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.)

 

What experiences should an IHS director have? In my book: Medicine & Medicaid.

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Robert Weaver, Quapaw, was President Trump’s first choice to head the Indian Health Service. His nomination was withdrawn last week. (Weaver Group photo)

Mark Trahant / Trahant Reports

Who should run the Indian Health Service? Not “who” exactly, but what kind of leader? What kind of skills and experience would be the most useful?

This question is more important than ever. The Trump administration has withdrawn the nomination of Robert Weaver to lead the agency. Weaver, a member of the Quapaw Tribe of Oklahoma, has a background in private insurance working with tribes to set up plans to cover tribal members. But his nomination was sidetracked after The Wall Street Journal reported serious misstatements on his resume both in terms of education and work experience. So last week a representative of the Department of Health and Human Services said: “Mr. Weaver is no longer the Administration’s nominee for Director of the Indian Health Service.”

For his part, in a letter to tribal leaders, Weaver said the president has been an “ardent supporter of fixing Indian Health throughout this process.” And he said “he will fight to give voice to the change needed at IHS until the mission is complete … the delivery of timely, high healthcare for Indian Country no matter where you live.”

But Weaver went further in an op-ed for Native News Online. He said he wanted to be IHS director for the “sole purpose” of being a part of the solution.  “… many Tribes supported me from around Indian Country. Why? I think because they know that babies are being born on IHS hospital floors. They know that people are dying of heart attacks because the crash carts at their IHS hospitals don’t have the proper medications. They know that some of the places where they live don’t have running water. They knew that I was the right person to start addressing these abuses because I’ve been an unwavering advocate for our peoples’ health and wellness for the past decade and I was willing to meet and listen.”

The key word is “mission.” The mission of the Indian Health Service has become so distorted that even policy makers cannot or will not articulate the challenges ahead. The discourse about the Indian Health Service continues to be about a federal agency that delivers health care to American Indians and Alaska Natives. And, within that story, there are so many clinics and hospitals that only require more order and funding in order to carry out even basic health care. The system is failing. Babies being born on hospital floors. The usual.

Only the IHS story is much more complex. We need to think differently about the IHS. (As I have written before: I would even change the name to the Indian Health System to reflect what the agency now does.)

Most of the Indian Health system is managed by tribes or non-profits. There are 26 IHS hospitals, and 19 tribal or or non-profit hospitals. But, and this is huge, there are 526 clinics, health centers and stations run by tribes and non-profits and only 91 by IHS. 

Hospitals Health Centers Alaska Village Clinics Health Stations
IHS 26 59 N/A 32
Tribal 19 284 163 79

 

The federal role is changing. The Indian Health Service still does operate health care delivery. And it sets standards. But it’s also a major funding source — and even that is misleading because it is Medicaid, not the Indian Health Service, that’s often the largest source of funding for tribal and non-profit facilities.

This is a critical difference because Medicaid has been under attack by the Trump administration from day one. The administration claims it’s protecting the Indian Health Service budget … all the while proposing deeper and deeper cuts into Medicaid.

There is a disconnect. And it’s visible in the budget. The line item for “collections,” that is money from Medicaid, Medicare and private insurance, is roughly $1.2 billion. That’s a number that has not changed much despite a huge expansion of Medicaid under the Affordable Care Act. This number should have been growing dramatically. But it’s not because it does not capture the amount of dollars collected tribes and non-profits, only the money that goes into IHS direct services.

This is misleading because when you talk to tribal and non-profit administrators, as I have, there is a different story to tell. Medicaid is now more important to local budgets than the IHS itself. 

The expansion of Medicaid also explains a lot about the shortages within the Indian health system. The federal Indian Health Service will take Medicaid funds, but it’s not growing the pot. Tribes and nonprofits have done that. And so there is more money for Indian health in states that have expanded Medicaid.

This is not the Indian Health Service we grew up with. And the next director of the Indian Health Service needs to acknowledge this complexity and own the new story. If I had my way: the next IHS director would have a solid background in medicine and Medicaid.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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First, do no harm. What it takes to manage the Indian health system

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Robert Weaver, Quapaw, is President Donald J. Trump’s nominee to head the Indian Health Service. Weaver’s background is insurance, not health care delivery. (Weaver Group photo)

 

Mark Trahant / Trahant Reports

What qualifications are needed to manage (and possibly reform?) the Indian health system? It’s Indian Country’s largest employer with more than 15,000 on the payroll and many, many more people who work in health care for tribes, non-profits and other related agencies. The IHS budget is $6.1 billion. Yet it’s also the least funded national health care delivery system, operating in a political atmosphere where critics ask, why can’t it do more?

