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.
A year ago ballots from across the country were being examined by citizens, journalists, and politicians, who were all wondering, “What the hell just happened?” The nation woke up to a President-elect Donald J. Trump.
And this morning? The Trump brand is like an overpriced hotel where you would never, ever stay a second time.
Voters from Maine to Washington and all points in between rejected Trumpism. They voted for Democrats, flipping legislatures in Washington and possibly Virginia. They voted for Medicaid. Medicaid! They voted for higher wages. And there is a clear message to Congress (if members pay attention) that governing still matters.
It was a good night for Native American candidates, too.
In Washington, Roxanne Murphy, Nooksack, won a second term on the Bellingham City Council with nearly 80 percent of the vote. What’s striking is that she ran against the ugly words of an opponent who called on hate instead of discourse. Murphy wrote on Facebook: “Got through so much racism and misogyny during this run for office. But that was all worth it for me to defend our Bellingham community, the work of our current Bellingham City Council, to mutilate a deplorable person at the polls, get more people to vote the whole ballot, and it proved that love can win over hate. Thank you for RoxingTheVote!”
Several other Native candidates won office in Washington. Chris Roberts , City of Shoreline, Zachary DeWolf, Seattle School District, and Candice Wilson, to the Ferndale School Board.
Washington voters also flipped the legislature from red to blue. The entire West Coast is now governed by Democrats.
Renee Van Nett, Leech Lake Ojibwe, won a seat on the Duluth, Minnesota, city council. She will be the first Native American woman on that body. She told the Duluth News Tribune that her victory was a credit to “traditional issues that people are worried about … they want someone who’s accessible, someone they can call and talk to, someone who will address their needs. They want economic development. They want to be heard.”
Across the country “diversity” was a theme from election night. The “first” is a phrase that seems odd in 21st century America. Yet the first African American Lt. Governor in New Jersey. Another in Virginia. (Hint: The first Native American woman to serve in that capacity should be be next up, Peggy Flanagan in Minnesota.)
The first Sikh mayor in Hoboken (who had to run against overt hate). The first immigrant from Liberia in Montana. The first openly lesbian mayor in Seattle. (Huffington Post has a list of many of the firsts.) The main take away: This was a rejection of the narrow world view of the Trump. The diversity that is the future of America, won. Bigly.
On the policy debate ahead, perhaps the most important vote came from Maine where voters overwhelmingly voted in favor of expanding Medicaid. Maine is one of 19 states whose Republican governors or legislatures have refused to expand Medicaid under Obamacare. This is an initiative — and a process — that could move to other states. “This will send a clear signal to where the rest of the country is on health care,” Jonathan Schleifer, executive director of the Fairness Project, told The Washington Post. This vote is important because it could tip the scales in states where the legislature says one thing and the people another. Alaska. Cough. Alaska. Put Medicaid expansion on the ballot: And it will win.
Elections, of course, are always snap shots. It’s dangerous to think this rout means more of the same a year from now. But the groundwork is there. And this election night will further divide many Republicans from Trump — as well as those who fund elections. There is now real evidence from the best poll of all that voters are not happy with the direction of Congress or the White House.
Last year about now I was pretty much writing all politics all the time. Indian Country had so many good candidates to offer. Interesting resumes. Better ideas. Campaigns that led to a few wins. A few more losses. And that’s life.
This year I am pretty much writing about health care policy all the time. The Republican plans are so bad — and especially for Indian Country — that they ought be dismissed as dangerous nonsense at every opportunity. As I have written before there is a conservative approach to health care. None of the current proposals are that; they are only a destructive force. (More about that after the Senate releases it latest attempt to reach a 50 vote majority.)
Of course there is also a connection between campaign politics and policy. We’re almost a year away from the next House and Senate election and we’re just starting to get a look at the candidates who will be making policy.
And it turns out there is news.
In Oklahoma, Democrats swept two state legislative seats this week in districts where Donald Trump won handily last year.
One of the seats in the Tulsa area had been held by Rep. Dan Kirby, Creek, and a Republican member of the Native American caucus. He resigned in February following allegations of sexual harassment by staff members. Kirby’s seat was won by a retired teacher, Karen Gaddis (who lost to Kirby in November by 12 percentage points). This had been a safe Republican seat.
A state Senate election (also stemming from a sex scandal) was won Tuesday by a Democrat in the Oklahoma City area.
