What experiences should an IHS director have? In my book: Medicine & Medicaid.

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Robert Weaver, Quapaw, was President Trump’s first choice to head the Indian Health Service. His nomination was withdrawn last week. (Weaver Group photo)

Mark Trahant / Trahant Reports

Who should run the Indian Health Service? Not “who” exactly, but what kind of leader? What kind of skills and experience would be the most useful?

This question is more important than ever. The Trump administration has withdrawn the nomination of Robert Weaver to lead the agency. Weaver, a member of the Quapaw Tribe of Oklahoma, has a background in private insurance working with tribes to set up plans to cover tribal members. But his nomination was sidetracked after The Wall Street Journal reported serious misstatements on his resume both in terms of education and work experience. So last week a representative of the Department of Health and Human Services said: “Mr. Weaver is no longer the Administration’s nominee for Director of the Indian Health Service.”

For his part, in a letter to tribal leaders, Weaver said the president has been an “ardent supporter of fixing Indian Health throughout this process.” And he said “he will fight to give voice to the change needed at IHS until the mission is complete … the delivery of timely, high healthcare for Indian Country no matter where you live.”

But Weaver went further in an op-ed for Native News Online. He said he wanted to be IHS director for the “sole purpose” of being a part of the solution.  “… many Tribes supported me from around Indian Country. Why? I think because they know that babies are being born on IHS hospital floors. They know that people are dying of heart attacks because the crash carts at their IHS hospitals don’t have the proper medications. They know that some of the places where they live don’t have running water. They knew that I was the right person to start addressing these abuses because I’ve been an unwavering advocate for our peoples’ health and wellness for the past decade and I was willing to meet and listen.”

The key word is “mission.” The mission of the Indian Health Service has become so distorted that even policy makers cannot or will not articulate the challenges ahead. The discourse about the Indian Health Service continues to be about a federal agency that delivers health care to American Indians and Alaska Natives. And, within that story, there are so many clinics and hospitals that only require more order and funding in order to carry out even basic health care. The system is failing. Babies being born on hospital floors. The usual.

Only the IHS story is much more complex. We need to think differently about the IHS. (As I have written before: I would even change the name to the Indian Health System to reflect what the agency now does.)

Most of the Indian Health system is managed by tribes or non-profits. There are 26 IHS hospitals, and 19 tribal or or non-profit hospitals. But, and this is huge, there are 526 clinics, health centers and stations run by tribes and non-profits and only 91 by IHS. 

Hospitals Health Centers Alaska Village Clinics Health Stations
IHS 26 59 N/A 32
Tribal 19 284 163 79

 

The federal role is changing. The Indian Health Service still does operate health care delivery. And it sets standards. But it’s also a major funding source — and even that is misleading because it is Medicaid, not the Indian Health Service, that’s often the largest source of funding for tribal and non-profit facilities.

This is a critical difference because Medicaid has been under attack by the Trump administration from day one. The administration claims it’s protecting the Indian Health Service budget … all the while proposing deeper and deeper cuts into Medicaid.

There is a disconnect. And it’s visible in the budget. The line item for “collections,” that is money from Medicaid, Medicare and private insurance, is roughly $1.2 billion. That’s a number that has not changed much despite a huge expansion of Medicaid under the Affordable Care Act. This number should have been growing dramatically. But it’s not because it does not capture the amount of dollars collected tribes and non-profits, only the money that goes into IHS direct services.

This is misleading because when you talk to tribal and non-profit administrators, as I have, there is a different story to tell. Medicaid is now more important to local budgets than the IHS itself. 

The expansion of Medicaid also explains a lot about the shortages within the Indian health system. The federal Indian Health Service will take Medicaid funds, but it’s not growing the pot. Tribes and nonprofits have done that. And so there is more money for Indian health in states that have expanded Medicaid.

