What matters? Tax fight is about seven competing values #IndigenousNewsWire

doc_057b_big
Original federal tax return in 1913.

Why Indian Country should have a voice in this debate

Mark Trahant / Trahant Reports

There is no better way for any legislature — be it a tribal council, a state assembly, or a Congress — to telegraph what’s most important to a society than through tax policy. How a government collects revenue says what constituent groups are seen to matter. And, conversely, what groups and issues are insignificant. And, that of course, is Indian Country.

As Adrian Sinclair wrote in Cronkite News: “Indian Country once again does not have a seat at the table.” Tribes “aren’t treated the same as state and local governments across the board on a whole series of issues,” John Dossett, general counsel for the National Congress of American Indians, said after the hearing. “Tribes are … either ignored or they’re an afterthought.” He said there are many cases where state governments have more power than tribal governments, like the federal Adoption Tax Credit, which gives a credit to parents who adopt a child with special needs. But the credit only applies when a state court, not a tribal court, rules that a child has special needs.

So Indian Country is a perfect illustration for my larger point: A country’s tax policy shows what it values. The key to this idea is simple when a nation wants more of something, then taxes it less. And, other hand, if a nation wants less of something? Tax it more.

All interest on debt was deductible when the first income tax was created in 1894. Why? Because Americans did not like to borrow. It was almost immoral. As a writer for Harper’s Weekly warned a man in debt “must smile on those he hates, he must extend his hand where he would strike, he must speak pleasantly with a curse in his throat … He wears dependence like a yoke.”

But Congress made debt a better deal. You could borrow money for that new farm, or especially a home, and the government would subsidize the loan by making it a tax deductible transaction. By the 1920s car loans were the bigger deal. Americans were borrowing, buying and deducting. Congress created a monster with that policy and today debt is one of America’s great loves. Then in 1986 Congress switched gears: Today individuals can only deduct mortgage interest. But even that single benefit was generous. You could buy a big house. A bigger house. A ginormous house. And deduct 100 percent of the interest up to the cost up to $1.1 million of debt. And that tax deal includes second homes.

So as a policy the Congress was telling we the people buy bigger houses. And go ahead, get that second house in the woods or on the lake.

That’s what tax reform is, setting parameters for what the elected leaders think important for a national policy. So, if it becomes law, this tax reform will change the way we consumers spend money. Perhaps we’ll buy and build smaller houses and rent a cabin on the lake instead of purchasing one. This might be a good outcome for all of us. This is actually a pro-climate policy (please don’t tell Congress.)

This same priority process is true for renewable energy. Congress created incentives for wind, solar and other renewable energy. But, now the Republican plan is to reverse course, and reward oil, gas, and especially coal. Tax policy will favor fossil fuel development and renewable energy will therefore cost more. But will companies still invest? Who knows? We do know the calculations will be way more complicated. And, did I mention, renewable energy will cost more.

Let’s consider the overarching messages, the narrative, that will form policy in the tax bill before the Senate and the one already passed by the House of Representatives.

8-21-17tax_f1.png

ONE: The bigger the corporation, the bigger the break

The tax bills paid by corporations are driving the legislation in both the House and the Senate. Republicans argue that if taxes are lower, companies will invest more in the United States (instead of other countries) and hire more people at higher wages.  This debate is complicated because the current tax code is full of loopholes (something that Republicans say will be fixed). But the bottom line is that U.S. companies have a higher tax rate than what other countries charge, but, and this is huge, the companies actually pay less in federal taxes than what other other countries charge.

As the Harvard Business Review says: “First and foremost, corporate taxes are important because they help pay for government services. While they don’t account for as much U.S. tax revenue as they once did, they remain one of the central ways the government raises funds. According to the Tax Policy Center, “The corporate income tax is the third largest source of federal revenue, after the individual income tax and payroll taxes.”

The House bill cuts the top rate that large corporations pay from 35 percent to 20 percent. It would be the largest one-time drop in the big-business tax rate ever. And it’s a permanent change (the individual rates expire after a decade) at least until there’s another tax bill.

Companies will also get more deductions for purchasing new equipment. And there is an incentive for companies to move their profits back to the United States from low-tax countries.

The Senate bill is evolving. It also rewards big business. But in order to reduce the cost of the entire package, it delays reducing the corporate rate until 2019. (Imagine every business in the country holding off on just about any new activity because the tax laws changed next year.)

The metaphor: Multinational corporations rule.

TWO: It’s tough being rich

The New York Times’ Nicholas Kristof writes that it’s hard being a billionaire these days. “Why, some wealthy folks don’t even have a home in the Caribbean and on vacation are stuck brooding in hotel suites: They’re practically homeless! Fortunately President Trump and the Republicans are coming along with some desperately needed tax relief for billionaires.”

One way this works is be reducing the tax when someone inherits a wealthy estate. Both versions start this tax at $11 million. The House eliminates the so-called “death tax” in 2024 while the Senate keeps the tax but raises the exemption.

A second provision changes what’s called the Alternative Minimum Tax. The way that works is that after a tax return is completed, and there’s a whole slew of deductions, there is a calculation to see if that taxpayer should still pay something. The idea is to make sure that people earning more than $130,000 a year still pay an income tax, even if they find deductions in every corner. That goes away.

And there is one more goody for the rich. Charitable contributions can still be deducted.

The metaphor: Wealthy families so need our help. OMG.

THREE: Why work?

This part of the debate starts with the corporate tax rates. The Trump administration argues that cutting corporate taxes will benefit workers because companies will reward workers with better wages.

Treasury Secretary Steven Mnuchin claims that “many, many economic studies show that more than 70 percent of the burden of corporate taxes are passed on to the workers.”  However economists are divided. As the Center for Budget and Policy Priorities points out “this claim is misleading … the evidence indicates that most of the benefits from a corporate rate cut would go to those at the top, with only a small share flowing to low- and moderate-income families.  Mainstream estimates conclude that more than one-third of the benefit of corporate rate cuts flows to the top 1 percent of Americans, and 70 percent flows to the top fifth. Corporate rate cuts could even hurt most Americans since they must eventually be paid for with other tax increases or spending cuts.”

The bottom line is that the tax bill will not make life easier for people earning under $75,000 a year. The income tax portion might go down (depending on family size, smaller in this case is better) but costs will go up for education and health care.

