Indian Country & Health Care Reform: Spotlight on the Native American provisions

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. This is the essence of the "pre-paid" health care notion.

Some of the other provisions in the Senate bill are even less in the spotlight. For example the Indian Health Service could get more resources because the legislation would end some cost sharing requirements for premiums and deductibles for American Indians and Alaskan Natives at 300 percent below the federal poverty guideline. This is a large percentage of the IHS patients.

Sen. Kent Conrad, D-No. Dakota, also successfully added language to the Senate bill that would eliminate the tax liability for individuals receiving tribal health insurance benefits. This became a problem after the IRS determined that tribal programs didn't qualify for tax waivers unless they are either income based or employment based.

Another clause identifies tribes, tribal organizations and urban Indian organizations as an "Express Lane Agency." The idea is to make easier for individual Native Americans to apply for health care benefits across the spectrum, including Medicaid, CHIP (insurance for children) and other such programs that are state administered.

However, Iowa Sen. Chuck Grassley, the ranking Republican on the committee, said last week he is troubled by this provision because of his immigration concerns. "As we have discussed in this committee in the past," he said, "the role of Indian tribes in verifying citizenship has been questionable."

The politics of that particular tangent is fascinating: So First Americans cannot identify immigrants (I guess the best evidence is the entire colonial history of the United States) when helping tribal people apply for benefits? Strange. Or how about this? Another senator warns that not everyone wants insurance benefits to include maternity care. All this stagecraft is designed to prevent the Democrats from reaching 60 votes in the Senate, the magic number that would make the Republican minority disappear.

The Senate process is the most transparent (at least right now) but there are other deeper currents. The House of Representatives is expected as soon as this week to merge together elements from three committee health care reform proposals. The House's Indian Country provisions should surface at that point and provide more clarity about how the legislation will impact the Indian health care system.

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. Comment at www.marktrahant.com