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Indian health money left behind

trahant MARK
TRAHANT

 
Austerity

Monday was a key deadline for the Affordable Care Act. In order to begin insurance coverage on January 1, 2014, people were supposed to sign up by December 23, 2013, for that shiny new policy.

(On Monday the White House announced the deadline is extended a stay. That’s a good thing for people trying to navigate the web site at the last minute.)

How many American Indians and Alaska Natives signed up for this new program? Who knows? But you’d think that something this important would have so much information posted about that it would almost be annoying. There should be posters, flyers, signup fairs, reminders and banners. This should be a big deal.

Instead this deadline whizzed by, hardly making a sound in Indian Country.

So this is why the deadline, and health insurance, matters.

From this point forward every American Indian and Alaska Native who signs up for some form of insurance, through a tribe or an employer, via Medicaid, or through these new Marketplace Exchanges, adds real money to the Indian health system.

How much funding? Healthcare reform expert Ed Fox estimates the total could exceed $2 billion. But what makes that $2 billion even more important is that it does not need to be appropriated by Congress. (more…)

Health reform ahead

trahant MARK
TRAHANT

 
Austerity

The healthcare.gov web site is working. I spent some time on it this weekend and it was easy to navigate, pages popped up when they should, and I quickly found answers.

All of this is good news because it will make it easier for folks to fill out the forms and see what’s possible under the Affordable Care Act. If you want insurance to begin on January 1, 2014, then you need to fill these forms out this month. The deadline is December 23.

But for American Indians and Alaska Natives this process is both confusing and damning. It’s confusing because it’s a form that requires financial information, a lot like a tax return, so it means rounding up some documents. The damning part? I’ll get to that shortly. First let’s explore the healthcare.gov process.

For American Indians and Alaska Natives: The most important form is “Appendix B.” This is the paperwork that secures a lifetime exemption from the insurance mandate. Lifetime is a pretty good deal. So paperwork or not, this is worth doing this month (or you can also file this with your tax returns in April).

There is help to fill out these forms. Go to the Indian Health Service or a local urban or tribal clinic. Find someone there who has been trained. You should get answers, because, as IHS acting director Yvette Roubideaux wrote recently, “I don’t know is not an acceptable answer.”

One of the best things I read this weekend was an item in Montana’s Char-Koosta News with a schedule of community meetings on the Affordable Care Act. Yes! This should be happening across Indian Country.

There needs to be information, not just cheerleading, about what this law means and how it might change the Indian health system. (This is the main reason for my five-part video series with Vision Maker Media .) The law will shake up the Indian health system dramatically, opening up new funding sources, as well as presenting new challenges.

The problem is that so much of the discourse has been cast in absolute terms. Democrats need to recognize that this law, like the web site, is not perfect. It’s just one step -- and a complicated one at that. And Republicans would better serve the country if they would stop crying repeal and look for constructive additions or subtractions. (more…)

Filibusters and Indian country

trahant MARK
TRAHANT

 
Austerity

The United States Senate is a curious institution. It's not democratic. It's not representative. And it's the ultimate millionaire's sandbox.

So in the U.S. constitutional scheme: The 38 million people living in California get two votes out of 100, the same as the 576,000 folks who are residents of Wyoming.

One person's vote is worth more if they live in a tiny state, but at least it's a vote. Because some four million American Indians and Alaska Natives -- citizens of tribal governments -- aren’t counted as a unique constituency. By land mass, Indian Country's 50-plus million acres are bigger than almost half the states. Even breaking that number up into population counts, Cherokee’s 819,000 people or Navajo's 350,000 is in the same ballpark as one of those small states.

But that’s the deal. And the Constitution is sacred script (roll the organ-heavy musical theme now). So get over it, right?

But the thing is the U.S. Senate, this undemocratic institution, is made worse by the filibuster. Especially now that the filibuster has become a routine, invoked on every nominee or every bill. Instead of fifty votes, a supermajority of 60 votes, was required to get anything done. That changed last week. Senate Majority Leader Harry Reid, D-Nevada, used another rule (one requiring just 50 votes) to overrule the filibuster on judicial and executive nominees. Only now that that procedure has been invoked, it’s only a matter of time before the filibuster is gone forever. (The filibuster is only a tradition, not a constitutional procedure. It’s only been used for about a century. And in the past decade it’s use has increased significantly.)

Let’s be clear: The super-majority has not been good for Indian Country. One of the reasons it took so long to pass the reauthorization of the Violence Against Women Act was that 60-vote hurdle. Or reach a final settlement on the Cobell lawsuit. Or we’ve been reading all about the complications with the Affordable Care Act. One of the key appointments, Donald Berwick, was never confirmed as the director of the Centers for Medicare and Medicaid, and took the job with a limited timeframe as a recess appointment. (more…)

A promise that can’t be kept

trahant MARK
TRAHANT

 
Austerity

Modern U.S. presidents have a curious relationship with North America’s first residents, American Indians and Alaska Natives.

