Speaker Paul Ryan said House Republicans are close to a deal that would allow them to pass the American Health Care Act. He says this is because of “improvements” suggested by President Donald J. Trump.
Let’s be clear about these so-called improvements: The bill would still wipe out Medicaid as we know it. Medicaid represents 13 percent of the Indian Health Service budget (or $808 million). Now. It could produce even more revenue as more states opt into the plan and more American Indians and Alaska Natives sign up for that public insurance program. This is how the Indian health system reaches full-funding one day.
Ryan tweeted that the idea behind the new bill is “to give the states the ability to kind of customize the reforms to maximize the ability to lower premiums.” And the method for that is to allow states to walk away from requiring essential services. The result would be people who have insurance policies that do not cover what would be covered under the Affordable Care Act. This weakens the idea of protecting people from insurance companies that use pre-existing conditions to limit or exclude coverage.
That’s the debate that is taking center state right now. But for Indian Country the bigger concern ought to be Medicaid, Medicaid and Medicaid.
There are now 30 million children covered by Medicaid; more than half of all Native children,
I wrote last month that two states show the impact: Alaska and Montana. Both are new to Medicaid expansion. Montana currently does not have representation in Congress — so there is no voice in this “reform.” Alaska’s Rep. Don Young, a Republican, is so far listed as an undecided for this new House proposal. I also wrote that the previous House bill was particularly bad for Alaska. That’s still true but now those voting for the measure have a way to spin it: They can say it will lower premiums. Sure. And that will be fine as long as you never need the policy to actually pay for expensive medical treatment.
A House vote could come as soon as Friday. — Mark Trahant
President Donald J. Trump’s legislative agenda has crashed. The Republican promise to quickly repeal and replace the Affordable Care Act on Friday failed to win enough votes from conservatives to make it so.
As House Speaker Paul Ryan said in a post-failure news conference: “Obamacare is the law of the land … We’re going to be living with Obamacare for the foreseeable future.”
For his part, President Donald J. Trump (who, of course, says he is not to blame for the loss) told The Washington Post, “the best thing politically is to let Obamacare explode.” He called the law, “totally the property of the Democrats,” and that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”
The president and his administration can do a lot to make that happen. The Secretary of Health and Human Services has extraordinary authority under the Affordable Care Act and they can use the power regulation to gunk up Obamacare. There will be many battles ahead on the regulation front. But, and this is the good part, states will have a say in this too. And there is the potential for a few states to engage in experiments that might improve the law. The question here: Is the administration willing to work to improve insurance options for Americans or are they more interested in punishing Democrats? (Yeah, I know, but there is a political upside to answering that question correctly.)
Here’s the thing: There is a crisis in insurance markets. And a bipartisan solution, meaning most Republicans working in partnership with Democrats, is the best way to reach a solution. There are three ways most of us get health insurance: our employers, public insurance such as Medicare and Medicaid, and the individual market when we buy our own insurance policies. Employer-based care is an accident of history (it’s a long story) and has been shrinking for the past fifteen years. Public health insurance has been growing (something the conservatives in Congress really object to because it codifies the notion that health care is a right) and under the Affordable Care Act individual insurance has increased from about 10.6 million people to 15.6 million.
Individual markets were troubled prior to the ACA’s enactment in 2010. One reason was that premiums for these policies were increasing more than 10% a year, on average, while the policies themselves had major deficiencies. They often excluded pre-existing conditions, charged higher premiums for people with health risks and for young women, placed limits on annual and lifetime benefits, or refused to renew policies for individuals who became sick. Many people who tried to buy plans were turned down. In 2010, an estimated 9 million adults who had tried to buy a plan in the individual market over the prior three years reported that they were turned down, charged a higher price, or had a condition excluded from their plan because of their health.
Thus “returning to the status quo ante — before the ACA — is not a viable option for the individual markets.”
The fix does not involve a “great mystery” according to Blumenthal and Collins. It’s simply making certain that more young people buy insurance to help pay for the higher health care costs of older Americans. The bigger the pool, the lower the cost. (Which, I should add, is why single payer works as a public policy.) One part of that solution is to increase the government subsidies so more people will buy in. That’s how the insurance market could work better.
More money for Indian health
Enough background. Where does Indian Country fit into this matrix? So there is a legal understanding that the Indian health system is federal obligation that stems from the promises made in treaties to provide doctors and nurses to reservation communities. Yet no Democrat nor Republican government has ever (as in ever) proposed fully-funding that Indian health system. Members of Congress often acknowledge the treaty responsibility, but have never followed those words with a budget.
But the Affordable Care Act separates insurance from health care delivery. It basically makes the Indian health system (both the government-operated Indian Health Service facilities, and those run by tribes and tribal organizations) medical care that’s mostly funded by federal appropriations and funded by insurance. Nationally that mix right now is about 80 percent appropriations and 20 percent insurance. But, and this ought to be huge, the insurance side of the equation under the Affordable Care Act is unlimited. That pool of money grows every time an eligible American Indian or Alaska Native signs up for insurance. This makes full-funding of Indian health a possibility. (Even better: Insurance collections remain at the local clinic or hospital. It really is the best kind of funding.)
There are three ways to add money to Indian health now.
First: More American Indians and Alaska Natives can sign up for Medicaid. The fact is there are many more people eligible than have signed up. The Kaiser Family Foundation estimates that nationwide one million American Indians and Alaska Natives lack coverage (depending on the state). Already Medicaid covers more than half of all children but 11 percent of those children remain uninsured.
