Latest attack on Medicaid also sabotages Treaty Rights, Indian health programs

Agency Says Indian Health Should Not Be Exempt From Medicaid Work Rules Because They Are ‘Race-Based’

Mark Trahant / Trahant Reports

The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.

A story in Politico Sunday raised the issue. It said “the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. ‘HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,’ according to a review by administration lawyers,” Politico said.

The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians. “Our political relationship is not based upon race.”

“The United States has a legal responsibility to provide health care to Native Americans,” Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation, told Politico. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.

Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).

But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.

Other states report similar increases. Kaiser Family Foundation found that in Arizona, one tribally-operated health system reported that about half of visits were by patients covered by Medicaid in 2016. And, an Urban Indian Health Program, reported that its uninsured rate at one clinic fell from 85 percent before the Affordable Care Act to under 10 percent.

Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). In Alaska more than two-thirds of those dollars are spent on private sector doctors and hospitals through purchased care for Alaska Native patients. And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.

A recent report by Kaiser Health News looked at Census data and found that 52 percent of residents in New Mexico’s McKinley County have coverage through the Medicaid.  That’s the highest rate among U.S. counties with at least 65,000 people. “The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program,” Kaiser reported. Most of McKinley County is located on the Navajo and Zuni reservations.


Kaiser Health News said Medicaid has opened up new opportunities for Native patients to “get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.”

However the growth of Medicaid is resulting in unequal care for patients in the Indian health system. The benefits in some states, including those that expanded Medicaid under the Affordable Care Act, are more generous. Other states not only refused to expand Medicaid and have been adding new restrictions such as requiring “able-bodied” adults to have their Medicaid eligibility contingent on work.

But the Indian health system — the federal Indian Health Service and tribally and nonprofit operated programs — are in a special case because there is a 100 percent federal match for most services. So states set the rules, but do not have to pay the bill. (Medicaid is often the second largest single item in a state budget behind public schools.)

Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.

Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.

A letter from the Tribal Technical Advisory Group for Medicare and Medicaid said American Indians and Alaska Natives “are among the nation’s most vulnerable populations, and rely heavily on the IHS for health care. However, the IHS is currently funded at around 60 percent of need, and average per capita spending for IHS patients is only $3,688.” The latest per person cost for health care nationally is $10,348 (totalling $3.3 trillion, nearly 20 percent of the entire economy).

The tribal advisory group said it is “critically important” that there be a blanket exemption for IHS beneficiaries from the mandatory work requirements.

A report in September by the Kaiser Family Foundation showed that the majority of American Indians and Alaska Natives on Medicaid already work, yet continue to face high rates of poverty. It said over three-quarters of American Indians and Alaska Natives are in working families, but that’s a gap of about 8 percent compared to other Americans (83 percent).

The Trump administration’s characterization of tribal health programs as “race-based” is particularly troubling to tribal leaders because it would reverse historical precedence.

A memo last month from the law firm of Hobbs, Straus, Dean & Walker said the Centers for Medicare and Medicaid Services “has ample legal authority to single out IHS beneficiaries for special treatment in administering the statutes under its jurisdiction if doing so is rationally related to its unique trust responsibility to Indians. Under familiar principles of Indian law, such actions are political in nature, and as a result do not constitute prohibited race based classifications. This principle has been recognized and repeatedly reaffirmed by the Supreme Court and every Circuit Court of Appeals that has considered it, and has been extended to the actions of Administrative Agencies like the Department of Health and Human Services even in the absence of a specific statute.”

Mark Trahant is editor of Indian Country Today. He is a Shoshone-Bannock tribal citzen. On Twitter: @TrahantReports Cross posted on Indian Country Today.

(The National Congress of American Indians is the owner of Indian Country Today and manages its business operations. The Indian Country Today editorial team operates independently as a digital journalism enterprise.)

 

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

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Seriously? States complain to Senate about the burden of Native health care #IndigenousNewsWire

 

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Medicaid has worked under the Affordable Care Act, reducing the number of uninsured in Indian Country. (Kaiser Family Foundation)

Mark Trahant / Trahant Reports

First: A fantasy. Wouldn’t it be cool if once, just once, there was a debate in Congress that could only be decided by a vote that benefits Native people? I don’t know. Something like, “I won’t vote for any bill unless it fulfills the treaty obligations that the United States has promised Native people.” It could happen, right?

