Breakout Session: Tribal Sovereignty and Indian Health Care Delivery

1. Breakout Session: Tribal Sovereignty and Indian Health Care Delivery North Central ACH Annual Summit April 12, 2019

2. Part I Objectives

3. Objectives

4. Part II Tribal Sovereignty, Treaties and Inter-Governmental Relations, and Special Trust Responsibility

5. Tribal Sovereignty Recognized by U.S. Supreme Court in 1832 “The Indian nations had always been considered as distinct, independent, political communities, retaining their original natural rights, as the undisputed possessors of the soil, from time immemorial…” Worcester v. Georgia, 31 U.S. 515, 559 (1832)

6. Treaties Included as Supreme Law of the Land “This Constitution, and the laws of the United States which shall be made in pursuance thereof; and all treaties made, or which shall be made, under the authority of the United States, shall be the supreme law of the land; and the judges in every state shall be bound thereby, anything in the Constitution or laws of any State to the contrary notwithstanding.” - Article VI of the U.S. Constitution

7. Treaties Signed with Tribes in Washington State All treaties were signed under duress and most involved relocation.

8. Inter-Governmental Relations Governments Stakeholders

9. Special Trust Responsibility and Health Care Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians— 1. to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy; 2. to raise the health status of Indians and urban Indians to at least the levels set forth in the goals contained within the Healthy People 2010 initiative or successor objectives; 3. to ensure maximum Indian participation in the direction of health care services so as to render the persons administering such services and the services themselves more responsive to the needs and desires of Indian communities; 4. to increase the proportion of all degrees in the health professions and allied and associated health professions awarded to Indians so that the proportion of Indian health professionals in each Service area is raised to at least the level of that of the general population; 5. to require that all actions under this chapter shall be carried out with active and meaningful consultation with Indian tribes and tribal organizations, and conference with urban Indian organizations, to implement this chapter and the national policy of Indian self-determination; 6. to ensure that the United States and Indian tribes work in a government-to-government relationship to ensure quality health care for all tribal members; and 7. to provide funding for programs and facilities operated by Indian tribes and tribal organizations in amounts that are not less than the amounts provided to programs and facilities operated directly by the Service. - 25 U.S. Code §1602

10. Part III Health Disparities, Related History and Resiliency

11. AI/AN Have Highest Prevalence for: • Smoking • Obesity • Disabilities • Drug induced deaths • Infant mortality • Coronary heart disease • Adult tooth loss • Asthma • Colorectal cancer • Diabetes • Stroke • Suicide • Alcohol and abuse disorders • Poor mental health

12. Statewide Premature Mortality Rates, 2013

13. Historical Trauma and Adverse Childhood Experiences Situations where a community experienced traumatic events, the events generated high levels of collective distress, and the events were perpetrated by outsiders with destructive or genocidal intent. Historical trauma leads to post-traumatic stress and disrupted social and familial relationships among adults and ACEs in children. This cycle repeats over generations and results in high rates of adverse social conditions, including poverty, unemployment, low high school graduation rates – known risk factors for behavioral health disorders. “Historical” traumas continue into the present.

14. Colville Reservation and “Checkerboarding” • 1872 – Presidential Executive Order established the Colville Reservation and forced 12 tribes and bands from across Eastern Washington and Idaho onto the reservation. • Before this forced relocation, the 12 tribes and bands were nomadic. • 1887- Dawes Act abolished group title and allotted Tribal reservations into 80/160 acre parcels per Tribal household. Excess lands were sold to non-Indians. • 1892 – Congress took the northern half of the reservation.

15. Colville Reservation and “Checkerboarding” Clair Hunt's Map of the South Half or Diminished Colville Indian Reservation. [Map side.] (1916) Accessed at: https://content.libraries.wsu.edu/digital/collection/maps/id/1112/

16. 100 Years of Boarding Schools (1870s – 1970s) Children of all ages were taken from families by force and placed in boarding schools where they were stripped of their native clothing, punished for speaking their native languages, and often subject to abuse of all kinds. • Multi-generational harm • Prevented passing on cultural protective factors • Legacy of distrust of outsiders • Need for care informed by intergenerational trauma

17. Resiliency

18. Protective Factors: Native Ways of Thinking • Generosity as a symbol of wealth, assuring that contributing members of the community are honoring and caring for each other, or Wealth is determined by what you give, not receive or acquire. • The importance of striving to live in balance so all our needs get the attention they deserve. • Our relationships and recognition we are connected to each other and all things.

19. Part IV Indian Health Care

20. Three Types of Indian Health Care Providers

21. Indian Health Service (IHS) • Federal agency in the Department of Health and Human Services. • Coordinates and oversees funding of health care for AI/AN through IHS Service Units, tribally administered programs, and urban Indian health programs. • IHS eligibility is based on AI/AN descendancyor marriage to AI/AN. • Three Service Units in Washington State • Colville Service Unit (1 facility in Nespelem, 1 facility in Omak) • Wellpinit Service Unit (on Spokane reservation) • Yakama Service Unit

22. Tribal Health Programs • Tribe enters into a contract or compact with the IHS agency. • Tribe takes responsibility to comply with various federal requirements that are attached to IHS funding. • Tribe is audited by U.S. Office of the Inspector General. • Tribe determines eligibility requirements; some tribal health programs serve everyone in the community, others serve only tribal members. • Direct Care: 27 tribes • Purchased and Referred Care: 29 tribes

23. National Health Care Spending Per Capita Source: Centers for Medicare and Medicaid Services (CMS) National Health Expenditure Accounts (NHEA) and the Department of Health and Human Services (DHHS) Budgets in Brief.

24. Indian Health Care = Patient Centered Care • Goal is to preserve, support, enhance Indian health care and improve coordination with non-Indian health care • Why? • Science/evidence-based practice tells us patient-centered care  high quality, effective care that produces better health outcomes • The patient centered medical home for an AI/AN is the Indian health clinic

25. Indian Health Care = Patient Centered Care • Indian Health Care Providers serve their people from birth to death, even if the patient is non-compliant with care plans. • Indian Health Care Providers have an investment and a lifetime commitment to that individual and to the health of AI/AN people. • Effective coordination requires having good procedures in place between the Indian and non-Indian systems of care.

26. Part V Indian Health and Medicaid

27. Alternate Resources *42 CFR 136.61 – IHS is payor of last resort

28. Many federal laws and rules in health care • AI/AN patients may choose Indian health care provider (IHCP) as their primary care provider, and Medicaid managed care entities must respect that choice. • Medicaid managed care entities must reimburse IHCPs – even if IHCPs are not in-network. • States may not force AI/ANs into Medicaid managed care. • States must consult with tribes and solicit advice from non-tribal health care providers on Medicaid programs. • States must accept other state licenses of health care professionals who are employed by IHS and tribal health programs.

29. Questions?Questions and Discussion • Jessie Dean • Tribal Affairs Administrator • Phone: 360.725.1649 • Email: jessie.dean@hca.wa.gov Potential Discussion Questions • How can you partner with tribes more effectively? • How can you support more appropriate care provided both by the Indian health care providers and by non-Indian health care providers? • How can you support better coordination of care between Indian health care providers and non-Indian health care providers?