Second: More American Indians and Alaska Natives can sign up for exchange plans under the Affordable Care Act. This is huge. According to healthcare.gov “If you get services from an Indian Health Care Provider, you won’t have any out-of-pocket costs like copayments, coinsurance, or deductibles, regardless of your income. (This benefit also applies to Purchased and Referred Care.).” And this benefit has essentially a permanent open enrollment.
Signing up for insurance (including plans from an employer) makes the Indian health system stronger for everyone. It’s the same principle as any insurance, the larger the pool of people who participate, the lower the cost.
Third: It’s time to make the case for Medicaid expansion in state governments that have said no. Now that the Affordable Care Act remains the law of the land there remains unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments such as imposed work rules). It’s a win for Indian Country when a state does this because it increases the number of people eligible for insurance. It’s a win for the state because Indian health patients are a 100 percent federal obligation so the state will be reimbursed by Washington.
Kansas is the latest state to consider expansion. And it’s likely that the Trump/Ryan failure to repeal and replace will push other state legislatures to consider this approach. Indian health patients would benefit from Medicaid expansion in Oklahoma, South Dakota, Texas, Maine, Mississippi, Nebraska, North Carolina, Utah, Idaho, Wisconsin, and Wyoming. A total of 19 states are on this list.
The dangers for Indian Country ahead
It’s easy to see the defeat of Trump and Ryan’s plan as a huge win. But it is also a warning sign. Make that a flashing red light with sirens. The problem is that Congress is deeply divided and cannot govern.
The same Republican divisions that killed their health reform plan will kill President Trump’s budget (thank you). But it will also make it nearly impossible to pass any kind of budget. As I have written before the best outcome might be a Continuing Resolution, a status quo budget.
An even bigger challenge will be for Congress to pass an increase in the debt ceiling. Secretary of Treasury Steven Mnuchin informed Congress that the United States reached its limit on March 15. The Treasury is now juggling accounts so that the government can continue to pay bills.
Conservatives in Congress (actually, just about every member of Congress) hate this part of governing. But a no vote here has enormous consequences for everyone’s finances. markets. There is an absolute requirement that Congress increase that borrowing authority. It will be a nasty fight.
Of course there is one solution: Create a new coalition of Republicans and Democrats. This works in state legislatures across the country (most recently Alaska). It takes 216 votes to pass legislation in the House so a working body of 22 or so Republicans, plus the 194 Democrats in the House, could accomplish a lot together. But that would mean rethinking the role of party politics. And governing.
The story of Alaska and Montana is not front and center in the health care debate in the House today. But it should be.
Montana does not get a vote. (The state does not currently have a member of Congress after former Rep. Ryan Zinke was confirmed as Secretary of the Interior.)
And Alaska ends up with legislation that is by all measures, a raw deal. No state (and no pool of voters) will lose more under the Republican replacement for the Affordable Care Act than Alaska.
Alaska only expanded Medicaid in 2016. But the program has been a success. As Chris Ashenbrenner wrote in the Anchorage Dispatch News: “Expansion is a bright spot in a dismal Alaska economy. Over 25,000 people now have health coverage at no cost to the state of Alaska. Alaska health care providers have received over $288 million in revenues since it started in September 2015.” One reason for that is the role Medicaid plays in funding the Indian health system. Recent changes (promoted by Alaska Gov. Bill Walker) resulted in “a change to their policy resulting in even more Alaska general fund savings — projected to be over $30 million this year and growing each year. By 2022, it’s estimated to be over $90 million. This would not have happened without expansion.”
Alaska Health and Social Services Commissioner Valerie “Nurr’araaluk” Davidson recently told a state legislative committee that the American Health Care Act does not save money but shifts costs to the states. would shift the cost of health care to states. “I get nervous every time I hear a member of Congress talk about the great savings to the Medicaid program, because what they’re saying is, it’s a savings to the federal government,” Davidson said on Alaska Public Media. “They’re not saying it’s a savings to states – they’re actually shifting that cost to states, and that’s a problem for Alaska.”
But that’s not the only problem for Alaska. The Republican plan to give taxpayers a flat rate subsidy to purchase individual plans will mean that Alaskans would pay far more for insurance. “That’s because unlike the ACA’s tax credits, the House plan’s tax credits wouldn’t adjust for geographic variation in insurance premiums,” according to the Center for Budget and Policy Priorities. “They’d be the same for a 45-year-old consumer in Alaska, where benchmark health insurance coverage costs $12,600 this year on average, as in New Hampshire, where it costs $3,600.” The total bill: A whopping $10,500 more for a health insurance policy in Alaska.
Watch Rep. Don Young today. Alaska’s only member of Congress will likely demand a special deal from the House leadership. If not, will he still vote for the bill? Young told Alaska Dispatch News that he’s undecided. And on Facebook today, Sen. Lisa Murkowski will brief Alaskans on the legislation.
A poll published by FiveThirtyEight shows that 45% of Alaskans oppose the House bill, and 33 percent strongly oppose the legislation. It’s a similar story in Montana where 43 percent oppose the bill and 31 percent would strongly say no.
Montana, like Alaska, has a short experience with Medicaid expansion. But the numbers are strong. Montana Public Radio reported after seven months the program was nearly double the projected number of people insured. “Recipients have used their benefits to get $75 million worth of health care, 100 percent paid for by the federal government. That’s a big windfall in this state with slightly more than 1 million residents,” Montana Public Radio said.
Medicaid and Medicaid expansion are a critical, and growing, source of funding for the Indian health system.
It’s hard to think of a more make or break moment for the Speaker of the House of Representatives than what happens over the next two days. Well, sort of.
The Speaker needs 216 votes to move his health care reform proposal on to the Senate. If he loses, then Paul Ryan will have a difficult time rounding up the votes for the next tough vote (which is supposed to be tax reform).
