#NativeVote16 – Stick games with Republicans; hiding the Trump marker

 

Republican candidate for Gov. Greg Gianforte playing stick games at Arlee Celebration. “Great time at the pow-wow in Arlee … Thanks to CSKT Tribal Chairman Vernon Finley for the hospitality.” (Photo via the candidate’s Twitter feed.) 
Mark Trahant / TrahantReports

Make no mistake: The 2016 election is not routine. If you want proof, look no further than the weekend encampment at the Arlee Celebration. On Friday afternoon the Republican candidate for governor, Greg Gianforte, showed up at the celebration with a GOP colleague and then proceeded to serve grilled burgers to all comers. Free food? At a powwow? Sure. Fire. Hit. Gianforte proceeded to play a round of stick games (a tradition that’s been practiced by several former Montana governors). 

Gianforte’s visit was friendly; he wasn’t exactly talking policy. But this is where a Republican gamble for Indian Country gets tricky. 

In any election it is smart for a Republican to try and peel off a few Native American votes. Montana Democrats have been successful reaching out to tribal communities for a long time, especially after the 2005 election of Gov. Brian Schweitzer. So it makes perfect sense for the GOP to pitch Native voters at a powwow.

But just a few miles from the camp is a visible reminder about how complex a simple idea can be.

Just as you enter the reservation, a billboard advertises against the water compact with the Confederated Salish and Kootenai Tribes as an assault against non-Indian property rights. Many of the complaints are focused on state officials, who critics say, gave the tribes everything in the negotiations. (The deal must still be approved by the federal government. The Interior Department said last week that it likes the structure of the compact but not its $2.3 billion price tag. Montana Sen. Jon Tester has introduced legislation to make it law.) Critics understand it’s bipartisan and blame the Republican Attorney General Tim Fox as well as Gov. Steve Bullock, a Democrat.

Again in normal times it would be easy to dismiss antics of what are essentially fringe groups. But the Confederated Tribes’ territory, where the annual July 4th celebration occurs, is the heart of Montana’s opposition to tribal treaty rights, tribal management of resources, and, well just about anything with a reference to a tribe in any phrase.

This is where the Republican fault line is visible. The same people who shout at their government for working with tribes to solve problems are the ones who formed the Tea Party. A report by the Montana Human Rights Network said: “Over the years, anti-Indian activists and organizations have tried to couch their opposition to treaty rights and tribal sovereignty under the banner of ‘civil rights’ for non-Indians … All of these comments are a smokescreen to try and distract from the reality that compact opponents are trying to deny legally-established rights guaranteed to CSKT by treaty.”

The GOP divide is present in many forms. The state’s Republican platform says it supports tribes and treaties (and, of course, tribal development of natural resources). But at the same time a party resolution calls for the transfer of federal lands to the state government. Not a word about how original land owners would fit into such a transfer or how treaty-protected activities on public lands would be protected. The party document even discounts the idea of federal law enforcement: “The Sheriff is the chief law enforcement officer of the county. We support the requirement that a federal officer may not arrest, search or seize in Montana without the advanced, written permission of the elected county sheriff.”

What makes the GOP divide even more pronounced is Donald Trump. As the presumptive nominee of the Republican Party he is adding fuel to The Hateful Mix, a blend of racism and anti-government rhetoric.

And that’s a mixture that not every Republican can tolerate.

On Friday former Montana Gov. Marc Racicot wrote in The Washington Post: “It is inescapable that every decision made by every leader reflects the character of the man or woman making the decision. Character is the lens through which a leader perceives the path to be followed. It conceives and shapes every thought and is inextricably interwoven into every word spoken, every policy envisioned and every action taken.” And, as a result, Racicot said, he could not endorse nor vote for Trump.

On the other side of the divide: Rep. Ryan Zinke not only endorsed Trump but suggested he might make a good pick for vice president. (Denise Juneau is running against Zinke for Montana’s only House seat.)

This election is different because the internal debate within the Republican Party is so visible. There will always be policy differences, but this year there is more than that, because the logic of Trump requires buying into the premise of hating government so much that you must destroy it.

So every Republican candidate this election will play stick games. Look close: Which hand is hiding the bone marked Trump and which hand will be free?

