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A Race of Medicaid Policy

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New Medicaid rules by the Trump administration undermine the treaty right to health care.

The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.

This is Trahant Reports.

A story in Politico Sunday raised the issue, saying the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules would be illegal preferential treatment.

The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians.

Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.

Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).

But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.

Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.

Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.

Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.

I am Mark Trahant.

Ryan’s Big Idea – Closing out the Term

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Speaker Paul Ryan greeting President Donald J. Trump at the State of the Union.  (Photo via Speaker.gov)

Paul Ryan came to Washington to blow up Washington. He was first elected to represent his Wisconsin district at 28 years old. He campaigned over his career for a federal government that should shrink dramatically, spend far less, that taxes should be low, and that the Republicans should be the party of big ideas.

This is Trahant Reports.

Ryan announced last week that he will not run for re-election. He says he will complete his term as Speaker, but even that’s not certain. He faces pressure to step down early, so another Republican can lead the party’s team into the November election.

Speaker Ryan leaves behind a legacy. He did get his tax cuts and substantial changes in the regulatory framework. But he also delivered more federal spending than ever. The deficit will hit $804 billion this year (a jump of 21 percent in a single year) and exceed $1 trillion by 2020. A new report by the Congressional Budget Office, says that a decade from now the total debt will be larger than the entire economy.

The problem for Ryan, like Speaker John Boehner before him, is that the Republican majority is nearly impossible to govern. The only way for Congress to function, to actually pass a budget, is to build a coalition that includes most Republicans, some Democrats, and work with a similar coalition in the Senate. That often means spending more money. That’s not the Congress — and the party of big ideas — that Ryan had once imagined.

President Donald J. Trump has made that process worse. He caters to the bloc in Congress that cares little about actually governing. Chaos is fine. Big ideas, not so much.

Ryan wanted to reform government. A couple of years ago he proposed a reform of the Indian Health Service by “giving choices to American Indians.” His idea was to have the government issue vouchers for Indian health, outside the system. “Not only will this give American Indians more choice in where they receive care,” the Ryan plan promised. “It will challenge Indian health facilities to provide the best care possible to American Indians.”

Of course that voucher system would have cost less. The Ryan plan also included a provision for a Native American Health Savings Account so individual tribal members could buy their own healthcare services (Never mind that healthcare is a treaty right).
Rep. Tom Cole, a Republican from Oklahoma and a Chickasaw Nation citizen, said Ryan will be missed in Congress. “He is not only the best Speaker I’ve had the opportunity to serve with, he’s also the finest person. Even Paul’s political opponents readily concede that he’s a person of absolute integrity, deep sincerity and of profound decency.”

I am Mark Trahant.

Trade Wars: Who are the Casualties?

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The growing trade war with China is politics all mixed up. It’s an issue that divides many Republicans from President Donald J. Trump. And some of the president’s most strident supporters from coal companies to farmers are not happy with his policy.

This is Trahant Reports.

But make no mistake: The outcome (when it finally occurs) is a dollar-and-cents issue that will impact the daily lives of Native people, tribal governments, and businesses. Why? A tariff is a tax.

It’s a tax bill that’s paid every time someone buys a product that’s on a country’s tariff list. And so now many agriculture products, such as soybeans, will be taxed by China.

According to the National Congress of American Indians: “Agriculture is increasingly important to Native economies, representing the economic backbone of more than 200 tribal communities and witnessing an 88 percent increase in the number of American Indian farmers between 2002 and 2007. According to the Census of Agriculture, in 2007 annual Indian agriculture production exceeded $1.4 billion in raw agriculture products.”

Agriculture represents one risk in a trade war.

Rep. Tom Cole, R-Oklahoma, wrote last month, “In general, free trade contributes to our national prosperity as well. However, having open markets is not an invitation for others to take advantage of us.” Cole, who is Chickasaw, called tariffs bad news for his state.

Cole told CNBC Friday that “outside of agricultural areas” the trade issue is a net plus because “somebody is finally doing something about China, which has simply ripped us off since we let them in” the World Trade Organization.

A potential trade war also has huge implications for global warming. The Trump administration, of course, has attacked virtually every climate policy from the past administration. And, the first action in this trade dispute involved solar panels. Now the trade war could upend extractive industries, especially coal.