Oklahoma is one of the most Republican states in the country. So it’s huge to see such a significant shift in a special election. (Unless, that is, it’s just those sex scandals and not the Trump factor.)
One person who ought to be especially concerned by these two election results: Rep. Markwayne Mullin.
Mullin won 70 percent of the vote in his third re-election bid in 2016. Mullins, a member of the Cherokee Nation, first ran in the Tea Party-inspired wave in 2012. He ran against too much government, a repeal of Obamacare, and a silly promise to limit his time in office to three terms.
Now he’s running for his fourth term and some prominent conservatives are unhappy. Former Sen. Tom Coburn told Oklahoma’s KFAQ radio that it was sad because this “nice young man … has drunk the Kool-Aid in Washington.”
It’s funny and prescient. Mullin’s ads said: “A Rancher. A Businessman. Not a politician.” Mullin can hardly say that now. It’s like the great line in the movie “The Candidate” when young Bill McKay is elected governor and his father (who was a governor) tells him: “Bud, you’re a politician.”
Even the story changed. In his early ads, Mullin talks about term limits as an answer to the problem of being an insider in Washington. But in his video explaining why he’s running again, Mullin said — after much prayer — that he’s changing his mind for family reasons. “I’m not hiding from that because we did say we’re going to serve six years, and it was out of true concerns,” he said. But that’s ok now. The family is doing great.
And, like every politician before him, the voters really need him. Just him. Especially during this era of Donald Trump (that is … if the era even lasts until the next election).
But while Mullin complained about the power of Standing Rock to slow down the Dakota Access Pipeline, he says he’s all for increased powers of tribes to develop such energy projects. The president should “provide tribes with the resources they need in order to best decide how their land should be developed,” he said. How. Not if.
Then perhaps that gets to the actual dialogue part. Or lack thereof.
Mullin supports the House health care bill that would wreck the Indian health system. Then Mullin does not see it that way. In a May Q & A published by the Miami News-Record he said flat out that Republican plans will not hurt the Indian Health Service. “The American Health Care Act (AHCA), which the House passed on May 4th to repeal and replace Obamacare, makes no changes to Indian Health Services (IHS). In addition, the spending bill passed to fund the government through September funds IHS at a rate of $5 billion – an increase of $232 million from last year’s levels. I anticipate the native people of Oklahoma will welcome both of these things.”
Excuse me. But as I’ve been reporting (often) Medicaid is a significant funding stream for Indian health. And the House bill (and its Senate twin) destroy that whole infrastructure.
He told his constituents that no one who has health care will lose it because of the Republican plans. He said emergency rooms cannot turn people away. Seriously. That’s a health care plan? Mullin told the Tulsa World: “We think the federal government is going to solve all of our problems, but let me ask you, how is (that) going?”
That explains a lot. Mullin was against the Violence Against Women Act (which will need to be reauthorized by Congress next year) including the provisions that recognize tribal judicial authority.
Back to politics. If there is a voter groundswell of Trump opposition — even in Oklahoma — then Mullin’s re-election race could become interesting. The right candidate could push him on the left while Coburn and other conservatives will question his integrity from the right.
But who will challenge him? I’d like to see a candidate from one of the tribes. Oklahoma’s 2nd Congressional District is 17 percent Native American and it’s 65 percent rural. That’s two constituent groups that will be deeply impacted by Republican health care plans. There is an issue to run on here. (Not to mention that Coburn, who once held this seat, will campaign against Mullin. And the Trump chaos.)
We’re a little more than a year away from the next election. So this is the time to sort out who’s running from Indian Country, who should be running, and to pass on those candidates who regularly vote against Indian Country. I’d add Mullin to that last list.
The Senate bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions from Medicaid and passes on that savings to wealthy Americans.
How bad could it be? The official financial review from the Congressional Budget Office is expected early next week. The scoring of the similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured. Under the House bill only a few million would use tax credits to purchase policies that even then would not cover major medical risks.
So the important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) and gives back most of those to high-income taxpayers ($664 billion). The Senate bill takes a little time to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. Then, like the House, Medicaid would become a state block grant program. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid spending is automatic: If you are eligible, the money is there.)
Medicaid now accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.
But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or what’s especially what’s covered by insurance.
This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent federal funding through what’s called the Federal Medical Assistance Percentage for Medicaid or FMAP. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. But the money would still flow from Washington to the states for administration. Messy (as it often is now). And the states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.
