The 2020 Census identified 9.7 million people as American Indian and Alaska Native (AI/AN), alone and in combination with another race. As upheld by the Supreme Court. the United States government has a “trust responsibility to provide services to American Indians and Alaska Native persons”. This doctrine upholds that, among other provisions, the federal government is responsible for ” for the well-being of the tribes” that they are in treaties with. In fulfillment of this trust responsibility the federal government established the Indian Health Service (IHS) within the Department of Health and Human Services (HHS). However, the IHS is not the sole provider of health care services for Native Americans. Tribal programs and urban Indian organizations are also essential providers, completing the IHS, Tribal, and Urban – or “I/T/U” – system of health care delivery for Native Americans. With the pandemic’s disproportionate impacts on Native Americans, it is important to understand available policy options to improve access to quality and culturally appropriate health care services to facilitate better overall health outcomes for all American Indians and Alaska Native persons.
In this briefing, experts overviewed demographics of the Native American population in the United States as well as the current policy and regulatory landscape that guides and directs Native American health care infrastructure. The audience learned about the historical and prevailing social determinants of health faced by this population alongside potential policy solutions at the community, tribal, and federal levels.
- Christopher Chavis, J.D., MPA, Policy Center Director, National Indian Health Board
- John Molina, M.D., J.D., LHD, Corporate Compliance Officer, Native Health
- Nicole Redvers, ND, MPH, Assistant Professor, University of North Dakota School of Medicine & Health Sciences (moderator)
(listed chronologically, beginning with the most recent)
“New Data Shows COVID-19’s Disproportionate Impact on American Indian, Alaska Native Tribes.” Weeks, R. HUB Johns Hopkins University. October 11, 2021. Available here.
“Native Americans & Health Equity.” NIHCM Foundation. June 22, 2021. Available here.
“Understanding Meaningful Engagement Practices with Tribal Nations.” Clelland, C., Holmes, W., Miller, J. Journal of Public Health Management and Practice. March 2021. Available here.
“2021 Legislative and Policy Agenda for Indian Health.” National Indian Health Board. February 26, 2021. Available here.
“Investing in the Health of American Indians and Alaska Natives.” Incze, M., Tobey, M., Sequist, T. JAMA Internal Medicine. March 16, 2020. Available here.
“Indigenous Health Equity.” Echo-Hawk, A. Urban Indian Health Institute. August 7, 2019. Available here.
“American Indians and Alaska Natives – The Trust Responsibility.” HHS Office of the Administration for Children and Families Administration for Native Americans. Available here.
(listed chronologically, beginning with the most recent)
“Patient-Planetary Health Co-Benefit Prescribing: Emerging Considerations for Health Policy and Health Professional Practice.” Redvers, N. Frontiers in Public Health. April 30, 2021. Available here.
“Roadmap for the Biden Administration to Advance American Indian/Alaska Native Health and Public Health.” National Indian Health Board. February 26, 2021. Available here.
“American Indians and Alaska Natives are Dying of COVID-19 at Shocking Rates.” Akee, R., Reber, S. Brookings Institution. February 18, 2021. Available here.
“Medicaid’s Role in Health Care for American Indians and Alaska Natives.” Medicaid and CHIP Payment and Access Commission (MACPAC). February 2021. Available here.
“Pandemic Highlights Deep-Rooted Problems in Indian Health Service.” Walker, M. The New York Times. September 29, 2020. Available here.
“The Challenge of COVID-19 and American Indian Health.” Shah, A., Seervai, S., Paxton, I., et al. The Commonwealth Fund. August 12, 2020. Available here.
“Traditional Indigenous Medicine in North America: A Scoping Review.” Redvers, N., Blondin, B. PLOS ONE. August 13, 2020. Available here.
“Closing the Health Disparity Gap for American Indians and Alaska Natives Through Health IT Modernization.” Cullen, T., Demaree, M., Effler, S. Health Affairs. January 27, 2020. Available here.
“Fed Up with Deaths, Native Americans Want to Run Their Own Health Care.” Walker, M. The New York Times. October 15, 2019. Available here.
“Regional Differences in Coverage Among American Indian and Alaska Natives Before and After the ACA.” Frerichs, L., Bell, R., Lich, K., et al. Health Affairs. September 2019. Available here.
“Broken Promises: Continuing Federal Funding Shortfall for Native Americans.” U.S. Commission on Civil Rights. December 2018. Available here.
“Native Americans Feel Invisible in U.S. Health Care System.” Whitney, E. National Public Radio. December 12, 2017. Available here.
