What’s next? Schoolhouse Rock, funding inequity & making sure law is followed

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How a bill becomes law, School House Rock style.

Mark Trahant / Trahant Reports

Senate Republicans campaigned against “Obamacare” for seven years. Yet there was never an alternative that had support from a majority of their own party.

The problem is simple: Many (not all) Republicans see health care programs that help people — the Affordable Care Act, Medicaid, etc. — as welfare. Others look at the evidence and see these programs that are effective: Insuring people, creating jobs, supporting a rural economy, and actually resulting in better health outcomes. Evidence-based success stories.

Of course Indian Country is squarely in the middle of this debate. Congress has never even considered, let alone acted, to fully fund Indian health programs. But the Affordable Care Act basically defined the Indian Health Service (and tribal, nonprofit, and urban operations) as health care delivery vehicles. And one way to pay for that delivery was by providing health insurance through an expanded Medicaid, no-cost insurance that tribal members could get through exchanges and employers. The ACA with all its faults sets out a plan to fully fund the Indian Health Service.

That’s the challenge now. Making sure that every American Indian and Alaska Native has insurance of some kind. Because of what happened (or, more accurately, what did not happen) in the Senate this week the money remains on autopilot. If you are eligible, the funding is there.

Yet the uninsured rate for American Indians and Alaska Natives remains high, as a Kaiser Family Foundation report noted a couple of months ago. “The Affordable Care Act’s Medicaid expansion provides an opportunity to enhance this role by increasing coverage among American Indians and Alaska Natives and providing additional revenue to IHS- and Tribally-operated facilities,” The Kaiser report said. “In states that do not expand Medicaid, American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities.”

This is a problem that will grow because of congressional inaction. Nineteen states including Oklahoma, South Dakota, Wisconsin, Wyoming, Idaho, Kansas, Nebraska, Florida, and Maine, have rejected Medicaid expansion. So a tribal citizen in those states gets fewer dollars for healthcare than some Indian health patients in North Dakota, Montana, Alaska, Arizona, New Mexico, or any other state that took advantage of the expansion.

As Kaiser notes: “American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities in states that do not expand Medicaid. In states that do not expand Medicaid, many poor adults remain without an affordable coverage option and will likely remain uninsured. Similarly, IHS providers in these states will not realize gains in Medicaid revenue.”

This is the what’s next? How does the country manage this divide, especially in Indian Country. (And, just as important, we also need to see the gap measured. What are the differences in treatment and outcome between Montana and Idaho or North Dakota and South Dakota? Data, please.) This is critical because under current law, third-party billing (including Medicaid) remains at the local service unit. There is now a funding inequity that needs to be addressed by state legislatures. Recently Rep. Tom Cole, R-Oklahoma, said he knows these states and they won’t expand Medicaid. (Back to the welfare, thinking.) I hope not.

The Trump administration recently made it easier for states to get a 100 percent reimbursement for Indian health patients (enticing South Dakota to reconsider joining the ranks of expansion states.)

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So it’s possible, and a challenge, to make sure that the law is implemented, and that innovation continues. The ACA gives much power to an administration to a state to change the rules. You will see a lot of that now. Indian Country needs to keep a sharp eye on that process and raise objections if the result is unsatisfactory.

So why did the Senate bill fail? Sure, full credit should go to the heroic stands by Sen. Susan Collins, R-Maine, and Sen. Lisa Murkowski, R-Alaska. From the very beginning of the debate they were the party advocates for a Medicaid system that does produce better healthcare outcomes. And Alaska is a great example of that because nearly a quarter of the state’s population is served. This is how it should be across Indian Country and the nation.

And, of course, there was Sen. John McCain’s dramatic late night thumb’s down. The Arizona Republican was a no vote when it counted.

But that’s not why the bill failed. Fact is it’s remarkable that such nonsense got so far. It’s inconceivable that a plan was written at lunch the day before the vote. The bill failed because the Republicans, as a group, do not know where they want to lead the country on health care. They know they don’t want Obamacare (even though it’s based on conservative, market-based ideas). They sure as hell know they don’t want universal health insurance, either Single Payer such as Medicare for All or a government health service like Great Britain’s.

