Indian Country & Health Care Reform: A spirited consensus about health care reform

Op-ed by Mark Trahant

Are we in the final days of the health care reform debate?

"The historic movement to bring real, meaningful health insurance reform to the American people gathered momentum this week as we approach the final days of this debate," President Barack Obama said in his weekly radio address. "The Senate Finance Committee is finishing deliberations on their version of a health insurance reform bill that will soon be merged with other reform bills produced by other Congressional committees."

"What's remarkable is not that we've had a spirited debate about health insurance reform, but the unprecedented consensus that has come together behind it," the president said. "This consensus encompasses everyone from doctors and nurses to hospitals and drug manufacturers." He listed a Republican governors and out of office politicians as part of that consensus.

But when Congress votes it's more likely we'll see something other than consensus. We could call it a "spirited consensus." There is clearly consensus to do something - but any agreement breaks down when the specifics are spelled out. It's likely there will not be a single Republican vote in the House and at best only one or two Republican votes in the Senate. That division is both partisan and philosophical.

But it's that divide that represents our biggest challenge as a nation, our ability to govern ourselves.

There is consensus that our health care structure is not sustainable. But that will remain true even if the health care reform proposals pass. Much of the hope for long term cost control is pinned on an independent Medicare Commission. The idea from the Senate Finance Committee: "In years when Medicare costs are projected to be unsustainable, the Commission's proposals will take effect unless Congress passes an alternative measure. Congress would be allowed to consider an alternative proposal on a fast-track basis."

The Medicare system is unsustainable now. Medicare's trustees - including Treasury Secretary Timothy Geithner, Labor Secretary Hilda L. Solis, and Health and Human Services Secretary Kathleen Sebelius - in their annual report look at both the near and long term viability. Right now the "trust fund does not meet the short-range test of financial adequacy." The fund is in worse shape because the payroll tax is shrinking with so many people either out of work or being paid less.

The bigger challenge is longer term. "The financial outlook for the Medicare program continues to raise serious concerns. Total Medicare expenditures were $468 billion in 2008 and are expected to increase in future years at a faster pace than either workers' earnings or the economy overall," the trustees reported. "As a percentage of GDP, expenditures are projected to increase from 3.2 percent in 2008 to 11.4 percent by 2083 (based on our intermediate set of assumptions). Growth of this magnitude, if realized, would substantially increase the strain on the nation's workers, Medicare beneficiaries, and the Federal Budget."

It's important to understand the impact of these numbers on Indian Country. The Indian Health Service - and for that matter, every federal program in Indian country - operates with annual appropriations from Congress. The growth of Medicare (plus other entitlement programs plus debt service) means that the rest of the federal budget will shrink in the decades to come. Every dollar will be harder to get because so much federal spending is on automatic pilot. That will make it even more difficult for the Indian health system to receive even adequate funding.

Driving this bleak outlook is the fact that the federal government made more promises than the country can afford.

So how is Congress, under the plan of health care reform, tackling this sustainability question? It's telling citizens that to reach sustainability Congress would let an independent, unelected body make the hard decisions.

But this is the screwy part: It would limit what the Medicare Commission could do. "The Commission would be prohibited from making proposals that ration care, raise taxes, or change Medicare benefit or eligibility standards," according to the Senate Finance Committee's proposal.

Are we in the final days of the health care reform debate? Sorry. This debate represents only the first baby step. Whether health care reform passes or not, we have a long way to go before we reach a real consensus.

Mark Trahant is an advisory board member of InvestigateWest and a  Kaiser Media Fellow examining the Indian Health Service and its relevance to the national health care reform debate. He is a member of Idaho's Shoshone-Bannock Tribes. For more information see  www.marktrahant.com