“Impact of ACA Repeal on American Indians and Alaska Natives.” Warne, D., Delrow, D., Angus-Hornbuckle, C., et al. State Health & Value Strategies. March 24, 2017. Available here.
“American Indian Health Policy: Historical Trends and Contemporary Issues.” Warne, D., Frizzell, L. American Journal of Public Health. May 15, 2014. Available here.
“American Indian/Alaska Native Cancer Policy: Systemic Approaches to Reducing Cancer Disparities.” Warne, D., Kaur, J., Perdue, D. Journal of Cancer Education. February 7, 2012. Available here.
Nicole Redvers, N.D., MPH (Deninu K’ue First Nation)
University of North Dakota, Assistant Professor of Family & Community Medicine
Christopher D. Chavis, J.D., MPA (Lumbee Tribe of North Carolina)
National Indian Health Board, Policy Center Director
John Molina, M.D., J.D., LHD (Pascua Yaqui and Yavapai-Apache)
Native Health, Corporate Compliance Officer
Experts and Analysts
Allison Barlow, Ph.D., M.A., MPH
Johns Hopkins Center for American Indian Health, Director
Stacey Bohlen, M.A. (Sault Ste. Marie Tribe of Chippewa Indians)
National Indian Health Board, Chief Executive Officer
Abigail Echo-Hawk, M.A. (Pawnee Nation of Oklahoma)
Urban Indian Health Institute, Director
Linda Frizzell, Ph.D., MS (Eastern Band of Cherokee Indians and Lakota)
University of Minnesota School of Public Health, Director of American Indian Health and Wellness Studies
Yvette Roubideaux, M.D., MPH (Rosebud Sioux Tribe)
National Congress of American Indians, Policy Research Center, Director
Donald Warne, M.D., MPH (Oglala Lakota)
University of North Dakota, Director of Indians into Medicine (INMED) and Public Health Programs
Loretta Christensen, M.D. (Navajo Nation)
Indian Health Service, Chief Medical Officer
Jennifer Cooper, J.D., MPA (Seneca Nation)
Indian Health Service, Office of Tribal Self-Governance, Director
Elizabeth A. Fowler (Comanche Nation)
Indian Health Service, Acting Director
Rear Adm. Francis Frazier, MSN/FNP, MPH (Cheyenne River Sioux Tribe)
Indian Health Service, Office of Public Health Support, Director
Kitty Marx, J.D.
Centers of Medicare and Medicaid Services, Division of Tribal Affairs, Director
Rose Weahkee, Ph.D. (Navajo Nation)
Indian Health Service, Office of Urban Indian Health Programs, Director
David R. Wilson, Ph.D. (Navajo Nation)
National Institutes of Health, Tribal Health Research Office, Director
Tom Anderson, MPH (Cherokee Nation)
Association of American Indian Physicians, Executive Director
Adriann Begay, M.D. (Navajo Nation)
Navajo Nation Senior Advisor, UCSF HEAL Initiative
Francys Crevier, J.D. (Algonquin)
National Council of Urban Indian Health, Chief Executive Officer
Gail Dana-Sacco, Ph.D., MPH (Passamaquoddy Tribe at Sipayik)
Wayfinders for Health, Principal
Valerie Davidson, J.D. (Yup’ik)
Alaska Native Tribal Health Consortium, President
Bonnie Duran, Dr.PH (Opelousas/Coushatta)
Indigenous Wellness Research Institute, Center for Indigenous Health Research, Director
Jill Jim, Ph.D., MPH, MHA (Navajo Nation)
Navajo Nation Department of Health, Executive Director
Walter Murillo (Choctaw Nation of Oklahoma)
Native Health (Phoenix, Arizona), Chief Executive Officer
Sophie Neuner, M.D. (Karuk Tribe)
Johns Hopkins Center for American Indian Health, Research Associate
Thomas D. Sequist, M.D., MPH (Taos Pueblo)
Mass General Brigham, Chief Patient Experience and Equity Officer
Heather Tanana, J.D., MPH (Diné)
University of Utah S.J. Quinney College of Law, Research Associate and Wallace Stegner Center Fellow
Brian Thompson, M.D., FACOG (Oneida and Mohawk)
Upstate Medical University, Clinical Assistant Professor of Obstetrics and Gynecology
This is an unedited transcript.
Thank you for joining today’s briefing Policymaking to Support the Health of Native American People. I’m Madeline Cree, Health Policy Analyst at the Alliance for Health Policy.
For those of you who are not familiar with the alai and welcome, we’re a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issue.
Today’s briefing is brought to you and generous support with the National Institute for Health Care Management Foundation, Foundation.
