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.)
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.”
The Congressional Budget Office report on the Senate majority’s health care bill — the ironically titled “Better Care Reconciliation Act of 2017” — ought to be enough to put to rest any idea that Republicans want to improve health care in this country.
There are legitimate conservative ideas about how to reform health care. You know, the stuff they have been saying for years about market-based reforms where people can shop for their doctors and clinics online across state lines. Think Amazon. Modern, high tech, affordable care.
But that’s not on the table. Instead the House and the Senate are trying to legislate a huge tax cut, make a small dent in the long-term federal spending, trim spending on insurance subsidies, and the destroy Medicaid (and, as a bonus, shift responsibility from Washington, D.C., to state governments.)
Here are the numbers to back up that paragraph: CBO says the tax cut is worth $541 billion. The long term deficit reduction totals $321 billion. Getting rid of insurance subsidies under the Affordable Care Act saves $408 billion. And recasting Medicaid as a block grant (as well as phasing out the expansion) is worth $772 billion.
Neither the Senate nor the House bill accomplish any health care goal. Neither bill will help people get insured. CBO says “in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026.”
And down the road when Medicaid reflects “lower spending” that too would “lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”
CBO says that even employer-based health care would shrink.
The crazy thing is that older people would be impacted the most by both the Senate and House approach. As the Center for Budget and Policy Priorities reports: “For people age 60 or older with income at or below the poverty line, individual-market premiums would consume at least 45 percent of their income. The share would be even higher in higher-cost states and for people at lower incomes.”
And that’s where geography impacts Indian Country. Alaska, for example, would have the highest cost in the nation. In fact: If you are 60 and trying to buy insurance … it’s basically unaffordable. Insurance costs will far exceed affordability in North Carolina, Oklahoma, Arizona, and Wyoming.
This is what’s so important to the Indian health system. Instead of getting funding from third-party billing — mostly Medicaid — the Indian Health Service would have to rely almost entirely on appropriations. The bottom line: There will not be enough money.
Remember both the House and the Senate want to convert Medicaid to a block grant. This is not just rolling back Obamacare, it’s returning health care to before Lyndon B. Johnson’s Great Society programs.
As the CBO puts it that will lower Medicaid participation by 9 million in 2020 and by more than 14 million by 2026. That’s a lot of people.
Most of the discourse about Medicaid centers on health care. But the program also provides long-term care to elders and disabled in assisted care or in-home care. The way this program works: You give up your assets (except Trust-based assets) and then the government promised to pay for your care. The Centers for Medicare and Medicaid say American Indian and Alaska Natives are a fast growing population that already rely on these services. “Between 2000 and 2010, the number of AI/AN adults 65 years or older increased by 40.5%, a growth rate that is 2.7 times greater than that of the overall population of older adults (all races) over the same 10-year period. The AI/AN elder population is projected to reach 1,395,000 by the year 2050; that’s a 3.5-fold increase from 2010 to 2050. In addition to studies that reflect the growing population of older AI/AN adults, other studies have revealed that AI/ANs suffer a disproportionately higher rate of disabilities including (lower body) functional disabilities that increase this population’s risk for falls, demonstrating a clear need for LTSS within this population.”
So if the Senate or House bill becomes law future services — as the need grows — will be sharply curtailed. And I can’t answer what will happen to people living in nursing homes now. If a state cuts the payment to a private facility, they could, in theory at least, ask people to leave. Let that sink in. People who have given up everything to live in an extended care facility could end up with no place to go. It will all depend on state legislatures or tribal budgets.
I am used to looking at both sides of any issue. I’m interested in views different than my own and exploring whether they have merit. As I wrote above: There is a conservative approach to health care that’s worthy of debate (I’d likely still come down on the side of single-payer.) But the House and Senate bills are not it. The only ideology at work is a tax cut; a painful tax cut at that.
The Senate bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions from Medicaid and passes on that savings to wealthy Americans.