The Wall Street Journal published a story last week that raised questions about Robert Weaver, the Trump Administration’s nominee to head the Indian Health Service. The Journal challenged Weaver’s history at St. John’s Regional Medical Center in Joplin, Mo., from 1997 to 2006. However it quoted Jennifer Talhelm, an HHS representative, saying “any suggestion Mr. Weaver is unqualified to run IHS is a pure act of character assassination.”

Weaver is a member of the Quapaw Tribe of Oklahoma.

A few facts: Weaver will be the least educated director of the Indian Health Service ever. If confirmed, Weaver will the tenth permanent director. All but one prior to Weaver have been physicians, most with multiple degrees in public health, science, and health administration. One former director, Robert McSwain, was not a medical doctor, but he was a longtime health manager and holds a Master of Public Administration from the University of Southern California. On his CV, Weaver lists his education at Missouri Southern State University in International Business with an emphasis in Marketing and Accounting; Minor in Spanish; Minor in Vocal Music & Piano. However the Journal reported that he was seeking a degree and did not graduate.

Weaver’s background is insurance. In a September 2016 profile in Native Oklahoma magazine, Weaver said, “We have Native Americans who are brilliant — geniuses — at gaming, but where are the Native American geniuses at insurance? It’s the second-largest cost we pay other than payroll. Yet it just goes to the wayside.” He told the magazine that his business saved the Quapaw Tribe more than $5 million a year.

“I try to be a translator for tribal leaders to understand this convoluted, difficult-to-understand, most of the time full of lies and deception industry, into ‘this is what it is. This is what your choices are.’ I get it,” he told Native Oklahoma.

Perhaps the Indian Health Service should be led by someone with an insurance background. It would surely help if the agency could come up with a better funding model, including a mix of insurance funds (third-party billing in IHS-speak.)

But there are three problems that ought to be clearly addressed through the Senate confirmation process.

First there is the problem of scale. Weaver would jump from managing a $10 million a year small business — one where he can hire and fire at will — to running a $6 billion agency where personnel decisions are made by folks higher in the chain of command at the Department of Health and Human Services or even as a favor to a United States Senator. And firing? Just one such action could take up more time than the three years left in this administration. And that’s the easy stuff. The agency’s operations are complicated by Congress, law, regulation, tribal relations, the Veterans Administration, Medicare, Medicaid, and private insurance.

To his credit, Weaver has been outspoken about the underfunding of the Indian health system. (Question: Will he say so again in his confirmation testimony?) In a paper he wrote a year ago, Weaver said: “Healthcare is a treaty right for all Native Americans. The method of delivering healthcare for Native Americans is the Indian Health Service system established through the Federal Government. The Federal Government allocates funds to the IHS system each fiscal year. This allocation has been and continues to be inadequate to meet the healthcare needs of Native Americans. Currently it is underfunded by thirty billion dollars annually.”

That figure of $30 billion would eliminate the funding disparity for Indian health. (The National Congress of American Indians has published a plan to make that so over a decade.)

The second problem is how to articulate the Indian health story. This is a problem of “duality,” two competing ideas. On one hand you have some significant health and management problems such as those identified in the Great Plains by The Wall Street Journal. On the other hand you have a system that is innovative and includes models of excellence (such as clinics in the Pacific Northwest or the Alaska Native Medical Center.) One story is told. The other less so. I am convinced that a fully-funded system will only happen when we tell both stories. The narrative of failure is not an incentive to invest more money.

The third problem is the Affordable Care Act and Medicaid. Weaver wrote that the law works for Native Americans but overall it was a failure. “We now see that it did not provide health insurance for the forty million uninsured Americans identified as the target market in 2008, it is not affordable for those who were pulled into the ACA system, and the out of pocket maximums associated with the plan effectively make access to healthcare unattainable,” he wrote. The first part of that sentence is factually incorrect. The uninsured rate dropped from 20.5 percent in 2013 to 12.2 percent in 2016, a 40 percent decline. You can argue about the cost of that insurance, but it’s complicated because the ACA required minimum standards for insurance, covering such things as women’s health. All of the Republican plans are designed to save money by getting rid of those standards.