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Before I introduce today’s expert moderator at the Alliance for Health Policy wants to acknowledge that Washington, DC serves as a hub for advocacy and information sharing for tribal nations across the United States and territories.
Many of you are joining us from locations outside of Washington, DC. Welcome, We encourage you to learn about the Tribal Nations whose land you join us from. And connect with tribal leadership and community members as partners in your work.
What our short time together, we hope today’s events serve as an Introduction to the Complex Policy and Health Care Systems that serve American Indians and Alaska Native person in the US.
And, although we cannot cover everything that we would hope to in a short hour, we encourage you to leverage the additional resources on the Alliance website and from Tribal Nations around the country to learn more about this important topic.
Now, I’m so excited to be introducing our moderator for today’s event, doctor Nicole Redvers. Doctor Redvers is a member of the …, First Nation and the Dinette, excuse me, that day area of Canada.
She is Assistant Professor in the Department of Family and Community Medicine at the University of North Dakota, where she helped develop and launch the first Indigenous Health PHD. Program.
Doctor Edwards is co-founder and current Board Chair of the Canadian Charity, the Arctic Indigenous Women’s Foundation based in Yellowknife north-west Territories, which provides traditional Indigenous land based excuse me, a web based support for Northerners.
She has been actively involved at regional, national, and international level promoting the inclusion of Indigenous perspective, and both human and planetary health research and practice.
Doctor Redvers, we’re so excited to have you here with us today leading this discussion. I would love to turn it over to you. Thank you.
Let’s see to Thank you, ….
Happy to be here in Happy to be a part of this incredibly important conversation today, as we bring together experts within this field to help inform and promote discussion Within the space that we have today.
I’m, I’m privileged and honored to be a part of this, this process of asking some key questions of our Native American colleagues. As we think about very complex issues in complex spaces for the purposes, of course, of improving the health and wellness of our tribal community members, and our urban American Indian Alaskan Native community relatives. And before we get started, I just wanted to take a moment to also thank the organizers, as well as hosts for pop for me in this important discussion today, And I look forward to the audience participation in the Q&A portion of the event, which will occur, as noted a little bit later.
But right now, I’m very excited to formally introduce our panelists first, for today’s event. Our first speaker is mister Christopher Chavis, Deputy Director of the Policy Center at the National Indian Health Board.
He has a deep interest in the intersection of public policy and access to resources for rural communities, Mister Chavis.
Chavis has a bachelor of Arts from Dartmouth College, where he majored in Native American Studies and sociology modified with public policy, a Juris Doctor, from Michigan State University, where he worked as a research assistant in the Indigenous Law and Policy Center.
And additionally, a Master of Public Administration, from the University of North Carolina, Chapel Hill, where he was a North Carolina public service fellow.
He is from Robeson County, North Carolina, and a citizen of the …
Tribe of North Carolina clearly impressive resume and and great expertise for this topic here today.
And our second speaker is, doctor John Molina.
Is … Key and you have a Pi Apache and currently serves as compliant officer for Native Health in Phoenix, Arizona. He has held positions as the Health Systems Director for the …
Indian Tribe in Kenai Alaska, Chief Executive Officer Officer for Phoenix, Indian Medical Center, assistant director and medical director for the Arizona Health Care Cost Containment System in an OB GYN physician with the Indian Health Service. Doctor Molina is also the founder of the … Health Clinic in his hometown of Guadalupe Arizona, doctor. Molina is a graduate of the University of Arizona College of Medicine and the Sandra Day O’Connor College of Law Arizona State University.
He’s the recipient of an honorary doctoral degree and letters, literary honorarium from 80 still University of Health Sciences, in Kirksville, Missouri for his humanitarian work.
And his interests are in the integration of Indigenous medicine and Western medicine, and also Indian Health Care Law and Policy. And he’s also a US. Navy Veteran, thank you for your your service, doctor Merlino. So, thank you both for, for joining us today, and I’d like to, if possible, start with Chris. If you wanna take over and give us some of your opening remarks on this important topic here today.
So, I’m going to give you all a very brief overview of federal Indian law as it relates to in the healthcare space, and try to set the stage for our discussion.
So, we can go ahead to the next slide.
So I think it’s important to understand, is we’re kind of trying to frame what are the, what’s the role of tribal nations within a broader legal framework. I think it’s important to tribal nations are the oldest governments in North America, right. And I think this should perhaps be obvious, right? Tribal nations were here before the United States of America was a nation state. And we were here before. The first Europeans arrived on the shoreline.
But I wanted to kind of you establish that framework. And I also want to establish the fact that I’m tribes are mentioned explicitly in the US. Constitution, right?
