Here we go again: The congressional attack on health care, higher education #IndigenousNewsWire

Updated.

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Mark Trahant / Trahant Reports

Here we go again. The Congress is hell bent on wrecking the Affordable Care Act.

This time the mechanism is the so-called tax reform bill that will be voted in the U.S. Senate. The logic is rich (and, yes, “rich” is absolutely the right word and sentiment) because this tax cut will wreck the individual health insurance market so that the rich will pay less in taxes. But the problem gets at the core of insurance itself. How do you make sure there is a large enough pool to cover high cost patients? The Affordable Care Act did this by requiring everyone to buy health insurance or pay a penalty. Without that provision people who are healthy are free to skip out. But sick people always want coverage. And that creates an imbalance that does not work.

Senate Republicans added the provision because it saves money, some $338 billion according to the Congressional Budget Office. It estimates 13 million people will drop health insurance.

“We’re optimistic that inserting the individual mandate repeal would be helpful,” Senate Majority Leader Mitch McConnell said Tuesday.

The Senate bill is now being shaped into its final form. Wait. That’s funny. That’s what they say. But both the Senate and the House will change these tax bills all the way up until the final vote (unless it’s a sure thing, anyway). One of the reasons the bill will evolve is what’s called the Byrd Rule. This Senate is using the reconciliation process, like the Affordable Care Act repeal bills, so only 50 votes are required to pass. But that means the bill has limit of $1.5 trillion in new debt over 10 years and cannot add more after that. None of the bills, so far, accomplish that.

So the health care fight is back. And the Senate majority is confident this time they have the votes to pass the legislation.

There are other provisions in Senate tax bill that will impact American Indians and Alaska Natives.

One of the key ideas is to increase the size of the standard deduction so that fewer taxpayers will have to itemize. But to pay for that the simplicity the Senate bill is getting rid of some popular deductions, including the ability to deduct state and local taxes from your federal tax return. The bill also gets rid of deductions for dependents. The math works out so that families with fewer than three children will pay about the same. But if your family size is larger, then you will pay more. This is Indian Country. The average American family has 3.2 children, but in Indian Country it’s 4.2 children per family.

Update: The Joint Committee on Taxation released its findings on Thursday. Its research shows that taxes will increase for those earning less than $30,000 per year. And by a wide margin. The calculation is based, in part, on the current subsidy to purchase health insurance.

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And this is where it gets weird. The Senate bill does increase a tax credit, from $1,000 now to $1,650 per child. But, and this is huge, the additional $650 credit is only available to those who owe federal income taxes. It’s not refundable. This is important to people who are not rich because so many pay more in payroll taxes (Social Security, Medicare, etc.) than in income taxes.

Add it all up and the Senate bill would increase taxes on 13.8 million moderate income households. But, hey, at least the rich get a break, right?

The House of Representatives passed its version of tax reform Thursday by a vote of 227-205. No Democrats voted for the bill, while 13 Republicans opposed it.

The House bill is similar but takes a different tack on mortgages and the deduction of state and local taxes. The House would also eliminate the ability of families to deduct medical expenses. (Think about that when matched with the Senate’s plan to mess up health insurance.)

And the House bill really goes after university graduate students.

Many graduate students earn a small stipend for working on campus, doing research or teaching, and get a break on tuition. The stipend is already taxed. But the House would tax the tuition waiver, thousands of dollars. The average cost of graduate school is $30,000 a year at a public university and $40,000 at a private school. The Washington Post explains the problem this way: “Say you’re a married graduate student at Princeton. Your spouse has a full-time job and makes $50,000 a year; you have two school-age children. You’re filing a joint tax return. For sake of simplicity, you have no other deductions beyond the standard. According to H&R Block’s tax calculator, you would owe about $5,000 under the current law. Under the proposed Republican plan, you would owe about $15,000.”

The House bill also eliminates the deduction for interest on student loans and it eliminates tax credits for higher education.

This is terrible public policy. The digital age demands more education, not less, and the tax code should be in alignment. The House bill does the opposite. It will make higher education more expensive and less likely for too many people.

And just to make sure that higher education gets the message about what the country values, the House bill also would tax the larger university endowments, such as Harvard, Princeton, and even smaller colleges that have reserves of more than $250,000 per student.

But both the House and Senate do have one group in mind when writing this new tax code, business. The total “tax cuts” in the bill add up to $1.4 trillion over the next decade and of that amount, $1 trillion goes to businesses and corporations. It does this by reducing the corporate tax bracket from to 20 percent.

