Indian Country

By Mark Trahant
Special to News From Indian Country

The month of December promises to be full of drama: Will the Senate pass health care reform? Is there enough time to debate the hundreds of expected amendments before Christmas? And at the top of the wish list, are there really 60 votes to pass a bill?

The notion of requiring a super-majority in the Senate may be one of our nation’s most anti-democratic traditions.  The Senate elects two members from each state. California’s 36 million citizens get two votes – exactly the same two votes as Wyoming’s 532,000 people. The super-majority makes matters worse because senators representing less than 40 percent of the population can block the legislation that most Americans favor.

The Senate has a unique history and in that favorite argument used by so many, “we have always done it that way.” But let’s be clear about this, the structure of the Senate does not represent democratic values. Why does this matter? Especially when it’s worked for more than two centuries? It matters because health care reform is a test of our continued ability to govern ourselves.

Politicians have been putting off difficult decisions for generations and we are moving toward a date of resolution. The requirement of fixing health care must be seen in the context of a political system where it’s easier to spend than to save, and easier to borrow than to tax.

The current scare over health care rationing makes this point exactly: No one has to give up anything. We can afford the very best, most expensive treatments even when they don’t work.

But we really can’t. We can’t borrow enough money indefinitely. We have to reform the system so that we can make choices about what’s the best medical option for the most people. This is a concept that has been applied to Indian Country for a long time (often with tragic consequences). When Indian Health Service contract funds are depleted, many medical options disappear as well. It’s my hope that health care reform will improve, if not fix, this problem because there will be more funding sources open to IHS patients.

But despite the grand promises of the same doctor, the same insurance company and yada yada, for most Americans there will be a day when cost controls are an essential part of the equation. One way or another there needs to be a rational discussion about rationing care.

Before the end of the month Congress will once again have to increase the legal limit for the national debt that now exceeds $12 trillion. This is a number so big it doesn’t mean anything. But it’s not just a number; it’s a call to those of us who believe in self-government to figure out a strategy for us to say “no” to ourselves (and elect those who say “no” as well).

“The nation faces an unsustainable fiscal future unless the president and Congress change current policies,” according to updated projections from the Center on Budget and Policy Priorities. … “The main driver of the long-term fiscal imbalance is the rising per-person cost of health care, which will increase spending and reduce revenues.”

Why is health care so expensive? It boils down to two things: More of us are growing older and we live longer. A study in the new issue of Diabetes Care is a good example. It says the cost of treating diabetes (the most expensive health care treatment regime) will double in the next 25 years to $336 billion a year. “These changes are driven more by the size of incoming age cohorts than by changes in obesity or overweight rates,” the study found.

We are growing older and more expensive. We can’t afford to borrow whatever amount we need to pay for any treatment we think might work. And, if we get this wrong, we risk either a generational civil war (“I’m not paying for you, old man”) or the United States collapses as quickly as the Soviet Union did. It’s the demographic imperative that ought to be at the heart of the Senate debate. Too bad it’s too much drama for politics.