The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The bills move health care back to the states in a big way. That can be good or bad. California is debating how to create a single payer system. The Nevada legislature recently passed a Medicaid-for-all statute (where any citizen could buy into the program) only to have the law vetoed by the governor. But other states see health care only as a cost. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity” care.
Some numbers here. The American Hospital Association opposes both bills for one reason. In 1990 uncompensated care cost $12.1 billion or about 6 percent of total hospital expenses. By 2012 that figure reached $45.9 billion. And, after the Affordable Care Act, the total uncompensated care costs dropped to $35.7 billion or 4.2 percent of total hospital expenses, the lowest level in 26 years.
But this shows the futility of cutting Medicaid and insurance programs for the poor. It doesn’t save money, it just shifts it around. People who get sick will go to emergency rooms when it’s later in their illness and more expensive. So hospitals will cost more for everybody. (But at least the wealthy get their tax break, right?)
The opioid crisis is an example of that. The costs will not go away. Some money will be found by states, cities and tribes. The Senate bill adds a funding stream of $45 billion over 10 years for substance abuse treatment and prevention that’s now funded by the Affordable Care Act. But Medicaid expansion has been a key funding source. The Associated Press reports that Medicaid expansion accounted for 61 percent of total Medicaid spending on substance abuse treatment in Kentucky, 56 percent in Michigan, and 43 percent in Ohio.
The Senate has only a few days to consider their version of health care “reform.” Already a few conservatives are saying the bill doesn’t go far enough and want more changes. This is the script the House used: The conservatives throw a fit, get their way, and then the so-called moderates give in and vote yes anyway.
My bet is that Senate leaders have already written off Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins because of their past support for Planned Parenthood (there are already restrictions against the federal funding of abortion, but the Senate bill says Planned Parenthood cannot bill Medicaid for a year for all women’s health services). So I think Senate Majority Leader Mitch McConnell is banking on a fifty-fifty split with Vice President Mike Pence casting the deciding vote.
That means the moderate senators, those that support Medicaid in their states, can say what ever they want now. But it’s their vote that will count. Destroy Medicaid or cut taxes? That’s the choice for these four: Rob Portman of Ohio, Shelley Moore Capito, West Virginia, Dean Heller of Nevada, and Cory Gardner from Colorado. Perhaps it’s wishful thinking but I will add Alaska Sen. Dan Sullivan to this list because Alaska will be hit particularly hard by the overall legislation, the opioid epidemic, the state’s successful expansion of Medicaid, and its impact on the Alaska Native Medical system. Sullivan said on Facebook that he will read every word of the bill and he wants “a sustainable and equitable path forward for Medicaid” and he won’t vote for a bill that makes things worse for Alaskans. So will it be his party or Alaskans? Health care or tax cuts?
And, since I am asking already asking questions, will the Senate bill pass next week? Remember it will only take one senator to force the Senate to start over.
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.
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.”
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.)
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.”
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.
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.
President Donald J. Trump’s legislative agenda has crashed. The Republican promise to quickly repeal and replace the Affordable Care Act on Friday failed to win enough votes from conservatives to make it so.
As House Speaker Paul Ryan said in a post-failure news conference: “Obamacare is the law of the land … We’re going to be living with Obamacare for the foreseeable future.”
For his part, President Donald J. Trump (who, of course, says he is not to blame for the loss) told The Washington Post, “the best thing politically is to let Obamacare explode.” He called the law, “totally the property of the Democrats,” and that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”
The president and his administration can do a lot to make that happen. The Secretary of Health and Human Services has extraordinary authority under the Affordable Care Act and they can use the power regulation to gunk up Obamacare. There will be many battles ahead on the regulation front. But, and this is the good part, states will have a say in this too. And there is the potential for a few states to engage in experiments that might improve the law. The question here: Is the administration willing to work to improve insurance options for Americans or are they more interested in punishing Democrats? (Yeah, I know, but there is a political upside to answering that question correctly.)
Here’s the thing: There is a crisis in insurance markets. And a bipartisan solution, meaning most Republicans working in partnership with Democrats, is the best way to reach a solution. There are three ways most of us get health insurance: our employers, public insurance such as Medicare and Medicaid, and the individual market when we buy our own insurance policies. Employer-based care is an accident of history (it’s a long story) and has been shrinking for the past fifteen years. Public health insurance has been growing (something the conservatives in Congress really object to because it codifies the notion that health care is a right) and under the Affordable Care Act individual insurance has increased from about 10.6 million people to 15.6 million.