This is not the Indian Health Service we grew up with. And the next director of the Indian Health Service needs to acknowledge this complexity and own the new story. If I had my way: the next IHS director would have a solid background in medicine and Medicaid.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18

 

This is a first: Legislation would fully-fund Indian health system, raise billions

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Sen. Bernie Sanders proposed “Medicare for all” bill would fully-fund the Indian Health system for the first time in history. (Senate photo)
Mark Trahant / Trahant Reports

Bernie Sanders is expected to introduce his version of health care reform, a plan he calls “Medicare for all.” At least fifteen Democrats have signed on as co-sponsors to the single-payer plan.

“This is where the country has got to go,” Sanders told The Washington Post. “Right now, if we want to move away from a dysfunctional, wasteful, bureaucratic system into a rational health-care system that guarantees coverage to everyone in a cost-effective way, the only way to do it is Medicare for All.”

Sanders’ bill has no chance in a Republican Congress. Yet the Vermont Independent (who caucuses with the Democrats) is adding to the richness of the debate. He is showing a clear alternative to Republican plans (the latest is one by Sens. Lindsey Graham, R-South Carolina, and Bill Cassidy, R-Louisiana.)

But Indian Country should take note. Sanders bill would fully-fund the Indian health system. Let’s do the math. The current budget for the Indian Health Service is $6.091 billion dollars. And of that, roughly $1.2 will come from Medicaid, Medicare and other insurance. This serves about 2.2 million American Indians and Alaska Natives in 39 states.

But if Sanders’ proposal for universal care were enacted every one of those 2.2 million patients would have funding from insurance. The national average for Medicare beneficiary is $10,986. The total: $24.191 billion. A four-fold increase (and this does not include appropriations, just insurance dollars). So if you include both, the total is roughly $30 billion.

This sound like an awful lot of money, right? That big number reflects what other health systems already spend. So actually it’s the ideal demonstration of just how underfunded the Indian Health Service is under current law and insurance schemes. This is what a fully-funded Treaty Right looks like.

Of course some of this can be done now, even without Sanders’ bill. Many people in tribal communities are posting on Facebook exactly how to sign up for Medicaid (the government insurance program that so many in Indian Country already qualify for.) They are doing this as an act of defiance, because the Trump administration has recently quit advertising the program and is not actively promoting sign-ups.

But, again, let’s do the math. If every American Indian and Alaska Native was eligible for Medicaid that would net the Indian health system about $7.211 billion (instead of the $1.2 billion from third-party billing now). I actually think this is a more realistic number (even under a Sanders’ plan) because it does not include some of the spending by Medicare (and for that matter, Medicaid) on senior citizens. The national average for Medicaid is a modest $3,278 for an adult and for $2,577 average for children. The total for IHS would be in the neighborhood of $15 billion. More than double what is spent now.

Either Medicare or Medicaid: This is what full funding looks like. And a Treaty Right fulfilled. Finally.

Speaking of children, the Senate has reached a bipartisan deal in the Senate to reauthorize the Children’s Health Insurance Plan or CHIP. This insurance plan covers 9 million young people through Medicaid. The program is set to expire at the end of the month unless Congress acts and then President Donald J. Trump signs a new legislation into law.

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

Note: A correction was made to the original post.   Sen. Bernie Sanders is an independent. 

 

 

Did you hear the one about the Senator raising concerns about Indian health?

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Sen. John McCain votes yes on the Senate’s Motion to Proceed, then attacks the process, only to vote yes on the first bill that failed his test of regular order. Quite a day. (Photo via Senate video)

Mark Trahant / Trahant Reports

The Senate is now going through 20 hours of debate on a House Resolution 1628 to repeal and replace the Affordable Care Act. But the House bill was stripped of every word except the title. Now the idea is to come up with the right language to reach 50 votes (so when like the Motion to Proceed, Vice President Mike Pence can break the tie and vote yes).

The first proposal, Senate Amendment 267, had all sorts of problems on the floor. The Senate’s Parliamentarian ruled that parts of the bill did not get a score from the Congressional Budget Office and other parts violated budget rules. So 60 votes, not 50 were needed for this version to pass. But the Republican leadership wasn’t even close to 50 votes — Nine Republicans voted against it.

