Latest attack on Medicaid also sabotages Treaty Rights, Indian health programs

Agency Says Indian Health Should Not Be Exempt From Medicaid Work Rules Because They Are ‘Race-Based’

Mark Trahant / Trahant Reports

The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.

A story in Politico Sunday raised the issue. It said “the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. ‘HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,’ according to a review by administration lawyers,” Politico said.

The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians. “Our political relationship is not based upon race.”

“The United States has a legal responsibility to provide health care to Native Americans,” Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation, told Politico. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.

Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).

But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.

Other states report similar increases. Kaiser Family Foundation found that in Arizona, one tribally-operated health system reported that about half of visits were by patients covered by Medicaid in 2016. And, an Urban Indian Health Program, reported that its uninsured rate at one clinic fell from 85 percent before the Affordable Care Act to under 10 percent.

Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). In Alaska more than two-thirds of those dollars are spent on private sector doctors and hospitals through purchased care for Alaska Native patients. And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.

A recent report by Kaiser Health News looked at Census data and found that 52 percent of residents in New Mexico’s McKinley County have coverage through the Medicaid.  That’s the highest rate among U.S. counties with at least 65,000 people. “The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program,” Kaiser reported. Most of McKinley County is located on the Navajo and Zuni reservations.


Kaiser Health News said Medicaid has opened up new opportunities for Native patients to “get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.”

However the growth of Medicaid is resulting in unequal care for patients in the Indian health system. The benefits in some states, including those that expanded Medicaid under the Affordable Care Act, are more generous. Other states not only refused to expand Medicaid and have been adding new restrictions such as requiring “able-bodied” adults to have their Medicaid eligibility contingent on work.

But the Indian health system — the federal Indian Health Service and tribally and nonprofit operated programs — are in a special case because there is a 100 percent federal match for most services. So states set the rules, but do not have to pay the bill. (Medicaid is often the second largest single item in a state budget behind public schools.)

Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.

Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.

A letter from the Tribal Technical Advisory Group for Medicare and Medicaid said American Indians and Alaska Natives “are among the nation’s most vulnerable populations, and rely heavily on the IHS for health care. However, the IHS is currently funded at around 60 percent of need, and average per capita spending for IHS patients is only $3,688.” The latest per person cost for health care nationally is $10,348 (totalling $3.3 trillion, nearly 20 percent of the entire economy).

The tribal advisory group said it is “critically important” that there be a blanket exemption for IHS beneficiaries from the mandatory work requirements.

A report in September by the Kaiser Family Foundation showed that the majority of American Indians and Alaska Natives on Medicaid already work, yet continue to face high rates of poverty. It said over three-quarters of American Indians and Alaska Natives are in working families, but that’s a gap of about 8 percent compared to other Americans (83 percent).

The Trump administration’s characterization of tribal health programs as “race-based” is particularly troubling to tribal leaders because it would reverse historical precedence.

A memo last month from the law firm of Hobbs, Straus, Dean & Walker said the Centers for Medicare and Medicaid Services “has ample legal authority to single out IHS beneficiaries for special treatment in administering the statutes under its jurisdiction if doing so is rationally related to its unique trust responsibility to Indians. Under familiar principles of Indian law, such actions are political in nature, and as a result do not constitute prohibited race based classifications. This principle has been recognized and repeatedly reaffirmed by the Supreme Court and every Circuit Court of Appeals that has considered it, and has been extended to the actions of Administrative Agencies like the Department of Health and Human Services even in the absence of a specific statute.”

Mark Trahant is editor of Indian Country Today. He is a Shoshone-Bannock tribal citzen. On Twitter: @TrahantReports Cross posted on Indian Country Today.

(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.)

 

Paul Ryan’s legacy includes ‘big ideas’ such as a voucher for Indian health

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House Speaker Paul Ryan said he will not run for re-election. His legacy includes a massive spending while calling for smaller government. (Photo by Vince Schilling / Indian Country Today)

 

Mark Trahant / Indian Country Today

Paul Ryan came to Washington to blow up Washington. He was first elected to represent his Wisconsin district at 28 years old. He campaigned over his career for a federal government that should shrink dramatically, spend far less, that taxes should be low, and the Republicans should be the party of big ideas.

