First, do no harm. What it takes to manage the Indian health system

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Robert Weaver, Quapaw, is President Donald J. Trump’s nominee to head the Indian Health Service. Weaver’s background is insurance, not health care delivery. (Weaver Group photo)

 

Mark Trahant / Trahant Reports

What qualifications are needed to manage (and possibly reform?) the Indian health system? It’s Indian Country’s largest employer with more than 15,000 on the payroll and many, many more people who work in health care for tribes, non-profits and other related agencies. The IHS budget is $6.1 billion. Yet it’s also the least funded national health care delivery system, operating in a political atmosphere where critics ask, why can’t it do more?

The Wall Street Journal published a story last week that raised questions about Robert Weaver, the Trump Administration’s nominee to head the Indian Health Service. The Journal challenged Weaver’s history at St. John’s Regional Medical Center in Joplin, Mo., from 1997 to 2006. However it quoted Jennifer Talhelm, an HHS representative, saying “any suggestion Mr. Weaver is unqualified to run IHS is a pure act of character assassination.”

Weaver is a member of the Quapaw Tribe of Oklahoma.

A few facts: Weaver will be the least educated director of the Indian Health Service ever. If confirmed, Weaver will the tenth permanent director. All but one prior to Weaver have been physicians, most with multiple degrees in public health, science, and health administration. One former director, Robert McSwain, was not a medical doctor, but he was a longtime health manager and holds a Master of Public Administration from the University of Southern California. On his CV, Weaver lists his education at Missouri Southern State University in International Business with an emphasis in Marketing and Accounting; Minor in Spanish; Minor in Vocal Music & Piano. However the Journal reported that he was seeking a degree and did not graduate.

Weaver’s background is insurance. In a September 2016 profile in Native Oklahoma magazine, Weaver said, “We have Native Americans who are brilliant — geniuses — at gaming, but where are the Native American geniuses at insurance? It’s the second-largest cost we pay other than payroll. Yet it just goes to the wayside.” He told the magazine that his business saved the Quapaw Tribe more than $5 million a year.

“I try to be a translator for tribal leaders to understand this convoluted, difficult-to-understand, most of the time full of lies and deception industry, into ‘this is what it is. This is what your choices are.’ I get it,” he told Native Oklahoma.

Perhaps the Indian Health Service should be led by someone with an insurance background. It would surely help if the agency could come up with a better funding model, including a mix of insurance funds (third-party billing in IHS-speak.)

But there are three problems that ought to be clearly addressed through the Senate confirmation process.

First there is the problem of scale. Weaver would jump from managing a $10 million a year small business — one where he can hire and fire at will — to running a $6 billion agency where personnel decisions are made by folks higher in the chain of command at the Department of Health and Human Services or even as a favor to a United States Senator. And firing? Just one such action could take up more time than the three years left in this administration. And that’s the easy stuff. The agency’s operations are complicated by Congress, law, regulation, tribal relations, the Veterans Administration, Medicare, Medicaid, and private insurance.

To his credit, Weaver has been outspoken about the underfunding of the Indian health system. (Question: Will he say so again in his confirmation testimony?) In a paper he wrote a year ago, Weaver said: “Healthcare is a treaty right for all Native Americans. The method of delivering healthcare for Native Americans is the Indian Health Service system established through the Federal Government. The Federal Government allocates funds to the IHS system each fiscal year. This allocation has been and continues to be inadequate to meet the healthcare needs of Native Americans. Currently it is underfunded by thirty billion dollars annually.”

That figure of $30 billion would eliminate the funding disparity for Indian health. (The National Congress of American Indians has published a plan to make that so over a decade.)

The second problem is how to articulate the Indian health story. This is a problem of “duality,” two competing ideas. On one hand you have some significant health and management problems such as those identified in the Great Plains by The Wall Street Journal. On the other hand you have a system that is innovative and includes models of excellence (such as clinics in the Pacific Northwest or the Alaska Native Medical Center.) One story is told. The other less so. I am convinced that a fully-funded system will only happen when we tell both stories. The narrative of failure is not an incentive to invest more money.

