First, Congress tried to repeal and replace the Affordable Care Act by rolling back that law plus the decades long public health insurance known as Medicaid. That effort failed in the Senate. Twice. And Congress hasn’t given up. There are all sorts of proposals floating that would try yet again through the budget or another mechanism.
Meanwhile the Trump administration is trying to unravel the Affordable Care Act using administrative authority. And, in the process, guaranteeing a network of insurance chaos. The President signed an executive order that eliminates payments to insurance companies to subsidize the cost of health insurance for families that cannot afford the full cost. Insurance companies will likely increase health insurance premiums — and by a lot — or get out of the individual health insurance market all together.
This policy change impacts American Indians and Alaska Natives who get their health insurance through the exchanges. Under the Affordable Care Act, many tribal members and Alaska Native shareholders quality for a “bronze plan” from exchanges at no cost. A silver plan could also have been purchased, depending on income, using subsidized rates.
The Kaiser Family Foundation figures that insurers will need to raise silver premiums between 15 and 21 percent on average to compensate for the loss of the subsidy payments.
It’s interesting: Ending the subsidy will cost consumers more in states that have not expanded Medicaid (such as Oklahoma) since there are a large number of marketplace enrollees in those states with incomes at 100-138 percent of poverty who qualify for the largest cost-sharing reductions.
The Congressional Budget Office (CBO) estimated that the total payments were $7 billion in fiscal year 2017 and would rise to $10 billion in 2018 and $16 billion by 2027. The House of Representatives sued the Obama Administration to try and stop these insurance subsidies arguing that Congress never appropriated the money.
The CBO also said that ending the insurance subsidies will increase federal deficits by $6 billion in 2018, $21 billion in 2020, and $26 billion in 2026.
A second administrative order will change the way insurance companies write policies. The Affordable Care Act set out standards so that basic health care issues, including women’s reproductive health, would be covered. But the new rules will make it easier for people to buy limited policies that cost less, but cover fewer medical issues.
“Congressional Democrats broke the American healthcare system by forcing the Obamacare nightmare onto the American people. And it has been a nightmare,” the president said. “You look at what’s happening with the premiums and the increases of 100 percent and 120 percent, and even in one case, Alaska, over 200 percent. And now, every congressional Democrat has blocked the effort to save Americans from Obamacare, along with a very small, frankly, handful of Republicans — three. And we’re going to take care of that also because I believe we have the votes to do block grants at a little bit later time, and we’ll be able to do that.”
But the actions by the administration will only lower the cost of health insurance for one group of Americans, young, healthy ones. Insurance costs for nearly every other plan will sharply increase because of these actions. And especially at risk: Patients who are facing expensive medical treatments such as cancer.
Earlier in the week, the administration also rolled back Affordable Care Act coverage requirements for access to birth control. According to the Kaiser Family Foundation: “These new policies, effective immediately, also apply to private institutions of higher education that issue student health plans. The immediate impact of these regulations on the number of women who are eligible for contraceptive coverage is unknown, but the new regulations open the door for many more employers to withhold contraceptive coverage from their plans.”
The actions of the Trump administration mean two things: There will be chaos in the insurance markets as companies and individuals rebalance the value of those policies; and there will be litigation ahead because every one of these policy shifts will be challenged in court.
Here we go again: Congress is finding new ways to complicate health care.
It really boils down to the philosophy that government-funded health care is just another word for welfare. So it’s a good thing to cut it back and limit it. The other side of that is that funding health care is a right and smart because a healthy population is more productive and better for everyone. There is a third element, of course, for Indian Country, and that’s the notion that health care delivery represents a solemn promise made through treaties; thus a pre-paid obligation.
Over the past few months I’ve written a lot about the role of Medicaid in the Indian Health system, a revenue stream that raises about $880 billion. Medicaid is a federal-state partnership, so even though the federal government ultimately pays the bill for American Indians and Alaska Natives, the rules and regulations go through the states. And if that’s not complicated enough, there’s an “and” added to Medicaid … the Children’s Health Insurance Program or CHIP. On budget lines these two programs are lumped together, Medicaid and CHIP. Mostly because the funds are administered by state Medicaid programs.
The idea of CHIP is simple. The richest country in the world ought to make sure that children have health insurance and are able to see doctors (it was added to a budget resolution in 1997). “In general, CHIP reaches children whose families have incomes too high to qualify for Medicaid but too low to afford private health insurance,” the government says.
The key here is that American Indian and Alaska Children rely on Medicaid and CHIP at higher levels than the general population. In 2015 54 percent of Native children were enrolled in Medicaid or CHIP compared to 39 percent of children nationally (which is still a big number).
Congress works on two tracks. One track is language to authorize spending and an additional track is when Congress appropriates the money. The problem here comes from track one: The authorization for CHIP expired October 1 and it must be renewed before new funding.
This was supposed to be easy. A letter to Congress from the National Governors Association was clear: “CHIP is widely supported by governors, who recognize that access to health insurance is critical to ensuring a healthy start for our nation’s children. Since CHIP was enacted, the uninsured rate for children age 18 or younger has fallen from 14.9% to 4.8% … Governors urge you to protect children’s coverage and give states certainty by providing an extension of funding for the program.”
Not only do governors from both parties agree that CHIP worked but so do a vast majority of Americans, one Kaiser Family Foundation polls pegged support at 75 percent.