Of course in the Trump era there’s probably not a candidate for any public office who champions the ACA.

But I also don’t see any Medicaid experience in Weaver’s background and that is an expertise area that is critical. Some of the medical, treatment, and ethical issues are extraordinarily complex. They will require a solid team to help consider all of the alternatives that have life and death consequences. (So, if confirmed, he’ll need a lot of help.) Oklahoma is not a Medicaid expansion state, so there would not be a lot of experience in squeezing every dollar from Medicaid by making more people eligible or rethinking the coding of costs. The public insurance of Medicaid (and Medicare) now total $1.05 billion of the IHS budget, but it could be a lot more.

Weaver could use his expertise to help tribes improve insurance for tribal members and employees — and that could boost funding for IHS. Private insurance is now only about $110 million of the agency’s revenue.

So what are the qualifications necessary to run the Indian health system? I have a bias. I have met some of the great physicians who ran the agency. I remember Emery Johnson’s passion and thoughtfulness about what IHS could be. I’d even argue that IHS has had remarkable leadership since its founding. So the standard, for me, at least, is quite high. There are also two Native women who have run state health agencies — an ideal background for managing the IHS. There is a lot of talent out there.

But the Trump administration likes the idea of shaking up government. And, appointing someone to run the IHS with a very different background, does just that. Perhaps Weaver brings a new way of thinking and managing. Then again we would do well to remember the latin phrase that medical doctors learn early in their training, Primum non nocere. It means: First, do no harm.

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 do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18 #IndianHealth

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(Note: I use the phrase, Indian health system (lower case) unless I am specifically talking about the agency. My reason is that the narrative of a government-run health care agency, the Indian Health Service, doesn’t reflect what most of what the agency does now. The funding mechanism that supports tribes and non-profit health care agencies is the largest part of the system.)

 

Tax cuts? Hell. No. Thousands of American Indian and Alaska Native children will lose health insurance

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Mark Trahant / Trahant Reports

Congress has yet to reenact the Children’s Health Insurance Program and states will soon run out of funds to prop up the program. That will mean that thousands of American Indian and Alaska Native children will lose their health insurance. And, the result is the Indian Health Service will have to stretch its already thin dollars to try and cover the budget hole.

The Children’s Health Insurance Program expired Sept. 30. This federal program insures young people and pregnant women who make just enough money not to qualify for Medicaid (but can’t afford private insurance). The idea is to make sure that every child has the resources to see a doctor when they are ill.

It’s hard to break down precise numbers because agencies lump funds from the Children’s Health Insurance Program or CHIP into Medicaid data. But we do know that the law worked really well. We also know there are more than 216,000 children that have health insurance because of Medicaid and the CHIP. Indeed, Native American children rely on Medicaid and CHIP at much higher percentages than other population groups. A study by Georgetown reported that 54 percent of American Indian and Alaska Native children were enrolled in Medicaid or CHIP as compared to 39 percent of all children. “Even though much progress has been made in extending Medicaid coverage to American Indians and Alaska Natives, the uninsured rate for American Indian and Alaska Native children and families remain unacceptably high,” the report said.

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Source: Georgetown University Health Policy Institute. Coverage Trends for American Indian and Alaska Native Children and Families.

Overall the uninsured rate among non-elderly American Indians and Alaska Natives fell by 7 percentage points from 24 percent to 17 percent, according to the Kaiser Family Foundation.

This is a big deal and here’s why: The Indian Health Service is a health care delivery operation that works best when insurance (third-party billing in government-speak) pays for the medical costs. Medicaid, CHIP, Medicare, and other third-party billing now accounts for 22 percent of the IHS’ $6.15 billion budget.

But if Children’s health is no longer funded (because Congress did not reauthorize the legislation) then the Indian Health Service will have to make up the difference. That means taking money away from other patients and programs. It will be a critical problem for clinics because by law dollars from third-party billing (or Medicaid and CHIP) remain local.

Alaska is the state most impacted by Congress’ failure to act because two-thirds of the children in the Native health system are covered by Medicaid or CHIP. Other states where there will be significant hits: Montana, North Dakota, South Dakota, Washington, New Mexico, Oklahoma, North Carolina, and California.

