Elections 2012: Romney and Ryan Debate the Indian Health System … Without Saying a Word

Sunday talk shows are an important part of the national conversation. But if you want to know about policies that impact American Indians and Alaska Natives you need to read between the lines, zooming in on indirect references.

Republican presidential candidate Mitt Romney was on NBC’s “Meet the Press” this weekend – the first time since 2009 – and he said he doesn’t hate all of the Affordable Care Act.

“I say we’re going to replace ObamaCare. And I’m replacing it with my own plan. And, you know, even in Massachusetts where I was governor, our plan there deals with pre-existing conditions and with young people. Everybody… Well, I’m not getting rid of all of health-care reform. Of course there are a number of things that I like in health-care reform that I’m going to put in place,” Romney said.


That framework could be important to Indian country after the election, should Romney and the Republicans win, because it could be the basis for continuing the Indian Health Care Improvement Act (which is a section of the Affordable Care Act). If the Affordable Care Act is repealed – and there is a wait for a replacement – that could cause legal chaos for many of the Indian health provisions. However if there is an agreement to rework the Affordable Care Act, then, perhaps, that would mean the Indian Health Improvement Act could continue as is.

On the other hand, follow the money.

On ABC’s “This Week” host George Stephanopoulos asked the vice presidential candidate, Paul Ryan, about his proposed Medicaid cuts, some $800 billion and a 35 percent reduction over the next decade.

“Here’s the secret on this one,” Ryan responded. “Medicaid spending still goes up under what we’re proposing. What we’re saying is we want to repeal ObamaCare, because we think it’s a terrible law. And so we’re taking away the massive increases in ObamaCare that are attributable to Medicaid. About a third of the people that ObamaCare is supposed to serve, they’re just pushing people on Medicaid.”

Ryan continued: “Medicaid is not working. More and more doctors are less likely to even take people with Medicaid. It’s a system that needs reforming. So we don’t want to put more money and force more people on a program that’s failing, that’s not working. We want to reform Medicaid. And so what we’re saying is, don’t expand this program as dramatically as ObamaCare does. Keep it like it is, increase its funding and send it to the states so the states can fix this problem. I think government closest to the people, especially in providing health care for the poor, works the best.”

Pushing Medicaid decisions back to state capitals is, of course, not helpful to Indian country. That means 50 different sets of rules, eligibility requirements and reimbursement procedures.

But Ryan raised a core funding question about the Indian health system. Traditional funding of the Indian Health Service (IHS) goes through the appropriations process. That means the agency must ask Congress for money to spend every year. And the result is a shortage of funds. But Medicaid is an entitlement. If someone is eligible for the service, the money is there. The Affordable Care Act – or ObamaCare, you prefer – expands Medicaid significantly. That should increase the flow of money into IHS, urban Indian health programs, and tribally-contracted facilities.

But there’s something else that’s telling. When Ryan talks about Medicaid “not working.” or that more doctors are refusing to see patients, that’s true among private providers. But it’s the opposite in the Indian health system. A tribally-contracted or urban Indian clinic is much more likely to make money under Medicaid because the cost structure is so much lower. A patient on Medicaid is an advantage, not a problem. (This is also true in community health clinics and other programs designed to deliver health services to the poor.)

The bottom line for Indian country: Medicaid doesn’t run out of money at the end of the fiscal year. If a patient is eligible for those services, the Medicaid money is there.

Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. He has been writing about Indian Country for more than three decades. His e-mail is:


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Elections 2012: Romney and Ryan Debate the Indian Health System ... Without Saying a Word