And, on top of that, this tax policy will sharply reduce federal spending across the board. Last week the National Congress of American Indians (NCAI) and the Native American Finance Officers Association (NAFOA) came out against both the House bill and the Senate Finance Committee bills in part because of this point. “NCAI and NAFOA view it as deeply regrettable that neither the House nor the Senate bill takes seriously Indian Country’s priorities for tax reform,” a news release said.  “With respect to tribal nations, unless tribal provisions are included, the current tax reform legislation amounts to little more than a $1.5 trillion increase in the federal deficit over the next ten years. This deficit increase will inevitably create pressure to cut federal programs and services that are extremely important to tribal communities. Deficit-financed tax cuts that lead to austerity budget cuts would affect all Americans, but would disproportionately impact American Indians and Alaska Natives who rely on federal funding of the trust responsibility as well as social programs.”

The metaphor: Workers don’t matter.

FOUR: Help mom and pop sell stuff

Most people who own a small business structure their entity as Limited Liability Corporations, S-Corps, or a partnership. This means that the income generated is reflected on the individual’s tax return. The House lowers the taxes on profits from 39.6 percent to 25 percent and has a 9 percent increase on the first $75,000. The Senate goes a different route with a new incentives for small business. This is “pass through income” because of the structure. And this part of reform really does solve a problem. Small business is critical — especially in Indian Country — but does not get the attention (or the breaks) that large corporations do.

Rep. Markwayne Mullin, R-Oklahoma, said last week, “As a former small business owner, I understand firsthand how burdensome the current tax code is on Main Street. The Tax Cuts and Jobs Act delivers relief to mom-and-pop shops in our communities so that they can hire more individuals, grow their business, and invest more in our local economy.”

The metaphor: Small business is cool, too.

23116827_1272478376190630_2501867125517842173_o.png

FIVE: Elite colleges? Or is it, college only for the elite?

The House bill is an all-out attack on higher education. This is nonsense. Especially when the country needs to be competitive in a digital, knowledge-based world.

First up: Tax private universities’ endowments with a tax of 1.4 percent on portfolios that exceed $250,000 per full-time student. Only about a hundred schools would be affected, and it penalize colleges that have resources. Since those university operating costs will not go down, it’s not likely that this will result in more financial aid for students. The House also makes it impossible for tax-exempt bonds from private — and some public — institutions. This will make campus construction projects more expensive.

The House bill eliminates the deduction of interest for student loans. Americans now owe more than $1.4 trillion on student loans. It already is making it more difficult for young college graduates to buy homes, and transition into the middle class. This provision will be just one more thing. (And student loans are already stacked against the borrower. You can’t get rid of them in bankruptcy.) So instead of solving a problem, Congress is making it worse.

The House bill also repeals the Lifetime Learning Credit, eliminates the Coverdell savings accounts, but does expand the American Opportunity Credit.

The House bill would also classify tuition waivers as income (making a graduate student wealthy for tax purposes.) Imagine a “bump” in student’s income that is equal to tuition, some $30,000, $40,000 or even more. 

Laurie Arnold, Colville, director of Native American Studies and an Assistant Professor of History at Gonzaga University, remembers trying to explain this to Congress when she was in graduate school. “Many members of Congress had children enrolled in large/research universities, yet had no idea that graduate students teach the majority of introductory classes at those institutions. In general, the disconnect about this was broad, and many Members fell back on the language that not taxing the stipends was simply another tax break.”

Stipends are now taxed. And Congress is keen to add tuition waivers to the tax revenue pool. This will make it more difficult for people to pay for graduate school, and increase the debt levels for those who do. As a national policy this makes no sense. None.

As UCLA neuroscientist Astra Bryant told Wired magazine:  “I mentor two underprivileged undergraduate women, and my concern for them is that an increased tax burden would make it financially impossible for them to afford to pursue a PhD.”

And for Indian Country? There is already a shortage of graduate students and PhDs. Why should it be made more difficult?

The metaphor: College is stupid.

SIX: The growing gap between rich and poor

The gap between rich and poor is growing wider. “The wealthier you are, the more likely you are to benefit from the proposed tax changes. The poorer you are, the less likely you are to leave poverty,” writes Camille Busette for the Brookings Institute.

“Let me distill that: over one third of American households had trouble putting food on the table, putting a roof over their heads, or getting medical care; blacks and Hispanics are falling further behind whites in net wealth; and 99 percent of Americans hold a diminishing 76 percent share of income in the U.S. These are all alarming trends, but to have one-in-three consumers report that they cannot regularly put food on the table in the U.S., one of the wealthiest countries in the world, is the most deeply disturbing,” Busette writes. “Such a miserly budget, in combination with the tax reform plan, could mean the loss of some very important services for low-income and poor Americans.”

The tax reform measures will require massive budget cuts. Soon. Tribal governments will be hit hard. We already know how difficult sequestration was for tribes a few years ago. The kinds of cuts that will be needed to pay for these tax cuts will cost significantly more than sequestration.

The Center for Budget and Policy Priorities pegs these coming budget cuts at $5.8 trillion, $800 billion in cuts below sequestration levels.

The metaphor: You can’t afford to be poor.

SEVEN: Obamacare? Really? Again?

A serious question: Which house of Congress hates healthcare more?

The House kept the Affordable Care Act insurance mandates, but eliminates medical deductions. So a family that is dealing with a catastrophic, expensive medical event won’t be able to offset any of those costs from their tax bill. Already this provision is limited to higher income taxpayers. It’s only open to people who itemize their deductions, an estimated 8.8 million claimed it on their 2015 taxes, according to the IRS. But for those families that need this break, it’s a big deal.

Then the best thing Congress could do to help people with medical debt is to legislate another expansion of Medicaid. As Kaiser Health News reported: “A study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid. In some cases, struggles with medical debt can be all-consuming.”

The Senate is using tax reform to repeal parts of the Affordable Care Act. Again. The Senate would “save” money by ending the requirement to purchase insurance. It saves tax dollars because the government would not have to pay the subsidies for those who sign up under the plan (including those from Indian Country who get no cost plans under the exchanges).

And, repeating myself here, should a form of these bills become law there will be cuts across the board. The Indian Health Service (as well as Medicaid) will need to restructure because it will have so many fewer dollars.

The metaphor: Healthcare is only for those who can afford it.

 

A cold December

Congress wants to wrap up this debate before the end of the year and begin the provisions in the new tax year.

One more thing about values. The two tax bills define what’s important to a society. Alaska’s Sen. Lisa Murkowski was a champion on health care and was a key vote to stop the last Affordable Care Act repeal effort in the Senate. But this time there are competing values. She has also been a longtime supporter of opening the Arctic National Wildlife Refuge to oil and gas development. That’s in the bill. It’s her provision. So is she willing to give up on health care for more oil? And what about climate change? Murkowski was eloquent at the Alaska Federation of Natives saying that she is witnessing first-hand the impact in northern communities. This tax bill gives fossil fuels a boost — at the expense of the climate.

What’s really important? We are about to find out.

