Writings and observations

trahantlogo1

A new White House report details the economic impact of Medicaid expansion and is sharply critical of the 22 states that have not done so. The report is titled, “Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid.”

I like that: Missed opportunities. Why? Because this Council of Economic Advisers’ 44-page report fails to include any calculation of Indian Country as one of those missed opportunities.

I get that the population of American Indian and Alaska Natives is small, one percent or so. But you cannot build an economic case for Medicaid in Alaska, Oklahoma, Montana, North Dakota, South Dakota, Arizona, New Mexico (and even Washington and Oregon) without at least back of the envelope estimates. This is important because of the way Medicaid is structured; it’s a shared partnership between the states and the federal government. However American Indians and Alaska Natives are eligible for a 100 percent federal match, so the money spent by a state Medicaid program is fully reimbursed by the federal government.

This system, of course, makes no sense. And it’s probably why the White House failed or forgot to include Indian Country. A much sounder approach would be for the Indian health system — whether federal, tribal, urban or nonprofit — to get funding and administrative rules directly from the Centers for Medicare and Medicaid Services. Then Alaska, Oklahoma, or the other states that are currently rejecting Medicaid expansion would lose their say about what happens to American Indian and Alaska Native patients.

Let’s dig deeper into the White House report — then I’ll add numbers and context.

The administration is quite right to hail the Affordable Care Act’s economic success story. “Since the law’s major coverage provisions took effect at the start of 2014, the nation has seen the sharpest reduction in the uninsured rate since the decade following the creation of Medicare and Medicaid in 1965, and … the nation’s uninsured rate now stands at its lowest level ever.”

However 22 States—including many of the states that would benefit most—have not yet expanded Medicaid (although Montana has passed legislation to expand Medicaid and is working with the Centers for Medicare and Medicaid Services to determine the structure of its expansion). These 22 States have seen sharply slower
progress in reducing the number of uninsured over the last year and a half, and researchers at the Urban Institute estimate that, if these States do not change course, 4.3 million of their citizens will be deprived of health insurance coverage in 2016.”

In Indian Country, the big three non-expansion states are Alaska, South Dakota and Oklahoma.

The Alaska Legislature recently adjourned without a vote on Medicaid expansion (a measure was proposed by Gov. Bill Walker). But an expansion may be still possible if the governor acts without legislative approval.

The White House report estimates Alaska would gain some $90 million in federal funds by expanding Medicaid. But that number, I believe, misses out the intersection between Medicaid and the Indian health system. The Alaska Native Tribal Health Consortium estimated that 41,500 Alaskans would be eligible for Medicaid — including 15,700 Alaska Natives and American Indians. In other words, more than a third of potential enrollees are eligible for a 100 percent federal reimbursement. Forever.

The numbers are similar and striking in South Dakota and Oklahoma.

The White House report says health insurance also reduces the risk of death. “This analysis estimates that if the 22 states that have not yet expanded Medicaid did so, 5,200 deaths would be avoided annually once expanded coverage was fully in effect. States that have already expanded Medicaid will avoid 5,000 deaths per year,” the report says.

This is a bit complicated, but I doubt if that number includes American Indians and Alaska Natives who are at risk of death because of funding shortages in the Indian health system. What’s now called Purchased and Referred Care is better funded than it has been in recent years, but that budget line still runs out of money for some patients needing specialty care outside of the Indian health system.

But the key point is that the Indian health system is underfunded and as the Kaiser Family Foundation noted “not equally distributed across facilities and they remain insufficient to meet health care needs.”

That unevenness is dangerous for the Indian health system — and it’s states that are limiting dollars by refusing to expand Medicaid.

We are seeing the evidence about how the Indian health system is picking up additional resources in states where there has been Medicaid expansion. In Washington, for example, I recently reported that tribal health facilities have increased their Medicaid funding by nearly 40 percent since expansion. This is new money in an era of austerity and it’s automatic funding that does not require appropriation from Congress.

Of course it would be ideal if the White House was making this case with hard numbers. The Indian health system is a federal obligation,— a Treaty right — that does not cost states. Yet states are setting the rules, so at the very least our advocate ought to be chronicling the impact. A missed opportunity.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Share on Facebook

Trahant

frazierlogo1

I have been a resident and home owner of the Vista Neighborhood for nearly 50 years. Over that half century I have watched as Boise’s city fathers and mothers–past and present–have dumped house trailers, low cost housing, sex offenders, skinny houses, refugees, and assorted “assistance programs” in our neighborhood.

To be fair, for the most part these deals were probably well intended. The latest plan is a high dollar deal to “Energize Vista.” To be realistic, most of the deals have flaws. To be cynical, there is probably little hope of any true “improvement.”

Boise City in cooperation with the Farmer’s Market downtown has begun to compete directly with Lowe in an effort to “bring nutrition” to the poor folks living in the Oak Park apartments near Cherry Lane and Vista. The City is subsidizing a refrigerated trailer stocked with fresh produce that makes stops at the apartment complex–much like the Schwan’s frozen food guy. We think a free taxi or shuttle to Lowe’s market would be cheaper.

