American Indian

Op-ed by Mark Trahant

I started my exploration of health care reform in July.

“The federal government accepts a double standard: Any discussion about rationing – or government care – is off the table unless you’re a member of an American Indian tribe or Alaskan Native community with a sort of pre-paid insurance program (many treaties, executive orders and laws were specific in making American Indian health care a United States’ obligation),” I wrote back then.

Six months later – or half way into this project – I am struck by how Indian Country is both a part of the health care debate and yet absent from its larger discussion.

We’re part of the conversation every time critics blast the Indian Health Service as a failure of government. We’re also included in the larger reform measure – the Indian Health Care Improvement Act – was added to the larger bill. That’s a good thing because this bill (unlike the original) has been awfully difficult to move through the Congress.

But we’re absent from the conversation because neither the Congress nor the Executive Branch has articulated what lessons can be learned from the history and experience of the Indian health system as it applies to the larger issue of health reform. It’s particularly frustrating to watch the politicians who are quick to point out the weaknesses of that system even though they have never proposed adequate funding or the dreaded idea of rationing.

Consider how the money question goes beyond Indian Country: If the federal government can’t deliver on this one, relatively small promise, how is it going to make good on remaking one-sixth of the economy in a few thousand pages of legislation?

 Op-ed by Mark Trahant

The idea that American Indians should be exempted from any mandate to purchase health insurance has almost become a given in the debate about health care reform.

 Last week Speaker of the House Nancy Pelosi wrote to the National Congress of American Indians and said: 
“We cannot ask Indian people to be penalized for choosing to use the Indian health care system. The House bill will ensure that the exemption from the financial penalties is extended to federally recognized tribes and that tribally provided health care benefits are appropriately protected.”


 The Senate Finance bill already contains such a provision. 

 I’ve wondered about this mandate from the beginning of the process. I know too many people who do not participate in the mainstream economy; many of these folks are either unable or unwilling to navigate such a complex system. Imagine someone who hunts, fishes or is involved in a subsistence enterprise, figuring out what part of their income should be used to purchase even subsidized health insurance.

But even if you agree with the exemption – as I do – there remains another issue to resolve, the money. Unless health care reform substantially improves the funding stream for the Indian health care delivery system, then the individual exemption is only a guarantee of permanent disparity.

By Mark Trahant

This week the Senate Finance Committee continues what's called an "open executive session," the process of weeding out hundreds of amendments to the America's Healthy Future Act of 2009. One by one amendments are considered, added or rejected until the bill takes a form ready for a vote by the full Senate.

There are a number of provisions for Indian Country that still need to survive this process. The first is the exemption for American Indians from the health insurance mandate (at least the penalties). The language of that provision is broad, a definition that includes American Indians and Alaskan Natives "irrespective of whether he or she lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside."

This definition makes the most sense because it will make the law fairly easy to administer. All it would take is to check a box on a Federal Income Tax Return and be identified as an eligible American Indian or Alaskan Native.

So far, at least, this exemption hasn't surfaced much in the larger public discourse. Jane Hamsher, one of the few bloggers who have written about the exemption, said it's not a surprise because "the three Democrats ... are part of the ‘gang of six' come from states (Montana, North Dakota, New Mexico) with disproportionately large Native American populations."

How this provision is viewed in the larger public discourse is important because it requires explanation: Most Americans know little about the Indian health care system or U.S. government's promises. A recent campaign by the Confederated Salish and Kootenai Tribes of Montana is a great example of jumping ahead of this issue: "The Rez We Live On" campaign makes the connection between land concessions and treaty health guarantees.