Senate is blind: Healthcare vote minus a draft, public hearings, or common sense

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Senate Majority Leader Mitch McConnell (R-Kentucky) and whip John Cornyn (R-Texas) brief the press on the upcoming vote on a repeal and replacement for the Affordable Care Act. (Photo via McConnell Press Office on Twitter.)

Mark Trahant / Trahant Reports

Here we go again. Another week and the United States Senate is ready to vote on legislation to remake the entire healthcare system, including Indian health. The Senate will do this without a draft circulated for debate, public hearings, or common sense.

So what does the replacement bill look like at this point? I have no clue. Neither do the 100 senators who will make that call. As Sen. John Cornyn (one of the managers for the bill) put it: Knowing the healthcare plan ahead of the vote is a “luxury we don’t have.”

Here is what President Donald J. Trump tweeted over the weekend: “The Republican Senators must step up to the plate and, after 7 years, vote to Repeal and Replace. Next, Tax Reform and Infrastructure. WIN!”

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So there will be a vote on legislation to at least repeal the Affordable Care Act. “We have decided to hold the vote to open debate on Obamacare repeal early next week. The Obamacare repeal legislation will ensure a stable, two-year transition period, which will allow us to wipe the slate clean and start over with real patient-centered healthcare reform. This is the same legislation that a majority of the Senate voted to send to the president in 2015. Now, we thankfully have a president in office who will sign it. So we should send it to him,” said Sen. Majority Leader Mitch McConnell, R-Kentucky.

But a straight repeal is complicated by Senate rules. The Senate Majority Leader is relying on the process of reconciliation (essentially matching the legislation to an existing budget) because that only requires a majority, or 50 votes. Most bills need 60 votes to stop a filibuster. Last week the Senate parliamentarian, Elizabeth MacDonough, said that defunding of Planned Parenthood, abortion coverage, and restrictions on insurance coverage does not meet that test and still required 60 voters. Same thing for the Alaska or rural exception, it’s a no go. But Senate Republicans were quick to say that any draft language (which is still missing from action) could be rewritten. Or Republicans could overrule the parliamentarian on the floor which would cause all sorts of future problems governing.

The Senate’s parliamentarian is a great example of the institutions of Congress pushing back on the Republican proposals. I don’t think it’s ideology; it’s incompetence. (As I have written before there is a conservative approach to healthcare reform, but we have not seen that yet.) The Congressional Budget Office said last week that the big ticket in this debate is Medicaid. Remember the proposals in the House and Senate go far beyond just repealing the Affordable Care Act because the proposals would fundamentally restructure Medicaid.

According to CBO: “By 2026, spending for that program would be reduced by 26 percent … About three-quarters of that reduction would result from scaling back the expansion of eligibility enacted in the Affordable Care Act (ACA). In 2026, for people who are made newly eligible under the ACA (certain adults under the age of 65 whose income is less than or equal to 138 percent of the federal poverty level [FPL]), Medicaid spending would be reduced by 87 percent, from $134 billion to $17 billion—mainly because the penalty associated with the individual mandate would be repealed and the enhanced federal matching rate for spending on that group would be phased out. As a result of the reduced matching rate, some states would roll back their expansion of eligibility and others that would have expanded eligibility under current law would choose not to do so. All other federal spending on Medicaid in that year would be reduced by 9 percent, from $490 billion to $447 billion.”

This is what pays for the tax cuts in the Republican plans.

Rolling back Medicaid expansion and the traditional Medicaid program would significantly reduce funding for the Indian Health Service.

Last week the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health, wrote McConnell because one of the Senate bills, the Better Care Reconciliation Act of 2017, would change the formula for funding Indian health patients. The three intertribal organizations call the proposal a “radical departure from over 40 years of federal policy” and it “should not be undertaken without nationwide tribal consultation.” The bill’s language reverses a policy where states get a 100 percent reimbursement for patients who get services from the Indian health system. This change, the intertribal organizations said, would “ take away this unique incentive for states to work with tribes to create Medicaid innovations that best support the Indian health system.” States could create new rules that could ignore Indian health as a partner and create new barriers that would sharply reduce funding.