Ryan announced Wednesday he will not run for re-election. He says he will complete his term as Speaker, but that’s not certain. He likely will face pressure to step down early, so another Republican can lead the party’s team into the November election. (More than forty Republicans have already announced their retirement contributing to the story about a coming Democratic wave.)

The Speaker leaves behind a different kind of legacy. He did get his tax cuts and substantial changes in the regulatory framework. But he also delivered more federal spending than ever. The deficit will hit $804 billion this year (a jump of 21 percent in a single year) and exceed $1 trillion by 2020. And, a new report by the Congressional Budget Office, says that a decade from now the total debt will be larger than the entire economy. “That amount is far greater than the debt in any year since just after World War II,” the CBO said Monday.

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The problem for Ryan, like Speaker John Boehner before him, is that the Republican majority is nearly ungovernable. The only way for Congress to function, to actually pass a budget, is to build a coalition that includes most Republicans, some Democrats, and work with a similar coalition in the Senate. That often means spending more money. That’s not the Congress — and the party of big ideas — that Ryan once had imagined.

And President Donald J. Trump has made that process worse. He caters to the bloc in Congress that cares little about actually governing. Chaos is fine. Big ideas, not so much.

Ryan proposed a major reform of government in 2010 long before he was elected Speaker of the House. It had his big ideas: Replace Medicare with direct payments to seniors who then could buy their own health insurance; turn Medicaid into a block grant to states; end employer-based health insurance; and dramatically cut government and taxes. There was no support for that plan.

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Then two years ago, as a new speaker, Ryan unveiled another plan for reshaping government. “A Better Way” included a reform of the Indian Health Service by “giving choices to American Indians.” His big idea was to have the government issue vouchers for Indian health, outside the system. “Not only will this give American Indians more choice in where they receive care,” the Ryan plan promised. “It will challenge Indian health facilities to provide the best care possible to American Indians.”

And of course that voucher system would have cost less. The Ryan plan also included a provision for a Native American Health Savings Account so individual tribal members could buy their own health care services  (Never mind a treaty sanctioned right.)

The basic premise of Ryan’s plan was that poverty is a problem because of government programs, thus, shrink the government, and poverty will go away. He told National Public Radio: “Let’s break up the welfare monopoly, instead of having just the welfare agency at the county level give people their benefits, which they basically rubber-stamp. … They don’t actually treat the person. Let other providers also provide these full-scale wraparound benefits. Let the Catholic Church do it. Let Lutheran social services. Let America Works, a for-profit agency that’s good at this.”

This is not a new idea; it was the same logic in the 1940s when Republican complained then that the Bureau of Indian Affairs was responsible for poverty, horrible living conditions, and general mismanagement. The solution over the next decade was the idea of “freeing the Indians” by terminating the federal responsibility, Termination. And a hundred and nine tribes were terminated, representing some 12,500 tribal members, and the end result was poverty conditions that were far worse.

That’s likely what would have happened again had Ryan’s “choice” approach to Indian health became law.

Ryan’s, “A Better Way,” once again called for turning Medicaid over to the states. “Instead of shackling states with more mandates, our plan empowers states to design Medicaid programs that best meet their needs, which will help reduce costs and improve care for our most vulnerable citizens.”

Medicaid has become a significant revenue source for the Indian health system. Under current law, Medicaid is a partnership between the federal and state governments. But states get a 100 percent federal match for patients within the Indian health system. Four-in-ten Native Americans are eligible for Medicaid insurance.

Rep. Tom Cole, a Republican from Oklahoma and a Chickasaw Nation citizen, said Ryan will be missed in Congress. “Paul Ryan is a visionary leader, a committed conservative and a master of the legislative process. His tenure as been marked by exceptional accomplishments – the largest tax cut and reform in a generation; the most regulatory reform for any Congress in the modern age; the most substantial defense buildup in 15 years; the end of the individual mandate in Obamacare – and a host of other important legislative accomplishments,” Cole said.

“He is not only the best Speaker I’ve had the opportunity to serve with, he’s also the finest person. Even Paul’s political opponents readily concede that he’s a person of absolute integrity, deep sincerity and of profound decency.”

Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. On Twitter: @TrahantReports (This story is cross posted with Indian Country Today.)

