Omnibus: Budgets, a Native voice in Seattle, and eyes on Montana

Seattle City Council candidate Debora Juarez (campaign photo)
Seattle City Council candidate Debora Juarez (campaign photo)

** Updated, Oct. 30. **

Omnibus is a Latin word that means “for all.” In legislation it means cramming everything into a bill that you think can pass. That’s exactly what the House did with its two-year $80 billion spending bill. That bill lifts caps from the Budget Control Act, or the sequester, and it raises the debt limit until March 2017. The Senate passed the measure early Friday morning. This bill awaits President Obama’s signature to become law.

The best part of this bill is that ends distractions such as defunding Planned Parenthood until after the election. The worst part of this deal is that the spending details still have to be written. As What it does not do, however, is push actual government dollars out the door to pay for discretionary federal programs—including major health, education, and science initiatives—after December 11, when the temporary funding measure passed at the end of September expires. Under the terms of the deal, members of the House and Senate appropriations committees will have until that December deadline to choose exactly how to spend according with the broader framework.”

Yay.

The politics of this deal (and another House action) are stunning, but, unfortunately, probably only temporary. More Democrats voted for the bill than Republicans. So the Leadership picked a bipartisan course. That happened again with individual members who used a parliamentary measure to bring the Export-Import Bank up for a vote.

The Senate still has to weigh in on the Export-Import Bank and there is no indication when that debate will occur or if the votes are there to pass it. Folks who want to shrink government want this international financing program to go away, calling it corporate welfare. Supporters say that the competition is from other countries and failure to re-establish the bank will put U.S. interests at a disadvantage.

Of course any budget that passes with more Democrats than Republicans is considered awful. The new Speaker of the House Paul Ryan said the process stinks. But the bill will make it easier for Ryan to govern his caucus because it takes away the threat of government shutdowns and general chaos. Ryan’s goal will be to unite the Republicans so what ever measures come forward next will be debated within the party caucus and then sent to the floor with more unity. So Democratic votes will not be needed. At least that’s the theory. We will see if it works.

Critics of the spending bill (including those Republican candidates in Wednesday’s debate) say this shows how government spending is out of control. The problem with that argument is the numbers. The deficit is shrinking. What’s missing from the discourse is that the United States has a long-term spending problem. Not a budget crisis. The Congressional Budget Office says, “This year’s deficit will be noticeably smaller than what the agency projected in March, and fiscal year 2015 will mark the sixth consecutive year in which the deficit has declined as a percentage of gross domestic product (GDP) since it peaked in 2009. Over the next 10 years, however, the budget outlook remains much the same as CBO described earlier this year: If current laws generally remain unchanged, within a few years the deficit will begin to rise again relative to GDP, and by 2025, debt held by the public will be higher relative to the size of the economy than it is now.”

Congressional Budget Office snapshot of federal spending.
Congressional Budget Office snapshot of federal spending.

So the question remains can Congress, can the next president, can the public, think long term?

My goal for this blog is to make it a “for all” place for politics in Indian Country. To that end, I will be posting more press releases, op-eds, and other material from campaigns. I’d like to see a roundup of candidates across the country running in races large and small.

One important race that I have neglected to write about is from Seattle. Debora Juarez is a candidate for Seattle City Council. She’s a member of the Blackfeet Tribe, grew up in the Seattle-Tacoma area, and is running for a seat on neighborhood issues. That means things people care about: more sidewalks, better bus service, and affordable housing.

Juarez happens to be also extraordinary well qualified. This is what The Seattle Times said about her in its endorsement editorial: “In a crowded field, Debora Juarez stands out. She has lived in the district for 25 years while building an impressive résumé as a legal-aid lawyer, a King County judge, a Native American affairs adviser for two governors and a Wall Street investment adviser. She currently is counsel for Northwest tribes in a respected law firm and is a member of the Blackfeet tribe. She would bring intellectual rigor and ideological independence to the council.”

It doesn’t get any better than this.

Of course great candidates make all the difference in elections. They bring experience and poise to the campaign. That’s why so many eyes are watching Montana right now. The only Native American to hold a statewide office, Denise Juneau, is considering a run for the U.S. House. She’s currently Montana’s Superintendent of Public Instruction and a member of the Mandan and Hidatsa Tribes. She grew up in Browning on the Blackfeet Reservation.