China has not yet levied a tariff on coal, but it’s widely expected because of the industry’s ties to President Trump. China is the world’s largest importer of coal.

Tribes that mine coal, such as the Crow Nation in Montana, have looked toward China and Asian markets as a way to make coal great again. But other tribes along the shipping route, such as the Lummi Nation in Washington, see dirty coal trains bound for Asia as a threat to salmon and their treaty rights.

There is a connection between global trade and global warming. A report by United Nations says this issue presents an “important policy conundrum: behind every trade transaction there is a production process and, in turn, associated greenhouse gas emissions. Policies that modify trade (trade policies) can influence emissions, while policies for reducing emissions (climate change policies) can also influence trade.”

So a trade war could slow commerce — and the emissions that cause global warming. I am Mark Trahant.

Mark’s Musings on the Idaho Governor’s race

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A couple of weeks ago I was driving across the border into Idaho from Montana. I stopped the car and took a picture of the “Welcome to Idaho” sign. I thought: It would be cool if that sign read, just under the Idaho greeting, “Paulette Jordan, Governor.”

Jordan, a Coeur d’Alene citizen, is running as a Democrat in what is perhaps the reddest, most Republican state in the country. So it’s an impossible task, right?

Let’s do the math. This is Trahant Reports.

Paulette Jordan is one of seven Native American candidates running for statewide office — and one two Native women running to a lead a state (something never been done before). She will be the first of those candidates to face voters — and she will need to win a contested Democratic primary on May 15.

One of the most important reasons for Native American candidates is the aspirational aspect. It’s a way for young people to see a future (one that is far more important than just politics.)

Jordan recently told a group of Native voters on the Shoshone-Bannock Reservation that public policy issues don’t affect just tribes. “Every single issue that tribes push forward are issues that are good for everyone.”

Jordan is running against A.J. Balukoff in a primary election and she has to earn a few thousand votes. That’s plausible, especially in a season where nontraditional candidates are getting a second and third look.

Votes from Idaho’s five reservations could help, too. The numbers are small, but if they are one-sided — say 100, 200, 300 votes to a handful, well, it could give her an edge. Especially in a primary.

Jordan should have an edge with younger Democratic voters and with Hispanics. These two constituent groups that are growing in numbers and importance. Idaho is a young state: There are more people under 18 than any other demographic group. And younger voters — 18 to 25 — are a relatively small cohort. But in the last elections this group increased its turnout rates, so there is a potential upside. Hispanics now account for 12 percent of Idaho’s population and, according to Pew Research, some 80,000 eligible voters (or far more than what would be needed in a primary election.)

So the math is there. It’s possible.

What about Jordan’s message? Is she reaching primary voters? That’s a much tougher call. She has to campaign in a state with two time zones and a distinct geographic north, south divide.

And after the primary? The toughest hill to climb come after the primary. Jordan would need to make her case to Idaho’s deeply conservative Republican voters. But if there is ever a year to do just that, this is this one.

I am Mark Trahant.

Trump complains and signs spending bill into law anyway

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The federal government’s newly enacted budget is a massive “omnibus,” it will spend $1.3 trillion and it makes some members of Congress pleased and others quite angry. It’s a document that reflects a broken budget system. And, at the same time, it’s a business as usual document in a White House that has promised change.

This is Trahant Reports.

President Donald J. Trump told reporters at the White House that he was unhappy with the bill, but he signed it anyway because it added money for the military.

But this bill is also good for Indian Country. Federal Indian programs, some of which had been slated for either elimination or deep cuts, pretty much continued on course.

The omnibus spending bill increases funding for the Indian Health Service by 10 percent, and the Bureau of Indian Affairs and Bureau of Indian Education by 7 percent to $3.064 billion. The IHS budget line is $5.5 billion. When the budget is compared to the president’s request, the increases are even sharper, more than 16 percent for the IHS and 23 percent for the BIA.

An analysis by Amber Ebarb at the National Congress of American Indians puts it this way: “Overall, the eliminations and reductions proposed in the president’s budget were rejected.”