#NativeVote18 The election math behind Paulette Jordan’s campaign in Idaho

Paulette Jordan is one of seven Native American candidates running for statewide office — and one of two Native women running to a lead a state

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Paulette Jordan: The issues “that tribes push forward are good for everyone.” Jordan is running for governor of Idaho and has a May 15 primary. (Official photo)

Mark Trahant / Indian Country Today

A couple of weeks ago I was driving across the border into Idaho from Montana. I stopped the car and took a picture of the “Welcome to Idaho” sign. I thought: It would be cool if that sign read, just under the Idaho greeting, Paulette Jordan, Governor.

Jordan, Coeur d’Alene, is running as a Democrat in what is perhaps the reddest, most Republican state in the country. So it’s an impossible task, right?

No. Let’s do the math.

The first part of that equation is done: Running. So many talented people survey a political campaign and then, for whatever reason, pass. But the inviolate rule of politics is that you must run in order to win. So that is a huge step.

Jordan is one of seven Native American candidates running for statewide office and one of two Native women running to a lead a state, (something that has never been done before.) She will be the first of those candidates to face voters and she will need to win a contested Democratic primary on May 15. A date that’s coming up fast.

One of the most important reasons for Native American candidates is the aspirational aspect. It’s a way for young people to see a future, (one that is far more important than just politics.) During a recent trip to Fort Hall, and the Shoshone-Bannock Tribes, Jordan took time out to visit the students. She also met with community members where she said on KPVI 6 that the issues that “tribes push forward are good for everyone, all of humanity. So when we talk about education in tribal communities, it’s the same for Hispanic communities, it’s the same for every single district up and down this state.”

Jordan is running against A.J. Balukoff, who, unlike Jordan, can use his own wealth to fund his campaign. (Something he has already done to the tune of $175,000.) Four years ago Balukoff was the Democratic nominee for governor and lost by a wide margin.

Idaho has an odd primary. The Republicans limit their ballots to anyone except those who publicly claim party membership. But anyone who is “unaffiliated” or independent can pick up a Democratic Party ballot on election day. Because Idaho is such a conservative state, most voters sign up with the Republicans. Four years ago more than 155,000 voters did just that, while only 25,638 voted in the Democratic primary.

This is actually an advantage for a candidate like Jordan. She only needs to find a few thousand votes (my bet is there will be more interest than four years ago.) So, let’s say that means the primary winner will earn at least 25,000 votes. That’s a plausible number in a season where nontraditional candidates are getting a second and third look.

There is only one county in Idaho that regularly votes for Democrats: Blaine County. That’s Sun Valley, Ketchum, the Wood River Valley. Think lifestyles of the rich and famous. Hillary Clinton had a two-to-one margin over President Donald J. Trump in Blaine County. Jordan must do well here.

Votes from Idaho’s five reservations could help, too. The numbers are small, but if they are one-sided, say 100, 200, 300 votes to a handful, it could give her an edge. Especially in a primary.

Jordan should also poll well with younger Democratic voters and with Hispanics. These two constituent groups are growing in numbers and importance. Well, sort of. Idaho is a young state: There are more people under 18 than any other demographic group. And younger voters from 18 to 25 are a relatively small cohort at roughly 155,000 people. But in the last elections this group increased its turnout rates, so there is a potential upside. Hispanics now account for 12 percent of Idaho’s population and, according to Pew Research, are some 80,000 eligible voters (far more than what would be needed in a primary election.)

The math is there. It’s possible.

What about Jordan’s message? Is she connecting with primary voters? That’s a much tougher call. She has to reach voters in a state with two time zones and a distinct geographic divide. I often joke that Idaho is the only state with three capitals: Salt Lake City, Spokane and Boise. Each major city has its influence over regions of the state.

Recently Jordan’s team made a rookie mistake adding the word “ever” to an email about her being the only Democrat elected in North Idaho. This took away from an important message: Jordan won re-election to the Idaho House two years ago in a terrible cycle for Democrats. Her campaign convinced voters who would not normally vote for a Democrat. This should be said over and over as a reason why Idaho Democrats should vote for Jordan.

And after that? The toughest hill to climb come after the primary. Jordan would then need to make her case to Idaho’s deeply conservative Republican voters. But if there is ever a year to do just that, it’s this one.

But first the May 15 primary is coming fast. That’s a hurdle that Jordan needs to clear first.

Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. On Twitter: @TrahantReports (Cross-posted on TrahantReports)