Republicans get their tax bill passed, and a shout out to the spirit of Andrew …

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Treasury Secretary Andrew Mellon championed tax cuts for the wealthy — and sharp budget cuts — in the years before the Great Depression. (Treasury Department photo)

Mark Trahant / Trahant Reports

Turns out we’ve been worried about the wrong, Andrew. The Republican tax plan, President Donald J. Trump’s signature legislation, would make Andrew Mellon proud.

Andrew Mellon was a wealthy industrialist who served in government as the Secretary of Treasury. Here’s what Trump’s own Treasury Department says about Mellon: “As the Nation embarked on the most materialistic period in its history, Mellon’s philosophy was one of debt reduction, tax reduction, and a balanced budget. His tax reform scheme, known as the Mellon Plan, reduced taxes for business. His theory was that big business would prosper in proportion to the lightening of its tax load and its profit would be transferred to the rest of the Nation. During much of his tenure, general prosperity and times of peace enabled Mellon to implement his measures. The Great Depression, however, beginning in 1929, undercut Mellon’s prestige and brought him under increasing criticism. Despite the downturn in the economy, Mellon continued his policy of balancing the budget by cutting spending and increasing taxes, which worsened the effect of the Depression on the ordinary citizen.”

History is prologue. Damn. You hardly have to change a word to know that this sentence is about now. Swap today’s Treasury Secretary Steven Terner Mnuchin for Mellon and the story still answers, what’s next?

Both the House and the Senate have now passed the legislation to cut taxes so that business will prosper by the lightening of its tax load and its profit would be transferred to the rest of the nation. The funny thing is that people really believe this load of crap. Then self-delusion was a common thread in the Senate debate. Maine Sen. Susan Collins voted yes because Mitch McConnell promised her budget cuts (including cuts to Medicare) would not follow. She even tweeted proof, a McConnell letter saying Congress has the power to waive such acts. But, does he have the will or the votes to do so?

The conservative wing is, at least, honest about this. When the tax cuts result in a massive expansion of debt they want sharp budget cuts. This is a core belief. And has been since Mellon’s time. Or as the Treasury Department puts it: “Despite the downturn in the economy, Mellon continued his policy of balancing the budget by cutting spending and increasing taxes, which worsened the effect of the Depression on the ordinary citizen.”

Or there was Arizona’s John McCain, the so-called champion of regular order, voting for a 479-page bill with handwritten amendments. A bill that will add (by Congress’ own estimate) about a trillion in debt was passed in a few weeks without the usual hearings or independent scoring. The maverick did not care about process. Get it done.

How bad is this bill? It’s right up there as one of the most unpopular bills ever. An average of polling shows its popular support at about one-third. And, get this, FiveThirtyEight reports that this bill is even more unpopular than tax hikes.

A couple of things about Indian Country: So many of our tribal citizens are the low end when it comes to earning. This bill does nothing to lighten that tax load. Indeed a late night effort to increase tax credits for children, making them refundable. (Remember nearly half of all Americans don’t pay income tax, it’s the payroll tax that is the burden. This would have helped.)

And instead of turning the dial back on fossil fuels this bill aligns the tax code for more development. Alaska Sen. Lisa Murkowski has made this part of the legislation her signature, not health care, and certainly not climate change (as she so eloquently talked about during the Alaska Federation of Natives convention in October.) She owns this.

The Atlantic magazine says this bill “could forever alter Alaska’s Indigenous communities” by development. “The issue still divides Native villages, counties, and Native nations in Alaska. It also sets tribes with differing claims to Alaska’s North Slope against each other.”

This bill also strips the mandate to buy insurance. A win for freedom, right? Perhaps. But it also means that healthy people will not buy as much insurance leaving sicker, older people to pay the bills. It will weaken the insurance framework. At least 13 million fewer people will carry health insurance as a result.

However there are winners: Big corporations, rich would-be heirs (like the Trump children) and religious schools (an amendment by Ted Cruz expands tax-free savings for this purpose).

The process ahead: This bill will still have to be reconciled with the House. There are differences, such as taxing graduate students and deducting medical expenses.

But cutting taxes (and then the budget) is something Republicans have championed long before Andrew Mellon. So this bill is likely to become law soon. President Trump can make both Andrews proud.