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

 

 

 

Indians don’t pay taxes? Or why the coming tax debate matters so damn much

Screen Shot 2017-10-01 at 1.24.06 PM.png
House Speaker Paul Ryan and Senate leaders announce their framework for Tax Reform. (Photo: Speaker.Gov)

Mark Trahant / Trahant Reports

The Senate has given up on destroying Medicaid and much of the health care system and is now focused on restructuring the federal tax system (and destroying entitlement programs in the process).

Here is what Speaker Paul Ryan said Sunday on CBS’ Face the Nation:  “We’re going to double that standard deduction. We’re going to make it so he can fill out his taxes on a postcard. We’re going to lower his taxes. That’s really important. So he has more tax-home pay. But there’s another component to this is, look at this machine shop, this business pays about a 40 percent tax rate but it competes with companies all around the world who pay an average 22 and a half percent on their taxes.”

The GOP Framework begins with this set of principles: “President Trump has laid out four principles for tax reform: First, make the tax code simple, fair and easy to understand. Second, give American workers a pay raise by allowing them to keep more of their hard-earned paychecks. Third, make America the jobs magnet of the world by leveling the playing field for American businesses and workers. Finally, bring back trillions of dollars that are currently kept off-shore to reinvest in the American economy.”

So how does Indian Country fit into that framework? Indians don’t pay taxes, remember? Actually if you Google that phrase it returns 2.17 million hits. It’s still a myth that will not fade away. But the larger issue of tax reform and its impact on Indian Country is still a complicated question, one that starts with the definition of “taxes.” Most so-called middle-income wage earners pay income taxes. Roughly one-third of all wage earners do not pay income taxes — and that would include a lot of tribal citizens, especially those living in their tribal nations. There are nearly 150 million tax returns filed every year and 36 million end up paying no tax at all. Another 16 million had taxable income but didn’t pay anything because of tax credits, deductions and other adjustments.

And, many of Indian Country’s working class especially benefit from one such credit, the Earned Income Tax Credit. This is a hugely successful policy that returns cash money to some 7 million family incomes; a paid bonus of sorts for working.

“Numerous studies show that working-family tax credits boost work effort,” according to The Center for Budget and Policy Priorities. “The EITC expansions of the 1990s contributed as much to the subsequent increases in work among single mothers and female heads of households as the welfare changes of that period, extensive research has found. Women who benefited from those EITC expansions also experienced higher wage growth in subsequent years than otherwise-similar women who didn’t benefit.  And, by boosting the employment and earnings of working-age women, the EITC boosts the size of the Social Security retirement benefits they ultimately will receive.

In addition, the research shows that by boosting the employment of single mothers, the EITC reduces the number of female-headed households receiving cash welfare assistance.”

So far, at least, there is no plan to end the Earned Income Tax Credit. However the House Budget Committee has proposed that the IRS require more proof from taxpayers and audit homes with an error. (Auditing the poor seems a long way from the Willie Horton philosophy of tax collection, or bank robbing, and that’s the idea you go where the money is.)

69acbbc5-36de-41de-942c-c1b9dd86047b

It turns out there is a lot of data on tax collection by county. So I looked at the counties with significant a Native American population and there is some fascinating data from the Internal Revenue Service, based on 2015 tax returns.

In Oglala Lakota County, for example, some 2,010 taxpayers out of 3,980 collected an average of $3,020. The bulk of that was collected by families earning less than $25,000. And the average tax bill was $7,170. The county is comprised almost entirely of Native Americans and the Pine Ridge Reservation.

The Earned Income Tax Credit is also critical to many Navajo families. In Apache County, Arizona, that includes a large portion of the Navajo Nation, some 27,172 take advantage of the Earned Income Tax Credit. And, like Pine Ridge, most are in the under $25,000 category, but the amounts are significantly more, an average return of a little more than $4,000.

In the Bethel Census Area of Alaska there are similar numbers. Nearly 2,400 people claimed the Earned Income Tax Credit and most of the workers earned under $25,000 and averaged a refundable return of $2,738.

My point here is that this is the one policy that is essential to Indian Country because it benefits so many people who have jobs but who barely earn a living wage. Any changes to this tax credit should be opposed vigorously.

It’s also important to remember that most tribal citizens pay  a higher percentage of our income toward payroll taxes, instead of income taxes. A report by the Congressional Joint Committee on Taxation says that the 80 million tax filers making $40,000 or less will collectively pay no federal income tax and many will even receive cash payments from the IRS in 2015. But they will pay $121 billion in Social Security and Medicare payroll taxes (including the employer share, which most economists believe falls on workers).

So that will be another important factor to watch as the debate heats up. Rarely does the payroll taxes — Medicare, Social Security, etc. — sneak into the larger debate about taxes. But it should be about the total taxation, not just income taxes.

And one other unique characteristic of Indian Country tax data is that the amount paid to state and local governments is significantly lower than the general population. In most states tribal members living on their home tribal nation pay zero in state and local taxes. This will be important to remember when Congress debates the deduction of state and local taxes. (A big deal for people living in high tax states such as California or New York, but less so in low tax states and where the sales tax is the primary method to fund state government.)

Congress has a complicated road ahead before it can even pass a tax bill. The plan is for both houses to enact a budget resolution, setting out the priorities for tax reform. This is a document that basically sets limits on spending (so the committees will still decide how to spend money for Indian programs, but will be limited by their budget ceiling). This will not be easy. The House and Senate will need Republicans to stick together on fiscal issues ranging from the border wall to how large federal programs should be cut back.

Basically the same tension that existed during the health care debate will play out between so-called moderates and the more strident anti-government wing of the Republican party.

If a budget is passed, the Senate can start take up tax reform and need only 50-votes to pass the legislation. Remember, if.

Speaker Ryan talked about fixing the business rate. The Republican mantra is that U.S. companies pay more than their global competitors. (Funny: This same argument doesn’t come up with health care where a company like Boeing spends a lot on its employee health care while the French Airbus can rely on its national health care system to save money.) But there is one last issue to watch: Don’t just believe any number that is posted as a tax rate. There may be a tax with 40 percent tax rate, but if the deductions and credits add up, the effective tax rate could be 20 percent. So that’s the number to watch and ask about, how much is that effective tax rate?

One final point: It’s interesting that so much of the discourse is about companies wanting to pay lower taxes as an incentive to create more jobs. Yet many technology companies are moving to the higher tax land called Canada. “As America closes its borders, Canada is playing the longer, smarter game,” Richard Florida and Joshua Gans wrote in Politico this week. “Canada, more than any other place, is uniquely positioned to benefit from Trump’s anti-immigrant posture … If he keeps up his anti-immigration push, the United States’ polite neighbor to the north could soon be eating Americans’ lunch.”

