Category: South Dakota

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

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

Mark Trahant / Trahant Reports

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

 

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

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Mark Trahant / Trahant Reports

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

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

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

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

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

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

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

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

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Source: Georgetown University Health Policy Institute

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

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

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

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

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18

Seriously? States complain to Senate about the burden of Native health care #IndigenousNewsWire

 

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Medicaid has worked under the Affordable Care Act, reducing the number of uninsured in Indian Country. (Kaiser Family Foundation)

Mark Trahant / Trahant Reports

First: A fantasy. Wouldn’t it be cool if once, just once, there was a debate in Congress that could only be decided by a vote that benefits Native people? I don’t know. Something like, “I won’t vote for any bill unless it fulfills the treaty obligations that the United States has promised Native people.” It could happen, right?

Well the current Senate debate on health care has a twist on this pipe dream. States are complaining about the burden, that’s right, the burden of Native American health care. So here’s the deal now: When an eligible Native American gets services through the Indian Health system, the cost is a 100 percent federal obligation. But, if that person or family is on Medicaid they could also get care from any provider. In that case the state would have to pay its share of the cost as it does for any other citizen. 

As the Kaiser Family Foundation points out: “Just as with other eligible individuals, AIANs who meet state eligibility standards are entitled to Medicaid coverage in the state in which they reside. AIANs may qualify for Medicaid regardless of whether they are a member of a federally-recognized Tribe, whether they live on or off a reservation, and whether they receive services (or are eligible to receive services) at an IHS- or Tribally-operated hospital or clinic. AIANs with Medicaid can access care through all providers who accept Medicaid for all Medicaid covered benefits. As such, they have access to a broader array of services and providers than those who rely solely on IHS services for care. Moreover, Medicaid has special eligibility rules and provides specific consumer protections to AIANs.”

The Graham-Cassidy plan would change that by making this cost a 100 percent federal obligation. States would be off the hook.

This is where it gets screwy. There are legitimate state concerns — basically it’s a complicated maze to figure out a patient’s path and how the money flows. But it’s still a benefit for states because Native people are citizens and so a full-federal match for most costs is a net gain.

South Dakota (a state that did not expand Medicaid) would gain $795 million from a block grant, but would still lose a significant share of its health care funding between 2020 and 2026, according to the Kaiser Family Foundation.

But (and I can’t believe I am writing this sentence) Sen. Mike Rounds told South Dakota Public Radio that the state would get a “large chunk of funds would cover 100 percent of the healthcare costs for Native Americans who receive Medicaid. Right now, the Affordable Care Act requires a state match.”

This is a fraction of what the state will lose — so this is a straight-faced claim that Native health care is a burden. (Remember this cost is only for tribal citizens who do not use Indian Health Service, a small slice of the population.)

South Dakota is not alone. A state legislative report in Arizona estimated that the state will lose a third of its Medicaid funding ($3.8 billion now, $4.9 billion by 2020). But according to the Capitol Media Services of the Arizona Daily Star, Gov. Doug Ducey dismisses those losses because the numbers are not from an independent review. Yet there is not enough time for the Senate to get a Congressional Budget Office assessment by the September 30 deadline. So this is all being made up on the fly.

“Christina Corieri, the governor’s health policy advisor, said one of those provisions would free the state of its financial obligations to share the cost when Native Americans get care at non-Indian Health Service facilities,” the Arizona Daily Star said. Corieri “could not say what that number would save Arizona other than ‘it’s a very large number.'”

Seriously?

There are roughly 130,000 Native Americans in Arizona on Medicaid, about 6 percent of the state’s version of Medicaid, the Arizona Health Care Cost Containment System. And of that, we’re talking about a subset, those who choose to go outside of the Indian health system. It’s just not a very large number. Period.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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

 

 

 

 

 

Trump’s deal with Democrats shows that governing is not out of the question

 

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President Donald J. Trump in North Dakota on Wednesday talking about his tax reform plans. (WhiteHouse.Gov)

Mark Trahant / Trahant Reports

Big news: The rest of the year will have less drama than the ups and downs we’ve been experiencing since January. The federal government will more or less operate on schedule, the federal debt limit fight has been pushed back to the end of the year, and President Donald J. Trump has successfully reached out to Democrats.