The third problem is the Affordable Care Act and Medicaid. Weaver wrote that the law works for Native Americans but overall it was a failure. “We now see that it did not provide health insurance for the forty million uninsured Americans identified as the target market in 2008, it is not affordable for those who were pulled into the ACA system, and the out of pocket maximums associated with the plan effectively make access to healthcare unattainable,” he wrote. The first part of that sentence is factually incorrect. The uninsured rate dropped from 20.5 percent in 2013 to 12.2 percent in 2016, a 40 percent decline. You can argue about the cost of that insurance, but it’s complicated because the ACA required minimum standards for insurance, covering such things as women’s health. All of the Republican plans are designed to save money by getting rid of those standards.

Of course in the Trump era there’s probably not a candidate for any public office who champions the ACA.

But I also don’t see any Medicaid experience in Weaver’s background and that is an expertise area that is critical. Some of the medical, treatment, and ethical issues are extraordinarily complex. They will require a solid team to help consider all of the alternatives that have life and death consequences. (So, if confirmed, he’ll need a lot of help.) Oklahoma is not a Medicaid expansion state, so there would not be a lot of experience in squeezing every dollar from Medicaid by making more people eligible or rethinking the coding of costs. The public insurance of Medicaid (and Medicare) now total $1.05 billion of the IHS budget, but it could be a lot more.

Weaver could use his expertise to help tribes improve insurance for tribal members and employees — and that could boost funding for IHS. Private insurance is now only about $110 million of the agency’s revenue.

So what are the qualifications necessary to run the Indian health system? I have a bias. I have met some of the great physicians who ran the agency. I remember Emery Johnson’s passion and thoughtfulness about what IHS could be. I’d even argue that IHS has had remarkable leadership since its founding. So the standard, for me, at least, is quite high. There are also two Native women who have run state health agencies — an ideal background for managing the IHS. There is a lot of talent out there.

But the Trump administration likes the idea of shaking up government. And, appointing someone to run the IHS with a very different background, does just that. Perhaps Weaver brings a new way of thinking and managing. Then again we would do well to remember the latin phrase that medical doctors learn early in their training, Primum non nocere. It means: First, do no harm.

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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(Note: I use the phrase, Indian health system (lower case) unless I am specifically talking about the agency. My reason is that the narrative of a government-run health care agency, the Indian Health Service, doesn’t reflect what most of what the agency does now. The funding mechanism that supports tribes and non-profit health care agencies is the largest part of the system.)

 

Tax cuts? Hell. No. Thousands of American Indian and Alaska Native children will lose health insurance

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Mark Trahant / Trahant Reports

Congress has yet to reenact the Children’s Health Insurance Program and states will soon run out of funds to prop up the program. That will mean that thousands of American Indian and Alaska Native children will lose their health insurance. And, the result is the Indian Health Service will have to stretch its already thin dollars to try and cover the budget hole.

The Children’s Health Insurance Program expired Sept. 30. This federal program insures young people and pregnant women who make just enough money not to qualify for Medicaid (but can’t afford private insurance). The idea is to make sure that every child has the resources to see a doctor when they are ill.

It’s hard to break down precise numbers because agencies lump funds from the Children’s Health Insurance Program or CHIP into Medicaid data. But we do know that the law worked really well. We also know there are more than 216,000 children that have health insurance because of Medicaid and the CHIP. Indeed, Native American children rely on Medicaid and CHIP at much higher percentages than other population groups. A study by Georgetown reported that 54 percent of American Indian and Alaska Native children were enrolled in Medicaid or CHIP as compared to 39 percent of all children. “Even though much progress has been made in extending Medicaid coverage to American Indians and Alaska Natives, the uninsured rate for American Indian and Alaska Native children and families remain unacceptably high,” the report said.

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Source: Georgetown University Health Policy Institute. Coverage Trends for American Indian and Alaska Native Children and Families.

Overall the uninsured rate among non-elderly American Indians and Alaska Natives fell by 7 percentage points from 24 percent to 17 percent, according to the Kaiser Family Foundation.

This is a big deal and here’s why: The Indian Health Service is a health care delivery operation that works best when insurance (third-party billing in government-speak) pays for the medical costs. Medicaid, CHIP, Medicare, and other third-party billing now accounts for 22 percent of the IHS’ $6.15 billion budget.