“The city never contacted me and I will have trouble staying open if these guys from downtown come into my area with subsidized competition,” lamented Lowe.

Pointing across the street to a rental property and a pair of skinny houses he added, “Those houses have never had anyone in them more than a year. We establish a customer base and they all move away.”

There in lies the problem. Skinny houses are allowed with multiple tenants–usually college students. Granted, the structures are probably visual improvements over the original structures, but cars are parked helter-skelter along the street and the occupants are transient in nature. The houses don’t attract upscale occupants.

Meanwhile, Boise planners and politicos proudly tout their efforts at creating upscale housing in the downtown area where taxes on improvements are all diverted away from all local governments and schools to benefit CCDC and developers. – from Boise Guardian

Share on Facebook

Frazier

trahantlogo1

The first ballots for the 2016 presidential election will be cast in a little more than seven months. That means between now and January there will be a rush of candidates, a winnowing of those who fail to raise money or attention, and, if we are lucky, a philosophical and practical debate about the challenges facing the United States.

In an ideal world that discussion would include American Indian and Alaska Native concerns. But that never happens (unless you read between the lines).
So the Democrats — Former Secretary of State Hillary Clinton, Vermont Sen. Bernie Sanders, former Maryland Gov. Martin O’Malley, and the newest entrant, Rhode Island Gov. Lincoln Chafee (who once was a “liberal” Republican) — campaign on issues ranging from protecting and expanding voting rights to switching the U.S. to the metric system.

And the Republicans? Well, just listing the candidates is kind of like making sure you get all the names right when reporting about a school play. There are so many, you’re bound to miss someone. But here goes (in order of recent polling by Real Clear Politics): Former Florida Gov. Jeb Bush, Wisconsin Gov. Scott Walker, Florida Sen. Marco Rubio, Dr. Ben Carson, Kentucky Sen. Rand Paul, former Arkansas Gov. Mike Huckabee, Texas Sen. Ted Cruz, New Jersey Gov. Chris Christie, Donald Trump, former Texas Gov. Rick Perry, Ohio Gov. John Kasich, former Penn. Sen. Rick Santorum, Carly Fiorina, South Carolina Sen. Lindsay Graham, and Louisiana Gov. Bobby Jindal. And that’s only the 15 “major” candidates. So in order to make noise in that large a field some of those would-be presidents rode Harley’s across Iowa this weekend, revving up their engines and their rhetoric. Hardly the right atmosphere for a discussion about tribal sovereignty.

The early primary campaign season is not ideal for a serious discussion about Indian Country’s issues. The election calendar starts with Iowa, New Hampshire and South Carolina in late January.

Nevada will be the fourth state to vote — and the first state with a significant tribal population. There are more than thirty reservation communities, urban residents, and a total Native American population of about 1.6 percent. More important, Nevada remains a caucus state. So if a large number of Native Americans show up in the right locations, well, all bets are off. (Only 33,000 Republicans voted in the last Nevada caucus out of some 400,000 G.O.P. voters.)

And what if there was a Native candidate as a draw? This ought to be the year to make that so.

A Native American candidate could take advantage of a nasty, undemocratic (but legal) structure. The law allows secret donors to spend unlimited sums of money to benefit a single candidate. So what if a few of the wealthy tribes, and, yes, I do mean casino tribes, raised a lot of money for such a super PAC? (Even though the money cannot go directly to a candidate, it still has been used to boost candidates. In 2012, for example, former House Speaker Newt Gingrich was on the receiving end of more than $15 million from casino owner Sheldon Adelson and his wife.)

Coming up with a super PAC candidate from Indian Country is a tough sell for Democrats. Even though there are many folks who could (and should) be candidates, there are too few with a large enough political footprint. And taking that much money from a single source runs against what many grassroots type candidates believe anyway.
But on the Republican side, there is someone who has that credibility right now, Rep. Tom Cole of Oklahoma, a member of the Chickasaw Tribe.

Cole is as conservative as his Oklahoma voters yet he is often the voice of reason in the House of Representatives. He’s said that new revenue — meaning taxes — might be needed to get past the sequester and that repealing the Affordable Care Act might not be possible as long as a Democrat is in the White House. This alone distinguishes him from the other fifteen Republican candidates running for president.

He’s championed tribal sovereignty and was a key player in the House vote for the Violence Against Women Act. Let me be clear here: Cole fits the orthodoxy of the Republican Party. He supports pipeline construction and increasing oil and gas production. Cole also wants less federal spending and votes for budgets that would have negative impact on tribal communities. But for a Republican primary, and for a Republican candidate, Indian Country would still come out ahead, if he were running and raised the issues in Indian Country that call out for a larger debate.

The down side of a Cole candidacy is that he would have to give up his seat in the House — and his seniority and influence. That’s probably too high a cost for an improbable presidential quest. But this might be the year to try something outrageous.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.

Share on Facebook

Trahant