In the Senate leaders have been saying, repeatedly, not to worry. CHIP renewal will happen. A bipartisan bill was in the works and put on hold while the Senate debated its larger Graham-Cassidy healthcare measure. (There were all sorts of provisions in that bill to muck up CHIP.)
But we are past that, right? Now Congress should just pass a clean extension of CHIP and, for good measure, make a few fixes to the Affordable Care Act, and then argue about other things. That was the Senate proposal.
However in the House: “Unlike the Senate KIDS Act, the House HEALTHY KIDS Act also includes offset policies designed to appropriately reduce federal spending so the extension of CHIP funding does not increase the deficit.”
In other words: The House wants to cut other programs first.
The House bill will add money to the Puerto Rico Medicaid program. But, as the Center for Budget and Policy Priorities point out it’s not enough. “The HEALTHY KIDS Act includes up to $1 billion in additional funding for Puerto Rico’s Medicaid program to help the Commonwealth recover from the devastation of Hurricane Maria. While this is a welcome move, it falls well short of what Puerto Rico needs, and the bill provides no assistance to the U.S. Virgin Islands, badly damaged by Hurricanes Irma and Maria.” Then the House bill cuts public health funding by $5 billion and shortens the grace period for people trying to pay Affordable Care Act premiums. Two kick-the-rich provisions: Allowing states to disenroll lottery winners (because we all could win, right?) and charging higher Medicare premiums to wealthy seniors.
The House committee is urging its members to vote fast. “States are currently using unspent FY2017 CHIP allotments and redistributed funds from the Centers for Medicare and Medicaid Services (CMS) to cover current spending needs for their CHIP programs,” the committee told its members. “Without Congressional action, states could start to exhaust these funds as early as November.”
Ten states could run out of money by next month, including Arizona, Utah and especially, Minnesota. According to Kaiser Health News, “Minnesota was among those most imperiled because it had spent all its funds … Emily Piper, commissioner of the Minnesota Department of Human Services, reported in a newspaper commentary last month that her state’s funds would be exhausted last Sunday.”
If a state does not reimburse the Indian health system for these costs, IHS, as the payer of last resort, could be on the hook for these additional costs.
The numbers are significant. A study by Georgetown University Health Policy Institute said the uninsured rate for AI/AN children declined from 25% to 15% between 2008 to 2015. All of the states with very high proportions of their AI/AN children on Medicaid saw very large double-digit declines. The two states with the largest declines in their uninsured rate for kids were New Mexico (38% to 11%) and Alaska (32% to 17%).
“At a time when Congress is considering extremely large cuts to Medicaid and a dangerous restructuring of the program, AI/AN families are especially at risk,” the study concluded.
The politics ahead are difficult. The House bill adds budget cuts as a way to reach 218 votes. This works by making it more conservative. But it also removes the bipartisan approach, something that’s worked so well since CHIP was created. And even the House’s conservative tilt might not generate enough support for the measure to pass.
This is all nonsense. We know CHIP works. It’s government at its best. (If we do anything … we should expand it and add more children.) So the law’s renewal should be a quick “yes” vote. Then, what’s next? But Congress has to complicate — make that muck up — a program that works.
You have to wonder why the latest Senate Republican plan to repeal and replace the Affordable Care Act did not get written with one senator in mind, Lisa Murkowski of Alaska.
Yet the bill by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) is more conservative than previous approaches. It has lots of wish-list boxes to tick, no money for Planned Parenthood, big tax cuts, and its spends way fewer federal dollars. The bill only needs 50 votes to pass but that must happen before the end of this month.
Medicaid would become a block grant program that states could design (and pay for). So it would likely disappear. The Center for Budget and Policy Priorities estimates that federal funding for health care would be reduced by $299 billion in 2027 alone with cuts impacting all states. And here’s a fun fact: Big states that expanded Medicaid would be hit harder. A lot harder.
Why 2027? That’s the year block grants disappear. Graham and Cassidy argue that only a temporary block grant would be allowed under the rules of debate. So no “new” thing. Congress would have to meet “pay for” standards to replace that after 2027; meaning there would be cuts in other federal programs equal to the new spending.
And, like other Republican plans, this one would add significantly to the ranks of the uninsured. The Center for Budget and Policy Priorities estimates 32 million would lose coverage. States could also end essential benefits, coverage of pre-existing conditions, and allow companies to charge people significantly more when they’re ill. (Health insurance coverage that you cannot afford is the same as no insurance.)
“Like the earlier version of the Cassidy-Graham plan, the revised plan would disproportionately harm certain states. The block grant would not only cut overall funding for the Medicaid expansion and marketplace subsidies but also, starting in 2021, redistribute the reduced federal funding across states, based on their share of low-income residents rather than their actual spending needs. In general, over time, the plan would punish states that have adopted the Medicaid expansion or been more successful at enrolling low- and moderate-income people in marketplace coverage under the ACA,” the CBPP reports. So by 2026, the “20 states facing the largest funding cuts in percentage terms would be Alaska, California, Connecticut, Delaware, the District of Columbia, Hawaii, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Montana, New Hampshire, New Jersey, New York, North Dakota, Oregon, Rhode Island, Vermont, and Washington. These states’ block grant funding would be anywhere from 35 percent to nearly 60 percent below what they would receive in federal Medicaid expansion and/or marketplace subsidy funding under current law.”