Individual markets were troubled prior to the ACA’s enactment in 2010. One reason was that premiums for these policies were increasing more than 10% a year, on average, while the policies themselves had major deficiencies. They often excluded pre-existing conditions, charged higher premiums for people with health risks and for young women, placed limits on annual and lifetime benefits, or refused to renew policies for individuals who became sick. Many people who tried to buy plans were turned down. In 2010, an estimated 9 million adults who had tried to buy a plan in the individual market over the prior three years reported that they were turned down, charged a higher price, or had a condition excluded from their plan because of their health.
Thus “returning to the status quo ante — before the ACA — is not a viable option for the individual markets.”
The fix does not involve a “great mystery” according to Blumenthal and Collins. It’s simply making certain that more young people buy insurance to help pay for the higher health care costs of older Americans. The bigger the pool, the lower the cost. (Which, I should add, is why single payer works as a public policy.) One part of that solution is to increase the government subsidies so more people will buy in. That’s how the insurance market could work better.
More money for Indian health
Enough background. Where does Indian Country fit into this matrix? So there is a legal understanding that the Indian health system is federal obligation that stems from the promises made in treaties to provide doctors and nurses to reservation communities. Yet no Democrat nor Republican government has ever (as in ever) proposed fully-funding that Indian health system. Members of Congress often acknowledge the treaty responsibility, but have never followed those words with a budget.
But the Affordable Care Act separates insurance from health care delivery. It basically makes the Indian health system (both the government-operated Indian Health Service facilities, and those run by tribes and tribal organizations) medical care that’s mostly funded by federal appropriations and funded by insurance. Nationally that mix right now is about 80 percent appropriations and 20 percent insurance. But, and this ought to be huge, the insurance side of the equation under the Affordable Care Act is unlimited. That pool of money grows every time an eligible American Indian or Alaska Native signs up for insurance. This makes full-funding of Indian health a possibility. (Even better: Insurance collections remain at the local clinic or hospital. It really is the best kind of funding.)
There are three ways to add money to Indian health now.
First: More American Indians and Alaska Natives can sign up for Medicaid. The fact is there are many more people eligible than have signed up. The Kaiser Family Foundation estimates that nationwide one million American Indians and Alaska Natives lack coverage (depending on the state). Already Medicaid covers more than half of all children but 11 percent of those children remain uninsured.
Second: More American Indians and Alaska Natives can sign up for exchange plans under the Affordable Care Act. This is huge. According to healthcare.gov “If you get services from an Indian Health Care Provider, you won’t have any out-of-pocket costs like copayments, coinsurance, or deductibles, regardless of your income. (This benefit also applies to Purchased and Referred Care.).” And this benefit has essentially a permanent open enrollment.
Signing up for insurance (including plans from an employer) makes the Indian health system stronger for everyone. It’s the same principle as any insurance, the larger the pool of people who participate, the lower the cost.
Third: It’s time to make the case for Medicaid expansion in state governments that have said no. Now that the Affordable Care Act remains the law of the land there remains unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments such as imposed work rules). It’s a win for Indian Country when a state does this because it increases the number of people eligible for insurance. It’s a win for the state because Indian health patients are a 100 percent federal obligation so the state will be reimbursed by Washington.
Kansas is the latest state to consider expansion. And it’s likely that the Trump/Ryan failure to repeal and replace will push other state legislatures to consider this approach. Indian health patients would benefit from Medicaid expansion in Oklahoma, South Dakota, Texas, Maine, Mississippi, Nebraska, North Carolina, Utah, Idaho, Wisconsin, and Wyoming. A total of 19 states are on this list.
The dangers for Indian Country ahead
It’s easy to see the defeat of Trump and Ryan’s plan as a huge win. But it is also a warning sign. Make that a flashing red light with sirens. The problem is that Congress is deeply divided and cannot govern.
The same Republican divisions that killed their health reform plan will kill President Trump’s budget (thank you). But it will also make it nearly impossible to pass any kind of budget. As I have written before the best outcome might be a Continuing Resolution, a status quo budget.
An even bigger challenge will be for Congress to pass an increase in the debt ceiling. Secretary of Treasury Steven Mnuchin informed Congress that the United States reached its limit on March 15. The Treasury is now juggling accounts so that the government can continue to pay bills.
