Mark Trahant: Real fight over health care reform all about funding

The Republican House of Representatives will make good on its promise later this week to repeal the health care reform bill -- only so far it's all for show. No one, not even Republicans, really believe the Senate or President Obama will suddenly support the "Repealing the Job-Killing Health Care Law Act."

So the House will vote to repeal and the Senate will do nothing. But if the House action is all theater, the real story will be what happens with the actual appropriations to implement the Affordable Care Act.

Amy Goldstein in The Washington Post reports that House Republicans “intend to take apart some of the sprawling law, which Democrats pushed through Congress last year, piece by piece before major aspects of it go into effect. At the same time, Republicans say, they will come up with their own plan to revise the health-care system, tailored along more conservative lines.” So what does this mean for the Indian Health Care Improvement Act (which was rolled into health care reform)? Is there a conservative alternative to addressing the health needs of Indian Country?

So far no. There isn't a Republican plan for health care reform. Sure, there are old standards such as buying insurance across state lines, tort reform and opposition to abortion. But other positions, including the Indian Health Care Improvement Act, have yet to be determined.

So for now the fight will be over implementation dollars. This debate should take center stage shortly after the presidentʼs budget is released in mid-February. This year will be especially complicated because Congress has yet to pass a budget for the current year (the government is operating on whatʼs called a “continuing resolution” a temporary budget until March.)

This means any budget cuts for the current fiscal year will be amplified by the short time frame remaining in this yearʼs budget. Thus, a ten percent cut effectively becomes a twenty percent cut because half the yearʼs budget has already been spent.

When conservative presidents were in office, there was an interesting budget back and forth with Congress over Indian health dollars. President Ronald Reagan, for example, proposed significant cuts to the Indian health budget in fiscal year 1982, including the elimination of urban Indian programs.

However Congress rejected Reagan's proposal and restored much of the cuts and protected the urban programs. Now the situation is reversed: President Obama's proposed budget will be dismissed by the House and it will be up to the Senate to try and reach a compromise over spending in order to get enough votes to pass a budget. A “compromise” in this setting means less money.

And that's if everything works as planned. A much greater problem could surface if either side refuses to compromise -- resulting in no appropriations and even a limited or severe government shut-down.

The appropriations process is crucial to the Indian Health Care Improvement Act because the law itself is only an authorization, there is no money attached to it. Congress must act to spend the money. For example the Indian Health Care Improvement Act amends current law and requires any appropriation cover medical inflation and population growth. That number will likely be reflected in the presidentʼs budget, but the new Congress is not required to actually appropriate that increase.

It's the same problem for new IHS spending for mental health programs -- including suicide prevention -- plus long term care, and a number of Indian health demonstration projects. The programs are authorized by law, but now it's up to the Congress to fund those efforts.

The question is will Indian programs be allowed to operate with some sort of business as usual? Certainly there are Republican friends of Indian Country -- including the chairman of the new House subcommittee on Native American Affairs Don Young -- who will try to hold that course. But given the broader Republican zeal to attack all things government that probably won't be enough.

Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s new book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.

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