What’s next? Three ways to add money to Indian health and bigger fights ahead

Governing without a working majority

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Smiles no more. President Donald J. Trump failed in his pitch to the Republicans who opposed the speaker’s Affordable Care Act replacement.  (Photo via Speaker Ryan’s page.)

 

Mark Trahant / Trahant Reports

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.

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Much of the current health insurance debate is about that individual market. Even if it is the smallest part of the problem. It’s important to understand, as David Blumenthal and Sara Collins wrote in the Harvard Business Review:

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.

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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.

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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.

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

 

 

Three things you need to know about the House’s Powerball Health Care Plan

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Trahant Reports

There’s a  bad joke that goes like this: What’s your plan to pay for the high cost of health care? No worries. I’ll win the Powerball.

Except the new Republican plan to repeal and replace the Affordable Care Act ends that option (and somehow takes it seriously). There are detailed instructions to prevent lottery winners from getting Medicaid coverage. That probably fixes a huge problem that we never heard about before.

It’s funny that the House Repeal and Replace plan (The American Health Care Act) includes several pages on that non-problem while the draft doesn’t even get around to mentioning the Indian Health Care Improvement Act.

But don’t get too worked up about this miss. Here are the three things you need to know about the House plan.

First: This plan is an urgent call for American Indians and Alaska Natives to sign up for Medicaid, children’s health insurance, or the Exchange Plans. This plan makes it clear that there is time to sign up as an act of defiance and that adds new money to the Indian health system.

Second: There will be fewer people covered under the House plan. We won’t know the numbers until it’s scored by the Congressional Budget Office. But it’s clear fewer people will be covered. And to top it off the plan will cost older Americans more. A lot more. Insurance companies would be allowed to charge older people five times as much as young people. (And to make that more odd: Older people are a GOP constituency.) There is no requirement that people carry insurance, but if there is a lapse in coverage, the cost goes up.

Third: The politics are a lot like President Trump’s election plan. Tick off everybody. Create chaos and hope there are enough votes left to win. I don’t think so. Conservatives already don’t like the provision to include tax credits. And state governments aren’t happy with a punt on Medicaid expansion (keep it until 2020 and then cut the heck out of program). And to top it off, the White House comment is at best only mild support. This plan is politically dead. A plan that looks so much like Obamacare is going to be really difficult to sell as change. It keeps, for example, the essential health benefits package, including family planning and maternity benefits. Yet at the same time it ends funding for Planned Parenthood. That means two very different constituent groups will be opposed. Finally the tax credits are complicated and unfair. They are based mostly on age. So someone under 30 gets a credit of $2,000 while someone who’s 60 or older could get $4,000. Once again that’s contradictory logic. Take from old people. Then give something back. Good politics? We shall see.

I just don’t see how this plan — or anything like it — gets out of the House of Representatives. Let alone become the law. So don’t get too excited. You’re better off buying a Powerball ticket. — Mark Trahant

 

 

 

About that repeal business, Democrats pick a party boss, and Peggy Flanagan

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Minnesota Rep. Peggy Flanagan (DFL-St. Louis Park) at the women’s march. (Campaign photo).

Mark Trahant / Trahant Reports

A short post for a big week: We should start to see some budget numbers coming out of the White House (as soon as today). Early reports suggest sharp cuts for domestic spending as well as increases for Defense. I’ll update once I see if that framework includes the Bureau of Indian Affairs, Bureau of Indian Education, Indian Health Service, and other federal programs that serve American Indians and Alaska Natives.

President Donald J. Trump could also refer to his spending plan in his speech to Congress on Tuesday.

The other big news is the ongoing problems the Republicans are having repealing and replacing the Affordable Care Act.

An analysis of the Congressional framework for repeal and replace would be a disaster for state governments and millions of Americans would lose coverage.  According to Sarah Kliff writing for Vox:  “The report estimates that coverage declines would be even higher in states that did not expand Medicaid — largely those run by Republican governors. There, the report presents an example of a state with 235,000 in the individual market. It estimates that coverage would decline by 120,000 people, about 50 percent.”

The presentation did not address the Indian health system. But the slides do make the case against converting Medicaid into a block grant program because states would have less federal funding when the need is greatest (such as during a recession). Remember states are partners with the federal government in Medicaid, but patients in the Indian health system are funded by a federal reimbursement. So this is a critical debate.

I want to come back to this theme later: But Indian Country has a solution. At least for now. Every proposal to repeal and replace the Affordable Care Act will take time. So for now. Right now. There should be a renewed push to enroll Indian Health patients (who don’t already have insurance) in Medicaid or the Bronze Plan from a state or federal insurance exchange. The exchange plan is free. This health insurance coverage should be good for a least a year. This is money that a Trump budget cannot strip from the Indian Health system.