What a week. When it began, I wrote: “Congress is back today and one of two things will happen: It will either do its work or all hell will break loose.” But I was off. It wasn’t exactly Congress doing its job, it was the president. He bypassed his own Republican party leaders (catching them off-guard by all accounts) and struck a deal with Democrats in the House and Senate to fund government for the rest of the year and push the debt limit fight back until December.

This is exactly what the president should have been doing all along. This is governing. It means, for now, at least, that he’s reaching out to the majority in Congress (moderate Republicans plus the Democrats) instead of catering to the far right wing of the party. It’s smart politics. But it’s also dangerous because his action undermined both House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell. If it’s a one-time event, Ryan and McConnell will get over the snub. But if this is the new way of doing business, well, then, there will be a different kind of drama ahead.

There is also movement this week on the Republican plans to repeal and replace the Affordable Care Act. According to The Hill newspaper, John McCain now favors legislation proposed by Senators Lindsey Graham, R-South Carolina, and Bill Cassidy, R-Louisiana. This plan would push more of the decision making about health care to the states through block grants. It would even let states keep many aspects of the Affordable Care Act such as Medicaid expansion, as long as they’re willing to pay for the extra costs. That’s a deal breaker.

The problem for the Indian health system in such a scheme is that states neither understand nor want to invest the resources required. The ideal scenario would be for Indian Country to be a 51st state and get funding directly. But that’s not a part of the legislative proposal.

This bill would have to be considered fast under Senate rules. The current set-up is to vote on a replacement plan using the budget reconciliation process. That only requires 50 votes instead of the more common 60 vote standard (to interrupt a filibuster). The Senate parliamentarian has ruled that reconciliation goes away on Sept. 30 unless there is a new budget in place. That’s unlikely.

Another health care issue that impacts Indian Country is the reauthorization of the Children’s Health Insurance Plan or CHIP. The current law expires Sept. 30. It pays for the insurance of 8.9 million children through Medicaid. The Kaiser Family Foundation reports that “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 (54%) versus 23% of nonelderly adults.” CHIP would be included in that number.

CHIP also pays for school programs and other health care outreach efforts. The federal Centers for Medicaid and Medicare said: “In 2014, CMS awarded $3.9 million in CHIPRA grants to engage schools and tribal agencies in Medicaid and CHIP outreach and enrollment activities. Grantees included Indian Health Service organizations, tribal health providers, and urban Indian health providers across 7 states.”

Important stuff. We need another presidential deal with Democrats. Quickly.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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

 

 

Senate Republicans will have to wait for John McCain to return after surgery

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When every senator could be the 50th vote, any one absence means no healthcare bill

Trahant Reports

The Senate healthcare bill looked like it was going to pass on Friday. There were only two public no votes (when three are needed to defeat the measure.) And you can only imagine how much pressure leadership was putting on its members to vote yes for the good of the party. This bill was (and is) a priority for the Republican leadership and the White House.

But over the weekend things changed. Sen. John McCain’s office announced that the senator had surgery for a blot clot over his eye. “Senator McCain received excellent treatment at Mayo Clinic Hospital in Phoenix, and appreciates the tremendous professionalism and care by its doctors and staff. He is in good spirits and recovering comfortably at home with his family. On the advice of his doctors, Senator McCain will be recovering in Arizona next week.”

Now the Senate cannot vote on the healthcare bill. There is no way to get to 50 votes without him. So Majority Leader Mitch McConnell will wait until McCain heals. At least a week.

That means there is a lot more time for the opposition to make its case. On Monday or Tuesday there will be a new Congressional Budget Office score of the bill. And that could be followed by some kind of alternative review from a federal agency. Think fake news but in a government document.

Another Not So Good for the Senate Bill moment was a letter from health insurance companies that said the Cruz amendment is unworkable in any form. The problem is that healthy people will buy cheaper plans leaving those who are already sick to buy the ones preserved from the Affordable Care Act.

