Agency Says Indian Health Should Not Be Exempt From Medicaid Work Rules Because They Are ‘Race-Based’
Mark Trahant / Trahant Reports
The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.
A story in Politico Sunday raised the issue. It said “the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. ‘HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,’ according to a review by administration lawyers,” Politico said.
The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians. “Our political relationship is not based upon race.”
“The United States has a legal responsibility to provide health care to Native Americans,” Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation, told Politico. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”
Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.
Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).
But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.
Other states report similar increases. Kaiser Family Foundation found that in Arizona, one tribally-operated health system reported that about half of visits were by patients covered by Medicaid in 2016. And, an Urban Indian Health Program, reported that its uninsured rate at one clinic fell from 85 percent before the Affordable Care Act to under 10 percent.
Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). In Alaska more than two-thirds of those dollars are spent on private sector doctors and hospitals through purchased care for Alaska Native patients. And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.
A recent report by Kaiser Health News looked at Census data and found that 52 percent of residents in New Mexico’s McKinley County have coverage through the Medicaid. That’s the highest rate among U.S. counties with at least 65,000 people. “The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program,” Kaiser reported. Most of McKinley County is located on the Navajo and Zuni reservations.
Kaiser Health News said Medicaid has opened up new opportunities for Native patients to “get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.”
However the growth of Medicaid is resulting in unequal care for patients in the Indian health system. The benefits in some states, including those that expanded Medicaid under the Affordable Care Act, are more generous. Other states not only refused to expand Medicaid and have been adding new restrictions such as requiring “able-bodied” adults to have their Medicaid eligibility contingent on work.
But the Indian health system — the federal Indian Health Service and tribally and nonprofit operated programs — are in a special case because there is a 100 percent federal match for most services. So states set the rules, but do not have to pay the bill. (Medicaid is often the second largest single item in a state budget behind public schools.)
Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.
Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.
A letter from the Tribal Technical Advisory Group for Medicare and Medicaid said American Indians and Alaska Natives “are among the nation’s most vulnerable populations, and rely heavily on the IHS for health care. However, the IHS is currently funded at around 60 percent of need, and average per capita spending for IHS patients is only $3,688.” The latest per person cost for health care nationally is $10,348 (totalling $3.3 trillion, nearly 20 percent of the entire economy).
The tribal advisory group said it is “critically important” that there be a blanket exemption for IHS beneficiaries from the mandatory work requirements.
A report in September by the Kaiser Family Foundation showed that the majority of American Indians and Alaska Natives on Medicaid already work, yet continue to face high rates of poverty. It said over three-quarters of American Indians and Alaska Natives are in working families, but that’s a gap of about 8 percent compared to other Americans (83 percent).
The Trump administration’s characterization of tribal health programs as “race-based” is particularly troubling to tribal leaders because it would reverse historical precedence.
A memo last month from the law firm of Hobbs, Straus, Dean & Walker said the Centers for Medicare and Medicaid Services “has ample legal authority to single out IHS beneficiaries for special treatment in administering the statutes under its jurisdiction if doing so is rationally related to its unique trust responsibility to Indians. Under familiar principles of Indian law, such actions are political in nature, and as a result do not constitute prohibited race based classifications. This principle has been recognized and repeatedly reaffirmed by the Supreme Court and every Circuit Court of Appeals that has considered it, and has been extended to the actions of Administrative Agencies like the Department of Health and Human Services even in the absence of a specific statute.”
Mark Trahant is editor of Indian Country Today. He is a Shoshone-Bannock tribal citzen. On Twitter: @TrahantReports Cross posted on Indian Country Today.
(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.)
The federal government’s newly enacted budget is a massive “omnibus” act that spends $1.3 trillion and makes some members of Congress pleased and others angry. It’s a document that reflects a broken budget system. And, at the same time, it’s a business-as-usual document in a presidential administration that has promised structural change.
“There are a lot of things I’m unhappy about,” President Donald J. Trump told reporters at the White House Diplomatic Reception room. “But I say to Congress, I will never sign another bill like this again. Nobody read it, it’s only hours old.”
But the negotiations were not hours old. The back and forth between Democratic and Republican lawmakers was essentially a year late. This spending bill only funds the federal government between now and the end of September. But the process took so long because neither side had enough votes to pass the document on their own; Republicans needed votes from Democrats and to get those votes there had to be deals. Lots of deals. Business as usual.
And business as usual is good for Indian Country. Federal Indian programs, some of which had been slated for either elimination or deep cuts, continued on course.
The omnibus spending bill increases funding for the Indian Health Service by 10 percent, and the Bureau of Indian Affairs and Bureau of Indian Education by 7 percent to $3.064 billion. The IHS budget line s $5.5 billion. When the budget is compared to the president’s request, the increases are even sharper, more than 16 percent for the IHS and 23 percent for the BIA.
The bill includes a 3 percent set aside for Indian tribes within the funds available under the Victims of Crimes Act. The cap for these funds was set at $4.4 billion, which amounts to $133 million. As Ebarb wrote: “This is an important step forward for Indian Country, which has the highest rate of criminal victimization and had up until this point been left out of this funding. This funding will address the long standing inequity and meaningfully improve the landscape of victim services in Indian Country.”
The bill provides $50 million for grants to Indian tribes or tribal organizations to address the epidemic, and $5 million for tribes in the Medication-Assisted Treatment for Prescription Drug and Opioid Addiction program.
Infrastructure spending would increase for BIA and IHS construction, BIA road maintenance, and a $100 million competitive grant program is added under Native American Housing Block Grants in addition to the $655 million provided for the NAHBG formula grants.
President Trump said he signed the bill into law because it increased military spending. “I looked very seriously at the veto. But because of the incredible gains that we’ve been able to make for the military, that overrode any of our thinking.”
(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.)
Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. On Twitter: @TrahantReports (Cross-posted on TrahantReports)
Congress did its job: The federal government’s budget is done. The last step was President Donald J. Trump’s signature and so now the government marches on. At least for the rest of this year, until the end of September.
But the White House said Friday that the president may veto the budget because there is not enough funding for a border wall or a solution for the so-called Dreamers. This is after the president assured House and Senate leaders that he would sign the measure into law.
A veto would mean the federal government would shut down at midnight and Congress would have to start a new round of budget negotiations. This will be even more complicated because many lawmakers have left Washington for a two-week recess.
There will be intense pressure from some Republicans for the president to sign this budget into law anyway.
Budgets are a guide to priorities: What programs are more important? Where is the support from Congress and from the people? Did the president get what he wanted?
That last question is the easy one. The money for the budget wall was minimal, at best.
It’s fair to say the administration’s budget was soundly rejected by a Republican Congress. Sure, Democrats contributed a great deal to this budget (and Democrat votes were required to make it so,) but even before that occurred, majority-party lawmakers were dismissing the harsh budget program changes sought by the president.