Well the current Senate debate on health care has a twist on this pipe dream. States are complaining about the burden, that’s right, the burden of Native American health care. So here’s the deal now: When an eligible Native American gets services through the Indian Health system, the cost is a 100 percent federal obligation. But, if that person or family is on Medicaid they could also get care from any provider. In that case the state would have to pay its share of the cost as it does for any other citizen. 

As the Kaiser Family Foundation points out: “Just as with other eligible individuals, AIANs who meet state eligibility standards are entitled to Medicaid coverage in the state in which they reside. AIANs may qualify for Medicaid regardless of whether they are a member of a federally-recognized Tribe, whether they live on or off a reservation, and whether they receive services (or are eligible to receive services) at an IHS- or Tribally-operated hospital or clinic. AIANs with Medicaid can access care through all providers who accept Medicaid for all Medicaid covered benefits. As such, they have access to a broader array of services and providers than those who rely solely on IHS services for care. Moreover, Medicaid has special eligibility rules and provides specific consumer protections to AIANs.”

The Graham-Cassidy plan would change that by making this cost a 100 percent federal obligation. States would be off the hook.

This is where it gets screwy. There are legitimate state concerns — basically it’s a complicated maze to figure out a patient’s path and how the money flows. But it’s still a benefit for states because Native people are citizens and so a full-federal match for most costs is a net gain.

South Dakota (a state that did not expand Medicaid) would gain $795 million from a block grant, but would still lose a significant share of its health care funding between 2020 and 2026, according to the Kaiser Family Foundation.

But (and I can’t believe I am writing this sentence) Sen. Mike Rounds told South Dakota Public Radio that the state would get a “large chunk of funds would cover 100 percent of the healthcare costs for Native Americans who receive Medicaid. Right now, the Affordable Care Act requires a state match.”

This is a fraction of what the state will lose — so this is a straight-faced claim that Native health care is a burden. (Remember this cost is only for tribal citizens who do not use Indian Health Service, a small slice of the population.)

South Dakota is not alone. A state legislative report in Arizona estimated that the state will lose a third of its Medicaid funding ($3.8 billion now, $4.9 billion by 2020). But according to the Capitol Media Services of the Arizona Daily Star, Gov. Doug Ducey dismisses those losses because the numbers are not from an independent review. Yet there is not enough time for the Senate to get a Congressional Budget Office assessment by the September 30 deadline. So this is all being made up on the fly.

“Christina Corieri, the governor’s health policy advisor, said one of those provisions would free the state of its financial obligations to share the cost when Native Americans get care at non-Indian Health Service facilities,” the Arizona Daily Star said. Corieri “could not say what that number would save Arizona other than ‘it’s a very large number.'”

Seriously?

There are roughly 130,000 Native Americans in Arizona on Medicaid, about 6 percent of the state’s version of Medicaid, the Arizona Health Care Cost Containment System. And of that, we’re talking about a subset, those who choose to go outside of the Indian health system. It’s just not a very large number. Period.

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

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

Mark Trahant / Trahant Reports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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And just like that … it’s back to square one for healthcare, budgets and taxes

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Trahant Reports

So the Senate (and therefore the House) plan to repeal the Affordable Care Act, destroy Medicaid as we know it, and shell out billions in tax cuts for the wealthy is no more. Monday night Utah Sen. Mike Lee and Kansas Sen. Jerry Moran said they would vote against even debating the Senate healthcare bill. So it was defeated by unanimous opposition of Democrats, the Senate’s most conservative members, and Republican Maine Sen. Susan Collins who opposed the Medicaid cuts.

“Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” McConnell said. “So, in the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care.”

So plan B, supported by President Donald J. Trump, is a repeal of the Affordable Care Act without a plan to figure out what a replacement looks like. Trump tweeted: “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!”

