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.'”
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.
When every senator could be the 50th vote, any one absence means no healthcare bill
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.
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.)
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.”
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.
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.
Reality TV works for one simple reason: The antics of the characters are beyond what’s believable in fiction. It’s compelling drama because normal people do not do such things. So part of watching is to find out when the story arc ends, to discover when the situation becomes “normal” again. (Even though the story does go on and on and on.)
That’s why the presidency of Donald J. Trump would make a terrible novel or screenplay: There’s no mechanism to suspend disbelief. Tell the story about a four-month term in the White House, a time marked by so much chaos, unprofessionalism, and distraction, and a reader (and especially an editor or producer) would shake their head and say, “Try again. This story is not believable.”
That’s why only the metaphor of reality TV works. America the unbelievable.
Last week the best moment of the new Trump Administration was the one where the president smiled in Saudi Arabia and said only 26 words. This was terrible reality TV but we all watched knowing that it was likely just a pause. Something outrageous must be coming up next.
The White House Reality Show is entertaining.
Meanwhile more important stories are still being written and played off-screen. That’s why our focus must return to the policy fights ahead: How this country (and our planet) deal with climate change, how we stop the rigging of elections, and, how we make certain the court system is fair. Next week the White House will formally send Congress its budget plan for the next year. We already know this plan will be nonsense. Another distraction. The real work of budgeting will occur in Congress and it will require votes from both Democrats and Republicans to make it so.
At a House hearing last week, for example, Rep. Tom Cole (R-Oklahoma) said he was disappointed in a White House recommendation to cut $5.8 billion from next year’s funding for the National Institutes of Health. He such a draconian cut would stall so much progress from recent investments.
In other words: No sale. Across the Congress, across the government, this same notion is being repeated. Eliminate the Corporation for Public Broadcast? No sale. Down the list the message is much the same, eliminate the Denali Commission? No sale. Etcetera, etcetera, etcetera.
Paying for health care
But while Congress might rewrite the budget in some areas, there are real dangers ahead. I’m obsessed with what this bunch is doing to the funding streams for health care, especially Medicaid.
This is what the Trump Show hides: The House’s American Health Care Act does much more than roll back the Affordable Care Act (or Obamacare as they like to say.) It ends a Medicaid program that works. It’s the single most effective form of “government” insurance that secures health care options for 62.3 million Americans. To add a little perspective here: Medicare — supposedly untouchable in politics — insures 43.3 million seniors.
These are huge numbers. Medicaid is expensive. And we all pay for this plan. As we should. It’s one of the best things this country does.
So it’s no wonder that Speaker Paul Ryan and Republicans are eager to make this go away (both because it costs so much and because it requires a lot of taxes to pay for this enterprise).
This is an issue where the philosophical divisions run deep. Every Republican wants to spend less federal money on this program. Significantly less. Once you do that, there will be fewer people who participate in this public insurance program. That’s math, not politics. The House plan (according to the Congressional Budget Office) strips $880 billion from Medicaid funding in order to reduce health care taxes on wealthy people by $883 billion. Tit for tat.
Watch this debate closely. Parse every word. The Republicans in the Senate who say they champion Medicaid often only talk about Medicaid expansion. And that’s followed by, there should be a transition to something else (namely, block grants that states cannot afford). What else? How does that work? And who pays?
At a town hall in Anchorage last week, Alaska Sen. Dan Sullivan followed this script to the letter. According to The Alaska Dispatch News the Republican senator told a contentious town hall, that he wanted to make sure the people who received health care coverage under Medicaid expansion “do not have the rug pulled out from under them.” Medicaid for now. Then something else. What else? How does that work? And who pays?
The answer is to protect the framework of Medicaid (and if we were smart, enhance and expand it). It’s the one part of Indian health funding that’s growing and already accounts for the insurance of record for more than half of all our children. (And, this is really important, third-party insurance billing, which includes Medicaid, is money that stays at a local IHS clinic or hospital. It does not go into the general budget.)
Medicaid is a partnership between the federal government and the states. So states set many of the rules, federal government then agrees or not, and pays only a portion of the bill. But patients within the Indian Health system are usually eligible for a 100 percent reimbursement.