Including Arizona Sen. John McCain who just a few hours before said he wasn’t happy with any of the legislative proposals. Think about this. He interrupted his cancer treatment (taxpayer funded health care) then gave a stirring speech about the break down of civility in the Senate. He said he would vote against the bills as presented, and then, votes yes anyway. Quite a day.  And so much for his words. I’ll admit: I thought McCain meant what he said.

Then at least McCain earned respect and praise from President Donald J. Trump. He tweeted: Thank you for coming to D.C. for such a vital vote. Congrats to all Rep. We can now deliver grt healthcare to all Americans!”

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Now that’s something — as is the process itself.

This week’s Senate debate on TV will be exciting. Seriously. There will be many hours ahead of members speaking to an empty chamber about why the Affordable Care Act works — or why it should be repealed. (And lots of images of staff shuffling papers on camera.) Great theater, right? Then every once in a while (about the time paint dries) there will be a call for a vote and the dramatic calling of each senator’s name for a vote.

There are two main versions that will surface soon. The first is a repeal — or at least as much of a repeal as possible with 50 votes — that’s been proposed by Sen. Rand Paul, R-Kentucky. That proposal has little chance.

Then later in the week, Senate Majority Leader Mitch McConnell, R-Kentucky, will propose an amendment that they’re calling a “Skinny Repeal.” It would eliminate some taxes, a few more regulations, but leaves Medicaid alone. It’s supposed to be something for both moderates who want to leave Medicaid alone and for conservatives who want a repeal. Ha! And remember: If this version passes the Senate the bill will move to a conference committee with the House. That’s where the Medicaid cuts will come back. This is a phony negotiating plank.

As the debate unfolds, the Senate is in a way making the case for why we need Native Americans in the legislative process. There will be all kinds of talk about what the law does to Americans, to the poor, to taxpayers, to just about every constituent group in America. What’s really needed though is for one Republican senator to explain about the Indian Health system and what havoc all of these proposals would wreak. (Last week several Democrats did just that.) One majority party senator could say the Indian Health Service has never been fully funded, despite treaty promises, so why strip millions of dollars away? Or ask about Indian children when more than half are covered by Medicaid. Or show why Indian Country needs the jobs that have been created (and will be lost) by these proposals. Better yet: One Native Senator could use data to prove that Medicaid works.

Indian Country deserves to be in this debate. Alaska Sen. Lisa Murkowski has been a key opponent of the Republican leadership’s health care legislation. It’s mostly about Medicaid. I am sure that it’s also due to her support of the Alaska Native medical system. She gets it.

But Murkowski will pay a political price for her votes, at least in a primary election. But then she’s gone through that before. And won.  Not long after the Senate vote on the Motion to Proceed, the Alaska Republican Party said Murkowski abandoned them. Party chairman Tuckerman Babcock said the “repeal of Obamacare is non-negotiable.” (Funny: I feel the same way about the Senate alternatives.)

And so the party talks about possible consequences for Murkowski. Babcock said her vote put at risk new oil drilling in the Arctic National Wildlife Refuge (would that be true) and said her Energy Committee “chairmanship could be at risk.”

And President Donald J. Trump tweeted Wednesday morning: “Senator of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!”

So will there be punishment? I would not be so sure. Remember the Republican majority is thin. As I reported last week: Three senators switch sides and it’s a new Senate.  Two are already really, unhappy. So the way to make it three is for Republicans to continue to attack their own members.

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

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Two members of Congress get an $8 billion favor … that’s more than 10 times what Indian Health programs will lose

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Trahant Reports

How much does it cost to buy the vote of a ‘moderate’ Republican? Today the going rate is $8 billion. (And that, by the way, is more than ten times amount of money the Indian health system is at risk of losing if Congress enacts the “American Health Care Act.”)
The $8 billion would fund a high-risk pool for individuals with pre-existing conditions. The idea surfaced Wednesday as an amendment from so-called moderate Reps. Fred Upton of Michigan and Billy Long of Missouri after a meeting with President Donald J. Trump. This pool of funds is supposed to make it easier to take away a requirement in the current law to cover pre-existing conditions. Upton is quoted by The Hill newspaper saying, “I think it is likely now to pass the House.”
Here’s the thing. An $8 billion pool won’t come anywhere close to meeting the need.
Just think about this: Chronic care, including diseases such as heart disease and diabetes, consume nearly nine-out-of-ten health care dollars (which totaled $2.9 trillion in 2013). Add to that cancer and other costly diseases and it’c clear that $8 billion is not even a down payment.

