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.
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
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