State governors also remain opposed to the Senate bill. Vice President Mike Pence attempted to change their minds. He spoke as a former governor who accepted Medicaid Expansion, but now says the Senate bill is all about freedom to redesign health insurance. “And if you take nothing else from what I say today, know that the Senate healthcare bill gives states the freedom to redesign your health insurance markets.  And, most significantly, under this legislation, states across the country will have an unprecedented level of flexibility to reform Medicaid and bring better coverage, better care, and better outcomes to the most vulnerable in your states.”  He argues that the Medicaid reforms will secure “Medicaid for the neediest in our society.  And this bill puts this vital America program on a path to long-term sustainability.”

But, as I said, the governors didn’t see the issue the same way. Democrat and Republican sees the numbers and now that the Senate bill will result in substantial budget cuts lasting more than a generation. (In fact: One of twisted messages from McConnell to moderate Republicans is don’t worry. The cuts down the road will never happen.) This bill would destroy the Medicaid that we have now. Including the money that helps fund the Indian Health system.

Looking for background? Here are recent pieces on the Senate health care bill and its impact on Indian Country: The special deal for Alaska; Lies we’re being told about budget cuts; The impact on jobs in Indian Country; Trump tells tribal leaders Medicaid cuts will be good; and health care policy is a debate worth having (but this is not that.)

 

 

 

 

Alaska’s special deal in Senate health bill isn’t enough to fund successful Medicaid

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Alaska’s Health and Human Services Commissioner Valerie “Nurr’araaluk” Davidson. A report by her agency says Medicaid now covers one in four people in Alaska; nearly half of whom are children. If Medicaid caps are enacted, the “magnitude of the federal cuts are such that they may well affect Alaska’s ability to finance other state priorities such as education and infrastructure.”

Mark Trahant / Trahant Reports

It would be cool, just this once, if the Senate would say, “Indian Country you are so important. So we are adding a special provision to this health care bill that adds big bucks to the Indian Health Service.” Then Senators with significant American Indian or Alaska Native populations would shift their votes from perhaps to yes.

That might sound like a fantasy. But it’s the track that the Alaska delegation is on; senators secured a special deal in the Senate health care plan for their state. Only it’s not about Alaska Natives. And it’s not nearly the same amount of dollars that the state will lose with Medicaid cuts (or, for that matter, in high cost insurance.) But it’s a “victory” of sorts that will be claimed if Sen. Lisa Murkowski eventually votes yes on the Senate bill. (Sen. Dan Sullivan was a likely yes, anyway, although he’s claiming credit too.)

Here’s the deal. The legislation includes a complicated formula to reduce Medicaid spending — except in states with a population density of less than 15 people per square mile. That’s Alaska, Wyoming, North and South Dakota, and Montana. New Mexico just misses but then it’s a Blue state and its senators would likely vote no anyway. And, the exception might be of use to Sen. John Hoeven from North Dakota but, like Sullivan, he probably would vote with leadership anyway.

So really it’s about Alaska — and Murkowski’s vote. She’s a firm maybe. So far three senators have said no (enough to kill the bill) but we won’t know how solid those no votes are until there’s an actual vote. The self-proclaimed no votes are Sen. Susan Collins of Maine, Rand Paul of Kentucky and John McCain of Arizona. (Republicans need 50 votes from their own party.)

The rural exception to the Senate bill adds up to just under $2 billion, according to The New York Times.

But special deal or not, the big picture might be more important to Murkowski.

Alaska is a state where the evidence is strong that the Affordable Care Act and Medicaid Expansion are working. Nearly a quarter of the state’s population is enrolled in Medicaid and the state’s 2015 expansion added more than 34,739 people. Half of the state’s children are insured by Medicaid.

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And, of course, Medicaid is an essential revenue source for the Alaska Native medical system — a system that Murkowski praised just this week at a hearing on the Indian Health Service.

A study done for Alaska’s Department of Health and Human Services — run by Commissioner Valerie “Nurr’araaluk” Davidson — is blunt. It says: To stay under a per capita cap Alaska would be required to cut its Medicaid program spending by $929 million in federal and State dollars between FY 2020 and 2026, with a federal funds loss of $473 million … The magnitude of the federal cuts are such that they may well affect Alaska’s ability to finance other State priorities such as education and infrastructure.”

The report says the cap will not include patients in the Indian Health system, but that Alaska will have to cut back on eligibility to reduce Medicaid spending.