A lot to like in Alaska, right? Murkowski said she is undecided until she sees the Congressional Budget Office assessment. She told CNN: “I will use the governor’s words,” Murkowski said, referring to Alaska Gov. Bill Walker. “He said, ‘I understand that a block grant gives me increased flexibility, but if I don’t have the dollars to help implement the flexibility, that doesn’t help us much.’ So, we are both trying to figure out how those dollars fall.”
Graham-Cassidy plan continues the 100 percent reimbursement to states for patients served by the Indian Health Service and it adds an increase in the federal match to 100 percent for medical assistance provided by non-Indian Health Service providers for tribal enrollees. The idea is more American Indians and Alaska Natives should take their business away from IHS facilities. Let’s be clear about this: It would drain resources away from the Indian health system.
This bill would also allow tribes to set up group plans to buy insurance for tribal members to replace the Medicaid expansion. “Creates new optional coverage group as of January 1, 2020 for members of Indian tribes up to 138% FPL in states that had expanded coverage as of December 31, 2019, who were enrolled in Medicaid as of December 31, 2019, and do not have a break in eligibility of 6 months (or a longer period specified by the state).”
So in summary this bill would not add any new resources to the Indian health system. But it would cut funding significantly (again, remember Medicaid).
The last Senate Republican plan failed by a single vote. It’s likely that Arizona Sen. John McCain will end up being a “yes” this time around (the state’s governor is giving him cover, saying it’s a good plan). However Kentucky Sen. Rand Paul says he’s now a “no.” In his mind this plan does not repeal the Affordable Care Act. Susan Collins remains a likely “no.” If those positions stay the same, then this bill’s fate could end up being decided by Senator Murkowski.
Is there anything in this legislative gem that improves health care in Alaska? No. Does it improve the Alaska Native medical system? No. The Indian Health Service? No. Then why is she even considering this vote. It should be an easy no. Again.
Senate Republicans campaigned against “Obamacare” for seven years. Yet there was never an alternative that had support from a majority of their own party.
The problem is simple: Many (not all) Republicans see health care programs that help people — the Affordable Care Act, Medicaid, etc. — as welfare. Others look at the evidence and see these programs that are effective: Insuring people, creating jobs, supporting a rural economy, and actually resulting in better health outcomes. Evidence-based success stories.
Of course Indian Country is squarely in the middle of this debate. Congress has never even considered, let alone acted, to fully fund Indian health programs. But the Affordable Care Act basically defined the Indian Health Service (and tribal, nonprofit, and urban operations) as health care delivery vehicles. And one way to pay for that delivery was by providing health insurance through an expanded Medicaid, no-cost insurance that tribal members could get through exchanges and employers. The ACA with all its faults sets out a plan to fully fund the Indian Health Service.
That’s the challenge now. Making sure that every American Indian and Alaska Native has insurance of some kind. Because of what happened (or, more accurately, what did not happen) in the Senate this week the money remains on autopilot. If you are eligible, the funding is there.
Yet the uninsured rate for American Indians and Alaska Natives remains high, as a Kaiser Family Foundation report noted a couple of months ago. “The Affordable Care Act’s Medicaid expansion provides an opportunity to enhance this role by increasing coverage among American Indians and Alaska Natives and providing additional revenue to IHS- and Tribally-operated facilities,” The Kaiser report said. “In states that do not expand Medicaid, American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities.”
This is a problem that will grow because of congressional inaction. Nineteen states including Oklahoma, South Dakota, Wisconsin, Wyoming, Idaho, Kansas, Nebraska, Florida, and Maine, have rejected Medicaid expansion. So a tribal citizen in those states gets fewer dollars for healthcare than some Indian health patients in North Dakota, Montana, Alaska, Arizona, New Mexico, or any other state that took advantage of the expansion.
As Kaiser notes: “American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities in states that do not expand Medicaid. In states that do not expand Medicaid, many poor adults remain without an affordable coverage option and will likely remain uninsured. Similarly, IHS providers in these states will not realize gains in Medicaid revenue.”
This is the what’s next? How does the country manage this divide, especially in Indian Country. (And, just as important, we also need to see the gap measured. What are the differences in treatment and outcome between Montana and Idaho or North Dakota and South Dakota? Data, please.) This is critical because under current law, third-party billing (including Medicaid) remains at the local service unit. There is now a funding inequity that needs to be addressed by state legislatures. Recently Rep. Tom Cole, R-Oklahoma, said he knows these states and they won’t expand Medicaid. (Back to the welfare, thinking.) I hope not.
The Trump administration recently made it easier for states to get a 100 percent reimbursement for Indian health patients (enticing South Dakota to reconsider joining the ranks of expansion states.)
So it’s possible, and a challenge, to make sure that the law is implemented, and that innovation continues. The ACA gives much power to an administration to a state to change the rules. You will see a lot of that now. Indian Country needs to keep a sharp eye on that process and raise objections if the result is unsatisfactory.
So why did the Senate bill fail? Sure, full credit should go to the heroic stands by Sen. Susan Collins, R-Maine, and Sen. Lisa Murkowski, R-Alaska. From the very beginning of the debate they were the party advocates for a Medicaid system that does produce better healthcare outcomes. And Alaska is a great example of that because nearly a quarter of the state’s population is served. This is how it should be across Indian Country and the nation.