Two years ago there was a lot of interest in Juneau running for an open U.S. Senate seat. I thought it would have been an interesting race, but it would have been a long shot. The problem is the type of voters Juneau would need only vote in presidential election years and that race would have been a low-turnout election. So she opted to stick with the job she loves, running public education.

But Juneau is now at her term limit. Her schools’ job will end. And since it’s a presidential year, the House seat is awfully tempting. It’s a  seat that can be won. (It’s how Jon Tester won.) Stay tuned.

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

Press skips the debate about tribal sovereignty in Alaska

President’s visit to Alaska is remarkable on so many levels. But what story do we tell?

Mark Trahant

President Barack Obama’s visit to Alaska was inspiring. I eagerly watched everything I could see online: The official restoration of the name Denali, his powerful words on the climate, his visits to Resurrection Bay, and his interaction with Alaska’s Native communities. I especially loved the Yup’ik dancing (and the president showing his moves).

But there is one story that’s missing from the national accounts of the president’s visit: the role of tribes in determining Alaska’s future. The president himself referred to this debate in several ways. The first mention was in his statement to tribal leaders when he said: “My administration also is taking new action to make sure that Alaska Natives have direct input into the management of Chinook salmon stocks, something that has been of great concern here.” Then a few sentences later he promised to follow up on “everything from voting rights to land trusts.”

Those last two words are the story that needs to be told. The president’s language was a bit off. It’s not land trusts, but land into trust. This issue goes far beyond the status of land; it’s about the nature of sovereignty in Alaska. It’s complicated but basically there are two competing narratives that need to be resolved into a single story.

One version says that tribes ceased to exist when the Alaska Native Claims Settlement Act (or ANCSA) became law in 1971. This story says that Alaska is the primary vehicle for all government in Alaska. The state sets the rules for education, law enforcement, land use, etc., etc.

But there is another reading of this history. This narrative says ANCSA was primarily a land settlement act. It did create a different structure, such as establishing Native corporations, but it did not end the right of Native people to determine their own future.

This second story arc began shortly after ANCSA. As a Native American Rights Fund attorney Robert Anderson said in 1973:  “….our work in Alaska is really on the cutting edge of Indian Law. We are establishing for essentially two hundred tribes, that they are recognized on the same level as those in the lower forty-eight (states) and that they have all the powers and authority.”

That story has multiple chapters that include the recognition of those tribes by the federal government, the push for Native hunting and fishing rights as well as the management of fish and game, law enforcement, and the most recent episode, a debate about land into trust. It’s this last issue that’s hot right now and worth a state and national conversation.

A few days before the president’s visit, Alaska’s new governor pursued an appeal that would prevent the Interior Department from taking land into trust, thus creating “Indian Country.”

The case involves Native villages Akiachak, Chalkyitsik, Chilkoot Indian Association, the tribe in Haines, and Tuluksak. These tribes seek to govern on issues ranging from law enforcement to zoning. The same powers held by other tribes. Indeed, the recognition (and expansion) of tribal authority was one of the main recommendations by the federal Indian Law and Order Commission, a bipartisan presidential and congressional task force.

But that’s unacceptable to Alaska. Simply put: The State wants to block tribal sovereignty.

As the state itself said:

“When the federal government takes land into trust, it holds it for the benefit of an individual Alaska Native or a Tribe. It is the federal government’s position that this land becomes Indian country—a legal status that can be likened to an Indian reservation. Currently, Alaska has only one reservation—the Metlakatla Indian Community’s reservation on the Annette Islands Reserve. Indian reservations are generally exempt from state jurisdiction, including taxation, except when Congress specifically authorizes such jurisdiction.

