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Exempting Native Americans from the mandate

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markt | Sep 17, 2009 11:45 AM

There is growing consensus about a key element of health care reform: a requirement that you must buy health insurance. The idea is that the insurance pools would be less expensive if every American were included – especially younger, healthier workers who for a variety of reasons decide not to buy insurance. The reform proposals would require people to sign up for Medicaid, buy subsidized insurance, or purchase a policy at work or on their own.

This would be difficult in Indian Country. Already Indian Country reflects the highest number of Americans who do not sign up for Medicare, the closest thing we have to universal coverage for the elderly (by my count almost a quarter of Native American elderly are not on the program). The story for Medicaid is similar. Moreover in recent studies one of the reasons for the low participation is the notion expressed by many who did not believe they should have to sign up for any program because health care is a treaty obligation of the United States.

Speaking at the National Indian Health Board Consumer Conference in Washington, D.C., Health and Human Service Secretary Kathleen Sebelius said the president supports an exemption from that mandate for individual American Indians and Alaskan Natives. “I’m going to make it very clear,” she said, “the administration strongly believes that the individual mandate and the subsequent penalties don’t apply to American Indians or Alaska Natives.”

There is consensus that the Senate Finance Committee’s bill when it surfaces will reflect this notion. The House bill does not address exemptions, but at the NIHB conference, Rep. Frank Pallone, D-NJ, said he would introduce amendments along those same lines.

The exemption is critical, I think, because of the already low participation by Native Americans in existing programs such as Medicaid. The enforcement of this mandate will be through the tax code. I don’t want to get ahead of the debate, but the definitions and regulations will be critical. Will the penalty exemption apply to those living within IHS service areas – the “on or near” reservations. Or will it be where ever an American Indian or Alaskan Native person lives, say Phoenix or Seattle?

The other mandate question is will tribes be required, as employers, to purchase insurance? The House bill does not address the issue, but does require states and local governments to buy insurance. The Senate might be more inclined to grant some sort of penalty exemption. And, again, the details are where the questions surface: Since the tax code is the enforcement mechanism, would tribes (or other governments) be required to file some sort of tax return to the IRS? Would tribal enterprises be treated differently than the governmental services?

Answers are hard to come by right now. Every item is subject to two pressure points: First, rounding up the votes to pass a bill. And, second, the “scoring,” or the estimated cost of the legislation, by the Congressional Budget Office.

Mark Trahant is the former editor of the editorial page for the Seattle Post-Intelligencer. He was recently named a Kaiser Media Fellow and will spend the next year examining the Indian Health Service and its relevance to the national health reform debate. He is a member of Idaho’s Shoshone-Bannock Tribes. Comment at




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