It’s not always about the taxes.

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

ICYMI: My first audio election special is on iTunes or Soundcloud. Download here. 

What’s next? Schoolhouse Rock, funding inequity & making sure law is followed

Screenshot 2017-07-28 05.23.41.png
How a bill becomes law, School House Rock style.

Mark Trahant / Trahant Reports

Senate Republicans campaigned against “Obamacare” for seven years. Yet there was never an alternative that had support from a majority of their own party.

The problem is simple: Many (not all) Republicans see health care programs that help people — the Affordable Care Act, Medicaid, etc. — as welfare. Others look at the evidence and see these programs that are effective: Insuring people, creating jobs, supporting a rural economy, and actually resulting in better health outcomes. Evidence-based success stories.

Of course Indian Country is squarely in the middle of this debate. Congress has never even considered, let alone acted, to fully fund Indian health programs. But the Affordable Care Act basically defined the Indian Health Service (and tribal, nonprofit, and urban operations) as health care delivery vehicles. And one way to pay for that delivery was by providing health insurance through an expanded Medicaid, no-cost insurance that tribal members could get through exchanges and employers. The ACA with all its faults sets out a plan to fully fund the Indian Health Service.

That’s the challenge now. Making sure that every American Indian and Alaska Native has insurance of some kind. Because of what happened (or, more accurately, what did not happen) in the Senate this week the money remains on autopilot. If you are eligible, the funding is there.

Yet the uninsured rate for American Indians and Alaska Natives remains high, as a Kaiser Family Foundation report noted a couple of months ago. “The Affordable Care Act’s Medicaid expansion provides an opportunity to enhance this role by increasing coverage among American Indians and Alaska Natives and providing additional revenue to IHS- and Tribally-operated facilities,” The Kaiser report said. “In states that do not expand Medicaid, American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities.”

This is a problem that will grow because of congressional inaction. Nineteen states including Oklahoma, South Dakota, Wisconsin, Wyoming, Idaho, Kansas, Nebraska, Florida, and Maine, have rejected Medicaid expansion. So a tribal citizen in those states gets fewer dollars for healthcare than some Indian health patients in North Dakota, Montana, Alaska, Arizona, New Mexico, or any other state that took advantage of the expansion.

As Kaiser notes: “American Indians and Alaska Natives will continue to face gaps in coverage and growing inequities in states that do not expand Medicaid. In states that do not expand Medicaid, many poor adults remain without an affordable coverage option and will likely remain uninsured. Similarly, IHS providers in these states will not realize gains in Medicaid revenue.”

This is the what’s next? How does the country manage this divide, especially in Indian Country. (And, just as important, we also need to see the gap measured. What are the differences in treatment and outcome between Montana and Idaho or North Dakota and South Dakota? Data, please.) This is critical because under current law, third-party billing (including Medicaid) remains at the local service unit. There is now a funding inequity that needs to be addressed by state legislatures. Recently Rep. Tom Cole, R-Oklahoma, said he knows these states and they won’t expand Medicaid. (Back to the welfare, thinking.) I hope not.

The Trump administration recently made it easier for states to get a 100 percent reimbursement for Indian health patients (enticing South Dakota to reconsider joining the ranks of expansion states.)

IMG_0078.JPG

So it’s possible, and a challenge, to make sure that the law is implemented, and that innovation continues. The ACA gives much power to an administration to a state to change the rules. You will see a lot of that now. Indian Country needs to keep a sharp eye on that process and raise objections if the result is unsatisfactory.

So why did the Senate bill fail? Sure, full credit should go to the heroic stands by Sen. Susan Collins, R-Maine, and Sen. Lisa Murkowski, R-Alaska. From the very beginning of the debate they were the party advocates for a Medicaid system that does produce better healthcare outcomes. And Alaska is a great example of that because nearly a quarter of the state’s population is served. This is how it should be across Indian Country and the nation.

And, of course, there was Sen. John McCain’s dramatic late night thumb’s down. The Arizona Republican was a no vote when it counted.

But that’s not why the bill failed. Fact is it’s remarkable that such nonsense got so far. It’s inconceivable that a plan was written at lunch the day before the vote. The bill failed because the Republicans, as a group, do not know where they want to lead the country on health care. They know they don’t want Obamacare (even though it’s based on conservative, market-based ideas). They sure as hell know they don’t want universal health insurance, either Single Payer such as Medicare for All or a government health service like Great Britain’s.

Yet when I listened to the debate yesterday so many of the complaints about insurance and costs could be solved by such a path. The problem here is that the United States made a huge mistake with employer-based insurance and that left out people who work for themselves or small businesses. The only way to fix that is a large pool of people spreading the costs, so that healthy people pay for sick people. The ACA tried to do that with mandates. Most countries accomplish that goal with universal insurance.

Another factor in the Republican plans — and another reason for the bill’s failure — is their absolute certainty in a market-based solution. Healthcare delivery and free markets do not play well together. The proof of that is simple: How much is an empty hospital bed worth to a business? Yet that should be the goal. And how much is it worth to a hospital-as-a-business to help a patient not need surgery? What market incentives are there for people to eat better?

Seven years ago, when I started writing a lot about health care, I did so because I saw the Indian Health Service as a fascinating example of government-run and managed healthcare. As we began this debate, I thought, let’s figure out what works and what needs work.

But I was way wrong. IHS is no longer only a government-run system. Much of the agency is now a funding mechanism for tribal, nonprofit, and urban operations). And that’s where so much of the innovation and excellence in Indian health exists. We need to more more about what’s working and why. Yet Congress (and the public narrative) continue to think of an IHS that no longer exists. At least entirely.

This might be a moment to focus on the latter part of what the agency does, improving the flow of funds, and adding more of our people to insurance rolls. Here’s the thing: We cannot do anything about universal health care. At least not yet. But we can have universal health care for Indian Country. It’s a huge task, but the ACA remains the law and it’s only a matter of execution (not a policy debate).

8840-02-figure-4.png

Third-party collections now account for about $1.8 billion out of the IHS’ budget. The dollars Congress appropriates is $4.8 billion. The third-party portion can grow through more insurance coverage. The appropriations side will require hard fights in Congress and the outcome is uncertain.

Back to the Senate. Texas Sen. John Cornyn, a member of the Republican leadership, joked that perhaps it’s time for a new way of doing business. “I guess we ought to go back to Schoolhouse Rock,” he said. That’s been a clear message from both Republicans and Democrats throughout this messy project. Get a bill. Hold hearings. Let a committee debate alternatives. Then let the bill come to the floor. Regular order. Schoolhouse rock.