The president’s team had all kinds of ideas: Deep spending cuts, the elimination of public broadcasting, replace Medicaid with block grants, and, yes, even deeper spending cuts. Yet Congress enacted a budget that increased federal spending both for the military and domestic programs. It’s Congress, not the president, writing the checks.
How bad was the president’s budget? The National Congress of American Indians put it this way in recent testimony: “The president’s budget would cut the Bureau of Indian Affairs by about half a billion dollars, or 15 percent. BIA Social Services would be reduced by more than a third, Indian Child Welfare by more than a quarter, and critical human services programs, law enforcement and courts programs, environmental protection, housing, and education programs would face unconscionable reductions. Infrastructure programs, such as the Indian Community Development Block Grant would be eliminated, and the Indian Housing Block Grant and road maintenance would be reduced.”
Instead, Congress added dollars and protected programs that the White House sought to eliminate.
“This bill represents real progress for Indian Country, significantly increasing our investments in Native health care, infrastructure, economies, and communities. It rejects the president’s dangerous proposed budget cuts and instead provides funding increases that will lead to healthier communities and better outcomes across Indian Country,” said Sen. Tom Udall, D-New Mexico, in a news release. Udall is vice chairman of the Senate Committee on Indian Affairs and ranking member of the Appropriations Subcommittee on Interior, Environment, and Related Agencies.
The omnibus spending bill would have increased funding for the Indian Health Service by 10 percent, and the Bureau of Indian Affairs and Bureau of Indian Education by 7 percent to $3.064 billion. The IHS budget line is $5.5 billion.
Conservatives were not happy with the additional spending in the omnibus bill. “Republicans control the government, yet Congress still follows the Democrats’ playbook,” Sen. Rand Paul, R-Kentucky said. “Time and again, spending skyrockets, and conservatives are expected to fall in line to praise the party for making the big-spending status quo worse.”
However Rep. Tom Cole, R-Oklahoma, a member of the House’s leadership team praised the legislation. “Despite divisions, both sides of the aisle have the responsibility to deliver this legislation for the American people so that the federal government runs efficiently and effectively,” Cole said. “Neither side got everything it wanted, but the end product reflects a broadly supported compromise. A majority of Republicans and Democrats voted for this bill. President Trump urged its passage and has promised to sign this legislation. As we begin to consider funding for Fiscal Year 2019, it is imperative that Congress remain committed to the return to regular order in the appropriations process.”
The president will decide in the next few hours whether or not he got enough of what he wanted.
(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.) Mark Trahant is editor of Indian Country Today. He is a member of the Shoshone-Bannock Tribes. Follow him on Twitter @TrahantReports (Crossposted on Trahant Reports.)
Budgets are statements: This is what “we” care about. It’s money that reveals priorities. The “we” could be, and ought to be, the country. Or the “we” could be a presidential administration that’s not really equipped to govern. So there will be lots of stories this year, like last year, about the Trump’s administration’s desire to cut federal Indian programs, wipe out public broadcasting, end student loan forgiveness, wreck Medicaid and Medicare, food stamps, housing programs, and generally just about every federal program that serves poor people.
And what a message: Rich people face tough times so they deserved a huge tax cut. Poor people are poor because of their own failures. And more money is needed for a wall that’s not needed, for the largest military in the world, and the Republicans no longer believe that deficits matter.
But Mulvaney has a different version. Here is what he says are the messages.
“Number one, you don’t have to spend all of this money, Congress. But if you do, here is how we would prefer to see you spend it,” he said. “And the other message is that we do not have to have trillion-dollar deficits forever.”
Ok. So the action is in Congress. Even Republicans on Capitol Hill know that this budget cannot be. It’s chaos as numbers.
Perhaps the best line of nonsense was written a line written by the budget director to House Speaker Paul Ryan saying domestic spending at the levels Congress has already approved would add too much to the federal deficit. That’s funny.
For this budget to become law (and overwrite the current spending bill) the House and Senate would have to agree to a budget. That’s unlikely. As I have written before there are lots of votes against any budget but not enough votes to pass any budget. A budget resolution would allow the Senate to move forward with a spending plan with only Republican votes (and even then only one to spare). But unless the rules change (which President Trump wants) the Senate needs 60 votes for regular appropriations bills. That means a lot of compromise before federal spending.
The most popular part of the president’s budget is infrastructure spending. But most of his plan would be funding from state, local, and tribal governments. That’s a problem. Congress will not be eager to follow this approach, especially in an election year. Members of Congress love announcing new roads and other projects. It means jobs back home.
It’s telling that in the White House statement on infrastructure tribes are not mentioned (something that was routinely done in the Obama White House).
Gary Cohn, the director of the National Economic Council, wrote: “Our infrastructure is broken. The average driver spends 42 hours per year sitting in traffic, missing valuable time with family and wasting 3.1 billion gallons of fuel annually. Nearly 40 percent of our bridges predate the first moon landing. And last year, 240,000 water main breaks wasted more than 2 trillion gallons of purified drinking water—enough to supply Belgium.”
So the Trump administration’s answer is to fund this with local government dollars because, as Cohn puts it, “the federal government politically allocated funds for projects, leading to waste, mismanagement, and misplaced priorities. The answer to our nation’s infrastructure needs is not more projects selected by bureaucrats in Washington, D.C Instead, the President’s plan designates half of its $200 billion for matching funds to stimulate State, local, and private investment.”
Another thing for a broken Congress to fix. If the votes are there. In theory that should be easy. This is an area where Republicans and Democrats agree (actually anyone who looks at the crumbling state of infrastructure can figure this one out). But in this Congress? We shall see.
At the State of the Indian Nations Monday, National Congress of American Indians President Jefferson Keel said: “Native peoples are also builders and managers of roads and bridges, and other essential infrastructure. These projects are often in rural areas. They connect tribal and surrounding communities with each other, and the rest of the Nation. Tribal infrastructure is American infrastructure. In 2018, NO infrastructure bill should pass, UNLESS it includes Indian Country’s priorities.”
Back to the budget as a messaging document. The Center for Budget and Policy Priorities says this budget “violates the spirit of the bipartisan agreement that congressional leaders negotiated just a few days ago.” That’s going to make it much more difficult to come up with the next agreement in Congress (unless the law is ironclad, stripping the administration of some of its governing authority).
The budget assumes that Congress would repeal the Affordable Care Act and replace it with a block grant formula. The votes are not there for that. It’s fantasy.
The current bipartisan agreement “calls for adding $2.9 billion per year over the next two years to the discretionary Child Care and Development Block Grant, boosting this key federal program to help make child care affordable for low- and modest-income parents. But the budget reneges on that and proposes essentially flat funding for the program. The Administration’s blatant dismissal of a major bipartisan agreement on which the ink is barely dry may make bipartisan agreements harder to reach in the future,” the budget center reports. “And then, in years after 2019, the budget calls for cuts of unprecedented depth in non-defense discretionary programs even though that’s the part of the budget that contains many federal investments in long-term economic growth. By 2028, funding for non-defense discretionary programs would fall 42 percent below the 2017 level, after adjusting for inflation. Indeed, by 2028, total NDD spending, measured as a share of gross domestic product, would be at its lowest level since Herbert Hoover was president.”