And the week starts off with the Democratic National Committee having new leadership. Over the weekend Tom Perez was elected chair and he immediately appointed Keith Ellison as his deputy. 

I have read from so many friends on social media who see this contest as a policy debate. It is not. It’s about who will make sure there are candidates running. That those candidates have support and money. And there is a machinery that’s built. The policy debates are down the road.

But this DNC election does mean that Minnesota Rep. Peggy Flanagan (White Earth Ojibwe) won’t be launching a bid for Congress. (Yet.)

(Previous post: Turning fear into fight.)

Flanagan posted on Facebook:  “Earlier today, the DNC elected Tom Perez Chair, to lead the party and I congratulate him on his victory. I also want to applaud our Congressman Keith Ellison for running a strong campaign based on positive ideas for the future of our party.

Obviously, this means that I am not running for Congress now and I’m excited to keep working with Keith to build the movement we need to win and protect victories for real progressive change.

“I will continue to work with you to turn our fear into fight, our emotion into empathy, our sorrow into strategy, and our despair into hope. I am incredibly grateful for all your support. Miigwech (Thank You).”

And she’s right of course. There remains much to do to turn fear into fight. In Congress or 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

 

 

Pushing repeal of the Affordable Care Act (while a replacement can wait)

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Rep. Tom Price, R-Georgia, is President-elect Donald Trump’s choice to head the Department of Health and Human Services. Price is a physician and has been a consistent critic of Obamacare. (Photo via Facebook).

 

Price plan calls for Indian Health savings accounts

Mark Trahant / Trahant Reports

President-elect Donald Trump and Congress are moving quickly to reshape health care, including the Indian Health system. And so far the path looks to be chaotic.

First, the who: The Trump administration will be led on health care issues by Tom Price, a Georgia physician, a persistant critic of the Affordable Care Act, and a member of Congress. Seema Verma will be the next Administrator of the Centers for Medicare and Medicaid Services. As a consultant Verma has helped conservative governors, including the Vice President-elect Mike Pence, implement Medicaid expansion.

And let’s be clear about their task. As the president-elect said, “he is exceptionally qualified to shepherd our commitment to repeal and replace Obamacare and bring affordable and accessible healthcare to every American. I am proud to nominate him as Secretary of Health and Human Services.”

These two appointees know the machinery of the Affordable Care Act and Medicaid, including how to effectively dismantle the programs.

Price has already floated in Congress an alternative to the Affordable Care Act, the Empowering Patients First Act. That bill would repeal Obamacare in its entirety (including the Indian Health Care Improvement Act) and replace it with a free-market version. The plan would give tax credits that “makes it financially feasible for all to purchase coverage they want for themselves and their families – not that Washington forces them to buy.”

This plan would impact the Indian Health System in several ways. First it would allow participants of federal programs, such as Medicaid, Medicare, Veterans health, and even military TRICARE, to opt out and get a tax credit to buy a personal health plan. (Making it less likely those plans will survive on their own.) In the bill’s section on government health programs there is no mention of the Indian Health system, although the bill later calls for a personal health savings accounts that can be spent at IHS. In other words: save your money so you can pay for your own doctor (at IHS or elsewhere).

But forget the details for a minute. Price’s plan is important because it signals the radically different approach to health care that’s ahead, basically less government spending, more tax credits if you choose to buy health insurance, individual health savings account, and shifting Medicaid to a block grant program run by states.

It’s important to remember that Medicaid now accounts for more than $800 million of the IHS’ $6.1 billion budget and that’s often money targeted for the local service unit. (A smaller Indian health system impact would be ending the requirement that tribes provide insurance for employees. That accounts for about $100 million in the IHS budget.)

The problem for Congress is that any replacement of the Affordable Care Act requires at least 60 votes in the Senate, and that means some Democrats will have to agree to new legislation. That’s where chaos begins.

Legislation to repeal the Affordable Care Act can be done through a process called budget reconciliation (the same method that enacted the law in the first place). That means tightly tying the legislation to the budget (something that has not passed in this Congress yet). But a replacement law would require legislation. And to do that there would have to be a consensus in the House (218 votes) and a filibuster-proof majority in the Senate (60 votes).

House Majority Leader Kevin McCarthy said Monday that Congress should move quickly to repeal the Affordable Care Act and then come up with a replacement plan down the road. McCarthy told The Washington Times: “I think once it’s repealed you will have hopefully fewer people playing politics, and then everybody coming to the table to find the best policy.”

