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.)

 

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

THE ELECTED: Opening up a channel for discourse about Indian Country’s issues

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Updated interactive version of this graphic, here.  (Trahant Reports)

Native American Republicans include two elected members of Congress; a dozen serving in seven state legislatures

Mark Trahant / Trahant Reports

Indian Country cannot afford to close the door to Republicans in Congress and in state legislatures, especially those Native Americans who have been elected to office and serve as Republicans.

There are two tribal citizens serving in Congress: Representatives Tom Cole, a member of the Chickasaw Nation, and Markwayne Mullin, a member of the Cherokee Nation.

There are at least at least a dozen Native American Republicans serving in state legislatures (compared to 51 Democrats) in seven states. That list includes Alaska Sen. Lyman Hoffmana Democrat, but he caucuses with the Republican majority and now serves as a chair of several committees and sub-committees. Hoffman is Yup’ik. In the Alaska House, Rep. Charisse Millett, Inupiaq, is now her party’s minority leader.

Not all the elected Native American Republicans make tribal issues any sort of priority. Minnesota Rep. Steve Green, for example, does not include tribal membership in his biography or in his campaign literature. Yet his district includes the White Earth Nation.

However most of the Native American Republicans who are elected to office also engage in Native policy issues before state legislatures, including support for enhancing tribal languages, teaching Native history, expanding or limiting tribal jurisdiction, voting rights, and, soon, state measures to shape the next version of health care reform.

One shared trait of the Native Americans who are elected as Republicans is support for fossil fuel energy development. “As a local elected official, I am outraged that Indian Country is prevented from harnessing our own energy resources by ever-increasing regulations,” New Mexico State Representative Sharon Clachischillage said in a Native Americans for Trump promotion. “The Trump Administration will ease restrictions on American energy reserves worth trillions of dollars. Together we will block the bureaucrats holding Native American businesses back and bring new jobs into our communities.”

But even the idea of energy development gets more complicated in Indian Country.  As Sen. Hoffman reports on his biography page: “Every Alaskan deserves affordable energy. As a resource rich state (oil, gas, wind, and tidal), our state should and could, harness all of this energy to benefit all of its citizens. I pledge to continue to work towards reducing the high cost of energy in rural Alaska.” Anyone who’s purchased gas in a village — topping $6 a gallon in Hoffman’s home in Bethel — gets that.

But many of these same communities, especially in rural Alaska, are at the global warming frontline and more money will soon be required to build sea walls, fight more fires, or even relocate entire villages. In his biography, Hoffman only cites the opportunity. “Our backyard is changing opening new ventures, with the thawing of the tundra and the melting of the Arctic ice,” he writes. “It is my intent and my responsibility as your state Senator, to ensure our region participates …”

Then not every Republican even goes that far. Montana Sen. Jason Small, Northern Cheyenne, ran for office against Sharon Stewart-Peregoy, a Crow, to spur reinvestment in coal. Small recently wrote in The Billings Gazette: “Thirty million dollars a year in lost royalties, hundreds of direct jobs lost, thousands of families out of work and out of options, entire towns destroyed, statewide economic ripples, and over $1 trillion dollars in stranded assets, not necessarily because of market forces, but directly attributable to a political agenda. That is what we face in the current and unprecedented assault on reason and Montana’s economy in what has been dubbed ‘the War on Coal.’”

Then market forces will be a test of this notion. Can pro-coal Republicans legislate the revival of the coal industry? Small argued in the piece that “carbon capture and combined cycle technology can solve the global climate challenge posed in part by the world’s more than 7,000 coal-fired power plants.” Coal prices did surge after Trump’s election, at one point topping $110 per metric ton, but have since declined to about $83.50 per ton. Since the election at least one major power plant, the Navajo Generating Station near Page, has been marked for closure in two years. The Arizona utilities that own the generating station say that the low cost of natural gas is their primary reason for closing the plant. That in two words, market forces.

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Waiting for Congress

Most state legislatures are waiting for Congress before taking action before another round of healthcare reform at the state level. And that’s a debate that is still hot. There are three distinct points of view about repealing and replacing the Affordable Care Act (or Obamacare). The plan by the House leadership (which has not been released yet) is supposed to be designed around tax credits instead of the insurance subsidies that are in the current law. Several of the most conservative members of the House and Senate see that as a new entitlement and have signaled their opposition. A third group of Republican moderates have been working with state governors to preserve Medicaid expansion because that insures some 22 million people (including more than $800 million for the Indian health system).