And, if he wins, that’s the odd part. Then the bill moves to the Senate where the most likely outcome is a major rewrite. And if that works, then it’s back to the House where the same division between conservatives and leadership surface again. In the Republican Party there are three factions: Conservatives, Moderates, and those who fit into either camp but yet are inclined to support leadership. (That would be the majority of members in both the House and Senate).
I think I’ve told this story before, but here goes again, many years ago when I was at The Seattle Post-Intelligencer we had an editorial board meeting with Rep. Jim McDermott. A tough vote was coming up in the House about the war in Iraq. We knew where McDermott stood. His inclination would be to vote no. But, he told us, “I will not do that to my speaker.” A “no” would have undermined Nancy Pelosi.
That’s not the way Congress works now. House conservatives do not fear the consequences of voting against their speaker (even though in the past it’s resulted in loss of committee assignments and the perks). The thing is that they represent districts that are not competitive. So there is little the speaker can do to punish them. (This is not new. These are exactly the same dynamics that resulted in the end of John Boehner’s speakership.)
So the leadership challenge over the next two days is to make sure there are 216 votes to pass the American Health Care Act (after making minor changes). There are only three options: Make sure the votes are there. Pull the bill back and rewrite it again. Or, least likely, lose the vote and use that as a mechanism to try and punish the members who would not play along.
President Trump has his reputation (such that it is) on the line, too. He went to Capitol Hill trying to close the deal. According to Politico: “Trump entered the meeting to loud cheers. ‘We have a chance to do something fantastic, to do something amazing,’ Trump told the lawmakers, according to sources in the room. He later added: ‘Many of you came in on the pledge to repeal and replace Obamacare. I honestly think many of you will lose your seats in 2018 if you don’t get this done.’ ”
Once again, though, the polls show a different story. “A strong plurality of voters think congressional Republicans are moving too quickly to overhaul the nation’s health care system,” according to a new Morning Consult/POLITICO poll. This is the big reveal: The poll shows that Obamacare is more popular than the GOP alternative.
This is not a prescription for winning the next election.
It makes it easier for any member of Congress who votes no to tell voters that they stuck up for their interests, instead of following the speaker’s command.
Today the president will meet with the Congressional Black Caucus. He’s likely to make the case there, too. But Trump will have a tough time getting any votes from Democrats unless this health care bill changes into something quite different. The more I read about the legislation, and the review by the Congressional Budget Office, it’s clear that this bill is more of a Medicaid repeal than a repeal of the Affordable Care Act. That’s where most of the “savings” in the bill is found.
There is a notion in the Republican reform, one that I find deeply troubling, that Medicaid is only another word for welfare. In this logic, people who are “able-bodied” are only gaming the system when they have this insurance. Nonsense. Health care is health care. Period. I think we should be expanding access to basic insurance, and Medicaid is a cost-effective program that works. (A tack I took in a recent piece for Yes! Magazine.) I’d like to see Medicaid expanded, perhaps to 300 percent of the federal poverty level.
Again, back to my Seattle days. We had an editorial board meeting on health care reform and at that time the single largest source of Medicaid “customers” was people who worked at Wal-Mart. Fact is they had access to health insurance but could not afford it. And their incomes were so low that they qualified for Medicaid.
An increase in Medicaid eligibility would be a huge gain for Indian Country. That 300 percent number I cited would cover most of the people who use the Indian Health System. If you then add the people who have employer-based insurance, I would bet you would be awfully close to universal coverage. And that ought to be the goal. (Working or not.)
Of course the House plan goes in the other direction. The New York Times reported today that this bill is so bad that even a straight up repeal of the Affordable Care Act would be better. “Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report,” The Times said. “In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.”
That little nugget is not going to help the Speaker reach 216 votes on Thursday. If there is a vote.
I wrote a couple of days ago that the House bill doesn’t mention a word about the Indian Health Care Improvement Act. True enough. Because, it turns out, the proposed replacement for Affordable Care Act is not a complete repeal. The current law would remain in tact.
“The two proposed bills do not repeal the ACA. They leave in place the ACA’s titles affecting Medicare, quality of care, program integrity, biosimilars, workforce reform, the Indian Health Service—indeed virtually all of the ACA except for its insurance affordability provisions, individual and employer mandates, taxes, and Medicaid reforms,” writes Timothy Jost in the journal Health Affairs.
This idea is important. Instead of a repeal, the Republican leadership took the framework of the Affordable Care Act. Then the House authors wrote adjustments to Medicaid spending, the way the bill is paid for, how people get help to buy insurance, and along the way added a few gold coins for insurance company executives. (Compare the bills here in this Kaiser Family Foundation graphic.)
I like the way Jim Roberts described the process on his Facebook page: “Take the ACA, tear out the pages that have been repealed, and see what’s left on the table. Its pretty easy to figure out. Its like cutting the face of an ex-spouse out of the family photos! The entire family photo is still intact and everyone knows who that cutout is. Its Obamacare … You can cut Obama out of the picture, but guess what people, He’s still there!” Jim Roberts is a Senior Executive Liaison for Intergovernmental Affairs at Alaska Native Tribal Health Consortium and a long time expert analyst on how health care policy impacts Indian Country.
So this is the problem I have writing about the bill. Do you go into detail about how bad it is? I could easily type 10,000 words just on Medicaid. Or is it better to focus on the politics, because the odds of this package becoming law are slim. That’s where I headed.
Here is the short version of the politics: Two committees have moved the legislation forward through the House. The House Budget Committee will consider the bill before it goes to the full House for a vote. Then, if the House has enough votes, on to the Senate for consideration.
