Just over a year ago, President Barack Obama signed the health care reform bill into law, the Patient Protection and Affordable Care Act. That measure, of course, also includes the permanent authorization of the Indian Health Care Improvement Act.
So what has happened since the president signed the bill into law on March 23, 2010? That question cannot be answered. Not yet. Part of the answer is working its way through the court system with legal challenges. And other parts of the answer are stuck in a political debate even as federal agencies continue to write rules for its implementation.
The administration has lived up to the spirit and the intent of the health care reform law. A new report by the National Congress of American Indians, National Indian Health Board and the National Council of Urban Indian Health says it this way: “... the President’s budget was a true commitment to the successful implementation of the Affordable Care Act. The FY12 budget shows increased funding for IHS, Administration on Aging, and Health Resources and Services Administration.”
Indeed the president asked Congress for a 14 percent increase for programs such as the always underfunded Contract Health Services, alcohol and substance abuse, facility construction, and to implement the Indian Health Care Improvement Act.
In any other year that all would be great news. But the rub is that Congress, not the president, appropriates money. And that process is left hanging by the deep divide in Congress about the very nature and role of the federal government.
The new law, for example, sets out a funding formula for IHS, tribal-contracted or tribal-organization health care facilities based on what is spent for health insurance for federal employees. The “need” is at least 55 percent of that benchmark, but even with recent gains the spending-level remains at about 46 percent. At best allies of tribes in Congress are talking about protecting the Indian health system -- not securing additional money. It’s going to be a tough sell on Capitol Hill to get even modest funding.
It’s important to remember that most of the money that will be required for health care comes from the entitlement portion of the budget. That is Medicare, Medicaid, and Children’s Health Insurance. This is money on automatic pilot. If a person is eligible, the money is supposed to be there without an annual appropriation.
But the money for the Indian health system requires Congress to act in the affirmative. It has to agree to spend the money. That difference is why there’s always a shortage of money and a failure to reach the 55 percent federal employee benchmark.
We in Indian Country understand health care as a federal government obligation. We know the history— and have been painful witnesses to the shortage of funds. I bring this up because there’s another narrative surfacing; one that parallels the language used decades ago to justify termination of federal services.
First, Kentucky Sen. Rand Paul called for the elimination of the Bureau of Indian Affairs and a drastic reduction in Indian health spending. Then last week Fox’s John Stoessel said: “Why is there a Bureau of Indian Affairs? There is no Bureau of Puerto Rican Affairs or Black Affairs or Irish Affairs. And no group in America has been more helped by the government than the American Indians, because we have the treaties, we stole their land. But 200 years later, no group does worse.”
Rand and Stoessel might as well have attributed their ideas to Sen. Arthur Watkins. A generation ago the Republican from Utah was the congressional champion of termination. He promised to “free the Indians” from all those special restrictions against private property (the same ones Stoessel talked about on Fox). “This is not a novel development, but a natural outgrowth of our relationship with the Indians,” Watkins wrote in 1957. “...After all, the matter of freeing the Indian from wardship status is not rightfully a subject to debate in academic fashion, with facts marshalled here and there to be maneuvered and countermaneuvered in a vast battle of words and ideas.”
By every measure termination was a disaster as a public policy. It was legal theft and a failure so great that even a casual reference should be outside that battle of words and ideas.