But if Children’s health is no longer funded (because Congress did not reauthorize the legislation) then the Indian Health Service will have to make up the difference. That means taking money away from other patients and programs. It will be a critical problem for clinics because by law dollars from third-party billing (or Medicaid and CHIP) remain local.

Alaska is the state most impacted by Congress’ failure to act because two-thirds of the children in the Native health system are covered by Medicaid or CHIP. Other states where there will be significant hits: Montana, North Dakota, South Dakota, Washington, New Mexico, Oklahoma, North Carolina, and California.

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Source: Georgetown University Health Policy Institute

The House of Representatives passed a CHIP reauthorization in early November. But that bill included a $6.35 billion budget cut to other health programs, including the Prevention and Public Health Fund, which provides money for vaccines, smoking cessation, and other initiatives to improve public health. The House would also ban lottery winners from being insured by Medicaid, tighten the timetable for people to sign up, and to change other rules.

It’s unlikely the Senate will agree. But the Senate is not moving quickly to pass its own legislation. The Senate is too busy working out tax cuts that will benefit large corporations and the very wealthy. (Previous post: What matters? Tax fight is about seven competing values.)

Across the country, some nine million low- and middle-income children rely on CHIP for health coverage. And, according to The Hill newspaper, States have asked the Centers for Medicare and Medicaid Services for funding to hold them over in the interim, and the agency has awarded about $607 million in redistributed funds to states and U.S. territories. Tribes will also lose hundreds of thousands of dollars in CHIP-related grants.

Last month, Utah Republican Orrin Hatch, who chairs the Senate committee responsible, called CHIP a “top priority” that had bipartisan support. The committee passed the bill October 2. But it’s up to Majority Leader Mitch McConnell, R-Kentucky, to bring the legislation to the floor for enactment. Then the House and Senate would have to iron out and agree on their differences before the bill can become law.

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

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

Children’s health insurance should be an easy vote, but not so in this Congress

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More than half of all American Indian and Alaska Native children are insured by Medicaid and the Children’s Health Insurance Program (IHS.gov photo)

Mark Trahant /Trahant Reports

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.

 

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Source: Kaiser Family Foundation

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.

 

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 do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Obesity in Indian Country is mostly the same; why that’s incremental progress

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IHS Diabetes Fact Sheet, published July 2017.

A fundamental question about government

Mark Trahant / Trahant Reports

The most fundamental question about government is this: Does it work? When does government — tribal, state or federal — actually make a difference in our lives?

There are two ways to answer that question, data and story. Data tells what happens over time, a reference point that ought to provide the proof of self-government. But story is what we tell ourselves about what works, and more often, what does not work. Ideally data and story lead us to the same conclusion.

One problem with data is that it measures incremental progress. That should be a good thing. But when telling a story it’s awfully difficult to report that things are kinda, sorta getting better. We humans want clarity, a success story, right? Or even an outright failure.

Yet progress is often measured slowly.

We all know there is an epidemic of diabetes in Native American communities. Yet it’s also true that adult diabetes rates for American Indian and Alaska Natives have not increased in recent years, and there has been a significant drop in both vision-related diseases and kidney failures. Incremental progress.

Now a new study, one that is built on a massive amount of data, reports that obesity among Native American youth is mostly the same.

“The prevalence of overweight and obesity among AI/AN children in this population may have stabilized, while remaining higher than prevalence for US children overall,” according to a study published last month by the American Journal of Public Health. The study concluded that American Indian and Alaska Native youth still have higher rates of obesity than the total population, but those rates have remained constant for a decade. In other words: The problem is not getting worse. (At least, mostly.) This report is remarkable because it reflects a huge amount of data – reports from at least 184,000 active patients in the Indian health system – from across geographic regions and age groups. Most scientific studies rely on a small sample group, making it difficult to compare regions or even break down the data by gender or age. (So Native Americans who are treated outside of the Indian health system would not be included in this data.)

The results: “In 2015, the prevalence of overweight and obesity in AI/AN children aged 2 to 19 years was 18.5% and 29.7%, respectively. Boys had higher obesity prevalence than girls (31.5% vs 27.9%). Children aged 12 to 19 years had a higher prevalence of over- weight and obesity than younger children. The AI/AN children in our study had a higher prevalence of obesity than US children overall in the National Health and Nutrition Examination Survey. Results for 2006 through 2014 were similar.”