And, of course, there was Sen. John McCain’s dramatic late night thumb’s down. The Arizona Republican was a no vote when it counted.
But that’s not why the bill failed. Fact is it’s remarkable that such nonsense got so far. It’s inconceivable that a plan was written at lunch the day before the vote. The bill failed because the Republicans, as a group, do not know where they want to lead the country on health care. They know they don’t want Obamacare (even though it’s based on conservative, market-based ideas). They sure as hell know they don’t want universal health insurance, either Single Payer such as Medicare for All or a government health service like Great Britain’s.
Yet when I listened to the debate yesterday so many of the complaints about insurance and costs could be solved by such a path. The problem here is that the United States made a huge mistake with employer-based insurance and that left out people who work for themselves or small businesses. The only way to fix that is a large pool of people spreading the costs, so that healthy people pay for sick people. The ACA tried to do that with mandates. Most countries accomplish that goal with universal insurance.
Another factor in the Republican plans — and another reason for the bill’s failure — is their absolute certainty in a market-based solution. Healthcare delivery and free markets do not play well together. The proof of that is simple: How much is an empty hospital bed worth to a business? Yet that should be the goal. And how much is it worth to a hospital-as-a-business to help a patient not need surgery? What market incentives are there for people to eat better?
Seven years ago, when I started writing a lot about health care, I did so because I saw the Indian Health Service as a fascinating example of government-run and managed healthcare. As we began this debate, I thought, let’s figure out what works and what needs work.
But I was way wrong. IHS is no longer only a government-run system. Much of the agency is now a funding mechanism for tribal, nonprofit, and urban operations). And that’s where so much of the innovation and excellence in Indian health exists. We need to more more about what’s working and why. Yet Congress (and the public narrative) continue to think of an IHS that no longer exists. At least entirely.
This might be a moment to focus on the latter part of what the agency does, improving the flow of funds, and adding more of our people to insurance rolls. Here’s the thing: We cannot do anything about universal health care. At least not yet. But we can have universal health care for Indian Country. It’s a huge task, but the ACA remains the law and it’s only a matter of execution (not a policy debate).
Third-party collections now account for about $1.8 billion out of the IHS’ budget. The dollars Congress appropriates is $4.8 billion. The third-party portion can grow through more insurance coverage. The appropriations side will require hard fights in Congress and the outcome is uncertain.
Back to the Senate. Texas Sen. John Cornyn, a member of the Republican leadership, joked that perhaps it’s time for a new way of doing business. “I guess we ought to go back to Schoolhouse Rock,” he said. That’s been a clear message from both Republicans and Democrats throughout this messy project. Get a bill. Hold hearings. Let a committee debate alternatives. Then let the bill come to the floor. Regular order. Schoolhouse rock.
Today is humor day in the Senate. But at least the healthcare debate will go on and on without a conclusion. And no matter what happens today and Friday there is still a long way to go.
The Senate has at least ten more hours of official debate on a House bill that’s been substituted with language that neither we nor senators have yet seen. (Leading to great theatrics by the Senate Democrats who said they’d offer no more amendments until there was an actual bill with, you know, like words in it.) But even without an actual bill Democrats sent the framework of the so-called “Skinny Repeal” to the Congressional Budget Office for a score and the answer is more of the same, the number of uninsured would increase from 28 million to 44 million in a decade.
Nonetheless by Friday there will be some sort of proposal that’s designed to get 50 votes so the legislation will go to a conference committee with the House. This Skinny Repeal strips the individual mandate (causing a mess in insurance) but leaves Medicaid alone. For now. Basically this means the House will get its way and senators will be forced to vote for that approach or nothing. It’s a risky strategy when the Republican majority is so slim. Actually in both houses.
Today the Senate will consider a proposal for universal health care, Medicare for all. Consider is not the right word here because the proposal is already doomed. But Montana Sen. Steve Daines wants Democrats on record voting for this scary, scary idea. But as Pat Bagley, the cartoonist for The Salt Lake Tribune tweeted yesterday, not one country that’s gone down the single payer path has reversed course. It’s the United States that is the outlier with our incomprehensible health care “system.” Even Bernie Sanders, who is for Medicare for All, said he won’t vote for this amendment because it’s a ruse.
Daines won’t be voting for his own amendment either. That’s not the point. Daines told the Helena Independent Record Wednesday night “It’s time for every senator to go on the record on whether or not they support a single-payer system.”
So, while we are at it, let’s be clear about what Single Payer could do for the Indian health system. Indian Health Service funding would jump by at least 40 percent in a Medicare for all approach. The agency (and the tribal and nonprofit operations) would be equal with other healthcare providers; getting paid for every patient instead of worrying about appropriations or tracking down insurance payments from companies, Medicaid, and other third-party payers. So it would be a financial boom. Big time.
But as I said: Medicare for all is really not on the table. The Senate vote is just supposed to frighten Democrats. So. Be careful. Or Congress will give you health care. Aye.
Speaking of bad jokes, I laughed at the Trump administration’s threats to Alaska Sen. Lisa Murkowski. According to the Alaska Dispatch News, Interior Secretary Ryan Zinke warned Murkowski that Alaska energy projects could suffer because of her vote (and her leadership) against the GOP health care proposals. (I do think she could lose her Energy Committee chairmanship, but that, too is a silly move by Republicans in a narrowly divided Senate.)