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

 

 

 

 

 

 

Humor day in the Senate; Scary single payer & a halt to Alaska energy projects

Screenshot 2017-07-27 07.07.09.png
Single payer? A vote today on an amendment that Montana Sen. Steve Daines hopes will pout Democrats on record for such a scary idea. (YouTube photo)

Mark Trahant / Trahant Reports

Today is humor day in the Senate. But at least the healthcare debate will go on and on without a conclusion. And no matter what happens today and Friday there is still a long way to go.

The Senate has at least ten more hours of official debate on a House bill that’s been substituted with language that neither we nor senators have yet seen. (Leading to great theatrics by the Senate Democrats who said they’d offer no more amendments until there was an actual bill with, you know, like words in it.) But even without an actual bill Democrats sent the framework of the so-called “Skinny Repeal” to the Congressional Budget Office for a score and the answer is more of the same, the number of uninsured would increase from 28 million to 44 million in a decade.

Nonetheless by Friday there will be some sort of proposal that’s designed to get 50 votes so the legislation will go to a conference committee with the House. This Skinny Repeal strips the individual mandate (causing a mess in insurance) but leaves Medicaid alone. For now. Basically this means the House will get its way and senators will be forced to vote for that approach or nothing. It’s a risky strategy when the Republican majority is so slim. Actually in both houses.

C_aGbRyVoAE9v7N.jpg
Via a Tweet from Pat Bagley, editorial cartoonist at The Salt Lake Tribune.

Today the Senate will consider a proposal for universal health care, Medicare for all. Consider is not the right word here because the proposal is already doomed. But Montana Sen. Steve Daines wants Democrats on record voting for this scary, scary idea. But as Pat Bagley, the cartoonist for The Salt Lake Tribune tweeted yesterday, not one country that’s gone down the single payer path has reversed course. It’s the United States that is the outlier with our incomprehensible health care “system.” Even Bernie Sanders, who is for Medicare for All, said he won’t vote for this amendment because it’s a ruse.

Daines won’t be voting for his own amendment either. That’s not the point. Daines told the Helena Independent Record Wednesday night “It’s time for every senator to go on the record on whether or not they support a single-payer system.”

Screenshot 2017-07-27 07.18.40.png

So, while we are at it, let’s be clear about what Single Payer could do for the Indian health system. Indian Health Service funding would jump by at least 40 percent in a Medicare for all approach. The agency (and the tribal and nonprofit operations) would be equal with other healthcare providers; getting paid for every patient instead of worrying about appropriations or tracking down insurance payments from companies, Medicaid, and other third-party payers. So it would be a financial boom. Big time.

But as I said: Medicare for all is really not on the table. The Senate vote is just supposed to frighten Democrats. So. Be careful. Or Congress will give you health care. Aye.

Speaking of bad jokes, I laughed at the Trump administration’s threats to Alaska Sen. Lisa Murkowski. According to the Alaska Dispatch News, Interior Secretary Ryan Zinke warned Murkowski that Alaska energy projects could suffer because of her vote (and her leadership) against the GOP health care proposals. (I do think she could lose her Energy Committee chairmanship, but that, too is a silly move by Republicans in a narrowly divided Senate.)

So the Trump administration that wants Energy for All is telling a Senator who’s pro-energy that Alaska development is in trouble because she’s against their destruction of health care. Now that’s some weighty logic. Nonetheless Alaska Senator, Dan Sullivan reported this threat with a straight face. He told the Alaska Dispatch News that it’s a “troubling message … I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop.”

So oil companies be warned. You could be punished. As will we all. Be afraid. And remember universal care for all is up today.  So keep the children away from the Senate TV.

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

Today’s NewsRimes4lines …Screenshot 2017-07-27 08.37.40.png

Did you hear the one about the Senator raising concerns about Indian health?

Screenshot 2017-07-26 06.41.18.png
Sen. John McCain votes yes on the Senate’s Motion to Proceed, then attacks the process, only to vote yes on the first bill that failed his test of regular order. Quite a day. (Photo via Senate video)

Mark Trahant / Trahant Reports

The Senate is now going through 20 hours of debate on a House Resolution 1628 to repeal and replace the Affordable Care Act. But the House bill was stripped of every word except the title. Now the idea is to come up with the right language to reach 50 votes (so when like the Motion to Proceed, Vice President Mike Pence can break the tie and vote yes).

The first proposal, Senate Amendment 267, had all sorts of problems on the floor. The Senate’s Parliamentarian ruled that parts of the bill did not get a score from the Congressional Budget Office and other parts violated budget rules. So 60 votes, not 50 were needed for this version to pass. But the Republican leadership wasn’t even close to 50 votes — Nine Republicans voted against it.

Including Arizona Sen. John McCain who just a few hours before said he wasn’t happy with any of the legislative proposals. Think about this. He interrupted his cancer treatment (taxpayer funded health care) then gave a stirring speech about the break down of civility in the Senate. He said he would vote against the bills as presented, and then, votes yes anyway. Quite a day.  And so much for his words. I’ll admit: I thought McCain meant what he said.

Then at least McCain earned respect and praise from President Donald J. Trump. He tweeted: Thank you for coming to D.C. for such a vital vote. Congrats to all Rep. We can now deliver grt healthcare to all Americans!”

Screenshot 2017-07-26 06.34.31.png

Screenshot 2017-07-26 06.50.10.png

Now that’s something — as is the process itself.

This week’s Senate debate on TV will be exciting. Seriously. There will be many hours ahead of members speaking to an empty chamber about why the Affordable Care Act works — or why it should be repealed. (And lots of images of staff shuffling papers on camera.) Great theater, right? Then every once in a while (about the time paint dries) there will be a call for a vote and the dramatic calling of each senator’s name for a vote.

There are two main versions that will surface soon. The first is a repeal — or at least as much of a repeal as possible with 50 votes — that’s been proposed by Sen. Rand Paul, R-Kentucky. That proposal has little chance.

Then later in the week, Senate Majority Leader Mitch McConnell, R-Kentucky, will propose an amendment that they’re calling a “Skinny Repeal.” It would eliminate some taxes, a few more regulations, but leaves Medicaid alone. It’s supposed to be something for both moderates who want to leave Medicaid alone and for conservatives who want a repeal. Ha! And remember: If this version passes the Senate the bill will move to a conference committee with the House. That’s where the Medicaid cuts will come back. This is a phony negotiating plank.

As the debate unfolds, the Senate is in a way making the case for why we need Native Americans in the legislative process. There will be all kinds of talk about what the law does to Americans, to the poor, to taxpayers, to just about every constituent group in America. What’s really needed though is for one Republican senator to explain about the Indian Health system and what havoc all of these proposals would wreak. (Last week several Democrats did just that.) One majority party senator could say the Indian Health Service has never been fully funded, despite treaty promises, so why strip millions of dollars away? Or ask about Indian children when more than half are covered by Medicaid. Or show why Indian Country needs the jobs that have been created (and will be lost) by these proposals. Better yet: One Native Senator could use data to prove that Medicaid works.