Other items in the budget … well, the bill includes a 3 percent set aside for Indian tribes within the funds under the Victims of Crimes Act. The cap for these funds was set at $4.4 billion, so that amounts to $133 million for Indian Country. As Ebarb wrote: This is an important step. Indian Country has the highest rate of criminal victimization and had up until this point been left out of the funding. This will address the long standing inequity and meaningfully improve the landscape of victim services in Indian Country.”
The bill also provides $50 million for grants to tribes or tribal organizations to address the epidemic.

Infrastructure spending would increase for BIA and IHS construction, BIA road maintenance, and a $100 million competitive grant program is added under Native American Housing Block Grants in addition to the $655 million provided in current Native American formula grants.

This legislation is about a year late in the normal process. Leaders from both parties had to come together and find compromise. So this Omnibus bill has something for every constituent … and something that every constituent does not like.

In October the spending plan expires and Congress will have to find the votes yet again.

I am Mark Trahant.

A Case for Native Voters

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Linda Yardley is a long time voter advocate from the Taos Pueblo. She testified Friday at a hearing of the Native American Voter Alliance at the Pueblo of Isleta.

The Native American Voting Rights Coalition has been holding hearings across the country since last September to document the challenges faced by Native American voters. Witnesses include tribal leaders, advocates, and voters.  Barriers to equal voting rights have been documented such as “unreasonably long distances to polls and inability to access transportation keep Natives from voting.”

Why should Native Americans vote? Linda Yardley from Taos Pueblo had one answer at a field hearing of the Native American Voting Rights Coalition Friday.

This is Trahant Reports.

Yardley told the story of Taos Pueblo and its century-long fight to have the United States return its sacred Blue Lake. The land had been taken by the U.S. Forest Service in 1906 and a former U.S. Secretary of Agriculture (and therefore head of the Forest Service), Clinton P. Anderson, was by the late 1960s a U.S. Senator from New Mexico.

Yardley said he told our tribal leaders: “I’ll be dead before you ever get your land back.”

And that was their U.S. Senator. The Pueblo eventually won, when President Richard Nixon agreed to return Blue Lake.

But. as Yardley testified, “If our people had been voters, registered voters, Clinton Anderson probably would not have had the ability to say that. This is why it’s so important for me personally because I don’t want our people to go through the hardship that we did to secure our tribal lands, our sacred lands back to us.”

The Native American Voting Rights Coalition has been holding hearings across the country since last September to document the challenges faced by Native American voters. Witnesses include tribal leaders, advocates, and voters.

In earlier hearings, witnesses documented the persistent suppression of the Native vote in North Dakota, South Dakota, Wyoming, and Montana. This included a number of barriers to equal voting rights including “unreasonably long distances to polls and inability to access transportation  keep Natives from voting.”

Other documented hurdles:

  • Dismal conditions at reservation voting polling locations, one of which included a dirt floor chicken coop that did not have restrooms.
  • Restrictions on the number of voter registrations that one can submit to the county clerk’s office, requiring repeated trips to the office.
  • County employees chastising organizers submitting voter registrations for being a “nuisance” and “making more work” for the county office by submitting Native American registrations.
  • Being turned away at the polls because a tribal identification card did not include a street address.

Deb Haaland, Laguna Pueblo, is now running for the U.S. Congress to represent Albuquerque, and has worked on voting rights issues in New Mexico for many years. She recalled a Saturday morning visit to a home in San Felipe Pueblo in 2008 where she registered seven people to vote. She said the last person to register was a man, probably in his mid 50s,  “stood up, shook my hand, and said, ‘thank you so much, I have always wanted to vote but I never knew how.’ If that does make you feel like we have a lot of work to do in New Mexico, I don’t know what will.”

 

I am Mark Trahant.

Indian Country Today

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There is a new chapter for Indian Country Today. The newspaper and media network has new owners, but an old task, serving readers of tribal nations.

This is Trahant Reports.

Many years ago Richard LaCourse and I would sit around and toss ideas around what the perfect Indigenous newspaper would look like. LaCourse, at the time, was trying to create a new publication in Washington, DC.

Imagination was his currency. What was possible?

LaCourse had a lot of experience answering that question. He had helped build the American Indian Press Association. He had edited or written for several tribal newspapers, including his own, The Yakama Nation Review. He launched a one-person crusade to raise the standards of Native American journalism.