So states set the rules for Indian Country — including limitations — yet don’t pay the cost. Already six states are already looking to tighten Medicaid rules. Arizona is keen on adding work requirements. Wisconsin wants drug testing (imagine the trap that sets for patients in opioid treatment programs). Maine wants to test assets beyond income. The goal of each new regulation is to shrink the number of people insured by Medicaid.
Medicaid works, especially in Indian Country
I’ve heard Republicans say they like the results of Medicaid but that we as a country cannot afford it. That’s particularly troubling because Medicaid is more efficient that private insurance. (Even with its convoluted payments from the federal government to states and Indian health programs). How can that be? Julia Paradise, associate director of the Program on Medicaid and the Uninsured for the Kaiser Family Foundation, says Medicaid acts as a “high risk pool.” Because so many people are excluded (or out-priced) from private insurance Medicaid is the only option. “Among adult Medicaid enrollees who are not working, illness or disability is the main reason. By covering many of the poorest and sickest Americans, Medicaid effectively serves as a high-risk pool for the private health insurance market, taking out the highest-cost people, thereby helping to keep private insurance premiums more affordable.”
The Senate is now busy rewriting the House’s awful health bill. It will be a different entity, that’s for sure. But will the Senate protect (and if they are smart, enhance and expand) the best basic public health insurance program that we have now? There is no evidence to suggest that. And too many people are watching reality TV to even notice.
The House of Representatives passed the American Health Care Act by four votes, 217 to 213. The legislation now moves to the U.S. Senate. If this bill becomes law it will do five things: Cut taxes for people who make a lot of money, end health insurance subsidies and much of the coverage from Medicaid, cause more people to go uninsured and eventually bankrupt, and frame the most important political debate in a long time.
Every Republican who voted for this mean-spirited bill must now defend against every American who has any problem with insurance or health care. (I know that’s not fair. But it’s essentially what happened to the Democrats.) You get a doctor’s bill you don’t like: Blame Trump and Ryan. Lose insurance coverage at work: Ditto. This is why the optics are so lousy for Republicans, the health care system is now their mess.
Oh. I know. This bill is not law yet. And it’s not likely to be. But it doesn’t matter. Months after the House voted its first repeal of the Affordable Care Act people reported that they thought the law was gone. It was not then. Nor now.
Remember the House bill still must get through the Senate and that body is as divided as the House. But one difference is that there is a constituency in the Senate for Medicaid. (As I have been writing: This is the most significant impact on Indian Country. This bill doesn’t just repeal the Affordable Care Act, it ends Medicaid as we know it. Medicaid insures more than half of all children in the Indian Health system and it accounts for 13 percent of the Indian Health Service budget.)
At least four Republican Senators, Rob Portman (Ohio), Shelley Moore Capito (West Virginia), Cory Gardner (Colorado), and Lisa Murkowski (Alaska) have been clear about their support for Medicaid and Medicaid expansion. (Medicaid is a state, federal partnership to provide health care for families with low incomes. The Affordable Care Act expanded that to single people and lowered the income limits to 138 percent of federal poverty guidelines. The numbers are huge. Before the ACA about 56 million people were insured by Medicaid. Today the number is nearly 75 million.)
A bloc of four senators — if they don’t budge — has the power to say “no” to any legislation. This is the Medicaid Protection Block. And Republicans only have two votes to spare in the Senate because all of the Democrats will likely oppose this measure (as they did in the House). So the thing is that if the Senate language satisfies theMedicaid Protection Block that will enrage the Freedom Caucus in the House. That bloc stuck together and killed the House’s first version of the legislation, so the second version was even more to their liking (removing federal requirements to provide basic health services including pre-existing conditions).
Complicated, right? Add to that mix the conservative members of the Senate who don’t think this bill goes far enough in the outright repeal of the Affordable Care Act. Sen. Paul Rand (Kentucky) said on Fox News: “It will take a little bit of work to get me to ‘yes’ vote on health care bill.” In other words make the bill more ideological, not something that will get support from the Medicaid Protection Bloc.
And if that’s not complicated enough, there are also Republicans in the Senate that object to the bill’s attack on Planned Parenthood because of the impact of such a policy on women’s health. That bloc includes Murkowski and Maine’s Susan Collins.