Indian Country deserves to be in this debate. Alaska Sen. Lisa Murkowski has been a key opponent of the Republican leadership’s health care legislation. It’s mostly about Medicaid. I am sure that it’s also due to her support of the Alaska Native medical system. She gets it.

But Murkowski will pay a political price for her votes, at least in a primary election. But then she’s gone through that before. And won.  Not long after the Senate vote on the Motion to Proceed, the Alaska Republican Party said Murkowski abandoned them. Party chairman Tuckerman Babcock said the “repeal of Obamacare is non-negotiable.” (Funny: I feel the same way about the Senate alternatives.)

And so the party talks about possible consequences for Murkowski. Babcock said her vote put at risk new oil drilling in the Arctic National Wildlife Refuge (would that be true) and said her Energy Committee “chairmanship could be at risk.”

And President Donald J. Trump tweeted Wednesday morning: “Senator of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!”

So will there be punishment? I would not be so sure. Remember the Republican majority is thin. As I reported last week: Three senators switch sides and it’s a new Senate.  Two are already really, unhappy. So the way to make it three is for Republicans to continue to attack their own members.

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

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

 

Senate is blind: Healthcare vote minus a draft, public hearings, or common sense

Screenshot 2017-07-23 08.05.39.png
Senate Majority Leader Mitch McConnell (R-Kentucky) and whip John Cornyn (R-Texas) brief the press on the upcoming vote on a repeal and replacement for the Affordable Care Act. (Photo via McConnell Press Office on Twitter.)

Mark Trahant / Trahant Reports

Here we go again. Another week and the United States Senate is ready to vote on legislation to remake the entire healthcare system, including Indian health. The Senate will do this without a draft circulated for debate, public hearings, or common sense.

So what does the replacement bill look like at this point? I have no clue. Neither do the 100 senators who will make that call. As Sen. John Cornyn (one of the managers for the bill) put it: Knowing the healthcare plan ahead of the vote is a “luxury we don’t have.”

Here is what President Donald J. Trump tweeted over the weekend: “The Republican Senators must step up to the plate and, after 7 years, vote to Repeal and Replace. Next, Tax Reform and Infrastructure. WIN!”

Screenshot 2017-07-23 06.19.54.png

So there will be a vote on legislation to at least repeal the Affordable Care Act. “We have decided to hold the vote to open debate on Obamacare repeal early next week. The Obamacare repeal legislation will ensure a stable, two-year transition period, which will allow us to wipe the slate clean and start over with real patient-centered healthcare reform. This is the same legislation that a majority of the Senate voted to send to the president in 2015. Now, we thankfully have a president in office who will sign it. So we should send it to him,” said Sen. Majority Leader Mitch McConnell, R-Kentucky.

But a straight repeal is complicated by Senate rules. The Senate Majority Leader is relying on the process of reconciliation (essentially matching the legislation to an existing budget) because that only requires a majority, or 50 votes. Most bills need 60 votes to stop a filibuster. Last week the Senate parliamentarian, Elizabeth MacDonough, said that defunding of Planned Parenthood, abortion coverage, and restrictions on insurance coverage does not meet that test and still required 60 voters. Same thing for the Alaska or rural exception, it’s a no go. But Senate Republicans were quick to say that any draft language (which is still missing from action) could be rewritten. Or Republicans could overrule the parliamentarian on the floor which would cause all sorts of future problems governing.

The Senate’s parliamentarian is a great example of the institutions of Congress pushing back on the Republican proposals. I don’t think it’s ideology; it’s incompetence. (As I have written before there is a conservative approach to healthcare reform, but we have not seen that yet.) The Congressional Budget Office said last week that the big ticket in this debate is Medicaid. Remember the proposals in the House and Senate go far beyond just repealing the Affordable Care Act because the proposals would fundamentally restructure Medicaid.

According to CBO: “By 2026, spending for that program would be reduced by 26 percent … About three-quarters of that reduction would result from scaling back the expansion of eligibility enacted in the Affordable Care Act (ACA). In 2026, for people who are made newly eligible under the ACA (certain adults under the age of 65 whose income is less than or equal to 138 percent of the federal poverty level [FPL]), Medicaid spending would be reduced by 87 percent, from $134 billion to $17 billion—mainly because the penalty associated with the individual mandate would be repealed and the enhanced federal matching rate for spending on that group would be phased out. As a result of the reduced matching rate, some states would roll back their expansion of eligibility and others that would have expanded eligibility under current law would choose not to do so. All other federal spending on Medicaid in that year would be reduced by 9 percent, from $490 billion to $447 billion.”

This is what pays for the tax cuts in the Republican plans.

Rolling back Medicaid expansion and the traditional Medicaid program would significantly reduce funding for the Indian Health Service.

Last week the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health, wrote McConnell because one of the Senate bills, the Better Care Reconciliation Act of 2017, would change the formula for funding Indian health patients. The three intertribal organizations call the proposal a “radical departure from over 40 years of federal policy” and it “should not be undertaken without nationwide tribal consultation.” The bill’s language reverses a policy where states get a 100 percent reimbursement for patients who get services from the Indian health system. This change, the intertribal organizations said, would “ take away this unique incentive for states to work with tribes to create Medicaid innovations that best support the Indian health system.” States could create new rules that could ignore Indian health as a partner and create new barriers that would sharply reduce funding.

North Dakota Sen. John Hoeven, who is chair of the Senate Indian Affairs committee, said the changes would provide “more choice and competition in our health care system, while at the same time insuring that low-income individuals have access to healthcare coverage” via Medicaid or tax credits.

The key thing here: Native Americans could take their insurance (and the state Medicaid dollars) to another provider, reducing funding for IHS. (Competition, you know.)

It would be one more costly strike to an Indian health system that’s already underfunded.

Hoeven said a draft Senate bill also would end the requirement that tribes purchase insurance for employees. Again, the result would be less money for the Indian health system. (And, as the three intertribal organizations point out, this would be done without any tribal consultation.)

Then again the Senate and House bills are designed to strip money from the health system period. And Medicaid is such a rich target. The Kaiser Family Foundation estimates the total cost to states under the Better Care bill is $519 billion.