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But that will not be easy either. The idea of a repeal without a plan is crazy when you’re talking about such a huge chunk of the economy. And many Republican senators have already said so. As I have been writing (often) the problem is that the Republicans do not have a governing majority.  They are split. Hopelessly. They really needed their healthcare bill (something they all campaigned on) as a glue to keep their coalition together. Now it gets tougher.

There are practical problems with a “just repeal” approach too. The Senate language has to be narrowly drafted on fiscal issues in order to meet the test of a budget reconciliation bill. This process is arcane but it eliminates any filibuster by Democrats. It also means there will be no outright repeal (which would require 60 votes to stop the filibuster) just the budget applications of the Affordable Care Act. Complicated, right? The budget the Senate is working off of requires a billion dollars in savings from any repeal.

Even this will be tricky. First there will need to be consensus for a new vote to bring up the House bill. (It’s called a Motion to Proceed.) That measure would be open to amendments, including the repeal provision. (The president must have just been informed about this problem. He tweeted: “The Senate must go to a 51 vote majority instead of current 60 votes. Even parts of full Repeal need 60. 8 Dems control Senate. Crazy!”

That’s just one of the crazy, sticky issues for a repeal amendment (not to mention any other amendment that surfaces). Language that would lift the individual mandate to purchase insurance could also eliminate coverage for pre-existing conditions — and doing that would make health insurance unworkable for the companies. This could cause widespread market panic.

Depending on how it’s written, an outright repeal could impact Indian Country because it could include the Indian Health Care Improvement Act. The Senate and House plans were careful to sidestep that issue. This is a blank slate. A political danger zone.

However the Senate’s political implosion also shows how difficult it will be for the House and Senate to pass a budget, lift the debt ceiling, and get on with other important work.

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The House released its budget plan Tuesday morning and it sets its course for using the reconciliation process too. (In theory: Life is so much easier if you don’t need votes from Democrats.) That budget bill will be marked up on Wednesday and it will be tough to win a majority of Republicans. It has every controversial Trump project included, money for a border wall, cuts to social welfare programs, including Medicare. Some Members don’t like the increases in military spending coupled with sharp budget cuts for domestic programs, more than $200 billion worth. (It will be up to committees to figure out where the cuts would happen.) Other Members think there ought to be more cuts. And to make this process even more complicated, the House budget includes tax provisions. That only makes the task ahead more difficult.

Buckle your seat belts. — Mark Trahant

 

 

 

 

 

House bill skips Indian health care; but has narrow path to actually become law

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Sen. Lisa Murkowski says Alaska should have the option to keep Medicaid expansion under any Affordable Care Act replacement. Three Republican members of the Senate have said as much. Republicans only have three votes to spare to pass the measure. (Senate photo)

Mark Trahant / Trahant Reports

I wrote a couple of days ago that the House bill doesn’t mention a word about the Indian Health Care Improvement Act. True enough. Because, it turns out, the proposed replacement for Affordable Care Act is not a complete repeal. The current law would remain in tact.

“The two proposed bills do not repeal the ACA. They leave in place the ACA’s titles affecting Medicare, quality of care, program integrity, biosimilars, workforce reform, the Indian Health Service—indeed virtually all of the ACA except for its insurance affordability provisions, individual and employer mandates, taxes, and Medicaid reforms,” writes Timothy Jost in the journal Health Affairs.

This idea is important. Instead of a repeal, the Republican leadership took the framework of the Affordable Care Act. Then the House authors wrote adjustments to Medicaid spending, the way the bill is paid for, how people get help to buy insurance, and along the way added a few gold coins for insurance company executives. (Compare the bills here in this Kaiser Family Foundation graphic.)

I like the way Jim Roberts described the process on his Facebook page: “Take the ACA, tear out the pages that have been repealed, and see what’s left on the table. Its pretty easy to figure out. Its like cutting the face of an ex-spouse out of the family photos! The entire family photo is still intact and everyone knows who that cutout is. Its Obamacare … You can cut Obama out of the picture, but guess what people, He’s still there!” Jim Roberts is a Senior Executive Liaison for Intergovernmental Affairs at Alaska Native Tribal Health Consortium and a long time expert analyst on how health care policy impacts Indian Country.

