Health care is now the Republican’s mess and it will define the 2018 elections

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President Donald J. Trump and House Republicans celebrate their legislative win, the passage of the American Health Care Act. The bill now moves to the U.S. Senate where it will be considered and likely amended significantly. (White House photo via YouTube.)

 

Mark Trahant / Trahant Reports

The House of Representatives passed the American Health Care Act by four votes, 217 to 213. The legislation now moves to the U.S. Senate. If this bill becomes law it will do five things: Cut taxes for people who make a lot of money, end health insurance subsidies and much of the coverage from Medicaid, cause more people to go uninsured and eventually bankrupt, and frame the most important political debate in a long time.

Every Republican who voted for this mean-spirited bill must now defend against every American who has any problem with insurance or health care. (I know that’s not fair. But it’s essentially what happened to the Democrats.) You get a doctor’s bill you don’t like: Blame Trump and Ryan. Lose insurance coverage at work: Ditto. This is why the optics are so lousy for Republicans, the health care system is now their mess. 

Oh. I know. This bill is not law yet. And it’s not likely to be. But it doesn’t matter. Months after the House voted its first repeal of the Affordable Care Act people reported that they thought the law was gone. It was not then. Nor now. 

Remember the House bill still must get through the Senate and that body is as divided as the House. But one difference is that there is a constituency in the Senate for Medicaid. (As I have been writing: This is the most significant impact on Indian Country. This bill doesn’t just repeal the Affordable Care Act, it ends Medicaid as we know it. Medicaid insures more than half of all children in the Indian Health system and it accounts for 13 percent of the Indian Health Service budget.)

At least four Republican Senators, Rob Portman (Ohio), Shelley Moore Capito (West Virginia), Cory Gardner (Colorado), and Lisa Murkowski (Alaska) have been clear about their support for Medicaid and Medicaid expansion. (Medicaid is a state, federal partnership to provide health care for families with low incomes. The Affordable Care Act expanded that to single people and lowered the income limits to 138 percent of federal poverty guidelines. The numbers are huge. Before the ACA about 56 million people were insured by Medicaid. Today the number is nearly 75 million.)

A bloc of four senators — if they don’t budge — has the power to say “no” to any legislation. This is the Medicaid Protection Block. And Republicans only have two votes to spare in the Senate because all of the Democrats will likely oppose this measure (as they did in the House). So the thing is that if the Senate language satisfies theMedicaid Protection Block that will enrage the Freedom Caucus in the House. That bloc stuck together and killed the House’s first version of the legislation, so the second version was even more to their liking (removing federal requirements to provide basic health services including pre-existing conditions).

Complicated, right? Add to that mix the conservative members of the Senate who don’t think this bill goes far enough in the outright repeal of the Affordable Care Act. Sen. Paul Rand (Kentucky) said on Fox News: “It will take a little bit of work to get me to ‘yes’ vote on health care bill.” In other words make the bill more ideological, not something that will get support from the Medicaid Protection Bloc.

And if that’s not complicated enough, there are also Republicans in the Senate that object to the bill’s attack on Planned Parenthood because of the impact of such a policy on women’s health. That bloc includes Murkowski and Maine’s Susan Collins.

Complex or not, no matter what comes out of the Senate (unless it’s the House bill exactly) the House will have to vote again. Then the illogical Freedom Caucus gets another shot at defying their own party leadership.

But the real politics of Wednesday’s action is not in Congress. It’s playing out on social media and communities across the country. It’s the idea that this vote was a definition for the next election. One side believes that health care is not a right.  The other sees the Affordable Care Act as imperfect, but a step in the right direction.

Indian Country should be included in this debate. And we’re not. Our right to health care is simple, it’s based on treaties, history, and thus a pre-payment for whatever insurance mechanism the country comes up with. The Affordable Care Act at least opens up an avenue to fully fund the Indian Health system something that’s never been accomplished before.

This is also the ideal moment for Indian Country to have more of a say. This is when a political coalition can be built around idea that health care is a right. Health care is already defining the 2018 elections.

And the politics of that start in Red states (those that voted for President Donald J. Trump). This bill, in a quest for free market purity (if that’s even possible in health care), would benefit young people, healthy people, and people who live in cities. And paying for that experiment are older people, sicker people, and rural people.