So the Trump administration that wants Energy for All is telling a Senator who’s pro-energy that Alaska development is in trouble because she’s against their destruction of health care. Now that’s some weighty logic. Nonetheless Alaska Senator, Dan Sullivan reported this threat with a straight face. He told the Alaska Dispatch News that it’s a “troubling message … I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop.”
So oil companies be warned. You could be punished. As will we all. Be afraid. And remember universal care for all is up today. So keep the children away from the Senate TV.
It would be cool, just this once, if the Senate would say, “Indian Country you are so important. So we are adding a special provision to this health care bill that adds big bucks to the Indian Health Service.” Then Senators with significant American Indian or Alaska Native populations would shift their votes from perhaps to yes.
That might sound like a fantasy. But it’s the track that the Alaska delegation is on; senators secured a special deal in the Senate health care plan for their state. Only it’s not about Alaska Natives. And it’s not nearly the same amount of dollars that the state will lose with Medicaid cuts (or, for that matter, in high cost insurance.) But it’s a “victory” of sorts that will be claimed if Sen. Lisa Murkowski eventually votes yes on the Senate bill. (Sen. Dan Sullivan was a likely yes, anyway, although he’s claiming credit too.)
Here’s the deal. The legislation includes a complicated formula to reduce Medicaid spending — except in states with a population density of less than 15 people per square mile. That’s Alaska, Wyoming, North and South Dakota, and Montana. New Mexico just misses but then it’s a Blue state and its senators would likely vote no anyway. And, the exception might be of use to Sen. John Hoeven from North Dakota but, like Sullivan, he probably would vote with leadership anyway.
So really it’s about Alaska — and Murkowski’s vote. She’s a firm maybe. So far three senators have said no (enough to kill the bill) but we won’t know how solid those no votes are until there’s an actual vote. The self-proclaimed no votes are Sen. Susan Collins of Maine, Rand Paul of Kentucky and John McCain of Arizona. (Republicans need 50 votes from their own party.)
The rural exception to the Senate bill adds up to just under $2 billion, according to The New York Times.
But special deal or not, the big picture might be more important to Murkowski.
Alaska is a state where the evidence is strong that the Affordable Care Act and Medicaid Expansion are working. Nearly a quarter of the state’s population is enrolled in Medicaid and the state’s 2015 expansion added more than 34,739 people. Half of the state’s children are insured by Medicaid.
And, of course, Medicaid is an essential revenue source for the Alaska Native medical system — a system that Murkowski praised just this week at a hearing on the Indian Health Service.
A study done for Alaska’s Department of Health and Human Services — run by Commissioner Valerie “Nurr’araaluk” Davidson — is blunt. It says: To stay under a per capita cap Alaska would be required to cut its Medicaid program spending by $929 million in federal and State dollars between FY 2020 and 2026, with a federal funds loss of $473 million … The magnitude of the federal cuts are such that they may well affect Alaska’s ability to finance other State priorities such as education and infrastructure.”
The report says the cap will not include patients in the Indian Health system, but that Alaska will have to cut back on eligibility to reduce Medicaid spending.
Analysis of the House plan (remember at some point the House and Senate bills would have to be merged and passed again) would cost Alaska $2.8 billion in Medicaid funds between 2020 and 2026.
What’s even more problematic: “Alaska will have to establish its Medicaid budget almost two years before it knows the amount of federal Medicaid funding available for that budget year.” That could result in a “claw back” effect where money has to be returned to the federal treasury after its already spent. The impact of the Senate bill would be quick. The state’s report estimates that within three years a quarter of all Medicaid funding would be eliminated. And, more important, by 2022 95% of expansion enrollees will have lost coverage due to Alaska’s highly seasonal workforce.”
So will the rural exception be enough to buy votes? It’s certainly not enough funding to maintain Alaska’s successful Medicaid Expansion.
A Senate hearing Wednesday on Indian health illustrates the larger problem exactly: How can you strip millions of dollars from a health care system and get better results?
The answer is you cannot.
But that’s not what the Trump administration testified. And it’s not what the Senate leadership is saying about its health care bill. Or the House for that matter.
So they lie. And it’s a lie that is so bold, so outrageous, that it should not told with a straight face. There is no defense. That’s why doctors, governors, hospitals, patients, economists, policy-makers, anyone willing to tell the truth about the destructive nature of these so-called health plans are in the opposition. A recent USA TODAY/Suffolk University poll shows the support for the Senate plan by only 12 percent making it one of the most unpopular bills ever.
And yet the Senate bill is still on the table. A new bill is out today and a vote could come as soon as next week. President Donald J. Trump told a Christian television show that he would be “very angry” if this bill fails. “I am sitting in the Oval Office with a pen in hand, waiting for our senators to give it to me,” the president said. “It has to get passed. They have to do it. They have to get together and get it done.”
