Gov. Sean Parnell announcing his decision not to expand Medicaid. Photo from Alaska governor's office
The State of Alaska had a busy week. There are only so many ways to demonstrate contempt for Alaska Natives. Yet the state seemed to find many ways. Logic be damned. On Monday the state asked for a review by the U.S. Supreme Court of the Katie John case. According to the Native American Rights Fund: “The Katie John litigation, more than any other subsistence case exemplifies the contentious battle waged between federal, tribal and state interests over jurisdiction of Alaska Native subsistence fishing rights.” The state of Alaska has a different take. “Alaska entered the Union in 1959 on equal footing with the lower 48 States, which included “the right to control and regulate navigable streams within [her borders],” says the state’s argument. “One of the primary reasons Alaskans sought statehood in the first place was to secure the ability to save Alaska’s fisheries. And the authority to regulate fishing and hunting within its borders is central to Alaska’s sovereignty and critical to Alaskans generally. Fishing and hunting not only remain a way of life in Alaska; they are key to Alaska’s economy and its residents’ livelihood.” In other words: The state says its sovereignty trumps and tribal people in Alaska cannot hunt and fish as they have done for thousands of years without a state say so. I could go on. But that’s just one day. Because by week’s end, the state was making the total opposite argument, saying that the federal government, not the state, should be responsible for health insurance for Alaska Natives. The second issue involves expanding Medicaid. Despite numerous studies about its economic benefits to Alaska, Gov. Sean Parnell announced the state would not participate. A study by the Alaska Native Tribal Health Consortium projected that the state would earn $12 for every dollar it invested, creating some 4,000 jobs. Medicaid, the governor said, costs too much. “Effectively, the state’s operating budget would then revolve around the expanded Medicaid program,” he said. “This decision has to be about setting policy that helps the poor, without saddling future generations with the debt and risk. Attaching a costly Medicaid expansion to a flagging national health care program is like buying a high-priced ticket on a sinking ship.” The governor cited a report about the impact on Medicaid in Alaska. What’s curious is that report does not detail how a failure to expand Medicaid would impact the Alaska Native tribal health system. So here is the governor’s logic: He subtracted Alaska Natives from the state’s uninsured population. Alaska Natives don’t count. The governor said the federal government and the tribal health network will take care of this population (even though the Indian health service does not legally qualify as an insurance program). Alaska is off the hook. This is wrong on so many levels. In the first place, the governor of Alaska is putting at risk what should be one of the state’s most remarkable features. The tribal health system in Alaska is excellent by any measure. It is designed, managed and operated by Alaska Natives; it is not the Indian Health Service. Without Medicaid expansion, this health care network will be limited by the sequester, budget cuts, and operate largely on dollars appropriated from Congress. (To be fair: Medicaid will grow anyway. More people will sign up as they learn more about the Affordable Care Act, but that’s a different framework than an expansion.) Any discussion about Medicaid in Alaska should start with its impact on Alaska Native health systems. Even now, without Medicaid expansion, Alaska Natives account for more than a third of all Medicaid recipients. If the expansion were to occur, that number would climb to more than half of the system. Alaska, of course, is not the only state with a large Native American population to reject Medicaid. That list, unfortunately, includes Oklahoma, South Dakota, and Montana, all states with large native populations. It’s particularly poor policy because the state pays nothing for the expansion when American Indian and Alaska Natives sign up for Medicaid and get treatment within the Indian health system; it’s a 100 percent federal reimbursement. Yet the states set the policy, eligibility, and control far too much of the outcome. As I pointed out in my recent video series, more than half of the American Indian and Alaska Native population lives in states without Medicaid expansion. That to me is the hope in this nonsense. If state governments continue to demonstrate their contempt for Native citizens, then it’s time for Congress, the president, and the Centers for Medicaid and Medicare to treat Indian Country as the 51st state for Medicaid purposes. The federal government already pays for this funding; Medicaid policy should match that spending. So forget Alaska’s equal footing. How about equal footing for the American Indians and Alaska Natives? It’s not the money. It’s the ability to build a healthier future; real sovereignty. Then that’s what the Katie John case is all about, too. Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of the Shoshone-Bannock Tribes.
Join the Conversation