Rep. Cole is a likely supporter of the plan that emerges from House leadership. That includes a repeal of the Affordable Care Act as well as the Medicaid expansion. He recently told Native America Calling that Oklahoma did not choose to expand Medicaid and that made the system unequal.

However Cole said what ever plan emerges he said the Indian Health Care Improvement Act is a “bedrock” legal authority that must remain. “This legislation was included … purely as ‘vote bait’ to secure Democratic votes and has nothing to do with” the Affordable Care Act,” Cole said. “It is vital and ensures that Native Americans have quality health care available to them and their families. There is no controversy here – it sets the national policy for many programs and services provided by the Indian Health Service.”

A few weeks ago the repeal of the Affordable Care Act seemed like a sure thing. And now? The next week or two could answer that question. And the course that’s picked will have a huge impact on the Indian health system. 

And, over that same time frame, Native American Republicans will be asked to take a stand about deep budget cuts across federal agencies. Several news agencies have reported that the Office of Management and Budget is calling for a $1.3 billion cut at the Interior Department. Interior Secretary Ryan Zinke employees that he did look at the budget and is not happy about it, according to Energy & Environment News. “We’re going to fight about it,” Zinke said, “and I think I’m going to win at the end of the day.” E & E News reported that Zinke would engage in a major reorganization of the department, one that focuses the agency on the next one hundred years (including the promotion of tribal sovereignty).

It’s easy to find the issues where Native American Democrats and Republicans disagree. Indeed it would be simple for me to shape every column as doom and gloom, the logic of “Oh, what is that Trump going to do next?” But that won’t help the policy debates that are so important to Indian Country. But that idea discounts how much agreement there is out there — even in this hyper-partisan climate. It was Rep. Cole who helped champion the reauthorization of the Violence Against Women Act in 2013, including the provisions for tribal jurisdiction over non-Indians. Tribes still have a lot of work to do to implement that law. Deborah Parker, former vice chair of the Tulalip Tribes, and a key supporter of the act, said tribes should get their law and order codes ready now to comply with the law. Too few tribes have taken that step and VAWA will again require reauthorization in 2018 so Indian Country has to present its strongest case for this Congress.

One example of a Native American issue that cuts across party lines is unfolding in Wyoming. The Indian Education for All, House Bill 76, would require the state’s schools to educate all children about the history and economic contributions by the Eastern Shoshone and Northern Arapaho Tribes.

Sen. Affie Ellis was just elected in November and is a co-sponsor of the legislation. She’s a Navajo who grew up in Wyoming and she told the Casper Star-Tribune that Native American students sometimes are threatened by verbal abuse during sports trips across the state. “It’s a really important first step to understanding each other a little bit better,” she told The Star-Tribune. “It’s a brief idea, and I think it’s a fitting one.”

At the recent Conservative Political Action Conference, or CPAC, Ellis spoke at a panel titled, “Rising Stars in the Conservative Movement.” Back in Wyoming her appearance generated both praise and criticism. The newspaper Planet Jackson Hole asked the question if Ellis was a “sane Republican alternative” to Trumpism? The paper quoted Ellis saying:  “I think our country needs so desperately some thought and some well researched responses …  There’s so many times when it’s easy to name call and have these cute hashtags that stick but we have to have strong facts and start communicating those facts in a very effective way. I think the hard part is the devil in the details of policy you’re working on doesn’t fit into small hashtags. Maybe we just need long hashtags.”

I don’t know about longer hashtags. The one I use,  #NativePolicy, is short. But we certainly need more thoughtful, complex policy debates.

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

History to be made as Native legislators take on leadership roles across country

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Speaker Bryce Edgmon is the first Alaska Native in that post. (360North.Org photo)

Mark Trahant / Trahant Reports

Last year I expected a record number of Native Americans to get elected to offices across the country. There were just so many really superb candidates running for Congress, state legislatures, and statewide offices. At one point my list topped a hundred candidates. Of course it didn’t turn out that way. Too many of those exceptional #NativeVote16 candidates lost. But my tally to date: Sixty-six elected representatives and senators.  So the 2016 election cycle turned out to be more of a rebuilding year instead of one that broke records.

Yet it turns out there is still history to be made.

State legislatures are convening around the country this month and there is an interesting twist: Native Americans are in key leadership positions in at least seven states. That’s impressive — and critical right now because of the types of conversations that will be going back and forth between Washington, D.C., and state capitals about Medicaid, health care and energy policy.

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Interactive version of this graphic here.

Alaska is a great bipartisan example.

