The House of Representatives voted to repeal the Affordable Care Act on February 3. Then, this is not new. The House has voted nearly 60 times to either revoke the law or to make huge changes. But this time the House and the Senate are in Republican hands. So that means what was a symbolic act now has the potential of becoming law.
The Affordable Care Act is like a national soap opera that should rivet any audience. Will the law survive? What sort of challenges does it face legally and politically? And, most important, what does this daytime drama mean to Indian country?
Here is the story so far.
Turn back to 1974. President Gerald Ford signed the Indian Health Care Improvement Act into law, a measure that modernized the federal delivery of health care in Indian country. But that law had an expiration date; it needed another act of Congress to renew it. And that did not happen. Congress let the bill lapse despite repeated attempts. That’s where the story takes a turn. The whole health care reform debate was heating up and folks in Congress decided to roll the Indian Health Care Improvement Act into the Patient Protection and Affordable Care Act. This language was shortened to the Affordable Care Act or “Obamacare” — and it’s now the law of the land. The Indian health provisions were made permanent so future Congresses would not have to renew them.
The Affordable Care Act had other benefits to Indian country. The law improved funding channels for Indian health facilities, a source of money that’s growing during lean budget years. Next year’s Indian Health Service budget estimates more than $1.1 billion collected from Medicaid, Medicare, Veterans Health Administration and private insurance.
But Republicans have been adamantly against the Affordable Care Act. Four years ago a Republican House was elected and that body started voting over and over to repeal the law. But nothing ever happened because the Democratic controlled Senate ignored the actions in the House.
But like any good soap opera there are new characters joining the story. The Supreme Court could strike down part of the law, causing a lot of confusion. And the Senate is now run by Republicans who will definitely consider the House legislation to repeal the law. This will not be easy. The Senate usually needs 60 votes in order to pass legislation (stopping the threat of a filibuster). And there are not 60 votes to repeal the Affordable Care Act.
That's another twist. Democrats were short 60 votes back in 2010 — so they turned to an arcane process called budget reconciliation that allowed the legislation to pass with a simple majority, or 51 votes. Now many Republicans are asking their party leaders to do the same thing and use the budget reconciliation to repeal the Affordable Care Act. That idea would probably work if there was a Republican in the White House. But you can bet that President Barack Obama will veto any attempt to roll back his signature health care legislation. So that means Congress would need a two-thirds majority to override a presidential veto. There are not nearly enough votes in either the House or the Senate to do that.
But many Republicans see repeal (enacted or not) as an important statement that will define the 2016 election campaigns.
If Republicans find a way to repeal the Affordable Care Act that would raise new questions and chaos. For example what happens to those people who’ve purchased insurance now or who signed up for the expanded Medicaid programs? Would people lose coverage and get nothing in return?
The questions for Indian country are troubling, too. What happens to the Indian Health Care Improvement Act? Or how will the Indian health system replace money from Medicaid and other sources opened up through the Affordable Care Act?
A few Republican Senators have started a “framework” about what kinds of alternative law they would pass to replace the Affordable Care Act. Utah’s Sen. Orrin Hatch, chairman of the Finance Committee, said in a Senate floor speech: “Our plan rests on four simple principles. First: Repeal ObamaCare – with all its costly mandates, taxes, and regulations – in its entirety. Second: Reduce costs by taking the government out of the equation, and, instead, empowering consumers to make choices about their own health care. Third: Provide common-sense consumer protections to protect individuals with pre-existing conditions. And, finally: Reform our broken Medicaid system by giving states more flexibility to provide the best coverage for their citizens.”
There are key issues here for Indian country. First, the Indian health system is not part of the debate. It must be. Any repeal of the Affordable Care Act is also a repeal of the Indian Health Care Improvement Act. Second, there is no easy way to eliminate “government” from the Indian health system. And, finally, a reform of Medicaid, especially one that grants more power to states, will reduce health care funding for Indian health facilities. Already nearly half the Indian health system is shortchanged by the states that refuse to expand Medicaid. This is a real problem.
Cue the organ music. This daytime drama has many twists and turns ahead. But the story’s ending should be simple: the United States promised American Indians and Alaska Natives healthcare. The only question should be, “how will that promise be delivered?” Stay tuned.
Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.