The findings show that the problem is not getting worse. And that is incremental progress.

To put this report into a policy context, think about the hundreds of programs that are designed to get Native American youth more active. Or the education campaigns to improve diet and to encourage exercise that occur every day across Indian Country.

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This is timely data because Congress must soon reauthorize the Special Diabetes Program for Indians. And this report is evidence that $150 million program works and it’s also worth a continued investment by taxpayers. (Remember: Chronic diseases, such as diabetes, are by far the most expensive part of health care. Every dollar spent on prevention saves many, many more down the road.)

The goal of course must be a decline in overweight and obesity statistics, not just stability. (And one warning sign in the report is that there was a slight increase in severe obesity even while the general trend is stable.)

The report, by Ann Bullock, MD, Karen Sheff, MS, Kelly Moore, MD, and Spero Manson, PhD, said there are many reasons for a higher obesity prevalence in American Indian and Alaska Native children but also said this was a “relatively new phenomenon seen only in the past few generations. The explanations range from the rapid transition from a physically active subsistence lifestyle to the wage economy and sedentary lifestyle. Add to that the risk factors of poverty, stress, and trauma.

“Indeed, many AI/ AN people live in social and physical environments that place them at higher risk than many other US persons for exposure to traumatic events,” the study found. “Among children in a National Institute of Child Health and Human Development study, the experience of numerous negative life events in childhood increased risk for overweight by age 15 years. Another contributing factor to obesity in children living in lower-income households is food insecurity, which is the lack of dependable access to sufficient quantities of high-quality foods. Even before birth, stress and inadequate nutrition during pregnancy alter metabolic programming, increasing the risk for later obesity in the offspring.”

Because obesity is a relatively new phenomenon seen only in the past few generations, there is much that can be done to reverse the trend. And that starts with making sure the problem is not getting worse. Then we can get healthier. Kinda, sorta, at least.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Senate Republicans will have to wait for John McCain to return after surgery

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When every senator could be the 50th vote, any one absence means no healthcare bill

Trahant Reports

The Senate healthcare bill looked like it was going to pass on Friday. There were only two public no votes (when three are needed to defeat the measure.) And you can only imagine how much pressure leadership was putting on its members to vote yes for the good of the party. This bill was (and is) a priority for the Republican leadership and the White House.

But over the weekend things changed. Sen. John McCain’s office announced that the senator had surgery for a blot clot over his eye. “Senator McCain received excellent treatment at Mayo Clinic Hospital in Phoenix, and appreciates the tremendous professionalism and care by its doctors and staff. He is in good spirits and recovering comfortably at home with his family. On the advice of his doctors, Senator McCain will be recovering in Arizona next week.”

Now the Senate cannot vote on the healthcare bill. There is no way to get to 50 votes without him. So Majority Leader Mitch McConnell will wait until McCain heals. At least a week.

That means there is a lot more time for the opposition to make its case. On Monday or Tuesday there will be a new Congressional Budget Office score of the bill. And that could be followed by some kind of alternative review from a federal agency. Think fake news but in a government document.

Another Not So Good for the Senate Bill moment was a letter from health insurance companies that said the Cruz amendment is unworkable in any form. The problem is that healthy people will buy cheaper plans leaving those who are already sick to buy the ones preserved from the Affordable Care Act.

State governors also remain opposed to the Senate bill. Vice President Mike Pence attempted to change their minds. He spoke as a former governor who accepted Medicaid Expansion, but now says the Senate bill is all about freedom to redesign health insurance. “And if you take nothing else from what I say today, know that the Senate healthcare bill gives states the freedom to redesign your health insurance markets.  And, most significantly, under this legislation, states across the country will have an unprecedented level of flexibility to reform Medicaid and bring better coverage, better care, and better outcomes to the most vulnerable in your states.”  He argues that the Medicaid reforms will secure “Medicaid for the neediest in our society.  And this bill puts this vital America program on a path to long-term sustainability.”