The Republican Party is divided by serious differences of opinions about health care reform and the nature of government. Conservatives do not believe that health care is a right. They see it as an individual responsibility (Or say they do. If they really believed that, we’d get rid of the employer-based system that insures most people. But that’s another story). This group wants Planned Parenthood defunded. It doesn’t even like the idea of insuring family planning of any kind.
On the other side of the divide are practical Republicans who represent states that have made progress insuring more people because of Medicaid expansion. This group of legislators, mostly in the Senate, see this bill as a way to flip the cost of health care to the states. (Or allow conservative states to do nothing.) The House plan would keep Medicaid running sort of as is between now and 2020 and then turn it into a capped program.
The National Indian Health Board says the House bill would keep in place the 100 percent federal reimbursement to states for American Indians and Alaska Natives patients who use the Indian health system.
One huge problem with capping Medicaid cost is that it works backwards: Because when Medicaid is most needed, such as during a recession, then states have less money available to spend on health care. So people would not get the help they need, when they most need it.
Alaska Sen. Lisa Murkowski spoke at the state legislature about Medicaid last month. According to the Alaska Dispatch News, she said Medicaid strengthened Alaska’s Native health care system and reduced the number of uninsured people visiting emergency rooms. “So as long as this Legislature wants to keep the expansion, Alaska should have that option,” Murkowski said. “So I will not vote to repeal it.” At least three Senators have said they would vote no unless Medicaid is protected. And Republicans cannot lose more than three votes in the Senate for the bill to pass. (According to a new report by the Center for Budget and Policy Priorities Alaska would lose the most under the House plan for tax credits, a whopping $10,243.)
Another deal breaker for many members is the nearly unified opposition from the medical establishment. The American Medical Association “is concerned with the proposed rollback of Medicaid expansions, which have been highly successful in providing coverage for lower income individuals. The AMA is also concerned that changes to Medicaid could limit states’ ability to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction.”
The challenge paying for opioid treatment will be a factor because it’s a crisis in so many communities across the country. The House plan leaves this up to the states. Without funding.
Nonetheless President Donald J. Trump is trying to make his first deal. And he is working it hard. He’s trying to get conservatives to support his deal despite their philosophical misgivings. But if the president gives any more ground, then more moderates will be “no” votes. Trump’s strategy seems to be daring conservatives to vote no. He will demand a party-line vote and say, basically, this is the best deal conservatives are going to get. It’s also why the president and House Speaker Paul Ryan are trying to move fast. Every day they wait, the opposition has more resources to counter that strategy.
Here is what to watch for in the days ahead. Will conservative interest groups such as Heritage Action, Club for Growth, and Americans for Prosperity, “score” the vote? That’s a record that groups use to rate how conservative are members of Congress. Going against this vote could mean less money, support in primary elections, and less conservative street cred.
Meanwhile Rep. Tom Cole, R-Oklahoma, has introduced a just-in-case bill to reauthorize the Indian Health Care Improvement Act. That measure will be ready in case Congress repeals the Affordable Care Act outright (which is what the conservatives argue is the back-up plan).
We live in odd times. Congress is moving forward with promised legislation that will roll back much of the health care reform enacted during the past eight years. The Trump administration is issuing regulations to do the same. The key here is that President Donald J. Trump and Republicans in Congress have the votes (mostly). But in state capitals there are real debates about public policy. What happens next will be determined by lots of people working together.
The future of the Affordable Care Act is a case in point. Republicans in Congress are eager to ditch the law, but coming up with a replacement or even a fix is a much more difficult task. This is one issue where there are not enough votes in Congress to do anything. Yet.
But in state capitals there is an understanding that a wholesale repeal of the law could be a financial disaster for states that have already expanded Medicaid. So many Republicans at the state level, such as Ohio Gov. John Kaisch, are pushing back. He recently told CNN that that any repeal without addressing Medicaid expansion is a “very, very bad idea.”
But several of the states prefer a real solution, one that doesn’t grab as many headlines, yet would be practical. And that is to continue with current law and then Secretary of Health and Human Services Tom Price would grant states many more waivers to design the programs the way they want.
This makes more sense than a block grant because it keeps in place the idea that if people are eligible for Medicaid, then it will be funded. Under a block grant scenario, it’s likely the total amount would be capped and people who currently get insurance could lose that. (Perhaps the most difficult problem is this: How do you protect the states that expanded Medicaid and still add funding to those states that said no?)
This is a huge issue for Indian Country because Medicaid could cover even more of the people who currently use the Indian health system. (Best of all: Money from insurance is supposed to stay at the local healthcare facility.) States also come out ahead with American Indian and Alaska Native clients because the federal government is obligated to pick up the tab. It’s a 100 percent federal “match.”
This is one of those issues that divide Republicans, especially in Congress. The members who are listening to states understand the problem: What happens when you take away people’s health insurance? The answer is not good. And it’s even life or death for some people because without insurance there will be no medical care for ongoing issues.
This week in Washington state there was a victory for health care reform in Indian Country. The Legislature passed, and Gov. Jay Inslee, signed into law, a measure that opens up the practice of dental health therapy.
Dental health therapists are mid-level providers. They work under the supervision of a dentist and offer routine and preventive services, like dental exams; provide fillings; clean teeth; placing sealants; and perform simple tooth extractions. This law is important because it opens up Medicaid funding to pay for dental care. And it expands access making it much easier for patients to get appointments.
“We have one dentist to see more than 6,000 patients on the Colville Indian Reservation,” said Mel Tonasket, vice-chairman of the Colville Confederated Tribes. “This law will help us hire a dental therapist to make sure our people are getting the oral health care they need.”
Most experts in health care reform argue for increasing value in health care by lowering costs and at the same time improving quality. This is that.