Yet when I listened to the debate yesterday so many of the complaints about insurance and costs could be solved by such a path. The problem here is that the United States made a huge mistake with employer-based insurance and that left out people who work for themselves or small businesses. The only way to fix that is a large pool of people spreading the costs, so that healthy people pay for sick people. The ACA tried to do that with mandates. Most countries accomplish that goal with universal insurance.

Another factor in the Republican plans — and another reason for the bill’s failure — is their absolute certainty in a market-based solution. Healthcare delivery and free markets do not play well together. The proof of that is simple: How much is an empty hospital bed worth to a business? Yet that should be the goal. And how much is it worth to a hospital-as-a-business to help a patient not need surgery? What market incentives are there for people to eat better?

Seven years ago, when I started writing a lot about health care, I did so because I saw the Indian Health Service as a fascinating example of government-run and managed healthcare. As we began this debate, I thought, let’s figure out what works and what needs work.

But I was way wrong. IHS is no longer only a government-run system. Much of the agency is now a funding mechanism for tribal, nonprofit, and urban operations). And that’s where so much of the innovation and excellence in Indian health exists. We need to more more about what’s working and why. Yet Congress (and the public narrative) continue to think of an IHS that no longer exists. At least entirely.

This might be a moment to focus on the latter part of what the agency does, improving the flow of funds, and adding more of our people to insurance rolls. Here’s the thing: We cannot do anything about universal health care. At least not yet. But we can have universal health care for Indian Country. It’s a huge task, but the ACA remains the law and it’s only a matter of execution (not a policy debate).

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Third-party collections now account for about $1.8 billion out of the IHS’ budget. The dollars Congress appropriates is $4.8 billion. The third-party portion can grow through more insurance coverage. The appropriations side will require hard fights in Congress and the outcome is uncertain.

Back to the Senate. Texas Sen. John Cornyn, a member of the Republican leadership, joked that perhaps it’s time for a new way of doing business. “I guess we ought to go back to Schoolhouse Rock,” he said. That’s been a clear message from both Republicans and Democrats throughout this messy project. Get a bill. Hold hearings. Let a committee debate alternatives. Then let the bill come to the floor. Regular order. Schoolhouse rock.

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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Humor day in the Senate; Scary single payer & a halt to Alaska energy projects

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Single payer? A vote today on an amendment that Montana Sen. Steve Daines hopes will pout Democrats on record for such a scary idea. (YouTube photo)

Mark Trahant / Trahant Reports

Today is humor day in the Senate. But at least the healthcare debate will go on and on without a conclusion. And no matter what happens today and Friday there is still a long way to go.

The Senate has at least ten more hours of official debate on a House bill that’s been substituted with language that neither we nor senators have yet seen. (Leading to great theatrics by the Senate Democrats who said they’d offer no more amendments until there was an actual bill with, you know, like words in it.) But even without an actual bill Democrats sent the framework of the so-called “Skinny Repeal” to the Congressional Budget Office for a score and the answer is more of the same, the number of uninsured would increase from 28 million to 44 million in a decade.

Nonetheless by Friday there will be some sort of proposal that’s designed to get 50 votes so the legislation will go to a conference committee with the House. This Skinny Repeal strips the individual mandate (causing a mess in insurance) but leaves Medicaid alone. For now. Basically this means the House will get its way and senators will be forced to vote for that approach or nothing. It’s a risky strategy when the Republican majority is so slim. Actually in both houses.

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Via a Tweet from Pat Bagley, editorial cartoonist at The Salt Lake Tribune.

Today the Senate will consider a proposal for universal health care, Medicare for all. Consider is not the right word here because the proposal is already doomed. But Montana Sen. Steve Daines wants Democrats on record voting for this scary, scary idea. But as Pat Bagley, the cartoonist for The Salt Lake Tribune tweeted yesterday, not one country that’s gone down the single payer path has reversed course. It’s the United States that is the outlier with our incomprehensible health care “system.” Even Bernie Sanders, who is for Medicare for All, said he won’t vote for this amendment because it’s a ruse.

Daines won’t be voting for his own amendment either. That’s not the point. Daines told the Helena Independent Record Wednesday night “It’s time for every senator to go on the record on whether or not they support a single-payer system.”

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So, while we are at it, let’s be clear about what Single Payer could do for the Indian health system. Indian Health Service funding would jump by at least 40 percent in a Medicare for all approach. The agency (and the tribal and nonprofit operations) would be equal with other healthcare providers; getting paid for every patient instead of worrying about appropriations or tracking down insurance payments from companies, Medicaid, and other third-party payers. So it would be a financial boom. Big time.