“If lands are put into trust in Alaska, the exact scope of federal, state, and tribal powers on trust lands would be played out as specific factual scenarios develop. Alaska would retain some civil and criminal powers over trust lands because Alaska is a P.L. 280 state. But generally, the federal government has the power to manage tribal and individual land that it holds in trust. The federal government will potentially have powers to approve and cancel leases of tribal trust land; as well as to govern the leasing of mineral resources (including oil and gas), regulate certain fishing activities, manage timber resources, issue grazing permits, and deal with certain water rights and irrigation matters on trust land. And Tribes have jurisdiction over civil and regulatory matters occurring on trust land. Gaming can occur on certain trust land in accordance with the Indian Gaming Regulatory Act.”

This is twisted. The state fears tribal authority. Then, this is not a new position. The one constant theme from the past four decades is that Alaska favors litigation over negotiation. And, when Alaska Natives win, the state appeals until every avenue is exhausted. This is a tired approach.

Indeed, since the Interior Department announced rules in December 2014 the state hasn’t had a formal consultation process about lands into trust, held public hearings or even set up informal town halls. This was the ideal time for a conversation about the future. (The state says it’s still talking. That’s rich. While we’re suing you, let’s negotiate, ok?)

What’s particularly disappointing about this chapter is that the new governor, Bill Walker, promised a different ending. I had a conversation with him during a public forum at the University of Alaska Anchorage last August where he said tribal-state relations would improve. And that’s been mostly true. The governor has been fantastic on many issues, especially the expansion of Medicaid. But on this big one, the future of tribes in Alaska, well, it’s back to court.

This is the story that the rest of the country needs to hear.

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. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

The Mother of the Earth returns to Tyonek Native Village

Al Goozmer, president of the Native Village of Tyonek, explains the significance of land donated to the tribe by The Nature Conservancy.
Al Goozmer, president of the Native Village of Tyonek, explains the significance of land donated to the tribe by The Nature Conservancy.

Culturally significant land represents rebuilding of a tribal land base

MARK TRAHANT

TYONEK, Alaska — This is a great day for Al Goozmer. So the tribal president wants to show us everything in this village of about 200 people.

We start at the airstrip where there’s a new fire station. A mural painted in vivid colors proclaims, “TUBUGHNA: The Beach People.”

Then he shows us the tribal garden growing fresh produce. A few vegetables are already sprouting inside the greenhouse. But this is just a beginning, Goozmer said, “I asked them to look into putting another garden on the other side, that is going to be dealing, primarily, with our native berries, blueberries, salmonberries, and all the other berries here.”

But the real gem is ahead. We’re on our way to visit a piece of land that’s being donated to the tribe by The Nature Conservancy. The land is a couple of miles from the village. On the way, between the beach and a high bank of soil, Goozmer picks up a clump of earth, and explains how the land evolved over time.

He is that passionate about the land.

“I have a son who was 36-years-old and I never have seen him until he was 36. When we first met, we just fell into each other’s arms and cried and cried. It was just an awesome, awesome thing,” Goozmer said. “This is the same thing with the land. Our land, it was traditionally our land for the past thousand years, is coming back into tribal government, tribal hands. It’s like meeting your long lost relative again and reuniting with them.”

Goozmer starts his telling of the story with a coal mine that has been proposed by PacRim Coal. The land is near a deportation point for the minerals that would be shipped out. It’s a 160-acre parcel that had been homesteaded and was later donated to the Catholic Church. Then, in 2008, instead of selling the land for development (for what Goozmer calls “boo koo bucks”) title was purchased from the church by The Nature Conservancy for $400,000. The Nature Conservancy has now donated that land back to its first owners with support from the Great Land Trust. The deal includes a conservation easement, limiting development and allowing  tribal members use of the land for subsistence hunting, fishing, and berry-picking.

The return of such a parcel to an Alaska Native village is historic because the idea of tribal lands in Alaska is growing in both importance and inevitability. However a discovery a couple of years ago made this particular site even more important: It’s a rich cultural and archaeological site showing significant evidence about how Tubughna people have lived for the past thousand years.

“When we learned of the deep cultural significance of this place to the Tebughna people, we realized that the people of the Native Village of Tyonek would be its best long-term stewards,” said Rand Hagenstein, Alaska state director for The Nature Conservancy.

The formal title for this land is now, Etnen Bunkda, or Mother of the Earth.  It comes from the Dena’ina name for the region. There is evidence of several homes from different periods of time, demonstrating a long arc of history for Tebughna as residents.