How bad could it be? The official financial review from the Congressional Budget Office is expected early next week. The scoring of the similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured. Under the House bill only a few million would use tax credits to purchase policies that even then would not cover major medical risks.
So the important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) and gives back most of those to high-income taxpayers ($664 billion). The Senate bill takes a little time to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. Then, like the House, Medicaid would become a state block grant program. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid spending is automatic: If you are eligible, the money is there.)
Medicaid now accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.
But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or what’s especially what’s covered by insurance.
This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent federal funding through what’s called the Federal Medical Assistance Percentage for Medicaid or FMAP. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. But the money would still flow from Washington to the states for administration. Messy (as it often is now). And the states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.
The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The bills move health care back to the states in a big way. That can be good or bad. California is debating how to create a single payer system. The Nevada legislature recently passed a Medicaid-for-all statute (where any citizen could buy into the program) only to have the law vetoed by the governor. But other states see health care only as a cost. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity” care.
Some numbers here. The American Hospital Association opposes both bills for one reason. In 1990 uncompensated care cost $12.1 billion or about 6 percent of total hospital expenses. By 2012 that figure reached $45.9 billion. And, after the Affordable Care Act, the total uncompensated care costs dropped to $35.7 billion or 4.2 percent of total hospital expenses, the lowest level in 26 years.
But this shows the futility of cutting Medicaid and insurance programs for the poor. It doesn’t save money, it just shifts it around. People who get sick will go to emergency rooms when it’s later in their illness and more expensive. So hospitals will cost more for everybody. (But at least the wealthy get their tax break, right?)
The opioid crisis is an example of that. The costs will not go away. Some money will be found by states, cities and tribes. The Senate bill adds a funding stream of $45 billion over 10 years for substance abuse treatment and prevention that’s now funded by the Affordable Care Act. But Medicaid expansion has been a key funding source. The Associated Press reports that Medicaid expansion accounted for 61 percent of total Medicaid spending on substance abuse treatment in Kentucky, 56 percent in Michigan, and 43 percent in Ohio.
The Senate has only a few days to consider their version of health care “reform.” Already a few conservatives are saying the bill doesn’t go far enough and want more changes. This is the script the House used: The conservatives throw a fit, get their way, and then the so-called moderates give in and vote yes anyway.
My bet is that Senate leaders have already written off Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins because of their past support for Planned Parenthood (there are already restrictions against the federal funding of abortion, but the Senate bill says Planned Parenthood cannot bill Medicaid for a year for all women’s health services). So I think Senate Majority Leader Mitch McConnell is banking on a fifty-fifty split with Vice President Mike Pence casting the deciding vote.
That means the moderate senators, those that support Medicaid in their states, can say what ever they want now. But it’s their vote that will count. Destroy Medicaid or cut taxes? That’s the choice for these four: Rob Portman of Ohio, Shelley Moore Capito, West Virginia, Dean Heller of Nevada, and Cory Gardner from Colorado. Perhaps it’s wishful thinking but I will add Alaska Sen. Dan Sullivan to this list because Alaska will be hit particularly hard by the overall legislation, the opioid epidemic, the state’s successful expansion of Medicaid, and its impact on the Alaska Native Medical system. Sullivan said on Facebook that he will read every word of the bill and he wants “a sustainable and equitable path forward for Medicaid” and he won’t vote for a bill that makes things worse for Alaskans. So will it be his party or Alaskans? Health care or tax cuts?
And, since I am asking already asking questions, will the Senate bill pass next week? Remember it will only take one senator to force the Senate to start over.
I have been wondering what I should say about the Republican health care legislation in the Senate. We do know that there is a policy split among Senators about how much and how fast to cut Medicaid. We know the bill will cut taxes. But beyond that there is more information on one of my whiteboards than what is posted in public.