But as I said: Medicare for all is really not on the table. The Senate vote is just supposed to frighten Democrats. So. Be careful. Or Congress will give you health care. Aye.

Speaking of bad jokes, I laughed at the Trump administration’s threats to Alaska Sen. Lisa Murkowski. According to the Alaska Dispatch News, Interior Secretary Ryan Zinke warned Murkowski that Alaska energy projects could suffer because of her vote (and her leadership) against the GOP health care proposals. (I do think she could lose her Energy Committee chairmanship, but that, too is a silly move by Republicans in a narrowly divided Senate.)

So the Trump administration that wants Energy for All is telling a Senator who’s pro-energy that Alaska development is in trouble because she’s against their destruction of health care. Now that’s some weighty logic. Nonetheless Alaska Senator, Dan Sullivan reported this threat with a straight face. He told the Alaska Dispatch News that it’s a “troubling message … I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop.”

So oil companies be warned. You could be punished. As will we all. Be afraid. And remember universal care for all is up today.  So keep the children away from the Senate TV.

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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Did you hear the one about the Senator raising concerns about Indian health?

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Sen. John McCain votes yes on the Senate’s Motion to Proceed, then attacks the process, only to vote yes on the first bill that failed his test of regular order. Quite a day. (Photo via Senate video)

Mark Trahant / Trahant Reports

The Senate is now going through 20 hours of debate on a House Resolution 1628 to repeal and replace the Affordable Care Act. But the House bill was stripped of every word except the title. Now the idea is to come up with the right language to reach 50 votes (so when like the Motion to Proceed, Vice President Mike Pence can break the tie and vote yes).

The first proposal, Senate Amendment 267, had all sorts of problems on the floor. The Senate’s Parliamentarian ruled that parts of the bill did not get a score from the Congressional Budget Office and other parts violated budget rules. So 60 votes, not 50 were needed for this version to pass. But the Republican leadership wasn’t even close to 50 votes — Nine Republicans voted against it.

Including Arizona Sen. John McCain who just a few hours before said he wasn’t happy with any of the legislative proposals. Think about this. He interrupted his cancer treatment (taxpayer funded health care) then gave a stirring speech about the break down of civility in the Senate. He said he would vote against the bills as presented, and then, votes yes anyway. Quite a day.  And so much for his words. I’ll admit: I thought McCain meant what he said.

Then at least McCain earned respect and praise from President Donald J. Trump. He tweeted: Thank you for coming to D.C. for such a vital vote. Congrats to all Rep. We can now deliver grt healthcare to all Americans!”

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Now that’s something — as is the process itself.

This week’s Senate debate on TV will be exciting. Seriously. There will be many hours ahead of members speaking to an empty chamber about why the Affordable Care Act works — or why it should be repealed. (And lots of images of staff shuffling papers on camera.) Great theater, right? Then every once in a while (about the time paint dries) there will be a call for a vote and the dramatic calling of each senator’s name for a vote.

There are two main versions that will surface soon. The first is a repeal — or at least as much of a repeal as possible with 50 votes — that’s been proposed by Sen. Rand Paul, R-Kentucky. That proposal has little chance.

Then later in the week, Senate Majority Leader Mitch McConnell, R-Kentucky, will propose an amendment that they’re calling a “Skinny Repeal.” It would eliminate some taxes, a few more regulations, but leaves Medicaid alone. It’s supposed to be something for both moderates who want to leave Medicaid alone and for conservatives who want a repeal. Ha! And remember: If this version passes the Senate the bill will move to a conference committee with the House. That’s where the Medicaid cuts will come back. This is a phony negotiating plank.

As the debate unfolds, the Senate is in a way making the case for why we need Native Americans in the legislative process. There will be all kinds of talk about what the law does to Americans, to the poor, to taxpayers, to just about every constituent group in America. What’s really needed though is for one Republican senator to explain about the Indian Health system and what havoc all of these proposals would wreak. (Last week several Democrats did just that.) One majority party senator could say the Indian Health Service has never been fully funded, despite treaty promises, so why strip millions of dollars away? Or ask about Indian children when more than half are covered by Medicaid. Or show why Indian Country needs the jobs that have been created (and will be lost) by these proposals. Better yet: One Native Senator could use data to prove that Medicaid works.

