I’m reading a
job announcement for a great gig. It pays $15 an hour. Flexible hours.
Important work – and it’s classified as “long-term temporary.” That’s
another way of saying: no benefits.
In
a country that has opted for an “employer-based” health care system
this should be the smoking gun; primary evidence that it’s a mistake to
tie health insurance to our work.
But
under health care reform there would be an employer mandate and the
company that put out the job announcement would be required to offer
insurance or pay a fine. Right? Wrong. The letterhead on the job
announcement says: U.S. Census Bureau. The same government that demands
employers offer health care tells its own workers simply, “no
benefits.” This is not uncommon in either government or in the private
sector. Some 12 percent of the work force is classified as part time
and employers design jobs keeping in mind a rigorous enforcement of
that 30-hour work week. A few employers do provide benefits to part
time employees, but there are also people who work two or more part
time jobs without benefits.
Here
is the strange part: What would happen to this Census worker with the
health care bills that require individuals to purchase insurance? The
United States would have to write a subsidy check for the individual it
has hired on the cheap in order to save money on benefits.
The individual mandate has been called the common thread in all of the health care reform proposals before Congress.
The
idea is to require the purchase of health insurance, similar to laws
enforcing automobile liability insurance. Congress would then subsidize
the cost of that insurance, based on income-levels. This would be true
for either the so-called “public option” or private insurance.
This
is where it gets thorny for Indian Country. Would a treaty right to
health care be considered “insurance” under the law? Or would
individuals eligible for IHS services be required to purchase insurance
under a mandate? And, if so, would the subsidy be automatic or based on
income-levels? The result could be some sort of means test.
A working paper by the staff of Senate
Indian Affairs Committee Chairman Byron Dorgan, D-North Dakota, calls
for a blanket exemption of individual Indians from this mandate. The
paper says: “Exempt Indian tribes from any employer mandate penalties
and individual Indians from individual mandate penalties. In
recognition of the U.S. federal government’s trust responsibility to
provide health care to AI/AN individuals’, financial penalties should
not be assessed against individual Indians failing to obtain health
insurance coverage.”
On
the House side, the pending bills do not spell out protections for the
federal trust responsibility. House Natural Resource Committee Chairman
Nick Rahall, D-West Virginia, has proposed a similar amendment to
protect the Indian Health system from “inadvertent harm.”
The
National Indian Health Board put it this way on Aug. 14: “Now is the
time for Indian Country to reach out to Congressional members … it is
extremely critical that Congress hears about the support for health
care reform and the need for specific provisions to address the unique
nature of the Indian health care delivery system.”
The
fact is we don’t know if this language will be in the final bill. The
health reform proposals in both Houses are about as firm as a pool of
water.
But even if
there is an exemption for Indian Country, how will that provision be
executed? Will it apply to individual Indians living on reservations
and other areas considered Indian Country? What about people who move
back and forth? Will they be subject to the mandate and penalties when
working in the city – but free when they move back home?
There
are also questions about an exemption for tribes under the employer
mandate as well. Would this apply to the government operations only?
What about tribal enterprises? Even casinos? On top of that will the
law be different for employees who are not tribal members? This is a
big deal because in many rural communities tribes are the largest
regional employer.
Robert J. Blendon, a professor of health policy and management at Harvard,
said earlier this month that what is being debated now is not a
restructuring of the American health care system but a proposed “law
that says ‘everybody who works at Dunkin’ Donuts has to have
insurance.’ It turns out millions of people work full time, but they
get no [health] benefits … People across the country can be heard
crying, ‘I can’t afford to pay. Do whatever you want – just don’t ask
me to pay.’”
That
notion is especially complicated for Indian Country because of the
fundamental declaration that a treaty right is the highest form of a
government promise, pre-paid health care.
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 year examining the Indian Health Service and its
relevance to the national health reform debate. His regular blog posts on the subject can be found at marktrahant.com. Trahant is a member of
Idaho’s Shoshone-Bannock Tribes.
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