Senate Majority Leader Mitch McConnell is moving this legislation in secret. And there’s a reason. As The Washington Post puts it: “ So McConnell’s theory is that if the Senate’s bill were seen, debated and discussed, opposition would grow and grow, and eventually at least three of his members would bail out (the Republicans’ 52-48 majority means they can only lose two votes). Which might well be true.”
So true in fact that I am not sure which is a worse outcome for Republicans: Failing to pass a bill (ticking off their conservative base) or passing this legislation that by all independent measures will make the U.S. health care system worse.
It’s easy to imagine the coming 2018 election commercials: Millions lose health insurance; health care-related bankruptcies on the rise; and all done in secret so that wealthy campaign donors pay less in taxes.
Indian Country, of course, is largely missing from this debate. There is an assumption that the bill doesn’t impact the Indian Health Service. But Medicaid is growing and it could be, no, ought to be, a significant funding stream for IHS. Even the Trump administration’s budget recognizes that. It projects $914 million in third-party billing for IHS in fiscal year 2018, a slight increase. That’s mostly Medicaid. But the numbers don’t reflect what will happen if that Medicaid money is taken away because the IHS appropriations (which is essentially flat) will have to serve more patients with less resources. Remember half of all Native American children are insured by Medicaid or the Children’s Health Insurance Program.
When the House passed the American Health Care Act a number of “moderate” House members said the bill was bad, but don’t worry the Senate will fix it. Even President Donald J. Trump echoed that idea, telling Senators the House bill was mean and that the Senate should be more generous.
In fact the idea that the Senate would make the bill better was a key part of the House vote. Alaska Rep. Don Young, for example, was said to be a no vote (Alaska gets the worse deal of any state in the House legislation) but ended voting yes. Young told the Alaska Dispatch News two things: First, the bill was moving too fast. And, more important, “this bill we passed today will not become law. It’ll be changed as time goes by. But unless we move it, or move a vehicle, nothing’s going to happen, and that’s not good.”
So process mattered. Then. Now the Senate is engaged in the screwiest legislative path ever; essentially asking Senators to support a blank page. And improving the bill? Hardly. The secret Senate bill is only trying to win with 50 votes, not shape sound public policy.
Every member of the Senate Republican caucus agrees on cutting taxes. That’s the fuel that keeps this bill moving forward. But not all agree about cutting Medicaid (and funding for Planned Parenthood). In a closely divided Senate some members are going to have to take one for the team; vote against their own state interests and voters. Thirty-one states expanded Medicaid coverage under the Affordable Care Act — and twenty of those states are represented by Republicans. All but three have to agree to take away insurance from their voters.
But that’s the easy sell. If there is a long transition period probably nearly all of the 20 Senators will go along. But the conservatives (especially those that represent states that did not expand Medicaid) want a quicker timetable. That means the “moderates” will be going before voters right away and campaigning on less Medicaid for all. That’s terrible politics because the numbers are staggering: Seventy million Americans are on Medicaid. If Congress turns this into a block grant program millions will lose health insurance. Millions of voters.
There are new studies that show how devastating the American Health Care Act would be to public health and the economy. A study by the Commonwealth Fund says nearly a million Americans would lose jobs if this legislation passes. “By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses,” the Commonwealth Fund study found.
Indian Country would lose jobs, too. There are no numbers yet but the Indian Health Service budget would take a significant hit and there would be pressure to reduce the number of employees. Remember the Indian Health system is Indian Country’s largest employer.
The Senate only has a few working days before it’s July recess. If it’s to become law, the bill will need a “score” from the Congressional Budget Office (because of Senate rules this bill must be budget-related). But that won’t happen unless McConnell thinks he has the 50 votes needed to pass. Policy be damned.
Fair to say this budget will result in the early death of too many people
Mark Trahant / Trahant Reports
It’s easy to blame Donald J. Trump for a terrible budget. This is classic disruption; it’s designed to change the nature of government immediately. It’s also a destructive document that would result in great hardship across the nation and Indian Country. It’s not too strong to say that this plan would mean an early death for too many people.
