When President Trump announced last month that Native American Medicaid recipients will not be exempt from new work requirements proposed in some states, the reaction from tribal leaders was swift. “The United States has a legal responsibility to provide health care to Native Americans,” Mary Smith told Politico. Smith, a member of the Cherokee Nation who served as acting head of the Indian Health Service during the Obama administration, suggested that Native Americans had already prepaid into the system “through land and massacres—and now you’re going to take away health care and add a work requirement?”
But the new requirements, which include holding a job, undergoing drug treatment, or continuing schooling, could have positive effects on communities mired in poverty. Unemployment among Native Americans, estimated at 12 percent in 2016, is the highest of any racial group in the country, and the numbers are much higher on reservations. According to the Census Bureau, on the Pine Ridge Reservation in South Dakota, 50 percent of those 16 and older are not in the labor force. On the Hopi Reservation in Arizona, it’s 52 percent. And these older teenagers are not necessarily in high school: on Pine Ridge, 21 percent of people over 25 have no high school diploma, while another 28 percent hold only a high school diploma or GED. In the Hopi community, those numbers are 14 percent and 42 percent. Reservations offer little opportunity because they limit economic freedom and deemphasize property rights; a culture of dependence prevails. On the Crow reservation, able-bodied men hang around in the middle of the afternoon, doing little.
But just as 1990s welfare reform, with its work requirements, proved to have “generally positive average effects on employment, earnings and income, and generally negative effects on poverty,” in the words of John Hopkins economist Robert Moffitt, so we might expect similar results from the Trump administration’s new policy. Tribal leaders object that Indians should not have to work for their benefits because their treaties entitle them to education and health care. But in Cherokee Nation v. Hitchcock (1902) and Lone Wolf v. Hitchcock (1903), the Supreme Court ruled that such treaties could be modified or terminated without Indians’ consent, and no subsequent decision has altered that precedent. Indians and their advocates may find this unfair, but we should start thinking less about what the country owes Indian tribes because of treaties and more about what we owe individual Native Americans as citizens of the United States. They should have the same opportunities for life, liberty, and property that the rest of us enjoy. As long as the reservation system endures, it will restrict the ability of American Indians to own property or to engage in private commercial exchanges without federal oversight, while keeping children in failing schools.
To sell the new work requirement and build trust among Native Americans, President Trump could offer something in return: serious reforms to the Indian Health Service, where the vast majority of Indians on reservations receive their health care. The corruption-ridden IHS is in an awful state. As the Wall Street Journal reported last year, IHS “failed to meet minimum U.S. standards for medical facilities, turned away gravely ill patients and caused unnecessary deaths.” Yet the IHS budget has grown each year, from $5.6 billion in 2014 to $6.8 billion for 2019. As Representative Byron Dorgan (who led a 2010 investigation into IHS) told a committee last year, “I see the weaving of friendships and favors, relatives, incompetence, corruption and yes, even criminal behavior. And it has all too often—and continues to be in my judgment—been overlooked, excused and denied.”
Trump’s nominee to lead IHS recently withdrew after it was learned that he had lied about his experience and left previous employers in financial disarray. If the president wants to show that he is serious about lifting our most vulnerable population out of poverty, he should move ahead and allow the IHS to impose work-related requirements on Medicaid recipients—and find a qualified professional who can fix Native America’s sclerotic health care service.
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