So this is the problem I have writing about the bill. Do you go into detail about how bad it is? I could easily type 10,000 words just on Medicaid. Or is it better to focus on the politics, because the odds of this package becoming law are slim. That’s where I headed.

Here is the short version of the politics: Two committees have moved the legislation forward through the House. The House Budget Committee will consider the bill before it goes to the full House for a vote. Then, if the House has enough votes, on to the Senate for consideration.

The Republican Party is divided by serious differences of opinions about health care reform and the nature of government. Conservatives do not believe that health care is a right. They see it as an individual responsibility (Or say they do. If they really believed that, we’d get rid of the employer-based system that insures most people. But that’s another story). This group wants Planned Parenthood defunded. It doesn’t even like the idea of insuring family planning of any kind.

On the other side of the divide are practical Republicans who represent states that have made progress insuring more people because of Medicaid expansion. This group of legislators, mostly in the Senate, see this bill as a way to flip the cost of health care to the states. (Or allow conservative states to do nothing.) The House plan would keep Medicaid running sort of as is between now and 2020 and then turn it into a capped program.

The National Indian Health Board says the House bill would keep in place the 100 percent federal reimbursement to states for American Indians and Alaska Natives patients who use the Indian health system.

One huge problem with capping Medicaid cost is that it works backwards: Because when Medicaid is most needed, such as during a recession, then states have less money available to spend on health care. So people would not get the help they need, when they most need it.

Alaska Sen. Lisa Murkowski spoke at the state legislature about Medicaid last month. According to the Alaska Dispatch News, she said Medicaid strengthened Alaska’s Native health care system and reduced the number of uninsured people visiting emergency rooms. “So as long as this Legislature wants to keep the expansion, Alaska should have that option,” Murkowski said. “So I will not vote to repeal it.” At least three Senators have said they would vote no unless Medicaid is protected.  And Republicans cannot lose more than three votes in the Senate for the bill to pass. (According to a new report by the Center for Budget and Policy Priorities Alaska would lose the most under the House plan for tax credits, a whopping $10,243.)

Another deal breaker for many members is the nearly unified opposition from the medical establishment. The American Medical Association “is concerned with the proposed rollback of Medicaid expansions, which have been highly successful in providing coverage for lower income individuals. The AMA is also concerned that changes to Medicaid could limit states’ ability to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction.”

The challenge paying for opioid treatment will be a factor because it’s a crisis in so many communities across the country. The House plan leaves this up to the states. Without funding.

Nonetheless President Donald J. Trump is trying to make his first deal. And he is working it hard. He’s trying to get conservatives to support his deal despite their philosophical misgivings. But if the president gives any more ground, then more moderates will be “no” votes. Trump’s strategy seems to be daring conservatives to vote no. He will demand a party-line vote and say, basically, this is the best deal conservatives are going to get. It’s also why the president and House Speaker Paul Ryan are trying to move fast. Every day they wait, the opposition has more resources to counter that strategy.

Here is what to watch for in the days ahead. Will conservative interest groups such as Heritage Action, Club for Growth, and Americans for Prosperity, “score” the vote? That’s a record that groups use to rate how conservative are members of Congress. Going against this vote could mean less money, support in primary elections, and less conservative street cred.

Meanwhile Rep. Tom Cole, R-Oklahoma, has introduced a just-in-case bill to reauthorize the Indian Health Care Improvement Act. That measure will be ready in case Congress repeals the Affordable Care Act outright (which is what the conservatives argue is the back-up plan).

Stay tuned.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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Three things you need to know about the House’s Powerball Health Care Plan

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Trahant Reports

There’s a  bad joke that goes like this: What’s your plan to pay for the high cost of health care? No worries. I’ll win the Powerball.

Except the new Republican plan to repeal and replace the Affordable Care Act ends that option (and somehow takes it seriously). There are detailed instructions to prevent lottery winners from getting Medicaid coverage. That probably fixes a huge problem that we never heard about before.

It’s funny that the House Repeal and Replace plan (The American Health Care Act) includes several pages on that non-problem while the draft doesn’t even get around to mentioning the Indian Health Care Improvement Act.

But don’t get too worked up about this miss. Here are the three things you need to know about the House plan.