So we ignore what’s proposed and turn to Congress for the real spending plan. The idea is that Congress will do something better. They must. Or face the consequences from voters in the 2018 elections. And it’s already clear that few Republicans are eager to reshape government (at least as dramatically as the president.) It’s unlikely that Congress will vote to eliminate agencies ranging from the Corporation for Public Broadcast to the Denali Commission. And the minus signs inked across budget lines will be less severe than requested.
But let’s be clear: The best outcome is probably another Continuing Resolution that patches together a temporary budget for a few months or possibly the entire year. Again. That’s become business as usual in Washington.
The ‘worse’ news: A failure to govern
That’s the good news. The bad news — strike that — make it the worse news is that neither political party has enough support to enact a thoughtful spending plan. The crisis is not a financial one (well, it is sort of) but represents a systemic failure to govern.
The best example of that problem is the debt ceiling. Basically it’s a law that allows the Secretary of Treasury to finance the debt that the United States already owes. The money has already been appropriated or authorized by Congress. It’s spent. So the only question is to pay the bill or not. Yet nearly every member of Congress (from the Tea Party to Sen. Barack Obama) bluster about the debt and threaten to withhold their vote. But the party in the White House cannot operate that way. Obama changed his tune as quickly as did Trump. It’s the nature of the job.
Congress isn’t run by two political parties; there are at least three major factions. (This is not unusual: Just before the Civil War the Republican Party was deeply divided by economic conservatives and the Radical Republicans who were organized against slavery.) Today’s Congress is composed of Republicans, the more strident House Freedom Caucus, and the Democrats.
It will take votes from two of the three factions to lift the debt ceiling and pass a budget in the House. This is important because the first “test” of a coalition was the vote to repeal the Affordable Care Act and replace it with the American Health Care Act. The moderate Republicans sided with the House Freedom Caucus to pass a measure that would strip insurance coverage from 23 million Americans (according to the Congressional Budget Office). You’d think this would be nonsense politics for Republican moderates. Yet they still voted yes. The thing here is that this is the coalition to watch. So if Speaker Paul Ryan goes that route again it will mean a debt ceiling bill that results in even more spending cuts than the Trump budget. Imagine that.
The other alternative is just as unthinkable. It’s for Ryan to reach out to Democrats and build a majority coalition. This happens in state capitals all the time. But it’s considered near treason in politics and it would cost Ryan his job. Beyond that, the votes of the Democrats would come with a price, most likely a promise not to cut taxes on the wealthy.
Then whatever spending bill that emerges from the House must win 60 votes in the Senate. That’s not going to happen if the House Freedom Caucus wins the day. (Remember there are currently 52 Republicans, 46 Democrats and 2 independents in the Senate).
This is real juggling. Debt. Budget. And health care. And the Juggler-in-Chief doesn’t even like balls in the air. He tweeted last month: “Our Country needs a good ‘shutdown’ in September to fix mess!”
The same division in Congress over the debt ceiling (or health care) will play out on the budget. The House Freedom Caucus essentially agrees with the president’s budget. If there’s any reluctance … it’s that the spending cuts are not deep enough. The argue that the federal budget must be balanced in a decade and it will take painful cuts to reach that goal. (So the other Republicans, such as Rep. Tom Cole, will need to find votes for their moderate course from Democrats to reach a legislative majority).
The tension over national spending priorities, historically, has impacted federal Indian policy before.
President Franklin D. Roosevelt initially sharply cut federal Indian programs as part of an austerity drive.
In the late 1920s and early 1930s spending by the Bureau of Indian Affairs doubled from 1928 to 1932 (following the publication of the Meriam Report about the failure of federal programs and declining health, education and just about social indicator for Native Americans. “Several past policies adopted by the government in dealing with the Indians have been of a type which, if long continued, would tend to pauperize any race,” the report said, calling the government’s efforts “ineffective.” But Hoover’s 1933 budget reversed that progress and cut the Bureau of Indian Affairs budget by 15 percent, dropping from $25.6 million to $22.1 million. Then a year later, in 1934, dropped another 13 percent to $18.7 million.