But, as I said, the governors didn’t see the issue the same way. Democrat and Republican sees the numbers and now that the Senate bill will result in substantial budget cuts lasting more than a generation. (In fact: One of twisted messages from McConnell to moderate Republicans is don’t worry. The cuts down the road will never happen.) This bill would destroy the Medicaid that we have now. Including the money that helps fund the Indian Health system.

Looking for background? Here are recent pieces on the Senate health care bill and its impact on Indian Country: The special deal for Alaska; Lies we’re being told about budget cuts; The impact on jobs in Indian Country; Trump tells tribal leaders Medicaid cuts will be good; and health care policy is a debate worth having (but this is not that.)

 

 

 

 

Alaska’s special deal in Senate health bill isn’t enough to fund successful Medicaid

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Alaska’s Health and Human Services Commissioner Valerie “Nurr’araaluk” Davidson. A report by her agency says Medicaid now covers one in four people in Alaska; nearly half of whom are children. If Medicaid caps are enacted, 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.”

Mark Trahant / Trahant Reports

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.

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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.

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

 

Health care debate should also focus on the thousands of jobs in Indian Country

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Mark Trahant / Trahant Reports

I am not sure of the exact year. It probably happened around 1996. That’s when the Indian Health Service became the single largest employer in Indian Country.

This makes sense when you think about it: Indian health was once a small (unappreciated) division of the Bureau of Indian Affairs. But by 1996 the agency’s budget was larger than the BIA’s — and there were likely more workers. The administration estimates that next year the BIA will have some 6,770 full-time employees (a decrease of 241) while the Indian Health Service will have more than 15,119 employees (including 1,928 uniformed Public Health Service officers).

Big numbers, right? But that reflects what is happening with health care generally. Google “region’s top employers” and it’s common to see clinics, hospital systems, and university medical centers as any region’s largest employer.

“Employment of healthcare occupations is projected to grow 19 percent from 2014 to 2024, much faster than the average for all occupations, adding about 2.3 million new jobs,” reports the Bureau of Labor Statistics. “Healthcare occupations will add more jobs than any other group of occupations. This growth is expected due to an aging population and because federal health insurance reform should increase the number of individuals who have access to health insurance.”

But here’s the thing: Many of these health care jobs are dismissed as “low wage.” The BLS calls these health care support jobs and the median income (or half pay more and half pay less) as $27,910 which is lower than the median annual wage for all occupations in the economy. The list of support jobs would include Community Health Representatives (long a staple in Indian Country), medical record keeping and coding jobs, as well as different kinds of medical technicians. But what’s considered low wage in the general population, and in cities, can be a good gig in a rural, tribal community.

Alaska is a prime example. More than half of Medicaid spending serves rural constituents, three times more than the national average. Medicaid covers two-thirds of all American Indian and Alaska Native children and more than one in four, or 28%, of American Indian and Alaska Native adults. The Urban Institute estimates that the kind of block grants found in the Senate’s Better Care Reconciliation Act would cost the state $590 million in federal funding — a number that would decline even sharper after 2025. The job losses would be substantial.

This is another reason why the House and Senate plans to roll back the Affordable Care Act (and the destruction of Medicaid as part of the deal) are so important to the Indian health system. The Senate plan especially reverses decades of Medicaid growth. That’s no good for patients (as I have reported before here and here) but it also will cost Indian Country jobs.

Medicaid directly accounts for 24 percent of IHS’ workforce, but even that is short of the kinds of jobs that serve tribal communities. It does not include school-based programs. Or those private companies that bill Medicaid for transportation of patients or other patient services. Same story for jobs that stem from medical coding, accounting and third-party billing services.

Across the country, Medicaid is a major job creator for women, supporting at least 3 million direct jobs.  According to a report by the National Women’s Law Center: “When Medicaid pays for a health service—a visit with a health professional, a laboratory test, a hospital stay, a home health visit—this payment supports the facility, agency, or medical practice that delivers the service, and the individuals who provide this care receive compensation as well. Women’s high participation in the health care industry, which employs more than 22.8% of all women in the workforce, means that Medicaid disproportionately creates jobs for women.”

I don’t have a breakdown for these jobs in Indian Country, but from personal experience I would bet the numbers are similar if not higher.