First: This plan is an urgent call for American Indians and Alaska Natives to sign up for Medicaid, children’s health insurance, or the Exchange Plans. This plan makes it clear that there is time to sign up as an act of defiance and that adds new money to the Indian health system.

Second: There will be fewer people covered under the House plan. We won’t know the numbers until it’s scored by the Congressional Budget Office. But it’s clear fewer people will be covered. And to top it off the plan will cost older Americans more. A lot more. Insurance companies would be allowed to charge older people five times as much as young people. (And to make that more odd: Older people are a GOP constituency.) There is no requirement that people carry insurance, but if there is a lapse in coverage, the cost goes up.

Third: The politics are a lot like President Trump’s election plan. Tick off everybody. Create chaos and hope there are enough votes left to win. I don’t think so. Conservatives already don’t like the provision to include tax credits. And state governments aren’t happy with a punt on Medicaid expansion (keep it until 2020 and then cut the heck out of program). And to top it off, the White House comment is at best only mild support. This plan is politically dead. A plan that looks so much like Obamacare is going to be really difficult to sell as change. It keeps, for example, the essential health benefits package, including family planning and maternity benefits. Yet at the same time it ends funding for Planned Parenthood. That means two very different constituent groups will be opposed. Finally the tax credits are complicated and unfair. They are based mostly on age. So someone under 30 gets a credit of $2,000 while someone who’s 60 or older could get $4,000. Once again that’s contradictory logic. Take from old people. Then give something back. Good politics? We shall see.

I just don’t see how this plan — or anything like it — gets out of the House of Representatives. Let alone become the law. So don’t get too excited. You’re better off buying a Powerball ticket. — Mark Trahant

 

 

 

Federal Indian programs labeled as ‘high risk,’ but real solutions need Congress

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GAO calls three federal Indian programs “high risk,” the Indian Health Service, the Bureau of Indian Education and the Bureau of Indian Affairs. (GAO video.)

It’s impossible to defy gravity #NativePolicy

Mark Trahant / Trahant Reports

Federal Indian programs have been added to the “high-risk” category by the Government Accountability Office. That designation could not come at a worse time.

The details. This is how the GAO defines its high risk identification: “The federal government is one of the world’s largest and most complex entities: about $3.9 trillion in outlays in fiscal year 2016 funded a broad array of programs and operations. GAO’s high-risk program identifies government operations with greater vulnerabilities to fraud, waste, abuse, and mismanagement or the need for transformation to address economy, efficiency, or effectiveness challenges.”

The GAO said it added federal Indian programs to its high risk category because “we have found numerous challenges facing Interior’s Bureau of Indian Education and Bureau of Indian Affairs and the Department of Health and Human Services’ Indian Health Service in administering education and health care services, which put the health and safety of American Indians served by these programs at risk. These challenges included poor conditions at BIE school facilities that endangered students, and inadequate oversight of health care that  hindered IHS’s ability to ensure quality care to Indian communities. In addition, we have reported that BIA mismanages Indian energy resources held in trust and thereby limits opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities.”

More from the GAO: “Congress recently noted, ‘through treaties, statutes, and historical relations with Indian tribes, the United States has undertaken a unique trust responsibility to protect and support Indian tribes and Indians.’ In light of this unique trust responsibility and concerns about the federal government ineffectively administering Indian education and health care programs and mismanaging Indian energy resources, we are adding these programs as a high-risk issue because they uniquely affect tribal nations and their members.”

The three agencies are lumped together as one in this report, yet the causes of what makes the agencies high risk are considerably different, requiring solutions that go well beyond what the agencies themselves can accomplish.

So let’s break it down.

First: GAO complains that the BIA has a problem quickly approving energy projects. This is Congress’ favorite problem. Congress can’t wait to solve this one by making the approval process faster than filling your car with a tank of gas. But the solutions ahead will also have unintended consequences for the very notion of trust lands, tribal control of energy projects, and the challenge of global warming. What happens when a tribe says, “hell no!” to say, the Keystone XL pipeline? That is a policy question that this Congress has all but answered.