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Source: Georgetown University Health Policy Institute

The House of Representatives passed a CHIP reauthorization in early November. But that bill included a $6.35 billion budget cut to other health programs, including the Prevention and Public Health Fund, which provides money for vaccines, smoking cessation, and other initiatives to improve public health. The House would also ban lottery winners from being insured by Medicaid, tighten the timetable for people to sign up, and to change other rules.

It’s unlikely the Senate will agree. But the Senate is not moving quickly to pass its own legislation. The Senate is too busy working out tax cuts that will benefit large corporations and the very wealthy. (Previous post: What matters? Tax fight is about seven competing values.)

Across the country, some nine million low- and middle-income children rely on CHIP for health coverage. And, according to The Hill newspaper, States have asked the Centers for Medicare and Medicaid Services for funding to hold them over in the interim, and the agency has awarded about $607 million in redistributed funds to states and U.S. territories. Tribes will also lose hundreds of thousands of dollars in CHIP-related grants.

Last month, Utah Republican Orrin Hatch, who chairs the Senate committee responsible, called CHIP a “top priority” that had bipartisan support. The committee passed the bill October 2. But it’s up to Majority Leader Mitch McConnell, R-Kentucky, to bring the legislation to the floor for enactment. Then the House and Senate would have to iron out and agree on their differences before the bill can become law.

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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Government’s own report says climate change is getting worse … yet it’s taxes that are on Congress’ mind

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House Speaker Paul Ryan says the tax cut legislation is on track. He projected that nearly a million new jobs would be created. (House photo)

Mark Trahant / Trahant Reports

Two serious debates in Washington right now: Climate change and taxes. These are connected. And the decisions made over the next few days and weeks will impact you and your children’s future.

The federal government is required by law to publish a climate assessment. The report is out and it’s troubling. “Climate change, once considered an issue for a distant future, has moved firmly into the present. Corn producers in Iowa, oyster growers in Washington State, and maple syrup producers in Vermont are all observing climate-related changes that are outside of recent experience. So, too, are coastal planners in Florida, water managers in the arid Southwest, city dwellers from Phoenix to New York, and Native Peoples on tribal lands from Louisiana to Alaska.”

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The National Climate Assessment concludes that the evidence of human-induced climate change continues to strengthen and that impacts are increasing across the country. This bill was required by Congress in 1990 to “understand, assess, predict and respond” to global warming. It represents the best science from across the federal government.

So how is the Congress and the Trump administration responding to the report?

Well, the White House basically said, no worries, the climate is always changing. Especially because the president and Congress are focused instead on tax cuts.

Tax policy is, of course, an important concern for tribal governments and enterprises. As Adrienne St. Clair reported for Cronkite News about a complaint from tribal leaders about not being included in the discussion. “Tribes struggle with economic growth because of things like basic federal tax law, dual taxation from state governments and budget cuts from the federal programs that serve them. They urged lawmakers to push for legislation that will help Indian Country, including increasing investment incentives and allowable tax credits,” St. Clair wrote.

And it’s not just tribes. A restructuring of federal taxes will impact American Indians and Alaska Natives in all sorts of ways.

I get tired of the debate being about “middle class” taxpayers. First of all, I (and most policy makers) don’t really know what that means any more. Most working families consider themselves middle class. And what about a young single mother trying to raise a family on $25,000 a year? In an ideal setting she would not pay any income taxes.

And the Republican proposal (that party distinction is important because there were no open hearings, or amendments, this is a Republican bill designed to win or lose on Republican votes) on the surface will save many American Indian and Alaska Native families money. The tax proposal would double the standard deduction to $12,000 for individuals and $24,000 for joint filers. That’s the amount of money you can earn sort of tax free. But the plan takes away deductions for children — so a larger family could end up paying more from the start because of the fewer deductions. (So less than half needed for the scenario of a single mother raising children.)

And that’s not all. The tax cuts for families don’t last. The Joint Committee on Taxation (the congressional agency that does the math) reports that families earning between $20,000 and $40,000 a year and between $200,000 to $500,000 would pay more in individual income taxes in 2023 and beyond. Republicans argue the tax measure would result in a million new jobs.

The total cost is not a bargain either, the tax cuts would add some $1.5 trillion to the debt over the next decade.

Let’s be clear: The goal of this tax measure is to cut taxes for businesses. Individuals are a side debate. Nonetheless, as the Center for Budget and Policy Priorities, points out 70 percent of that tax cut would flow to the top fifth of households, with one-third flowing to the top 1 percent alone.