North Dakota Sen. John Hoeven, who is chair of the Senate Indian Affairs committee, said the changes would provide “more choice and competition in our health care system, while at the same time insuring that low-income individuals have access to healthcare coverage” via Medicaid or tax credits.

The key thing here: Native Americans could take their insurance (and the state Medicaid dollars) to another provider, reducing funding for IHS. (Competition, you know.)

It would be one more costly strike to an Indian health system that’s already underfunded.

Hoeven said a draft Senate bill also would end the requirement that tribes purchase insurance for employees. Again, the result would be less money for the Indian health system. (And, as the three intertribal organizations point out, this would be done without any tribal consultation.)

Then again the Senate and House bills are designed to strip money from the health system period. And Medicaid is such a rich target. The Kaiser Family Foundation estimates the total cost to states under the Better Care bill is $519 billion.

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Back to the math and this week’s vote. There are 100 members of the Senate. The 48 Democrats are certain to vote no. And of the 52 Republicans, it’s unlikely Sen. John McCain would leave his cancer treatment in Arizona to vote on a motion to proceed (the opening of the debate and the consideration of amendments). That leaves 51 votes. Sen. Susan Collins of Maine is a certain no because she objects to the attacks on Medicaid. That reduces the number to 50 (and 49 no votes). There are lots of questions about Senators Lisa Murkowski of Alaska, Rob Portman of Ohio, and Shelley Moore Capito of West Virginia. Capito tweeted: “I will only vote to proceed to repeal legislation if I am confident there is a replacement plan that addresses my concerns.” And Portman said he’ll review whatever bill comes up for a vote. Murkowksi told CNN: “I don’t think it’s asking too much to say give us the time to fairly and critically analyze these numbers. And if you say, well, CBO numbers don’t matter, let’s look at the numbers that you don’t think matter. But it really does make a difference. And these numbers that we’re talking about, these are men and women, these are our families that are being impacted. So let’s please get it right.”

Does that sound like three no votes? Right now, I’d only count all three as firm maybes. Then only one needs to be the no.

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

 

 

#NativeVote16 – Still loving Obamacare, elders, and new round of endorsements

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Joe Pakootas speaks to voters in Walla Walla, Washington. (Photo via Facebook)

Mark Trahant / Trahant Reports

Thirteen days and counting. And the election issue once again is the Affordable Care Act.

A report by the Department of Health and Human Services details the rising costs for individual policies. So after two years of moderate premium increases (2% for 2015 and 7.5% for 2016) premiums are going up sharply in 2017. The is ideal for Republicans because the say this highlights why the law won’t work. So it’s an election issue. Again.

But here’s the thing. Yes, this is a problem. It needs to be fixed. But most people are not impacted, especially in Indian Country. (The problem here is that not enough young people are buying that insurance. There are many solutions to that specific issue.)

Let me explain.

The increase in premiums is only for people who buy their plans through healthcare.gov. Most people who do that get a tax subsidy as part of the deal. And most American Indians and Alaska Natives would be eligible for a subsidy in any case.

Most Americans, and most in Indian Country, do not buy individual plans. Most of us get health insurance through work.

Still other Native Americans benefit from the single greatest success of the Affordable Care Act, the expansion of Medicaid.

If you look at the big picture: More people are covered by health insurance than ever before. Most of the law is working, well, brilliantly.

But Republicans will be campaigning on a repeal and replace pledge. Except there is not now, nor has there ever been, consensus from the Right about what a replacement would look like. There is nothing behind the curtain.

One more thing: Remember that any repeal of the Affordable Care Act is also a repeal of the Indian Health Care Improvement Act.

Fear not. This election should bury the very notion of repeal. Perhaps then Congress will actually tinker with the law (like it does with all legislation) to make it work better. Because if you look at the numbers – all of the numbers – then the Affordable Care Act remains a success story.