President Richard Nixon in July of 1970 sent a special message to Congress calling for a new era with the indigenous tribes because “on virtually every scale of measurement -- employment, income, education, health -- the condition of the Indian people ranks at the bottom.” Nixon called for a “new era in which the Indian future is determined by Indian acts and Indian decisions.”

Not every president got the memo.

President Ronald Reagan, for example, found himself in Moscow confused by the entire premise of federal-Indian relations. “Let me tell you just a little something about the American Indian in our land,” he told a group of students in the former Soviet Union. “We have provided millions of acres of land for what are called preservations—or reservations, I should say. They, from the beginning, announced that they wanted to maintain their way of life, as they had always lived there in the desert and the plains and so forth. And we set up these reservations so they could, and have a Bureau of Indian Affairs to help take care of them. At the same time, we provide education for them—schools on the reservations. And they're free also to leave the reservations and be American citizens among the rest of us, and many do. Some still prefer, however, that way—that early way of life. And we've done everything we can to meet their demands as to how they want to live. Maybe we made a mistake. Maybe we should not have humored them in that wanting to stay in that kind of primitive lifestyle. Maybe we should have said, no, come join us; be citizens along with the rest of us.”

Reagan’s idea was insulting to the five hundred tribal governments that existed before the United States. These tribal government survived conquest and exist today because the United States negotiated treaties with them for lands and other concessions. Those treaties promised doctors and hospitals, schools, and other basic governmental services.

That history sets the stage for Barack Obama.

As president he has announced no new sweeping policy initiatives -- how do you trump self-determination? Yet most of his policies have been generally supportive of tribal governments. At the 5th White House Tribal Nations Conference (held at the Interior Department because the largest room at the White House -- the East Room -- is too small for such a gathering) Obama promised to make his first “state” visit to Indian Country as president. (more…)

Health in Indian country

trahant MARK
TRAHANT

 
Austerity

There has been much controversy about the Affordable Care Act, what some call Obamacare. The politics are beyond intense. And those computer glitches are making it virtually impossible for people to enroll.

But for American Indians and Alaska Natives there is a whole different story to tell about the Affordable Care Act. Native Americans have a right to health care. This is a deal the United States made, a promise that including sending doctors to the tribes that signed treaties in exchange for peace and for titles to lands.

Promise or not, treaty or not, the entire history of healthcare in Indian Country has been defined by shortages. There has never been enough money to carry out that sacred bargain.

The modern Indian Health Service was created in 1955. And over the following decades, more clinics were built, more doctors were hired, and health care for Native people improved. Still, the agency never had enough money.

In 1965 when Medicare and Medicaid were enacted into law there wasn’t even consideration about how these programs would impact American Indians and Alaska Natives. The Indian Health Service could not bill the agencies for serving eligible services. Native Americans were essentially left out of that health care reform effort.

That history of shortages is critical context to understanding the Affordable Care Act. Because from the very beginning of the legislative process, the Affordable Care Act included Indian Country. This happened because a decision was made by tribal leaders to roll the Indian Health Care Improvement Act into the larger legislation.

“Let me tell you why it was different this time,” said Jacqueline Pata, executive director of the National Congress of American Indians. For nearly twenty years tribes urged Congress to reauthorize the Indian Health Care Improvement Act. Then the discussion began about a health care reform.

“We were sitting at an NCAI board meeting, tribal leaders around the table, and said we really have to engage in this health care debate this time around. There were those that said, “no, let’s stay where we are,’” she said. But former NCAI President Jefferson Keel knew the health care industry and he agreed with the broader approach. “So we immediately started to look at the overall health care bill, working with the members of Congress, to be able to find all those other places that it was important to insert ‘and tribes.’ So not only did we get Indian Health Care (Improvement Act) reauthorized permanently. But we were able to get provisions into Medicaid, we were able to get the tax exemption (for tribes that purchase insurance for members), we were able to include a lot of places where tribes should have been considered but probably wouldn’t have been if we didn’t integrate those two pieces of legislation.”

But there still is a question of why? Why American Indians and Alaska Natives need insurance of any kind when there is a treaty right, a statutory call to healthcare, that transcends this latest national experiment? Then recall the long history of shortages. The Indian health system has never been adequately funded, probably less than half of the appropriation that would bring about some sort of parity with other federal health systems.

The main idea in the Affordable Care Act is to require health insurance for all Americans because that lowers the cost for everyone, the so-called “mandate.” But American Indians are exempt from that mandate (even if the Indian health system does not count as insurance). So the way that exemption works, this year at least, is that American Indians and Alaska Natives will have to fill out forms for an exemption (once granted, it’s a lifetime deal). The good news here is that the whole website mess does not apply.