This oral health reform was started a decade ago by Alaska Native Tribal Health Consortium. According to The Kellogg Foundation: Since then “45,000 Alaska Natives now have access to dental care and the dental health aide program has generated 76 full time jobs with a net economic effect of $9.7 million, one-third of which is spent in rural Alaska. Now, as a way to replicate the same dramatic oral healthcare improvements in Alaskan villages, i.e., reduced caries disease, healthier teeth and patient satisfaction with culturally competent care given by home-grown providers, tribes are blazing a trail to bring dental therapy to the lower 48 states as a high-quality, cost-effective strategy to reduce dental care shortages. Washington State is on the leading edge of this movement.”
This is a great example of the principle of lead, follow, or get the hell out of the way. A year ago Swinomish President Brian Cladoosby announced that the tribe was using its sovereign powers to hire a dental health therapist in contradiction to federal and state law. The case was clear that the tribe had the authority even while raising questions about Medicaid funding or licensing. (The American Dental Association was successful getting language into the Affordable Care Act that required state action.) But the state of Washington was reasonable and the result is the new law.
The bill was sponsored by Sen. John McCoy, a member of the Tulalip Tribes. “This is a tribal-based solution that will make a tremendous difference for Native people—especially children,” he said.
According to Kellogg: Dental therapists are now practicing in Minnesota, in addition to Native American communities in Alaska and Washington. They’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio are exploring the potential for dental therapists to significantly improve oral health care for many more children and communities.
So look for more action and more success stories coming from state capitals.
The details. This is how the GAO defines its high risk identification: “The federal government is one of the world’s largest and most complex entities: about $3.9 trillion in outlays in fiscal year 2016 funded a broad array of programs and operations. GAO’s high-risk program identifies government operations with greater vulnerabilities to fraud, waste, abuse, and mismanagement or the need for transformation to address economy, efficiency, or effectiveness challenges.”
The GAO said it added federal Indian programs to its high risk category because “we have found numerous challenges facing Interior’s Bureau of Indian Education and Bureau of Indian Affairs and the Department of Health and Human Services’ Indian Health Service in administering education and health care services, which put the health and safety of American Indians served by these programs at risk. These challenges included poor conditions at BIE school facilities that endangered students, and inadequate oversight of health care thathindered IHS’s ability to ensure quality care to Indian communities. In addition, we have reported that BIA mismanages Indian energy resources held in trust and thereby limits opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities.”
More from the GAO: “Congress recently noted, ‘through treaties, statutes, and historical relations with Indian tribes, the United States has undertaken a unique trust responsibility to protect and support Indian tribes and Indians.’ In light of this unique trust responsibility and concerns about the federal government ineffectively administering Indian education and health care programs and mismanaging Indian energy resources, we are adding these programs as a high-risk issue because they uniquely affect tribal nations and their members.”
The three agencies are lumped together as one in this report, yet the causes of what makes the agencies high risk are considerably different, requiring solutions that go well beyond what the agencies themselves can accomplish.
So let’s break it down.
First: GAO complains that the BIA has a problem quickly approving energy projects. This is Congress’ favorite problem. Congress can’t wait to solve this one by making the approval process faster than filling your car with a tank of gas. But the solutions ahead will also have unintended consequences for the very notion of trust lands, tribal control of energy projects, and the challenge of global warming. What happens when a tribe says, “hell no!” to say, the Keystone XL pipeline? That is a policy question that this Congress has all but answered.
Next the GAO says the Bureau of Indian Education “improves how it manages Indian education … including that Indian Affairs develop a strategic plan for BIE that includes goals and performance measures for how its offices are fulfilling their responsibilities to provide BIE with support; revise Indian Affairs’ strategic workforce plan to ensure that BIA regional offices have an appropriate number of staff with the right skills to support BIE schools in their regions; and develop and implement decision-making procedures for BIE to improve accountability for BIE schools.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Only hiring for BIE schools is easier said than done and the decision-making process is complicated by community priorities.
There is another problem at play: Conservative think-tanks have targeted BIE as operating “failing schools” and would replace them with a whacky scheme to create Education Savings Accounts.(Previous: Day One. Dramatic restructuring of government.) This whole notion is written by people who have no understanding of the geography of Indian Country or the makeup of the Native students. The BIE has unique challenges and there are many, many improvements that could be made. So adding to this discourse a GAO high-risk warning is, well, not helpful.
The third high-risk agency identified by the GAO is the Indian Health Service. The report says: “To help ensure that Indian people receive quality health care, the Secretary of HHS should direct the Director of IHS to take the following two actions: as part of implementing IHS’s quality framework, ensure that agency-wide standards for the quality of care provided in its federally operated facilities are developed and systematically monitor facility performance in meeting these standards over time; and develop contingency and succession plans for replacing key personnel, including area directors.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Again, it’s not as if the IHS is not trying to hire people. The problem is funding and a hiring process that is both cumbersome and required by law.
What I don’t get is why the GAO doesn’t see that the IHS mission has changed dramatically. One part of the agency is a funding mechanism, directing resources to tribal, non-profit, and urban health care facilities. The report alludes to that fact with this recommendation: “To help ensure that timely primary care is available and accessible to Indians, IHS should: develop and communicate specific agency-wide standards for wait times in federally-operated facilities, and monitor patient wait times in federally-operated facilities and ensure that corrective actions are taken when standards are not met.” The key phrase here is “federally-operated” because many of the tribal and nonprofit centers have solved this problem. GAO should have said this and focused on what works and why.
Another GAO recommendation about IHS might be the most tone deaf. It says, “we recommend that IHS realign current resources and personnel to increase capacity to deal with enrollment in Medicaid and the exchanges and prepare for increased billing to these payers.”