But it was Congress — not the president — that was stingy. But at a public hearing in 1938 tribal leaders from Wisconsin, Minnesota and Michigan complained about the “resistance of the government itself against any increased appropriations.”
However after the passage of the Indian Reorganization Act in 1934 spending did pick up and budgets increased.
After World War II the government again sharply cut spending in Indian Country. The 1948 budget declined by 9 percent, but that turned out to be a one-time hit. A year later the budget increased by more than 50 percent, to $62.1 million.
The figures were similar after President Richard Nixon announced the new policy of self-determination without termination on July 8, 1970. Nixon said, “we must begin to act on the basis of what the Indians themselves have long been telling us. The time has come to break decisively with the past and to create the conditions for a new era in which the Indian future is determined by Indian acts and Indian decisions.”
And the BIA’s budget reflected that idea. The budget increased by 18.5 percent in 1971, another 19 percent in 1972, and 23 percent in 1973.
But Nixon, like many Republicans, separates federal spending on the Bureau of Indian Affairs and the Indian Health Service from other programs that benefits Native people. President Lyndon B. Johnson’s Great Society programs such as the Office of Economic Opportunity opened up new channels for tribal innovation. For the first time tribal leaders were managing significant budgets without the Bureau of Indian Affairs. The agency’s director wrote Congress in 1974 that OEO was ineffective and an “old approach” that did not serve the poor.
This is a pattern that continues today. Many mainstream Republicans are supportive of appropriations for the Bureau of Indian Affairs or the Indian Health Service, but less so for other general programs that benefit Indian Country, such as the Comprehensive Employment and Training Act (signed into law by Nixon but ended by Ronald Reagan.)
A twist here: My first professional job as editor of The Sho-Ban News was funded by CETA in 1976. Tribes could use the money to create jobs — even at a tribal newspaper. And did so.
I had moved to Washington, D.C., before Ronald Reagan was elected in 1980 and he, like Trump, promised sharp cuts across the federal government. One plan was floated that would cut social programs by a third (shifting some of the money to states as block grants).
But Congress was on the other side of this equation and mostly ignored the president’s requests.
Yvette Joseph, Colville, who was working for the Senate Committee on Indian Affairs, compared the budget on Indian programs from 1968-1988 to similar government programs and found significant underfunding. She wrote: “Gwen Ifil did a story on my research when she worked for the Washington Post. It made it on the front page of the newspaper and was the impetus for Senator Dan Inouye seeking a billion dollar increase to the Indian Budget because we could show how significantly, the federal Indian budget had been been reduced under Ronald Reagan’s zero-sum budget policies. That year, we did not reach our goal, but were in fact able to increase the American Indian / Alaska Native budget by $750 million in FY 1989. It was amazing to be a part of this work.”
Obama is the exception to the rule
The Obama era is another exception, and on the upside. As former Assistant Secretary for Indian Affairs Kevin Washburn wrote in Indian Country Today: “In his first term, Obama increased the Indian Health Service budget by more than $800 million and steadily increased IHS funding by more than $1.2 billion, reaching $4.8 billion in total. Obama’s second term began inauspiciously with sequestration imposed by Congress in 2013, but the Indian Affairs budget at Interior for the Bureau of Indian Affairs and the Bureau of Indian Education nevertheless increased from approximately $2.3 billion to $2.8 billion before Obama left office, an increase of a half-billion dollars. These increases significantly outpaced inflation and produced real and significant gains for Indian country.”
