Senate Indian Affairs Committee Chairman John Barrasso, R-Wyoming, says a patient-centered culture at Indian Health Service is long overdue. Barrasso is a physician. What happens to Indian health after the repeal of the Affordable Care Act, especially Medicaid as a funding source. Photo by SCIA
The billion dollar dilemma: Funding Indian health in the Trump Era
By Mark Trahant
A few years ago I had a chance to ask President George Bush what he thought about tribal sovereignty in the 21st century. His answer went viral: “Tribal sovereignty means that. It’s sovereign. You’re a … you’re a … you’ve been given sovereignty and you’re viewed as a sovereign entity.”
Think about that question today; we would be lucky to get a similar answer. Bush (except for the “given” part) was correct: tribal sovereign means that, you’re sovereign.
This idea is relevant now because during the campaign Donald Trump was dismissive of any sovereignty except his perception of what America’s sovereignty is all about.
So a treaty with Mexico and Canada? Junk it, day one. A United States pledge to reduce global warming? Out. Perhaps even historic military alliances will disappear into lost budgets.
And when it comes to the federal relationship with American Indian and Alaska Native governments as sovereigns we will likely see ideas pop up that were long ago discarded as impractical, expensive, or out-and-out wrong.
At the top of that list: Shifting power from the federal government to state capitals. That was Ronald Reagan’s plan when he came to Washington. In 1981 he proposed rolling dozens of federal programs into block grants for states. Then the budget was cut by 25 percent, the argument being states could deliver the services more efficiently. But a Republican Senate didn’t buy the whole plan. In the end most of the programs were managed by states, but under federal oversight.
According to Congressional Quarterly, Sen. Orrin Hatch, R-Utah, then chairman of the Senate Labor Committee said at the time, it was the best deal possible. “We’ve come 70 to 80 percent of the way to block grants,” Hatch said. “The administration is committed to pure block grants, and so am I. But there was no way we could do that.”
Expect Hatch, and House Speaker Paul Ryan, to take another shot at substantial block grants to states, representing a fundamental shift for programs that serve American Indians and Alaska Natives.
Ryan’s agenda, “A Better Way,” proposes to do this with Medicaid. It says: “Instead of shackling states with more mandates, our plan empowers states to design Medicaid programs that best meet their needs, which will help reduce costs and improve care for our most vulnerable citizens.”
This is a significant issue for the Indian health system. Under current law, Medicaid is a partnership between the federal and state governments. But states get a 100 percent federal match for patients within the Indian health system. Four-in-ten Native Americans are eligible for Medicaid funding, and, according to Kaiser Family Foundation, at least 65,000 Native Americans don’t get coverage because they live in states that did not expand Medicaid.
Eligibility for Coverage Among American Indians and Alaska Natives Who are Uninsured as of 2015. Source: Kaiser Family Foundation
The Affordable Care Act, which is priority one for repeal and replacement, used third-party billing as a funding source for Indian health programs because it could grow without congressional appropriations. The idea is that when a person is eligible, the money is there. The Indian Health Service budget in fiscal year 2017 includes $1.19 billion in third-party billing, $807 million from Medicaid programs. This funding source is especially important because by law third-party billing remains at the local clinic or other unit. And, most important, when the Indian Health Service runs short of appropriated dollars it rations health care. That’s not the case with Medicaid funding.
One problem with the Affordable Care Act (after a Supreme Court decision) is that not every state participates in Medicaid expansion. So an IHS clinic in South Dakota would have less local resources than in North Dakota or Montana. This especially important for health care that is purchased outside of the Indian health system.
The most important gain from the Affordable Care Act has been insuring Native children. According to the Kaiser Family Foundation: “Medicaid plays a more expansive role for American Indian and Alaska Native children than adults, covering more than half of American Indian and Alaska Native children (51%), but their uninsured rate is still nearly twice as high as the national rate for children (11% vs. 6%).”
Ryan’s House plan would convert Medicaid spending to a per capita entitlement or a block grant depending on the state’s choice. There is no indication yet how the Indian health system would get funded through such a mechanism.
During the campaign Trump promised to repeal the Affordable Care Act, including Medicaid expansion, but said there would be a replacement insurance program of some kind.
Allocation of Indian Health Service Program Funding, in Billions, FY2016. Source: Kaiser Family Foundation
Earlier this year Sen. John Barrasso, R-Wyoming, chairman of the Senate Indian Affairs Committee, and Sen. John Thune, R-South Dakota, introduced legislation to “improve accountability and transparency at the IHS.”
Barrasso is a physician.“A patient-centered culture change at the Indian Health Service is long-overdue,” he said. “This bill is an important first step toward ensuring that tribal members receive proper healthcare and that there is transparency and accountability from Washington. We have heard appalling testimonies of the failures at IHS that are unacceptable and will not be tolerated. We must reform IHS to guarantee that all of Indian Country is receiving high quality medical care.”
What will reform look like after the Affordable Care Act goes away?
Last week Rep. Tom Cole, R-Oklahoma, said on CSPAN that the Indian Health Care Improvement Act was one of the good features of the Affordable Care Act and ought to be kept. But nothing has been said by Republican leaders about how to replace the Indian health funding stream from Medicaid, potentially stripping $800 million from the Indian health system that is by all measures underfunded.
Perhaps the most important idea in government, one that had been expanding, is the idea of including the phrase “… and tribes” in legislation and funding. That means tribes get money directly from Washington rather than the round about from DC to state capital to tribal nations. And clearly in this era that’s a hard sell. Just last week the state of North Dakota opted to punish (or so it thinks) tribes by canceling a joint appearance before the legislature because the state is not happy with the Dakota Access Pipeline protests. At a moment where there should be more talk, not less, the state walks away.
That, of course, begs the question, is this how government will work over the next four years?
Mark Trahant is the Charles
R. Johnson Endowed Professor of Journalism at the University of North
Dakota. He is an independent journalist and a member of the Shoshone-Bannock
Tribes. To read more of his regular #NativeVote16 updates, follow trahantreports.com On Facebook:
On Twitter: @TrahantReports