) But the state of Washington was reasonable and the result is the new law.
The bill was sponsored by Sen. John McCoy, a member of the Tulalip Tribes. “This is a tribal-based solution that will make a tremendous difference for Native people—especially children,” he said.
According to Kellogg: Dental therapists are now practicing in Minnesota, in addition to Native American communities in Alaska and Washington. They’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio are exploring the potential for dental therapists to significantly improve oral health care for many more children and communities.
So look for more action and more success stories coming from state capitals.
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
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