Indian Country deserves to be in this debate. Alaska Sen. Lisa Murkowski has been a key opponent of the Republican leadership’s health care legislation. It’s mostly about Medicaid. I am sure that it’s also due to her support of the Alaska Native medical system. She gets it.

But Murkowski will pay a political price for her votes, at least in a primary election. But then she’s gone through that before. And won.  Not long after the Senate vote on the Motion to Proceed, the Alaska Republican Party said Murkowski abandoned them. Party chairman Tuckerman Babcock said the “repeal of Obamacare is non-negotiable.” (Funny: I feel the same way about the Senate alternatives.)

And so the party talks about possible consequences for Murkowski. Babcock said her vote put at risk new oil drilling in the Arctic National Wildlife Refuge (would that be true) and said her Energy Committee “chairmanship could be at risk.”

And President Donald J. Trump tweeted Wednesday morning: “Senator of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!”

So will there be punishment? I would not be so sure. Remember the Republican majority is thin. As I reported last week: Three senators switch sides and it’s a new Senate.  Two are already really, unhappy. So the way to make it three is for Republicans to continue to attack their own members.

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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Senators say the darndest things … before the vote

Senators say the darndest things … a few of their own words before the vote.Bottom line: no matter which version is the one to surface, there is no way to take $800 billion out of a health insurance system and make it stronger. Indian Country will suffer.

I have written past posts about why this is a terrible idea and how it will impact Indian Health System at trahantreports.com

#indianhealth #medicaid #failedlogic

Senate is blind: Healthcare vote minus a draft, public hearings, or common sense

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Senate Majority Leader Mitch McConnell (R-Kentucky) and whip John Cornyn (R-Texas) brief the press on the upcoming vote on a repeal and replacement for the Affordable Care Act. (Photo via McConnell Press Office on Twitter.)

Mark Trahant / Trahant Reports

Here we go again. Another week and the United States Senate is ready to vote on legislation to remake the entire healthcare system, including Indian health. The Senate will do this without a draft circulated for debate, public hearings, or common sense.

So what does the replacement bill look like at this point? I have no clue. Neither do the 100 senators who will make that call. As Sen. John Cornyn (one of the managers for the bill) put it: Knowing the healthcare plan ahead of the vote is a “luxury we don’t have.”

Here is what President Donald J. Trump tweeted over the weekend: “The Republican Senators must step up to the plate and, after 7 years, vote to Repeal and Replace. Next, Tax Reform and Infrastructure. WIN!”

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So there will be a vote on legislation to at least repeal the Affordable Care Act. “We have decided to hold the vote to open debate on Obamacare repeal early next week. The Obamacare repeal legislation will ensure a stable, two-year transition period, which will allow us to wipe the slate clean and start over with real patient-centered healthcare reform. This is the same legislation that a majority of the Senate voted to send to the president in 2015. Now, we thankfully have a president in office who will sign it. So we should send it to him,” said Sen. Majority Leader Mitch McConnell, R-Kentucky.

But a straight repeal is complicated by Senate rules. The Senate Majority Leader is relying on the process of reconciliation (essentially matching the legislation to an existing budget) because that only requires a majority, or 50 votes. Most bills need 60 votes to stop a filibuster. Last week the Senate parliamentarian, Elizabeth MacDonough, said that defunding of Planned Parenthood, abortion coverage, and restrictions on insurance coverage does not meet that test and still required 60 voters. Same thing for the Alaska or rural exception, it’s a no go. But Senate Republicans were quick to say that any draft language (which is still missing from action) could be rewritten. Or Republicans could overrule the parliamentarian on the floor which would cause all sorts of future problems governing.

The Senate’s parliamentarian is a great example of the institutions of Congress pushing back on the Republican proposals. I don’t think it’s ideology; it’s incompetence. (As I have written before there is a conservative approach to healthcare reform, but we have not seen that yet.) The Congressional Budget Office said last week that the big ticket in this debate is Medicaid. Remember the proposals in the House and Senate go far beyond just repealing the Affordable Care Act because the proposals would fundamentally restructure Medicaid.