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

Alaska says yes, boosts Indian health system by expanding Medicaid

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

One more state adds “new money” to the Indian health system via Medicaid

MARK TRAHANT

These days “new” money is hard to find. That’s the kind of money that’s added to a budget, money that allows programs to expand, try out new ideas, and look for ways to make life better. Most government budgets are doing the opposite: Shrinking. Calling on program managers and clients alike to do more with less.

That’s why the news from Alaska last week is so exciting: Alaska’s new governor announced the expansion of Medicaid and this will significantly boost money for the Alaska Native medical system. Indeed, the significance of this announcement to the Indian health system was clear when Alaska’s Gov. Bill Walker and Department of Health and Social Services Commissioner Valerie Davidson made the announcement at the Alaska Native Medical Center on July 16. The governor took this action using executive authority because the Alaska legislature had failed to even vote on legislation to accept Medicaid.

The governor says Medicaid expansion would reduce state spending by $6.6 million in the first year, and save over $100 million in state general funds in the first six years. “Every day that we fail to act, Alaska loses out on $400,000,” the governor said. “With a nearly $3 billion budget deficit, it would be foolish for us to pass up that kind of boost to Alaska’s economy.”

“We know Gov. Walker has worked tirelessly to expand Medicaid since he came into office on December first,” Davidson said at the news conference. It was one of the campaign promises made by the independent governor. “He included it in the budget. He introduced a bill both in the House and in the Senate side. It was a subject of both special sessions. And, it’s the right thing do do for Alaska.”

The expansion of Medicaid is one of key components of the Affordable Care Act. It’s critical a tool for the Indian health system because it opens up a revenue channel for clinics and hospitals to bill Medicaid, a third-party insurance, for services and that boosts budgets at the local level. (In a climate where Congress is unlike to spend more money on Indian health.) How big a number? More than a million American Indians and Alaska Natives are now insured by Medicaid. The Kaiser Family Foundation estimated in 2013 that Indian health facilities collected $943 million in third-party payments.  “By far the largest third-party payer is Medicaid, which accounts for $683 million or 70% of total third party revenues, and 13% of total IHS program funding for FY2013,” Kaiser reported. Nearly 150,000 Alaska Natives and American Indians receive health services across the state from tribal and non-profit health organizations funded by the Indian Health Service. By law the IHS-funded clinics must seek third party billing from patients, such as Medicaid, the Veterans Administration or private, employer-based health insurance.

Medicaid is an odd program for Indian Country. Most of us understand the Indian Health Service to be the government’s fulfillment of its treaty obligations. However the IHS has never been fully funded. Medicaid, however, is an unlimited check. If a person is eligible, then the money is there. Yet states, not tribes nor the federal government, determine the rules for Medicaid. And many Republican states have been determined to fight the Affordable Care Act, or Obamacare, at every turn, and that means refusing to accept Medicaid expansion (the Supreme Court ruled in 2012 that states could turn it down).

Alaska’s decision means that the number of states rejecting Medicaid is continuing to shrink. Most recently Montana agreed to expand Medicaid in April. The states with large American Indian and Alaska Native populations that have not expanded Medicaid include Oklahoma, South Dakota, Wisconsin, North Carolina, Maine, Wyoming, and Idaho. Utah is the next state considering an expansion.

The Affordable Care Act continues to evolve — and improve. But more important, steps that states are taking to expand Medicaid are adding real dollars to the Indian health system.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Court affirms Affordable Care Act again; good time to step up Indian Country’s participation

President Obama hugs Kristie Canegallo and Vice President Biden hugs Denis McDonough President Barack Obama hugs Kristie Canegallo, Deputy Chief of Staff, and Vice President Joe Biden hugs Chief of Staff Denis McDonough as they celebrate the Supreme Court ruling on Affordable Care Act subsidies in the Oval Office, June 25, 2015. (Official White House Photo by Pete Souza)
President Obama hugs Kristie Canegallo and Vice President Biden hugs Denis McDonough
President Barack Obama hugs Kristie Canegallo, Deputy Chief of Staff, and Vice President Joe Biden hugs Chief of Staff Denis McDonough as they celebrate the Supreme Court ruling on Affordable Care Act subsidies in the Oval Office, June 25, 2015. (Official White House Photo by Pete Souza)

MAKING THE LAW WORK BEYOND MEDICAID EXPANSION

MARK TRAHANT

The Supreme Court once again affirmed the legality of the Affordable Care Act. This time the court’s answer is unambiguous.  As Chief Justice John Roberts wrote: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

The 6-3 ruling means that people who buy insurance using tax credits as subsidies — some 6.4 million people — will continue to do so regardless of where they live. Thirty-four states have not set up health insurance exchanges and sao consumers must purchase plans through a federal exchange.

