Exempting Native Americans from the health care mandate

Indian Country & Health Care Reform

By Mark Trahant

There is growing consensus about a key element of health care reform: a requirement that you must buy health insurance. The idea is that the insurance pools would be less expensive if every American were included - especially younger, healthier workers who for a variety of reasons decide not to buy insurance. The reform proposals would require people to sign up for Medicaid, buy subsidized insurance, or purchase a policy at work or on their own.

This would be difficult in Indian Country. Already Indian Country reflects the highest number of Americans who do not sign up for Medicare, the closest thing we have to universal coverage for the elderly (by my count almost a quarter of Native American elderly are not on the program). The story for Medicaid is similar. Moreover in recent studies one of the reasons for the low participation is the notion expressed by many who did not believe they should have to sign up for any program because health care is a treaty obligation of the United States.

Speaking at the National Indian Health Board Consumer Conferencein Washington, D.C., Health and Human Service Secretary Kathleen Sebelius said the president supports an exemption from that mandate for individual American Indians and Alaskan Natives. "I'm going to make it very clear," she said, "the administration strongly believes that the individual mandate and the subsequent penalties don't apply to American Indians or Alaska Natives."

There is consensus that the Senate Finance Committee's billwhen it surfaces will reflect this notion. The House bill does not address exemptions, but at the NIHB conference, Rep. Frank Pallone, D-NJ, said he would introduce amendments along those same lines.

The exemption is critical, I think, because of the already low participation by Native Americans in existing programs such as Medicaid. The enforcement of this mandate will be through the tax code. I don't want to get ahead of the debate, but the definitions and regulations will be critical. Will the penalty exemption apply to those living within IHS service areas - the "on or near" reservations. Or will it be where ever an American Indian or Alaskan Native person lives, say Phoenix or Seattle?

The other mandate question is will tribes be required, as employers, to purchase insurance? The House bill does not address the issue, but does require states and local governments to buy insurance. The Senate might be more inclined to grant some sort of penalty exemption. And, again, the details are where the questions surface: Since the tax code is the enforcement mechanism, would tribes (or other governments) be required to file some sort of tax return to the IRS? Would tribal enterprises be treated differently than the governmental services?

Answers are hard to come by right now. Every item is subject to two pressure points: First, rounding up the votes to pass a bill. And, second, the "scoring," or the estimated cost of the legislation, by the Congressional Budget Office.

Tribes in the larger health care debate: An endorsement

Most of the conversation in Indian Country is about how health care reform will impact the Indian health care system. But this week the five tribes of North Dakota added their voiceto the wider debate, backing President Barack Obama's health care initiatives.

The United Tribes of North Dakota Board passed the resolution September 10 urging significant health care reform during the current session of Congress. The United Tribes includes the Sisseton-Wahpeton Oyate, Spirit Lake Tribe, Standing Rock Tribe, Three Affiliated Tribes and the Turtle Mountain Band of Chippewa. Two of the tribes, Sisseton and Standing Rock, are located in both North and South Dakota.

The president's proposals will greatly assist Native Americans who do not have access to health care through the Indian Health Service (IHS), said the resolution.

"Sixty percent of American Indians are now living off the reservation," said David M. Gipp, United Tribes Technical College president. "Generally these people are not able to receive services from the IHS and are falling through the cracks when it comes to health care in America."

The larger issue of health care reform should also include improvements in the Indian health care system.

"Our population is typically at greater health risk for most all diseases and especially diabetes, heart disease and cancer," said Myra Pearson, Spirit Lake tribal chairwoman, Fort Totten, ND. "Our need for a better health care system is among the greatest of any population in the country."

The White House released a statement from Kimberly Teehee, senior policy advisor for Native American affairs: "The president greatly appreciates the United Tribes of North Dakota for adopting a resolution supporting his health insurance reform plan, and for their call to Congress to take action. He looks forward to working with Indian Country as we act on this important moral issue."

Mark Trahant is a member of the advisory board of InvestigateWest and the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho's Shoshone-Bannock Tribes. Comment at www.marktrahant.com