Let’s start with the hearing on Capitol Hill Wednesday. Rear Admiral Michael Weahkee, the acting director of the Indian Health Service, testified about the agency’s budget to the Senate Appropriations Subcommittee on Interior, Environment and Related Agencies, chaired by Alaska’s Sen. Lisa Murkowski. “I am pleased to provide testimony on the President’s Fiscal Year (FY) 2018 Budget Request for the IHS, which will allow us to maintain and address our agency mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/ANs) to the highest level,” began his written statement. It gets better: “The Budget reflects the Administration’s high priority commitment to Indian Country, protecting direct health care investments and reducing IHS’s overall program level by only 0.9 percent when compared to the Annualized Continuing Resolution, in the context of an 18 percent reduction within the overall HHS discretionary budget.”
In other words we’re cutting the hell out of all budgets — so be happy with your cuts Indian Country.
So what if the words “maintain” and “raise” don’t fit with the highest level of health care. It’s no secret that Indian Health is already underfunded.
The measure of that shortage that makes the most sense is to compare spending by IHS to what’s spent by the federal government on federal employees. According to the National Congress of American Indians that measure shows IHS funding at about 60 percent of need.
(Of course you could argue that the U.S. health care system is too expensive. But that’s a different conversation. Reform is not even on the table right now. This whole fight is just about money; money for health care or tax cuts.)
The problem with the Senate hearing and a recent Wall Street Journal article on the failure of the Indian Health Service in the Great Plains is that the Indian Health Service is not what it was. It’s no longer just a government health care agency. In fact most of the agency is a funding mechanism for tribal and non-profit health care facilities. The congressional oversight needs to be re-imagined to fit both of these missions.
The Journal stories highlighted operational issues in South Dakota and Nebraska that demonstrate a tragic failure. (This is the IHS story most of us already know.) And after years of warning the agency has not come up with a strategy to effectively fix its own management.
“Because this is our IHS. These are our facilities that are supposed to care for our first people,” Sen. Murkowski said. “And the stories that were detailed were shocking.”
But Sen. Murkowski correctly identified the division within IHS. She told Alaska Public Media that Alaska’s Native health facilities are run by tribes, under contract to the IHS, so their problems aren’t the same. True. But that’s more than half of the system. That’s the story that the Journal did not tell (and do the reporting about why tribes and non-profits are able to deliver better care than the agency itself.)
The answer, in part, take us back to the larger Senate debate. The Alaska Native Medical Center has balanced funding: Money from IHS, aggressive third-party billing from private insurance and especially Medicaid as well as foundation grants. This kind of balance ought to be the future (unless Congress says, “well, let’s fund Indian health at 100 percent of need”) for others across Indian Country.
That’s why the narrative of failure is problematic. It’s true that there is a systemic crisis — especially in the Dakotas. So much so that Montana Sen. Steve Daines has even suggested changing the name of IHS to “Indian Health Suffering.” Old story.
But that’s why there should also be a narrative of success. I, too, would change the name of IHS, but to the Indian Health System. Because parts of that system are excellent and ought to be a model for health care, period.
And that’s where Medicaid comes into the picture. At the Senate hearing there was frustration because IHS did not provide enough data.
The IHS budget calls for $1.2 billion in third-party billing. Most of that is Medicaid. That will work for next year. But it’s important to remember the House and Senate plans will cap and reduce what is spent on Medicaid. Right now: If a person is eligible, the money is there. Under the GOP alternative there will be a set amount of some kind. The money will run out.
But IHS officials did not talk about Medicaid much. And Montana Sen. Jon Tester pointed out: “I think it’s absolutely unbelievable that you can’t separate how much Medicaid has helped your with third-party billing.” This is is what we need to know.
The Indian Health Service operates in both Medicaid and Medicaid expansion states. Remember not every state expanded Medicaid under the Affordable Care Act (To date: Thirty one states and Washington, D.C. are on board). For example: South Dakota did not and North Dakota did. So we ought to have data about how much Medicaid money goes into the system, for what kind of patents, and how it’s used (hint: by law it’s supposed to remain at the local service unit.) We should have similar data for tribal or non-profit facilities. Life-saving data.
The Center for Budget and Policy Priorities released a report earlier this week that highlighted the connection between Medicaid and Indian Health. “The Medicaid expansion has improved access to care for thousands of American Indians and Alaska Natives especially in states with large AI/AN populations including Alaska, Arizona, and New Mexico. It has also provided much-needed revenue to Indian Health Service (IHS) and Tribally operated facilities, allowing them to expand services and hire and retain more staff. Ending Medicaid expansion would jeopardize coverage for these newly insured low-income AI/AN adults, and reduce revenue for IHS and Tribally operated facilities, forcing them to revert to pre-ACA service levels.”
In Montana, a state that recently expanded Medicaid, more than 11,000 American Indians have signed up for the insurance. “At a time when Montana is working in a bipartisan basis to address the suicide epidemic and improving health outcomes for American Indians, D.C. politicians are threatening to take away health insurance for thousands of Americans Indians in Montana,” said Heather Cahoon, State Tribal Policy Analyst for the Montana Budget and Policy Center. “More than 11,000 American Indians in Montana now have access to health insurance through our bi-partisan Medicaid expansion plan, and we can’t afford to go back.”
But going back is on the Senate agenda today. The Republican caucus is counting votes to see if a compromise is possible within their own ranks. The bill will be released, scored by the Congressional Budget Office, and, if Sen. Mitch McConnell gets his way, there will be a vote early next week.