Beyond that top-line there was another potentially significant action that’s being debated again: The Affordable Care Act. This law opened a door for the full-funding of the Indian Health Service because it recognized that health care delivery and insurance are not the same thing. So if more American Indians and Alaska Nations could bring insurance to their federal, tribal, or not-for-profit clinic, it could add significant resources to the entire system. It did this by expanding Medicaid, requiring tribal employees to have insurance, and by setting up a free insurance plan under the ACA. I think a lot more could have been done to promote this idea, but it’s all at risk now anyway. But it’s important to note that Medicaid works — especially in Indian Country. (I will be writing more about that next week as health care debate moves to the Senate). More than half of our children are now covered by that public insurance. And we still have thousands of people who are eligible but who have not yet signed up.
Medicaid is an entitlement. That is different from appropriations because Congress does not have to act for the money to be there. (Which is exactly why the Republicans want it to go away by changing the law.) Medicaid was the most successful part of the Affordable Care Act, both in Indian Country, and among the general population. Yet the House plan would cut spending by $834 billion over ten years and shift more of the cost of public health insurance to the states (leaving huge questions about where American Indian and Alaska Natives fit in).
Ok. Stay with me here. This will be complicated. Much of the budget cuts — including those that would impact Indian Country — are taken from the smallest part of the budget, domestic discretionary. All safety net programs (except for health and social security) total about 10 percent of the budget. The big bucks are found at Social Security (33 percent); Medicare, Medicaid, Children’s Health Insurance Program, and marketplace subsidies together total about 28 percent of the budget. Defense is 16 percent of the budget and Veterans programs at about 4 percent. And interest on the debt is 7 percent (thanks to low interest rates). But expect that category to grow as interest rates increase.
Domestic spending (except for health) has been declining since 2010. Depending on the final numbers in Trump’s budget, it’s likely that spending will drop to less than what was spent on 1962 on such programs. Before the Great Society. This is the part of the budget that includes Indian Country programs.
The point here is that the Congress could zero out domestic spending and there still would be a deficit.
The bigger problem is demographic. Two trends to consider. First the sheer size of the Baby Boom generation. And, second, humans are living longer than ever before. As Pew Research points out “about 10,000 Baby Boomers are retiring every single day, many of them not as well prepared financially as they’d hoped. The graying of our population will put stresses on our social safety net and present our elected leaders with a daunting challenge: how to keep faith with the old without bankrupting the young.”
Medicaid is a great example of this divide. Most of the news stories (including mine) focus on the health care aspects of this great program. Yet two-thirds of Medicaid — nearly $400 billion — is spent on the elderly and the disabled. About 60 percent of nursing home residents are supported by Medicaid and it’s the only program for seniors and for people with disabilities that pays for long-term care. Our discourse and the debate seems to ignore that.
Then our elders in Congress aren’t any better than those of us who write. Consider the illogic of the House Republican budget: It protects Social Security but it could wipe out funding for the older Americans who live in nursing homes. That same budget proposal cuts Medicaid for the poor both adults and children, but protects Medicare for those 65 years and older.
So who, exactly, are the constituents? (The only answer that is consistent: Tax cuts for the wealthy. That’s the point of the GOP health care plan.)
Also from Pew: “Today’s Millennials – well-educated, tech savvy, and underemployed – are at risk of becoming the first generation in American history to have a lower standard of living than their parents.” (It’s worth noting that young people in the United Kingdom turned out in record numbers and one of their top concerns was “austerity.”)
To be fair, Democrats haven’t come to grips with the cost side of this equation. There are just not enough taxes to pay for the growth of Medicare and Medicaid unless there is also a significant restructuring of the health care system. Still. The Affordable Care Act was just a start. A baby step at that. Get this: The Indian Health system is more in line with a health care system should cost than what is spent by the rest of the country. The gap that we so often complain about must be the country’s future. (As a reminder: According to the National Congress of American Indians, In 2014, the IHS per capita expenditures for patient health services were just $3,107, compared to $8,097 per person for health care spending nationally.)
So, yes, eventually, that means a single payer system of some kind. Sooner would be better than later. There is no other way to make the budget work.
Neither the Congress nor the White House is ready to take on these big issues. It’s much easier to cut smaller programs that matter to people, again, like those that serve Indian Country, and think the task is complete. It’s not.