Senate debate begins again next week

The Senate, of course, still does not have consensus about a bill to replace the Affordable Care Act. Majority Leader Mitch McConnell suggested this week that Republicans might need to try another direction because “no action is not an alternative.” The Associated Press quoted the senator saying: “If my side is unable to agree on an adequate replacement, then some kind of action with regard to private health insurance markets must occur.” That plan would require votes from Democrats and would likely include a compromise.

Other senators, including Paul Rand, have proposed repealing all of the Affordable Care Act without a replacement, basically putting that off for another day. That would be particularly troubling for Indian Country because a full repeal would likely include the Indian Health Care Improvement Act. But that, too, is complicated by Senate rules. A full repeal would need 60 votes unless that legislation was framed narrowly around budget issues.

But Republican leaders have not given up. The new story they are telling is that 22 million people would “choose” to not carry health insurance. It’s a freedom thing. But that does not square with the destruction of Medicaid. And the jobs that public insurance program has created.

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

 

Trump tells tribal leaders that Medicaid cuts will be ‘great for everybody’

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President Donald J. Trump meets with tribal leaders for Energy Week. He calls the Medicaid cuts will be great for everybody. (White House photo via YouTube.)

Senate bill ‘mostly dead,’ but will it revive after break?

Mark Trahant / Trahant Reports

The Senate’s health care bill is “mostly dead.” But that’s not the same as all dead. And this holiday weekend will decide either the legislation has a second life or if there is a better way to proceed.

Republican Senate Majority Leader Mitch McConnell is planning another shot at health care reform (excuse me, a plan to cut taxes and roll back Medicaid) this week producing yet another draft of the health care bill. Meanwhile Senators (as well as members of the House) will break and return to their home districts. This is where the people have a chance to weigh in with a “hell, no!” The Senate bill may be the most unpopular piece of legislation ever, currently earning support of between 12 and 17 percent depending on which poll you read. To borrow the TSA phrase, if you see someone (as in a member of Congress) say something.

Consider this: Medicaid is popular across the board. A poll by Kaiser Health News illustrates this point. It shows that some three-fourths of Americans view Medicaid favorably. (But the poll also points out that most Americans don’t know that both GOP bills would cut deeply into the popular program.) Even Republicans think Medicaid works.

For the past few weeks I have been writing post after post about how bad this approach to health care — I mean, tax cuts — is as a policy. The problem is basic. Many Republicans do not believe health care is a right. So it’s their mission to roll back government. But not every Republican believes that. Some see the effectiveness of programs such as Medicaid and see it’s rollback as unconscionable. (Previous: Health care deserves policy debate.)

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Recent polling from Kaiser Family Foundation shows support for Medicaid across the political spectrum.

 

At a meeting with tribal leaders at The White House, President Donald J. Trump was asked about cutting Medicaid. His answer: “It’s going to great.  This will be great for everybody.”

Read “great” as “clueless.” But the president did say it was going to be difficult to get the votes, “it’s very tough …  I think we’re going to get at least very close, and I think we’re going to get it over the line. ”

We shall see. Mostly dead or all dead? And an all dead GOP health care bill could deliver a miracle.

This is the moment where McConnell will pull out his checkbook. He will be trying to win *cough* buy * cough* support from senators with sweet deals for the folks back home. If that doesn’t work, McConnell said he might be forced to work with Democrats on legislation. Imagine that! A Congress that works with both parties.

This is what really ought to happen. The Affordable Care Act has problems that need to be fixed. But it’s in specific areas, such as the individual insurance market, and a bipartisan approach would actually yield the best results.

But more important the only way that Congress governs again is for leadership to recognize that they cannot govern with Republican votes alone because they don’t have enough votes. There is a split within the Republican Party on the very question of health care as a right, let alone specifics about how much to cut and where.  And that same division plays out on just about every major public policy issue.

But a few Republicans working with Democrats do constitute a majority in both Houses. A lot could get done. The Congress could pass a budget. Raise the debt limit (averting another crisis) and do the jobs that we the people hired them to do. That would take a miracle right? But we can always hope and the first step is an all dead Republican health care bill.

