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Funding Indian Health

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Why did the U.S. Senate fail to repeal Obamacare? Two Republican Senators, Susan Collins of Maine and Lisa Murkowski of Alaska, were clear from the beginning of the debate that they did not want to see Medicaid destroyed. Then, last week, Arizona Sen. John McCain walked to the floor of the Senate and gave his thumb’s down. McCain was a no vote when it counted.

This is Trahant Reports.

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

Many (but not all) Republicans see health care programs that help people as welfare. This includes: the Affordable Care Act, Medicaid, even Medicare. Other Republicans look at the evidence and see these programs as effective: insuring people, creating jobs, supporting a rural economy, and actually resulting in better health outcomes.

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 last week the money remains on autopilot. If you are eligible, the funding is there.

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.

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.

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. Indian Health programs can be fully funded — even in the era of President Donald J. Trump.

 

I am Mark Trahant.

Senate ready to vote again

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Republican leaders in the Senate Mitch McConnell (R-Kentucky) and John Cornyn (R-Texas) say a vote on health care will be scheduled early this week. But Senators are unclear about which proposal will be voted on. (Senate photo)

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, public hearings, or common sense.

So what does the healthcare bill look like at this point? I have no clue. Neither do the 100 senators who will make that call.

This is Trahant Reports.

There will be a vote to at least repeal the Affordable Care Act. And perhaps replace it, too. But what the bill looks like is unclear.

Last week the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health, wrote that one of the Senate proposals, the Better Care Reconciliation Act of 2017, would change the formula for funding Indian health programs.

The three intertribal organizations called 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 shifts the funding formula for Indian Health Service patients who are funded by Medicaid. This change would take away from the 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 even ignore the Indian health system as a partner and create new barriers that would sharply reduce funding.

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

Back to the math:

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 (that’s the opening of the debate and consideration of amendments).

That leaves 51 votes. Sen. Susan Collins of Maine is a certain no. 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.” Portman said he’ll review whatever bill comes up. Murkowksi has said she is concerned with the process — and the impact of a bill on families.

Does that sound like three no votes? Right now, I’d only count all three as a firm maybe. Then again only one needs to be the “no” vote.

I am Mark Trahant.

Senate Health bill would cut jobs in Indian Country

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The Indian Health Service is Indian Country’s largest employer. Proposals in the House and Senate would significantly cut Medicaid — a program that accounts of IHS jobs. (Trahant photo)

The Senate is back this week and Republican leaders are once again looking for votes for their health care plan. It’s a tough sell for lots of reasons. The bill tips towards conservatives and moderates say no. Rewrite the language so that moderates are happy — and the conservatives bolt. And it only takes three GOP no votes for this bill to fail.

Both the Senate bill, and the House counterpart, are supposed to be about repealing the Affordable Care Act. But for Indian Country there is something else at stake, jobs.

This is Trahant Reports.

Some history. I am not sure of the exact year. It probably happened around 1996. That’s when the Indian Health Service became the single largest employer in Indian Country.

This makes sense when you think about it: Indian health was once a small (unappreciated) division of the Bureau of Indian Affairs. But by 1996 the agency’s budget was larger than the BIA’s — and there were likely more workers. The administration estimates that next year the BIA will have some 6,770 full-time employees while the Indian Health Service will have more than 15,119 employees.

Big numbers, right?

A fast-growing category of jobs is called “healthcare support jobs.” The list here would include Community Health Representatives (long a staple in Indian Country), medical record keeping and coding jobs, as well as different kinds  f medical technicians. These can be good gigs in a rural, tribal community.

That’s an area of jobs where Medicaid funding is key and it’s a resource that would go away in both the House and Senate plans.

Alaska is a prime example. More than half of Medicaid spending serves rural constituents. Medicaid covers two-thirds of all American Indian and Alaska Native children and more than one in four of American Indian and Alaska Native adults. The Urban Institute estimates that the kind of block grants found in the Senate’s Better Care Reconciliation Act would cost the state $590 million in federal funding — a number that would decline even sharper after 2025. And, of course, the job losses would be substantial.

Medicaid already directly accounts for 24 percent of IHS’ workforce, but even that is short of the kinds of jobs that serve tribal communities. It does not include school-based programs. Or those private companies that bill Medicaid for transportation of patients or other patient services.