Complex or not, no matter what comes out of the Senate (unless it’s the House bill exactly) the House will have to vote again. Then the illogical Freedom Caucus gets another shot at defying their own party leadership.
But the real politics of Wednesday’s action is not in Congress. It’s playing out on social media and communities across the country. It’s the idea that this vote was a definition for the next election. One side believes that health care is not a right. The other sees the Affordable Care Act as imperfect, but a step in the right direction.
Indian Country should be included in this debate. And we’re not. Our right to health care is simple, it’s based on treaties, history, and thus a pre-payment for whatever insurance mechanism the country comes up with. The Affordable Care Act at least opens up an avenue to fully fund the Indian Health system something that’s never been accomplished before.
This is also the ideal moment for Indian Country to have more of a say. This is when a political coalition can be built around idea that health care is a right. Health care is already defining the 2018 elections.
And the politics of that start in Red states (those that voted for President Donald J. Trump). This bill, in a quest for free market purity (if that’s even possible in health care), would benefit young people, healthy people, and people who live in cities. And paying for that experiment are older people, sicker people, and rural people.
Alaska is at the top of this list. The Affordable Care Act pays insurance companies to help keep costs down. The Republican plan ends that business. The result: “Consumers in 11 states would see tax credits fall by more than $3,000 on average, or more than 50 percent, and consumers in seven states would lose an average of more than $4,000. In Alaska, by far the highest-premium state, the average reduction in tax credits would be $10,200, or 78 percent,” according to a study by the Center for Budget and Policy Priorities.
And that doesn’t even include Medicaid. Another study on that issue found the program saved Alaska significant dollars, projecting a billion dollar return after a decade. The state’s Commissioner of the Department of Health and Social Services, Valerie Davidson, told KTUU News that “with our $3.5 billion budget deficit, we don’t have an additional one billion dollars more to pay for services that we currently have, we just can’t afford it.”
She also said the House bill would strip behavioral health funding when it’s so important in the middle of an opioid epidemic.
So for an Alaska representative, one that works for constituents, this should have been a no-brainer. This bill is terrible for Alaska. Last week Rep. Don Young said as much. He claimed victory when the previous bill was pulled from consideration without a vote. He told The Alaska Dispatch News: “My job is to represent those people in that state, and I think we did this this week. I work with (House Speaker Paul Ryan), don’t get me wrong — the speaker talked to me quite a bit. But it didn’t come to a point where I could support this bill. He needed my vote.”
The bill that passed Wednesday is not significantly different. Alaska is still hosed. And Don Young voted “yes.” Now he says, don’t worry, this bill will not become law. The Senate will change it.
That’s basically the position of Rep. Tom Cole, a Republican in leadership, and a member of the Chickasaw Nation. He told National Public Radio: “This thing is going to go to the United States Senate. It’s going to change, in my view, in the United States Senate in some way. Then we have to have a Congress — a conference to work out the differences. If we can do that, then it has to still pass the House and the Senate again before it ever gets to the president. So, you know, at some point, you just have to move. And we think this is it and that this will create some momentum. Again, I’m interested to see what our friends in the Senate will do in response.”
Cole is a champion for Indian health programs, especially when it comes to the budget. He’s often the critical voice and the only Native American at the table when budgets are written. However he dismisses Medicaid Expansion quickly because Oklahoma is one of the states that’s passed. Ok. We disagree. Understandable.
But this House measure is not just about Medicaid Expansion; it’s a radical restructuring of Medicaid and capping costs. Even in Oklahoma Medicaid serves more than 800,000 people. And, remember that Medicaid is 13 percent of the IHS budget, more than $800 million now and growing. Already more than half of our children are insured this way. Plus this is the best kind of money because it’s used by local clinics and hospitals.
This is what Tom Cole, Don Young, and 215 other Republicans voted to take away from Indian Country. This is what’s on the ballot next year.
How much does it cost to buy the vote of a ‘moderate’ Republican? Today the going rate is $8 billion. (And that, by the way, is more than ten times amount of money the Indian health system is at risk of losing if Congress enacts the “American Health Care Act.”)
The $8 billion would fund a high-risk pool for individuals with pre-existing conditions. The idea surfaced Wednesday as an amendment from so-called moderate Reps. Fred Upton of Michigan and Billy Long of Missouri after a meeting with President Donald J. Trump. This pool of funds is supposed to make it easier to take away a requirement in the current law to cover pre-existing conditions. Upton is quoted by The Hill newspaper saying, “I think it is likely now to pass the House.”