But the facts are this: The Senate bill still strips $700 billion from Medicaid. And that number will grow over time. And the Trump administration is cutting from the already underfunded Indian Health Service budget by 6 percent. Now. That, too, will get worse down the road.
And so there will be many lies flying fast. It’s a health care bill. Or this legislation won’t take away your insurance. Medicaid will be better off. So will the patients. Whatever. The Congressional Budget Office is wrong. Then there’s that forever lie: That United States is meeting its solemn treaty promises to American Indians and Alaska Natives.
The Congressional Budget Office report on the Senate majority’s health care bill — the ironically titled “Better Care Reconciliation Act of 2017” — ought to be enough to put to rest any idea that Republicans want to improve health care in this country.
There are legitimate conservative ideas about how to reform health care. You know, the stuff they have been saying for years about market-based reforms where people can shop for their doctors and clinics online across state lines. Think Amazon. Modern, high tech, affordable care.
But that’s not on the table. Instead the House and the Senate are trying to legislate a huge tax cut, make a small dent in the long-term federal spending, trim spending on insurance subsidies, and the destroy Medicaid (and, as a bonus, shift responsibility from Washington, D.C., to state governments.)
Here are the numbers to back up that paragraph: CBO says the tax cut is worth $541 billion. The long term deficit reduction totals $321 billion. Getting rid of insurance subsidies under the Affordable Care Act saves $408 billion. And recasting Medicaid as a block grant (as well as phasing out the expansion) is worth $772 billion.
Neither the Senate nor the House bill accomplish any health care goal. Neither bill will help people get insured. CBO says “in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026.”
And down the road when Medicaid reflects “lower spending” that too would “lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”
CBO says that even employer-based health care would shrink.
The crazy thing is that older people would be impacted the most by both the Senate and House approach. As the Center for Budget and Policy Priorities reports: “For people age 60 or older with income at or below the poverty line, individual-market premiums would consume at least 45 percent of their income. The share would be even higher in higher-cost states and for people at lower incomes.”
And that’s where geography impacts Indian Country. Alaska, for example, would have the highest cost in the nation. In fact: If you are 60 and trying to buy insurance … it’s basically unaffordable. Insurance costs will far exceed affordability in North Carolina, Oklahoma, Arizona, and Wyoming.
This is what’s so important to the Indian health system. Instead of getting funding from third-party billing — mostly Medicaid — the Indian Health Service would have to rely almost entirely on appropriations. The bottom line: There will not be enough money.
Remember both the House and the Senate want to convert Medicaid to a block grant. This is not just rolling back Obamacare, it’s returning health care to before Lyndon B. Johnson’s Great Society programs.
As the CBO puts it that will lower Medicaid participation by 9 million in 2020 and by more than 14 million by 2026. That’s a lot of people.
Most of the discourse about Medicaid centers on health care. But the program also provides long-term care to elders and disabled in assisted care or in-home care. The way this program works: You give up your assets (except Trust-based assets) and then the government promised to pay for your care. The Centers for Medicare and Medicaid say American Indian and Alaska Natives are a fast growing population that already rely on these services. “Between 2000 and 2010, the number of AI/AN adults 65 years or older increased by 40.5%, a growth rate that is 2.7 times greater than that of the overall population of older adults (all races) over the same 10-year period. The AI/AN elder population is projected to reach 1,395,000 by the year 2050; that’s a 3.5-fold increase from 2010 to 2050. In addition to studies that reflect the growing population of older AI/AN adults, other studies have revealed that AI/ANs suffer a disproportionately higher rate of disabilities including (lower body) functional disabilities that increase this population’s risk for falls, demonstrating a clear need for LTSS within this population.”
So if the Senate or House bill becomes law future services — as the need grows — will be sharply curtailed. And I can’t answer what will happen to people living in nursing homes now. If a state cuts the payment to a private facility, they could, in theory at least, ask people to leave. Let that sink in. People who have given up everything to live in an extended care facility could end up with no place to go. It will all depend on state legislatures or tribal budgets.
I am used to looking at both sides of any issue. I’m interested in views different than my own and exploring whether they have merit. As I wrote above: There is a conservative approach to health care that’s worthy of debate (I’d likely still come down on the side of single-payer.) But the House and Senate bills are not it. The only ideology at work is a tax cut; a painful tax cut at that.
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.
President Donald J. Trump’s legislative agenda has crashed. The Republican promise to quickly repeal and replace the Affordable Care Act on Friday failed to win enough votes from conservatives to make it so.
As House Speaker Paul Ryan said in a post-failure news conference: “Obamacare is the law of the land … We’re going to be living with Obamacare for the foreseeable future.”
For his part, President Donald J. Trump (who, of course, says he is not to blame for the loss) told The Washington Post, “the best thing politically is to let Obamacare explode.” He called the law, “totally the property of the Democrats,” and that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”
The president and his administration can do a lot to make that happen. The Secretary of Health and Human Services has extraordinary authority under the Affordable Care Act and they can use the power regulation to gunk up Obamacare. There will be many battles ahead on the regulation front. But, and this is the good part, states will have a say in this too. And there is the potential for a few states to engage in experiments that might improve the law. The question here: Is the administration willing to work to improve insurance options for Americans or are they more interested in punishing Democrats? (Yeah, I know, but there is a political upside to answering that question correctly.)