So as the debate heats up this week, remember that the Senate bill is about a lot more than just how healthcare is delivered. It’s also about jobs. Thousands of jobs. I am Mark Trahant.

 

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Trahant Reports: Fake News

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What is fake news? And, how do you spot it? How do you make sure you know you are reading or hearing something of value.

This is Trahant Reports.

 

Fake news is not a new thing. I remember the Weekly World News – a supermarket tabloid – with headlines such as:

“Dick Cheney is a robot!”

Many, many versions of “Elvis is Alive” (and usually doing something remarkable).

And, my favorite, “Bat Child Found in Cave!”

So fake news is not new at all. But what makes it a topic is that stories like the ones I just mentioned are easily shared on social media. In a supermarket line, we look at the headlines and laugh. On social media too many treat the sources as legitimate and serious.

The web site Fake News Watch breaks the content into three categories. Out and out Fake News; Satire; and Clickbait.

The goal of fake news sites is to get people angry after they believe the story, to discredit other media, and to get people to share.

Satire sites, such as The Onion, are supposed to be funny. A laugh. But connected to the truth?  Sometimes. Humor also requires discernment. There is a difference between the Daily Show — one that builds its humor off of real news and The Onion. The Onion is funny but it just makes stuff up. We need both kinds of humor. But we also have to know the difference.

The third category is clickbait. Clickbait websites take bits of true stories but insinuate and make up other details to sew fear.

So how do you defend yourself against this nonsense?

Facebook is taking some steps. But the best thing is for everyone who uses social media to ask themselves, Is this really true? Do that before passing it along. A few things to look for are lots of exclamation points, phrases written in all caps, and bad grammar or spelling.

Real journalism practices the craft of verification. It’s not enough to learn a fact — that fact should be checked out.

Indian Country has its own stories about fake news, too. There have been reports from Standing Rock, for example, that were passed along on social media (such as helicopters gassing the people at the camps) that did not stand up to verification. On a story that big, that important, it’s especially critical that people share accurate accounts. Rumors and hoaxes are dangerous business.

So it’s one thing to learn from what you read, see or hear. But it’s also essential to also verify that information.

Now back to the adventures of Bat Boy … I am Mark Trahant.

Senate Healthcare Bill

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Alaska Sen. Dan Sullivan will have to decide what’s more important: Tax cuts or Medicaid? The Senate vote is expected to be close. Both Sullivan and Sen. Lisa Murkowski have said they remain undecided about the legislation because of its impact on Alaska.


The Senate healthcare  bill, like its House counterpart, has a simple message for Indian Country: Don’t get sick. Not in June. Not anytime soon. This bill is not about health care because it takes billions of dollars away from public health insurance and passes that savings to wealthy Americans via tax cuts.

This is Trahant Reports.

How bad could the legislation be? The official financial review from the Congressional Budget Office is expected soon. The scoring of a similar House bill projected that by next year 14 million more people would be uninsured. And by 2026, an estimated 51 million people under age 65 would be uninsured.

The important takeaway from both the Senate bill and the House version is that it strips money away from Medicaid ($834 billion) — a public insurance program for people who are poor or disabled — and gives that money back to high-income taxpayers ($664 billion).

The Senate bill takes a little longer to destroy Medicaid. It begins phasing out the expansion in 2021 and that will be completed by 2024. The Republicans argue that this would control costs, slowing the growth of government spending. (Now Medicaid is automatic: If you are eligible, the money is there.)

Medicaid accounts for about 20 percent of the budget in most Indian health system clinics and hospitals. And, more important, it’s a growing source of funding. It pays for medical procedures and for transportation to clinics. It’s the big ticket.

But Medicaid is also an odd duck. It’s officially a state-federal partnership so the federal government picks up most of the cost and sets some of the rules, while states get to determine other rules. Both the Senate and the House bills would let states do more (such as requiring patients to work) or especially, what’s covered by insurance.

This is particularly messy for Indian Country. Both the Senate and House bills recognize the Indian Health System as unique (and paid for by the federal government). So the legislation preserves the 100 percent match. And in theory both the Senate and House would keep in place federal rules for tribal members on some state requirements such as work rules. The states that now have Medicaid expansion, through the Affordable Care Act would have to phase that out.