Here’s the thing. An $8 billion pool won’t come anywhere close to meeting the need.
Just think about this: Chronic care, including diseases such as heart disease and diabetes, consume nearly nine-out-of-ten health care dollars (which totaled $2.9 trillion in 2013). Add to that cancer and other costly diseases and it’c clear that $8 billion is not even a down payment.
But as I have been reporting: “The bill would still wipe out Medicaid as we know it. Medicaid represents 13 percent of the Indian Health Service budget (or $808 million).” Indian Country’s biggest concern right now ought to be Medicaid, Medicaid and Medicaid. There are now 30 million children covered by Medicaid; more than half of all Native children.
The last version of the bill sticks with its revision of Medicaid by capping the costs.
The crazy part of this equation is “why?” The Senate is not going to pass this bill. Several Republican Senators, including Alaska’s Lisa Murkowski, have said they support Medicaid as a state decision. This bill will, however, put House Republicans on the record. Alaska’s Rep. Don Young has been listed throughout this process as an undecided or a “lean no.” No other state will lose as much in this legislation as Alaska. So the choice will be a vote for the party or one for constituents.
The revised bill is expected to move to the House floor as soon as today. This legislation is moving so fast that few will have a chance to review it. And the Congressional Budget Office will not be able to look at the bill’s impact on either the budget or on American’s access to insurance. — Mark Trahant
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).
A short post for a big week: We should start to see some budget numbers coming out of the White House (as soon as today). Early reports suggest sharp cuts for domestic spending as well as increases for Defense. I’ll update once I see if that framework includes the Bureau of Indian Affairs, Bureau of Indian Education, Indian Health Service, and other federal programs that serve American Indians and Alaska Natives.
President Donald J. Trump could also refer to his spending plan in his speech to Congress on Tuesday.
The other big news is the ongoing problems the Republicans are having repealing and replacing the Affordable Care Act.
An analysis of the Congressional framework for repeal and replace would be a disaster for state governments and millions of Americans would lose coverage. According to Sarah Kliff writing for Vox: “The report estimates that coverage declines would be even higher in states that did not expand Medicaid — largely those run by Republican governors. There, the report presents an example of a state with 235,000 in the individual market. It estimates that coverage would decline by 120,000 people, about 50 percent.”
The presentation did not address the Indian health system. But the slides do make the case against converting Medicaid into a block grant program because states would have less federal funding when the need is greatest (such as during a recession). Remember states are partners with the federal government in Medicaid, but patients in the Indian health system are funded by a federal reimbursement. So this is a critical debate.
I want to come back to this theme later: But Indian Country has a solution. At least for now. Every proposal to repeal and replace the Affordable Care Act will take time. So for now. Right now. There should be a renewed push to enroll Indian Health patients (who don’t already have insurance) in Medicaid or the Bronze Plan from a state or federal insurance exchange. The exchange plan is free. This health insurance coverage should be good for a least a year. This is money that a Trump budget cannot strip from the Indian Health system.
And the week starts off with the Democratic National Committee having new leadership. Over the weekend Tom Perez was elected chair and he immediately appointed Keith Ellison as his deputy.
I have read from so many friends on social media who see this contest as a policy debate. It is not. It’s about who will make sure there are candidates running. That those candidates have support and money. And there is a machinery that’s built. The policy debates are down the road.
But this DNC election does mean that Minnesota Rep. Peggy Flanagan (White Earth Ojibwe) won’t be launching a bid for Congress. (Yet.)
Flanagan posted on Facebook: “Earlier today, the DNC elected Tom Perez Chair, to lead the party and I congratulate him on his victory. I also want to applaud our Congressman Keith Ellison for running a strong campaign based on positive ideas for the future of our party.
Obviously, this means that I am not running for Congress now and I’m excited to keep working with Keith to build the movement we need to win and protect victories for real progressive change.
“I will continue to work with you to turn our fear into fight, our emotion into empathy, our sorrow into strategy, and our despair into hope. I am incredibly grateful for all your support. Miigwech (Thank You).”