So, Article one, Section 8 Cost 3 says that Congress shall have the power to regulate commerce with foreign nations and among the several states and with Indian tribes.
So, tribal nations, we were here before the European powers arise when they arrive.
They obviously carry a continent that already had sovereign nations, so how does it carry forward into, you know, the present day? Next slide.
So, as the European powers came in and colonize this landmass, they made treaties with various tribes in some cases, in order to get access to land.
A number of these treaties actually explicitly provide for health care, and the provision of other needs for the tribal nations. So again, the European Powers and their successor state, the United States.
I’m saying these treaties made these promises.
And they and this is obviously carry forward, or should be carrying forward into the present day. I do want to stop here.
And kind of take this is kind of an inflection point, consider how this kind of builds the federal trust. Responsibility, right? So you have treaties have relationships with the federal government, and you can go more in depth on that piece. But it’s been fairly explicit in Supreme Court opinions, federal statutes and treaties. Innumerous acts by the federal government, that this relationship is between the tribes and the federal government. What that means is the states don’t have a role in the trust responsibility, right? I’m sorry, I just wanted to draw that distinction here for you all, as you’re kind of thinking about where to tribes fit into this broader legal scheme and the trust responsibility, which established the treaties, as I mentioned here.
And kind of, it’s, it’s, it’s codified, morsel more through Supreme Court opinions, federal law, federal statutes, and other actions by the federal government, exists between the federal government and the tribes. So that’s important to keep in mind, here, is you start looking at how healthcare is given to any country.
So, the state have, have no role in us, in with some exceptions, but usually it’s something delegated from the federal government.
So, just want to make sure I hammer that point home. So, next slide.
So, how did we end up with the current scheme that we have for the provision of health care to American Indian and Alaska Native people? So it kind of starts with, at least a modern form of this rather.
Snyder iterate, the Spider Act 121 provided the authorization for funding of Indian health Care.
Then kind of frame that formalized structure.
Then we, and again, you’ll note here that Indian Healthcare started out under the Department of the Interior, and again, I think there’s some pretty obvious flaws with that setup.
So again, 33 years later, if you have the next slide here, which was the Transfer Act, which Congress said, OK, well, we knowledge that health care should probably not be in the Department of Interior. Let’s move this over to our later become the Department of Health and Human Services.
It also placed this under public health service as well.
So, again, you have this more, know, it’s a founding of the modern Indian Health Service, but it also, in some ways, because it got to form the structure that we kinda know of today.
Next slide, so, the Indian self Determination and Education Assistance Act allow tries to assume, control over their own health care systems. And over half of the IHS budget is controlled by tribes under this act. two tribes have taken advantage of this authority and assumed control of their own health care systems.
So then we had the Indian Health Care Improvement Act, which was permanently authorized, reauthorizing, the Affordable Care Act, as some of us in the Tribal Health Policy World. Are watching.
The Supreme Court case on that, on the Affordable Care Act, which unfortunately the Affordable Care Act was upheld. But one of the fears was if we lose the Affordable Care Act, and we also lose the Indian Health Care Improvement Act, because that was, that was, permanently be permanently, We off the rise in the Affordable Care Act, So, again, that has strengthened the position and regulatory structure of the Indian Health Care System and also permitted the reimbursement of IHS and tribal facilities by Medicare and Medicaid.
So, it is acknowledgement of Federal Government that they are not fully funding IHS.
And, you know, as a way to help providers, tribal providers, and IHS providers receive some degree, a supplemental funding, Congress said, OK, well, you could bill Medicare, and Medicaid, and third party shares.
Now, as I said earlier, you’ll remember, I said earlier, that the trust responsibility is between the federal government and tribes.
Obviously, Medicaid is a quasi federal program, but it’s mostly administered by the states.
So, there was an acknowledgement of that when Congress said, OK, we will get, we will authorize 100% F map for services billed to Medicaid through an IHS tribal facility. Federal government said, OK, we will pay on the entirety of, of this cost.
But the states obviously are, as I said earlier, one of the things I guess, delegated to administer the Medicaid program and handle enrollment and other such matters. And there are some problems with that structure. Especially with states are enacting restrictive measures of Medicaid work requirements or other items that may interfere with the access to Medicaid. But that’s a separate discussion. I just wanted to highlight that, one.
But the Indian Health Care Improvement Act, and in terms of broadening access to third party insurers and how the trust responsibilities kind of played into the Medicaid funding structure.
Next slide, And I wanna finish off with this quote, and it comes from the Indian Health Care Improvement Act, and I think that it’s a great, aspirational quote.
But I don’t, obviously, something that, know, the federal government still has to live up to in a lot of ways.