The biggest problem for Indian Country is that the Senate and House bills would destroy the framework of Medicaid. The thinking goes that Medicaid is just another word for welfare and states should sharply reduce what is spent by government and let hospitals cover the cost of “charity.”

The Senate vote is expected to be close. And that means the bill could change again as leaders try and round up enough votes for passage. I am Mark Trahant.

Trahant Reports: Standing Rock Wins Court Case

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The story of Standing Rock has always been about the water and the treaty rights of tribes. Now a federal court agrees with that interpretation. The next chapter of the Standing Rock story begins. (Trahant photo)


The story of Standing Rock was supposed to be over and done. The pipeline was completed. Oil is flowing. And the Water Protectors have moved on.

But Standing Rock is a story that won’t go away. And for many good reasons.

This is Trahant Reports.

Last week a federal court ruled in favor of the Standing Rock Sioux Tribe and the Cheyenne River Tribe in their complaint against the Dakota Access Pipeline. It’s not yet clear what impact that ruling will have, except this, the tribes won. That means all the players will have to pay attention to their concerns.

U.S. District Judge James Boasberg wrote that the tribes have a special relationship with Lake Oahe. When that lake was built by the Army Corps of Engineers it took 56,000 acres of some of ‘the best land’ from Standing Rock as well as 104,420 acres from Cheyenne River’s trust lands. Standing Rock tribal members rely on the lake’s waters to service ‘homes, a hospital, clinics, schools, businesses, and government buildings throughout the Reservation.’ The lake is also the primary source of water for the Cheyenne River Reservation. The judge said: Both tribes consider the waters to be ‘sacred’ and ‘central to their practice of their religion.’

In other words, water is life.

The ruling also reaffirmed the treaty relationship between the United States and the Standing Rock and Cheyenne River nations. The judge said the government has an obligation to work with the tribes. One way to make that happen, he said, is “early involvement” and that means the tribal government is given an opportunity to comment on a proposed action in time for a meaningful decision.

That did not happen. So what now? There will be a continued legal back and forth. And a remedy will be proposed. Some rulings will favor the tribes, others the pipeline company. And perhaps there will be a new Environmental Impact Statement.

But most important the two tribes basic arguments about Treaty Rights are now given the respect that is deserved.

This is the ideal moment for the Dakota Access Pipeline partners, the state of North Dakota and Morton County, to reassess. This is that moment when mutual respect can earn its way back into the conversation.

I’d start by ending the criminal prosecution of water protectors. It’s excessive and clearly an affront because it disrespects the right of a free people to dissent. There is nothing to be gained by sending hundreds of people to jail.

This could also be that moment where the state uses the court’s action as a call to re-negotiate. All parties could really listen to each other and see if there is a way to move forward. Together.

This could be a great next chapter to the Standing Rock story instead of more of the same.

I am Mark Trahant.

Budget Challenges for Indian Country

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The budget proposed by President Donald J. Trump would be disruptive and destructive in Indian Country. (White House photo)

The federal budget has huge challenges for Indian Country, including the prospect of a shutdown this fall. The coming fight over the debt limit is an example of the complexity ahead.

Let’s talk about the budget … and its impact on Indian Country.

This is Trahant Reports.

It’s easy to blame Donald J. Trump for a terrible budget, a budget that is designed to change the nature of government immediately. It’s also a destructive document that would result in great hardship across the nation and Indian Country. It’s not too strong to say that this plan would mean an early death for too many people.

Congress, not the president, decides how money is spent.

And it is unlikely that Congress will vote to eliminate agencies ranging from the Corporation for Public Broadcast to the Denali Commission. The minus signs inked across budget lines will be less severe than requested.

The best outcome is probably another Continuing Resolution, a document that patches together a ‘temporary’ budget for a few months or possibly the entire year. That’s become business as usual in Washington.

That’s the good news. The bad news — strike that — make it the worse news is that neither political party has enough support to enact a thoughtful spending plan. The crisis is not a financial one (well, it is sort of) but it’s a systemic failure to govern.

The best example of that problem is the debt ceiling. Basically it’s a law that allows the Secretary of Treasury to finance the debt that the United States already owes. The money has already been appropriated. It’s spent. So the only question is to pay the bill or not. Yet nearly every member of Congress (from the Tea Party to even then Sen. Barack Obama) bluster about the debt and threaten to withhold their vote. But the party in the White House cannot operate that way. Obama changed his tune as quickly as did Trump. It’s the nature of the job.  Why does this matter? Because failure to pass this bill would result in the “default” by the United States on its credit. This could force major spending cuts — far worse than those suggested in the Trump budget. And interest rates could go up sharply.