There is another problem for Indian Country.  This tax proposal is linked to a budget measure that has already passed Congress. And that budget calls for deep spending cuts across federal programs — think sequester times two or three. And because of the process used: the Senate will need just 50 votes to implement these severe budget cuts.

Congress’ budget also opens up the Arctic National Wildlife Refuge to oil and gas development — and an increase in fossil fuel production (the very cause of climate change).

This is a tough moment for that. The National Climate Assessment says Alaska is already at risk. “Alaska has warmed twice as fast as the rest of the nation, bringing widespread impacts. Sea ice is rapidly receding and glaciers are shrinking. Thawing permafrost is leading to more wildfire, and affecting infrastructure and wildlife habitat. Rising ocean temperatures and acidification will alter valuable marine fisheries.”

The Trump administration and the Republican leaders in Congress have made tax cuts their most important initiative. But the divide is similar to what we saw in the bills to repeal the Affordable Care Act. So the outcome is uncertain at best. And, unlike health care, there might be enough votes in either the House of Representative or the Senate to tank the tax bill.

However on Fox News Sunday Speaker Paul Ryan said the House is “on track” to pass this legislation before Thanksgiving. Hashtag: #TurkeyAlert.

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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Health care chaos continues as Trump administration ends insurance payments

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President Donald J. Trump announces executive orders that will end a subsidy for health insurance purchases and allow people to buy less expensive plans that cover fewer medical issues. (White House photo)

Mark Trahant / Trahant Reports

The chaos that is now Trump Care continues.

First, Congress tried to repeal and replace the Affordable Care Act by rolling back that law plus the decades long public health insurance known as Medicaid. That effort failed in the Senate. Twice. And Congress hasn’t given up. There are all sorts of proposals floating that would try yet again through the budget or another mechanism.

Meanwhile the Trump administration is trying to unravel the Affordable Care Act using administrative authority. And, in the process, guaranteeing a network of insurance chaos. The President signed an executive order that eliminates payments to insurance companies to subsidize the cost of health insurance for families that cannot afford the full cost. Insurance companies will likely increase health insurance premiums — and by a lot — or get out of the individual health insurance market all together.

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This policy change impacts American Indians and Alaska Natives who get their health insurance through the exchanges. Under the Affordable Care Act, many tribal members and Alaska Native shareholders quality for a “bronze plan” from exchanges at no cost. A silver plan could also have been purchased, depending on income, using subsidized rates.

The Kaiser Family Foundation figures that insurers will need to raise silver premiums between 15 and 21 percent on average to compensate for the loss of the subsidy payments.

It’s interesting: Ending the subsidy will cost consumers more in states that have not expanded Medicaid (such as Oklahoma) since there are a large number of marketplace enrollees in those states with incomes at 100-138 percent of poverty who qualify for the largest cost-sharing reductions.

The Congressional Budget Office (CBO) estimated that the total payments were $7 billion in fiscal year 2017 and would rise to $10 billion in 2018 and $16 billion by 2027. The House of Representatives sued the Obama Administration to try and stop these insurance subsidies arguing that Congress never appropriated the money.

The CBO also said that ending the insurance subsidies will increase federal deficits by $6 billion in 2018, $21 billion in 2020, and $26 billion in 2026.

A second administrative order will change the way insurance companies write policies. The Affordable Care Act set out standards so that basic health care issues, including women’s reproductive health, would be covered. But the new rules will make it easier for people to buy limited policies that cost less, but cover fewer medical issues.

“Congressional Democrats broke the American healthcare system by forcing the Obamacare nightmare onto the American people. And it has been a nightmare,” the president said. “You look at what’s happening with the premiums and the increases of 100 percent and 120 percent, and even in one case, Alaska, over 200 percent. And now, every congressional Democrat has blocked the effort to save Americans from Obamacare, along with a very small, frankly, handful of Republicans — three. And we’re going to take care of that also because I believe we have the votes to do block grants at a little bit later time, and we’ll be able to do that.”

But the actions by the administration will only lower the cost of health insurance for one group of Americans, young, healthy ones. Insurance costs for nearly every other plan will sharply increase because of these actions. And especially at risk: Patients who are facing expensive medical treatments such as cancer.

Earlier in the week, the administration also rolled back Affordable Care Act coverage requirements for access to birth control. According to the Kaiser Family Foundation: “These new policies, effective immediately, also apply to private institutions of higher education that issue student health plans. The immediate impact of these regulations on the number of women who are eligible for contraceptive coverage is unknown, but the new regulations open the door for many more employers to withhold contraceptive coverage from their plans.”