It is a policy of this nation and fulfillment of special trust responsibilities and legal obligations to Indians to ensure the highest possible health status for Indians and Urban Indians answer, provide all the resources necessary to affect that policy. I would like to finish with a quote, because I think it is a powerful quote is a powerful aspiration, and something that I think we should be holding government accountable for.
And if you have any questions, please reach out to me. I’m always happy to answer questions on this topic.
Again, I just gave you all a very short version of a presentation that I’ve given on multiple occasions on Indian health is available on an ISPs YouTube channel if you went to longer, an hour, long version of this presentation. But thank you, Anna. And if you have any questions, please feel free to reach out to me.
Thank you. Christopher, I think that’s a great introduction to some of these considerations around treaties. Trader responsibilities within the nation are incredibly important to foundation this work. And I know, you know, with many of our communities and discussions with elders, on all levels of governance, ultimately, the conversation always comes back to the treaties. What’s in the treaties? And what is the trust responsibility of government as a part of that?
And you also brought in an important element of that, that state: meteor, which, which sometimes comes into components of Medicaid.
You know, there’s been issues, of course, with the states, expanding Medicaid and others, not. So, how these conversations play. And, perhaps, these are some of the discussion points that we can bring in further, once we get to the question and answer period, and can delve in a little bit more to this particular topic area. So, so, thanks for providing that great overview, and encourage folks to look out for the longer presentation is, as you hit noted. So, at this point in time, I’d like to turn the platform over to John to give us his opening remarks from his perspectives. John?
OK, well hello, everybody, your symptom yowell Monitor weather, He knowing hello everybody, I’m Jon Molina. and IHS Credit Union or Yaki or UML Language, Agreed, ended up question to everyone.
Thank you all for the supporters of this program and also, for the panelists, the people involved is great activity together.
Again, my name is John Molina and I’ve had the wonderful pleasure and honor to have worked within the Indian Health Service system or really for over 25 years.
And I appreciate mister Chavez, given the really great summary about the Indian Health Service, because I think that that really serves as a foundation for not only for what was in the past, was brought together four Indigenous health care, what it means for the future.
What I’d like to share with you in my portion of my introduction is really looking at the urban Indian clinics, urban Indian health organizations, which is part of the Indian Health Service.
The Indian Health Service, again, is really a system of care.
That we have talked within our within our policy and environmental areas as being composed of the federally managed systems, under the Indian Health Service.
Tribally managed programs under public law 638 and urban Indian clinics.
So these are really three different entities that operate under the umbrella of Indian Health Service.
And I’ve had the pleasure and honor to work both as an administrator and as a clinician, both in the federal system, in tribal governments, and also now with the Indian Health Organization in Phoenix, Arizona, the Urban Indian Health Clinic.
Just just to give you a background of the urban Indian clinics, these urban Indian clinics were funded by the Indian Health Service as a way to provide health care, um, too Indigenous people who move into the urban areas and the big cities like Phoenix in Chicago and San Francisco, because it’s that we’re moving away from the reservations.
Their homes, they were in urban cities.
And because of the federal trust responsibility, there was a need for providing health care to them without any co-pays or at no cost, as as mister Chavez explained.
So, Native health is really one of those urban Indian clinics that was brought forward and created in 19 78, as a way for Native American families who lived in the Phoenix area to be able to access outpatient care.
The urban Indian clinics usually provide primary care in the areas of behavioral health, primary care, medical, dental services, and also a component of community health and wellness programs.
Native Health currently serves approximately 18,000 people in the Metropolitan Phoenix area, now, in 19 78, it was really an urban Indian organization, so we can only provide services to enroll members of federally recognized tribes.
But in 2010, we also became a community health center under HRSA, which allowed us to open our doors to non indigenous families and people who could access services based on a sliding fee scale.
Now, I mentioned this because I think it’s important for us as an Organization and Phoenix, to have this sort of a system.
Because what happens is that many our families and Phoenix are blended.
The mom might be native, maybe, though, the dad isn’t, or maybe one of the children might be native, and another child is not native.
And when the with these blended families and metropolitan areas, native health, as a result of being a Indian health Service facility, as well as community health center, are able to provide that care to the family, whether they’re native or not, And that way, it really provides for continuity of care and for the care to be offered to the family as a whole.
This also brings up an interesting point with her urban Indian populations, as we now know that over 70% of Indigenous people of Native American people now reside in major cities and urban areas.
Now, that should be really a policy concern, because people, as a movement to urban areas really need the support of Indian Health Service Program services to continue to provide that care.