But as I have been reporting: “The bill would still wipe out Medicaid as we know it. Medicaid represents 13 percent of the Indian Health Service budget (or $808 million).” Indian Country’s biggest concern right now ought to be Medicaid, Medicaid and Medicaid. There are now 30 million children covered by Medicaid; more than half of all Native children.
The last version of the bill sticks with its revision of Medicaid by capping the costs.
The crazy part of this equation is “why?” The Senate is not going to pass this bill. Several Republican Senators, including Alaska’s Lisa Murkowski, have said they support Medicaid as a state decision. This bill will, however, put House Republicans on the record. Alaska’s Rep. Don Young has been listed throughout this process as an undecided or a “lean no.” No other state will lose as much in this legislation as Alaska. So the choice will be a vote for the party or one for constituents.

The revised bill is expected to move to the House floor as soon as today. This legislation is moving so fast that few will have a chance to review it. And the Congressional Budget Office will not be able to look at the bill’s impact on either the budget or on American’s access to insurance. — Mark Trahant

Revised GOP health care bill would still undermine funding for Indian health

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Trahant Reports

Speaker Paul Ryan said House Republicans are close to a deal that would allow them to pass the American Health Care Act. He says this is because of “improvements” suggested by President Donald J. Trump.

Let’s be clear about these so-called improvements: The bill would still wipe out Medicaid as we know it. Medicaid represents 13 percent of the Indian Health Service budget (or $808 million). Now. It could produce even more revenue as more states opt into the plan and more American Indians and Alaska Natives sign up for that public insurance program. This is how the Indian health system reaches full-funding one day.

(Previous: Three ways to add money to Indian health.)

Ryan tweeted that the idea behind the new bill is “to give the states the ability to kind of customize the reforms to maximize the ability to lower premiums.” And the method for that is to allow states to walk away from requiring essential services. The result would be people who have insurance policies that do not cover what would be covered under the Affordable Care Act. This weakens the idea of protecting people from insurance companies that use pre-existing conditions to limit or exclude coverage.

That’s the debate that is taking center state right now. But for Indian Country the bigger concern ought to be Medicaid, Medicaid and Medicaid.

There are now 30 million children covered by Medicaid; more than half of all Native children,

I wrote last month that two states show the impact: Alaska and Montana. Both are new to Medicaid expansion. Montana currently does not have representation in Congress — so there is no voice in this “reform.” Alaska’s Rep. Don Young, a Republican, is so far listed as an undecided for this new House proposal. I also wrote that the previous House bill was particularly bad for Alaska. That’s still true but now those voting for the measure have a way to spin it: They can say it will lower premiums. Sure. And that will be fine as long as you never need the policy to actually pay for expensive medical treatment.

A House vote could come as soon as Friday. — Mark Trahant

 

 

 

 

 

 

Quick note before today’s vote

Good morning.
No post this morning, but a couple of thoughts before the House vote on the plan to repeal & replace the Affordable Care Act.
President Trump has made this an either, or vote for House members. With the president or not? Are they more worried about a primary from Trump supporters or their own constituents? As I wrote yesterday, Alaska’s Rep. Don Young will be worth watching on that score. This bill is terrible for Alaska. And a “yes” vote will be risky come election time. Or will Trump supporters use this an opportunity to take on Young in the primary?
Second point (and future stories) If this is end of repeal and replace, then the action will shift (as it already has) to the rule making process. Secretary Tom Price has a lot of power to make deals with the states on how ACA is implemented (and for that matter, Medicaid).
Third. It’s really interesting to see the new round of leaks coming from the White House. They were against this whole thing from the beginning, see. Blame is directed to Paul Ryan. (Trump’s news favorite Brietbart even calls this bill RyanCare.) So the question is what does this do to Ryan’s speakership going forward (if he continues in office)? As I wrote the budget divisions ahead are even greater than those that surfaced in the health care policy debate.
That’s it for now. Working on something not-Trump-related for the weekend. — Mark

Alaska, Montana & Indian health benefits deserve to be in House debate

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Governor Bill Walker and Health and Social Services Commissioner Valerie Davidson announcing the expansion of Medicaid in Alaska in 2016. (Picture from video feed.)

