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.
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.”
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.
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: @SenJohnMcCain 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!”
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 @lisamurkowski 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.
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!”
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.
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.
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.
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!”
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.
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.
When every senator could be the 50th vote, any one absence means no healthcare bill
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.
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.”
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.
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.
“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.
I am not sure of the exact year. It probably happened around 1996. That’s when the Indian Health Service became the single largest employer in Indian Country.
This makes sense when you think about it: Indian health was once a small (unappreciated) division of the Bureau of Indian Affairs. But by 1996 the agency’s budget was larger than the BIA’s — and there were likely more workers. The administration estimates that next year the BIA will have some 6,770 full-time employees (a decrease of 241) while the Indian Health Service will have more than 15,119 employees (including 1,928 uniformed Public Health Service officers).
Big numbers, right? But that reflects what is happening with health care generally. Google “region’s top employers” and it’s common to see clinics, hospital systems, and university medical centers as any region’s largest employer.
“Employment of healthcare occupations is projected to grow 19 percent from 2014 to 2024, much faster than the average for all occupations, adding about 2.3 million new jobs,” reports the Bureau of Labor Statistics. “Healthcare occupations will add more jobs than any other group of occupations. This growth is expected due to an aging population and because federal health insurance reform should increase the number of individuals who have access to health insurance.”
But here’s the thing: Many of these health care jobs are dismissed as “low wage.” The BLS calls these health care support jobs and the median income (or half pay more and half pay less) as $27,910 which is lower than the median annual wage for all occupations in the economy. The list of support jobs would include Community Health Representatives (long a staple in Indian Country), medical record keeping and coding jobs, as well as different kinds of medical technicians. But what’s considered low wage in the general population, and in cities, can be a good gig in a rural, tribal community.
Alaska is a prime example. More than half of Medicaid spending serves rural constituents, three times more than the national average. Medicaid covers two-thirds of all American Indian and Alaska Native children and more than one in four, or 28%, of American Indian and Alaska Native adults. The Urban Institute estimates that the kind of block grants found in the Senate’s Better Care Reconciliation Act would cost the state $590 million in federal funding — a number that would decline even sharper after 2025. The job losses would be substantial.
This is another reason why the House and Senate plans to roll back the Affordable Care Act (and the destruction of Medicaid as part of the deal) are so important to the Indian health system. The Senate plan especially reverses decades of Medicaid growth. That’s no good for patients (as I have reported before here and here) but it also will cost Indian Country jobs.
Medicaid directly accounts for 24 percent of IHS’ workforce, but even that is short of the kinds of jobs that serve tribal communities. It does not include school-based programs. Or those private companies that bill Medicaid for transportation of patients or other patient services. Same story for jobs that stem from medical coding, accounting and third-party billing services.
Across the country, Medicaid is a major job creator for women, supporting at least 3 million direct jobs. According to a report by the National Women’s Law Center: “When Medicaid pays for a health service—a visit with a health professional, a laboratory test, a hospital stay, a home health visit—this payment supports the facility, agency, or medical practice that delivers the service, and the individuals who provide this care receive compensation as well. Women’s high participation in the health care industry, which employs more than 22.8% of all women in the workforce, means that Medicaid disproportionately creates jobs for women.”
I don’t have a breakdown for these jobs in Indian Country, but from personal experience I would bet the numbers are similar if not higher.
Senate debate begins again next week
The Senate, of course, still does not have consensus about a bill to replace the Affordable Care Act. Majority Leader Mitch McConnell suggested this week that Republicans might need to try another direction because “no action is not an alternative.” The Associated Press quoted the senator saying: “If my side is unable to agree on an adequate replacement, then some kind of action with regard to private health insurance markets must occur.” That plan would require votes from Democrats and would likely include a compromise.
Other senators, including Paul Rand, have proposed repealing all of the Affordable Care Act without a replacement, basically putting that off for another day. That would be particularly troubling for Indian Country because a full repeal would likely include the Indian Health Care Improvement Act. But that, too, is complicated by Senate rules. A full repeal would need 60 votes unless that legislation was framed narrowly around budget issues.