Analysis of the House plan (remember at some point the House and Senate bills would have to be merged and passed again) would cost Alaska $2.8 billion in Medicaid funds between 2020 and 2026.

What’s even more problematic: “Alaska will have to establish its Medicaid budget almost two years before it knows the amount of federal Medicaid funding available for that budget year.” That could result in a “claw back” effect where money has to be returned to the federal treasury after its already spent. The impact of the Senate bill would be quick. The state’s report estimates that within three years a quarter of all Medicaid funding would be eliminated. And, more important, by 2022 95% of expansion enrollees will have lost coverage due to Alaska’s highly seasonal workforce.”

So will the rural exception be enough to buy votes? It’s certainly not enough funding to maintain Alaska’s successful Medicaid Expansion.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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

 

She Represents. A survey of Native American women who’ve been elected

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Click for interactive version of this graphic.

Mark Trahant / Trahant Reports

Former Montana State Sen. Carol Juneau once said that she considered state office because that’s where she could make a difference. (She is a member of the Mandan Hidatsa Arikara Tribe but was living in the Blackfeet Nation). The year was 1998. She was first appointed to the legislature to replace a man who left office to take up a seat on the Blackfeet Tribal Council and then she became one of two Native American members of the Montana House of Representatives. In February of 1999 she made the case to the House Democratic Caucus that Montana’s American Indians ought to have better representation, because tribal people “are citizens of the state of Montana, the same as any other citizens. I’d like to see that Indian people and Indian tribes in Montana aren’t left outside of everything.”

Today Native Montanans are not left out.

The state has the most Native Americans elected as legislators in the country, three members of the Senate and six members of the House. More than that: Montana has elected more women than any other state: Four of the nine legislators.

And though she is not currently in office, Denise Juneau (Carol’s daughter) was the only Native American woman to ever win a state constitutional office, she served two terms as the State Superintendent of Public Instruction, as well as a congressional candidate.

The Montana story has a national application, too. A higher percentage of Native American women serve in state legislatures than do women nationally.

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Women make up about 25 percent of state legislatures. But a little more than 40 percent of all American Indian and Alaska Native legislators are female. The numbers break down this way: There are at least 67 Native American legislators out of 7,383 seats in 50 states or nearly one percent. (If you think that’s bad: Congress only has Native representation pegged at one-third of one percent.) Of those 67 seats, at least 25 of them are held by Native American women. So another way to look at the data: There are 1,800 legislative seats held by women; that works out to a Native representation of 1.4 percent.

There is still a long way to go to reach parity with the population, but it’s much better than just about any other category in the body politic. For example: A recent report by the Bureau of Indian Affairs shows more than 570 elected tribal leaders and, in that group, just under 25 percent are women.

The Native delegation in Minnesota is eighty percent female; its own caucus. (You could even argue that women are 100 percent of the delegation because the other tribal member in the legislature, Republican Rep. Steve Green, is White Earth Ojibwe, but he rarely champions or mentions tribal issues.)

A recent article in the Minnesota Post was headlined, “Something new for the Minnesota Legislature: A caucus of first Minnesotans.” Rep. Susan Allen, a member of the Rosebud Sioux Tribe, was first elected in a special election. “Before Allen was elected in 2012, only nine legislators in state history who self-identified as American Indian served in the Legislature — all men — and most of them were elected back when Minnesota was still considered a territory,” the Post said.

Allen told the Post: “You can be a part of an institution that is predominantly white and not have to lose your identity. I can be here without having to lose my identity to do it, and previous generations, I don’t think they had that.”

The Post explained several reasons why it’s so important for a legislature to hear from Native American legislators and for those elected representatives to keep an eye out for bills that impact the Native community.

One anecdote in particular was powerful. The Post said Rep. Mary Kunesh-Poden, a Standing Rock descendent, was giving American Indian students a tour of the Capitol. She could see they were overwhelmed. “I said, come back again and again and bring other Natives to the Capitol so that you’re not nervous, so that you’re not intimidated, so that some day you’ll be sitting in this office doing the work that we’re doing,” she said in the Post. “You could almost see the light bulb go off in their head: I could do this?”