Clearing my throat here. Umm. Congress is going in exactly the opposite direction. The serious questions — the ones that Congress ought to be answering — are how much will it cost IHS when Medicaid is turned into a block grant? What replaces Medicaid expansion funding at the local unit level? And, will states even fund a federal health care delivery system?
The GAO report makes a big deal about IHS developing a fair method for how it spends money on purchased and referral care. What the report should have said is that Congress is to blame. The problem is not the architecture; it’s the funding. No federal agency. No state agency. Hell, no private medical system spends less than the Indian health system. The real problem here is that it’s impossible to defy gravity.
Last year I expected a record number of Native Americans to get elected to offices across the country. There were just so many really superb candidates running for Congress, state legislatures, and statewide offices. At one point my list topped a hundred candidates. Of course it didn’t turn out that way. Too many of those exceptional #NativeVote16 candidates lost. But my tally to date: Sixty-six elected representatives and senators. So the 2016 election cycle turned out to be more of a rebuilding year instead of one that broke records.
Yet it turns out there is still history to be made.
State legislatures are convening around the country this month and there is an interesting twist: Native Americans are in key leadership positions in at least seven states. That’s impressive — and critical right now because of the types of conversations that will be going back and forth between Washington, D.C., and state capitals about Medicaid, health care and energy policy.
Alaska is a great bipartisan example.
Two years ago former Sealaska chairman Byron Mallott, Tlingit, was elected the state’s Lt. Gov. (He was the Democratic Party’s nominee for governor, but joined an independent fusion ticket along with Gov. Bill Walker.) The Walker-Mallott administration elevated Native issues to an unprecedented level of influence. One of the governor’s first appointments was Valerie Nurr’araaluk Davidson, an Orutsararmiut Native Council tribal member, and a long time health advocate, as the state’s commissioner for the the state’s Department of Health and Social Services. She will be the one negotiating with the Trump administration about what Medicaid will look like if Congress acts to repeal the Affordable Care Act.
Then the state legislature and the Walker-Mallott administration have been at odds over state spending and resources. Alaska has a multibillion dollar budget deficit largely because of the state’s reliance on taxes from oil and gas. As The Fairbanks Daily Miner put it: “Fortunately for the state, previous years when oil revenues were high allowed legislators to sock away billions of dollars in savings accounts. Unfortunately for the state, it was easier for legislators to spend from these savings accounts than make the hard decisions that would put Alaska on a path to a balanced budget.” Further complicating that budget challenge, Alaska citizens are paid a per capita distribution instead of paying income or other general taxes.
So after this election a new alliance was formed in the legislature to try and come up solutions, three Republicans and two independents joined the Democrats to form a majority caucus. The Speaker of the House in this coalition is Bryce Edgmon, Yup’ik. He said his native background is how he views the world. He told the Bristol Bay Times: “I know it’s not only my children and maybe their children’s future, but it’s also the future of our way of life out here in rural Alaska and a lot of our Native villages.”
There are now eight Alaska Natives in the legislature representing both parties. Rep. Sam Kito III, Tlingit, is chair of the Labor & Commerce Committee as well as the Legislative Council (a joint committee with the Senate). Neal Foster is co-chair of the Finance Committee.And Dean Westlake, Inupiaq, is chair of the Economic Development Committee and Arctic Policy. In the Senate, Lyman Hoffman, a Democrat who caucuses with Republicans, is co-chair of the Senate Finance Committee. The House Minority Leader is Charisse Millett, Inupiaq. In a previous legislature, Millett was instrumental in legislating Alaska Native languages as official state languages.
Actually I wrote “bipartisan.” That’s probably the wrong word for what’s occurring in Alaska because a few elected representatives run for election identifying with one party, only to caucus with the other after the election. (Perhaps a model for Congress?)
Oklahoma and Montana are the two states with the most Native legislators, nine. A larger group of Native legislators makes it easier to form a caucus so members can work together on issues important in Native communities. And both states have an active Native caucus.
Oklahoma legislators are leaders in both parties. In the House, Rep. Mark McBride, Potawatomi, is the Assistant Majority Floor Leader. Rep. Chuck Hoskin, Cherokee, is the Minority Whip. And in the Senate, Anastasia Pittman, Seminole, is the Assistant Democratic Leader.
Montana’s newly elected Rep. Shane Morigeau, Confederated Salish and Kootenai Tribes, will serve in leadership this session as Minority Whip. It’s a rare honor for a freshman.
Montana’s American Indian caucus was an important voice in the last legislature on issues ranging from tribal college funding to water compacts. “We’ve been literally and figuratively the minority’s minority,” Rep. Susan Webber, Blackfeet, told the Billings Gazette. “I know it looks like we have a lot of people in the Indian caucus, a lot of people were elected, but in reality it should be more. But just us getting in there, from my perspective, is a real positive.”
A critical challenge for the American Indian Caucus this session will be Medicaid. Montana came late to Medicaid expansion under the Affordable Care Act but its impact has been swift. The state’s uninsured rate dropped from 20 percent in 2012 to 7.4 percent last year. A report by The Montana Budget and Policy Center says a repeal of the Affordable Care Act “could have disastrous impacts on Montana, putting at risk the health care coverage of over 142,000 Montanans who have benefited from ACA measures. At the greatest risk are the over 61,000 Montanans who gained access to affordable health care coverage through Montana’s Medicaid expansion plan.” Worse: the report found that “repeal could cause a greater number of uninsured Montanans than before the ACA was enacted.”