Two years ago former Sealaska chairman Byron Mallott, Tlingit, was elected the state’s Lt. Gov. (He was the Democratic Party’s nominee for governor, but joined an independent fusion ticket along with Gov. Bill Walker.) The Walker-Mallott administration elevated Native issues to an unprecedented level of influence. One of the governor’s first appointments was Valerie Nurr’araaluk Davidson, an Orutsararmiut Native Council tribal member, and a long time health advocate, as the state’s commissioner for the the state’s Department of Health and Social Services. She will be the one negotiating with the Trump administration about what Medicaid will look like if Congress acts to repeal the Affordable Care Act.

Then the state legislature and the Walker-Mallott administration have been at odds over state spending and resources. Alaska has a multibillion dollar budget deficit largely because of the state’s reliance on taxes from oil and gas. As The Fairbanks Daily Miner put it: “Fortunately for the state, previous years when oil revenues were high allowed legislators to sock away billions of dollars in savings accounts. Unfortunately for the state, it was easier for legislators to spend from these savings accounts than make the hard decisions that would put Alaska on a path to a balanced budget.” Further complicating that budget challenge, Alaska citizens are paid a per capita distribution instead of paying income or other general taxes.

So after this election a new alliance was formed in the legislature to try and come up solutions, three Republicans and two independents joined the Democrats to form a majority caucus. The Speaker of the House in this coalition is Bryce Edgmon, Yup’ik. He said his native background is how he views the world. He told the Bristol Bay Times: “I know it’s not only my children and maybe their children’s future, but it’s also the future of our way of life out here in rural Alaska and a lot of our Native villages.”

There are now eight Alaska Natives in the legislature representing both parties. Rep. Sam Kito III, Tlingit, is chair of the Labor & Commerce Committee as well as the Legislative Council (a joint committee with the Senate). Neal Foster is co-chair of the Finance Committee.  And Dean Westlake, Inupiaq, is chair of the Economic Development Committee and Arctic Policy. In the Senate, Lyman Hoffman, a Democrat who caucuses with Republicans, is co-chair of the Senate Finance Committee. The House Minority Leader is Charisse Millett, Inupiaq. In a previous legislature, Millett was instrumental in legislating Alaska Native languages as official state languages.

Actually I wrote “bipartisan.” That’s probably the wrong word for what’s occurring in Alaska because a few elected representatives run for election identifying with one party, only to caucus with the other after the election. (Perhaps a model for Congress?)

Oklahoma and Montana are the two states with the most Native legislators, nine. A larger group of Native legislators makes it easier to form a caucus so members can work together on issues important in Native communities. And both states have an active Native caucus.

Oklahoma legislators are leaders in both parties. In the House, Rep. Mark McBride, Potawatomi, is the Assistant Majority Floor Leader. Rep. Chuck Hoskin, Cherokee, is the Minority Whip. And in the Senate, Anastasia Pittman, Seminole, is the Assistant Democratic Leader.

Montana’s newly elected Rep. Shane Morigeau, Confederated Salish and Kootenai Tribes, will serve in leadership this session as Minority Whip. It’s a rare honor for a freshman.

Montana’s American Indian caucus was an important voice in the last legislature on issues ranging from tribal college funding to water compacts. “We’ve been literally and figuratively the minority’s minority,” Rep. Susan Webber, Blackfeet, told the Billings Gazette. “I know it looks like we have a lot of people in the Indian caucus, a lot of people were elected, but in reality it should be more. But just us getting in there, from my perspective, is a real positive.”

A critical challenge for the American Indian Caucus this session will be Medicaid. Montana came late to Medicaid expansion under the Affordable Care Act but its impact has been swift. The state’s uninsured rate dropped from 20 percent in 2012 to 7.4 percent last year. A report by The Montana Budget and Policy Center says a repeal of the Affordable Care Act “could have disastrous impacts on Montana, putting at risk the health care coverage of over 142,000 Montanans who have benefited from ACA measures. At the greatest risk are the over 61,000 Montanans who gained access to affordable health care coverage through Montana’s Medicaid expansion plan.” Worse: the report found that “repeal could cause a greater number of uninsured Montanans than before the ACA was enacted.”

Montana Budget and Policy says 8,000 American Indians are enrolled in insurance through the Medicaid expansion program. Third-party insurance, such as Medicaid, has added nearly a billion dollars to the Indian Health Service budget. “Nationwide, reimbursements at IHS facilities, tribal operated facilities, and urban Indian clinics have increased 21% since the expansion of Medicaid,” the report said. “In 2014, nearly 40% of American Indians did not have health insurance, but Medicaid expansion represented one of the most significant opportunities to expand coverage for American Indians.”