Medicaid is available for people who are able to meet the eligibility requirements, but sometimes this is not so in urban areas, because maybe a family might make just a little bit too much to apply for Medicaid.
That’s why Medicaid expansion was so important in states like Arizona, where there’s a high Indigenous population, so people can afford special afford to get specialty care that cannot be provided under the Indian Health Service.
Also, the Medicaid program also helps, because, as an urban Indian organization, we’re able to bill for their services when they come to, to Native health.
Our clinic is also important, not only because it provides medical care, dental care, and behavioral health services, but also, it provides a culturally appropriate environment of care for indigenous population.
In Phoenix, we have over 350 Native American tribes who are or living in Phoenix.
And as a result, we have a diversity of tribes, and a lot of these families come from reservations too.
For, for schooling, for employment, and what happens, though, is that there are sort of separated from their cultural environment. And we have native on health to understand this.
So we really attempting to work and really providing culturally based programs that are able to provide families for their connection to their culture.
We do this through a lot of culturally Native events, now during the pandemic.
A lot of them are online, but we really try to continue to engage our Native families in their culture because I believe as many people do, the culture is really so important to the health and well-being of our people. Now, we do struggle with our health challenges. We still have a lot of chronic diseases that we tried to address in our urban Indian populations.
And, unfortunately, the IHS budget is really quite insufficient.
Is only up by 1% of the discretionary funding.
Goes to urban Indian clinics.
When as many as 70% of Native Americans are living in urban areas, that’s really a policy issue that needs to be addressed.
As well as the other issue of what’s called the Indian Urban Indian Confer Program.
What happens under this program, which is part of Chapter 26, Part five of the Indian Health Service Manual, is that Indian Health Service proper needs to confer with urban Indian popular urban Indian organizations when there is going to be a material change in programs or services, or to actually be able to confer with urban Indian populations and innovative projects that urban Indian organizations are wanting to do.
So, this is critically important, in being able to provide sort of a continuity of care services, so that Indian households and urban Indian populations can actually work together to be able to enhance the care of our Indigenous people who live in urban areas.
So with that, I’ll just close for that, and hopefully that’ll spark some some questions related to our organization, her mission, or activities, and some of the challenges that we do continue to face, Especially, sir, social determinants of health, in the urban Indian population. So thank you very much.
Wonderful. Thank you. And looking forward to jumping into the next portion of our event today with the question and answer portion. And before we get in there, I think you brought up a very sort of timely point, Doctor Molina on the Urban Indian Health Confer Act, which says I understand is in the process right now a bill that’s been proposed. I’m not sure if also Christopher has some updates on this where of course it would be a new requirement for being able to engage with the urban Indian organizations. Do either of you have any updates on that policy?
I did not have any updates, other than as far as Native health. With actually tried to work with the Phoenix Area Indian Health Service here in Phoenix.
Because there were some activities taking place with an Indian Health Service, the large medical center, which we weren’t aware of that impacted the operations for Native Cowell.
And we try to remind them of the confer Act, and then need to confer with urban Indian populations.
Because what’s interesting, the Phoenix Indian Medical Center only lies about three miles away from the Native Health Organization.
And it’s unfortunate that I’ve seen in the six years that I’ve been there, that IHS does not do a very good job about conferring with an Urban Indian organization on activities and programs that could materially impact the operations of the urban Indian clinics.
But I don’t have any specific updates, as has, as far as, what’s going on with that now.
Yeah, I don’t have any updates either.
The policy at this time is still relatively new, so, I think folks are just kinda waiting to see how it plays out and what ends up happening.
Wonderful, well, in keeping with that, I, you know, highlighting the importance, given the fact that, you know, around 71% of our American Indian and Alaska Native relatives are living in urban areas. It’s, it’s a timely conversation. And an important one, as noted given the lack of directed funding to the urban Indian health organizations comparatively to the tribal organizations, at least per capita now, in considering some of these, you know, basic pieces and foundational elements of understanding on this topic.
Perhaps, Christopher, you can give us an indication on some of the key stakeholders that possess important roles in improving Native American. How from the policy level, you know, how do tribal and federal governments interact to establish and enforce policies related to this topic?
Thank you, I thought, most fundamentally, the power of health and human services has a key role to play. So I started sobbing, take good thing at the top and then going down. And each of the operating divisions within HHS has a key role in Indian country.
You know, whether it’s SAMHSA working on substance abuse and mental health issues, whether it’s HRSA helping with workforce shortages and another issue that acutely impact rural communities, whether it’s the CDC, especially, I think we’ve seen her in a pandemic, the role of the CDC has to play in health care.
You know, the yield in, especially in the obviously, IHS, has a very key role to play.