According to CBO: “By 2026, spending for that program would be reduced by 26 percent … About three-quarters of that reduction would result from scaling back the expansion of eligibility enacted in the Affordable Care Act (ACA). In 2026, for people who are made newly eligible under the ACA (certain adults under the age of 65 whose income is less than or equal to 138 percent of the federal poverty level [FPL]), Medicaid spending would be reduced by 87 percent, from $134 billion to $17 billion—mainly because the penalty associated with the individual mandate would be repealed and the enhanced federal matching rate for spending on that group would be phased out. As a result of the reduced matching rate, some states would roll back their expansion of eligibility and others that would have expanded eligibility under current law would choose not to do so. All other federal spending on Medicaid in that year would be reduced by 9 percent, from $490 billion to $447 billion.”

This is what pays for the tax cuts in the Republican plans.

Rolling back Medicaid expansion and the traditional Medicaid program would significantly reduce funding for the Indian Health Service.

Last week the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health, wrote McConnell because one of the Senate bills, the Better Care Reconciliation Act of 2017, would change the formula for funding Indian health patients. The three intertribal organizations call the proposal a “radical departure from over 40 years of federal policy” and it “should not be undertaken without nationwide tribal consultation.” The bill’s language reverses a policy where states get a 100 percent reimbursement for patients who get services from the Indian health system. This change, the intertribal organizations said, would “ take away this unique incentive for states to work with tribes to create Medicaid innovations that best support the Indian health system.” States could create new rules that could ignore Indian health as a partner and create new barriers that would sharply reduce funding.

North Dakota Sen. John Hoeven, who is chair of the Senate Indian Affairs committee, said the changes would provide “more choice and competition in our health care system, while at the same time insuring that low-income individuals have access to healthcare coverage” via Medicaid or tax credits.

The key thing here: Native Americans could take their insurance (and the state Medicaid dollars) to another provider, reducing funding for IHS. (Competition, you know.)

It would be one more costly strike to an Indian health system that’s already underfunded.

Hoeven said a draft Senate bill also would end the requirement that tribes purchase insurance for employees. Again, the result would be less money for the Indian health system. (And, as the three intertribal organizations point out, this would be done without any tribal consultation.)

Then again the Senate and House bills are designed to strip money from the health system period. And Medicaid is such a rich target. The Kaiser Family Foundation estimates the total cost to states under the Better Care bill is $519 billion.

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Back to the math and this week’s vote. There are 100 members of the Senate. The 48 Democrats are certain to vote no. And of the 52 Republicans, it’s unlikely Sen. John McCain would leave his cancer treatment in Arizona to vote on a motion to proceed (the opening of the debate and the consideration of amendments). That leaves 51 votes. Sen. Susan Collins of Maine is a certain no because she objects to the attacks on Medicaid. That reduces the number to 50 (and 49 no votes). There are lots of questions about Senators Lisa Murkowski of Alaska, Rob Portman of Ohio, and Shelley Moore Capito of West Virginia. Capito tweeted: “I will only vote to proceed to repeal legislation if I am confident there is a replacement plan that addresses my concerns.” And Portman said he’ll review whatever bill comes up for a vote. Murkowksi told CNN: “I don’t think it’s asking too much to say give us the time to fairly and critically analyze these numbers. And if you say, well, CBO numbers don’t matter, let’s look at the numbers that you don’t think matter. But it really does make a difference. And these numbers that we’re talking about, these are men and women, these are our families that are being impacted. So let’s please get it right.”

Does that sound like three no votes? Right now, I’d only count all three as firm maybes. Then only one needs to be the no.

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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The Alaska Fix: How the Senate could fix healthcare & govern in the Trump era

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

Mark Trahant / Trahant Reports

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

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

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

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

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

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

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

Enough.

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

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

A new Senate independent bloc could work the same way.

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

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

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

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

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

It’s time for new management in the Senate.

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

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And just like that … it’s back to square one for healthcare, budgets and taxes

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Trahant Reports

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

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

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

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

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

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

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

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

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

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

Buckle your seat belts. — Mark Trahant

 

 

 

 

 

Senate Republicans will have to wait for John McCain to return after surgery

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

Trahant Reports

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

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

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

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

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

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

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

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

 

 

 

 

Alaska’s special deal in Senate health bill isn’t enough to fund successful Medicaid

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

Mark Trahant / Trahant Reports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Lies we’re told: Strip millions (billions) from health care & call it better

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

Mark Trahant / Trahant Reports

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

The answer is you cannot.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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