The other side of this tax debate is that it will reduce the amount of revenue that goes into the federal treasury. That means that soon after one of these measures passes, Congress will be required to look again at cutting spending.

Already the Congressional Budget Office estimates the tax bill will require $136 billion cuts from Medicare, Medicaid, and other entitlement programs. “Without enacting subsequent legislation to either offset that deficit increase, waive the recordation of the bill’s impact on the scorecard, or otherwise mitigate or eliminate the requirements of the [pay-go] law, OMB would be required to issue a sequestration order within 15 days of the end of the session of Congress to reduce spending in fiscal year 2018 by the resultant total of $136 billion,” CBO said Tuesday.

The Center for Budget and Policy Priorities pegs these coming budget cuts at $5.8 trillion. “These include $1.8 trillion in cuts in Medicaid, Medicare, and other health care entitlement programs and $800 billion in cuts below the already austere sequestration levels in ‘non-defense discretionary’ programs, the budget area that includes education and training, transportation, scientific and medical research, protection of the food and water supply, child care, low-income housing assistance, services for frail elderly people, and much more,” the center reports.

So we are just at the beginning of the debate. The conservative dream is to sharply cut taxes for corporations and the wealthy — and then to shrink government. The House and Senate tax bills do just 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 do so. Just credit: Mark Trahant / TrahantReports.com #IndigenousNewsWire #NativeVote18

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Lies we’re told: Strip millions (billions) from health care & call it better

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At a Senate appropriations subcommittee hearing Wednesday there was a testy exchange between Sen. Jon Tester, D-Montana, and the acting director of the Indian Health Service Rear Admiral Michael Weahkee (Zuni). Tester asked how money can be taken from the budget without hurting the quality of care or staffing at IHS. The Senate video is here.

Mark Trahant / Trahant Reports

A Senate hearing Wednesday on Indian health illustrates the larger problem exactly: How can you strip millions of dollars from a health care system and get better results?

The answer is you cannot.

But that’s not what the Trump administration testified. And it’s not what the Senate leadership is saying about its health care bill. Or the House for that matter.

So they lie. And it’s a lie that is so bold, so outrageous, that it should not told with a straight face. There is no defense. That’s why doctors, governors, hospitals, patients, economists, policy-makers, anyone willing to tell the truth about the destructive nature of these so-called health plans are in the opposition. A recent USA TODAY/Suffolk University poll shows the support for the Senate plan by only 12 percent making it one of the most unpopular bills ever.

And yet the Senate bill is still on the table. A new bill is out today and a vote could come as soon as next week. President Donald J. Trump told a Christian television show that he would be “very angry” if this bill fails.  “I am sitting in the Oval Office with a pen in hand, waiting for our senators to give it to me,” the president said. “It has to get passed. They have to do it. They have to get together and get it done.”

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I have been writing a lot about the GOP plans in the House and Senate. Three recent pieces: The impact on jobs in Indian Country; Trump tells tribal leaders Medicaid cuts will be good; and health care policy is a debate worth having (but this is not that.) And I still find I have something to say because the Senate and House bills are so harmful to Indian Country.

Let’s start with the hearing on Capitol Hill Wednesday. Rear Admiral Michael Weahkee, the acting director of the Indian Health Service, testified about the agency’s budget to the Senate Appropriations Subcommittee on Interior, Environment and Related Agencies, chaired by Alaska’s Sen. Lisa Murkowski. “I am pleased to provide testimony on the President’s Fiscal Year (FY) 2018 Budget Request for the IHS, which will allow us to maintain and address our agency mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/ANs) to the highest level,” began his written statement. It gets better: “The Budget reflects the Administration’s high priority commitment to Indian Country, protecting direct health care investments and reducing IHS’s overall program level by only 0.9 percent when compared to the Annualized Continuing Resolution, in the context of an 18 percent reduction within the overall HHS discretionary budget.”

In other words we’re cutting the hell out of all budgets — so be happy with your cuts Indian Country.

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So what if the words “maintain” and “raise” don’t fit with the highest level of health care. It’s no secret that Indian Health is already underfunded.

The measure of that shortage that makes the most sense is to compare spending by IHS to what’s spent by the federal government on federal employees. According to the National Congress of American Indians that measure shows IHS funding at about 60 percent of need.

(Of course you could argue that the U.S. health care system is too expensive. But that’s a different conversation. Reform is not even on the table right now. This whole fight is just about money; money for health care or tax cuts.)

