Can We Trust Medicaid Expansion Advocates?

What the Native Americans can teach us about the U.S. government and healthcare


The federal government of the United States has treated native American Indians abysmally throughout much of the nation's history. Recently, it has been adding another sad chapter to the anthology of abuse. Virginians should pay attention, because the story has important implications for the debate over expanding Medicaid.

The Washington Post reported the tale shortly before Christmas. D.C. has contracted with hundreds of Indian tribes to provide medical services on reservations across the country. But then, claiming to be constrained by tight budgets, the Bureau of Indian Affairs and the Indian Health Service soon began to refuse to pay what they owed. They reneged on the deal not once, but repeatedly - year after year.

The consequences have sometimes been grim: In Nevada, for instance, the downgrading of a hospital to a sometimes-closed health clinic meant "pregnant women were sent off by ambulance, at times giving birth along the side of the road. Elders died before they even reached" other hospitals several hours away. The emergency room closed. Funds for specialized treatment now go for triage.

The tribes sued for breach of contract, and the Supreme Court said they were right: "The government is responsible to the contractor for the full amount due under the contract," the high court ruled. "This principle safeguards both the expectations of government contractors and the long-term fiscal interests of the United States."

After the ruling, the agencies repaid some of the money owed. But then, reports the Post, "agency officials began questioning the accuracy of their own calculations of what they owed the tribes." And they still claim they simply don't have the funds to keep their word: "There is not enough money to go around," an Indian Affairs functionary told Congress in November. The Obama administration sides with the agencies, not the tribes.

The implications for Virginia are obvious. Thousands of federal contractors call the state home, reaping tens of billions of dollars' worth of business a year - second only to California in the value of federal government contracts. If Washington makes it a practice to renege on payments, the consequences for the private sector here would be enormous.

Then there's Medicaid.

The Supreme Court's 2012 ruling on Obamacare gave states a choice about whether to go along with expansion. Virginia continues to deliberate over the question. Gov.-elect Terry McAuliffe has been stumping for expansion; the Republican-controlled House of Delegates seems unlikely to go along.

A chief selling point for expansion advocates is the lure of ostensibly free money: Washington would pay 100 percent of the cost for the first three years, after which reimbursements would step down until reaching a 90 percent plateau in 2020.

Expansion skeptics warn that Washington might not keep that promise. Right now, there is no way to tell. But we do know this much: Nine out of 10 times, new government programs end up costing far more than original estimates projected. Current estimates say the federal government's share of the tab for Medicaid expansion from 2014 through 2022 will come to $931 billion. If the cost is lowballed to even a small degree, then the feds will see more than $1 trillion in new expenses over the next decade.

By contrast, the federal government owes Indian tribes a comparatively paltry $2 billion or so. And that obligation is not merely statutory, but contractual. Yet even after Supreme Court intervention, Washington refuses to cough up the dough.

Shifting more of the cost of Medicaid expansion to the states would be well in keeping with Washington's long-standing practice of taking all the credit for something - but little or none of the responsibility. A Congressional Research Service report says the cost of unfunded federal mandates imposed from 1983 to 1990 alone cost state and local governments at least $8.9 billion. Mandates the next year added at least $2.2 billion more.

By 1995, that problem had grown so acute that Congress, prodded by outrage from the hinterlands, tried to stop itself by passing the Unfunded Mandates Reform Act. Yet according to the National Conference of State Legislatures, Washington has passed numerous measures that flatly violate UMRA's restrictions. As a result, from 2003 to 2008 "Congress … shifted at least $131 billion in costs to states," it says.

If the federal government can ignore its contractual obligations, its own statutes and its own Supreme Court, then it certainly can ignore its own funding formulas, too. This doesn't necessarily clinch the case against Medicaid expansion; it's just one point among many. But it does suggest those hawking the promise of free federal money epitomize Samuel Johnson's definition of second marriages: "the triumph of hope over experience."

This column originally appeared in the Richmond Times-Dispatch.

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  1. I'll just get this out of the way right now: Iron Eyes Cody wasn't Indian, he was a wop.

    1. No he wasn't. He was a Sicilian.

    2. Woman of Playboy?

    3. From what I understand, though Iron Eyes Cody was not Native American by birth, he was recognized by the tribe as a full member, even learning the language. Being Native American is not about blood. I am 1/4 Blackfoot, but do not consider myself Native American in any way.

      1. Blackfoot? Is that anything like Adam Sandler in Mr. Deeds?

  2. How many Medicaid expansion advocates have actually been on Medicaid? Other than the, you know, free-ness (IOW, cost hidden to the end user), it absolutely sucks.

    1. My father become a Medicaid beneficiary when he became disabled, and his overall health was much, much better when he was paying out of pocket for treatment and getting his medications from overseas himself. Nobody who'd ever used it would wish it on a friend.

  3. I'm eager to hear what Liz Warren has to say on the subject. - she being a wild injun and all. And articles like this make me miss White Indian.