Mark Trahant / Trahant Reports

The story of Alaska and Montana is not front and center in the health care debate in the House today. But it should be.

Montana does not get a vote. (The state does not currently have a member of Congress after former Rep. Ryan Zinke was confirmed as Secretary of the Interior.)

And Alaska ends up with legislation that is by all measures, a raw deal. No state (and no pool of voters) will lose more under the Republican replacement for the Affordable Care Act than Alaska.

Alaska only expanded Medicaid in 2016. But the program has been a success. As Chris Ashenbrenner  wrote in the Anchorage Dispatch News: “Expansion is a bright spot in a dismal Alaska economy. Over 25,000 people now have health coverage at no cost to the state of Alaska. Alaska health care providers have received over $288 million in revenues since it started in September 2015.” One reason for that is the role Medicaid plays in funding the Indian health system. Recent changes (promoted by Alaska Gov. Bill Walker) resulted in “a change to their policy resulting in even more Alaska general fund savings — projected to be over $30 million this year and growing each year.  By 2022, it’s estimated to be over $90 million. This would not have happened without expansion.”

Alaska Health and Social Services Commissioner Valerie “Nurr’araaluk” Davidson recently told a state legislative committee that the American Health Care Act does not save money but shifts costs to the states. would shift the cost of health care to states. “I get nervous every time I hear a member of Congress talk about the great savings to the Medicaid program, because what they’re saying is, it’s a savings to the federal government,” Davidson said on Alaska Public Media. “They’re not saying it’s a savings to states – they’re actually shifting that cost to states, and that’s a problem for Alaska.”

But that’s not the only problem for Alaska. The Republican plan to give taxpayers a flat rate subsidy to purchase individual plans will mean that Alaskans would pay far more for insurance. “That’s because unlike the ACA’s tax credits, the House plan’s tax credits wouldn’t adjust for geographic variation in insurance premiums,” according to the Center for Budget and Policy Priorities. “They’d be the same for a 45-year-old consumer in Alaska, where benchmark health insurance coverage costs $12,600 this year on average, as in New Hampshire, where it costs $3,600.” The total bill: A whopping $10,500 more for a health insurance policy in Alaska.

Watch Rep. Don Young today. Alaska’s only member of Congress will likely demand a special deal from the House leadership. If not, will he still vote for the bill? Young told Alaska Dispatch News that he’s undecided. And on Facebook today, Sen. Lisa Murkowski will brief Alaskans on the legislation.

A poll published by FiveThirtyEight shows that 45% of Alaskans oppose the House bill, and 33 percent strongly oppose the legislation. It’s a similar story in Montana where 43 percent oppose the bill and 31 percent would strongly say no.

Montana, like Alaska, has a short experience with Medicaid expansion. But the numbers are strong. Montana Public Radio reported after seven months the program was nearly double the projected number of people insured. “Recipients have used their benefits to get $75 million worth of health care, 100 percent paid for by the federal government. That’s a big windfall in this state with slightly more than 1 million residents,” Montana Public Radio said.

Medicaid and Medicaid expansion are a critical, and growing, source of funding for the Indian health system.

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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President, Speaker pitch for 216 votes in the House as the make or break moment

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President Donald J. Trump makes a pitch to Republicans who are reluctant votes for the speaker’s Affordable Care Act replacement. The House vote is scheduled for Thursday. (Photo via Speaker Paul Ryan’s official page.)

Mark Trahant / Trahant Reports

It’s hard to think of a more make or break moment for the Speaker of the House of Representatives than what happens over the next two days. Well, sort of.

The Speaker needs 216 votes to move his health care reform proposal on to the Senate. If he loses, then Paul Ryan will have a difficult time rounding up the votes for the next tough vote (which is supposed to be tax reform).