But Republican leaders have not given up. The new story they are telling is that 22 million people would “choose” to not carry health insurance. It’s a freedom thing. But that does not square with the destruction of Medicaid. And the jobs that public insurance program has created.
Senate bill ‘mostly dead,’ but will it revive after break?
Mark Trahant / Trahant Reports
The Senate’s health care bill is “mostly dead.” But that’s not the same as all dead. And this holiday weekend will decide either the legislation has a second life or if there is a better way to proceed.
Republican Senate Majority Leader Mitch McConnell is planning another shot at health care reform (excuse me, a plan to cut taxes and roll back Medicaid) this week producing yet another draft of the health care bill. Meanwhile Senators (as well as members of the House) will break and return to their home districts. This is where the people have a chance to weigh in with a “hell, no!” The Senate bill may be the most unpopular piece of legislation ever, currently earning support of between 12 and 17 percent depending on which poll you read. To borrow the TSA phrase, if you see someone (as in a member of Congress) say something.
Consider this: Medicaid is popular across the board. A poll by Kaiser Health News illustrates this point. It shows that some three-fourths of Americans view Medicaid favorably. (But the poll also points out that most Americans don’t know that both GOP bills would cut deeply into the popular program.) Even Republicans think Medicaid works.
For the past few weeks I have been writing post after post about how bad this approach to health care — I mean, tax cuts — is as a policy. The problem is basic. Many Republicans do not believe health care is a right. So it’s their mission to roll back government. But not every Republican believes that. Some see the effectiveness of programs such as Medicaid and see it’s rollback as unconscionable. (Previous: Health care deserves policy debate.)
At a meeting with tribal leaders at The White House, President Donald J. Trump was asked about cutting Medicaid. His answer: “It’s going to great. This will be great for everybody.”
Read “great” as “clueless.” But the president did say it was going to be difficult to get the votes, “it’s very tough … I think we’re going to get at least very close, and I think we’re going to get it over the line. ”
We shall see. Mostly dead or all dead? And an all dead GOP health care bill could deliver a miracle.
This is the moment where McConnell will pull out his checkbook. He will be trying to win *cough* buy * cough* support from senators with sweet deals for the folks back home. If that doesn’t work, McConnell said he might be forced to work with Democrats on legislation. Imagine that! A Congress that works with both parties.
This is what really ought to happen. The Affordable Care Act has problems that need to be fixed. But it’s in specific areas, such as the individual insurance market, and a bipartisan approach would actually yield the best results.
But more important the only way that Congress governs again is for leadership to recognize that they cannot govern with Republican votes alone because they don’t have enough votes. There is a split within the Republican Party on the very question of health care as a right, let alone specifics about how much to cut and where. And that same division plays out on just about every major public policy issue.
But a few Republicans working with Democrats do constitute a majority in both Houses. A lot could get done. The Congress could pass a budget. Raise the debt limit (averting another crisis) and do the jobs that we the people hired them to do. That would take a miracle right? But we can always hope and the first step is an all dead Republican health care bill.
How long will it take for this process to unfold? This will only happen when congressional leaders run out of options and see working with Democrats as the only path forward. This will take time because as Miracle Max said in The Princess Bride: “You rush a miracle man, you get rotten miracles.”
I have been wondering what I should say about the Republican health care legislation in the Senate. We do know that there is a policy split among Senators about how much and how fast to cut Medicaid. We know the bill will cut taxes. But beyond that there is more information on one of my whiteboards than what is posted in public.
Senate Majority Leader Mitch McConnell is moving this legislation in secret. And there’s a reason. As The Washington Post puts it: “ So McConnell’s theory is that if the Senate’s bill were seen, debated and discussed, opposition would grow and grow, and eventually at least three of his members would bail out (the Republicans’ 52-48 majority means they can only lose two votes). Which might well be true.”
So true in fact that I am not sure which is a worse outcome for Republicans: Failing to pass a bill (ticking off their conservative base) or passing this legislation that by all independent measures will make the U.S. health care system worse.
It’s easy to imagine the coming 2018 election commercials: Millions lose health insurance; health care-related bankruptcies on the rise; and all done in secret so that wealthy campaign donors pay less in taxes.