The actions of the Trump administration mean two things: There will be chaos in the insurance markets as companies and individuals rebalance the value of those policies; and there will be litigation ahead because every one of these policy shifts will be challenged in court.

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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Children’s health insurance should be an easy vote, but not so in this Congress

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More than half of all American Indian and Alaska Native children are insured by Medicaid and the Children’s Health Insurance Program (IHS.gov photo)

Mark Trahant /Trahant Reports

Here we go again: Congress is finding new ways to complicate health care.

It really boils down to the philosophy that government-funded health care is just another word for welfare. So it’s a good thing to cut it back and limit it. The other side of that is that funding health care is a right and smart because a healthy population is more productive and better for everyone. There is a third element, of course, for Indian Country, and that’s the notion that health care delivery represents a solemn promise made through treaties; thus a pre-paid obligation.

Over the past few months I’ve written a lot about the role of Medicaid in the Indian Health system, a revenue stream that raises about $880 billion. Medicaid is a federal-state partnership, so even though the federal government ultimately pays the bill for American Indians and Alaska Natives, the rules and regulations go through the states. And if that’s not complicated enough, there’s an “and” added to Medicaid … the Children’s Health Insurance Program or CHIP. On budget lines these two programs are lumped together, Medicaid and CHIP. Mostly because the funds are administered by state Medicaid programs.

The idea of CHIP is simple. The richest country in the world ought to make sure that children have health insurance and are able to see doctors (it was added to a budget resolution in 1997). “In general, CHIP reaches children whose families have incomes too high to qualify for Medicaid but too low to afford private health insurance,” the government says.

The key here is that American Indian and Alaska Children rely on Medicaid and CHIP at higher levels than the general population. In 2015 54 percent of Native children were enrolled in Medicaid or CHIP compared to 39 percent of children nationally (which is still a big number).

Congress works on two tracks. One track is language to authorize spending and an additional track is when Congress appropriates the money. The problem here comes from track one: The authorization for CHIP expired October 1 and it must be renewed before new funding.

This was supposed to be easy. A letter to Congress from the National Governors Association was clear:  “CHIP is widely supported by governors, who recognize that access to health insurance is critical to ensuring a healthy start for our nation’s children. Since CHIP was enacted, the uninsured rate for children age 18 or younger has fallen from 14.9% to 4.8% … Governors urge you to protect children’s coverage and give states certainty by providing an extension of funding for the program.”

Not only do governors from both parties agree that CHIP worked but so do a vast majority of Americans, one Kaiser Family Foundation polls pegged support at 75 percent.

In the Senate leaders have been saying, repeatedly, not to worry. CHIP renewal will happen. A bipartisan bill was in the works and put on hold while the Senate debated its larger Graham-Cassidy healthcare measure. (There were all sorts of provisions in that bill to muck up CHIP.)

But we are past that, right? Now Congress should just pass a clean extension of CHIP and, for good measure, make a few fixes to the Affordable Care Act, and then argue about other things. That was the Senate proposal.

However in the House: “Unlike the Senate KIDS Act, the House HEALTHY KIDS Act also includes offset policies designed to appropriately reduce federal spending so the extension of CHIP funding does not increase the deficit.”

In other words: The House wants to cut other programs first.

The House bill will add money to the Puerto Rico Medicaid program. But, as the Center for Budget and Policy Priorities point out it’s not enough. “The HEALTHY KIDS Act includes up to $1 billion in additional funding for Puerto Rico’s Medicaid program to help the Commonwealth recover from the devastation of Hurricane Maria.  While this is a welcome move, it falls well short of what Puerto Rico needs, and the bill provides no assistance to the U.S. Virgin Islands, badly damaged by Hurricanes Irma and Maria.” Then the House bill cuts public health funding by $5 billion and shortens the grace period for people trying to pay Affordable Care Act premiums. Two kick-the-rich provisions: Allowing states to disenroll lottery winners (because we all could win, right?) and charging higher Medicare premiums to wealthy seniors.

The House committee is urging its members to vote fast. “States are currently using unspent FY2017 CHIP allotments and redistributed funds from the Centers for Medicare and Medicaid Services (CMS) to cover current spending needs for their CHIP programs,” the committee told its members. “Without Congressional action, states could start to exhaust these funds as early as November.”