And, if he wins, that’s the odd part. Then the bill moves to the Senate where the most likely outcome is a major rewrite. And if that works, then it’s back to the House where the same division between conservatives and leadership surface again. In the Republican Party there are three factions: Conservatives, Moderates, and those who fit into either camp but yet are inclined to support leadership. (That would be the majority of members in both the House and Senate).

I think I’ve told this story before, but here goes again, many years ago when I was at The Seattle Post-Intelligencer we had an editorial board meeting with Rep. Jim McDermott. A tough vote was coming up in the House about the war in Iraq. We knew where McDermott stood. His inclination would be to vote no. But, he told us, “I will not do that to my speaker.” A “no” would have undermined Nancy Pelosi.

That’s not the way Congress works now. House conservatives do not fear the consequences of voting against their speaker (even though in the past it’s resulted in loss of committee assignments and the perks). The thing is that they represent districts that are not competitive. So there is little the speaker can do to punish them. (This is not new. These are exactly the same dynamics that resulted in the end of John Boehner’s speakership.)

So the leadership challenge over the next two days is to make sure there are 216 votes to pass the American Health Care Act (after making minor changes). There are only three options: Make sure the votes are there. Pull the bill back and rewrite it again. Or, least likely, lose the vote and use that as a mechanism to try and punish the members who would not play along.

President Trump has his reputation (such that it is) on the line, too. He went to Capitol Hill trying to close the deal. According to Politico: “Trump entered the meeting to loud cheers. ‘We have a chance to do something fantastic, to do something amazing,’ Trump told the lawmakers, according to sources in the room. He later added: ‘Many of you came in on the pledge to repeal and replace Obamacare. I honestly think many of you will lose your seats in 2018 if you don’t get this done.’ ”

Once again, though, the polls show a different story. “A strong plurality of voters think congressional Republicans are moving too quickly to overhaul the nation’s health care system,” according to a new Morning Consult/POLITICO poll. This is the big reveal: The poll shows that Obamacare is more popular than the GOP alternative.

This is not a prescription for winning the next election.

It makes it easier for any member of Congress who votes no to tell voters that they stuck up for their interests, instead of following the speaker’s command.

Today the president will meet with the Congressional Black Caucus. He’s likely to make the case there, too. But Trump will have a tough time getting any votes from Democrats unless this health care bill changes into something quite different. The more I read about the legislation, and the review by the Congressional Budget Office, it’s clear that this bill is more of a Medicaid repeal than a repeal of the Affordable Care Act. That’s where most of the “savings” in the bill is found.

There is a notion in the Republican reform, one that I find deeply troubling, that Medicaid is only another word for welfare. In this logic, people who are “able-bodied” are only gaming the system when they have this insurance. Nonsense. Health care is health care. Period. I think we should be expanding access to basic insurance, and Medicaid is a cost-effective program that works. (A tack I took in a recent piece for Yes! Magazine.) I’d like to see Medicaid expanded, perhaps to 300 percent of the federal poverty level.

Again, back to my Seattle days. We had an editorial board meeting on health care reform and at that time the single largest source of Medicaid “customers” was people who worked at Wal-Mart. Fact is they had access to health insurance but could not afford it. And their incomes were so low that they qualified for Medicaid.

An increase in Medicaid eligibility would be a huge gain for Indian Country. That 300 percent number I cited would cover most of the people who use the Indian Health System. If you then add the people who have employer-based insurance, I would bet you would be awfully close to universal coverage. And that ought to be the goal. (Working or not.)

Of course the House plan goes in the other direction. The New York Times reported today that this bill is so bad that even a straight up repeal of the Affordable Care Act would be better. “Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report,” The Times said. “In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.”

That little nugget is not going to help the Speaker reach 216 votes on Thursday. If there is a vote.

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

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A win from Washington and a funding challenge from the states to Congress

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Sen. John McCoy was the sponsor of Washington State legislation to authorize dental health therapy in tribal communities. (Senate photo)
Mark Trahant / Trahant Reports

We live in odd times. Congress is moving forward with promised legislation that will roll back much of the health care reform enacted during the past eight years. The Trump administration is issuing regulations to do the same. The key here is that President Donald J. Trump and Republicans in Congress have the votes (mostly). But in state capitals there are real debates about public policy. What happens next will be determined by lots of people working together.

