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Reauthorization of health care lost in the endgame


WASHINGTON - Meetings and discussions designed to bring about
reauthorization of the Indian Health Care Improvement Act have gone on
since 1998, and steering committee activities predated those.

But not until July 2004 did those efforts attain a high profile in Congress
at large. Tommy Thompson, at that time Cabinet secretary of the Department
of Health and Human Services, raised the issue at a hearing of the Senate
Committee on Indian Affairs, and later during a visit to the Navajo Nation.
He also called for full funding of the Indian Health Service - $3.44
billion in 2005, instead of the $3 billion that was ultimately enacted.

Thompson's commitment to the bill was considered significant. Democrats had
largely kept Indian health care reauthorization alive as an issue. But in a
Republican-controlled Congress, they would need Republican support to pass
a bill. And here was Thompson, extending a helping hand in no uncertain
terms. He could not have been more emphatic, assuring Sen. Ben Nighthorse
Campbell, then chairman of the Senate Committee on Indian Affairs (and
since retired, along with Thompson), that passing a reauthorization bill
would be the capstone of their careers.

Thompson joined other prominent GOP congressional members in supporting a
reauthorization bill, which ultimately found 57 co-sponsors in the House
and six in the Senate. Though July was already late in the legislative
calendar, Campbell called for an all-out effort to pass the bill in the
Senate. Thompson committed his staff to work on the bill with Campbell's.

Rep. Richard Pombo, R-Calif., chairman of the Resources Committee in the
House of Representatives, called H.R. 2440 "the first substantive step
forward in Indian health care in over a decade."

He explained that since the last reauthorization of the Indian Health Care
Improvement Act, "more than half of the tribes in the United States have
exercised their rights under the Indian Self-Determination and Education
Assistance Act to assume responsibility to carry out health programs on
their own behalf. Congress should encourage this progress and flexibility
by allowing tribes continued input through their powers of self-governance
so that they can tend to the needs and priorities of their tribal members."

According to Rep. Frank Pallone, D-N.J., a longtime tribal health advocate,
additional support for the bill reached Washington in the form of Indian
advocacy groups and individuals who spoke for the issue across Capitol Hill
during the National Museum of the American Indian's opening week in
September. By Sept. 22, 2004, bills would pass out of both Campbell's and
Pombo's committees, where they had previously languished during the 108th

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In addition, Sens. Bill Frist, R-Tenn., the Senate Majority Leader, and Ted
Stevens, R-Alaska, emerged as "Dutch uncles" of the Senate bill, friendly
influencers who proved willing to smooth out points of difficulty behind
the scenes.

So with all this support - more certainly than reauthorization has known
before -- how did the Indian Health Care Improvement Act fail to get
reauthorized in the 108th Congress?

A crowded legislative calendar was one reason; but that's a constant
nowadays. The insistence of advocates on appropriating funds to go with the
reauthorization also hurt the bill's chances in a tight budget; but that
too is a constant.

Campbell had declared in July that White House support would be necessary.
But when it came, it came with qualifications, particularly over a Medicare

Thompson spoke passionately of the need for the bill, but he also surprised
Campbell's staff with his suggestion that DHHS must still go over it all,
even though the bill's draft language had been previously vetted by DHHS.
Once DHHS staffers took over for Thompson, a whole different feeling
evolved. They weren't gung-ho as Thompson had been.

Once the bills were finalized, few working days were left before the 108th
Congress adjourned. If the bills didn't pass by then, they would have to be
reintroduced in the 109th Congress. For the bills to have a chance,
negotiations had to go forward with a number of committees of jurisdiction.

Down-to-the-wire negotiations between committee staff, White House
representatives and DHHS were unproductive. The goal was to finalize a
version of the bill that could pass both chambers for President George W.
Bush to sign into law late in the session. In particular, the
administration kept revisiting settled issues and insisting on changes in
language. When negotiators abandoned tribal priorities such as the Medicare
section in order to get a compromise bill into law, the concessions were
met with further demands.

Ultimately, it became clear that no bill would pass, most certainly no bill
with appropriations attached. At that point, tribal groups decided against
endorsing a bill that had been seriously weakened. It wouldn't pass, and
the administration would take the watered-down version as a starting point
in the 109th Congress.

With that the bill failed in the 108th Congress. A new version, compromised
on some points but still strong enough to serve tribal interests, is sure
to be introduced in the 109th Congress, convening in January.