To me that’s the key point. Domestic spending, the programs that serve Indian Country, are already dropping and have been for a long time. All domestic discretionary programs add up to about 4.6 percent of the budget — and federal spending on Indian Country is a tiny fraction of that.
And, as the budget center points out, that means Trump budgets would actually “go below the 2019 sequestration levels, which Congress just agreed is too low to meet national needs.”
The messaging document (the budget, remember?) has another problem. It’s based on assumptions that are even more of a fantasy than repealing the Affordable Care Act. The budget assumes a 3 percent growth rate this year and 4 percent next year. So lots more people earning more and paying more income taxes (since corporations will be paying less). Not. Going. To. Happen.
Even economists think this is nonsense. The crackdown on immigration, for example, is shrinking the economy, not growing it. And the Congressional Budget Office projects a long term growth rate of just under 2 percent. Last year the economy grew at 2.6 percent, below what Trump said would happen and even below the consensus of economists.
This 2019 budget will accomplish one thing: It will serve as a mile post for the fall election. Republicans can make the case for defense spending and, I suppose, that they used to be against deficits. And Democrats will make the case for protecting health care and other domestic priorities.
Gavin Clarkson is clear: He supports President Donald J. Trump. And he’s running for Congress because “the swamp is deep, the alligators, bite, and the taxpayers are getting ripped off every day.” He wants less regulation and more oil and gas development. And don’t get him started on what he dismisses as “fake news.” More on that, shortly.
Clarkson, a Choctaw tribal member, is running in the Republican primary for New Mexico’s second congressional district. The district is now represented by the state’s only Republican in Congress, Steve Pearce, who is a candidate for governor. It’s a crowded field. There are at least four Republican candidates and a half dozen Democrats. (Two of the Republicans have already raised nearly a half million dollars between them.) The filing deadline comes up in March and the primary is in June. The district is 5.5 percent Native American, and includes the homelands of the Mescalero Apache Tribe, and the Zuni, Laguna, Isleta Pueblos. A small portion of the Navajo Nation and Ft. Sill Apache are also included.
This is a fascinating district. It’s huge, the largest congressional district in the United States that’s not a single state district, such as Alaska or Montana. It’s also considered a “lean Republican” district by about five points. And Trump did carry the district, but he only barely reached 50 percent of the vote. Obama won over the same voters in his last race.
It’s also a district that is changing demographically. Pew Research says only 40 percent of Hispanics in the district are now eligible to vote, but potentially that number could soon top 56 percent. That would be a game changer and the current divide over childhood arrivals and immigration reform could exacerbate that shift.
Clarkson has served in the Trump administration as the Deputy Assistant Secretary for Indian Affairs. He is a business professor at New Mexico State University. And says he’s the first Native American to earn a PhD from the Harvard Business School.
His short stint at Interior was focused on modernizing the Indian trader regulations.
However Clarkson’s role become controversial after an Inspector General released a report that said stronger “internal controls” were needed over the management of Indian loan program guarantees. ProPublica and The Washington Post reported that Clarkson resigned after the report — something he calls “fake news.” That’s harsh. After reading the stories, it’s clear that someone at Interior had said he had resigned. There is a source there. Two different news organizations would not independently make that fact up. And Interior would not comment on the record, only saying it was a personnel matter.
The issue involves a $22.5 million loan guarantee for an enterprise of the Lower Brule Sioux Tribe that the Inspector General said did not meet guidelines and the deal “went south.” Clarkson blamed Lois Lerner, then an IRS official, for changing the rules. But reports from the Inspector General and from Human Rights Watch cite a the lack of internal control and a fiscal shell game. The Inspector General report said: “Appropriate controls are important due to the level of risk of this Program. Between 2010 and 2016, DCI paid approximately $12.4 million in claims resulting from defaults, and received an additional claim for approximately $20 million, which had not been paid at the time of our review. As of September 30, 2016, DCI was potentially liable for $606 million in guaranteed loans. Should any of the borrowers default on these loans, it is ultimately taxpayers who would carry the burden of bailing out the lenders since their obligations are guaranteed by the U.S. Government.”
Clarkson said he did not personally profit from this venture nor did not resign from the Interior Department until the end of this year. And then, he said, it was to run for Congress. “The story spiraled out of control,” Clarkson said. He said the department said he could not comment, or correct the record, only told to “suck it up.” Now that he is out of government, however, he said he can tell his side of the story.
** Update. The IG report said: “Finally, the company’s business plan relied on an expectation of a favorable tax ruling from the Internal Revenue Service, which it did not receive.” However a 2008 letter from the IRS does say the business plan could raise capital based on an exemption from federal taxes. That, Clarkson said, was later reversed by Lerner.
And in his news release announcing his candidacy Clarkson went on the attack. After exposing “Lois Lerner’s racist practice of conducting IRS audits of tax-exempt bonds thirty-two times more often against tribes than state and local governments,” Clarkson said he was able to convince one of Lerner’s subordinates to admit the IRS’s wrongdoing and change its policy. “Lois Lerner retaliated by pulling the rug out from under my initiative to leverage capital gains tax treatment to attract outside capital investment into tribal economies. She changed the rules in the middle of the game, ignoring the plain reading of a statute, just like far too many activist judges do.”
Clarkson said he is running as a conservative and a lifelong Republican. He said his advocacy of tribal sovereignty is not a partisan issue and he will have support from tribes, individual Indians, and the oil and gas industry.
I asked Clarkson about climate change. He said he’s not convinced it’s necessary to destroy the economy to take action. “I fully support the president for pulling out of climate deal,” he said. We have to “do what’s best for America.” Translation in the Trump era: Do what’s best for gas and oil.
To me, doing what’s best for America means to take climate change seriously and to act accordingly. Clarkson told me as a “scientist” he’s skeptical. However his resume reports that he was awarded a grant from the National Science Foundation to study the dynamics of tribal finance. His expertise is not in climate science, but economics.
This is important because it’s misleading to say that the science is not there when it comes to climate change. It’s a political talking point and nothing more. One of the standards of academic research is the peer review process. According to a recent roundup of scientific studies by the National Aeronautics and Space Administration, “peer-reviewed scientific journalsshow that 97 percent or more of actively publishing climate scientists agree: Climate-warming trends over the past century are extremely likely due to human activities.” My point here is that to say, “the evidence is not there,” is an attack on the scientific process (which is exactly why the Trump administration is so keen to make research less rigorous).