This is important because if Congress repeals the Affordable Care Act, it will be up to state governments to pick up the pieces (as well as the cost) or strip millions of Americans from health insurance coverage. Repeal without new resources could devastate the Indian health system.

Other states where Native American legislators are included in the leadership structure: Hawaii, where Andria Tupola is Minority Floor Leader; and in Colorado, Rep. Joseph Salazar is a committee vice chair.

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Sen. John McCoy is the chair of the Washington Senate Democratic Caucus and will help foster the party’s vision and values during the session. (Legislature photo)

In Washington Sen. John McCoy, Tulalip, has been a long-time champion of issues that are important in Native communities.

McCoy sponsored legislation to close coal burning power plants and “dramatically reduce the amount of coal burned to generate energy for Washington residents, reducing greenhouse gas emissions in Colstrip by 5 million tons — the equivalent of a million cars — a year.”

The senator says Washington Republicans and dental lobbyists are blocking the creation of a mid-level dental practice along the lines of what’s been done in several states. “Indian country may not have the loudest voice in Olympia, but it still has basic needs,” McCoy wrote in The Seattle Times.

“The idea is pretty simple — allow native communities to train and recruit dental therapists to help clear the backlog of an ongoing oral-health crisis. The research is alarming — one-quarter of Native Americans aged 35 to 44 years have fewer than 20 of their natural teeth,” he wrote. “The dentists also ignore the groundbreaking success of similar programs in other states. It’s been working for 11 years for indigenous communities in Alaska, where 45,000 people are seeing reliable providers for the first time in their lives.”

This issue is not going to go away. A new national survey reports that 45 percent of U.S. voters say they go without dental care because of cost or lack of insurance. But 8 of 10 favor adding midlevel providers as a solution. “Good oral health is critical to overall health, yet policies to expand access to dental care do not reflect this,” said Tera Bianchi, project director of the Dental Access Project at Community Catalyst. “Dental therapists offer better access to care for the most underserved populations in a cost-effective way to the system. They are a smart, effective bipartisan way to improve access to care.”

And this session McCoy will be the he face of the Democratic Party, chairing the caucus where he says he will help “foster the vision and values of Senate Democrats as they navigate the 2017 session.”

In other words: Sen. McCoy has a seat at the head of the table.

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

Winning the election of ideas

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Cover photo: Rep. Paulette Jordan via Facebook

 

Rethinking tribal policy at the state level

Mark Trahant / Trahant Reports

Elections are about ideas. What should our world look like? How do tribal nations, Alaska Native corporations, and communities fit into the American experience?

Elections are about tactics. Who runs? Are there resources? (And, when I say resources, I really mean, cash money.) And, does that make it possible to win?

Elections are about power. Do you have the votes to change the world? To protect a pipeline? Or to sell coal in a world that is shifting away from fossil fuels?

Elections are about people. The people who expect the Indian health clinic to have enough money to pay for a hospital stay. Or the people that decide how medical care should be funded, and who’s even eligible.

And elections are never forever. There is always another ahead. And that’s true win or lose. If you win, get ready to defend the gains you’ve made. If you lose, pick up the pieces, and start working for the next ballot.

Let’s examine 2016 and what worked, what needed work, and what must be rethought.
At one point more than a hundred candidates were running for Congress, state legislatures, and a variety of state offices. That is fabulous. Yes, the field was narrowed after primary contests, and, of course, the general election. But the point is you gotta run to win. So many talented people from across Indian Country gave elective office a shot. (In fact, for me, the one take away from this election: We have some incredibly talented people out there. And that talent is not disappearing just because voters didn’t discover them.)

There are some extraordinary hurdles. Money is a big one. There has to be at least enough money so that the Native candidates get consideration by voters. Then again. This election was a bit odd. Money played less a role than you would think.

Chase Iron Eyes (Standing Rock Sioux) ran a frugal campaign. At one point he was basically selling t-shirts to finance his enterprise (although he did receive more money toward the end). And the result: His opponent easily won re-election with 69 percent of the vote, while Iron Eyes was stuck at 25 percent. This is not as bad as it looks because the Democrat-NPL candidate for governor only earned 19 percent of the vote. And the party’s Senate candidate: 17 percent.

What this tells me? Iron Eyes has a base of support. It’s his first run and I know he learned a lot. So a next time? Something to think about.

