It’s a great job (except for the benefits)

I’m reading a job announcement for a great gig. It pays $15 an hour. Flexible hours. Important work – and it’s classified as “long-term temporary.” That’s another way of saying: no benefits.

In a country that has opted for an “employer-based” health care system this should be the smoking gun; primary evidence that it’s a mistake to tie health insurance to our work.

But under health care reform there would be an employer mandate and the company that put out the job announcement would be required to offer insurance or pay a fine. Right? Wrong. The letterhead on the job announcement says: U.S. Census Bureau. The same government that demands employers offer health care tells its own workers simply, “no benefits.” This is not uncommon in either government or in the private sector. Some 12 percent of the work force is classified as part time and employers design jobs keeping in mind a rigorous enforcement of that 30-hour work week. A few employers do provide benefits to part time employees, but there are also people who work two or more part time jobs without benefits.

Here is the strange part: What would happen to this Census worker with the health care bills that require individuals to purchase insurance? The United States would have to write a subsidy check for the individual it has hired on the cheap in order to save money on benefits.

The individual mandate has been called the common thread in all of the health care reform proposals before Congress. 

The idea is to require the purchase of health insurance, similar to laws enforcing automobile liability insurance. Congress would then subsidize the cost of that insurance, based on income-levels. This would be true for either the so-called “public option” or private insurance.

This is where it gets thorny for Indian Country. Would a treaty right to health care be considered “insurance” under the law? Or would individuals eligible for IHS services be required to purchase insurance under a mandate? And, if so, would the subsidy be automatic or based on income-levels? The result could be some sort of means test.

A working paper by the staff of Senate Indian Affairs Committee Chairman Byron Dorgan, D-North Dakota, calls for a blanket exemption of individual Indians from this mandate. The paper says: “Exempt Indian tribes from any employer mandate penalties and individual Indians from individual mandate penalties. In recognition of the U.S. federal government’s trust responsibility to provide health care to AI/AN individuals’, financial penalties should not be assessed against individual Indians failing to obtain health insurance coverage.”

On the House side, the pending bills do not spell out protections for the federal trust responsibility. House Natural Resource Committee Chairman Nick Rahall, D-West Virginia, has proposed a similar amendment to protect the Indian Health system from “inadvertent harm.”

The National Indian Health Board put it this way on Aug. 14: “Now is the time for Indian Country to reach out to Congressional members … it is extremely critical that Congress hears about the support for health care reform and the need for specific provisions to address the unique nature of the Indian health care delivery system.”

The fact is we don’t know if this language will be in the final bill. The health reform proposals in both Houses are about as firm as a pool of water.

But even if there is an exemption for Indian Country, how will that provision be executed? Will it apply to individual Indians living on reservations and other areas considered Indian Country? What about people who move back and forth? Will they be subject to the mandate and penalties when working in the city – but free when they move back home?

There are also questions about an exemption for tribes under the employer mandate as well. Would this apply to the government operations only? What about tribal enterprises? Even casinos? On top of that will the law be different for employees who are not tribal members? This is a big deal because in many rural communities tribes are the largest regional employer.

Robert J. Blendon, a professor of health policy and management at Harvard, said earlier this month that what is being debated now is not a restructuring of the American health care system but a proposed “law that says ‘everybody who works at Dunkin’ Donuts has to have insurance.’ It turns out millions of people work full time, but they get no [health] benefits … People across the country can be heard crying, ‘I can’t afford to pay. Do whatever you want – just don’t ask me to pay.’”

That notion is especially complicated for Indian Country because of the fundamental declaration that a treaty right is the highest form of a government promise, pre-paid health care.

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 year examining the Indian Health Service and its relevance to the national health reform debate. His regular blog posts on the subject can be found at marktrahant.com. Trahant is a member of Idaho’s Shoshone-Bannock Tribes.