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Out on the campaign trail last night, Joe Pakootas had a huge crowd in Walla Walla. He wrote on Facebook: “I am the embodiment of the American dream: a minority that came out of poverty, through foster care, into a minimum wage job, turned CEO and now Congressional Candidate. The incredible support I was shown tonight, whether through each handshake, Pakootas sticker or shirt that was worn, or the uproar of applause when I took my seat, is humbling and encouraging. I never thought I would make it here, but it’s all for the people that I’m fighting. I will stay true to that when I’m in Congress.”

More endorsements.

Chase Iron Eyes was endorsed by the Alliance for Retired Americans, a union-based advocacy group. “Could it be due to the fact that I respect my elders, that I won’t let Washington privatize social security unlike my opponent, or is it that I will lift the tax cap so that those making over $125,000 per year pay the same taxes as those making under that amount already pay,” Iron Eyes wrote on Facebook. “We need you to stand for those who invested their whole working lives laying into social security and are not seeking ‘entitlements’ as politicians say.”

Or not an endorsement. In Fargo, the Forum newspaper endorsed Rep. Kevin Cramer for re-election. The paper says he “has no serious competition. Democrat Chase Iron Eyes is running a shoestring campaign with virtually no help from his party.”

However the Forum makes an eloquent case against Cramer. “If he has a blind spot in this election cycle, it’s his near-worship of presidential candidate Donald Trump. Unlike other prominent state Republicans, who have been muted in their squishy support for Trump, Cramer is positively giddy about the New York billionaire, often acting like a cow-eye high school cheerleader who is smitten by the thuggish captain of the football team. Cramer has been too willing to set aside his oft-stated values of family, faith and decency for a heady ride on the Trump party bus.

In Minnesota, Donna Bergstrom, a Red Lake tribal member, was endorsed by the Duluth News Tribune as a “clear choice.” She is a retired Lt. Col. in the U.S. Marine Corps Reserve. The paper says Bergstrom, a Republican, has “a wealth of research and knowledge, strong positions, even stronger leadership experience, and an impressive resume.”

“I’m not a politician but a common citizen who is concerned over the direction of the state just like you,” she said at the paper’s candidate forum.

And that direction will be settled in 13 days.

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

#NativeVote16 – Sanders at NCAI: Real dollars to Indian Country won’t cost a lot

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President Nixon and John Ehrlichman at the Western White House in California.

Mark Trahant / TrahantReports

A couple of decades ago I had a chance to interview John Ehrlichman.  He had been recently released from prison for perjury and other Watergate-related crimes. We were talking about President Nixon’s American Indian and Alaska Native policies. He talked about some of the successes, some of the challenges, and then I asked him “why?”

Why was Richard Nixon interested in Indian affairs? Ehrlichman said the usual story was because of Nixon’s coach, Wallace Newman. Then he smiled. He said another reason was the number of Native Americans was so small. He said the federal government ought to be able to use its resources to bring about real change. (He added that he also liked the idea that it would drive Democrats crazy.)

I was thinking of this moment after listening to Bernie Sanders speak to the National Congress of American Indians via YouTube. The politics of the Nixon administration and Sanders could not be more different. Yet both hit on what ought to be an absolute truth in Washington: You can spend a lot of money on Indian Country and it’s still a tiny slice of the federal pie.

“We need to commit to fully funding the Indian Health Service,” Sanders said. “As I have said in every one of our tribal meetings, the tribal population is not massive. It does not take an incredible amount of resources to meet this obligation. It only takes a president who is prepared to make it a priority.”

This might be one of the  most important statements made during the 2016 campaign. And it’s not only presidents that could benefit Sanders’ thinking.

Republicans in the House and Senate have discovered the Indian Health Service crisis in the Great Plains region. Yet not one solution has called for spending more money  (although there are proposals to reform third-party billing which could add resources). The Indian Health Service budget looks huge on paper, next year’s request is for $5.7 billion. But when you break it down per person it’s less than $2,500 (a little more for those with insurance or Medicaid). And the national average for health care spending is $8,402 per person.

In other words: If the United States “fully funded” Indian health the cost would be roughly $8.8 billion. That’s a big number, unless you consider, the federal government spends about $1 trillion a year on health care.

Bernie Sanders is right. The country should redefine its relationship with its first people. And fully-funding the promise of health care is an excellent place to start.

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