At the White House, President Barack Obama said “the Affordable Care Act is here to stay.”

But Congress has other ideas. The House has voted to repeal the Affordable Care Act some fifty times and this is certain to again be an election year issue in 2016. This ruling will also increase the political pressure for conservatives to try and derail the law using the budget, making it much more difficult for the Congress and the Obama administration to reach a deal over federal spending next year.

There is an interesting twist on this case for American Indian and Alaska Native consumers. Early on both supporters in Congress and in the Obama administration decided to play up the portion of the law that exempted Native Americans from the mandatory insurance requirements. The idea was that delivery of health care is seen as a treaty right, so it was impossible to force Native Americans to buy insurance. But the problem is the Indian health system does not have adequate funding — and the best course for improving that revenue stream is to sign up more Native Americans for some kind of insurance through a job, Medicaid, Medicare, Childrens’ Health Insurance Program, or these health insurance exchanges.

According to a report by the Kaiser Family Foundation, nearly one in three American Indians and Alaska Natives is uninsured and most have far less access to employer-based insurance than other Americans.”Less than four in ten American Indians and Alaska Natives have private coverage, compared to 62% of the overall non elderly population,” Kaiser reported. “Medicaid helps fill this gap, covering one in three non-elderly American Indians and Alaska Natives. Medicaid also provides key financing for IHS providers and has special financing rules and protections for American Indians and Alaska Natives. However, nearly one in three nonelderly American Indians and Alaska Natives remains uninsured.”

One way to improve that insurance rate is to encourage more American Indians and Alaska Natives to take advantage of subsidized plans purchased through exchanges. There are, for example, plans for a family of four earning up $70,650 (or $88,300 in Alaska) that have no cost, including deductibles and co-pays. If a family earns more than that amount, an insurance plan purchased through the exchange could still be eligible for no out-of-pocket costs when using the Indian health system. Native Americans can also sign up for the insurance plans every month, instead of during limited open enrollment periods.

Jim Roberts, a policy analyst for the Northwest Portland Area Indian Health Board, said it’s difficult to get data from the federal and state exchanges. However one report, that Roberts said is “suspect,” does have some data showing that approximately 22,000 American Indians and Alaska Natives in the federal exchange Native Americans have received cost-sharing benefits. “What’s interesting about this report is that 41,626 person were determined eligible for cost-sharing reductions, however only 22K were covered by a selected plan.  A very low take up rate despite high eligibility. Indian participation is a real problem,” Roberts said, both in the state and federal exchanges.

Perhaps that should be the outcome of the court’s ruling Thursday: A new emphasis on making certain that American Indians and Alaska Natives take advantage of every dollar eligible under the law. This would be one way of boosting funding for Indian health clinics and hospitals. And this money does not require appropriations from Congress or approval from a state (as is the case with Medicaid).

As he celebrated the court’s ruling Thursday,

President Obama said: “On March 23, 2010, I sat down at a table in the East Room of the White House and signed my name on a law that said, once and for all, that health care would no longer be a privilege for a few. It would be a right for everyone.”

But that right also requires action. Action from the administration informing American Indians and Alaska Natives about the benefits; as well as action from every clinic and patient to make sure we all havel the insurance we’re entitled to receive under the law. Call it, the pre-paid, Treaty Insurance plan.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Missed Opportunities: Indian Country’s economic case for Medicaid expansion

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MARK TRAHANT

A new White House report details the economic impact of Medicaid expansion and is sharply critical of the 22 states that have not done so. The report is titled, “Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid.

I like that: Missed opportunities. Why? Because this Council of Economic Advisers’ 44-page report fails to include any calculation of Indian Country as one of those missed opportunities.

I get that the population of American Indian and Alaska Natives is small, one percent or so. But you cannot build an economic case for Medicaid in Alaska, Oklahoma, Montana, North Dakota, South Dakota, Arizona, New Mexico (and even Washington and Oregon) without at least back of the envelope estimates. This is important because of the way Medicaid is structured; it’s a shared partnership between the states and the federal government. However American Indians and Alaska Natives are eligible for a 100 percent federal match, so the money spent by a state Medicaid program is fully reimbursed by the federal government.