On the other hand, Denise Juneau (Mandan Hidatsa Arikara) broke fundraising records for a Native American running for Congress as a challenger (it’s way easier if you are an incumbent). She raised more than $2 million in an extraordinarily expensive House race. But Juneau demonstrated success. She was competitive. And that will be important in future races, too.

Indeed, the match between a well-funded incumbent and a challenger from Indian Country was true in Washington state, too, where former Colville Chairman Joe Pakootas ran against Cathy McMorris-Rodgers, a member of Republican leadership.

And elections are never forever: It’s entirely possible that one of the Republicans that Iron Eyes, Juneau, or Pakootas, ran against could be recruited to the new Trump administration. And, then, well, opportunity time. North Dakota’s Kevin Cramer could end up serving in the Trump administration as Energy Secretary (or more likely, a Deputy Secretary.)

This election cycle at least 31 Native American candidates ran unopposed. Often these were reservation-based districts where there aren’t as many potential Republicans who would surface as opponents. But Rep.-elect Tanwa Sanchez (Shoshone-Bannock) was also in this group, running in Portland, Oregon, as well as Rep. Ponke-We Victors in Kansas.
Another twist this year: Districts where both candidates are Native American. There were two such districts in Montana. Sen-elect Frank Smith (Assiniboine Sioux), a Democrat, defeated Rep. G. Bruce Meyers (Chippewa Cree) in the northern part of the state. And Sen.-elect Jason Small (Northern Cheyenne), a Republican, defeated incumbent Carolyn Pease Lopez (Crow).

This was also true in New Mexico where Rep. Sharon Clahchischilliage narrowly won with 5,042 to GloJean Todacheene’s 4,246 votes. Both women are Navajo.

Wyoming will have a new member of its legislator, Affie Ellis (Navajo) was elected to the state Senate as a Republican, defeating an incumbent. She posted on Facebook: “I am humbled. And honored. Thank you for all the kind words of support. We knew it would be a tough race and I’m proud of our efforts. In the end, I secured 60% of the vote and am looking forward to serving in the Wyoming State Senate.”

 

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Nine Native Americans now serve in the Montana Legislature. That’s the most in the country both in percentage terms and as a total. (Trahant photo)

Montana continues to be the state with the largest Native American caucus in the legislature, 8 Democrats and 1 Republican. Rep. Susan Webber (Blackfeet) told The Montana Standard: “We’ve been literally and figuratively the minority’s minority. I know it looks like we have a lot of people in the Indian caucus, a lot of people were elected, but in reality it should be more. But just us getting in there, from my perspective, is a real positive.”

In Minnesota the Native American caucus is also a Native women’s caucus after the re-election of Rep. Susan Allen (Rosebud), Rep. Peggy Flanagan (White Earth Ojibwe), Rep. Mary Kunesh-Podein (Standing Rock Sioux) and Rep.-Elect Jamie Becker Finn (Ojibwe).

And every election sows seeds of what can be. This one is no exception. In Idaho Rep. Paulette Jordan (Coeur d’Alene) showed how to get elected as a Democrat in a largely Republican state. Jordan is the only Democrat elected north of Boise and the legislature will be 84 percent controlled by Republicans, a super-majority.

Jordan posted on Facebook: “We worked hard, with great diligence and incredible dignity above all else. However, while we continue moving forward after a shocking outcome, it’ll be up to us, the next generation of millennials to make a more productive change our state and country needs. We have to chalk this up as a valuable lesson learned, while challenging ourselves to be more engaged and begin organizing in all the best ways possible. I remain optimistic for my community, as I have been blessed with your support and tasked to protect our base values for another term!”

Last week’s election will require new thinking and new alliances. And that is already happening in Alaska. A new coalition of Democrats, Republicans and Independents has flipped the state House away from Republicans. The state is facing a multi-billion budget crisis. One of the Republicans who joined what’s being called the Musk Ox Revolt is Gabrielle LeDoux who told The Alaska Dispatch News, “We’re hired to do a job, and the purpose of our job is not to keep our job. It’s to actually do something.”

There are six Alaska Natives in the legislature, five Democrats and one Republican (whose race remains in recount territory).

Elections are about ideas, tactics, and power. Yet the outcomes determine policy. What choices the Congress will make, how a state chooses to implement those policies, and who gets to decide. There will be a lot of action in state houses over the next four years as the Trump administration goes about shedding federal power. This shift could mean a state-based energy policy. Or a new block grant to pay for health care, even for people in the Indian health system.

There will be challenges ahead. But remember: Elections are never final. There is always another one ahead.

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