Screenshot 2017-07-23 07.56.11.png

Back to the math and this week’s vote. There are 100 members of the Senate. The 48 Democrats are certain to vote no. And of the 52 Republicans, it’s unlikely Sen. John McCain would leave his cancer treatment in Arizona to vote on a motion to proceed (the opening of the debate and the consideration of amendments). That leaves 51 votes. Sen. Susan Collins of Maine is a certain no because she objects to the attacks on Medicaid. That reduces the number to 50 (and 49 no votes). There are lots of questions about Senators Lisa Murkowski of Alaska, Rob Portman of Ohio, and Shelley Moore Capito of West Virginia. Capito tweeted: “I will only vote to proceed to repeal legislation if I am confident there is a replacement plan that addresses my concerns.” And Portman said he’ll review whatever bill comes up for a vote. Murkowksi told CNN: “I don’t think it’s asking too much to say give us the time to fairly and critically analyze these numbers. And if you say, well, CBO numbers don’t matter, let’s look at the numbers that you don’t think matter. But it really does make a difference. And these numbers that we’re talking about, these are men and women, these are our families that are being impacted. So let’s please get it right.”

Does that sound like three no votes? Right now, I’d only count all three as firm maybes. Then only one needs to be the no.

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

 

 

The Alaska Fix: How the Senate could fix healthcare & govern in the Trump era

LAM edit.jpg
The Senate is broken. Sen. Lisa Murkowski (who has already lost a primary only to win a general election) should consider The Alaska Fix for the good of the country. Three senators could put the Senate under new management (like the Alaska House of Representatives). (Senate photo)

Mark Trahant / Trahant Reports

The Senate is broken. Republicans control 52 seats only part of the time. Enough votes to win a majority and pass a judicial nominee. But not enough votes to fix the healthcare legislation sent up by the House. Or, more important, not enough votes to govern. Watch that problem grow on issues ranging from the federal budget to raising the debt limit.

The latest plan is a doomed vote on healthcare. Majority Leader Mitch McConnell told reporters that “as of today we simply do not have 50 senators who can agree on what ought to replace the existing law.” His response is to demand a vote to repeal the Affordable Care Act with a plan to pass a replacement bill later. The old kick-the-can-down-the-road approach. But first a vote — and already at least three senators have said they will oppose a motion to proceed so there will not even be a debate.

The Senate will be on record. And we will know which Republicans are more loyal to their party than the country. Then, the thinking goes, Republican voters could punish those members next election with primary challenges. (Already the White House is shopping for a candidate to run against Arizona Sen. Jeff Flake.)

This is governing in the Trump era. Make that, this is not governing in the Trump era. The twist in this story is that the majority of the Senate wants to work together, find common ground, and move on. The majority in the Senate could pass a budget. A majority in the Senate would raise the debt limit. And, most important, the majority of the Senate would act as a constitutional check on the executive branch.

This is actually what senators say they want. And get this: More than 70 percent of the public want bipartisan cooperation, according to a new Kaiser Family Foundation poll. Even 46 percent of Trump supporters say “they want to see Republicans work with Democrats to improve the Affordable Care Act — statistically tied with the 47% who would rather see Republicans continue working on their own plan to repeal and replace it.”

Meanwhile the White House is blaming Democrats for the failure to get 52 Republican votes. (Logic be damned.) And President Trump’s is again saying just let Obamacare fail (with his management help). He said: “It will be a lot easier. … We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail and then the Democrats are going to come to us.”

Same story from Republican leaders across the board. McConnell has used “working with Democrats” as kind of a threat. The message is GOP loyalty is more important than governing.

Enough.

The Senate could get back on track by picking up a lesson from Alaska: Choose to govern.

The Senate could function again if the majority — Republicans and Democrats — came together to lead. This is how it works in the Alaska House of Representatives; a governing caucus brings together 17 Democrats, 3 Republicans, and 2 independents.

A new Senate independent bloc could work the same way.

It would only take 3 Republicans to make it so. They’d join all of the Senate’s Democrats and independents to run the show. You could start with Senators Lisa Murkowski of Alaska, Susan Collins of Maine, and, since he’s so unpopular at the White House, Jeff Flake from Arizona. Either Murkowski or Collins would make a fine Majority Leader. (Yes, there will be retaliation from Republican loyalists. But even that might not work. Murkowski already knows what it’s like to lose a Republican primary only to win the general election.)

The Senate would be the counterweight to a Trump administration out of control.

This would mean new committee chairs, including Democrats. Imagine Patty Murray in charge of heath care legislation.  Or Bernie Sanders calling the shots on the budget. And Indian Affairs would be chaired by Tom Udall. A new day.

There is precedent. In 2001 the Senate was divided equally among Democrats and Republicans. The leadership went to Republicans because Richard Cheney was Vice President and could cast the deciding vote. But in May 2001 Vermont Sen. James Jeffords switched from Republican to Independent. One Senator flipped control from the Republicans to the Democrats in the middle of a session.

Jeffords’ obituary in The New York Times put it this way: “As chairman of the Education and Labor Committee … he had become frustrated by what he viewed as Republican parsimony.” As the dictionary puts it parsimony is cheap to the point of stinginess. True today. But then, like now, Republicans weren’t serious about governing. So for the good of the country — politics be damned — Jeffords placed the Senate under new management.

It’s time for new management in the Senate.

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

 

 

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

Screenshot 2017-07-13 08.38.41.png
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.”

Screenshot 2017-07-13 08.50.05.png

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.

Screenshot 2017-07-13 08.51.52.png

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.

Screenshot 2017-07-13 08.52.04.png

“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

 

 

 

 

 

 

 

 

 

 

 

The secret Republican health care plan: Cutting taxes and destroying Medicaid

 

 

DCPEt_hWAAASTB3
Make or break week? Senate Majority Leader Mitch McConnell said it was important to vote on a Senate health care bill before the July 4th holiday recess. But what’s in that bill? Ah. That won’t be known until it’s time to vote. (McConnell press office photo via Twitter.)

How to destroy the economy with 50 votes

Mark Trahant / Trahant Reports

I have been wondering what I should say about the Republican health care legislation in the Senate. We do know that there is a policy split among Senators about how much and how fast to cut Medicaid. We know the bill will cut taxes. But beyond that there is more information on one of my whiteboards than what is posted in public.

Senate Majority Leader Mitch McConnell is moving this legislation in secret. And there’s a reason. As The Washington Post puts it: “ So McConnell’s theory is that if the Senate’s bill were seen, debated and discussed, opposition would grow and grow, and eventually at least three of his members would bail out (the Republicans’ 52-48 majority means they can only lose two votes). Which might well be true.”

So true in fact that I am not sure which is a worse outcome for Republicans: Failing to pass a bill (ticking off their conservative base) or passing this legislation that by all independent measures will make the U.S. health care system worse.

img_0051

It’s easy to imagine the coming 2018 election commercials: Millions lose health insurance; health care-related bankruptcies on the rise; and all done in secret so that wealthy campaign donors pay less in taxes.