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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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

Senate’s ‘last’ shot at Repeal and Replace? Indian health still gets dinged

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Alaska Sen. Lisa Murkowski could once again be a deciding vote on the future of health care. (Senate photo)

Mark Trahant / Trahant Reports

You have to wonder why the latest Senate Republican plan to repeal and replace the Affordable Care Act did not get written with one senator in mind, Lisa Murkowski of Alaska.

Yet the bill by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) is more conservative than previous approaches. It has lots of wish-list boxes to tick, no money for Planned Parenthood, big tax cuts, and its spends way fewer federal dollars. The bill only needs 50 votes to pass but that must happen before the end of this month.

Medicaid would become a block grant program that states could design (and pay for). So it would likely disappear. The Center for Budget and Policy Priorities estimates that federal funding for health care would be reduced by $299 billion in 2027 alone with cuts impacting all states. And here’s a fun fact: Big states that expanded Medicaid would be hit harder. A lot harder.

Why 2027? That’s the year block grants disappear.  Graham and Cassidy argue that only a temporary block grant would be allowed under the rules of debate. So no “new” thing. Congress would have to meet “pay for” standards to replace that after 2027; meaning there would be cuts in other federal programs equal to the new spending.

And, like other Republican plans, this one would add significantly to the ranks of the uninsured. The Center for Budget and Policy Priorities estimates 32 million would lose coverage. States could also end essential benefits, coverage of pre-existing conditions, and allow companies to charge people significantly more when they’re ill. (Health insurance coverage that you cannot afford is the same as no insurance.)

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“Like the earlier version of the Cassidy-Graham plan, the revised plan would disproportionately harm certain states. The block grant would not only cut overall funding for the Medicaid expansion and marketplace subsidies but also, starting in 2021, redistribute the reduced federal funding across states, based on their share of low-income residents rather than their actual spending needs. In general, over time, the plan would punish states that have adopted the Medicaid expansion or been more successful at enrolling low- and moderate-income people in marketplace coverage under the ACA,” the CBPP reports. So by 2026, the “20 states facing the largest funding cuts in percentage terms would be Alaska, California, Connecticut, Delaware, the District of Columbia, Hawaii, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Montana, New Hampshire, New Jersey, New York, North Dakota, Oregon, Rhode Island, Vermont, and Washington. These states’ block grant funding would be anywhere from 35 percent to nearly 60 percent below what they would receive in federal Medicaid expansion and/or marketplace subsidy funding under current law.”

A lot to like in Alaska, right? Murkowski said she is undecided until she sees the Congressional Budget Office assessment. She told CNN: “I will use the governor’s words,” Murkowski said, referring to Alaska Gov. Bill Walker. “He said, ‘I understand that a block grant gives me increased flexibility, but if I don’t have the dollars to help implement the flexibility, that doesn’t help us much.’ So, we are both trying to figure out how those dollars fall.”

Graham-Cassidy plan continues the 100 percent reimbursement to states for patients served by the Indian Health Service and it adds an increase in the federal match to 100 percent for medical assistance provided by non-Indian Health Service providers for tribal enrollees. The idea is more American Indians and Alaska Natives should take their business away from IHS facilities. Let’s be clear about this: It would drain resources away from the Indian health system.

This bill would also allow tribes to set up group plans to buy insurance for tribal members to replace the Medicaid expansion. “Creates new optional coverage group as of January 1, 2020 for members of Indian tribes up to 138% FPL in states that had expanded coverage as of December 31, 2019, who were enrolled in Medicaid as of December 31, 2019, and do not have a break in eligibility of 6 months (or a longer period specified by the state).”

So in summary this bill would not add any new resources to the Indian health system. But it would cut funding significantly (again, remember Medicaid).

The last Senate Republican plan failed by a single vote. It’s likely that Arizona Sen. John McCain will end up being a “yes” this time around (the state’s governor is giving him cover, saying it’s a good plan). However Kentucky Sen. Rand Paul says he’s now a “no.” In his mind this plan does not repeal the Affordable Care Act. Susan Collins remains a likely “no.” If those positions stay the same, then this bill’s fate could end up being decided by Senator Murkowski.

