A question for any Republican running for any federal office: If you are successful repealing “ObamaCare,” what happens to the Indian Health Care Improvement Act?
South Dakota Rep. Kristi Noem illustrates the GOP’s mixed message. Her web page says: “I will support efforts to fully repeal the health care bill.” A few clicks later, she adds, “A lack of resources and medical staff are constantly the biggest hurdles to quality health care on our reservations. Improving access and quality of care should be a key priority.”
It’s nice to have it both ways. At least on paper. But it is an important question because the Affordable Care Act—ObamaCare—includes the Indian Health Care Improvement Act. If you repeal one, you repeal both. Sure, you could pass another Indian Health Care Improvement Act, but that’s a tall order.
But this dilemma shows the larger Republican problem with health-care reform. If not the Affordable Care Act, then what? And once a proposal is on paper, do the numbers add up? Do the ideas really reduce health care costs and by extension the single largest budget issue facing the federal government?
Don’t hold your breath waiting for real answers. The problem in our political discourse is that folks are not required to give answers as complex as the problems. It’s enough to say, “I am against ObamaCare,” without detailing what should happen next.
First, it’s important to repeat, over and over, that many of the provisions of the Affordable Care act do not begin until 2014. There remains plenty of time in this election cycle to repeal, replace, beef up, add the public option, or somehow amend the Affordable Care Act.
Only one thing: You need the votes to do that. There has to be a majority in the House, a supermajority in the Senate of 60 votes, and a president who all agree. That would require a November 2012 sweep that’s currently not showing up in any of the polls. In fact: The opposite seems more likely today. The most recent fights over the payroll tax has given Democrats hope of retaking that chamber. Real Clear Politics says the odds favor Republican control the Senate but, more important, a sweep of the toss-up races would only result in 55 seats, well short of a supermajority.
Of course a Republican president could throw up all sorts of roadblocks to implementation of the Affordable Care Act. Mitt Romney for example has talked about granting a 50-state waiver. But that, it seems to me, is the best and a rather limited alternative to repealing ObamaCare.
As I mentioned last week: The Supreme Court could also strike down the act. But it’s far more likely that it would strip the individual mandate to purchase health care insurance, leaving the remainder of the law intact. The Obama administration makes an interesting pitch to the court for the mandate, citing a Nixon Administration’s plan as well as Romney’s Massachusetts plan because it “has strengthened private employer-based coverage: despite the economic downturn, the number of workers offered employer-based coverage has actually increased.”
A second issue before the court is the Medicaid expansion under the Affordable Care Act. Some states say that part of the law goes too far and is “coercive.” (But that’s a tough case to make in a voluntary program because a state could simply quit Medicaid.) States are looking for an out because Medicaid is the most expensive item in their budgets, adding up to nearly a quarter of all state spending (when you include the federal match). Medicaid is also problematic for the Indian health system. On one hand it’s an important funding stream for people who are eligible. On the other hand states set the rules for services and eligibility — even when the federal government pays 100 percent of the costs.
The word “repeal” carries certainty. It makes it seem like if only we voters elect … then, finish the sentence, and all of this mess goes away. Only a repeal requires as much consensus as putting forth an alternative. And that’s not a likely election outcome.
Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s recent book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.