Indian Country, of course, is largely missing from this debate. There is an assumption that the bill doesn’t impact the Indian Health Service. But Medicaid is growing and it could be, no, ought to be, a significant funding stream for IHS. Even the Trump administration’s budget recognizes that. It projects $914 million in third-party billing for IHS in fiscal year 2018, a slight increase. That’s mostly Medicaid. But the numbers don’t reflect what will happen if that Medicaid money is taken away because the IHS appropriations (which is essentially flat) will have to serve more patients with less resources. Remember half of all Native American children are insured by Medicaid or the Children’s Health Insurance Program.
When the House passed the American Health Care Act a number of “moderate” House members said the bill was bad, but don’t worry the Senate will fix it. Even President Donald J. Trump echoed that idea, telling Senators the House bill was mean and that the Senate should be more generous.
In fact the idea that the Senate would make the bill better was a key part of the House vote. Alaska Rep. Don Young, for example, was said to be a no vote (Alaska gets the worse deal of any state in the House legislation) but ended voting yes. Young told the Alaska Dispatch News two things: First, the bill was moving too fast. And, more important, “this bill we passed today will not become law. It’ll be changed as time goes by. But unless we move it, or move a vehicle, nothing’s going to happen, and that’s not good.”
So process mattered. Then. Now the Senate is engaged in the screwiest legislative path ever; essentially asking Senators to support a blank page. And improving the bill? Hardly. The secret Senate bill is only trying to win with 50 votes, not shape sound public policy.
Every member of the Senate Republican caucus agrees on cutting taxes. That’s the fuel that keeps this bill moving forward. But not all agree about cutting Medicaid (and funding for Planned Parenthood). In a closely divided Senate some members are going to have to take one for the team; vote against their own state interests and voters. Thirty-one states expanded Medicaid coverage under the Affordable Care Act — and twenty of those states are represented by Republicans. All but three have to agree to take away insurance from their voters.
But that’s the easy sell. If there is a long transition period probably nearly all of the 20 Senators will go along. But the conservatives (especially those that represent states that did not expand Medicaid) want a quicker timetable. That means the “moderates” will be going before voters right away and campaigning on less Medicaid for all. That’s terrible politics because the numbers are staggering: Seventy million Americans are on Medicaid. If Congress turns this into a block grant program millions will lose health insurance. Millions of voters.
There are new studies that show how devastating the American Health Care Act would be to public health and the economy. A study by the Commonwealth Fund says nearly a million Americans would lose jobs if this legislation passes. “By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses,” the Commonwealth Fund study found.
Indian Country would lose jobs, too. There are no numbers yet but the Indian Health Service budget would take a significant hit and there would be pressure to reduce the number of employees. Remember the Indian Health system is Indian Country’s largest employer.
The Senate only has a few working days before it’s July recess. If it’s to become law, the bill will need a “score” from the Congressional Budget Office (because of Senate rules this bill must be budget-related). But that won’t happen unless McConnell thinks he has the 50 votes needed to pass. Policy be damned.
Reality TV works for one simple reason: The antics of the characters are beyond what’s believable in fiction. It’s compelling drama because normal people do not do such things. So part of watching is to find out when the story arc ends, to discover when the situation becomes “normal” again. (Even though the story does go on and on and on.)
That’s why the presidency of Donald J. Trump would make a terrible novel or screenplay: There’s no mechanism to suspend disbelief. Tell the story about a four-month term in the White House, a time marked by so much chaos, unprofessionalism, and distraction, and a reader (and especially an editor or producer) would shake their head and say, “Try again. This story is not believable.”
That’s why only the metaphor of reality TV works. America the unbelievable.
Last week the best moment of the new Trump Administration was the one where the president smiled in Saudi Arabia and said only 26 words. This was terrible reality TV but we all watched knowing that it was likely just a pause. Something outrageous must be coming up next.
The White House Reality Show is entertaining.
Meanwhile more important stories are still being written and played off-screen. That’s why our focus must return to the policy fights ahead: How this country (and our planet) deal with climate change, how we stop the rigging of elections, and, how we make certain the court system is fair. Next week the White House will formally send Congress its budget plan for the next year. We already know this plan will be nonsense. Another distraction. The real work of budgeting will occur in Congress and it will require votes from both Democrats and Republicans to make it so.