Is there anything in this legislative gem that improves health care in Alaska? No. Does it improve the Alaska Native medical system? No. The Indian Health Service? No. Then why is she even considering this vote. It should be an easy no. Again.

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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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

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Health care delivery is worth a policy debate; but Senate bill is not that

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Mark Trahant / Trahant Reports

The Congressional Budget Office report on the Senate majority’s health care bill — the ironically titled “Better Care Reconciliation Act of 2017” — ought to be enough to put to rest any idea that Republicans want to improve health care in this country.

There are legitimate conservative ideas about how to reform health care. You know, the stuff they have been saying for years about market-based reforms where people can shop for their doctors and clinics online across state lines. Think Amazon. Modern, high tech, affordable care.

But that’s not on the table. Instead the House and the Senate are trying to legislate a huge tax cut, make a small dent in the long-term federal spending, trim spending on insurance subsidies, and the destroy Medicaid (and, as a bonus, shift responsibility from Washington, D.C., to state governments.)

 

Here are the numbers to back up that paragraph: CBO says the tax cut is worth $541 billion. The long term deficit reduction totals $321 billion. Getting rid of insurance subsidies under the Affordable Care Act saves $408 billion. And recasting Medicaid as a block grant (as well as phasing out the expansion) is worth $772 billion.

 

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Neither the Senate nor the House bill accomplish any health care goal. Neither bill will help people get insured. CBO says “in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026.”

And down the road when Medicaid reflects “lower spending” that too would “lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

CBO says that even employer-based health care would shrink.

The crazy thing is that older people would be impacted the most by both the Senate and House approach.  As the Center for Budget and Policy Priorities reports: “For people age 60 or older with income at or below the poverty line, individual-market premiums would consume at least 45 percent of their income.  The share would be even higher in higher-cost states and for people at lower incomes.”

And that’s where geography impacts Indian Country. Alaska, for example, would have the highest cost in the nation. In fact: If you are 60 and trying to buy insurance … it’s basically unaffordable. Insurance costs will far exceed affordability in North Carolina, Oklahoma, Arizona, and Wyoming.

This is what’s so important to the Indian health system. Instead of getting funding from third-party billing — mostly Medicaid — the Indian Health Service would have to rely almost entirely on appropriations. The bottom line: There will not be enough money.

Remember both the House and the Senate want to convert Medicaid to a block grant. This is not just rolling back Obamacare, it’s returning health care to before Lyndon B. Johnson’s Great Society programs.

As the CBO puts it that will lower Medicaid participation by 9 million in 2020 and by more than 14 million by 2026. That’s a lot of people.

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Most of the discourse about Medicaid centers on health care. But the program also provides long-term care to elders and disabled in assisted care or in-home care. The way this program works: You give up your assets (except Trust-based assets) and then the government promised to pay for your care. The Centers for Medicare and Medicaid say American Indian and Alaska Natives are a fast growing population that already rely on these services. “Between 2000 and 2010, the number of AI/AN adults 65 years or older increased by 40.5%, a growth rate that is 2.7 times greater than that of the overall population of older adults (all races) over the same 10-year period. The AI/AN elder population is projected to reach 1,395,000 by the year 2050; that’s a 3.5-fold increase from 2010 to 2050. In addition to studies that reflect the growing population of older AI/AN adults, other studies have revealed that AI/ANs suffer a disproportionately higher rate of disabilities including (lower body) functional disabilities that increase this population’s risk for falls, demonstrating a clear need for LTSS within this population.”

So if the Senate or House bill becomes law future services — as the need grows — will be sharply curtailed. And I can’t answer what will happen to people living in nursing homes now. If a state cuts the payment to a private facility, they could, in theory at least, ask people to leave. Let that sink in. People who have given up everything to live in an extended care facility could end up with no place to go. It will all depend on state legislatures or tribal budgets.

I am used to looking at both sides of any issue. I’m interested in views different than my own and exploring whether they have merit. As I wrote above: There is a conservative approach to health care that’s worthy of debate (I’d likely still come down on the side of single-payer.) But the House and Senate bills are not it. The only ideology at work is a tax cut; a painful tax cut at that.

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