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A Race of Medicaid Policy

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New Medicaid rules by the Trump administration undermine the treaty right to health care.

The Trump administration is supporting a major policy shift on Indian health programs which could result in a loss of millions of dollars and sabotage treaty rights.

This is Trahant Reports.

A story in Politico Sunday raised the issue, saying the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules would be illegal preferential treatment.

The new policy on Medicaid work requirements “does not honor the duty of the federal government to uphold the government-to-government relationship and recognize the political status enshrined in the Constitution, treaties, federal statutes, and other federal laws, said Jacqueline Pata, executive director of the National Congress of American Indians.

Medicaid has become a key funding stream for the Indian health system — especially in programs managed by tribes and non-profits. Medicaid is a state-federal partnership and public insurance. The Affordable Care Act expanded Medicaid eligibility, but the Supreme Court ruled that each state could decide whether or not to expand. Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives in 19 states have become insured.

Officially Medicaid represents 13 percent of the Indian Health Service’s $6.1 billion budget (just under $800 million).

But even that number is misleading because it does not include money collected from third-party billing from tribal and non-profit organizations. In Alaska, for example, the entire Alaska Native health system is operated by tribes or tribal organizations and the state says 40 percent of its $1.8 billion Medicaid budget is spent on Alaska Native patients. That one state approaches the entire “budgeted” amount for Medicaid.

Those Medicaid (and all insurance) dollars are even more significant because by law they remain with local service units where the patient is treated (and the insurance is billed). And, unlike IHS funds, Medicaid is an entitlement. So if a person is eligible, the money follows.

Medicaid is the largest health insurance program in America, insuring one in five adults, and many with complex and long-term chronic care needs. The Trump administration and many state legislatures controlled by Republicans see Medicaid as a welfare program. While most Democrats view it simply as a public health insurance program.

Work rules are particularly challenging for Indian Country. Unlike other Medicaid programs, patients in the Indian health system will still be eligible to receive basic care. So stricter rules will mean fewer people will sign up for Medicaid and the Indian Health Service — already significantly underfunded — will have to pick up the extra costs from existing appropriations. That will result in less money, and fewer healthcare services, across the board.

I am Mark Trahant.

Ryan’s Big Idea – Closing out the Term

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Speaker Paul Ryan greeting President Donald J. Trump at the State of the Union.  (Photo via Speaker.gov)

Paul Ryan came to Washington to blow up Washington. He was first elected to represent his Wisconsin district at 28 years old. He campaigned over his career for a federal government that should shrink dramatically, spend far less, that taxes should be low, and that the Republicans should be the party of big ideas.

This is Trahant Reports.

Ryan announced last week that he will not run for re-election. He says he will complete his term as Speaker, but even that’s not certain. He faces pressure to step down early, so another Republican can lead the party’s team into the November election.

Speaker Ryan leaves behind a legacy. He did get his tax cuts and substantial changes in the regulatory framework. But he also delivered more federal spending than ever. The deficit will hit $804 billion this year (a jump of 21 percent in a single year) and exceed $1 trillion by 2020. A new report by the Congressional Budget Office, says that a decade from now the total debt will be larger than the entire economy.

The problem for Ryan, like Speaker John Boehner before him, is that the Republican majority is nearly impossible to govern. The only way for Congress to function, to actually pass a budget, is to build a coalition that includes most Republicans, some Democrats, and work with a similar coalition in the Senate. That often means spending more money. That’s not the Congress — and the party of big ideas — that Ryan had once imagined.

President Donald J. Trump has made that process worse. He caters to the bloc in Congress that cares little about actually governing. Chaos is fine. Big ideas, not so much.

Ryan wanted to reform government. A couple of years ago he proposed a reform of the Indian Health Service by “giving choices to American Indians.” His idea was to have the government issue vouchers for Indian health, outside the system. “Not only will this give American Indians more choice in where they receive care,” the Ryan plan promised. “It will challenge Indian health facilities to provide the best care possible to American Indians.”

Of course that voucher system would have cost less. The Ryan plan also included a provision for a Native American Health Savings Account so individual tribal members could buy their own healthcare services (Never mind that healthcare is a treaty right).
Rep. Tom Cole, a Republican from Oklahoma and a Chickasaw Nation citizen, said Ryan will be missed in Congress. “He is not only the best Speaker I’ve had the opportunity to serve with, he’s also the finest person. Even Paul’s political opponents readily concede that he’s a person of absolute integrity, deep sincerity and of profound decency.”

I am Mark Trahant.

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