What can American Indians and Alaska Natives expect from a Donald Trump administration? Let’s start with a billion dollar dilemma.
This is Trahant Reports.
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 even a Republican Senate did not buy the whole plan.
So now Republicans, led by House Speaker Paul Ryan, will take another shot at creating state block grants.
Ryan’s agenda, “A Better Way,” proposes to do this with Medicaid. “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,” the speaker’s plan says.
This is a significant issue for the Indian health system. Under current law, Medicaid is a partnership between the federal and state governments. And 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.
The Affordable Care Act, which is priority one for repeal and replacement, uses third-party billing as a funding source for Indian health programs because it can grow without congressional appropriations. The idea is that when a person is eligible, the money is there. The Indian Health Service budget in fy 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.
Ryan’s House plan would convert Medicaid spending to a per capita entitlement or a block grant depending on the state’s choice. And there is no indication yet how the Indian health system would get any money 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.
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 a funding stream from Medicaid, potentially stripping money from an Indian health system that is by all measures underfunded.
I am Mark Trahant.