The site also includes a number of cold storage pits. These were the first refrigerators, deep holes once lined with grass and bark to preserve salmon and other foods for winter consumption. The Mother of the Earth site is a clear example of the Tebughna reliance on fish for a thousand years.

“Land managers do not fully take into consideration the fact that indigenous people have a whole cultural identity that’s related to land and subsistence, an appreciation for what the land provides,” said Heather Kendall-Miller, an attorney for the Native American Rights Fund. So the agencies responsible for making decisions about land, fish and game did not get the subsistence connection to the land. “The Chuitt River is one of the last rivers in the entire Cook Inlet that still has habitat for King Salmon. And that would have been impacted by the coal project,” Miller said.

The Native American Rights Fund represents the village in the land transfer.

In addition to subsistence, the transfer of this land adds to the larger Alaska debate about tribal lands. This agreement recognizes the possibility of the land being taken into trust by the Interior Department once that process is open.

“For us to again have a land base is just awesome. We have our identity refocused and reconnected back to the land of who we are,” said Goozmer. The village was once a part of the Moquawkie Indian Reservation.

However, he said, “the Alaska Native Claims Settlement Act took away our ability to own land.”

Instead the land title was conveyed to regional and village corporations. “So we became shareholders instead of land owners. The corporations … are the owners and we have shares, but it’s not the same.” But the transfer of such a significant piece of land is a step in a new direction. “For us, as Natives, to be land owners intricately tied to the land, its resources, its animals, and what it produces, this is our grocery store and our pharmacy,” Goozmer said. “Hopefully this is just a beginning to get our identity back and reconnect us to the land.”

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.

Reversing diabetes in Indian Country

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The next phase in the epidemic: Reducing the rate of growth and other success stories

MARK TRAHANT

Indian Country has long faced the epidemic of diabetes with rates 2.3 times greater than the general population. The toll from this deadly disease was so great that a federal Special Diabetes Program for Indians was launched some thirteen years ago.

Across America diabetes rates are exploding. A recent piece in The Washington Post put it this way: “Diabetes has reached epidemic proportions in the U.S., due to sugary diets and the lack of exercise. If current disease rates continue, one in three Americans will have diabetes by 2050. Over time, the condition can lead to kidney failure, limb amputations and blindness, among other complications.”

The post linked to a blogger, The Data Dude, and a chart that shows diabetes rates increasing in all but a few counties across the nation, a total of 2,992 of counties. Only five counties had rates that stayed the same and only ten counties showed an actual decrease.

Here is the thing. Two of the ten counties showing a decrease in diabetes rates are found on Indian reservations, Fort Peck, Montana, and Rosebud, South Dakota. According to the United States Centers for Disease Control and Prevention, the rate of growth for diabetes in Roosevelt County, Montana, dropped from 13.2 percent to 12.9 percent, a three-tenths decline from 2004 to 2012. And a similar decline occurred in Mellette County, South Dakota, where the rates declined from 13 percent to 12.7 percent.

If these two reservation communities are showing a decline, what do the numbers look like across Indian Country?

Unfortunately the CDC and the Indian Health Service use different data because, of course, the county map is not ideal. The Indian Health Service reported that its data would not be comparable with the county data cited.

However — and this is important — IHS data do indicate a slowing in the rate of rise of the prevalence of diabetes in American Indian and Alaska Native people nationally. From 2001-2005, there was a relative increase in age-adjusted diabetes prevalence in American Indian and Alaska Native adults of 2.2% per year on average. Contrast that with the period between 2006 and 2013 where diabetes prevalence among the same population increased at a rate of 0.8% per year on average.

Another measurement of that trend comes from the United States Renal Data System. The data show that the incidence of end-stage renal disease due to diabetes in American Indian and Alaska Native people decreased by 43 percent between 2000 to 2011. Looking at the numbers another way, between 1995 and 2006, the incident rate of End Stage Renal Disease in American Indians and Alaska Natives with diabetes fell by 27.7 percent—a greater decline than for any other racial or ethnic group.