Alaska is at the top of this list. The Affordable Care Act pays insurance companies to help keep costs down. The Republican plan ends that business.  The result: “Consumers in 11 states would see tax credits fall by more than $3,000 on average, or more than 50 percent, and consumers in seven states would lose an average of more than $4,000. In Alaska, by far the highest-premium state, the average reduction in tax credits would be $10,200, or 78 percent,” according to a study by the Center for Budget and Policy Priorities.

And that doesn’t even include Medicaid. Another study on that issue found the program saved Alaska significant dollars, projecting a billion dollar return after a decade. The state’s Commissioner of the Department of Health and Social Services, Valerie Davidson, told KTUU News that “with our $3.5 billion budget deficit, we don’t have an additional one billion dollars more to pay for services that we currently have, we just can’t afford it.”

She also said the House bill would strip behavioral health funding when it’s so important in the middle of an opioid epidemic.

So for an Alaska representative, one that works for constituents, this should have been a no-brainer. This bill is terrible for Alaska. Last week Rep. Don Young said as much. He claimed victory when the previous bill was pulled from consideration without a vote. He told The Alaska Dispatch News: “My job is to represent those people in that state, and I think we did this this week. I work with (House Speaker Paul Ryan), don’t get me wrong — the speaker talked to me quite a bit. But it didn’t come to a point where I could support this bill. He needed my vote.”

The bill that passed Wednesday is not significantly different. Alaska is still hosed. And Don Young voted “yes.” Now he says, don’t worry, this bill will not become law. The Senate will change it.

That’s basically the position of Rep. Tom Cole, a Republican in leadership, and a member of the Chickasaw Nation. He told National Public Radio: “This thing is going to go to the United States Senate. It’s going to change, in my view, in the United States Senate in some way. Then we have to have a Congress — a conference to work out the differences. If we can do that, then it has to still pass the House and the Senate again before it ever gets to the president. So, you know, at some point, you just have to move. And we think this is it and that this will create some momentum. Again, I’m interested to see what our friends in the Senate will do in response.”

Cole is a champion for Indian health programs, especially when it comes to the budget. He’s often the critical voice and the only Native American at the table when budgets are written. However he dismisses Medicaid Expansion quickly because Oklahoma is one of the states that’s passed. Ok. We disagree. Understandable.

But this House measure is not just about Medicaid Expansion; it’s a radical restructuring of Medicaid and capping costs. Even in Oklahoma Medicaid serves more than 800,000 people. And, remember that Medicaid is 13 percent of the IHS budget, more than $800 million now and growing.  Already more than half of our children are insured this way. Plus this is the best kind of money because it’s used by local clinics and hospitals.

This is what Tom Cole, Don Young, and 215 other Republicans voted to take away from Indian Country. This is what’s on the ballot next year.

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

 

 

This week Republicans have a nearly impossible task: Fund government, start their wall & get votes from Democrats

 

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The new health care team: President Donald J. Trump (clockwise from left) Seema Verma, Administrator of the Centers for Medicare and Medicaid Services, Secretary Tom Price, U.S. Secretary of Health and Human Services, and Vice President Mike Pence in an Oval Office meeting last month. (Official White House Photo by Shealah Craighead)

 

Brace for another government shutdown

Mark Trahant / Trahant Reports

Can President Donald J. Trump and the Republicans actually govern? As we near the 100th day mark the answer has been a loud “no.” So far. This week the Congress and the president will once again try for wins to fund the government, repeal the Affordable Care Act, extra money for Defense, and to construct a wall on the southern border. A nearly impossible order.

The House of Representatives does not have a governing coalition. There remains, essentially, three parties: Republicans, Democrats, and the Freedom Caucus. Two of these three groups must work together in order to pass any legislation. And to complicate the politics even more, many of the Republican members are already worried about their own re-election, so they might not support their own party’s leaders. Especially if that deal is sanctioned by the Freedom Caucus.

Yet Speaker Paul Ryan told his caucus Saturday that funding the government is the priority. The president was equally optimistic. “I think we’re in good shape,” President Trump said.

There are two budgets at issue. First there is the one proposed by the White House, “America First: A Budget Blueprint to Make America Great Again.” That budget would not begin until October and would result in a dramatic restructuring of the federal government. Many members of Congress have said there is no chance this budget will be enacted as proposed.

But this week there is another budget problem. Congress must pass budget extension for this year by April 29 or there will be another government shutdown.