The other issue I asked Clarkson about was Medicaid. Nearly every Republican plan in Congress pushes the idea of turning Medicaid into a block grant program for states. Clarkson said in an email: “I firmly believe that Medicaid is a critical program and must be improved by making it less bureaucratic. I believe that Medicaid has become too costly and complex for states to effectively manage, and it is already the biggest item in state budgets and is projected to absorb as much as 80-100 percent of all state revenues if left unreformed.” He said he supports the Navajo Nation’s efforts to assume Medicaid responsibility for on-reservation members. “The nation’s most disadvantaged, including many needy children, deserve an efficient health care program that will continue to provide essential services,” Clarkson said. “If Medicaid is left as it is currently, there will be no safety net for the poor in the future.”
I, too, would not leave Medicaid as it is. I would expand it. It’s more cost effective (yes, cheaper) than private sector health care. But more important Medicaid has become essential to the Indian health system.
What qualifications are needed to manage (and possibly reform?) the Indian health system? It’s Indian Country’s largest employer with more than 15,000 on the payroll and many, many more people who work in health care for tribes, non-profits and other related agencies. The IHS budget is $6.1 billion. Yet it’s also the least funded national health care delivery system, operating in a political atmosphere where critics ask, why can’t it do more?
The Wall Street Journal published a story last week that raised questions about Robert Weaver, the Trump Administration’s nominee to head the Indian Health Service. The Journal challenged Weaver’s history at St. John’s Regional Medical Center in Joplin, Mo., from 1997 to 2006. However it quoted Jennifer Talhelm, an HHS representative, saying “any suggestion Mr. Weaver is unqualified to run IHS is a pure act of character assassination.”
A few facts: Weaver will be the least educated director of the Indian Health Service ever. If confirmed, Weaver will the tenth permanent director. All but one prior to Weaver have been physicians, most with multiple degrees in public health, science, and health administration. One former director, Robert McSwain, was not a medical doctor, but he was a longtime health manager and holds a Master of Public Administration from the University of Southern California. On his CV, Weaver lists his education at Missouri Southern State University in International Business with an emphasis in Marketing and Accounting; Minor in Spanish; Minor in Vocal Music & Piano. However the Journal reported that he was seeking a degree and did not graduate.
Weaver’s background is insurance. In a September 2016 profile in Native Oklahoma magazine, Weaver said, “We have Native Americans who are brilliant — geniuses — at gaming, but where are the Native American geniuses at insurance? It’s the second-largest cost we pay other than payroll. Yet it just goes to the wayside.” He told the magazine that his business saved the Quapaw Tribe more than $5 million a year.
“I try to be a translator for tribal leaders to understand this convoluted, difficult-to-understand, most of the time full of lies and deception industry, into ‘this is what it is. This is what your choices are.’ I get it,” he told Native Oklahoma.
Perhaps the Indian Health Service should be led by someone with an insurance background. It would surely help if the agency could come up with a better funding model, including a mix of insurance funds (third-party billing in IHS-speak.)
But there are three problems that ought to be clearly addressed through the Senate confirmation process.
First there is the problem of scale. Weaver would jump from managing a $10 million a year small business — one where he can hire and fire at will — to running a $6 billion agency where personnel decisions are made by folks higher in the chain of command at the Department of Health and Human Services or even as a favor to a United States Senator. And firing? Just one such action could take up more time than the three years left in this administration. And that’s the easy stuff. The agency’s operations are complicated by Congress, law, regulation, tribal relations, the Veterans Administration, Medicare, Medicaid, and private insurance.
To his credit, Weaver has been outspoken about the underfunding of the Indian health system. (Question: Will he say so again in his confirmation testimony?) In a paper he wrote a year ago, Weaver said: “Healthcare is a treaty right for all Native Americans. The method of delivering healthcare for Native Americans is the Indian Health Service system established through the Federal Government. The Federal Government allocates funds to the IHS system each fiscal year. This allocation has been and continues to be inadequate to meet the healthcare needs of Native Americans. Currently it is underfunded by thirty billion dollars annually.”
That figure of $30 billion would eliminate the funding disparity for Indian health. (The National Congress of American Indians has published a plan to make that so over a decade.)
The second problem is how to articulate the Indian health story. This is a problem of “duality,” two competing ideas. On one hand you have some significant health and management problems such as those identified in the Great Plains by The Wall Street Journal. On the other hand you have a system that is innovative and includes models of excellence (such as clinics in the Pacific Northwest or the Alaska Native Medical Center.) One story is told. The other less so. I am convinced that a fully-funded system will only happen when we tell both stories. The narrative of failure is not an incentive to invest more money.
The third problem is the Affordable Care Act and Medicaid. Weaver wrote that the law works for Native Americans but overall it was a failure. “We now see that it did not provide health insurance for the forty million uninsured Americans identified as the target market in 2008, it is not affordable for those who were pulled into the ACA system, and the out of pocket maximums associated with the plan effectively make access to healthcare unattainable,” he wrote. The first part of that sentence is factually incorrect. The uninsured rate dropped from 20.5 percent in 2013 to 12.2 percent in 2016, a 40 percent decline. You can argue about the cost of that insurance, but it’s complicated because the ACA required minimum standards for insurance, covering such things as women’s health. All of the Republican plans are designed to save money by getting rid of those standards.
Of course in the Trump era there’s probably not a candidate for any public office who champions the ACA.
But I also don’t see any Medicaid experience in Weaver’s background and that is an expertise area that is critical. Some of the medical, treatment, and ethical issues are extraordinarily complex. They will require a solid team to help consider all of the alternatives that have life and death consequences. (So, if confirmed, he’ll need a lot of help.) Oklahoma is not a Medicaid expansion state, so there would not be a lot of experience in squeezing every dollar from Medicaid by making more people eligible or rethinking the coding of costs. The public insurance of Medicaid (and Medicare) now total $1.05 billion of the IHS budget, but it could be a lot more.
Weaver could use his expertise to help tribes improve insurance for tribal members and employees — and that could boost funding for IHS. Private insurance is now only about $110 million of the agency’s revenue.
So what are the qualifications necessary to run the Indian health system? I have a bias. I have met some of the great physicians who ran the agency. I remember Emery Johnson’s passion and thoughtfulness about what IHS could be. I’d even argue that IHS has had remarkable leadership since its founding. So the standard, for me, at least, is quite high. There are also two Native women who have run state health agencies — an ideal background for managing the IHS. There is a lot of talent out there.
But the Trump administration likes the idea of shaking up government. And, appointing someone to run the IHS with a very different background, does just that. Perhaps Weaver brings a new way of thinking and managing. Then again we would do well to remember the latin phrase that medical doctors learn early in their training, Primum non nocere. It means: First, do no harm.
(Note: I use the phrase, Indian health system (lower case) unless I am specifically talking about the agency. My reason is that the narrative of a government-run health care agency, the Indian Health Service, doesn’t reflect what most of what the agency does now. The funding mechanism that supports tribes and non-profit health care agencies is the largest part of the system.)
