Pushing Repeal of the Affordable Care Act (While a Replacement Can Wait)

Mark Trahant

The following was originally published at Trahant Reports

President-elect Donald Trump and Congress are moving quickly to reshape health care, including the Indian Health system. And so far the path looks to be chaotic.

First, the who: The Trump administration will be led on health care issues by Tom Price, a Georgia physician, a persistant critic of the Affordable Care Act, and a member of Congress. Seema Verma will be the next Administrator of the Centers for Medicare and Medicaid Services. As a consultant Verma has helped conservative governors, including the Vice President-elect Mike Pence, implement Medicaid expansion.

And let’s be clear about their task. As the president-elect said, “he is exceptionally qualified to shepherd our commitment to repeal and replace Obamacare and bring affordable and accessible healthcare to every American. I am proud to nominate him as Secretary of Health and Human Services.”

These two appointees know the machinery of the Affordable Care Act and Medicaid, including how to effectively dismantle the programs.

Price has already floated in Congress an alternative to the Affordable Care Act, the Empowering Patients First Act. That bill would repeal Obamacare in its entirety (including the Indian Health Care Improvement Act) and replace it with a free-market version. The plan would give tax credits that “makes it financially feasible for all to purchase coverage they want for themselves and their families – not that Washington forces them to buy.”

This plan would impact the Indian Health System in several ways. First it would allow participants of federal programs, such as Medicaid, Medicare, Veterans health, and even military TRICARE, to opt out and get a tax credit to buy a personal health plan. (Making it less likely those plans will survive on their own.) In the bill’s section on government health programs there is no mention of the Indian Health system, although the bill later calls for a personal health savings accounts that can be spent at IHS. In other words: save your money so you can pay for your own doctor (at IHS or elsewhere).

But forget the details for a minute. Price’s plan is important because it signals the radically different approach to health care that’s ahead, basically less government spending, more tax credits if you choose to buy health insurance, individual health savings account, and shifting Medicaid to a block grant program run by states.

It’s important to remember that Medicaid now accounts for more than $800 million of the IHS’ $6.1 billion budget and that’s often money targeted for the local service unit. (A smaller Indian health system impact would be ending the requirement that tribes provide insurance for employees. That accounts for about $100 million in the IHS budget.)

The problem for Congress is that any replacement of the Affordable Care Act requires at least 60 votes in the Senate, and that means some Democrats will have to agree to new legislation. That’s where chaos begins.

Legislation to repeal the Affordable Care Act can be done through a process called budget reconciliation (the same method that enacted the law in the first place). That means tightly tying the legislation to the budget (something that has not passed in this Congress yet). But a replacement law would require legislation. And to do that there would have to be a consensus in the House (218 votes) and a filibuster-proof majority in the Senate (60 votes).

House Majority Leader Kevin McCarthy said Monday that Congress should move quickly to repeal the Affordable Care Act and then come up with a replacement plan down the road. McCarthy told The Washington Times: “I think once it’s repealed you will have hopefully fewer people playing politics, and then everybody coming to the table to find the best policy.”

And that policy shift will be dramatic. Tax credits instead of funding. A bigger role for states. And the pretense that the private sector is equipped to deliver health care to all.

According to Drew Altman, president and CEO of the Henry J. Kaiser Family Foundation, “The larger story is GOP preparations for a health policy trifecta: to fundamentally change the ACA, Medicaid and Medicare–all three of health care’s major programs–and in the process, fundamentally alter the direction of the federal role in health and core elements of the social contract.”

American Indians and Alaska Natives are in a risky situation. Our best health care programs, those run by tribes and tribal organizations, will get less funding from this kind of trifecta. Neither tax credits nor state funding are likely to help. And interest from the private sector? Get real.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

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