This system, of course, makes no sense. And it’s probably why the White House failed or forgot to include Indian Country. A much sounder approach would be for the Indian health system — whether federal, tribal, urban or nonprofit — to get funding and administrative rules directly from the Centers for Medicare and Medicaid Services. Then Alaska, Oklahoma, or the other states that are currently rejecting Medicaid expansion would lose their say about what happens to American Indian and Alaska Native patients.

Let’s dig deeper into the White House report — then I’ll add numbers and context.

The administration is quite right to hail the Affordable Care Act’s economic success story. “Since the law’s major coverage provisions took effect at the start of 2014, the nation has seen the sharpest reduction in the uninsured rate since the decade following the creation of Medicare and Medicaid in 1965, and … the nation’s uninsured rate now stands at its lowest level ever.”

However 22 States—including many of the states that would benefit most—have not yet expanded Medicaid (although Montana has passed legislation to expand Medicaid and is working with the Centers for Medicare and Medicaid Services to determine the structure of its expansion). These 22 States have seen sharply slower progress in reducing the number of uninsured over the last year and a half, and researchers at the Urban Institute estimate that, if these States do not change course, 4.3 million of their citizens will be deprived of health insurance coverage in 2016.”

In Indian Country, the big three non-expansion states are Alaska, South Dakota and Oklahoma.

The Alaska Legislature recently adjourned without a vote on Medicaid expansion (a measure was proposed by Gov. Bill Walker). But an expansion may be still possible if the governor acts without legislative approval.

The White House report estimates Alaska would gain some $90 million in federal funds by expanding Medicaid. But that number, I believe, misses out the intersection between Medicaid and the Indian health system. The Alaska Native Tribal Health Consortium estimated that 41,500 Alaskans would be eligible for Medicaid — including 15,700 Alaska Natives and American Indians. In other words, more than a third of potential enrollees are eligible for a 100 percent federal reimbursement. Forever.

The numbers are similar and striking in South Dakota and Oklahoma.

The White House report says health insurance also reduces the risk of death. “This analysis estimates that if the 22 states that have not yet expanded Medicaid did so, 5,200 deaths would be avoided annually once expanded coverage was fully in effect. States that have already expanded Medicaid will avoid 5,000 deaths per year,” the report says.

This is a bit complicated, but I doubt if that number includes American Indians and Alaska Natives who are at risk of death because of funding shortages in the Indian health system. What’s now called Purchased and Referred Care is better funded than it has been in recent years, but that budget line still runs out of money for some patients needing specialty care outside of the Indian health system.

But the key point is that the Indian health system is underfunded and as the Kaiser Family Foundation noted “not equally distributed across facilities and they remain insufficient to meet health care needs.”

That unevenness is dangerous for the Indian health system — and it’s states that are limiting dollars by refusing to expand Medicaid.

We are seeing the evidence about how the Indian health system is picking up additional resources in states where there has been Medicaid expansion. In Washington, for example, I recently reported that tribal health facilities have increased their Medicaid funding by nearly 40 percent since expansion. This is new money in an era of austerity and it’s automatic funding that does not require appropriation from Congress.

Of course it would be ideal if the White House was making this case with hard numbers. The Indian health system is a federal obligation — a Treaty right —  that costs states little. Yet it’s the states that are setting the rules; so at the very least our advocate ought to be chronicling that impact. It’s a missed opportunity.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

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Congressional budget plan requires deep cuts in Indian programs

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Budget targets $246 million below last year’s committee levels, says Democrat on House Interior Appropriations

MARK TRAHANT / TRAHANTREPORTS.COM

House and Senate negotiators have reached a deal on a budget resolution. That agreement then would go to each House for a vote. (An outcome that is not certain.) But, if it passes, it would be the first budget enacted by Congress in six years.

Let’s be clear about this plan: It would require deep spending cuts in federal Indian programs.

While the budget itself is not law, it sets limits for each of the appropriations committees to follow. According to a report from The Associated Press the draft document adds some $40 billion to military spending and calls for deep cuts to all domestic programs, including the Bureau of Indian Affairs and the Indian Health Service.