And she’s right of course. There remains much to do to turn fear into fight. In Congress or not.
We live in odd times. Congress is moving forward with promised legislation that will roll back much of the health care reform enacted during the past eight years. The Trump administration is issuing regulations to do the same. The key here is that President Donald J. Trump and Republicans in Congress have the votes (mostly). But in state capitals there are real debates about public policy. What happens next will be determined by lots of people working together.
The future of the Affordable Care Act is a case in point. Republicans in Congress are eager to ditch the law, but coming up with a replacement or even a fix is a much more difficult task. This is one issue where there are not enough votes in Congress to do anything. Yet.
But in state capitals there is an understanding that a wholesale repeal of the law could be a financial disaster for states that have already expanded Medicaid. So many Republicans at the state level, such as Ohio Gov. John Kaisch, are pushing back. He recently told CNN that that any repeal without addressing Medicaid expansion is a “very, very bad idea.”
But several of the states prefer a real solution, one that doesn’t grab as many headlines, yet would be practical. And that is to continue with current law and then Secretary of Health and Human Services Tom Price would grant states many more waivers to design the programs the way they want.
This makes more sense than a block grant because it keeps in place the idea that if people are eligible for Medicaid, then it will be funded. Under a block grant scenario, it’s likely the total amount would be capped and people who currently get insurance could lose that. (Perhaps the most difficult problem is this: How do you protect the states that expanded Medicaid and still add funding to those states that said no?)
This is a huge issue for Indian Country because Medicaid could cover even more of the people who currently use the Indian health system. (Best of all: Money from insurance is supposed to stay at the local healthcare facility.) States also come out ahead with American Indian and Alaska Native clients because the federal government is obligated to pick up the tab. It’s a 100 percent federal “match.”
This is one of those issues that divide Republicans, especially in Congress. The members who are listening to states understand the problem: What happens when you take away people’s health insurance? The answer is not good. And it’s even life or death for some people because without insurance there will be no medical care for ongoing issues.
This week in Washington state there was a victory for health care reform in Indian Country. The Legislature passed, and Gov. Jay Inslee, signed into law, a measure that opens up the practice of dental health therapy.
Dental health therapists are mid-level providers. They work under the supervision of a dentist and offer routine and preventive services, like dental exams; provide fillings; clean teeth; placing sealants; and perform simple tooth extractions. This law is important because it opens up Medicaid funding to pay for dental care. And it expands access making it much easier for patients to get appointments.
“We have one dentist to see more than 6,000 patients on the Colville Indian Reservation,” said Mel Tonasket, vice-chairman of the Colville Confederated Tribes. “This law will help us hire a dental therapist to make sure our people are getting the oral health care they need.”
Most experts in health care reform argue for increasing value in health care by lowering costs and at the same time improving quality. This is that.
This oral health reform was started a decade ago by Alaska Native Tribal Health Consortium. According to The Kellogg Foundation: Since then “45,000 Alaska Natives now have access to dental care and the dental health aide program has generated 76 full time jobs with a net economic effect of $9.7 million, one-third of which is spent in rural Alaska. Now, as a way to replicate the same dramatic oral healthcare improvements in Alaskan villages, i.e., reduced caries disease, healthier teeth and patient satisfaction with culturally competent care given by home-grown providers, tribes are blazing a trail to bring dental therapy to the lower 48 states as a high-quality, cost-effective strategy to reduce dental care shortages. Washington State is on the leading edge of this movement.”
This is a great example of the principle of lead, follow, or get the hell out of the way. A year ago Swinomish President Brian Cladoosby announced that the tribe was using its sovereign powers to hire a dental health therapist in contradiction to federal and state law. The case was clear that the tribe had the authority even while raising questions about Medicaid funding or licensing. (The American Dental Association was successful getting language into the Affordable Care Act that required state action.) But the state of Washington was reasonable and the result is the new law.
The bill was sponsored by Sen. John McCoy, a member of the Tulalip Tribes. “This is a tribal-based solution that will make a tremendous difference for Native people—especially children,” he said.
According to Kellogg: Dental therapists are now practicing in Minnesota, in addition to Native American communities in Alaska and Washington. They’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio are exploring the potential for dental therapists to significantly improve oral health care for many more children and communities.
So look for more action and more success stories coming from state capitals.