Ten states could run out of money by next month, including Arizona, Utah and especially, Minnesota. According to Kaiser Health News, “Minnesota was among those most imperiled because it had spent all its funds … Emily Piper, commissioner of the Minnesota Department of Human Services, reported in a newspaper commentary last month that her state’s funds would be exhausted last Sunday.”

If a state does not reimburse the Indian health system for these costs, IHS, as the payer of last resort, could be on the hook for these additional costs.

 

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Source: Kaiser Family Foundation

The numbers are significant. A study by Georgetown University Health Policy Institute said the uninsured rate for AI/AN children declined from 25% to 15% between 2008 to 2015. All of the states with very high proportions of their AI/AN children on Medicaid saw very large double-digit declines. The two states with the largest declines in their uninsured rate for kids were New Mexico (38% to 11%) and Alaska (32% to 17%).

“At a time when Congress is considering extremely large cuts to Medicaid and a dangerous restructuring of the program, AI/AN families are especially at risk,” the study concluded.

The politics ahead are difficult. The House bill adds budget cuts as a way to reach 218 votes. This works by making it more conservative. But it also removes the bipartisan approach, something that’s worked so well since CHIP was created. And even the House’s conservative tilt might not generate enough support for the measure to pass.

This is all nonsense. We know CHIP works. It’s government at its best. (If we do anything … we should expand it and add more children.) So the law’s renewal should be a quick “yes” vote. Then, what’s next? But Congress has to complicate — make that muck up — a program that works.

 

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 do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18

ICYMI: My first audio election special is on iTunes or Soundcloud. Download here. 

 

This is a first: Legislation would fully-fund Indian health system, raise billions

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Sen. Bernie Sanders proposed “Medicare for all” bill would fully-fund the Indian Health system for the first time in history. (Senate photo)
Mark Trahant / Trahant Reports

Bernie Sanders is expected to introduce his version of health care reform, a plan he calls “Medicare for all.” At least fifteen Democrats have signed on as co-sponsors to the single-payer plan.

“This is where the country has got to go,” Sanders told The Washington Post. “Right now, if we want to move away from a dysfunctional, wasteful, bureaucratic system into a rational health-care system that guarantees coverage to everyone in a cost-effective way, the only way to do it is Medicare for All.”

Sanders’ bill has no chance in a Republican Congress. Yet the Vermont Independent (who caucuses with the Democrats) is adding to the richness of the debate. He is showing a clear alternative to Republican plans (the latest is one by Sens. Lindsey Graham, R-South Carolina, and Bill Cassidy, R-Louisiana.)

But Indian Country should take note. Sanders bill would fully-fund the Indian health system. Let’s do the math. The current budget for the Indian Health Service is $6.091 billion dollars. And of that, roughly $1.2 will come from Medicaid, Medicare and other insurance. This serves about 2.2 million American Indians and Alaska Natives in 39 states.

But if Sanders’ proposal for universal care were enacted every one of those 2.2 million patients would have funding from insurance. The national average for Medicare beneficiary is $10,986. The total: $24.191 billion. A four-fold increase (and this does not include appropriations, just insurance dollars). So if you include both, the total is roughly $30 billion.

This sound like an awful lot of money, right? That big number reflects what other health systems already spend. So actually it’s the ideal demonstration of just how underfunded the Indian Health Service is under current law and insurance schemes. This is what a fully-funded Treaty Right looks like.

Of course some of this can be done now, even without Sanders’ bill. Many people in tribal communities are posting on Facebook exactly how to sign up for Medicaid (the government insurance program that so many in Indian Country already qualify for.) They are doing this as an act of defiance, because the Trump administration has recently quit advertising the program and is not actively promoting sign-ups.

But, again, let’s do the math. If every American Indian and Alaska Native was eligible for Medicaid that would net the Indian health system about $7.211 billion (instead of the $1.2 billion from third-party billing now). I actually think this is a more realistic number (even under a Sanders’ plan) because it does not include some of the spending by Medicare (and for that matter, Medicaid) on senior citizens. The national average for Medicaid is a modest $3,278 for an adult and for $2,577 average for children. The total for IHS would be in the neighborhood of $15 billion. More than double what is spent now.

Either Medicare or Medicaid: This is what full funding looks like. And a Treaty Right fulfilled. Finally.