Conservatives in Congress (actually, just about every member of Congress) hate this part of governing. But a no vote here has enormous consequences for everyone’s finances. markets. There is an absolute requirement that Congress increase that borrowing authority. It will be a nasty fight.
Of course there is one solution: Create a new coalition of Republicans and Democrats. This works in state legislatures across the country (most recently Alaska). It takes 216 votes to pass legislation in the House so a working body of 22 or so Republicans, plus the 194 Democrats in the House, could accomplish a lot together. But that would mean rethinking the role of party politics. And governing.
Remember the sequester? Ah, the good old days. The new Trump Administration budget is short on details, but clear on direction. And we do know two things. First: If enacted, this budget would shrink the federal government to a much smaller size. Except for the military and the Veterans Administration. And, second, this budget guarantees chaos ahead.
Thursday morning the White House officially released the “skinny budget.” That’s an overall statement about the president’s financial goals for the year. It lists priorities, but provides few details. And this document does even less of that than previous skinny budgets. But the agenda, the direction ahead, would create a very different federal government. There is money available to approve (and pretend to regulate) energy projects, but nothing, really nothing, for public broadcasting, the arts, and the humanities. All told some 19 federal agencies would be eliminated.
This is where I should add: Hold on! Every one of these agencies has a constituency in Congress. You’ll see 535 budget revisions coming soon with members working to restore funding, and in some cases, even increasing the total amount of appropriation. But the overall direction is less. This is the eighth year of a slowing (and perhaps shrinking) federal government.
This is also where chaos kicks in. The political tension that surfaced in Congress over the repeal and replacement of the Affordable Care Act will only magnify in this budget debate. And to pass this budget, Republican leaders will need votes from Democrats. And if there is no agreement, then there could a shutdown of the government that could last much longer than previous episodes. The best case scenario is a continuing resolution that results in cuts, but not as dramatic as those proposed by the White House.
First throughout the document there is only one reference that include the phrase, “and Tribes.” The Obama administration often added that language to routine grants and programs for states and local governments to make it clear that tribes were eligible partners. No more.
The budget does not directly put a number on the Indian Health Service. It only lists IHS as part of the overall budget for the Department of Health and Human Services. That agency “requests $69.0 billion for HHS, a $15.1 billion or 17.9 percent decrease” from the Continuing Resolution level. The first mention in that request includes IHS (that must be good, right?) “The President’s 2018 Budget: Supports direct health care services, such as those delivered by community health centers, Ryan White HIV/AIDS providers, and the Indian Health Service. These safety net providers deliver critical health care services to low-income and vulnerable populations.”
The way this budget will work is that each department will figure out how to make the 18 percent cut (as I said, if it comes to that).
Many have compared this Trump budget to the Reagan-era budgets. I remember how that worked for IHS. The president would drop a number — and Congress would ignore it. Every time. That could happen again.
One interesting increase in the HHS budget is a request for $70 million to prosecute health care fraud. It claims a $5 return for every dollar spent tracking down “fraudulent or improper payments.”
The Department of Interior budget does not provide much information about the Bureau of Indian Affairs. It only says the budget: “Supports tribal sovereignty and self-determination across Indian Country by focusing on core funding and services to support ongoing tribal government operations. The Budget reduces funding for more recent demonstration projects and initiatives that only serve a few Tribes.” The budget says it will “sustain” funding for programs that bring in revenue from natural resources, including those programs that serve Indian mineral owners.
Many of these agencies will show a number in the budget because that reflects the cost to close the agency. Or as OMB put it “the amount of money that’s necessary for us to unwind our involvement …”
In addition Agriculture would eliminate the Water and Waste Disposal Loan and Grant Program, Commerce would eliminate the Minority Business Development Agency and NOAA grants supporting coastal and marine management. At Energy the budget would eliminate the weatherization program. At HHS, the budget proposes to end Community Services Block Grants as well as the Low Income Home Energy Assistance Program. Homeland Security would sharply curtail or eliminate grants to states and local governments (tribes, I assume). Even Meals on Wheels programs for seniors would be eliminated.
Another program that is slated for elimination is the Transportation Department’s Essential Air Service for rural airports — including those that serve remote reservation and 60 Alaska Native communities.