Congress isn’t run by two political parties; there are three major factions. (This is not unusual: Just before the Civil War the Republican Party was deeply divided by economic conservatives and the Radical Republicans who were organized against slavery.) Today’s Congress is composed of Republicans, the more strident House Freedom Caucus, and the Democrats.

It will take votes from two of the three factions to lift the debt ceiling and to pass a budget in the House.

Whatever spending bill emerges from the House must win 60 votes in the Senate.

This is real juggling — yet the Juggler-in-Chief, he tweeted last month: “Our Country needs a good ‘shutdown’ in September to fix mess!”

A shutdown is a terrible outcome for Indian Country.

I am Mark Trahant.

Tribal Responses to Paris Agreement

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Quinault Tribal President Fawn Sharp. The Quinault Nation must soon relocate a village because of climate change. (Photo by Larry Workman of Quinault Nation.)

A glacier on Mt. Anderson in the Olympic Mountain Range is gone because of climate change. Quinault President Fawn Sharp says that’s a clear sign that something is wrong. (Photo by Larry Workman of Quinault Nation.)

Tribes and climate change regulations

President Donald J. Trump announced last week that the United States was pulling out of the Paris agreement on climate change. That agreement includes every country in the world except Nicaragua, Syria … and now the United States.

The problems related to climate change are  enormous — so the thinking goes — and the best course is a planetary response.

But nearly every government will be involved, including tribal governments.

This is Trahant Reports.

Shortly after the president’s announcement four Native Nations announced their plans to support the Paris agreement.

The Standing Rock Sioux Tribe, the Quinault Indian Nation, the Swinomish Indian Tribal Community, and the Central Council of the Tlingit and Haida Indian Tribes of Alaska said they will fill the vacuum and take aggressive action to protect the places we call home. The tribes said in a news release that climate change touches all aspect of life, from those who have no voice, the salmon, buffalo, seals and polar bears, to those who are suffering the impacts of water loss, shoreline erosion, drought and loss of homelands and waters.

Across North American tribes see climate change, or global warming, as real, human-caused, and something that is changing life right now.

The Quinault Nation is already experiencing an increase in ocean storm surges that requires the Lower Village of Taholah be relocated because of flooding and a potential catastrophe if there were to be a tsunami.

Tribal President Fawn Sharp said: “We are talking about human lives here, and regardless of who is in office the fact is the federal government is our trustee … This responsibility is constitutionally mandated, and it’s not something the President or anyone else can wriggle out of.”

Last year the Bureau of Indian Affairs awarded $8.7 million for tribal climate change projects for 63 tribes. But more than 200 tribes applied for the program and the Trump administration says it is ending all federal spending on climate change programs.

The president said that withdrawing from the agreement will support more energy resource development, including a revival of the coal industry. And a couple of weeks ago Vice President Mike Pence toured a working coal mine on the Crow Reservation promising new jobs. But that might be an impossible dream. The job losses in the coal industry have more to do with the low price of natural gas and changing global markets.

Standing Rock Chairman Dave Archambault II says his tribe is actively moving away from fossil fuels and “we will continue to battle those who disregard our efforts to protect our water and lands.”

I am Mark Trahant.

A seat at the table? Claudia Kauffman launches bid for Seattle Port Commission

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Sen. Claudia Kauffman speaking in Seattle. She is a candidate for Seattle’s Port Commission. (Photo via Facebook.)

There is a lot of attention paid to Native American candidates running for Congress or many other visible political offices. But There are also elected offices that we don’t think about, yet are critical, and by definition, a that seat at the table. Claudia Kauffman is running for such a job, Commissioner for the Port of Seattle. This is a $650 million a year, public business that manages Seattle’s seaport, airport, and a portfolio of real estate.

It’s such a simple thing: Every citizen should have a voice at the table when decisions are made. It’s a powerful notion because no democracy can sustain itself unless all of its people, all of those who have a stake in the outcome, are included.

But that idea remains illusive. And never more important.