“The plan sets broad budget goals but by itself has little teeth; instead, painful follow-up legislation would be required to actually balance the budget,” the AP said. “It also permits the GOP majority to suspend the Senate’s filibuster rule and deliver a special measure known as a reconciliation bill to Obama without the threat of Democratic opposition. Republicans plan to use the special filibuster-proof bill to wage an assault on Obama’s Affordable Care Act rather than try to impose a variety of painful cuts to Medicare, Medicaid, food stamps, student loans, and other so-called mandatory programs over Obama’s opposition.”

The House budget is blunt about the next steps required to balance the budget within a decade, including another repeal of the Affordable Care Act. “None of the reforms proposed in this budget will be able to solve the underlying challenges in our health care system so long as Obamacare remains on the books. Our budget fully repeals Obamacare,” according to the budget plan.

This very notion sets up a debate. President Barack Obama would need to sign any appropriation into law — so a veto threat has merit. But the Congress still must pass a bill to appropriate money that would defy their own budget rules on programs such as the Indian Health Service (because some of that agency’s authorizing legislation is the Affordable Care Act. Remember: The Indian Health Care Improvement Act is a chapter of the ACA.)

So the actual final budget is going to be difficult to resolve.

At the same moment that the Congress is pursuing its latest “repeal” of the Affordable Care Act more states, even states controlled by Republicans, are moving forward with an expansion of Medicaid. This may be the most important part of the Affordable Care Act, especially for Indian Country because it’s adding new dollars to the underfunded health care system. Montana is the latest state to expand Medicaid.

A new report by the Kaiser Family Foundation says hospitals in states with Medicaid expansion are reporting a significant decrease in uncompensated care and a boost from Medicaid revenue. “Overall,” the report said, “hospitals in Medicaid expansion states saw increased Medicaid discharges, increased Medicaid revenue, and decreased cost of care for the poor, while hospitals in non-expansion states saw a very small increase in Medicaid discharges, a decline in Medicaid revenue, and growth in cost of care to the poor.”

In past budget years, American Indian and Alaska Native programs have been able to get support from the appropriations committees, but in this cycle there will be less flexibility because of the instructions in the budget. The ranking Democrat on the House Appropriations Committee, Rep. Nita Lowey from New York, said the “Majority’s allocations, which are based on the House budget resolution that passed on a party-line vote, are insufficient and fundamentally flawed.”

She said: “The Interior bill’s allocation paints a similar picture with an allocation that is $246 million below the FY 2015 enacted level. We will still have to cover the increased costs to combat deadly wild fires, provide contract support costs in the Indian Health Services, and prepare for Centennial anniversary of the National Park Service, all from an allocation below last year.”

This budget resolution would cut deeper than even the sequester. As Lowey said in a press release, “I think my colleagues on the other side generally agree that sequestration was a failure, and a return to those sequester-level caps threatens important defense and non-defense priorities alike.”

The Republicans have yet to identify specific spending numbers based on their budget targets.

No Democratic votes are required in either the House or the Senate to enact this budget resolution. The president does not need to sign the resolution, but he will need to sign into law any future appropriations based on the spending plan.

Mark Trahant serves as the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Op-Ed post: Medicaid expansion will boost Montana’s economy, people

Montanans love to talk about how special our state is. For those from some place other than Montana, you may think that we mean our beautiful mountains, the vast golden prairies, and incredible blue sky that never seems to end. And you would be right – we do mean that. But what really makes Montana special is the people.

The people of our state are kind and generous. We are the type of people who celebrate together during the good times, and look out for each other when times get tough.

Montana is particularly lucky because the people can dramatically change the direction and future of our state. Over the last few months, it was clear that the people of our state stepped up and did just that. They talked and our legislature listened. Late last week, the Montana Legislature passed the Health and Economic Livelihood Partnership (HELP) Act (SB 405). This bill is compromise legislation to extend health care coverage to low-income Montanans who need it, and the Governor has indicated that he will sign it as soon as it reaches his desk.

We are a group of organizations that have spent the past two and a half years working to expand access to affordable health care for the lowest-income Montanans. And we will forever be grateful to you, the people of Montana, for making your voices heard.

It was you who made more than 10,000 calls and emails to your legislators in support of Medicaid expansion. More than 150 of you submitted letters to the editor and opinion editorials. More than 300 of you came to the Capitol to testify. You kept the conversation going on social media. Hundreds of you came to rally on the Capitol steps or walk the halls talking to your legislators. It was you who passed Medicaid expansion.