Shutting the government has become too common: On Indigenous People’s Day in 1990 (Ok, back then it was called, Columbus Day) President Bush sent workers home after Congress failed to enact a spending bill. Then during the Clinton years there was a five-day closure in 1995 and another three-week shutdown in 1996. There was a 16-day shutdown in 2013, followed by the double-whammy of sequestration. Tribal governments were impacted almost immediately and had to suspend nutrition programs, foster care, law enforcement, schools and health care. Some tribes had to temporarily layoff workers.

A policy report by the National Congress of American Indians put this in perspective: “For many tribes, a majority of tribal governmental services is financed by federal sources. Tribes lack the tax base and lack parity in tax authority to raise revenue to deliver services. If federal funding is reduced sharply for state and local governments, they may choose between increasing their own taxes and spending for basic services or allowing their services and programs to take the financial hit. On the other hand, many tribes have limited ability to raise substantial new revenue, especially not rapidly enough to cover the reduction in services from the across the board reductions of the FY 2013 sequestration.”

That could be the good old days. The prospect of a serious meltdown is a far greater possibility in 2017 than it was four years ago.

First of all the White House is incompetent. Instead of laying out a plan that will lead to a working majority in the U.S. House of Representatives and the Senate it has offered nonsense. “I think we’ve made it very clear that we want border wall funding, we want greater latitude to deny federal grants to sanctuary cities,” Press Secretary Sean Spicer said last week. “We want hiring of immigration agents, and we want $30 billion to infuse the military budget. Those are our priorities.”

That adds up to a blank check for the wall and immigration control, at least $30 billion for Defense, and a cut of at least $18 billion to domestic spending.

Those priorities are not possible without at least a few Democratic votes in the Senate (unless the rules are changed) because it takes 60 votes to approve any new Continuing Resolution. There are only 52 Republicans. So which Democrats are going to favor punishing sanctuary cities? How about none. And that’s only point one. Leaders in the House will need nearly every Republican to vote yes as well, something that’s always unlikely.

(Building a coalition with Democrats is even more important when you consider that Congress must soon raise the national debt limit, something that many Republicans always oppose without conditions that are unacceptable to Democrats.)

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But this week what makes a government shutdown even more likely is that the White House, Republicans, and Democrats, are all staking out claims on a variety of issues.

Sen. John McCain, R-Arizona, said he would not vote for another budget extension unless it increases military funding. In the past, Democrats have gone along with that notion as long as there is a mechanism to protect domestic programs budget cuts, including those that serve American Indians and Alaska Natives.

But the Trump administration (here is that competence thing) is already acting if its stingy budget is the law, telling agencies to shrink and reduce the number of federal employees.

An April 12 memo from OMB Director Mick Mulvaney says: “The president’s FY 2018 Budget request to Congress will propose decreasing or eliminating funding for many programs across the federal government, and in some cases redefining agency missions. The president’s FY 2018 Budget should drive agencies’ planning for workforce reductions and inform their Agency Reform Plans, consistent with final 2017 appropriations and current applicable legal requirements. OMB and the Office of Personnel Management (OPM) will work with agencies to facilitate reductions in the size of their workforce and monitor progress.”

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Congress is unlikely to go along with President Trump’s budget plan. Unlikely is too strong a word. How about? There is absolutely no way to get 216 votes for such a radical restructuring of the entire federal government. But programs that serve American Indians and Alaska Natives could be hit hard if there is another government shutdown.  (Trahant photo)

Yet there is no way Congress will agree with the restructuring of the federal government as proposed. The votes are not there. But the OMB is basically moving forward anyway, directing agencies to “begin implementing some reforms immediately while others will require congressional action.”

The White House message is stick it in your eye, Congress. (Oh, by the way, we still need your votes.)

So how does the White House move the ball forward? By threatening Democrats over the Affordable Care Act by proposing an exchange one dollar of funding for health care for every dollar spent on the wall. That took Democrats a few seconds to well, uh, no.

And coming next week the president said on Twitter that he will announce “big tax reform and tax reduction.”

That will subtract a few more votes for everything else that needs to happen this week.

Of course there is a way of out of this mess. The White House could work with Democrats and spend money on their priorities. It’s the basic formula that has led to enactments of budgets for the past 8 years. The bargain would mean continued spending for domestic programs as well as add money to the military. The wall? No. Cutting support for Planned Parenthood? Get serious. And health care funding? That’s why it’s called the art of the deal.

There are three doors on the governing stage. Door number one: An impasse and a government shutdown. Door number two: A deal with Democrats. And door number three: A short-term budget extension so the debate can go on. And on. And on.

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