Modern US presidents have a curious relationship with North America's first residents, American Indians and Alaska Natives. President Richard Nixon in July 1970, sent a special message to Congress calling for a new era with the indigenous tribes because, "on virtually every scale of measurement - employment, income, education, health - the condition of the Indian people ranks at the bottom". Nixon called for a "new era in which the Indian future is determined by Indian acts and Indian decisions".
Not every president got the memo.
President Ronald Reagan, for example, found himself in Moscow confused by the entire premise of federal-Indian relations. He told a group of students in the former Soviet Union:
"Let me tell you just a little something about the American Indian in our land. We have provided millions of acres of land for what are called preservations - or reservations, I should say. They, from the beginning, announced that they wanted to maintain their way of life, as they had always lived there in the desert and the plains and so forth. And we set up these reservations so they could, and have a Bureau of Indian Affairs to help take care of them. At the same time, we provide education for them - schools on the reservations. And they're free also to leave the reservations and be American citizens among the rest of us, and many do. Some still prefer, however, that way - that early way of life. And we've done everything we can to meet their demands as to how they want to live. Maybe we made a mistake. Maybe we should not have humoured them in that wanting to stay in that kind of primitive lifestyle. Maybe we should have said, no, come join us; be citizens along with the rest of us."
Reagan's idea was insulting to the 500 tribal governments that existed before the United States. These tribal governments survived conquest and exist today because the US negotiated treaties with them for lands and other concessions. Those treaties promised doctors and hospitals, schools, and other basic governmental services.
American Indians and Alaska Natives are supposed to have a treaty right - a special right - to healthcare.
That history sets the stage for Barack Obama.
As president, he has announced no new sweeping policy initiatives - how do you trump self-determination? Yet most of his policies have been generally supportive of tribal governments. At the 5th White House Tribal Nations Conference - held at the Interior Department because the largest room at the White House, the East Room, is too small for such a gathering - Obama promised to make his first "state" visit to "Indian Country" as president sometime next year.
Before the president arrived, Secretary of the Interior Sally Jewell told tribal leaders that she heard from them "over and over and over again that sequestration is killing us".
One tribal leader said a few minutes later: "We need your help with sequestration. We did not create the federal debt ... Treaties are not discretionary."
But Congress, not the president, decides what's discretionary. So even a supportive president is limited by austerity.
"We've got to stop the self-inflicted wounds in Washington," the president said during the live broadcast. "Because for many tribal nations, this year's harmful sequester cuts and last month's government shutdown made a tough situation worse. Your schools, your police departments, child welfare offices are all feeling the squeeze. That's why I'm fighting for a responsible budget that invests in the things that we need in order to grow - things like education, and job training, and affordable housing and transportation, including for Native American communities."
Treaties are the ultimate promise, a constitutional promise by one government to another. But that framework collapses when Congress refuses to go along. President Obama may be the head of state, but the word of that state is dependent on a Congress that cannot agree on how to even write a budget.
So the president stuck to a politician's litany, ticking off what he considers success stories. "We've created jobs building new roads and high-speed Internet to connect more of your communities to the broader economy," the president said. "We've made major investments in job training and tribal colleges and universities. But the fact remains, Native Americans face poverty rates that are higher by far than the national average. And that's more than a statistic, that's a moral call to action. We've got to do better."
It's true that President Obama's budgets have added investment dollars to American Indian and Alaska Native communities. But since Congress has been operating without a budget, there have not been more resources available for the past couple of years. And last year, the process of sequester made the situation even worse because of across-the-board budget cuts.
Consider Native American health programs. More than half of the Indian health system is now operated by tribes and tribal organisations, but the funding comes from the federal government. Only, it's not enough money to do the job.
The Affordable Care Act is supposed to change that by encouraging American Indians to sign up for benefits under a variety of insurance schemes, ideally adding money into Indian health. President Obama put it this way: "We've got to keep our covenant strong by making sure Native Americans have access to quality, affordable healthcare just like everybody else."
That's it. American Indians and Alaska Natives are supposed to have a treaty right - a special right - to healthcare. One that's fully-funded. It's not "affordable healthcare just like everybody else's".
The Obama stump speech, in its own way, is no more enlightening than Reagan when he says: "For Native Americans, this means more access to comprehensive, affordable coverage."
Affordable coverage is not the same as pre-paid, treaty-based healthcare.
Then, treaty or not, there is a case to be made as to why American Indians and Alaska Natives should be included in the Affordable Care Act plans, especially Medicaid and even through the state-based exchanges. The problem is that the president did not make that case.
Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of The Shoshone-Bannock Tribes.
The views expressed in this article are the author's own and do not necessarily reflect Al Jazeera's editorial policy.