Next the GAO says the Bureau of Indian Education “improves how it manages Indian education … including that Indian Affairs develop a strategic plan for BIE that includes goals and performance measures for how its offices are fulfilling their responsibilities to provide BIE with support; revise Indian Affairs’ strategic workforce plan to ensure that BIA regional offices have an appropriate number of staff with the right skills to support BIE schools in their regions; and develop and implement decision-making procedures for BIE to improve accountability for BIE schools.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Only hiring for BIE schools is easier said than done and the decision-making process is complicated by community priorities.

There is another problem at play: Conservative think-tanks have targeted BIE as operating “failing schools” and would replace them with a whacky scheme to create Education Savings Accounts.  (Previous: Day One. Dramatic restructuring of government.) This whole notion is written by people who have no understanding of the geography of Indian Country or the makeup of the Native students. The BIE has unique challenges and there are many, many improvements that could be made. So adding to this discourse a GAO high-risk warning is, well, not helpful.

The third high-risk agency identified by the GAO is the Indian Health Service. The report says: “To help ensure that Indian people receive quality health care, the Secretary of HHS should direct the Director of IHS to take the following two actions: as part of implementing IHS’s quality framework, ensure that agency-wide standards for the quality of care provided in its federally operated facilities are developed and systematically monitor facility performance in meeting these standards over time; and develop contingency and succession plans for replacing key personnel, including area directors.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Again, it’s not as if the IHS is not trying to hire people. The problem is funding and a hiring process that is both cumbersome and required by law.

What I don’t get is why the GAO doesn’t see that the IHS mission has changed dramatically. One part of the agency is a funding mechanism, directing resources to tribal, non-profit, and urban health care facilities. The report alludes to that fact with this recommendation: “To help ensure that timely primary care is available and accessible to Indians, IHS should: develop and communicate specific agency-wide standards for wait times in federally-operated facilities, and monitor patient wait times in federally-operated facilities and ensure that corrective actions are taken when standards are not met.” The key phrase here is “federally-operated” because many of the tribal and nonprofit centers have solved this problem. GAO should have said this and focused on what works and why.

Another GAO recommendation about IHS might be the most tone deaf. It says, “we recommend that IHS realign current resources and personnel to increase capacity to deal with enrollment in Medicaid and the exchanges and prepare for increased billing to these payers.”

Clearing my throat here. Umm. Congress is going in exactly the opposite direction. The serious questions — the ones that Congress ought to be answering — are how much will it cost IHS when Medicaid is turned into a block grant? What replaces Medicaid expansion funding at the local unit level? And, will states even fund a federal health care delivery system?

The GAO report makes a big deal about IHS developing a fair method for how it spends money on purchased and referral care. What the report should have said is that Congress is to blame. The problem is not the architecture; it’s the funding. No federal agency. No state agency. Hell, no private medical system spends less than the Indian health system. The real problem here is that it’s impossible to defy gravity.

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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Cole says replacement of ‘Obamacare’ should include Indian health law

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Trahant Reports

Rep. Tom Cole, R-Oklahoma, speaking on C-SPAN Friday morning, said any replacement of the Affordable Care Act should include keeping the Indian Health Care Improvement Act. Cole said this was included in Obamacare as an incentive for Democrats to support the measure.

That’s an interesting interpretation. The reauthorization of the Indian Health Care Improvement Act was blocked by Republicans as well as President Bush. As The New York Times said in 2008: “The nation has clear legal and moral obligations to protect the welfare of Native Americans. Congress must rebuff President Bush’s veto threat and vote overwhelmingly to strengthen and reauthorize the Indian Health Care Improvement Act.”

A year later Democrats rolled the Indian Health Care Improvement Act into the Affordable Care Act because the votes were not there to pass the measure on its own.

That said: It’s important and essential that Cole is willing to argue for a new Indian Health Care Improvement Act as part of Obamacare replacement. (Previous: Tom Cole forges the GOP case for tribal sovereignty.) — Mark Trahant

#NativeVote16 – Trump’s Republicans will champion more coal this election

 

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Delegates will vote on the Republican platform on Monday.

 

Mark Trahant / TrahantReports

It’s time for the Republican Party and its soon-to-be nominee Donald J. Trump making their best case for winning the White House and Congress.