Correction: The chart I originally published was misleading. The CBO score for the tax bill (and most of the other measures) looks at the cost over ten years. Appropriations are made in a single year. So that made the tax bill appear more costly in visual form. I am working on a new version now, something that illustrates the downward pressure on federal spending but uses an apple-to-apple comparison. (I also added a sentence in the report below to stress that the tax cuts are measured over a decade.)
Funny thing: I was so intent on getting the area of the bubbles correct that I completely spaced the CBO’s measure of ten years as opposed to a single year for appropriations.
Two take aways. First. I still want to illustrate, visually, the downward pressure on the budget. The balloons I used were misleading, but the point remains the same. The pressure to cut is going to grow in intensity. Second: The reconfigured bubbles (which take up too much space because of their relationship) really show the problem of entitlement spending, such as Medicaid. That’s a whole different topic … but visually, wow.
Elections should be fought over policy not nonsense
Mark Trahant / Trahant Reports
Elections in America are usually fought over nonsense. Trivial topics. Stuff that grabs headlines. Or issues that remind voters why they are in Political Party A or B. (And for good measure there is always contention about the personality of a So So Candidate who does (or does not) connect with voters.)
This problem is particularly acute in the Trump era. The recent news cycle pits President Donald J. Trump versus Steve Bannon. The White House statement that Bannon “lost his mind” is attention grabbing. Our political minds want to know what this means for the next election and the Trump coalition (which still defies logic because it subtracts supporters, rather than reaching out and finding new ones).
But politics ought to be more about policy. What choices are being made in our name? What’s the best way to improve the lives of children, the next generation? How do we invest public resources, that means tax dollars, into making life better? These are questions that get far less attention than the latest presidential tweet.
Then the president and Congress have already set the rules for this debate when they passed tax cuts. Now, every act of Congress, every budget from the administration, will set out to justify (and pay for) that law.
This is the problem: The Congressional Budget Office predicts that the federal deficits will increase to $1.8 trillion over the next decade. “As a result of those higher deficits, debt held by the public would increase from the 91.2 percent of gross domestic product in CBO’s June 2017 baseline to 97.5 percent,” CBO said. That means that the annual budget deficit will be nearly equal to the entire economy.
But CBO is on the conservative side of this argument. The Committee for a Responsible Federal Budget warns that after adding interest costs the tax plan would be enough to “increase debt to 111 percent of gross domestic product … That would be higher than any time in U.S. history, and no achievable amount of economic growth could finance it.”
A federal debt that’s bigger than the entire economy. And, key phrase here, “no achievable amount of economic growth could finance it.”
Already leaders of the Congress — the same bunch who did proposed this tax legislation — are now saying the country cannot afford to spend money on social programs.
Congress gave corporations a tax break worth $1.3 trillion. And another $425 billion was rewarded to small businesses that pay their taxes on individual returns (so-called pass through taxes). On top of that (for desert, perhaps) the Congress gave the very wealthiest, those few who pay estate taxes on inherited wealth, a break worth $83 billion. Even though those numbers reflect a decade of revenue, it still means that many in Congress say there is not enough money to fund the government.
That’s a rotten framework. But it’s more complicated when you add one more layer: The Budget Control Act of 2011. That law was passed to limit Congress’ power to spend freely. It sets in place budget caps for domestic and defense spending. If the caps are exceeded, then an automatic sequester (remember that?) kicks in unless Congress passes a waiver. That deal linked spending for defense and domestic programs.
Now it’s a problem because the Republicans want to spend a lot more money on the Pentagon. They want that part of the budget to go up. But because it’s linked to domestic programs — such as those that impact Indian Country — that cannot happen without an agreement with the Democrats. Wednesday the leaders of both parties in the House and Senate met to try and make that happen. House Minority Leader Nancy Pelosi described the meeting as “positive and productive.”
Democrats, for once, have some power to bargain. More spending for defense cannot happen without their votes. (Republicans remain divided over all federal spending.) So Democrats are trying to see how much leverage they have and over what issues. It’s likely that domestic spending will be a part of any deal, and possibly the Children’s Health Insurance Program. Several Democrats, including Sen. Bernie Sanders of Vermont, have said they will not vote for any budget unless it includes a provision to protect immigrants who were brought to this country as children, the so-called Dreamers. (President Trump removed Obama-era protections for this group and it’s a moral imperative for Democrats (and many Republicans) to protect some 800,000 people from deportation. The Deferred Action for Childhood Arrivals, or DACA, began under President Obama.)
That’s a huge agenda. It’s likely that Congress will again push it forward past its deadline of Jan. 19. Even if there is a deal, say today, then the actual writing of the budget will have to go back to the Appropriations subcommittees to be put into legislative language. That will take time.
Federal spending on Indian Country ought to be in a different category, one that does not yet exist. There should be a line item for treaty obligations. Should.
So far the budget numbers are hard to know for federal Indian programs. The Trump administration’s budget was largely ignored. And the House and Senate committee numbers look lean, but fine. But the thing is until there is an actual deal, none of these numbers matter. After a deal each committee will have to go back and determine what money can actually be spent. If it’s a good deal, the numbers will stay the same or even improve. The alternative? No words.
Of course the bigger issue in Congress is about priorities. This Congress has already decided that tax cuts are the most important thing that had to be done. So every fight over the budget has to somehow go through that filter. There is not enough money because Congress is giving corporations $1.4 trillion so they can be more competitive and profitable. (Funny: thought they were both.)
As economist William G. Gale wrote for the Brookings Institute: “… tax cuts are not free; they eventually have to be financed with higher taxes or lower spending. And once those financing requirements are taken into account, most low- and middle-income households are likely to be worse off than they would have been without the tax cut in the first place.”
Worse off. Then Indian Country knew that before the tax bill ever reached the president’s desk.
Congress has yet to reenact the Children’s Health Insurance Program and states will soon run out of funds to prop up the program. That will mean that thousands of American Indian and Alaska Native children will lose their health insurance. And, the result is the Indian Health Service will have to stretch its already thin dollars to try and cover the budget hole.
The Children’s Health Insurance Program expired Sept. 30. This federal program insures young people and pregnant women who make just enough money not to qualify for Medicaid (but can’t afford private insurance). The idea is to make sure that every child has the resources to see a doctor when they are ill.
It’s hard to break down precise numbers because agencies lump funds from the Children’s Health Insurance Program or CHIP into Medicaid data. But we do know that the law worked really well. We also know there are more than 216,000 children that have health insurance because of Medicaid and the CHIP. Indeed, Native American children rely on Medicaid and CHIP at much higher percentages than other population groups. A study by Georgetown reported that 54 percent of American Indian and Alaska Native children were enrolled in Medicaid or CHIP as compared to 39 percent of all children. “Even though much progress has been made in extending Medicaid coverage to American Indians and Alaska Natives, the uninsured rate for American Indian and Alaska Native children and families remain unacceptably high,” the report said.