And that policy shift will be dramatic. Tax credits instead of funding. A bigger role for states. And the pretense that the private sector is equipped to deliver health care to all.

According to Drew Altman, president and CEO of the Henry J. Kaiser Family Foundation, “The larger story is GOP preparations for a health policy trifecta: to fundamentally change the ACA, Medicaid and Medicare–all three of health care’s major programs–and in the process, fundamentally alter the direction of the federal role in health and core elements of the social contract.”

American Indians and Alaska Natives are in a risky situation. Our best health care programs, those run by tribes and tribal organizations, will get less funding from this kind of trifecta. Neither tax credits nor state funding are likely to help. And interest from the private sector? Get real.

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

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New graphic from Kaiser Family Foundation looks at Indian health care by the numbers.

New project: The People’s House: Native Americans, Congress and data

This week I am teaching map making in my reporting class. As I was thinking through how to do that, I was thinking, “I ought to build a map.” What kind of map? Well, it would be cool to show where every American Indian or Alaska Native is running for office. At the federal level, Senate and House, at the state level, legislatures, and important offices, such as city councils or state superintendent of public instruction.
I’ll do this both in map form and build a graphic table.

As I have written before: Congressional parity would mean at least 7 House seats plus two in the Senate.

So … please send data. If you know someone running for office, send me a note, a tweet, or post a comment on Facebook.

Also hat tip to the Indigenous Politics Blog. I liked the data reports during Canada’s recent elections. It’s time to try that in the U.S.

For federal offices, this is what I have so far.

Washington

Joe Patookas, Democrat. http://www.pakootasforcongress.com

Montana

Potential. Denise Juneau, Democrat. http://www.krtv.com/story/30319249/state-superintendent-of-schools-juneau-may-challenge-zinke-for-us-house-in-2016

Arizona

Shawn Redd, Republican, http://www.foxnews.com/politics/2015/10/21/republican-mounts-uphill-bid-to-be-first-navajo-in-congress/

Oklahoma

Tom Cole, Republican. http://www.tomcoleforcongress.com

Markwayne Mullins, Republican. http://www.mullinforcongress.com

Now a pitch: Send data. Tips, spreadsheets, the works. (Or leave a reply.)

email: mntrahant@mac.com

Thank you.

Mark

Naked and afraid? Sixteen Republican candidates compete to survive

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Presidential Debate season begins on August 6

MARK TRAHANT

What do you do with sixteen candidates? It’s a thorny problem for Republicans. Why’s that? Because right now one of those candidates, Donald Trump, is loud enough to drown out all the other “major” candidates.

Wouldn’t it be fun if the nomination contest was more like a basketball tournament? Then top-seeded Donald Trump would battle 16th seed Ohio Gov. John Kasich a battle of ideas. Or how about dropping the bunch in the jungle Naked and Afraid. We could even start voting and eliminate a candidate every week, until it’s just the Republican versus a Democrat.

Enough. Back to the chaos. And Donald Trump.

As The Washington Post put it on Sunday: “For yet another week, Trump talk dominated the Sunday morning political shows, with several devoting roundtable discussions to his disruption of the GOP presidential primary and at least two of his GOP rivals using their clashes with him in recent days as a means of securing interviews on the shows — during which they continued to clash with him.”

On August 6 in Cleveland the first debate is set, an opportunity to raise serious issues. As if. It’s more likely that it will be Trump versus the other nine candidates tossing one liners back and forth.

Of course American Indian and Alaska Native issues don’t get attention this early anyway. Usually that happens late in the campaigns, during the general election, when a position paper is released that outlines the candidate’s official policy. That’s too bad. It would be good to press candidates from both parties about how they see treaties, the federal-Indian relationship, and the management of federal programs that serve Native Americans.

Then again it’s pretty clear where most stand. The Tea Party wing of the Republicans — Trump, Marco Rubio, Scott Walker, Ben Carson, Ted Cruz, and Rand Paul — would dramatically cut federal spending. Paul has even called for the elimination of the Bureau of Indian Affairs and drastic cuts at the Indian Health Service. If any of this happened, the Sequester would be the Good Old Days.

Even a self-described serious candidate, former Florida Gov. Jeb Bush, suggests its time to reshape government. A few days ago in Tallahassee, he said that as governor he used a hiring freeze to shrink state government. He suggested the same approach would work in Washington where only one employee could be hired for every three who retire or leave government service. Bush also said it ought to be easier to fire federal employees. “There are a lot of exemplary employees in the federal government, but they’re treated no better than the bad ones,” he said. “The bad ones are almost impossible to effectively discipline or remove.”