The only mention of “and Tribes” in the budget proposal is at the Environmental Protection Agency where the budget will avoid duplication by “concentrating EPA’s enforcement of environmental protection violations on programs that are not delegated to States, while providing oversight to maintain consistency and assistance across State, local, and tribal programs.”
The actual numbers of this budget mean little. They will go up and down. Some of the headlines, such as the elimination of public broadcasting, will survive because of support found in Congress. But it’s important to remember that this is the president’s agenda. This administration is hostile to every program that’s identified. So even if those programs are funded, the agencies will have a difficult task going forward.
Some of this agenda is nonsense. There are two ways to spend money on global warming: Learning about the science and trying to change behavior to lower carbon dioxide emissions. Or money for higher sea walls and community mitigation. This budget cuts the latter. That won’t work for long. When a community is severely impacted by fires or other climate catastrophe, the money will have to follow. Period.
But for now the debate is all about the president’s plan.
As OMB Director Mick Mulvaney said at the White House briefing room on Wednesday: “This is the “America First” budget. In fact, we wrote it using the President’s own words. We went through his speeches, we went through articles that have been written about his policies, we talked to him, and we wanted to know what his policies were, and we turned those policies into numbers. So you have an “America First” candidate, you have an “America First” budget.”
Only that’s a budget that means significantly less for the First Americans.
There is that moment when we take the plastic protection off a new phone screen. Everything was perfect until we peel it away. Then fingerprints, scratches, and the business of life take hold. That new thing is never the same.
That’s exactly where Doug Burgum was as the new governor of North Dakota. He could have taken that screen and made certain that there was a new image of North Dakota for the world to see.
Damn. Think about what was possible: A governor who is framing his entire administration on innovation just dismissed the most disruptive force in his state’s recent history. That is what Standing Rock is about. Instead of saying, “What can we learn from this? What can we do together?” The new governor relied on the screen saver that was there before; the idea that powerful forces will roll over the tribe and build the Dakota Access Pipeline without interference. Thank you.
Burgum also scratched away at an old story: The Obama administration created this problem.
But his larger message is that the state of North Dakota and its corporate partners are more powerful than any tribal government. Instead of a pause, a moment to engage in a government-to-government dialogue, the new governor emphatically says the pipeline will get built soon. No. Matter. What.
“Make no mistake, this infrastructure is good for our economy,” the governor said in his YouTube video. “And it’s the safest way to transport North Dakota products. Failure to finish it would send a chilling signal to those in any industry who wish invest in our state and play by the rules.”
But the rules are complicated. And the court cases are not resolved. In fact the governor could have taken advantage of the litigation schedule to begin an open dialogue. Even more important: The prospect of more litigation is growing and that is something that will not be resolved by the Trump administration. It will take time.
The new governor could have reset the law enforcement battle lines too. Nope. “As a result of the Obama administration’s refusal to uphold the rule of law on federally owned land, both our citizens and local and state law enforcement have been put in harm’s way,” he said. “These actions are putting daily demands on the scarce resources of our state and local government.”
Those daily demands are because the state of North Dakota made it so. Pick a word: defuse, de-escalate, negotiate. There were so many better alternatives, ones that were dismissed in favor of sending in the cavalry. I have interviewed many government officials over the years that successfully reduced tension instead of using the police powers of a state. In every test the state failed in this regard and the new governor is following the same path.
I had hopes that Gov. Burgum would see the potential of the Standing Rock story as one that could make North Dakota a beacon. Think about this: This moment in history has brought indigenous people together in a way that’s unprecedented. And the world is paying attention to that. What an amazing opportunity, something that could stir the imagination of investors, entrepreneurs, and governments. Potential partners in a state that found a solution by working with tribes to solve an intractable problem.
The former governor blamed social media for this global perception. But that misses the point that the Standing Rock Tribe owns the story. And that won’t change because the new governor posts a video his account. The problem is not social media. It’s the message that the State of North Dakota will use the rule of law, the police power of a state, to roll over a tribal nation. It’s a message of brut force instead of inspiration.
A missed opportunity? Sadly, yes. The governor says he will meet with tribes. But in North Dakota the context is business as usual. The plastic is off. And the new screen is already scratched.
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
Sometimes the stars do align. The short version: Minnesota Rep. Keith Ellison is campaigning to chair the Democratic National Committee. If he wins, that opens up a congressional seat in a special election. And, state Rep. Peggy Flanagan is thinking about running.