The IHS says: “This translates into far fewer American Indian and Alaska Native patients with diabetes starting dialysis. Also, obesity rates and diabetes prevalence in American Indian and Alaska Native youth have not increased since 2006.”

What’s working?

In Poplar, Montana, Tessie LeMere, diabetes coordinator for the Fort Peck Tribal Health Department, says a lot of the work is community focused. One important activity encouraging people to drink water instead of sugary soda. “We offer our water system. If you have your own jug, you can bring it in here and we’ll give you clean water. We do home visits. We do community screenings. The community screenings are a big thing because it’s not just for our patients, that’s for everybody just to get the awareness and prevention out there. We have wellness centers. We pay to those so our patients have access. We also have a dialysis program over at tribal health. That I think has brought the awareness more into reality.”

Perhaps that’s it. The success in Indian Country of the diabetes program is about doing everything, reaching out to both patients and those who are at risk for the disease. Again the numbers tell a story. A generation ago, before the Special Diabetes Program for Indians, only about a third of all Indian Health patients had access to diabetes clinics; today that number exceeds two-thirds. And 94 percent of patients have access to diabetes clinical teams, three times more than in 1997. And nearly 100 percent — 99 percent according to IHS — of people in the IHS system have access to diabetes education (up from 36 percent in 1997).

We hear all the time about how bad things are in Indian Country. The story of improving diabetes rates counters that narrative. It shows a lot of things: First, tribally designed programs work, government funding is important and lessons from Indian Country can help the larger nation treat its diabetes epidemic

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.

Fort Peck Tribal Health Department is a success story showing how a community can reduce diabetes rates. From left: Janene Padilla, Diabetes Coordinator Tessie LaMere.  Cheryl Bighorn-Savior (RN), and Laurel Cheek.
Fort Peck Tribal Health Department is a success story showing how a community can reduce diabetes rates. From left: Janene Padilla, Diabetes Coordinator Tessie LaMere. Cheryl Bighorn-Savior (RN), and Laurel Cheek.

Op-Ed post: Medicaid expansion will boost Montana’s economy, people

Montanans love to talk about how special our state is. For those from some place other than Montana, you may think that we mean our beautiful mountains, the vast golden prairies, and incredible blue sky that never seems to end. And you would be right – we do mean that. But what really makes Montana special is the people.

The people of our state are kind and generous. We are the type of people who celebrate together during the good times, and look out for each other when times get tough.

Montana is particularly lucky because the people can dramatically change the direction and future of our state. Over the last few months, it was clear that the people of our state stepped up and did just that. They talked and our legislature listened. Late last week, the Montana Legislature passed the Health and Economic Livelihood Partnership (HELP) Act (SB 405). This bill is compromise legislation to extend health care coverage to low-income Montanans who need it, and the Governor has indicated that he will sign it as soon as it reaches his desk.

We are a group of organizations that have spent the past two and a half years working to expand access to affordable health care for the lowest-income Montanans. And we will forever be grateful to you, the people of Montana, for making your voices heard.

It was you who made more than 10,000 calls and emails to your legislators in support of Medicaid expansion. More than 150 of you submitted letters to the editor and opinion editorials. More than 300 of you came to the Capitol to testify. You kept the conversation going on social media. Hundreds of you came to rally on the Capitol steps or walk the halls talking to your legislators. It was you who passed Medicaid expansion.

Montana will be a better place because you made your voices heard. This legislation will help create thousands of new jobs. Montanans will be healthier and more productive because when people have health care, medical problems are more likely to be treated earlier and illnesses are less likely to affect one’s ability to work. Our rural hospitals will be able to keep their doors open because more people will have insurance to cover medical expenses. Montana tax dollars will come back to our state to boost our economy. And most importantly, tens of thousands of Montanans will be able to get the health care they need and deserve.

Never forget that when you talk – and sometimes it has to be loud and often – but if you talk loud and often enough, your elected representatives will listen.

Montana thanks you.

Sincerely,

Montana Women Vote, Montana Human Rights Network, Montana Budget and Policy Center, Montana Primary Care Association, American Cancer Society Cancer Action Network, Montana Organizing Project, Planned Parenthood Advocates of Montana, Western Native Voice, SEIU 775, MHA…An Association of Montana Health Care Providers, and AARP Montana.