But within HHS, it’s important for Indian country to be working with the operating divisions to hold them accountable. And we see kind of a checkerboard of policies within each operating division. Some divisions have tribal advisory committees that directly work with them.
Others don’t know because the President Biden’s memorandum earlier this year, Obviously, the federal government is looking after tribal consultation policy isn’t. And we’ve been involved in the consultations on that.
But, I think fundamentally looking at the Department of Health and Human Services and the programming that they’re offering, as well as how, you know, and as well as how responsive is that programming to Indian country, I think, is very important.
I also recommend, folks, if you, if not every division, has a tribal advisory committee, find out who your representative is for the region that you’re in, and work with that person. ought to know your concern, so they can bring that to the agency.
But I also think that it’s important for folks who’ve been involved in tribal consultations, right. It was something that we track at the National Indian Health Board. If you, you get on our e-mail list, and we reach out to you, or reach out about either tribal consultation coming up, put that on your calendar, go, make sure the agencies are able to hear directly from you.
But I think that, you know, that nation in Asia dialog has to occur, and it has to be meaningful and something that we also advocate for As well.
As I mentioned earlier, the administration is reviewing the tribal consultation policy, So, you know, has to be a two-way street, and I think, fundamentally, I think it starts with holding the Department of Health Human Services accountable as well as the various operating divisions.
Also, I’d be remiss if I didn’t mention, obviously, the VA has a role to play as well in the VA, And IHS recently signed a memorandum of understanding, which kinda seeks to kind of increase the co-ordination between IHS and VA.
There’s a lot of veterans to go between the two facilities, that’s another area. That’s a key player here.
And also, within HHS, I do want to go back and mentioned CMS, particularly the Centers for Medicare and Medicaid Services. Because I mentioned in my presentation, right, they are big funder of Indian health care, because of Medicare and Medicaid. So, stay engaged with the policies that they’re pushing out, I think, are very important.
Again, they are, know, they are very important, and, you know, whether it’s what CMS is doing in the Medicare side, and also what the states are attempting to do on the Medicaid side, it’s important to stay stay informed.
So I think, you know, it’s, there’s a need to hold the federal government accountable, particularly HHS, VA.
You know, and there are multiple avenues through which that as possible, I’m from the Tribal side. And obviously an ISP, we’re here to help folks figure out how to best engage the Federal government and make sure folks have the resources in order to do so.
Thanks, Christopher, that’s a great overview of consideration. And doctor Molina any considerations on key stakeholders from the clinical perspective, the clinical policy side? Yeah, absolutely. I think, mister Chavez, Chris, did a great job to outline some of the key players.
Because that’s what’s happened for the years that we’ve had different agencies and organizations involved in trying to improve the health of the nation’s population.
But let me step back a little bit, because what I’ve seen, both as an administrator and the coalition over the last 25 plus years, is that there’s no doubt that health care the healthcare environment and technology has changed.
If you look at the private sector, innovations in healthcare systems have really undergone a change using innovative technologies and methodologies to improve healthcare to private citizens.
Now, Chris mentioned the IHS was created in 19 55.
I have not seen any significant changes in policies in the way businesses conducted in IHS since 19 55. They’re still working under an old system.
Now, that’s probably because it’s a government system, but it does of no benefit to Native Americans. It’s like we’re working with an antiquated system.
The one thing that I, I try to emphasize as a matter of policy, is that the government does have a treaty responsibility that they tend to forget in Congress.
I think, because I find a lot of Congress members live on the East Coast, east side and don’t recognize the real issues.
But with that said, I think what has to happen as a matter of policy and the federal government’s responsibility is we need to elevate and become more transparent about Indian health service issues.
I once proposed that perhaps the Director of Indian Health Service should become an Assistant Director under the Department of HHS, only because at that point, you’re at the actual table helping to make those decisions.
Because if you look at the organizational charge, DHHS, the Indian Health Service is down here, then there’s a Public Health Service up here and there’s these levels.
Government until you finally reached a table to say, hey, we need to make some difference in Indian Country.
The other thing that I’ve seen happen, that should change, is, that were addressed in Indian health service issues, whether it’s on the reservation or the urban areas.
It’s more than just health care.
It involves the environment, it involves resources, It involves land, all of these things that impact health.
Well, guess what?
We have the Department of Interior who takes care of that and we have a BIA who works with funding.
We got the Indian Health Service, we got all these different silos, that need to sort of come together under one and, two, addressing compulsory. Because, otherwise, it’s all fragmented. And people don’t talk to each other.