“After months of protests, I’m inspired by this victory by thousands of indigenous activists and Water Protectors, and millions of Americans who support them. This is a victory for all people who fight for social justice. And it is a victory won by the power of peaceful protest – a reminder of what people can do when they stand up and organize.
We use environmental impact statements to understand how key projects will impact our environment and communities. I hope that Energy Transfer Partners, and most importantly, the next Administration, recognize the concerns raised by the Standing Rock Tribe.
I also want to acknowledge that the responsibility for this project falls on the Energy Transfer board room, not the workers who are simply trying to do their jobs. Working Americans need our support as well. That’s why I support a broad infrastructure package that creates good jobs for millions of American workers.
We have a responsibility to respect the sovereignty of the Standing Rock Tribe, and to ensure their voices are heard. And we must ensure that the millions of people who depend on the Missouri and Cannonball rivers have access to clean water. As the Water Protectors at Standing Rock remind us every day: Water Is Life.”
This is not exactly the message we have been hearing from the Democratic National Committee. Instead, since the summer, when the presidential campaign was at its height, we heard statements about protecting peaceful protest and workers (without a definition of what was meant). The Democratic Party has been trying to represent corporate patrons (including those who build and fund pipelines) as well as some of its core constituent groups. That no longer works. If it ever did. In this age of social media and transparency, the people are demanding more accountability and a clear sense of direction about social justice.
And that’s the basis of Ellison’s campaign, building a party that champions grass roots efforts. He said last week: “The Democratic Party must be the party that delivers for working people. We can do that by meeting folks where they are, looking them in the eye, treating them with respect, and working to solve their problems. For me, that means a chair with only one full time commitment.”
So that means Ellison (unlike former DNC Chair Debbie Wasserman Shultz) would give up his congressinal seat. “I have decided to resign as a member of Congress if I win the election for DNC chair. Whoever wins the DNC chair race faces a lot of work, travel, planning and resource raising. I will be ‘all-in’ to meet the challenge.”
Ellison was a strong candidate before his announcement last week. But since then he is earning more endorsements from elected Democrats. According to Politico, supporters now include: Reps. John Lewis, Raul Grijalva, Luis Gutierrez and Tulsi Gabbard, a former DNC vice chair, as well as Sens. Martin Heinrich, Bernie Sanders, Chuck Schumer, Elizabeth Warren, and on Thursday, the AFL-CIO also announced its endorsement.
The election of the DNC chair will happen at the party’s winter meeting, sometime before March 2017. There are at least two other candidates: Raymond Buckley, a NH party leader, and Jaime Harrison, chairman of the South Carolina Democratic Party. There are other potential candidates as well, including Labor Secretary Thomas Perez.
And that’s the stage setting a Peggy Flanagan run for Congress.
Flanagan’s entry into the race would be historic. She’s a member of the White Earth Band of Ojibwe and she would be the first American Indian woman ever elected to Congress. That sentence is in itself remarkable when you think about this country’s history and the contributions from so many Native women. Montana and Arizona could, should, have broken that barrier in 2016 by electing Denise Juneau and Victoria Steele. But the geography and the timing weren’t there. Sometimes elections require a bit more, well, luck.
And Minnesota’s fifth congressional district could be the spot. As Ellison’s biography says, it’s one of the most vibrant and ethnically diverse districts in Minnesota. This is a place where voters would appreciate, even celebrate, the historical significance of this first. After all this is a state that just elected four Native women to its Legislature. Another record.
Flanagan also has the ideal background for this job. She’s been an organizer working on social justice issues for more than a decade. More than that: She teaches other people how to win campaigns and elections for Wellstone Action and The Management Center (an organization working for social change). She was executive director of the Children’s Defense Fund-Minnesota.
And, if that’s not enough, she knows how to win a special election. She was elected to the Minnesota House in 2015 when Rep. Ryan Winkler moved out of the country. She jumped into the race early, ran unopposed, and earned 96.4 percent of the vote.
It’s not likely that Flanagan will run unopposed for a congressional seat. But she is already getting early support on social media. (Hashtag: #RunPeggyRun.)
Former Minneapolis Mayor R.T. Rybak Jr. posted this on Twitter: “Wow! It would be great to have one of the best young leaders in the country be my rep in Congress.” He’s not alone. Others have expressed their fondness for Ellison and then say Flanagan is the right candidate to build on that legacy.
In politics timing is everything. Sometimes the stars do align.