The future of the Affordable Care Act is a case in point. Republicans in Congress are eager to ditch the law, but coming up with a replacement or even a fix is a much more difficult task. This is one issue where there are not enough votes in Congress to do anything. Yet.

But in state capitals there is an understanding that a wholesale repeal of the law could be a financial disaster for states that have already expanded Medicaid. So many Republicans at the state level, such as Ohio Gov. John Kaisch, are pushing back. He recently told CNN that that any repeal without addressing Medicaid expansion is a “very, very bad idea.”

But several of the states prefer a real solution, one that doesn’t grab as many headlines, yet would be practical. And that is to continue with current law and then Secretary of Health and Human Services Tom Price would grant states many more waivers to design the programs the way they want.

This makes more sense than a block grant because it keeps in place the idea that if people are eligible for Medicaid, then it will be funded. Under a block grant scenario, it’s likely the total amount would be capped and people who currently get insurance could lose that.  (Perhaps the most difficult problem is this: How do you protect the states that expanded Medicaid and still add funding to those states that said no?)

This is a huge issue for Indian Country because Medicaid could cover even more of the people who currently use the Indian health system.  (Best of all: Money from insurance is supposed to stay at the local healthcare facility.) States also come out ahead with American Indian and Alaska Native clients because the federal government is obligated to pick up the tab. It’s a 100 percent federal “match.”

This is one of those issues that divide Republicans, especially in Congress. The members who are listening to states understand the problem: What happens when you take away people’s health insurance? The answer is not good. And it’s even life or death for some people because without insurance there will be no medical care for ongoing issues.

This week in Washington state there was a victory for health care reform in Indian Country. The Legislature passed, and Gov. Jay Inslee, signed into law, a measure that opens up the practice of dental health therapy.

Dental health therapists are mid-level providers. They work under the supervision of a dentist and offer routine and preventive services, like dental exams; provide fillings; clean teeth; placing sealants; and perform simple tooth extractions. This law is important because it opens up Medicaid funding to pay for dental care. And it expands access making it much easier for patients to get appointments.

“We have one dentist to see more than 6,000 patients on the Colville Indian Reservation,” said Mel Tonasket, vice-chairman of the Colville Confederated Tribes. “This law will help us hire a dental therapist to make sure our people are getting the oral health care they need.”

Most experts in health care reform argue for increasing value in health care by lowering costs and at the same time improving quality. This is that.

This oral health reform was started a decade ago by Alaska Native Tribal Health Consortium. According to The Kellogg Foundation: Since then “45,000 Alaska Natives now have access to dental care and the dental health aide program has generated 76 full time jobs with a net economic effect of $9.7 million, one-third of which is spent in rural Alaska. Now, as a way to replicate the same dramatic oral healthcare improvements in Alaskan villages, i.e., reduced caries disease, healthier teeth and patient satisfaction with culturally competent care given by home-grown providers, tribes are blazing a trail to bring dental therapy to the lower 48 states as a high-quality, cost-effective strategy to reduce dental care shortages. Washington State is on the leading edge of this movement.”

This is a great example of the principle of lead, follow, or get the hell out of the way. A year ago Swinomish President Brian Cladoosby announced that the tribe was using its sovereign powers to hire a dental health therapist in contradiction to federal and state law. The case was clear that the tribe had the authority even while raising questions about Medicaid funding or licensing. (The American Dental Association was successful getting language into the Affordable Care Act that required state action.) But the state of Washington was reasonable and the result is the new law.

The bill was sponsored by Sen. John McCoy, a member of the Tulalip Tribes. “This is a tribal-based solution that will make a tremendous difference for Native people—especially children,” he said.

According to Kellogg: Dental therapists are now practicing in Minnesota, in addition to Native American communities in Alaska and Washington. They’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio are exploring the potential for dental therapists to significantly improve oral health care for many more children and communities.

So look for more action and more success stories coming from state capitals.

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

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