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 Conference in 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 bill when 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.
Mark Trahant is 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
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