So while it’s easy to blame the president for a terrible budget. The problem is much worse. And the solutions remain distant. The government is failing.
President Donald J. Trump announced last week that the United States was pulling out of the Paris agreement on climate change. That agreement includes every country in the world except Nicaragua, Syria … and now the United States.
The problems related to climate change are enormous — so the thinking goes — and the best course is a planetary response.
But nearly every government will be involved, including tribal governments.
Shortly after the president’s announcement four Native Nations announced their plans to support the Paris agreement.
“For hundreds of years the pollution based economy has degraded our home,” states Swinomish Chairman Brian Cladoosby in a news release. “We can no longer allow a failed system to continue to destroy the planet. The Paris Climate Change Agreement reflects the global consensus that we must act together and we must act now.”
The Standing Rock Sioux Tribe, the Quinault Indian Nation, the Swinomish Indian Tribal Community, and the Central Council of the Tlingit and Haida Indian Tribes of Alaska said they will fill the vacuum and take aggressive action to protect the places we call home. The tribes said in a news release that climate change touches all aspect of life, from those who have no voice, the salmon, buffalo, seals and polar bears, to those who are suffering the impacts of water loss, shoreline erosion, drought and loss of homelands and waters.
Across North American tribes see climate change, or global warming, as real, human-caused, and something that is changing life right now.
The Quinault Nation is already experiencing an increase in ocean storm surges that requires the Lower Village of Taholah be relocated because of flooding and a potential catastrophe if there were to be a tsunami.
Tribal President Fawn Sharp said: “We are talking about human lives here, and regardless of who is in office the fact is the federal government is our trustee … This responsibility is constitutionally mandated, and it’s not something the President or anyone else can wriggle out of.”
“Climate change is the definite direct cause of many other challenges as well, not just for us here at Quinault but for all citizens,” she said. “When a critically important glacier that’s thousands of years old totally disappears in a matter of a few years, it’s a sure sign that something’s wrong. And that something is man-caused climate change. The same goes for the massive algal blooms and the, warm areas and acidification problem in the ocean, the increased forest fire danger, slide and erosion problems, invasive species and low flows in our area rivers. These are very serious problems.”
Last year the Bureau of Indian Affairs awarded $8.7 million for tribal climate change projects for 63 tribes. But more than 200 tribes applied for the program and the Trump administration says it is ending all federal spending on climate change programs.
The president said that withdrawing from the agreement will support more energy resource development, including a revival of the coal industry. And a couple of weeks ago Vice President Mike Pence toured a working coal mine on the Crow Reservation promising new jobs. But that might be an impossible dream. The job losses in the coal industry have more to do with the low price of natural gas and changing global markets.
Standing Rock Chairman Dave Archambault II says his tribe is actively moving away from fossil fuels. “Indigenous communities around the world are among those being most quickly and severely affected by climate change. Regardless of the official position of the United States administration, we will continue to stand together in agreement with the Paris Climate Change Agreement,” Archambault said. “Our tribe is actively working to move away from fossil fuels and we continue to battle those who disregard our efforts to protect our water and lands.”
People living in Alaska are also already seeing impact of a warming planet. “Alaska tribal governments are living with the early but significant effects of climate change. Our traditional knowledge learned over millennia within our aboriginal lands leaves us with no doubt that immediate action to reduce the impacts of climate change is our duty as sovereign indigenous governments,” states Central Council of Tlingit and Haida Tribes of Alaska President Richard Peterson, “such, we will seek to participate in the Paris Climate Change Agreement.”
This might be a moment for tribes to engage in global diplomacy. In the news release, Sharp said: “When we get a seat at that table people in this country who understand the climate change problem might be able to convey their concerns through us at the international level. We might also be able to sign on to the Paris Agreement. We are looking into that possibility. So it is possible that even though the US has backed out of that historic agreement, the tribal governments from throughout the country could help fill the void,” said President Sharp.