Overall the uninsured rate among non-elderly American Indians and Alaska Natives fell by 7 percentage points from 24 percent to 17 percent, according to the Kaiser Family Foundation.
This is a big deal and here’s why: The Indian Health Service is a health care delivery operation that works best when insurance (third-party billing in government-speak) pays for the medical costs. Medicaid, CHIP, Medicare, and other third-party billing now accounts for 22 percent of the IHS’ $6.15 billion budget.
But if Children’s health is no longer funded (because Congress did not reauthorize the legislation) then the Indian Health Service will have to make up the difference. That means taking money away from other patients and programs. It will be a critical problem for clinics because by law dollars from third-party billing (or Medicaid and CHIP) remain local.
Alaska is the state most impacted by Congress’ failure to act because two-thirds of the children in the Native health system are covered by Medicaid or CHIP. Other states where there will be significant hits: Montana, North Dakota, South Dakota, Washington, New Mexico, Oklahoma, North Carolina, and California.
The House of Representatives passed a CHIP reauthorization in early November. But that bill included a $6.35 billion budget cut to other health programs, including the Prevention and Public Health Fund, which provides money for vaccines, smoking cessation, and other initiatives to improve public health. The House would also ban lottery winners from being insured by Medicaid, tighten the timetable for people to sign up, and to change other rules.
It’s unlikely the Senate will agree. But the Senate is not moving quickly to pass its own legislation. The Senate is too busy working out tax cuts that will benefit large corporations and the very wealthy. (Previous post: What matters? Tax fight is about seven competing values.)
Across the country, some nine million low- and middle-income children rely on CHIP for health coverage. And, according to The Hill newspaper, States have asked the Centers for Medicare and Medicaid Services for funding to hold them over in the interim, and the agency has awarded about $607 million in redistributed funds to states and U.S. territories. Tribes will also lose hundreds of thousands of dollars in CHIP-related grants.
Last month, Utah Republican Orrin Hatch, who chairs the Senate committee responsible, called CHIP a “top priority” that had bipartisan support. The committee passed the bill October 2. But it’s up to Majority Leader Mitch McConnell, R-Kentucky, to bring the legislation to the floor for enactment. Then the House and Senate would have to iron out and agree on their differences before the bill can become law.
Why Indian Country should have a voice in this debate
Mark Trahant / Trahant Reports
There is no better way for any legislature — be it a tribal council, a state assembly, or a Congress — to telegraph what’s most important to a society than through tax policy. How a government collects revenue says what constituent groups are seen to matter. And, conversely, what groups and issues are insignificant. And, that of course, is Indian Country.
As Adrian Sinclair wrote in Cronkite News: “Indian Country once again does not have a seat at the table.” Tribes “aren’t treated the same as state and local governments across the board on a whole series of issues,” John Dossett, general counsel for the National Congress of American Indians, said after the hearing. “Tribes are … either ignored or they’re an afterthought.” He said there are many cases where state governments have more power than tribal governments, like the federal Adoption Tax Credit, which gives a credit to parents who adopt a child with special needs. But the credit only applies when a state court, not a tribal court, rules that a child has special needs.
So Indian Country is a perfect illustration for my larger point: A country’s tax policy shows what it values. The key to this idea is simple when a nation wants more of something, then taxes it less. And, other hand, if a nation wants less of something? Tax it more.
All interest on debt was deductible when the first income tax was created in 1894. Why? Because Americans did not like to borrow. It was almost immoral. As a writer for Harper’s Weekly warned a man in debt “must smile on those he hates, he must extend his hand where he would strike, he must speak pleasantly with a curse in his throat … He wears dependence like a yoke.”
But Congress made debt a better deal. You could borrow money for that new farm, or especially a home, and the government would subsidize the loan by making it a tax deductible transaction. By the 1920s car loans were the bigger deal. Americans were borrowing, buying and deducting. Congress created a monster with that policy and today debt is one of America’s great loves. Then in 1986 Congress switched gears: Today individuals can only deduct mortgage interest. But even that single benefit was generous. You could buy a big house. A bigger house. A ginormous house. And deduct 100 percent of the interest up to the cost up to $1.1 million of debt. And that tax deal includes second homes.
So as a policy the Congress was telling we the people buy bigger houses. And go ahead, get that second house in the woods or on the lake.
That’s what tax reform is, setting parameters for what the elected leaders think important for a national policy. So, if it becomes law, this tax reform will change the way we consumers spend money. Perhaps we’ll buy and build smaller houses and rent a cabin on the lake instead of purchasing one. This might be a good outcome for all of us. This is actually a pro-climate policy (please don’t tell Congress.)
This same priority process is true for renewable energy. Congress created incentives for wind, solar and other renewable energy. But, now the Republican plan is to reverse course, and reward oil, gas, and especially coal. Tax policy will favor fossil fuel development and renewable energy will therefore cost more. But will companies still invest? Who knows? We do know the calculations will be way more complicated. And, did I mention, renewable energy will cost more.
Let’s consider the overarching messages, the narrative, that will form policy in the tax bill before the Senate and the one already passed by the House of Representatives.
ONE: The bigger the corporation, the bigger the break
The tax bills paid by corporations are driving the legislation in both the House and the Senate. Republicans argue that if taxes are lower, companies will invest more in the United States (instead of other countries) and hire more people at higher wages. This debate is complicated because the current tax code is full of loopholes (something that Republicans say will be fixed). But the bottom line is that U.S. companies have a higher tax rate than what other countries charge, but, and this is huge, the companies actually pay less in federal taxes than what other other countries charge.
As the Harvard Business Review says: “First and foremost, corporate taxes are important because they help pay for government services. While they don’t account for as much U.S. tax revenue as they once did, they remain one of the central ways the government raises funds. According to the Tax Policy Center, “The corporate income tax is the third largest source of federal revenue, after the individual income tax and payroll taxes.”
The House bill cuts the top rate that large corporations pay from 35 percent to 20 percent. It would be the largest one-time drop in the big-business tax rate ever. And it’s a permanent change (the individual rates expire after a decade) at least until there’s another tax bill.
Companies will also get more deductions for purchasing new equipment. And there is an incentive for companies to move their profits back to the United States from low-tax countries.
The Senate bill is evolving. It also rewards big business. But in order to reduce the cost of the entire package, it delays reducing the corporate rate until 2019. (Imagine every business in the country holding off on just about any new activity because the tax laws changed next year.)
The metaphor: Multinational corporations rule.
TWO: It’s tough being rich
The New York Times’ Nicholas Kristof writes that it’s hard being a billionaire these days. “Why, some wealthy folks don’t even have a home in the Caribbean and on vacation are stuck brooding in hotel suites: They’re practically homeless! Fortunately President Trump and the Republicans are coming along with some desperately needed tax relief for billionaires.”
