"“Democrats are leaving Washington for the July 4 recess without passing key parts of their health care agenda,” writes Andrew Villegas for Kaiser Health News. “…with states hit hard by the recession, an extension of extra Medicaid funds also seemed likely.” But because of a “contentious debate, with conservative Democrats and Republicans opposing programs that could add to the deficit.” The result, Villegas writes, is “the Medicaid and COBRA subsidies are still in limbo.”

Many American Indian and Alaska Native patients in the Indian health system are in a precarious spot because of this battle. Some of the increased spending for Indian Health Service depends on increasing Medicaid rolls. This is important because Medicaid, unlike the IHS budget, is an entitlement. Once a person is eligible, the money is supposed to be there (in contrast to a straight budget line that runs out of money once its spent). This problem should be simple: States don’t have to pay for patients in the Indian health system because the federal government eventually picks up the cost. But the problem is each state will define eligibility and a tightening of state rules will mean that patients that should be eligible for Medicaid, won’t qualify.

It would be easy to dismiss states as uncaring. But the problem is there are fewer dollars available from tax collections during the recession. State budgets are wrecked by too many promises, ranging from pension obligations to constitutional promises to always balance the budget.

The best course ahead is to be innovative, tap into as much new money now, and prepare for the worst. Indian Country can’t pretend that budgets will magically be dammed (or as the British say, ringfenced). The tsunami is on its way."

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Warning: Budget tsunamis are forecast (Mark Trahant 7/5)

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