Paul Ryan’s Call for Indian Health ‘Choices’ Would Be a Disaster

Mark Trahant

TRAHANT REPORTS—Every once in a while an idea is floated that’s so bad, you wonder, “what were they thinking?”  Or smoking? 

Today is such a day.

A little background: Elections are supposed to be how a democracy resolves a contentious issue. The United States was — and is — divided over health care policy. So eight years ago Barack Obama ran on a platform calling for major health care reform. He won. Six years ago he was able to get the Affordable Care Act through the Congress, barely, and that became the law of the land.

The Indian Health Care Improvement Act is a full chapter of the Affordable Care Act.

But Republicans never bought into the premise (even though it was an idea similar to one from a conservative think tank) and have promised over and over to repeal and replace the law with their own plan. That really never happened either because there was no consensus among Republicans about what health care reform ought to look like.

Wednesday House Speaker Paul Ryan unveiled the Republican health care alternative as part of his “a better way” agenda. The plan ends the mandate requiring individuals to buy insurance as well as many of the penalties. But the plan is not a specific piece of legislation, more of a general notion of what Republicans would like to do to repeal and replace the Affordable Care Act. Ryan said his goal is “to show the country a better way on the big issues of the day that can get into law in 2017 with a Republican president.”

So I was eager to see what ideas this proposal has for the Indian health system. If elected, what would Republicans do to improve the delivery of health care on reservations and in urban areas? After all in recent weeks the Senate Committee on Indian Affairs, chaired by a physician, Wyoming Sen. John Barrasso, has held hearings on the Indian Health Service. The first proposal, Senate bill 2953, is supposed to improve accountability. “As a doctor, I know that real quality healthcare is about putting the patient first,” Barrasso said. “This is the mentality we need to see at every level of the Indian Health Service.”

Uh. Ok. But what about Congress? The mentality of Congress is that it has never considered a single proposal to fully-fund Indian health. What does full-funding look like? To me it would at least equal the per person cost for federal employees. But whatever the number we know that the Indian health system needs more dollars.

So that’s where the Affordable Care Act fits in. The law was not perfect but it opened up new channels of funding by expanding Medicaid for eligible patients. It also funded individual patients’ insurance plans through private markets. And, on top of that, required tribes to purchase insurance as employers. Ideally, over time, the Affordable Care Act makes it possible for the IHS to earn significantly more from third-party pay. (And, if patients don’t like their service, they could take their insurance elsewhere.)

Ryan’s alternative does not really mention the Indian health provisions in the Affordable Care Act. But a repeal of the law, which Ryan says is necessary, would also get rid of the Indian Health Care Improvement Act.

However Ryan’s proposal does mention Indian health. The headline is “Giving Choice to American Indians.”

Instead of promising adequate funding Ryan’s plan gives the IHS “the ability to set up a system for eligible American Indians to access to care outside of the Indian Health Service facilities. Not only will this give American Indians more choice in where they receive care, it will challenge Indian health facilities to provide the best care possible to American Indians.”

Less money. That’s sure to result in better care for those who remain, right? There is also a provision to create individual Native Americans to have Health Savings Accounts. Come again. What about treaty rights? Not. So. Much.

 Damn. This is a play right out of the 1940s. The Republican complaints then were that the Bureau of Indian Affairs was responsible for poverty, horrible living conditions, and general mismanagement. The solution over the next decade was the idea of “freeing the Indians” by terminating the federal responsibility. A hundred and nine tribes were terminated, representing some 12,500 tribal members, and the end result was conditions that were far worse.

That’s exactly what will happen if Ryan’s “choice” approach to Indian health becomes law. The word “termination” used to be toxic in Indian country. But legislation that would destroy the Indian health system is beyond appalling.

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 @TrahantReports" target="_blank">Twitter @TrahantReports.

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Sammy7's picture
Submitted by Sammy7 on
Durn, I bet this little widow peaked winkie has never had a spanking. His fraudulency professes to damage the poor yet paint himself as saintly. Of course we know that this is nothing new in the Catholic Church. Death dealing elevates one to sainthood. Could that be his motivation? Saint Winkie?

Steve Gagne's picture
Steve Gagne
Submitted by Steve Gagne on
Mark -- did Paul Ryan even talk to anyone in Indian Country before coming up with his "Choices"?

smacmill's picture
Submitted by smacmill on
Thanks for the heads up Mark. I was laid off my job of 34 years in late 2013 at age 61. I was terrified of having no health care but was hugely relieved when I could sign of for the ACA with it's AI/AN provisions in 2014. I seethe every time I see some Conservative on TV pledge to end Obamacare the moment they are able. Thanks for warning us that they are not forgetting this pledge of theirs.

Old Lady's picture
Old Lady
Submitted by Old Lady on
Folks, let's be real. The Republican agenda was and remains to do away with all "social welfare" programs, including IHS facilities, unemployment, workers compensation, food stamps, healthcare for the lower income people, etc. so the rich will not have to pay into these things. This was the main focus of the Reagan administration and has continued under every Republican presidency, including Dubya's economic policies which drove the U.S. (and less directly other countries) into the worst economic time since the Great Depression. Yes, all the healthcare programs need some tweaking - but that needs to be done by those who have the people's interests at heart, which does not include the Republican party in general, and certainly not Paul Ryan in particular. Right now I am very afraid for this country...everyone, please please think about your families, your communities, your nations and your country - and vote come November.

cheroky2's picture
Submitted by cheroky2 on
You give this link - "even though it was an idea similar to one from a conservative think tank) Read more at - to say that it was a republican plan, but if anyone takes the time to actually read the link, it shows that there was NO republican plan like the ACA in the '90's. Therefore the whole story is based on a false premise. But then again, I am used to being the minority in all things Indian. They say that 96% of blacks vote democrat, I'm guessing it is the same among Indians. I don't understand why we would want to be dependent on a Federal gov't that has been so malicious towards us throughout history