One way this works is be reducing the tax when someone inherits a wealthy estate. Both versions start this tax at $11 million. The House eliminates the so-called “death tax” in 2024 while the Senate keeps the tax but raises the exemption.
A second provision changes what’s called the Alternative Minimum Tax. The way that works is that after a tax return is completed, and there’s a whole slew of deductions, there is a calculation to see if that taxpayer should still pay something. The idea is to make sure that people earning more than $130,000 a year still pay an income tax, even if they find deductions in every corner. That goes away.
And there is one more goody for the rich. Charitable contributions can still be deducted.
The metaphor: Wealthy families so need our help. OMG.
THREE: Why work?
This part of the debate starts with the corporate tax rates. The Trump administration argues that cutting corporate taxes will benefit workers because companies will reward workers with better wages.
Treasury Secretary Steven Mnuchin claims that “many, many economic studies show that more than 70 percent of the burden of corporate taxes are passed on to the workers.” However economists are divided. As the Center for Budget and Policy Priorities points out “this claim is misleading … the evidence indicates that most of the benefits from a corporate rate cut would go to those at the top, with only a small share flowing to low- and moderate-income families. Mainstream estimates conclude that more than one-third of the benefit of corporate rate cuts flows to the top 1 percent of Americans, and 70 percent flows to the top fifth. Corporate rate cuts could even hurt most Americans since they must eventually be paid for with other tax increases or spending cuts.”
The bottom line is that the tax bill will not make life easier for people earning under $75,000 a year. The income tax portion might go down (depending on family size, smaller in this case is better) but costs will go up for education and health care.
And, on top of that, this tax policy will sharply reduce federal spending across the board. Last week the National Congress of American Indians (NCAI) and the Native American Finance Officers Association (NAFOA) came out against both the House bill and the Senate Finance Committee bills in part because of this point. “NCAI and NAFOA view it as deeply regrettable that neither the House nor the Senate bill takes seriously Indian Country’s priorities for tax reform,” a news release said. “With respect to tribal nations, unless tribal provisions are included, the current tax reform legislation amounts to little more than a $1.5 trillion increase in the federal deficit over the next ten years. This deficit increase will inevitably create pressure to cut federal programs and services that are extremely important to tribal communities. Deficit-financed tax cuts that lead to austerity budget cuts would affect all Americans, but would disproportionately impact American Indians and Alaska Natives who rely on federal funding of the trust responsibility as well as social programs.”
The metaphor: Workers don’t matter.
FOUR: Help mom and pop sell stuff
Most people who own a small business structure their entity as Limited Liability Corporations, S-Corps, or a partnership. This means that the income generated is reflected on the individual’s tax return. The House lowers the taxes on profits from 39.6 percent to 25 percent and has a 9 percent increase on the first $75,000. The Senate goes a different route with a new incentives for small business. This is “pass through income” because of the structure. And this part of reform really does solve a problem. Small business is critical — especially in Indian Country — but does not get the attention (or the breaks) that large corporations do.
Rep. Markwayne Mullin, R-Oklahoma, said last week, “As a former small business owner, I understand firsthand how burdensome the current tax code is on Main Street. The Tax Cuts and Jobs Act delivers relief to mom-and-pop shops in our communities so that they can hire more individuals, grow their business, and invest more in our local economy.”
The metaphor: Small business is cool, too.
FIVE: Elite colleges? Or is it, college only for the elite?
The House bill is an all-out attack on higher education. This is nonsense. Especially when the country needs to be competitive in a digital, knowledge-based world.
First up: Tax private universities’ endowments with a tax of 1.4 percent on portfolios that exceed $250,000 per full-time student. Only about a hundred schools would be affected, and it penalize colleges that have resources. Since those university operating costs will not go down, it’s not likely that this will result in more financial aid for students. The House also makes it impossible for tax-exempt bonds from private — and some public — institutions. This will make campus construction projects more expensive.
The House bill eliminates the deduction of interest for student loans. Americans now owe more than $1.4 trillion on student loans. It already is making it more difficult for young college graduates to buy homes, and transition into the middle class. This provision will be just one more thing. (And student loans are already stacked against the borrower. You can’t get rid of them in bankruptcy.) So instead of solving a problem, Congress is making it worse.
The House bill also repeals the Lifetime Learning Credit, eliminates the Coverdell savings accounts, but does expand the American Opportunity Credit.
The House bill would also classify tuition waivers as income (making a graduate student wealthy for tax purposes.) Imagine a “bump” in student’s income that is equal to tuition, some $30,000, $40,000 or even more.
Laurie Arnold, Colville, director of Native American Studies and an Assistant Professor of History at Gonzaga University, remembers trying to explain this to Congress when she was in graduate school. “Many members of Congress had children enrolled in large/research universities, yet had no idea that graduate students teach the majority of introductory classes at those institutions. In general, the disconnect about this was broad, and many Members fell back on the language that not taxing the stipends was simply another tax break.”
Stipends are now taxed. And Congress is keen to add tuition waivers to the tax revenue pool. This will make it more difficult for people to pay for graduate school, and increase the debt levels for those who do. As a national policy this makes no sense. None.
As UCLA neuroscientist Astra Bryant told Wired magazine: “I mentor two underprivileged undergraduate women, and my concern for them is that an increased tax burden would make it financially impossible for them to afford to pursue a PhD.”
And for Indian Country? There is already a shortage of graduate students and PhDs. Why should it be made more difficult?
“Let me distill that: over one third of American households had trouble putting food on the table, putting a roof over their heads, or getting medical care; blacks and Hispanics are falling further behind whites in net wealth; and 99 percent of Americans hold a diminishing 76 percent share of income in the U.S. These are all alarming trends, but to have one-in-three consumers report that they cannot regularly put food on the table in the U.S., one of the wealthiest countries in the world, is the most deeply disturbing,” Busette writes. “Such a miserly budget, in combination with the tax reform plan, could mean the loss of some very important services for low-income and poor Americans.”
The tax reform measures will require massive budget cuts. Soon. Tribal governments will be hit hard. We already know how difficult sequestration was for tribes a few years ago. The kinds of cuts that will be needed to pay for these tax cuts will cost significantly more than sequestration.
The Center for Budget and Policy Priorities pegs these coming budget cuts at $5.8 trillion, $800 billion in cuts below sequestration levels.
The metaphor: You can’t afford to be poor.
SEVEN: Obamacare? Really? Again?
A serious question: Which house of Congress hates healthcare more?
The House kept the Affordable Care Act insurance mandates, but eliminates medical deductions. So a family that is dealing with a catastrophic, expensive medical event won’t be able to offset any of those costs from their tax bill. Already this provision is limited to higher income taxpayers. It’s only open to people who itemize their deductions, an estimated 8.8 million claimed it on their 2015 taxes, according to the IRS. But for those families that need this break, it’s a big deal.
Then the best thing Congress could do to help people with medical debt is to legislate another expansion of Medicaid. As Kaiser Health News reported: “A study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid. In some cases, struggles with medical debt can be all-consuming.”