Then insurance itself is a complicated idea for Indian Country. What is called “third party billing” has been a small, but growing part of the financial resources for the Indian health system.

You see there is this odd American idea that links health insurance to our jobs. That’s how most Americans now get their health care -- and will continue to do so even under the Affordable Care Act. But that one element is a big difference for Indian Country. Only 36 percent of American Indians and Alaska Natives have insurance purchased through work -- that’s half the rate for most Americans -- and 30 percent of us have no insurance at all. (more…)

Impact of the fiscal yahoos

trahant MARK
TRAHANT

 
Austerity

The Fiscal Yahoo Caucus of the United States Congress is ready to reach into your family wallet and grab cash. Need to buy or refinance a house? Ca-ching. Owe anything on credit cards, perhaps a revolving business loan, or need student loans? Ca-ching. Ca-ching. Ca-ching.

This nonsense -- a refusal to raise the federal debt limit without all sorts of conditions -- matters to everyone because we as Americans borrow money at extraordinary low rates. We borrow a lot of money, actually, so even a small increase in interest rates could really hurt.

The General Accountability Office says: “Spending on net interest as a percentage of federal spending has fluctuated over time, peaking in the late 1940s and in the mid 1990s. In the past, interest payments contributed to deficits and helped fuel a rising debt burden. Rising debt, in turn, raised interest costs in the budget, and the federal government increased debt held by the public to finance these interest payments. This has been called the ‘vicious cycle.’ Today’s relatively lower interest rates have lessened the pressure debt service places on the budget, despite the recent increase in the debt held by the public.”

We have a good deal. Interest payments as a percentage of the total economy were at 14.6 percent in 1948; today that number is only 6.4 percent.

So what if interest payments were that high again? The wheels of government come off.

Remember that government debt is financed in public markets. That debt is sold at auction, so someone has to be a “buyer” of bonds. “Consequently, the amount that the federal government spends for interest on its debt is directly tied to those interest rates,” the GAO said. “Under CBO's January 2012 baseline budget projections, debt held by the public would be 62 percent of GDP in 2022 and spending on net interest would rise from $227 billion in 2011 to $624 billion (or 2.5 percent of GDP) in 2022. CBO has assessed how changes in interest rates can affect federal spending. CBO notes that if interest rates are 1 percent higher than the rates assumed in CBO’s baseline budget projections, the government’s higher interest costs would add nearly $1 trillion to the cumulative budget deficit over the 10-year period.” (more…)

Spy vs. Spy

trahant MARK
TRAHANT

 
Austerity

Watch out for fights coming from the Capitol. The Senate versus the House. Republicans opposed to Democrats. And, of course, the most intense battle, Republicans against Republicans.

I grew up with the Spy versus Spy comics from Mad Magazine. Week after week a white clad spy would deliver some sort of lethal device (think exploding toilets) to a black suited spy. The scenarios were always outlandish and neither character ever really won. It’s that way in DC right now, except most of spies in combat are wearing Republican Red.

The Spy versus SpySpy versus Spy battle is alive and well on Twitter where there’s a #dontblink campaign to try and convince those squishes to support the filibuster. It’s not going to happen, but it does increase the possibility of a government shutdown simply because Congress is running out of time to meet the October 1st deadline. (The Senate has rules about how much time is allowed for a debate after cloture.) That means any vote for a temporary budget to fund the government cannot occur until the end of the week, Friday or Saturday. Then it will go back to the House. Perhaps with changes. Senate Majority Leader Harry Reid will send a “clean” resolution to the House, hoping that body will pass it without changes just to keep the doors open. But probably not. Then the process will start again -- with the government officially closed. (On Tuesday, Senator Reid announced the measure will only fund the government until Nov. 15, leaving open the possibility of a regular order budget.)

This is as goofy as Spy versus Spy. And just like the comic strip, there’s no real winner in sight. The games just go on and on.

There is a bigger problem for Indian Country, however. Actually two issues. First, any “resolution” of this crisis is completely temporary. The same debate will surface again over the debt limit in a couple of weeks and then again when this Continuing Resolution expires. The House bill only pays for government operations until December 15. So, even if the Senate’s shorter version passes, the whole mess will repeat. (more…)

A storm is coming

trahant MARK
TRAHANT

 
Austerity

So where to begin? I put my column on hold this summer so that I could make my move to Anchorage (I am teaching for a year at the University of Alaska Anchorage, holding the Atwood Chair for journalism) and to work on a couple of other longer range projects. Labor Day is over and now it’s time to get back to work.

There remain lots of dull, policy stories that are not being written by anyone else. Meaty stuff. Before I took my break, for example, it was unclear whether Congress would appropriate federal money on time and if another government shut-down was on the way. Now that I am back: Who knows? Some in the Congress are willing to shut down the government to stop the implementation of the Affordable Care Act.

