President Donald J. Trump’s legislative agenda has crashed. The Republican promise to quickly repeal and replace the Affordable Care Act on Friday failed to win enough votes from conservatives to make it so.
As House Speaker Paul Ryan said in a post-failure news conference: “Obamacare is the law of the land … We’re going to be living with Obamacare for the foreseeable future.”
For his part, Trump (who, of course, says he is not to blame for the loss) told The Washington Post, “The best thing politically is to let Obamacare explode.” He called the law “totally the property of the Democrats” and said that “when people get a 200 percent increase next year, or a 100 percent or 70 percent, that’s their fault.”
The president and his administration can do a lot to make that happen. The secretary of Health and Human Services has extraordinary authority under the Affordable Care Act and can use the power of regulation to gunk up Obamacare. There will be many battles ahead on the regulation front.
But, and this is the good part, states will have a say in this too. And there is the potential for a few states to engage in experiments that might improve the law. The question here: Is the administration willing to work to improve insurance options for Americans or is it more interested in punishing Democrats? (Yeah, I know, but there is a political upside to answering that question correctly.)
Here’s the thing: There is a crisis in insurance markets. And a bipartisan solution, meaning most Republicans working in partnership with Democrats, is the best way to reach a solution.
There are three ways most of us get health insurance: our employers, public insurance such as Medicare and Medicaid, and the individual market when we buy our own insurance policies. Employer-based care is an accident of history (it’s a long story) and has been shrinking for the past 15 years. Public health insurance has been growing (something the conservatives in Congress really object to because it codifies the notion that health care is a right), and under the Affordable Care Act the number of people who have individual insurance coverage has increased from about 10.6 million to 15.6 million.
Much of the current health insurance debate is about that individual market. Even if it is the smallest part of the problem, it’s important to understand, as David Blumenthal and Sara Collins wrote in the Harvard Business Review:
Individual markets were troubled prior to the ACA’s enactment in 2010. One reason was that premiums for these policies were increasing more than 10% a year, on average, while the policies themselves had major deficiencies. They often excluded pre-existing conditions, charged higher premiums for people with health risks and for young women, placed limits on annual and lifetime benefits, or refused to renew policies for individuals who became sick. Many people who tried to buy plans were turned down. In 2010, an estimated 9 million adults who had tried to buy a plan in the individual market over the prior three years reported that they were turned down, charged a higher price, or had a condition excluded from their plan because of their health.
Thus “returning to the status quo ante—before the ACA—is not a viable option for the individual markets.”
The fix does not involve a “great mystery,” according to Blumenthal and Collins. It’s simply making certain that more young people buy insurance to help pay for the higher health care costs of older Americans. The bigger the pool, the lower the cost. (Which is why single payer works as a public policy.)
One part of that solution is to increase the government subsidies so more people will buy in. That’s how the insurance market could work better.
Where does Indian Country fit into this matrix?
There is a legal understanding that the Indian health system is federal obligation that stems from the promises made in treaties to provide doctors and nurses to reservation communities. Yet no Democrat or Republican government has ever—ever—proposed fully funding that Indian health system. Members of Congress often acknowledge the treaty responsibility but have never followed those words with an adequate budget.
No Democrat or Republican government has ever—ever—proposed fully funding that Indian health system.
The Affordable Care Act separates insurance from health care delivery. It basically makes the Indian health system (both the government-operated Indian Health Service facilities and those run by tribes and tribal organizations) medical care that’s mostly funded by federal appropriations and by insurance. Nationally that mix right now is about 80 percent appropriations and 20 percent insurance. But the insurance side of the equation under the Affordable Care Act is unlimited. That pool of money grows every time an eligible American Indian or Alaska Native signs up for insurance.
This makes full-funding of Indian health a possibility. Even better: Insurance collections remain at the local clinic or hospital. It really is the best kind of funding.
There are three ways to add money to Indian health care now.
First: More American Indians and Alaska Natives can sign up for Medicaid. The fact is there are many more people eligible than have signed up. The Kaiser Family Foundation estimates that nationwide 1 million American Indians and Alaska Natives lack coverage. Already, Medicaid covers more than half of all children, but 11 percent of those children remain uninsured.
Second: More American Indians and Alaska Natives can sign up for exchange plans under the Affordable Care Act. This is huge. According to healthcare.gov, “If you get services from an Indian health care provider, you won’t have any out-of-pocket costs like co-payments, co-insurance, or deductibles, regardless of your income.” And this benefit has essentially a permanent open enrollment.
Signing up for insurance (including plans from an employer) makes the Indian health system stronger for everyone. It’s the same principle as any insurance: the larger the pool of people who participate, the lower the cost.
1 million American Indians and Alaska Natives lack coverage.
Third: It’s time to make the case for Medicaid expansion in state governments that have said no now that the Affordable Care Act will remain the law of the land. Currently, there’s unequal funding. States can remedy that by expanding Medicaid eligibility (even while trying some of the conservative experiments such as imposed work rules). It’s a win for Indian Country when a state does this because it increases the number of people eligible for insurance. It’s a win for the state because Indian Health Service patients are a 100 percent federal obligation— so the state will be reimbursed by Washington, D.C.
Kansas is the latest state to consider expansion. And it’s likely that the Trump-Ryan failure will push other state legislatures to consider this approach. Indian health patients would benefit from Medicaid expansion in Oklahoma, South Dakota, Texas, Maine, Mississippi, Nebraska, North Carolina, Utah, Idaho, Wisconsin, and Wyoming. A total of 19 states are on this list.
It might be easy to see the defeat of Trump and Ryan’s plan as a huge win. But it is also a warning sign—make that a flashing red light with sirens—that Congress is deeply divided and cannot govern.
The same Republican divisions that killed their health reform plan will kill President Trump’s budget (thank you). But it will also make it nearly impossible to pass any kind of budget. The best outcome might be a “continuing resolution,” a status quo budget.
An even bigger challenge will be for Congress to pass an increase in the debt ceiling. Secretary of Treasury Steven Mnuchin informed Congress that the United States reached its limit on March 15. The Treasury is now juggling accounts so that the government can continue to pay bills.
Conservatives in Congress—actually, just about every member of Congress—hate this part of governing. But a no vote here has enormous consequences for everyone’s finances: the markets. There is an absolute requirement that Congress increase that borrowing authority. It will be a nasty fight.
Of course there is a solution: Create a new coalition of Republicans and Democrats. This works in state legislatures across the country (most recently Alaska). It takes 216 votes to pass legislation in the House so a working body of 22 or so Republicans, plus the 194 Democrats in the House, could accomplish a lot together. But that would mean rethinking the role of party politics. And governing.
This article was originally published at Trahant Reports. It has been edited for YES! Magazine.
Mark Trahant is editor-at-large for Indian Country Today. Trahant leads the Indigenous Economics Project, a comprehensive look at Indigenous economics, including market-based initiatives. Trahant is a member of the Shoshone-Bannock Tribes and has written about American Indian and Alaska Native issues for more than three decades. He is a member of the American Academy of Arts and Sciences and has held endowed chairs at the University of North Dakota and University of Alaska Anchorage, and has worked as a journalist since 1976. Trahant is a YES! contributing editor.