The Senate is using tax reform to repeal parts of the Affordable Care Act. Again. The Senate would “save” money by ending the requirement to purchase insurance. It saves tax dollars because the government would not have to pay the subsidies for those who sign up under the plan (including those from Indian Country who get no cost plans under the exchanges).
And, repeating myself here, should a form of these bills become law there will be cuts across the board. The Indian Health Service (as well as Medicaid) will need to restructure because it will have so many fewer dollars.
The metaphor: Healthcare is only for those who can afford it.
A cold December
Congress wants to wrap up this debate before the end of the year and begin the provisions in the new tax year.
One more thing about values. The two tax bills define what’s important to a society. Alaska’s Sen. Lisa Murkowski was a champion on health care and was a key vote to stop the last Affordable Care Act repeal effort in the Senate. But this time there are competing values. She has also been a longtime supporter of opening the Arctic National Wildlife Refuge to oil and gas development. That’s in the bill. It’s her provision. So is she willing to give up on health care for more oil? And what about climate change? Murkowski was eloquent at the Alaska Federation of Natives saying that she is witnessing first-hand the impact in northern communities. This tax bill gives fossil fuels a boost — at the expense of the climate.
What’s really important? We are about to find out.
Here we go again. The Congress is hell bent on wrecking the Affordable Care Act.
This time the mechanism is the so-called tax reform bill that will be voted in the U.S. Senate. The logic is rich (and, yes, “rich” is absolutely the right word and sentiment) because this tax cut will wreck the individual health insurance market so that the rich will pay less in taxes. But the problem gets at the core of insurance itself. How do you make sure there is a large enough pool to cover high cost patients? The Affordable Care Act did this by requiring everyone to buy health insurance or pay a penalty. Without that provision people who are healthy are free to skip out. But sick people always want coverage. And that creates an imbalance that does not work.
Senate Republicans added the provision because it saves money, some $338 billion according to the Congressional Budget Office. It estimates 13 million people will drop health insurance.
“We’re optimistic that inserting the individual mandate repeal would be helpful,” Senate Majority Leader Mitch McConnell said Tuesday.
The Senate bill is now being shaped into its final form. Wait. That’s funny. That’s what they say. But both the Senate and the House will change these tax bills all the way up until the final vote (unless it’s a sure thing, anyway). One of the reasons the bill will evolve is what’s called the Byrd Rule. This Senate is using the reconciliation process, like the Affordable Care Act repeal bills, so only 50 votes are required to pass. But that means the bill has limit of $1.5 trillion in new debt over 10 years and cannot add more after that. None of the bills, so far, accomplish that.
So the health care fight is back. And the Senate majority is confident this time they have the votes to pass the legislation.
There are other provisions in Senate tax bill that will impact American Indians and Alaska Natives.
One of the key ideas is to increase the size of the standard deduction so that fewer taxpayers will have to itemize. But to pay for that the simplicity the Senate bill is getting rid of some popular deductions, including the ability to deduct state and local taxes from your federal tax return. The bill also gets rid of deductions for dependents. The math works out so that families with fewer than three children will pay about the same. But if your family size is larger, then you will pay more. This is Indian Country. The average American family has 3.2 children, but in Indian Country it’s 4.2 children per family.
Update: The Joint Committee on Taxation released its findings on Thursday. Its research shows that taxes will increase for those earning less than $30,000 per year. And by a wide margin. The calculation is based, in part, on the current subsidy to purchase health insurance.
And this is where it gets weird. The Senate bill does increase a tax credit, from $1,000 now to $1,650 per child. But, and this is huge, the additional $650 credit is only available to those who owe federal income taxes. It’s not refundable. This is important to people who are not rich because so many pay more in payroll taxes (Social Security, Medicare, etc.) than in income taxes.
Add it all up and the Senate bill would increase taxes on 13.8 million moderate income households. But, hey, at least the rich get a break, right?
The House of Representatives passed its version of tax reform Thursday by a vote of 227-205. No Democrats voted for the bill, while 13 Republicans opposed it.
The House bill is similar but takes a different tack on mortgages and the deduction of state and local taxes. The House would also eliminate the ability of families to deduct medical expenses. (Think about that when matched with the Senate’s plan to mess up health insurance.)
And the House bill really goes after university graduate students.
Many graduate students earn a small stipend for working on campus, doing research or teaching, and get a break on tuition. The stipend is already taxed. But the House would tax the tuition waiver, thousands of dollars. The average cost of graduate school is $30,000 a year at a public university and $40,000 at a private school. The Washington Post explains the problem this way: “Say you’re a married graduate student at Princeton. Your spouse has a full-time job and makes $50,000 a year; you have two school-age children. You’re filing a joint tax return. For sake of simplicity, you have no other deductions beyond the standard. According to H&R Block’s tax calculator, you would owe about $5,000 under the current law. Under the proposed Republican plan, you would owe about $15,000.”
The House bill also eliminates the deduction for interest on student loans and it eliminates tax credits for higher education.
This is terrible public policy. The digital age demands more education, not less, and the tax code should be in alignment. The House bill does the opposite. It will make higher education more expensive and less likely for too many people.
And just to make sure that higher education gets the message about what the country values, the House bill also would tax the larger university endowments, such as Harvard, Princeton, and even smaller colleges that have reserves of more than $250,000 per student.
But both the House and Senate do have one group in mind when writing this new tax code, business. The total “tax cuts” in the bill add up to $1.4 trillion over the next decade and of that amount, $1 trillion goes to businesses and corporations. It does this by reducing the corporate tax bracket from to 20 percent.
The other side of this tax debate is that it will reduce the amount of revenue that goes into the federal treasury. That means that soon after one of these measures passes, Congress will be required to look again at cutting spending.
Already the Congressional Budget Office estimates the tax bill will require $136 billion cuts from Medicare, Medicaid, and other entitlement programs. “Without enacting subsequent legislation to either offset that deficit increase, waive the recordation of the bill’s impact on the scorecard, or otherwise mitigate or eliminate the requirements of the [pay-go] law, OMB would be required to issue a sequestration order within 15 days of the end of the session of Congress to reduce spending in fiscal year 2018 by the resultant total of $136 billion,” CBO said Tuesday.
The Center for Budget and Policy Priorities pegs these coming budget cuts at $5.8 trillion. “These include $1.8 trillion in cuts in Medicaid, Medicare, and other health care entitlement programs and $800 billion in cuts below the already austere sequestration levels in ‘non-defense discretionary’ programs, the budget area that includes education and training, transportation, scientific and medical research, protection of the food and water supply, child care, low-income housing assistance, services for frail elderly people, and much more,” the center reports.
So we are just at the beginning of the debate. The conservative dream is to sharply cut taxes for corporations and the wealthy — and then to shrink government. The House and Senate tax bills do just that.