How long will it take for this process to unfold? This will only happen when congressional leaders run out of options and see working with Democrats as the only path forward. This will take time because as Miracle Max said in The Princess Bride: “You rush a miracle man, you get rotten miracles.”

We don’t need another rotten miracle.

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

 

 

 

 

 

 

 

How bad could it be? Don’t get sick if Senate (or House) bill becomes law

 

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Alaska Sen. Dan Sullivan speaking at a conference last year about the opioid crisis in Alaska. Critics say cuts to Medicaid will make it harder to find the resources to address the problem. (Photo via Sen. Sullivan’s web page.)

Mark Trahant / Trahant Reports

The Senate bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions from Medicaid and passes on that savings to wealthy Americans.

How bad could it be? The official financial review from the Congressional Budget Office is expected early next week. The scoring of the similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured.  Under the House bill only a few million would use tax credits to purchase policies that even then would not cover major medical risks.

So the important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) and gives back most of those to high-income taxpayers ($664 billion). The Senate bill takes a little time to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. Then, like the House, Medicaid would become a state block grant program. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid spending is automatic: If you are eligible, the money is there.)

Medicaid now accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.

But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or what’s especially what’s covered by insurance.

This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent federal funding through what’s called the Federal Medical Assistance Percentage for Medicaid or FMAP. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. But the money would still flow from Washington to the states for administration. Messy (as it often is now). And the states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.

The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The bills move health care back to the states in a big way. That can be good or bad. California is debating how to create a single payer system. The Nevada legislature recently passed a Medicaid-for-all statute (where any citizen could buy into the program) only to have the law vetoed by the governor. But other states see health care only as a cost. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity” care.

Some numbers here. The American Hospital Association opposes both bills for one reason. In 1990 uncompensated care cost $12.1 billion or about 6 percent of total hospital expenses. By 2012 that figure reached $45.9 billion. And, after the Affordable Care Act, the total uncompensated care costs dropped to $35.7 billion or 4.2 percent of total hospital expenses, the lowest level in 26 years.

But this shows the futility of cutting Medicaid and insurance programs for the poor. It doesn’t save money, it just shifts it around. People who get sick will go to emergency rooms when it’s later in their illness and more expensive. So hospitals will cost more for everybody. (But at least the wealthy get their tax break, right?)

The opioid crisis is an example of that. The costs will not go away. Some money will be found by states, cities and tribes. The Senate bill adds a funding stream of $45 billion over 10 years for substance abuse treatment and prevention that’s now funded by the Affordable Care Act. But Medicaid expansion has been a key funding source. The Associated Press reports that Medicaid expansion accounted for 61 percent of total Medicaid spending on substance abuse treatment in Kentucky, 56 percent in Michigan, and 43 percent in Ohio.

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The Senate has only a few days to consider their version of health care “reform.” Already a few conservatives are saying the bill doesn’t go far enough and want more changes. This is the script the House used: The conservatives throw a fit, get their way, and then the so-called moderates give in and vote yes anyway.

My bet is that Senate leaders have already written off Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins because of their past support for Planned Parenthood (there are already restrictions against the federal funding of abortion, but the Senate bill says Planned Parenthood cannot bill Medicaid for a year for all women’s health services).  So I think Senate Majority Leader Mitch McConnell is banking on a fifty-fifty split with Vice President Mike Pence casting the deciding vote.

That means the moderate senators, those that support Medicaid in their states, can say what ever they want now. But it’s their vote that will count. Destroy Medicaid or cut taxes? That’s the choice for these four: Rob Portman of Ohio, Shelley Moore Capito, West Virginia, Dean Heller of Nevada, and Cory Gardner from Colorado. Perhaps it’s wishful thinking but I will add Alaska Sen. Dan Sullivan to this list because Alaska will be hit particularly hard by the overall legislation, the opioid epidemic, the state’s successful expansion of Medicaid, and its impact on the Alaska Native Medical system. Sullivan said on Facebook that he will read every word of the bill and he wants “a sustainable and equitable path forward for Medicaid” and he won’t vote for a bill that makes things worse for Alaskans. So will it be his party or Alaskans? Health care or tax cuts?

 

And, since I am asking already asking questions, will the Senate bill pass next week? Remember it will only take one senator to force the Senate to start over.

 

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