Indian Country, of course, is largely missing from this debate. There is an assumption that the bill doesn’t impact the Indian Health Service. But Medicaid is growing and it could be, no, ought to be, a significant funding stream for IHS. Even the Trump administration’s budget recognizes that. It projects $914 million in third-party billing for IHS in fiscal year 2018, a slight increase. That’s mostly Medicaid. But the numbers don’t reflect what will happen if that Medicaid money is taken away because the IHS appropriations (which is essentially flat) will have to serve more patients with less resources. Remember half of all Native American children are insured by Medicaid or the Children’s Health Insurance Program.

When the House passed the American Health Care Act a number of “moderate” House members said the bill was bad, but don’t worry the Senate will fix it. Even President Donald J. Trump echoed that idea, telling Senators the House bill was mean and that the Senate should be more generous.

In fact the idea that the Senate would make the bill better was a key part of the House vote. Alaska Rep. Don Young, for example, was said to be a no vote (Alaska gets the worse deal of any state in the House legislation) but ended voting yes. Young told the Alaska Dispatch News two things: First, the bill was moving too fast. And, more important, “this bill we passed today will not become law. It’ll be changed as time goes by. But unless we move it, or move a vehicle, nothing’s going to happen, and that’s not good.”

So process mattered. Then. Now the Senate is engaged in the screwiest legislative path ever; essentially asking Senators to support a blank page. And improving the bill? Hardly. The secret Senate bill is only trying to win with 50 votes, not shape sound public policy.

Every member of the Senate Republican caucus agrees on cutting taxes. That’s the fuel that keeps this bill moving forward. But not all agree about cutting Medicaid (and funding for Planned Parenthood). In a closely divided Senate some members are going to have to take one for the team; vote against their own state interests and voters. Thirty-one states expanded Medicaid coverage under the Affordable Care Act — and twenty of those states are represented by Republicans. All but three have to agree to take away insurance from their voters.

But that’s the easy sell. If there is a long transition period probably nearly all of the 20 Senators will go along. But the conservatives (especially those that represent states that did not expand Medicaid) want a quicker timetable. That means the “moderates” will be going before voters right away and campaigning on less Medicaid for all. That’s terrible politics because the numbers are staggering: Seventy million Americans are on Medicaid. If Congress turns this into a block grant program millions will lose health insurance. Millions of voters.

There are new studies that show how devastating the American Health Care Act would be to public health and the economy. A study by the Commonwealth Fund says nearly a million Americans would lose jobs if this legislation passes. “By 2026, 924,000 jobs would be lost, gross state products would be $93 billion lower, and business output would be $148 billion less. About three-quarters of jobs lost (725,000) would be in the health care sector. States which expanded Medicaid would experience faster and deeper economic losses,” the Commonwealth Fund study found.

Indian Country would lose jobs, too. There are no numbers yet but the Indian Health Service budget would take a significant hit and there would be pressure to reduce the number of employees. Remember the Indian Health system is Indian Country’s largest employer.

The Senate only has a few working days before it’s July recess. If it’s to become law, the bill will need a “score” from the Congressional Budget Office (because of Senate rules this bill must be budget-related). But that won’t happen unless McConnell thinks he has the 50 votes needed to pass. Policy be damned.

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

 

Why run? Utah candidate cites Standing Rock as ‘awakening’ #NativeVote18

Screenshot 2017-04-26 05.41.42.png
James Singer will announce his candidacy for the U.S. Senate on May 2. (Campaign photo)

 

Mark Trahant / Trahant Reports

James Singer will run for the United States Senate in Utah. He’s the first Native American to run in 2018 elections. Singer is a member of the Navajo Nation. He’s also the first candidate to cite Standing Rock as the answer to the question, “why run?”

“This past year has marked an awakening for Indigenous Peoples,” Singer said on his web site, Singer for Senate.  “At the center has been the struggle at Standing Rock, North Dakota against the Dakota Access Pipeline. I was moved to action as I saw my Native sisters and brothers stand against an encroachment which threatened not only their inherent sovereignty, but also their humanity. These water protectors were pummeled with rubber bullets, sprayed with powerful water cannons in freezing temperatures, attacked with dogs, and shot with pepper spray, while bulldozers cleared away sacred land and burial sites so that a pipeline could be pushed through. The love of money by a small, but powerful few, is sickening to the rest of Americans, regardless of political affiliation.”

Singer has already filed his paperwork, but the official announcement will be made at the Glendale Public Library in Salt Lake City on May 2. Singer is from Kearns, Utah, and currently resides in Salt Lake City. He teaches sociology at Westminster College and Salt Lake Community College and is currently in the sociology doctoral program at Utah State University. More about his background here.

According to his web site: “The Singer for Senate campaign stands alone as not only a representation of Native voices in Utah, where James is the first Diné (Navajo) candidate in the state, but also a departure from the grip of establishment politics as a social democrat.”

This is an interesting idea because it raises questions about the next generation and the rise of a new kind of politics. Imagine: Running for office in Utah on the issues of Standing Rock, and therefore climate change, the excesses of capitalism, gender inequality, and “a vision to live more sustainably.”

And 2018 will not be an ordinary election. Even in Utah. Sen. Orrin Hatch has already raised $1.3 million for his re-election effort but he may not run. Hatch is 83 years old. There have been several other Republicans who are considering campaigns, including former presidential candidate Mitt Romney. It’s also possible that Evan McMullin, a former CIA agent who ran for president as an independent, could run again as a conservative independent.

It’s way too early to say this, but what the heck, a three-way race would be the ideal outcome for Singer because it could split the conservative votes (Utah is one of the reddest states in the country) and open up a path for a different kind of politician.

It’s also true that Utah’s demographics are changing. Recent census data show that nearly four out of every 10 new Utah residents are from a racial or ethnic group. And Salt Lake County, the base of Singer’s candidacy, is 27.4 percent minority (accounting for nearly half of the state’s diversity). Another urban county, Weber, is 22.9 percent minority. (One rural county, San Juan, is 53.4 percent Navajo.)

But to win a Senate seat a candidate must create a much broader coalition. “I have lived in Utah nearly my entire life,” Singer says. “I know our values: We work hard. We want safe communities and to have enough to provide for our families, whatever they look like. We want people to be treated fairly and justly. We want to be able to better our lives. Our hearts ache to see suffering. We have a spirit of service and giving that is unmatched. We want to help those in need and share when we are prospering. There are so many things that we share in common.”

The Singer campaign is asking for small donations of $27 to fund their campaign. (Six years ago Hatch spent nearly $12 million for his re-election. Hatch has been in office since 1977.)

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