Arizona is another state where most of the Native delegation — three out of four — are women. This fits Arizona. Its legislature is third in the nation for the highest percentage of women at nearly 40 percent.

New Mexico is the only state where the male-female balance is 50/50. And five states, Idaho, Kansas, Oregon, Utah and Wyoming, have only a woman representing Native Americans in the legislature. Conversely, Colorado, North Carolina, and North Dakota have only one Native American man serving in the legislature. Alaska (88 percent) and Oklahoma (86 percent) are primarily represented by men. South Dakota has three American Indian men in the legislature and no women.

Idaho’s Rep. Paulette Jordan, Couer d’Alene, is not only the only Native American in the legislature, she’s the only Democrat elected north of Boise. She told the Spokane Spokesman Review: “How can we continue to fight for balance in the state, with the overwhelming odds?That’s part of the beauty of our connection to our ancestors. We know that they’re always walking with us, guiding us and helping us in this lifetime … the fact that we’re still here – we still have the beauty, the inner identity, our connection to everything, to the land, to the earth itself, to our relatives both tribal and non-tribal alike.”

Nearly all of the Native American women who serve in state legislatures are Democrats. 21 out of 25. But it’s also worth mentioning that two of those Republican women are in leadership in Alaska and Hawaii. (Previously: Native Republicans open up a channel for discourse about Indian Country’s issues.)

I don’t have the total numbers for Native Americans elected at the city and county level. Yet. (Early drafts of spreadsheets are here and here. Please do let me know who should be on these lists.)

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Debora Juarez, Blackfeet, currently represents more citizens than any Native woman in America (more than 90,000 people live in her North Seattle district). She was elected to Seattle’s City Council in November of 2015. (City of Seattle photo)

But this much is clear: Debora Juarez, Blackfeet, currently represents more citizens than any Native woman in America (more than 90,000 people live in her North Seattle district). She was elected to Seattle’s City Council in November of 2015. In an interview with the Tacoma Art Museum she talked about her idea about the role of women: “While men were in charge of external power, women had interior, spiritual, and domestic power. They were the centers of the community.” That’s exactly how she’s approached her job on the council. She’s argued for community services from sidewalks to child car. On Juarez’ blog she reports: “In this budget I advocated for and secured $4.4 million in targeted investments in our community including improvements in human services, construction of sidewalks, and neighborhood planning initiatives. Ultimately, I achieved a 94% success rate for my specific District 5 budget priorities.”

Denise Juneau, of course, is the only Native American woman to hold statewide office (twice). She actually earned thousands of more votes from Montanans than did Barack Obama in 2012. (Previously: Denise Juneau’s eight years of promise.) She had a remarkable run even though last year fell short of being the first Native woman to ever win a seat in Congress.
In addition to Juneau, at least seven Native American women have run for Congress starting in 1988. Jeanne Givens, a Couer d’Alene tribal member in Idaho was the first. Then Ada Deer, Menominee, in Wisconsin, Kalyn Free, Choctaw, in Oklahoma, and Diane Benson, Tlingit, in Alaska, Three Native women have run in Arizona: Mary Kim Titla, White Mountain Apache, Arizona Rep. Wenona Benally, Navajo, and Victoria Steele, Seneca.

It’s so long past the time to erase that phrase, “ever” or for that matter, “the first” when it comes to Native women in office. And I suspect the 2018 elections will be a remarkable opportunity for more Native Americans to win office. It will be a referendum on President Donald J. Trump and his policies.

It’s also worth noting that Native American women have run for the vice presidency three times.

LaDonna Harris, Comanche, was on the ticket with Barry Commoner for the Citizen Party in 1980 (the year of Ronald Reagan’s landslide). This was Bernie Sanders before Bernie Sanders. The party highlighted the structural limits of the Democratic Party and blamed corporate America for the excess. The antidote was people power.

What’s interesting about the campaign now is that Commoner and Harris focused on environmental issues (long before the words global warming or climate change were in public discourse). Get this: The Citizens Party platform cited the role of science in managing complex environmental challenges.

“As a Comanche woman fighter, I’m proud to be a part of this party,” Harris said. “The traditions of my people have always held to the unity of the oppressed. That is why I want to show that we care about the problems of Chicanos, the Blacks, women, the elderly and the poor.”