    1. Nobody misses White Indian. Besides, she is probably happily gamboling nekkid across the fruited plains to the music in her head.

      1. Hypothermia for the win?

        1. One can only hope.

      2. "There are no Good White Indians"

      3. So gamboling is back?

      4. Then she is better off than most here.

        You said she was doing it happily.

        That's Freedom.

      5. Then she is better off than most here.

        You said she was doing it happily.

        That's Freedom.

      6. Then she is better off than most here.

        You said she was doing it happily.

        That's Freedom.

  4. Today on NPR, the morning host was flabbergasted by the results of an Oregon study that showed an increase in Emergency room visits as more people were added to the Medicaid rolls.
    The poor guy just could not understand how this could be possible.

  5. The "Indian" in the picture with the article is "Iron Eyes Cody" - whose real name was Frank de Corti, and he was 100% Italian-American. Interesting. The most iconic native American in history was actually Italian thanks to allowing his image to be used as a standard bearer for (environmental) leftism! More interesting still is, TODAY'S leftist standard-bearers are Elizabeth Warren, who is a white chick who pretends to be an Indian AND Bill De Blasio, born Warren Wilhelm, who is a WASP who pretends to be an Italian! That BOOM was my mind blowing. Full, circle, man.

    1. Johnny Depp killed it as Tonto, however.

      1. Johnny Depp gladly dons redface, but would probably balk at blackface.

    2. Did he have anything to do with the leftist environmental freak show? I remember him only in an anti-littering public service announcement commercial. The message was to stop throwing trash just anywhere, but there was no coercion suggested.

      Did I miss something?

    3. I don't think Iron Eyes Cody is the most iconic Native American in history

    4. And in fairness to De Blasio, he is half Italian. De Blasio is his mom's maiden name. His parents divorced when he was young, and he was raised mostly by his mom. He even speaks Italian. He's definitely not a WASP, as he was baptized Catholic (and is now non-practicing), and his dad was German, not Anglo-Saxon (I know the Anglo-Saxons originally came from Germany, but that was 1500 years ago, modern Germans are not Anglo-Saxons)

      1. Wow, you are a buzzkill. The comment was meant to be humorous, a riff on the weird tendency for left-wing politicial figures to pretend to be "ethnic" to score cheap points. I left out Hillary being 1/57th Jewish in the interest of bevity. As far as De Blasio, do you really believe that he changed his name in 2004 because he has mommy issues? No, he changed it because he thought it would get him some outer borough street cred? No, the guy is pure Central Park East / Montague street, not even a smidge Bensonhurst / Flushing. To those of us whose names ACTUALLY end in vowel, that's a WASP. And he SPEAKS Italian? Big whoop - my weirdo cousin speaks fluent Klingon - doesn't mean he has a big, deformed head - well, he sorta does, get the point. I wasn't expecting a dissertation on Teutonic migratory patterns.
        Oh and regarding Cody's status as an icon - try saying "That cryin' Indian" to anyone over the age of 30 -they know exactly who you're talking about. Now repeat the same experiment with "Squanto"...

  6. So, by using that picture, are you implying that Eyetalian Americans can gain the privledge of getting royally fucked by the Feds - previously only enjoyed by Indian Americans?

  7. The federal government of the United States has treated native American Indians abysmally throughout much of the nation's history.


    All... rather.

    1. Government's sole purpose is to treat everyone abysmally.

  8. I help out in the office of my neighbor's dental clinic. Because of her strong religious beliefs, she treats any MA patients under 16 and children on referral from the reservations under any other programs. Their coverage generally pays 30-40% of the bill, (I've seen as low as 17%), and she writes off the balance.

    Last summer we received a letter from a local tribal council stating, simply, that any past due bills not yet paid would not be paid. Period.

    She still accepts the patients.

    1. I suppose they read this article and feel their non payment is justified.

      They, and others, have been taught to believe that they didn't take the land from some Others at some point without reparations either.

  9. Not that the point doesn't hold up, but after 200 years of reparations, I'm getting slightly bored with hearing about the plight of the American Indian. The statute of limitations on stolen land is probably getting pretty close to running out. It's important to remember that things like the special clinics that ended up going unfunded, the gambling monopoly in most states, federal income stipend, etc, comes on top of all of the rights and privileges of American citizenship. There's no reason besides the generous gift of learned helplessness the government bestows upon everyone it ostensibly tries to help that reservations look like third world shit holes.

    1. That's just it. The land was not stolen. Stealing presupposes the concept of property rights--a concept that only a very few number of Native Americans (some of those in the Cherokee tribe) ever came to honor as the Europeans took over the continent and established this very important principle of individual rights.

      Until the Europeans came along, Indian tribes fought over the use of buffalo hunting grounds. The fiercest and most brutal got the use. Europeans changed that.

      Stating that the land was "stolen" from the Indians exposes a tribalist mentality--a variant of racism and collectivism.

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