Montana Budget and Policy says 8,000 American Indians are enrolled in insurance through the Medicaid expansion program. Third-party insurance, such as Medicaid, has added nearly a billion dollars to the Indian Health Service budget. “Nationwide, reimbursements at IHS facilities, tribal operated facilities, and urban Indian clinics have increased 21% since the expansion of Medicaid,” the report said. “In 2014, nearly 40% of American Indians did not have health insurance, but Medicaid expansion represented one of the most significant opportunities to expand coverage for American Indians.”
This is important because if Congress repeals the Affordable Care Act, it will be up to state governments to pick up the pieces (as well as the cost) or strip millions of Americans from health insurance coverage. Repeal without new resources could devastate the Indian health system.
Other states where Native American legislators are included in the leadership structure: Hawaii, where Andria Tupola is Minority Floor Leader; and in Colorado, Rep. Joseph Salazar is a committee vice chair.
In Washington Sen. John McCoy, Tulalip, has been a long-time champion of issues that are important in Native communities.
McCoy sponsored legislation to close coal burning power plants and “dramatically reduce the amount of coal burned to generate energy for Washington residents, reducing greenhouse gas emissions in Colstrip by 5 million tons — the equivalent of a million cars — a year.”
The senator says Washington Republicans and dental lobbyists are blocking the creation of a mid-level dental practice along the lines of what’s been done in several states. “Indian country may not have the loudest voice in Olympia, but it still has basic needs,” McCoy wrote in The Seattle Times.
“The idea is pretty simple — allow native communities to train and recruit dental therapists to help clear the backlog of an ongoing oral-health crisis. The research is alarming — one-quarter of Native Americans aged 35 to 44 years have fewer than 20 of their natural teeth,” he wrote. “The dentists also ignore the groundbreaking success of similar programs in other states. It’s been working for 11 years for indigenous communities in Alaska, where 45,000 people are seeing reliable providers for the first time in their lives.”
This issue is not going to go away. A new national survey reports that 45 percent of U.S. voters say they go without dental care because of cost or lack of insurance. But 8 of 10 favor adding midlevel providers as a solution. “Good oral health is critical to overall health, yet policies to expand access to dental care do not reflect this,” said Tera Bianchi, project director of the Dental Access Project at Community Catalyst. “Dental therapists offer better access to care for the most underserved populations in a cost-effective way to the system. They are a smart, effective bipartisan way to improve access to care.”
And this session McCoy will be the he face of the Democratic Party, chairing the caucus where he says he will help “foster the vision and values of Senate Democrats as they navigate the 2017 session.”
In other words: Sen. McCoy has a seat at the head of the table.
Price plan calls for Indian Health savings accounts
Mark Trahant / Trahant Reports
President-elect Donald Trump and Congress are moving quickly to reshape health care, including the Indian Health system. And so far the path looks to be chaotic.
First, the who: The Trump administration will be led on health care issues by Tom Price, a Georgia physician, a persistant critic of the Affordable Care Act, and a member of Congress. Seema Verma will be the next Administrator of the Centers for Medicare and Medicaid Services. As a consultant Verma has helped conservative governors, including the Vice President-elect Mike Pence, implement Medicaid expansion.
And let’s be clear about their task. As the president-elect said, “he is exceptionally qualified to shepherd our commitment to repeal and replace Obamacare and bring affordable and accessible healthcare to every American. I am proud to nominate him as Secretary of Health and Human Services.”
These two appointees know the machinery of the Affordable Care Act and Medicaid, including how to effectively dismantle the programs.
Price has already floated in Congress an alternative to the Affordable Care Act, the Empowering Patients First Act. That bill would repeal Obamacare in its entirety (including the Indian Health Care Improvement Act) and replace it with a free-market version. The plan would give tax credits that “makes it financially feasible for all to purchase coverage they want for themselves and their families – not that Washington forces them to buy.”
This plan would impact the Indian Health System in several ways. First it would allow participants of federal programs, such as Medicaid, Medicare, Veterans health, and even military TRICARE, to opt out and get a tax credit to buy a personal health plan. (Making it less likely those plans will survive on their own.) In the bill’s section on government health programs there is no mention of the Indian Health system, although the bill later calls for a personal health savings accounts that can be spent at IHS. In other words: save your money so you can pay for your own doctor (at IHS or elsewhere).
But forget the details for a minute. Price’s plan is important because it signals the radically different approach to health care that’s ahead, basically less government spending, more tax credits if you choose to buy health insurance, individual health savings account, and shifting Medicaid to a block grant program run by states.
It’s important to remember that Medicaid now accounts for more than $800 million of the IHS’ $6.1 billion budget and that’s often money targeted for the local service unit. (A smaller Indian health system impact would be ending the requirement that tribes provide insurance for employees. That accounts for about $100 million in the IHS budget.)
The problem for Congress is that any replacement of the Affordable Care Act requires at least 60 votes in the Senate, and that means some Democrats will have to agree to new legislation. That’s where chaos begins.
Legislation to repeal the Affordable Care Act can be done through a process called budget reconciliation (the same method that enacted the law in the first place). That means tightly tying the legislation to the budget (something that has not passed in this Congress yet). But a replacement law would require legislation. And to do that there would have to be a consensus in the House (218 votes) and a filibuster-proof majority in the Senate (60 votes).
House Majority Leader Kevin McCarthy said Monday that Congress should move quickly to repeal the Affordable Care Act and then come up with a replacement plan down the road. McCarthy told The Washington Times: “I think once it’s repealed you will have hopefully fewer people playing politics, and then everybody coming to the table to find the best policy.”
And that policy shift will be dramatic. Tax credits instead of funding. A bigger role for states. And the pretense that the private sector is equipped to deliver health care to all.