Winona LaDuke, White Earth Ojibwe, joined Ralph Nader on the Green Party Ticket in 2000 and again in 2004. When LaDuke announced her candidacy she was asked whether a Native woman from rural Minnesota should even be considered? “I would argue yes,” she said. “In fact, I would question the inverse. Can men of privilege … who do not feel the impact of policies on forests, children or their ability to breast-feed children … actually have the compassion to make policy that is reflective of the interests of others? At this point, I think not.”

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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

 

Updated numbers: A look at Native American women elected to office

***Updated***

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Good morning.

A quick update. So a reader points out that I really ought to include Debora Juarez in this list (and in the broader review of Native women in office). And it’s a spot on suggestion.

So I have added Juarez and a couple of county commissioners I know about … but there should be more. Please let me know about women serving on city councils, as mayors, county commissions, etc. Montana? South Dakota? Alaska?

Do you know of any Native women who are elected as city and county officials that should be included? Thank you.

I am working on a piece about Native American women who were elected to office at the state (or, I wish, at the federal) level.

**City of Seattle Council Member Debora Juarez Blackfeet NP
***Coconio County, Arizona Board of Supervisors Lena Fowler Navajo D
***McKinley County, New Mexico County Commission Carolyn Bowman-Muskett Navajo D
***McKinley County, New Mexico County Commission Genevieve Jackson Navajo D

This is my spreadsheet. Please take a look and let me know if anyone is missing.

I have identified 62 American Indian or Alaska Natives in state legislatures — 25 women (40 percent) and 37 men (60 percent). As a comparison, nationally, women make up just under a quarter of all elected legislative seats. (1,363 members or 24.4 percent).  And that means Native American women are 1.834 percent of the women who serve in office.

Also eight Native American women have run for Congress and two have run for the vice presidency.

I am planning a story and an interactive graphic for the weekend. (It’s taking me longer than I planned. I keep getting distracted by the frenetic pace of the Trump administration.

Thanks for any help (or ideas). — Mark

If, then, this. The shift from campaign promises to Indian Country policies

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President Barack Obama meets with President-elect Donald Trump in the Oval Office, Nov. 10, 2016. (Official White House Photo by Pete Souza)

Mark Trahant / Trahant Reports

If, then, this. A series of three words explaining what happens in any new White House. If Donald Trump wins the presidency, then many (not all) of the promises made during the campaign become policy. And it happens starting next month when the Congress races to try and make this so.

But “if, then, this,” is also about people. Who staffs the new campaign, especially those who represent Indian Country? And who represents the opposition?

So let’s start with what we know.

It’s likely that President-elect Donald J. Trump will nominate Cathy McMorris Rodgers as the next Interior Secretary and Tom Price as the Secretary of Health and Human Services. Who joins them? Who has their ear? How will their broad views on public policy impact Indian Country?  (Previous: Trump’s choice for Interior could risk salmon recovery, treaty rights.)

As The Atlantic said about Price. He will be running a massive federal healthcare agency, one that “administers the largest health-research centers in the world, most of the country’s public-health apparatus, the Indian Health Service, the Food and Drug Administration, and a collection of welfare and child-care services. While Price has a less-established policy record on many of these issues, his general philosophy of rolling back government spending and intervention suggests he may scale back HHS’s current efforts.” A less established policy record opens up a lot of questions.

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Another appointment, yet to be announced, would be in the next president’s executive office. Arizona State Sen. Carlyle Begay posted on Instagram: “It’s official … I’ll be working in the White House.” (Begay’s account is private, but it was reposted by Navajo Republicans on Facebook.) He doesn’t elaborate on the job title, but the most likely that post would be as a special assistant to the president on the Domestic Policy staff, a post now held by Karen Diver. Begay is Navajo.

One of the issues that the White House and Congress will have to flesh out is a proposal by Rep. Markwayne Mullin to reform the regulatory structure for tribal lands. A story in Reuters last week compared that plan to the termination, something that Mullin (who is a member of the Cherokee Nation) and former Interior Assistant Secretary Ross Swimmer say is not the case. Swimmer, who is also former principal chief for the Cherokee Nation, told Reuters: “It has to be done with an eye toward protecting sovereignty.”