Millions of Montanans, Alaskans and Native Americans wait for health insurance

Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).
Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).

Millions of Montanans, Alaskans and Native Americans wait for health insurance

MARK TRAHANT

The best case for Medicaid expansion in Alaska is being delivered by Valerie Davidson. She’s the recently appointed Commissioner of Alaska’s Department of Health and Social Services and a longtime advocate for improving Native health, most recently the senior director of Legal and Intergovernmental Affairs at the Alaska Native Tribal Health Consortium.

Davidson, who’s Yupik and a member of the Orutsararmiut Native Council, also chaired the Tribal Technical Advisory Group to the Centers for Medicare and Medicaid Services from its launch in 2004 until last year. In other words: She knows Medicaid cold. She knows how it benefits a state. She understands what works for Native communities. And, she conveys complicated ideas and statistics with ease.

This is the ideal time for that kind of logic.

Alaska’s Medicaid expansion has reached a decision point. The Alaska Dispatch News reported Tuesday that the governor is threatening a veto unless the Legislature takes on Medicaid reform and expands eligibility under the Affordable Care Act. (Update: The Alaska Dispatch News reports that Republicans are planning a caucus vote to kill the measure for this session.)

At a recent speech in Juneau, Davidson ticked off five reasons why Medicaid expansion makes so much sense.

First, it would expand health care insurance, thus improving health access for at least 42,000 Alaskans. Second, expansion would add money — and jobs — to a state that could use both right now. Third, expansion improves the state’s budget situation by adding more than a billion over the next six years. Fourth, it could be a catalyst for reform. And, fifth, expansion addresses uncompensated care.

Uncompensated care is perhaps the most important part of the Medicaid debate and it does not get a lot of attention. Even if government were to eliminate Medicaid or other insurance, people would still have health care costs. Someone always has to pay.

“We all end up paying for those uncompensated care costs. We pay through increased premiums. We pay for them when a hospital has to increase what it charges everybody else,” Davidson said. She said the hospitals provided more than $90 million worth of uncompensated care in Alaska.

Nationally the figures are huge. The Kaiser Family Foundation estimated uncompensated care at $84.9 billion in 2013. Most of that was paid for by hospitals (who pass the cost along to paying patients) and community-based clinics and health centers.

But here is the thing: The states that have expanded Medicaid are seeing the cost for uncompensated care figure dropping dramatically, saving those states some $5 billion.

The Indian health system has its own version of uncompensated care. We all understand and see the Indian Health Service as the government’s fulfillment of its treaty promises made to tribes. But the government does not fund IHS that way; the underfunding is substantial. The original Indian Health Care Improvement Act opened up new revenue from Medicare, Medicaid and other programs to add new dollars to the system.

So since the United States doesn’t fully fund IHS — and Indian Country has low insurance coverage — there remains a gap. Uncompensated care. Kaiser Family Foundation found that nearly a third, or 32 percent of American Indians and Alaska Natives are uninsured, and the cost to IHS for that care was at least $2.1 billion in 2013.

That’s why Medicaid expansion is critical to improve funding for Indian health delivery — especially in states with large Native populations such as Alaska and Montana.

Reservation Medicaid Benefits

Montana’s uncompensated care is nearly $400 million, according to the Montana Budget and Policy Center.

The Montana Legislature is nearing the finish line. Last week a key House committee voted to radically amend the legislation, essentially killing Medicaid expansion. For a bit. Then the legislation made it to the House floor where it passed 54 to 42 returning it to the Senate for minor changes. Supporters are hoping the Senate will make those changes and send the bill to the governor for his signature.

When the House passed the Medicaid legislation, a conservative group, Americans for Prosperity Montana, issued a press release saying the “decision stands directly against the voices of millions of Montanans who have made it clear that they do not want more Obamacare.” That phrase, #millionsofmontanans, quickly became a hashtag on Twitter (Montana has just barely a million citizens).