The only thing clear is that the Republican party is deeply divided on Capitol Hill.

A proposed Continuing Resolution had to be pulled from the House Wednesday because there wasn’t enough votes for that measure to pass. There is a bloc of members in the House and the Senate that will take about any step required to thwart the Affordable Care Act (or Obama Care, if you prefer). That means closing the government, refusing to pay the bills that Congress has already charged on the national credit card, and at the same time, destroying their own party’s leadership. As Politico put it: “The GOP is clearly struggling with itself over how best to keep the government operating and placate conservatives who want to cut off all funding for implementing Obama’s signature reforms.”

The problem is that no side has a majority. There are three distinct caucuses: Democrats, traditional Republicans and the new radical Republicans. None of those three groups has an easy way to win enough votes to win a majority.

Take the House: There is a natural governing coalition that could band together, Democrats with a few Republicans to make enough votes to pass a budget and basically keep the government humming. But the problem is that if Speaker John Boehner taps this coalition too often, then he’s toast. He’ll lose his job. He needs to keep a majority of Republicans happy. Even if that means chaos. (more…)

An era of limits and immigration reform

trahant MARK
TRAHANT

 
Austerity

The debate over immigration reform in the House and the Senate is an interesting lens to examine the future of austerity.

How so? Immigration is about immigration; secure borders, global migration pattens, and a path to citizenship for more than 11 million people living in the United States without a legal status. The Senate bill is a compromise that calls for an unprecedented buildup of border security, some 20,000 new agents, in exchange for that citizenship route. (Borrowing language from the Iraq war buildup, Senators are calling it a “surge.”)

Think about what that means: The United States can’t afford to invest in education, health, or infrastructure, but it can spend big bucks on border security. The Congressional Budget Office scores the cost side of the ledger in the Senate bill this way: “Appropriate $46.3 billion for expenses related to the security of the southern U.S. border and initial administrative costs.”

The Senate compromise also limits eleven million people’s right to participate in the health care system, while, at the same time, taxing them for services not rendered. This part of the bill is just mean. The CBO says “the net budgetary effect of decreasing the number of unauthorized residents would be relatively small—the small savings for Medicaid, child nutrition, and refundable tax credits would be more than offset by a slightly larger reduction in revenues paid by, or on behalf of, unauthorized residents.”

But at least the Senate bill is not all about costs. Despite what immigration critics say, historically immigration has always boosted the U.S. economy. (It’s not even a close call.) The CBO says the Senate bill would decrease the deficit by $158 billion in the next decade. That’s probably understating the economic benefit of moving undocumented workers from off-the-book jobs into the mainstream economy.

The House approach to immigration reform is to break apart the coalition of security in exchange for citizenship. Louisiana’s Rep. John Fleming said in The Hill newspaper that one reason Republicans oppose the Senate's immigration bill is because they don't trust President Obama to enforce the border enforcement provisions in that bill. (Even though Obama won’t be president when most of the law kicks in.) (more…)

Fixing the Great American Health Mistake

trahant MARK
TRAHANT

 
Austerity

The Obama administration’s decision last week to delay a mandate for large employers to provide health insurance or pay fine is both meaningless and significant.

It’s meaningless because it impacts such a small number of employers. Nearly all employers with more than 50 employees already provide health insurance. And those that do not, are unlikely to change course because of the penalty (even at $2,000 per full-time employee that costs far less than insurance).

But it’s significant because it highlights The Great American Health Care Mistake. This country should have never forged health care to work. It was an accident, a way to avoid wage controls during World War II. No other country in the world has such a crazy system. And it makes no sense to let our employers make decisions about our health care. All the basic stuff: What kind of coverage we buy, what should be covered, or even our provider networks and, therefore our doctors.

This mistake let Americans “pretend” that health insurance did not have a cost. It was a quiet part of our compensation, but because it’s not measured by the employee (although that will change soon), it wasn’t something we were willing to spend money on ourselves.

But employer-sponsored insurance is declining. It’s a trend that began before federal health care reform. The percentage of Americans who receive health insurance through employers dropped from 69.7 percent in 2000 to just 59.5 percent in 2011, according to a report by the Robert Wood Johnson Foundation.

And even when company insurance is offered, more employees are saying, “no thanks.” In 2000, 81.8 percent of employees who were offered coverage enrolled. A decade later, the Robert Wood Johnson Foundation study reported, only 76.3 percent did.

The reason for the decline in both employer and employee participation is simple: Insurance costs are out-of-sight. The study said the premium for employee-only coverage doubled from 2000 to 2011, increasing from $2,490 to $5,081. Family premiums went up by 125 percent, from $6,415 to $14,447, during the same time period.

Across the country, the Robert Wood Johnson Foundation study did not find a single state where employee-sponsored insurance actually increased, and 22 states saw decreases of 10 percent or more. (more…)