Speaking of children, the Senate has reached a bipartisan deal in the Senate to reauthorize the Children’s Health Insurance Plan or CHIP. This insurance plan covers 9 million young people through Medicaid. The program is set to expire at the end of the month unless Congress acts and then President Donald J. Trump signs a new legislation into law.

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

Note: A correction was made to the original post.   Sen. Bernie Sanders is an independent. 

 

 

Obesity in Indian Country is mostly the same; why that’s incremental progress

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IHS Diabetes Fact Sheet, published July 2017.

A fundamental question about government

Mark Trahant / Trahant Reports

The most fundamental question about government is this: Does it work? When does government — tribal, state or federal — actually make a difference in our lives?

There are two ways to answer that question, data and story. Data tells what happens over time, a reference point that ought to provide the proof of self-government. But story is what we tell ourselves about what works, and more often, what does not work. Ideally data and story lead us to the same conclusion.

One problem with data is that it measures incremental progress. That should be a good thing. But when telling a story it’s awfully difficult to report that things are kinda, sorta getting better. We humans want clarity, a success story, right? Or even an outright failure.

Yet progress is often measured slowly.

We all know there is an epidemic of diabetes in Native American communities. Yet it’s also true that adult diabetes rates for American Indian and Alaska Natives have not increased in recent years, and there has been a significant drop in both vision-related diseases and kidney failures. Incremental progress.

Now a new study, one that is built on a massive amount of data, reports that obesity among Native American youth is mostly the same.

“The prevalence of overweight and obesity among AI/AN children in this population may have stabilized, while remaining higher than prevalence for US children overall,” according to a study published last month by the American Journal of Public Health. The study concluded that American Indian and Alaska Native youth still have higher rates of obesity than the total population, but those rates have remained constant for a decade. In other words: The problem is not getting worse. (At least, mostly.) This report is remarkable because it reflects a huge amount of data – reports from at least 184,000 active patients in the Indian health system – from across geographic regions and age groups. Most scientific studies rely on a small sample group, making it difficult to compare regions or even break down the data by gender or age. (So Native Americans who are treated outside of the Indian health system would not be included in this data.)

The results: “In 2015, the prevalence of overweight and obesity in AI/AN children aged 2 to 19 years was 18.5% and 29.7%, respectively. Boys had higher obesity prevalence than girls (31.5% vs 27.9%). Children aged 12 to 19 years had a higher prevalence of over- weight and obesity than younger children. The AI/AN children in our study had a higher prevalence of obesity than US children overall in the National Health and Nutrition Examination Survey. Results for 2006 through 2014 were similar.”

The findings show that the problem is not getting worse. And that is incremental progress.

To put this report into a policy context, think about the hundreds of programs that are designed to get Native American youth more active. Or the education campaigns to improve diet and to encourage exercise that occur every day across Indian Country.

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This is timely data because Congress must soon reauthorize the Special Diabetes Program for Indians. And this report is evidence that $150 million program works and it’s also worth a continued investment by taxpayers. (Remember: Chronic diseases, such as diabetes, are by far the most expensive part of health care. Every dollar spent on prevention saves many, many more down the road.)

The goal of course must be a decline in overweight and obesity statistics, not just stability. (And one warning sign in the report is that there was a slight increase in severe obesity even while the general trend is stable.)

The report, by Ann Bullock, MD, Karen Sheff, MS, Kelly Moore, MD, and Spero Manson, PhD, said there are many reasons for a higher obesity prevalence in American Indian and Alaska Native children but also said this was a “relatively new phenomenon seen only in the past few generations. The explanations range from the rapid transition from a physically active subsistence lifestyle to the wage economy and sedentary lifestyle. Add to that the risk factors of poverty, stress, and trauma.

“Indeed, many AI/ AN people live in social and physical environments that place them at higher risk than many other US persons for exposure to traumatic events,” the study found. “Among children in a National Institute of Child Health and Human Development study, the experience of numerous negative life events in childhood increased risk for overweight by age 15 years. Another contributing factor to obesity in children living in lower-income households is food insecurity, which is the lack of dependable access to sufficient quantities of high-quality foods. Even before birth, stress and inadequate nutrition during pregnancy alter metabolic programming, increasing the risk for later obesity in the offspring.”

Because obesity is a relatively new phenomenon seen only in the past few generations, there is much that can be done to reverse the trend. And that starts with making sure the problem is not getting worse. Then we can get healthier. Kinda, sorta, at least.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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