Here’s the thing: There is a crisis in insurance markets. And a bipartisan solution, meaning most Republicans working in partnership with Democrats, is the best way to reach a solution. There are three ways most of us get health insurance: our employers, public insurance such as Medicare and Medicaid, and the individual market when we buy our own insurance policies. Employer-based care is an accident of history (it’s a long story) and has been shrinking for the past fifteen years. Public health insurance has been growing (something the conservatives in Congress really object to because it codifies the notion that health care is a right) and under the Affordable Care Act individual insurance has increased from about 10.6 million people to 15.6 million.
Individual markets were troubled prior to the ACA’s enactment in 2010. One reason was that premiums for these policies were increasing more than 10% a year, on average, while the policies themselves had major deficiencies. They often excluded pre-existing conditions, charged higher premiums for people with health risks and for young women, placed limits on annual and lifetime benefits, or refused to renew policies for individuals who became sick. Many people who tried to buy plans were turned down. In 2010, an estimated 9 million adults who had tried to buy a plan in the individual market over the prior three years reported that they were turned down, charged a higher price, or had a condition excluded from their plan because of their health.
Thus “returning to the status quo ante — before the ACA — is not a viable option for the individual markets.”
The fix does not involve a “great mystery” according to Blumenthal and Collins. It’s simply making certain that more young people buy insurance to help pay for the higher health care costs of older Americans. The bigger the pool, the lower the cost. (Which, I should add, is why single payer works as a public policy.) One part of that solution is to increase the government subsidies so more people will buy in. That’s how the insurance market could work better.
More money for Indian health
Enough background. Where does Indian Country fit into this matrix? So there is a legal understanding that the Indian health system is federal obligation that stems from the promises made in treaties to provide doctors and nurses to reservation communities. Yet no Democrat nor Republican government has ever (as in ever) proposed fully-funding that Indian health system. Members of Congress often acknowledge the treaty responsibility, but have never followed those words with a budget.
But the Affordable Care Act separates insurance from health care delivery. It basically makes the Indian health system (both the government-operated Indian Health Service facilities, and those run by tribes and tribal organizations) medical care that’s mostly funded by federal appropriations and funded by insurance. Nationally that mix right now is about 80 percent appropriations and 20 percent insurance. But, and this ought to be huge, the insurance side of the equation under the Affordable Care Act is unlimited. That pool of money grows every time an eligible American Indian or Alaska Native signs up for insurance. This makes full-funding of Indian health a possibility. (Even better: Insurance collections remain at the local clinic or hospital. It really is the best kind of funding.)
There are three ways to add money to Indian health now.
First: More American Indians and Alaska Natives can sign up for Medicaid. The fact is there are many more people eligible than have signed up. The Kaiser Family Foundation estimates that nationwide one million American Indians and Alaska Natives lack coverage (depending on the state). Already Medicaid covers more than half of all children but 11 percent of those children remain uninsured.
Second: More American Indians and Alaska Natives can sign up for exchange plans under the Affordable Care Act. This is huge. According to healthcare.gov “If you get services from an Indian Health Care Provider, you won’t have any out-of-pocket costs like copayments, coinsurance, or deductibles, regardless of your income. (This benefit also applies to Purchased and Referred Care.).” And this benefit has essentially a permanent open enrollment.
Signing up for insurance (including plans from an employer) makes the Indian health system stronger for everyone. It’s the same principle as any insurance, the larger the pool of people who participate, the lower the cost.
Third: It’s time to make the case for Medicaid expansion in state governments that have said no. Now that the Affordable Care Act remains the law of the land there remains unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments such as imposed work rules). It’s a win for Indian Country when a state does this because it increases the number of people eligible for insurance. It’s a win for the state because Indian health patients are a 100 percent federal obligation so the state will be reimbursed by Washington.
Kansas is the latest state to consider expansion. And it’s likely that the Trump/Ryan failure to repeal and replace will push other state legislatures to consider this approach. Indian health patients would benefit from Medicaid expansion in Oklahoma, South Dakota, Texas, Maine, Mississippi, Nebraska, North Carolina, Utah, Idaho, Wisconsin, and Wyoming. A total of 19 states are on this list.
The dangers for Indian Country ahead
It’s easy to see the defeat of Trump and Ryan’s plan as a huge win. But it is also a warning sign. Make that a flashing red light with sirens. The problem is that Congress is deeply divided and cannot govern.
The same Republican divisions that killed their health reform plan will kill President Trump’s budget (thank you). But it will also make it nearly impossible to pass any kind of budget. As I have written before the best outcome might be a Continuing Resolution, a status quo budget.
An even bigger challenge will be for Congress to pass an increase in the debt ceiling. Secretary of Treasury Steven Mnuchin informed Congress that the United States reached its limit on March 15. The Treasury is now juggling accounts so that the government can continue to pay bills.
Conservatives in Congress (actually, just about every member of Congress) hate this part of governing. But a no vote here has enormous consequences for everyone’s finances. markets. There is an absolute requirement that Congress increase that borrowing authority. It will be a nasty fight.
Of course there is one solution: Create a new coalition of Republicans and Democrats. This works in state legislatures across the country (most recently Alaska). It takes 216 votes to pass legislation in the House so a working body of 22 or so Republicans, plus the 194 Democrats in the House, could accomplish a lot together. But that would mean rethinking the role of party politics. And governing.