At a House hearing last week, for example, Rep. Tom Cole (R-Oklahoma) said he was disappointed in a White House recommendation to cut $5.8 billion from next year’s funding for the National Institutes of Health. He such a draconian cut would stall so much progress from recent investments.
In other words: No sale. Across the Congress, across the government, this same notion is being repeated. Eliminate the Corporation for Public Broadcast? No sale. Down the list the message is much the same, eliminate the Denali Commission? No sale. Etcetera, etcetera, etcetera.
Paying for health care
But while Congress might rewrite the budget in some areas, there are real dangers ahead. I’m obsessed with what this bunch is doing to the funding streams for health care, especially Medicaid.
This is what the Trump Show hides: The House’s American Health Care Act does much more than roll back the Affordable Care Act (or Obamacare as they like to say.) It ends a Medicaid program that works. It’s the single most effective form of “government” insurance that secures health care options for 62.3 million Americans. To add a little perspective here: Medicare — supposedly untouchable in politics — insures 43.3 million seniors.
These are huge numbers. Medicaid is expensive. And we all pay for this plan. As we should. It’s one of the best things this country does.
So it’s no wonder that Speaker Paul Ryan and Republicans are eager to make this go away (both because it costs so much and because it requires a lot of taxes to pay for this enterprise).
This is an issue where the philosophical divisions run deep. Every Republican wants to spend less federal money on this program. Significantly less. Once you do that, there will be fewer people who participate in this public insurance program. That’s math, not politics. The House plan (according to the Congressional Budget Office) strips $880 billion from Medicaid funding in order to reduce health care taxes on wealthy people by $883 billion. Tit for tat.
Watch this debate closely. Parse every word. The Republicans in the Senate who say they champion Medicaid often only talk about Medicaid expansion. And that’s followed by, there should be a transition to something else (namely, block grants that states cannot afford). What else? How does that work? And who pays?
At a town hall in Anchorage last week, Alaska Sen. Dan Sullivan followed this script to the letter. According to The Alaska Dispatch News the Republican senator told a contentious town hall, that he wanted to make sure the people who received health care coverage under Medicaid expansion “do not have the rug pulled out from under them.” Medicaid for now. Then something else. What else? How does that work? And who pays?
The answer is to protect the framework of Medicaid (and if we were smart, enhance and expand it). It’s the one part of Indian health funding that’s growing and already accounts for the insurance of record for more than half of all our children. (And, this is really important, third-party insurance billing, which includes Medicaid, is money that stays at a local IHS clinic or hospital. It does not go into the general budget.)
Medicaid is a partnership between the federal government and the states. So states set many of the rules, federal government then agrees or not, and pays only a portion of the bill. But patients within the Indian Health system are usually eligible for a 100 percent reimbursement.
So states set the rules for Indian Country — including limitations — yet don’t pay the cost. Already six states are already looking to tighten Medicaid rules. Arizona is keen on adding work requirements. Wisconsin wants drug testing (imagine the trap that sets for patients in opioid treatment programs). Maine wants to test assets beyond income. The goal of each new regulation is to shrink the number of people insured by Medicaid.
Medicaid works, especially in Indian Country
I’ve heard Republicans say they like the results of Medicaid but that we as a country cannot afford it. That’s particularly troubling because Medicaid is more efficient that private insurance. (Even with its convoluted payments from the federal government to states and Indian health programs). How can that be? Julia Paradise, associate director of the Program on Medicaid and the Uninsured for the Kaiser Family Foundation, says Medicaid acts as a “high risk pool.” Because so many people are excluded (or out-priced) from private insurance Medicaid is the only option. “Among adult Medicaid enrollees who are not working, illness or disability is the main reason. By covering many of the poorest and sickest Americans, Medicaid effectively serves as a high-risk pool for the private health insurance market, taking out the highest-cost people, thereby helping to keep private insurance premiums more affordable.”
The Senate is now busy rewriting the House’s awful health bill. It will be a different entity, that’s for sure. But will the Senate protect (and if they are smart, enhance and expand) the best basic public health insurance program that we have now? There is no evidence to suggest that. And too many people are watching reality TV to even notice.