The problem with the Senate hearing and a recent Wall Street Journal article on the failure of the Indian Health Service in the Great Plains is that the Indian Health Service is not what it was. It’s no longer just a government health care agency. In fact most of the agency is a funding mechanism for tribal and non-profit health care facilities.  The congressional oversight needs to be re-imagined to fit both of these missions.

The Journal stories highlighted operational issues in South Dakota and Nebraska that demonstrate a tragic failure. (This is the IHS story most of us already know.) And after years of warning the agency has not come up with a strategy to effectively fix its own management.

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“Because this is our IHS. These are our facilities that are supposed to care for our first people,” Sen. Murkowski said. “And the stories that were detailed were shocking.”

But Sen. Murkowski correctly identified the division within IHS. She told Alaska Public Media that Alaska’s Native health facilities are run by tribes, under contract to the IHS, so their problems aren’t the same. True. But that’s more than half of the system. That’s the story that the Journal did not tell (and do the reporting about why tribes and non-profits are able to deliver better care than the agency itself.)

The answer, in part, take us back to the larger Senate debate. The Alaska Native Medical Center has balanced funding: Money from IHS, aggressive third-party billing from private insurance and especially Medicaid as well as foundation grants. This kind of balance ought to be the future (unless Congress says, “well, let’s fund Indian health at 100 percent of need”) for others across Indian Country.

That’s why the narrative of failure is problematic. It’s true that there is a systemic crisis — especially in the Dakotas. So much so that Montana Sen. Steve Daines has even suggested changing the name of IHS to “Indian Health Suffering.” Old story.

But that’s why there should also be a narrative of success. I, too, would change the name of IHS, but to the Indian Health System. Because parts of that system are excellent and ought to be a model for health care, period.

And that’s where Medicaid comes into the picture. At the Senate hearing there was frustration because IHS did not provide enough data.

The IHS budget calls for $1.2 billion in third-party billing. Most of that is Medicaid. That will work for next year. But it’s important to remember the House and Senate plans will cap and reduce what is spent on Medicaid. Right now: If a person is eligible, the money  is there. Under the GOP alternative there will be a set amount of some kind. The money will run out.

But IHS officials did not talk about Medicaid much. And Montana Sen. Jon Tester pointed out:  “I think it’s absolutely unbelievable that you can’t separate how much Medicaid has helped your with third-party billing.” This is is what we need to know.

The Indian Health Service operates in both Medicaid and Medicaid expansion states. Remember not every state expanded Medicaid under the Affordable Care Act (To date: Thirty one states and Washington, D.C. are on board). For example: South Dakota did not and North Dakota did. So we ought to have data about how much Medicaid money goes into the system, for what kind of patents, and how it’s used (hint: by law it’s supposed to remain at the local service unit.) We should have similar data for tribal or non-profit facilities. Life-saving data.

The Center for Budget and Policy Priorities released a report earlier this week that highlighted the connection between Medicaid and Indian Health. “The Medicaid expansion has improved access to care for thousands of American Indians and Alaska Natives especially in states with large AI/AN populations including Alaska, Arizona, and New Mexico. It has also provided much-needed revenue to Indian Health Service (IHS) and Tribally operated facilities, allowing them to expand services and hire and retain more staff. Ending Medicaid expansion would jeopardize coverage for these newly insured low-income AI/AN adults, and reduce revenue for IHS and Tribally operated facilities, forcing them to revert to pre-ACA service levels.”

In Montana, a state that recently expanded Medicaid, more than 11,000 American Indians have signed up for the insurance. “At a time when Montana is working in a bipartisan basis to address the suicide epidemic and improving health outcomes for American Indians, D.C. politicians are threatening to take away health insurance for thousands of Americans Indians in Montana,” said Heather Cahoon, State Tribal Policy Analyst for the Montana Budget and Policy Center. “More than 11,000 American Indians in Montana now have access to health insurance through our bi-partisan Medicaid expansion plan, and we can’t afford to go back.”

But going back is on the Senate agenda today. The Republican caucus is counting votes to see if a compromise is possible within their own ranks. The bill will be released, scored by the Congressional Budget Office, and, if Sen. Mitch McConnell gets his way, there will be a vote early next week.

But the facts are this: The Senate bill still strips $700 billion from Medicaid. And that number will grow over time. And the Trump administration is cutting from the already underfunded Indian Health Service budget by 6 percent. Now. That, too, will get worse down the road.

And so there will be many lies flying fast. It’s a health care bill. Or this legislation won’t take away your insurance. Medicaid will be better off. So will the patients. Whatever. The Congressional Budget Office is wrong. Then there’s that forever lie: That United States is meeting its solemn treaty promises to American Indians and Alaska Natives.

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