This is Trahant Reports

So what does a seat at the table look like? It means more Native Americans elected as governors, members of Congress, U.S. Senators, mayors, county executives, judges, members of state legislatures, and, yes, why not, even the presidency. Indian Country deserves more of a voice, both in terms of fairness and electing representatives based on our share of the population. Wait. That’s fairness, too.

There are elected offices that we don’t think about, yet are critical, and by definition, are that seat at the table.

Claudia Kauffman is running for such a job, Commissioner for the Port of Seattle. This is a $650 million a year, public business that manages Seattle’s seaport, airport, and a portfolio of real estate.

Tribes and native people are impacted by port decisions ranging from cleaning up rivers and salmon habitat to regulating oil drilling rigs that berth in Seattle on their way to Arctic waters.

Kauffman is Nez Perce. She is the first Native American woman who was elected to the Washington state Senate a decade ago. She also works for the Muckleshoot Tribe as the Intergovernmental Affairs Director. One of her tasks is distributing $1.3 million a year to more than 200 local schools, churches and not-for-profit organizations. She’s also been a trustee at The Evergreen State College.

Kauffman grew up in Seattle’s Beacon Hill as the youngest of seven children. “I come from a family with a long history of giving back to the community,” Kauffman says on her web site.

A couple of years ago Kauffman told the port commission that it could use her perspective as a working mother, a small business owner, and a community leader.
In her campaign brochure, Kauffman said she will build on her tribal contacts and strengthen ties with the 29 tribes in Washington state. Tribes “are large employers,” she said. “In 2010, they paid $1.3 billion in wages and purchased $2.4 billion in goods and services.”
This will be a challenging race. But Kauffman is no stranger to that world. She raised nearly $300,000 in her bid for the Senate. She was one of those candidates who knocked on every door at every opportunity. She also has a political organization — a network of people willing to work extraordinarily hard so that she can win her election.
This is what a seat at the table looks like. I am Mark Trahant.

Trump Reality Show

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The best moment for the new Trump Administration was the one where the president smiled in Saudi Arabia and said only 26 words in public. This was terrible reality TV but we all watched knowing that it was likely just a pause. Something outrageous must be coming up next. Meanwhile, beyond the distraction, Republicans work to dismantle the most successful government health insurance for the poor, Medicaid. (White House photo)

Reality TV works for one simple reason: The antics of the characters are beyond what’s believable in fiction.

That’s why the presidency of Donald J. Trump would make a terrible novel or screenplay.

This is Trahant Reports.

The White House Reality Show may be entertaining. But more important stories are being written and played off-screen. This is what the Trump Show hides: The House’s Health Care Act does much more than roll back the Affordable Care Act (or Obamacare as they like to say.) It ends Medicaid, the single most effective form of “government” insurance that secures health care options for 62.3 million Americans. To add perspective: Medicare — supposedly untouchable in politics — insures 43.3 million seniors.

These are huge numbers. Medicaid is expensive. And we all pay for this plan. As we should. It’s one of the best things this country does.

So it’s no wonder that Speaker Paul Ryan and Republicans are eager to make this go away (both because it costs so much and because it requires a lot of taxes to pay for this enterprise).
At a town hall meeting in Anchorage last week, Alaska Sen. Dan Sullivan followed this script to the letter. According to The Alaska Dispatch News the Republican senator told a contentious town hall, that he wanted to make sure the people who received health care coverage under Medicaid expansion “do not have the rug pulled out from under them.” Medicaid for now? Then something else? What else?

The answer is to protect the framework of Medicaid. It’s the one part of Indian health funding that’s growing and already accounts for the insurance of record for more than half of all our children. (And, this is really important, third-party insurance billing, which includes Medicaid, is money that stays at a local IHS clinic or hospital. It does not go into the general budget.)

I’ve heard Republicans say they like the results of Medicaid but that we has a country cannot afford it. That’s particularly troubling because Medicaid is more efficient that private insurance. A study by the Kaiser Family Foundation says Medicaid acts as a “high risk pool.” Because so many people are excluded (or out-priced) from private insurance, Medicaid becomes the only option. That makes private insurance more affordable.

The Senate is now busy rewriting the House’s awful health bill. It will be a different entity, that’s for sure. But will the Senate protect the best basic public health insurance program that we have now? There is no evidence to suggest that. And too many people are busy watching reality TV to even notice.
I am Mark Trahant.

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