Candidate Kasich was chairman of the House Budget Committee when President Bill Clinton declared the “era of big government is over.” That suited Kasich then. And now. One proposal at the time was to “reinvent” the Bureau of Indian Affairs with a block grant program. “The reinvented Bureau of Indian Affairs would provide block grants, rather than engaging in the direct provision of services or the direct supervision of tribal activities,” the House proposal said. This “would reduce the central office operations of the BIA by 50 percent and eliminate funding for the Navajo and western Oklahoma area offices. It would eliminate technical assistance of Indian enterprises, through which technical assistance for economic enterprises is provided by contracts with the private sector or with other Federal agencies.” Congress would have ended direct loans and reduce loan guarantees.

The Republicans running for president all share contempt for the Affordable Care Act (and most don’t know that would include the provisions of the Indian Health Care Improvement Act.) All are also supportive of more development, such as the Keystone XL pipeline, and generally dismissive of any action to limit climate change.

I don’t know. I’m still partial to a Naked and Afraid competition.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Alaska says yes, boosts Indian health system by expanding Medicaid

Governor Bill Walker and Health and Social Services Commissioner Valerie Davidson announcing the expansion of Medicaid in Alaska. (Picture from video feed.)
Governor Bill Walker and Health and Social Services Commissioner Valerie Davidson announcing the expansion of Medicaid in Alaska. (Picture from video feed.)

One more state adds “new money” to the Indian health system via Medicaid

MARK TRAHANT

These days “new” money is hard to find. That’s the kind of money that’s added to a budget, money that allows programs to expand, try out new ideas, and look for ways to make life better. Most government budgets are doing the opposite: Shrinking. Calling on program managers and clients alike to do more with less.

That’s why the news from Alaska last week is so exciting: Alaska’s new governor announced the expansion of Medicaid and this will significantly boost money for the Alaska Native medical system. Indeed, the significance of this announcement to the Indian health system was clear when Alaska’s Gov. Bill Walker and Department of Health and Social Services Commissioner Valerie Davidson made the announcement at the Alaska Native Medical Center on July 16. The governor took this action using executive authority because the Alaska legislature had failed to even vote on legislation to accept Medicaid.

The governor says Medicaid expansion would reduce state spending by $6.6 million in the first year, and save over $100 million in state general funds in the first six years. “Every day that we fail to act, Alaska loses out on $400,000,” the governor said. “With a nearly $3 billion budget deficit, it would be foolish for us to pass up that kind of boost to Alaska’s economy.”

“We know Gov. Walker has worked tirelessly to expand Medicaid since he came into office on December first,” Davidson said at the news conference. It was one of the campaign promises made by the independent governor. “He included it in the budget. He introduced a bill both in the House and in the Senate side. It was a subject of both special sessions. And, it’s the right thing do do for Alaska.”

The expansion of Medicaid is one of key components of the Affordable Care Act. It’s critical a tool for the Indian health system because it opens up a revenue channel for clinics and hospitals to bill Medicaid, a third-party insurance, for services and that boosts budgets at the local level. (In a climate where Congress is unlike to spend more money on Indian health.) How big a number? More than a million American Indians and Alaska Natives are now insured by Medicaid. The Kaiser Family Foundation estimated in 2013 that Indian health facilities collected $943 million in third-party payments.  “By far the largest third-party payer is Medicaid, which accounts for $683 million or 70% of total third party revenues, and 13% of total IHS program funding for FY2013,” Kaiser reported. Nearly 150,000 Alaska Natives and American Indians receive health services across the state from tribal and non-profit health organizations funded by the Indian Health Service. By law the IHS-funded clinics must seek third party billing from patients, such as Medicaid, the Veterans Administration or private, employer-based health insurance.

Medicaid is an odd program for Indian Country. Most of us understand the Indian Health Service to be the government’s fulfillment of its treaty obligations. However the IHS has never been fully funded. Medicaid, however, is an unlimited check. If a person is eligible, then the money is there. Yet states, not tribes nor the federal government, determine the rules for Medicaid. And many Republican states have been determined to fight the Affordable Care Act, or Obamacare, at every turn, and that means refusing to accept Medicaid expansion (the Supreme Court ruled in 2012 that states could turn it down).

Alaska’s decision means that the number of states rejecting Medicaid is continuing to shrink. Most recently Montana agreed to expand Medicaid in April. The states with large American Indian and Alaska Native populations that have not expanded Medicaid include Oklahoma, South Dakota, Wisconsin, North Carolina, Maine, Wyoming, and Idaho. Utah is the next state considering an expansion.