I even remember the first time I heard him do that. It was on Feb. 24, 1977, at a workshop in Spokane. A speaker was telling tribal editors that they worked for tribal councils and should slant the news accordingly. LaCourse stood up. Angry. Shaking his finger. “Are you aware of the 1968 law that guarantees freedom of the press in Indian Country? Indian newspapers should be professional, straight reporting operations, and your assumptions about cheerleaders for a point of view has nothing do do with the field of journalism. Why are you making this presumption?”

I am thinking of Richard LaCourse as I set out to lead a new chapter for Indian Country Today. The news operation has been on hiatus since September. That cannot be.

Our goal is to build on the legacy of LaCourse—as well as from the first two chapters of Indian Country Today. The publication was founded by Tim Giago in South Dakota in 1991, followed by the ownership of the Oneida Nation of New York.

Indian Country Today is now owned by the National Congress of American Indians—but we will act independently. We are creating a framework to ensure that. But our primary task is the same as LaCourse’s vision: Professional, straight reporting that tells stories about Indigenous people and our nations.

The best way I know how to demonstrate our independence is to produce solid, thoughtful journalism. Every day. So there is a lot of hard work ahead. (And we will need some time to make this so.)

But  Indian Country Today is back in business and we are ready to serve.

I have been teaching journalism for the past seven years and I am always telling students that this is a time of great opportunity. The digital world means that we can reach our audiences instantly. We can communicate ideas. We can explain a complicated process. We can expose wrongdoing. Or write a story about pop culture that makes us smile.

We can even invent a new kind of news organization, one built on the currency of imagination.

 

I am Mark Trahant.

Indian Health Leader

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Who should run the Indian Health Service? Not “who” exactly, but what kind of leader? What kind of skills and experience?

This is Trahant Reports.

The Trump administration has withdrawn the nomination of Robert Weaver to lead the agency. Weaver, a member of the Quapaw Tribe of Oklahoma, had a background in private insurance working with tribes to set up plans to cover tribal members. Weaver’s nomination was sidetracked after The Wall Street Journal reported serious misstatements on his resume.

In a letter to tribal leaders, Weaver said the president has been an “ardent supporter of fixing Indian Health throughout this process.” And he said “he will fight to give voice to the change needed at IHS until the mission is complete … the delivery of timely, high quality healthcare for Indian Country no matter where you live.”

The mission? That is the key word here. The mission of the Indian Health Service has become so distorted that even policy makers cannot or will not articulate the challenges. All of the discourse about the Indian Health Service continues to be about a federal agency that delivers health care to American Indians and Alaska Natives. And, within that story, there are so many clinics and hospitals that only require more order and funding in order to carry out even basic health care. The system is failing.

Only the IHS story is much more complex. We need to think differently about the Indian health.

Most of the Indian Health system is managed by tribes or non-profits. The federal role is that of a funding agent and it sets standards. But even that is misleading because it is Medicaid, not the Indian Health Service, that’s often the largest source of funding for tribal and nonprofit facilities. The administration claims it’s protecting the Indian Health Service budget … all the while proposing deep cuts into Medicaid.

There is a disconnect and the proof is found in the budget. The line item for “collections,” that is money from Medicaid, Medicare and private insurance, is roughly $1.2 billion. That’s a number that has not changed much despite a huge expansion of Medicaid under the Affordable Care Act. But when you talk to tribal and non-profit administrators, as I have, there is a different story to tell. Medicaid is now more important to local budgets than the IHS itself.

The expansion of Medicaid explains a lot about the shortages within the Indian health system. The federal Indian Health Service will take Medicaid funds, but it’s not growing the pot. Tribes and non-profits have done that. And there is more money for Indian health in states that have expanded Medicaid.

This is not the Indian Health Service we grew up with. And the next director of the Indian Health Service needs to acknowledge this complexity and own the new story. If I had my way: the next IHS director would have a solid background in medicine and Medicaid.

I am Mark Trahant.

Trump’s New Budget

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National Economic Council discusses White House infrastructure plan. (White House photo)

Budgets are statements: This is what “we” care about.  It’s money that reveals priorities. The “we” could be, and ought to be, the country. Or the “we” could be a presidential administration that’s really not equipped to govern.

This is Trahant Reports.