This will not be an election where the color gray will be debated. The differences on issues between Republicans and Democrats are stark. On Monday convention delegates will vote on the party platform, the document that outlines the party’s stand on major issues. Wyoming Sen. John Barrasso, who is chairing the platform committee, told National Public Radio, “this was going to be a conservative platform, reflecting the views, and the values, and the vision of the Republican party, and I think we stayed true to that.”

So the draft of the document says the bible should be a guide when legislating and laws “must be consistent with God-given, natural rights.” The New York Times says the draft also encourages the teaching of the Bible in public schools because a good understanding of its contents is “indispensable for the development of an educated citizenry.”

According to the Times, Trump’s operators have not played much of a role in the writing of the platform at all. That said: “Another tweak to the platform’s language on immigration will also please Mr. Trump: Though the initial draft called for building a “physical barrier” along the United States border with Mexico, that passage was amended yesterday to call specifically for a wall.”

Republican platforms often include statements of policy on federal-Indian policy. And much of the party’s focus right now is on energy policy. Trump said in Montana and North Dakota this summer that he would remove barriers to oil and coal production to create more jobs.

Rep. Ryan Zinke, R-Montana, will speak at the convention. “In communities like Colstrip and other small communities, coal and other natural resources are the only answer,” Zinke said last month. “For the great coal nation of the Crow, there’s treaties. The treaties specifically state the United States shall not interfere with their destiny if they choose to mine their coal. As a sovereign nation they have every right to export their coal as they choose. But when the government gets in the way, as we have done, we have violated a treaty.”

I am not sure where that line in the Crow Treaty of 1868 is “specifically” found. Literally. (Pronounce “literally” as if you are Rob Lowe’s character in Parks and Recreation.)

In this election cycle, Republicans are carrying the banner for more coal. As the draft platform puts it:  Coal is “an abundant, clean, affordable, reliable domestic energy resource.”

The problem, however, is that a Republican victory will not bring coal markets back to life. Natural gas is cheaper. Shipping coal to China is problematic (and Chinese consumption is declining anyway) plus every day more renewable sources come on line. The future is doing something else instead of coal as the “only answer.” And, if a kicker is needed, it’s this: Northwest tribes have also asserted their treaty rights to fish for salmon. In waters that are not polluted by coal dust. (Previous: The power of what if? Paying tribes to leave coal in the ground.)

Another draft plank in the Republican platform impacts treaty rights and that’s the call for Congress to  “immediately pass universal legislation providing the timely and orderly mechanism requiring the federal government to convey certain federally controlled public lands to the states.”

As Oregon Public Broadcasting puts it: That’s a message with a familiar tone. “Throughout the refuge occupation, Ammon Bundy and other militant leaders said that the federal government had no right to control public lands.”

Tribal rights to hunt and fish on public lands are often included, yes, even, specifically in treaty language. So any transfer of those lands ought to go to the tribes whose land it was first. As a resolution by the National Congress of American Indians says: Federal lands should be “considered for disposal or transfer to the nearest federally recognized Indian tribe for direct sale at the appraised value prior to subjecting such land to the competitive bidding process.”

Then that’s not the only troubling idea that will be debated Monday. As The New York Times said: “… nearly every provision that expressed disapproval of homosexuality, same-sex marriage or transgender rights passed. The platform calls for overturning the Supreme Court marriage decision with a constitutional amendment and makes references to appointing judges ‘who respect traditional family values.'” Plus just about every cause that the most conservative elements of the party think critical.

How important are party platforms? Are they treaties with voters?

“As a rule, platforms don’t seem to matter much,” wrote Dan Balz in The Washington Post. “Few voters will search, find and read through the many pages of party doctrine — for either the Republicans or the Democrats, whose newly drafted platform reflects a significant left turn. Trump, as with some other previous nominees, will probably ignore it and carry on his campaign as he wishes. The document will be presented early next week, ratified and put on a shelf.”

Still this document reflects the many divisions that are found in today’s Republican Party. Instead of looking for solutions, say, on climate change, perhaps including practical, conservative approaches, the document reduces governing to slogans. There is no climate change, only coal. This reflects the best GOP case.

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