Make Medicaid work better

President-elect Donald Trump has already stepped back from his campaign pledge to repeal Obamacare entirely, saying he’ll keep a couple of the law’s popular insurance protections. Soon enough, certain governors in his own party can be expected to argue that it would also be smart to retain the law’s most successful component: the expansion of Medicaid. Trump should take that advice.

Thirty-one states — 11 led by Republican, but not Florida Gov. Rick Scott — have accepted Obamacare funding to extend Medicaid to anyone earning less than 138 percent of the federal poverty line (about $16,400 for an individual). As a result, at least 10 million Americans have insurance who would lose it without the expansion.

Most of these beneficiaries say they’re satisfied with the coverage. And their governors — including Vice President-elect Mike Pence of Indiana — have credited the expansion with encouraging preventive care, cutting emergency-room visits and saving money on health care. What’s more, the Medicaid expansion has succeeded without discouraging employment, as some people worried it might.

Whatever the problems with other parts of President Barack Obama’s Affordable Care Act (chiefly, rising premiums in the state insurance exchanges), Medicaid expansion has worked. Rolling it back now would hurt state budgets, the health-care industry and, most of all, the newly insured.

That isn’t to say Republicans shouldn’t make changes. Many governors already have, with permission from the Obama administration. In Indiana, for example, beneficiaries are required to pay into health savings accounts. The Trump administration will be able to allow other innovations.

Ideally, Trump’s Medicaid officials will resist modifications that make it unduly difficult for qualified people to become insured. Requirements that beneficiaries have jobs, for example, or that they shoulder unaffordable copayments would undermine the purpose of the expansion. More counterproductive still would be for Congress to drastically reduce Medicaid’s funding, as some congressional Republicans have proposed. Far better to let the individual states continue to tailor their operations as need be.

At this point, Medicaid provides insurance to about one in four Americans. With the rest of the Affordable Care Act under threat of drastic change, it’s essential to keep this pillar of health security in place, and even work to persuade the remaining states to accept it.

Power imbalance at the pipeline protest

When injustice aligns with cruelty, and heavy weaponry is involved, the results can be shameful and bloody. Witness what happened Sunday in North Dakota, when law enforcement officers escalated their tactics against unarmed American Indians and allies who have waged months of protests against the Dakota Access oil pipeline.

They drenched protesters with water cannons on a frigid night, with temperatures in the 20s. According to protesters and news accounts, the officers also fired rubber bullets, pepper spray, percussion grenades and tear gas. More than 160 people were reportedly injured, with one protester’s arm damaged so badly she might lose it.

The confrontation happened at Backwater Bridge, on a highway linking the Standing Rock Sioux Reservation and Bismarck, North Dakota. Burned-out trucks and a police barricade have made the bridge impassable. Protesters say this is a needless threat to public safety – forcing emergency vehicles to detour about 20 miles – as well as a spiteful attempt to keep them away from the pipeline construction site. The violence erupted after some in a group of 100 to 200 protesters tried to remove the truck carcasses Sunday.

“We’re just not going to let people or protesters in large groups come in and threaten officers, that’s not happening,” said the Morton County sheriff, Kyle Kirchmeier. The Sheriff’s Department’s Facebook page linked to a video of the armed and armored officers, the water cannon drenching the crowd, and a rock flying overhead.

The pipeline, all but built, is meant to ship crude oil from North Dakota to Illinois. Built almost entirely on private property, the pipeline crosses ancestral lands of the Standing Rock Sioux, passing less than a mile from the tribal reservation. Tribe members fear contamination of their drinking water and damage to sacred sites. They are trying to persuade the federal government to deny permits allowing the pipeline to cross the Missouri River near their reservation.

The department’s video was meant to portray the protesters as dangerous troublemakers, but the photos and videos in news reports suggest a more familiar story – an imbalance of power, where law enforcement fiercely defends property rights against protesters’ claims of environmental protection and the rights of indigenous people. American Indians have seen this sort of drama unfold for centuries – native demands meeting brute force against a backdrop of folly – in this case, the pursuit of fossil fuels at a time of sagging oil demand and global climatic peril.

The Army Corps of Engineers has called for more study and input from the tribe before it decides on whether to grant a permit. The pipeline company has asked a federal judge to give it the right to proceed with its plan to lay pipe under the river. There is no firm timeline for either decision.

In the meantime, President Barack Obama could step in to protect everyone’s safety and pressure the sheriff’s officers to stand down. Barring that, resolute protesters, a heavily militarized police force unwilling to budge, a company that refuses to consider an alternate route and an onrushing Great Plains winter – how can this possibly end well?

This story was originally published November 23, 2016 at 2:13 PM with the headline "Make Medicaid work better."