According to Drew Altman, president and CEO of the Henry J. Kaiser Family Foundation, “The larger story is GOP preparations for a health policy trifecta: to fundamentally change the ACA, Medicaid and Medicare–all three of health care’s major programs–and in the process, fundamentally alter the direction of the federal role in health and core elements of the social contract.”
American Indians and Alaska Natives are in a risky situation. Our best health care programs, those run by tribes and tribal organizations, will get less funding from this kind of trifecta. Neither tax credits nor state funding are likely to help. And interest from the private sector? Get real.
A few years ago I had a chance to ask President George Bush what he thought about tribal sovereignty in the 21st century. His answer went viral: “Tribal sovereignty means that. It’s sovereign. You’re a … you’re a … you’ve been given sovereignty and you’re viewed as a sovereign entity.”
Think about that question today; we would be lucky to get a similar answer. Bush (except for the “given” part) was correct: tribal sovereign means that, you’re sovereign.
This idea is relevant now because during the campaign Donald Trump was dismissive of any sovereignty except his perception of what America’s sovereignty is all about.
So a treaty with Mexico and Canada? Junk it, day one. A United States pledge to reduce global warming? Out. Perhaps even historic military alliances will disappear into lost budgets.
And when it comes to the federal relationship with American Indian and Alaska Native governments as sovereigns we will likely see ideas pop up that were long ago discarded as impractical, expensive, or out-and-out wrong.
At the top of that list: Shifting power from the federal government to state capitals. That was Ronald Reagan’s plan when he came to Washington. In 1981 he proposed rolling dozens of federal programs into block grants for states. Then the budget was cut by 25 percent, the argument being states could deliver the services more efficiently. But a Republican Senate didn’t buy the whole plan. In the end most of the programs were managed by states, but under federal oversight. According to Congressional Quarterly, Sen. Orrin Hatch, R-Utah, then chairman of the Senate Labor Committee said at the time, it was the best deal possible. “We’ve come 70 to 80 percent of the way to block grants,” Hatch said. “The administration is committed to pure block grants, and so am I. But there was no way we could do that.”
Expect Hatch, and House Speaker Paul Ryan, to take another shot at substantial block grants to states, representing a fundamental shift for programs that serve American Indians and Alaska Natives.
Ryan’s agenda, “A Better Way,” proposes to do this with Medicaid. It says: “Instead of shackling states with more mandates, our plan empowers states to design Medicaid programs that best meet their needs, which will help reduce costs and improve care for our most vulnerable citizens.”
This is a significant issue for the Indian health system. Under current law, Medicaid is a partnership between the federal and state governments. But states get a 100 percent federal match for patients within the Indian health system. Four-in-ten Native Americans are eligible for Medicaid funding, and, according to Kaiser Family Foundation, at least 65,000 Native Americans don’t get coverage because they live in states that did not expand Medicaid.
The Affordable Care Act, which is priority one for repeal and replacement, used third-party billing as a funding source for Indian health programs because it could grow without congressional appropriations. The idea is that when a person is eligible, the money is there. The Indian Health Service budget in fy 2017 includes $1.19 billion in third-party billing, $807 million from Medicaid programs. This funding source is especially important because by law third-party billing remains at the local clinic or other unit. And, most important, when the Indian Health Service runs short of appropriated dollars it rations health care. That’s not the case with Medicaid funding.
One problem with the Affordable Care Act (after a Supreme Court decision) is that not every state participates in Medicaid expansion. So an IHS clinic in South Dakota would have less local resources than in North Dakota or Montana. This especially important for health care that is purchased outside of the Indian health system.
The most important gain from the Affordable Care Act has been insuring Native children. According to the Kaiser Family Foundation: “Medicaid plays a more expansive role for American Indian and Alaska Native children than adults, covering more than half of American Indian and Alaska Native children (51%), but their uninsured rate is still nearly twice as high as the national rate for children (11% vs. 6%).”
Ryan’s House plan would convert Medicaid spending to a per capita entitlement or a block grant depending on the state’s choice. There is no indication yet how the Indian health system would get funded through such a mechanism.
During the campaign Trump promised to repeal the Affordable Care Act, including Medicaid expansion, but said there would be a replacement insurance program of some kind.
Earlier this year Sen. John Barrasso, R-Wyoming, chairman of the Senate Indian Affairs Committee, and Sen. John Thune, R-South Dakota, introduced legislation to “improve accountability and transparency at the IHS.”
Barrasso is a physician.“A patient-centered culture change at the Indian Health Service is long-overdue,” he said. “This bill is an important first step toward ensuring that tribal members receive proper healthcare and that there is transparency and accountability from Washington. We have heard appalling testimonies of the failures at IHS that are unacceptable and will not be tolerated. We must reform IHS to guarantee that all of Indian Country is receiving high quality medical care.”
What will reform look like after the Affordable Care Act goes away?
Last week Rep. Tom Cole, R-Oklahoma, said on CSPAN that the Indian Health Care Improvement Act was one of the good features of the Affordable Care Act and ought to be kept. But nothing has been said by Republican leaders about how to replace the Indian health funding stream from Medicaid, potentially stripping $800 million from the Indian health system that is by all measures underfunded.
Perhaps the most important idea in government, one that had been expanding, is the idea of including the phrase “… and tribes” in legislation and funding. That means tribes get money directly from Washington rather than the round about from DC to state capital to tribal nations. And clearly in this era that’s a hard sell. Just last week the state of North Dakota opted to punish (or so it thinks) tribes by canceling a joint appearance before the legislature because the state is not happy with the Dakota Access Pipeline protests. At a moment where there should be more talk, not less, the state walks away.
That, of course, begs the question, is this how government will work over the next four years?