But Medicaid expansion would benefit millions — Montanans, Alaskans, Native Americans, and people in other states. What makes this argument interesting is that conservatives have lost on the evidence. In state after state the research continues to mount that Medicaid expansion was the best part of the Affordable Care Act and is creating jobs and pumping dollars into state economies. A study by Robert Wood Johnson Foundation says the total amount lost for states that have said “no” is more than $423 billion.

What makes this “debate” particularly maddening is that opponents to Medicaid expansion have no viable alternative — except the system that sticks hospitals, clinics and doctors with even more uncompensated care.

Mark Trahant serves as the Atwood Chair at the University of Alaska Anchorage. He 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.

Fight for Indian health funding is at a critical juncture

Medicaid & Indian Country

Fight for Indian health funding is at critical juncture

MARK TRAHANT

One of Indian Country’s most important debates about increasing funding for the Indian health system is occurring far from Congress in state legislatures across the country. And that is unfamiliar ground to discussions about Indian health and treaty obligations.

The Affordable Care Act — or Obamacare as some call it — significantly expands Medicaid health insurance to more Americans, including American Indians and Alaska Natives. But the Supreme Court ruled in August 2012 that Congress could not force states into accepting the expansion. Medicaid is a state-federal partnership. So the money flows from Washington into states based on complicated formulas. The cost to states for American Indians and Alaska Natives is negligible because the federal government pays the bill. Only the states, not the federal government, determine who is eligible for the program. Twenty-nine states and the District of Columbia have expanded Medicaid.

One study by Robert Wood Johnson Foundation found that in the states that have not expanded Medicaid meant that 6.7 million residents remain uninsured in 2016 and these states gave up $423.6 billion in federal Medicaid funds from 2013 to 2022, which shrinks both economic activity and job growth.

Two states with large native populations are considering Medicaid expansion now: Alaska and Montana.

The Montana Budget & Policy Center estimates some 70,000 people would be eligible for the insurance and some 19,000 American Indians. Tuesday a House committee killed the Medicaid expansion bill, but according to the Helena Independent Record there remains a chance the bill could go directly to the House floor for a vote.

Legislators in Juneau are also considering Medicaid expansion this week. The Alaska Native Tribal Health Consortium estimates that expanded Medicaid would cover 40,000 Alaskans adding more than $1.1 billion and 4,000 new jobs.

There is new data that shows just how effective Medicaid expansion can be.

Ed Fox, tribal health director of Washington’s Port Gamble S’Klallam Tribe and a health care reform expert, has estimated that Medicaid expansion would add $2 billion to the Indian health system across the country. In Washington, Medicaid expansion increased revenues to Indian health clinics by 38 percent statewide, or $14, 451,345 in additional funds, a total of some $54 million for American Indian and Alaska Native patients. Remember this is money that does not need to be appropriated by Congress. Of the 25 tribes reporting in Washington only one showed a decrease in funding and two tribes doubled their Medicaid revenue (four tribes are not included in the data).

Fox called the numbers great. The data pulled from Medicaid claims and could increase slightly. “We plan to hire 4 positions thanks to these increases:  2 Registered Nurses, one social services Case Manager, one Community Health Representative,” Dr. Fox said. “These are the good old days-perhaps. I will now have to thank both IHS and Medicaid for this opportunity to enhance services.”

He also noted now small these numbers are compared to Alaska, should the legislature expand Medicaid. “Maybe $200 million compared to $500 to $600 million for all American Indians / Alaska Natives and only $54 million is paid to WA tribes,” Fox said.

But if these are the good old days in expansion states, the flip side is increased budget pressure on states without Medicaid expansion. At a Senate hearing last May, A.T. Stafne, Chairman of the Assiniboine Sioux Tribes of the Fort Peck Reservation, said he still hopes for increased insurance coverage for American Indians but he remains “uncertain about implementation in Indian Country, especially in states like Montana that rejected the Medicaid expansion … Clearly there is more work to be done if the government is to fulfill its trust responsibility to provide quality healthcare to Indian people, a mandatory obligation under treaties and agreements entered into with Tribal governments.”

That quote captures the challenge: The Affordable Care Act opens up a roadmap for better funding of the Indian health system. But the rules of the road are being drafted in state capitals, one by one, especially in Helena and Juneau.

Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He 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.