Montana will be a better place because you made your voices heard. This legislation will help create thousands of new jobs. Montanans will be healthier and more productive because when people have health care, medical problems are more likely to be treated earlier and illnesses are less likely to affect one’s ability to work. Our rural hospitals will be able to keep their doors open because more people will have insurance to cover medical expenses. Montana tax dollars will come back to our state to boost our economy. And most importantly, tens of thousands of Montanans will be able to get the health care they need and deserve.

Never forget that when you talk – and sometimes it has to be loud and often – but if you talk loud and often enough, your elected representatives will listen.

Montana thanks you.

Sincerely,

Montana Women Vote, Montana Human Rights Network, Montana Budget and Policy Center, Montana Primary Care Association, American Cancer Society Cancer Action Network, Montana Organizing Project, Planned Parenthood Advocates of Montana, Western Native Voice, SEIU 775, MHA…An Association of Montana Health Care Providers, and AARP Montana.

Updates: Medicaid expansion in Alaska, Montana — and oil prices.

MARK TRAHANT

Montana will be the next state to expand Medicaid. Gov. Steve Bullock is expected to sign the bill authorizing expansion into law on Wednesday at noon.

Remember this is a Republican-controlled legislature — so I think it demonstrates that when people really look at the numbers, the number of jobs, the number of people insured, the reduction in uncompensated care for health facilities, the case for expansion is overwhelming.

The Montana Budget and Policy Center reports that there remains work to be done. From the Center’s post: “Next, the state will have to submit a section 1115 waiver to the federal government to expand coverage and receive increased federal funds. Section 1115 waivers allow states to pursue experimental, pilot, or demonstration projects that promote the objectives of Medicaid, namely to keep low-income families healthy. (It’s called “1115 waiver” for short, because of the section in the Social Security Act where this flexibility is provided.)” That process will require approval from the Centers for Medicaid and Medicare Services (or CMS). “The 1115 waiver process is an important step, and we will be closely following it. 70,000 Montanans are depending on it.”

The Montana Budget and Policy Center also submitted an op-ed for publication. I’ll post that shortly.

Western Native Voice reports: Native Americans working for progressive change in Montana Indian communities will rally before the Medicaid expansion bill signing ceremony Wednesday, April 29th, at 11:30 AM on the stairs of the Capitol. Coming together to celebrate Medicaid expansion and all the other important legislative achievements for Montana Indians, the rally will also focus on the road ahead to building civic power in Native communities

In Alaska the outcome over Medicaid expansion is still unknown. The Alaska Legislature has not been keen on expansion despite a push from the Gov. Bill Walker.

The Republican strategy against Medicaid expansion focuses on reimbursement rates for Medicare, pitting seniors against those eligible for Medicaid (including the Alaska Native medical system). What’s interesting to me is that the job picture has not been a part of the debate when the evidence in every other state that has expanded Medicaid is that new jobs were added.

Two other Montana legislative developments: Enacting a water rights settlement and improving the funding for tribal colleges. The new law authorizes an 8% increase to the per-student funding that tribal colleges receive for non-Indian resident students, subject to appropriations, changing the distribution rate from $3,024 to $3,280 per non-Indian student. This is the first increase to the statute since 2006.

“In Montana, tribal colleges and universities benefit the state economy and provide an affordable option for quality post-secondary education,” said Laura John, State-Tribal Policy Analyst for the Montana Budget and Policy Center. “House Bill 196 takes us one step closer to reaching adequate funding levels needed to support Montana’s non-tribal students.”

The governor called the legislature back into special session. So there will be more twists and turns ahead.

I also wrote a few weeks ago about price of oil and its impact on Keystone, the tar sands, and other debates over energy policy versus the environment.

Two pieces are worth looking at. First, a Brookings report that says low oil prices are here to stay. (The reason is simple: Excess capacity, reduced consumption and lots of oil being pumped by every concern.) As the report points out: “The U.S. and its neighbor Canada have both increased oil output, and their response to the fall in oil prices has been to reduce the pace of production growth by reducing capital investment, but output and capacity continues to grow.”

Today Bloomberg posted five charts that tell the story quickly.  “Before deciding prices will race back to $100, here are five charts worth keeping in mind.”

Millions of Montanans, Alaskans and Native Americans wait for health insurance

Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).
Alaska Commissioner Valerie Davidson, Department of Health and Social Services, speaks about Medicaid expansion and reform at the University of Alaska Southeast. (YouTube photo).