President Donald J. Trump’s budget this year, like last year, expresses the administration’s desire to cut federal Indian programs, wipe out public broadcasting, end student loan forgiveness, starve Medicaid and Medicare, food stamps, housing programs, and generally, limit just about every federal program that serves poor people.

As Trump budget director Mick Mulvaney told reporters: “This is a messaging document.”

And what a message. Rich people face tough times so they deserve a huge tax cut. Poor people are poor because of their own failures. And more money is needed for a wall that’s not needed, for the largest military in the world, and the Republicans no longer believe that deficits matter.

Mulvaney has a different version. Here is what he says are the messages.

“Number one, you don’t have to spend all of this money, Congress.  But if you do, here is how we would prefer to see you spend it,” he said.

Now the action is in Congress. But even Republicans on Capitol Hill know that this budget cannot be. It’s chaos as numbers. Because for this proposal would become law only if you overwrite the current spending bill. Then, the House and Senate would have to agree on a budget. And that’s unlikely. As I have said before there are lots of votes against any budget but not enough votes to pass any budget.

The most popular part of the president’s budget is infrastructure spending. But most of his plan would be funding from state, local, and tribal governments. That’s a problem. Congress will not be easy to follow this approach, especially in an election year. Members of Congress love announcing new roads and other projects. It means jobs back home.

In theory infrastructure spending should be easy. This is an area where Republicans and Democrats agree (actually anyone who looks at the crumbling state of infrastructure can figure this one out). But in Congress? We shall see.

At the State of the Indian Nations Monday, National Congress of American Indians President Jefferson Keel said: “Tribal infrastructure is American infrastructure. In 2018, NO infrastructure bill should pass, UNLESS it includes Indian Country’s priorities.”

This 2019 presidential budget will accomplish one thing: It will serve as a mile post for the fall election. And the messages are clear for both Republicans and Democrats.

I am Mark Trahant.

State of Indian Nations

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What are the state of 573 tribal nations? Jefferson Keel, president of the National Congress of American Indians, gives his answer at the Newseum in Washington, DC.

This is Trahant Reports.

The State of the Union is a tradition in Washington. Its roots are in the Constitution as a presidential report to Congress. Members of Congress, the executive branch, and the Supreme Court listen to the words of every president since FDR in an annual report. (Before that there was a presidential message to Congress but some presidents sent it in writing while others went to the Congress.)

These days Indian Country is rarely mentioned in a formal State of the Union. But in July 1970  President Richard Nixon’s sent a special message to Congress on Indian affairs, announcing his policy on self-determination without termination.

But that was rare exception. And not the official State of the Union. So 15 years ago the National Congress of American Indians decided to deliver an annual message about tribal priorities for the Congress and the administration.

On Feb. 12, President Keel called this “an important moment. Our governments and our communities stand on high alert.” He said the echoes of America’s colonial past have continued to reverberate with disparaging rhetoric, failed policies, and, a disregard for the inherent sovereignty of tribal nations.

The recent tax legislation, for example, did not include Indian Country. Keel said tribal leaders met with members of Congress often. He said tribes offered thoughtful, pragmatic, deficit-neutral policy proposals. “But the bill came together in a flurry. And when the dust settled, Indian Country’s top priorities were absent from the version the President signed in December,” Keel said. “That is completely unacceptable.”

There are two pending pieces of legislation that still wait for a tribal voice — the most recent farm bill and a plan for national infrastructure spending. Keel said: “From wild rice and bison to salmon and blueberries, traditional Native foods are not only our way of life but are an economic driver too. Indian agriculture is a 3.2 billion-dollar industry, supporting nearly 72,000 jobs in Indian Country.” So, he added, no farm bill should pass  unless it also listens to and strengthen Indian Country’s agricultural potential.

Keel had a similar message on infrastructure, saying tribal infrastructure is American infrastructure.

The country, and Indian country, are better off when there is a recognition of the historic tribal-federal relationship, and when there is a true partnership of consultation between tribes and the federal government.

The State of Indian Nations is more than a tribal wish list. It’s an opportunity for a discourse about where Indian Country stands in the American government. And what the prospects are for improvement. The annual event draws members of Congress, the administration, and the public through a live broadcast. It’s become an important voice reminding the country what could be.

President Keel’s conclusion: “As it has been for thousands of years, the state of Indian nations is strong…. and everlasting.”

I am Mark Trahant.

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