Mullin said the press misunderstood him. He posted on Facebook: “This is a very personal and important issue for me and I want to clarify my actual comments that were distorted by the media. It is still and will always be my belief that the land entrusted to tribes belongs to the Native American people, and it ought to be up to them alone to decide how to best use and distribute the resources on their own land.”

Economist Terry Anderson has been making this case for years first from a think tank in Montana, The Property and Environment Research Center, and rom the Hoover Institution at Stanford University. He wrote just last month: “President-elect Trump is well positioned to grant more freedom to Native Americans.” (Note to Republicans: If you are serious about making this a policy, I would avoid the ‘free the Indians’ narrative. This was Arthur Watkins’ pitch during termination. The phrase has a definite and failed context.)

As will often be the case in a Trump White House, Anderson’s argument focuses on energy. “Considering the fact that tribes have an estimated $1.5 trillion in energy resources, President Trump should start by promoting more tribal authority over those resources,” Anderson wrote. “Such legislation is helping tribes like the coal-rich Crow. In 2013 it signed an option with Cloud Peak Energy, LLC to lease 1.4 billion tons of reservation coal. For the option, Cloud Peak paid the tribe $3.75 million and payments could increase to $10 million by 2018 if they start mining. These kinds of deals give Indians some reason for hope.”

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If, then, this. Except. I would question at least one variable in this argument. If tribes have more say about resource extraction, then will tribes also have more say about environmental concerns? Does this logic give tribes a veto over resource extraction? Would that include approval or rejection of the Missouri River crossing of the Dakota Access Pipeline?

And specifically on coal, if there is a smaller global market for coal, then what’s the point? The International Energy Agency last year reduced its prediction for coal demand (after a decade of growing sales) in part because China’s consumption is dropping sharply. “The coal industry is facing huge pressures, and the main reason is China, but it is not the only reason,” said the agency’s executive director Fatih Birol. “The economic transformation in China and environmental policies worldwide – including the recent climate agreement in Paris – will likely continue to constrain global coal demand.”

That study predicts coal from India and Australia are growing and that the pipeline is already exceeding the capacity. “Probable” new export mining capacities amount to approximately 95 million tonnes per annum. But the current market environment strongly discourages investments as a substantial rebound of coal prices before 2020 is unlikely. Consequently, further postponements or cancellations of projects are expected.” So it’s not a great time to unleash coal as a market force (unless even lower prices are the goal).

If the world is moving past fossil fuel expansion, then the markets will not be there. This will not change in a pro-coal administration.

If there is to be a Secretary McMorris Rodgers, then who would develop and implement policy for Indian Country as the Assistant Secretary for Indian Affairs? There are a lot of talented Republicans who will be making their case in the next few days and weeks. You would hope that people who have served in previous administrations, such as Swimmer, will have a say in what qualities should be sought to match the requirements of the office. Same goes for elected leaders such as Mullin, Rep. Tom Cole, and even those in state governments, such as New Mexico Rep. Sharon Clahchischilliage, a member of the Navajo Nation.

The idea of “if, then, this,” is also important to the opposition party, the Democrats.

McMorris Rodgers must give up her congressional seat. And already there are three candidates. But former Colville Chairman Joe Pakootas said he will not run in a special election. He’s now chief executive of Spokane Tribal Enterprises.

But there are other ballot possibilities. Minnesota Rep. Keith Ellison is a candidate to chair the Democratic National Committee. If he were to win that job, then he has said he would give up his seat in Congress. Already on Twitter there is speculation that the best candidate for the House seat would be Minnesota Rep. Peggy Flanagan, White Earth Band of Ojibwe.

If, then, this.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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

The billion dollar dilemma: Funding Indian health in the Trump Era

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Senate Indian Affairs Committee Chairman John Barrasso, R-Wyoming, says a patient-centered culture at Indian Health Service is long overdue. Barrasso is a physician. What happens to Indian health after the repeal of the Affordable Care Act, especially Medicaid as a funding source. (Senate photo)

 

Mark Trahant / Trahant Reports

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.

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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.

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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?

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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