Millions of Montanans, Alaskans and Native Americans wait for health insurance

MARK TRAHANT

The best case for Medicaid expansion in Alaska is being delivered by Valerie Davidson. She’s the recently appointed Commissioner of Alaska’s Department of Health and Social Services and a longtime advocate for improving Native health, most recently the senior director of Legal and Intergovernmental Affairs at the Alaska Native Tribal Health Consortium.

Davidson, who’s Yupik and a member of the Orutsararmiut Native Council, also chaired the Tribal Technical Advisory Group to the Centers for Medicare and Medicaid Services from its launch in 2004 until last year. In other words: She knows Medicaid cold. She knows how it benefits a state. She understands what works for Native communities. And, she conveys complicated ideas and statistics with ease.

This is the ideal time for that kind of logic.

Alaska’s Medicaid expansion has reached a decision point. The Alaska Dispatch News reported Tuesday that the governor is threatening a veto unless the Legislature takes on Medicaid reform and expands eligibility under the Affordable Care Act. (Update: The Alaska Dispatch News reports that Republicans are planning a caucus vote to kill the measure for this session.)

At a recent speech in Juneau, Davidson ticked off five reasons why Medicaid expansion makes so much sense.

First, it would expand health care insurance, thus improving health access for at least 42,000 Alaskans. Second, expansion would add money — and jobs — to a state that could use both right now. Third, expansion improves the state’s budget situation by adding more than a billion over the next six years. Fourth, it could be a catalyst for reform. And, fifth, expansion addresses uncompensated care.

Uncompensated care is perhaps the most important part of the Medicaid debate and it does not get a lot of attention. Even if government were to eliminate Medicaid or other insurance, people would still have health care costs. Someone always has to pay.

“We all end up paying for those uncompensated care costs. We pay through increased premiums. We pay for them when a hospital has to increase what it charges everybody else,” Davidson said. She said the hospitals provided more than $90 million worth of uncompensated care in Alaska.

Nationally the figures are huge. The Kaiser Family Foundation estimated uncompensated care at $84.9 billion in 2013. Most of that was paid for by hospitals (who pass the cost along to paying patients) and community-based clinics and health centers.

But here is the thing: The states that have expanded Medicaid are seeing the cost for uncompensated care figure dropping dramatically, saving those states some $5 billion.

The Indian health system has its own version of uncompensated care. We all understand and see the Indian Health Service as the government’s fulfillment of its treaty promises made to tribes. But the government does not fund IHS that way; the underfunding is substantial. The original Indian Health Care Improvement Act opened up new revenue from Medicare, Medicaid and other programs to add new dollars to the system.

So since the United States doesn’t fully fund IHS — and Indian Country has low insurance coverage — there remains a gap. Uncompensated care. Kaiser Family Foundation found that nearly a third, or 32 percent of American Indians and Alaska Natives are uninsured, and the cost to IHS for that care was at least $2.1 billion in 2013.

That’s why Medicaid expansion is critical to improve funding for Indian health delivery — especially in states with large Native populations such as Alaska and Montana.

Reservation Medicaid Benefits

Montana’s uncompensated care is nearly $400 million, according to the Montana Budget and Policy Center.

The Montana Legislature is nearing the finish line. Last week a key House committee voted to radically amend the legislation, essentially killing Medicaid expansion. For a bit. Then the legislation made it to the House floor where it passed 54 to 42 returning it to the Senate for minor changes. Supporters are hoping the Senate will make those changes and send the bill to the governor for his signature.

When the House passed the Medicaid legislation, a conservative group, Americans for Prosperity Montana, issued a press release saying the “decision stands directly against the voices of millions of Montanans who have made it clear that they do not want more Obamacare.” That phrase, #millionsofmontanans, quickly became a hashtag on Twitter (Montana has just barely a million citizens).

But Medicaid expansion would benefit millions — Montanans, Alaskans, Native Americans, and people in other states. What makes this argument interesting is that conservatives have lost on the evidence. In state after state the research continues to mount that Medicaid expansion was the best part of the Affordable Care Act and is creating jobs and pumping dollars into state economies. A study by Robert Wood Johnson Foundation says the total amount lost for states that have said “no” is more than $423 billion.

What makes this “debate” particularly maddening is that opponents to Medicaid expansion have no viable alternative — except the system that sticks hospitals, clinics and doctors with even more uncompensated care.

Mark Trahant serves as the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.