The Affordable Care Act continues to evolve — and improve. But more important, steps that states are taking to expand Medicaid are adding real dollars to the Indian health system.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Court affirms Affordable Care Act again; good time to step up Indian Country’s participation

President Obama hugs Kristie Canegallo and Vice President Biden hugs Denis McDonough President Barack Obama hugs Kristie Canegallo, Deputy Chief of Staff, and Vice President Joe Biden hugs Chief of Staff Denis McDonough as they celebrate the Supreme Court ruling on Affordable Care Act subsidies in the Oval Office, June 25, 2015. (Official White House Photo by Pete Souza)
President Obama hugs Kristie Canegallo and Vice President Biden hugs Denis McDonough
President Barack Obama hugs Kristie Canegallo, Deputy Chief of Staff, and Vice President Joe Biden hugs Chief of Staff Denis McDonough as they celebrate the Supreme Court ruling on Affordable Care Act subsidies in the Oval Office, June 25, 2015. (Official White House Photo by Pete Souza)

MAKING THE LAW WORK BEYOND MEDICAID EXPANSION

MARK TRAHANT

The Supreme Court once again affirmed the legality of the Affordable Care Act. This time the court’s answer is unambiguous.  As Chief Justice John Roberts wrote: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

The 6-3 ruling means that people who buy insurance using tax credits as subsidies — some 6.4 million people — will continue to do so regardless of where they live. Thirty-four states have not set up health insurance exchanges and sao consumers must purchase plans through a federal exchange.

At the White House, President Barack Obama said “the Affordable Care Act is here to stay.”

But Congress has other ideas. The House has voted to repeal the Affordable Care Act some fifty times and this is certain to again be an election year issue in 2016. This ruling will also increase the political pressure for conservatives to try and derail the law using the budget, making it much more difficult for the Congress and the Obama administration to reach a deal over federal spending next year.

There is an interesting twist on this case for American Indian and Alaska Native consumers. Early on both supporters in Congress and in the Obama administration decided to play up the portion of the law that exempted Native Americans from the mandatory insurance requirements. The idea was that delivery of health care is seen as a treaty right, so it was impossible to force Native Americans to buy insurance. But the problem is the Indian health system does not have adequate funding — and the best course for improving that revenue stream is to sign up more Native Americans for some kind of insurance through a job, Medicaid, Medicare, Childrens’ Health Insurance Program, or these health insurance exchanges.

According to a report by the Kaiser Family Foundation, nearly one in three American Indians and Alaska Natives is uninsured and most have far less access to employer-based insurance than other Americans.”Less than four in ten American Indians and Alaska Natives have private coverage, compared to 62% of the overall non elderly population,” Kaiser reported. “Medicaid helps fill this gap, covering one in three non-elderly American Indians and Alaska Natives. Medicaid also provides key financing for IHS providers and has special financing rules and protections for American Indians and Alaska Natives. However, nearly one in three nonelderly American Indians and Alaska Natives remains uninsured.”

One way to improve that insurance rate is to encourage more American Indians and Alaska Natives to take advantage of subsidized plans purchased through exchanges. There are, for example, plans for a family of four earning up $70,650 (or $88,300 in Alaska) that have no cost, including deductibles and co-pays. If a family earns more than that amount, an insurance plan purchased through the exchange could still be eligible for no out-of-pocket costs when using the Indian health system. Native Americans can also sign up for the insurance plans every month, instead of during limited open enrollment periods.

Jim Roberts, a policy analyst for the Northwest Portland Area Indian Health Board, said it’s difficult to get data from the federal and state exchanges. However one report, that Roberts said is “suspect,” does have some data showing that approximately 22,000 American Indians and Alaska Natives in the federal exchange Native Americans have received cost-sharing benefits. “What’s interesting about this report is that 41,626 person were determined eligible for cost-sharing reductions, however only 22K were covered by a selected plan.  A very low take up rate despite high eligibility. Indian participation is a real problem,” Roberts said, both in the state and federal exchanges.

Perhaps that should be the outcome of the court’s ruling Thursday: A new emphasis on making certain that American Indians and Alaska Natives take advantage of every dollar eligible under the law. This would be one way of boosting funding for Indian health clinics and hospitals. And this money does not require appropriations from Congress or approval from a state (as is the case with Medicaid).

As he celebrated the court’s ruling Thursday,

President Obama said: “On March 23, 2010, I sat down at a table in the East Room of the White House and signed my name on a law that said, once and for all, that health care would no longer be a privilege for a few. It would be a right for everyone.”

But that right also requires action. Action from the administration informing American Indians and Alaska Natives about the benefits; as well as action from every clinic and patient to make sure we all havel the insurance we’re entitled to receive under the law. Call it, the pre-paid, Treaty Insurance plan.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.