And it’s just the same old story: year after year after year. Now, there is Tribal consultation that does take place, and I appreciate that, a nation to nation type of consultation.
But I personally think that until the system is really looked at, and it’s changed, and to elevate that position of the director of Indian Health Service to a higher level, then perhaps the voice of Indigenous people can be heard at all levels.
And by the way, we still don’t have a permanent director for the Indian Health Service, wherever it is.
Year months into this administration, and I kind of wonder, if this administration is really serious about Indian health care, why don’t we still might have a permanent director for Indian Health Service.
That’s another question.
So, I think these is an issue for me, it’s the systems, the dilemma that we’re into. Because health care has changed over the last century, half a century.
And I think that government needs to take that into account.
Oh, and final one thing. Although I appreciate Medicaid because they do make up with a gap in funding.
Know, Medicaid is so tenuous, you know, with requirements and budgetary cuts and political agendas. IHS should not depend on Medicaid.
Why? Because, it may not be there. It doesn’t work for certain people. It’s different requirements and benefits in different states, or people are mobile, game play, move around the country. That makes it difficult for them.
But more than that, they’re not meeting their trust responsibility.
I propose that the money that’s spent in Medicaid, what does it go to IHS funding?
Because the other thing I’ve seen happen in the urban areas is that our people, because of IHS lack of resources or care, are going to private organizations for healthcare to private private health care system. I think that’s a detriment.
As part of like an assimilation process, they’re losing touch with their culture When you go to an Indian Health Service facility, Whether it’s tribal or urban or federally managed, there’s at least what they call a destination.
People feel like they’re being taken care of by their own people, by their own staff, but it’s almost like Medicaid is pushing them out into the private sector, and they’re losing their contact with their cultural identity.
But, that’s just kinda assumption things I wanted to share. Thank you.
Thank you, merci … for sharing that. It’s an important context. And I think we often hear, you know, the, the extreme health disparities that we see, you, know, are based on it on a health system that was set up to do what it was, what it was meant to do, which is to create health disparities. You know, is at a time where the the view of American Indian and Alaskan native within this country was, you know, a subset less. Then, in terms of the population, the old does, you know, kill the Indian saved them and kind of approach with this and, you know, thinking of the complexity of the system.
We’re seeing more and more push for systems approaches to thinking about governance. And leaderships focuses on relationships and nodes, and those leverage points that can really create a system that’s meant to help and improve those health disparities that we have. So just just to back up a little bit because I think it’s important to for some of our audience here, you know, with one of the questions that was posed by an audience members, know what makes a federally recognized tribe. Let’s consider that. You know comparatively to a state recognized tribes or an unrecognized tribe and what that means for health policy and care. Christopher, do you want to tackle that one?
Sure. It’s a very good question. So fundamentally, a fully recognized tribe has been recognized either through the Department of Interior or through Congress, and they have a formal nation to nation relationship with the Federal government.
State recognized tribes lacks that relationship, and obviously there are multiple ways you can become a recognized tribe. I mentioned the Department interior has a office of our acknowledgement. You can petition and it’s a fairly extensive paperwork process in order to do that. Number of tribes have become recognized through Congress, over my presentation, I mentioned that Congress, in the Constitution has an authority to to work with you.
And that’s not gonna go too far down the rabbit hole, but it’s kinda the basis for the Plenary Power Doctrine, Congress, disciplinary power over Tribal nations, So Congress, you know, also recognizes them, tried to, the basis of the authority for the Department Interior to do so is a delegation of that authority from Congress.
So, but a federally recognized tribe, a tribe that has that Nation to nation relationship. And it’s been formalized through one of those two avenues. State recognized tribes are often than not, is a tribal nation that is working through one of those two avenues to establish a nation to nation relationship.
And that plays out in the health care realm in kinda the ability to access IHS, right?
IHS is limited to members or descendants of federally recognized tribes.
So again, in order to access these services, you have to have a nation to nation relationship And it has to come through either the part of the interior or through an act of Congress.
Thanks, that’s helpful. I think, to platform some of the conversation today and Christopher, I have one more question for you before I want to move back to doctor Molina. We’re thinking about the future. You know, one of the questions that came through is you know, we often hear about IHS be this antiquated system, this dysfunctional system, there’s a lot of issues sort of with that. But can you provide to you know, perhaps a few tangible examples of you know what that means? What is dysfunctional? What makes it an antiquated system? Is there something from a policy perspective that’s still in play, that, you know, would be helpful, just to, to, to ground our audience and what we mean when we say that?
Absolutely, So, I wanna go back to what was said earlier, I, just as a chronically underfunded system.
You know, and NIH be across Indian Country long advocated for full funding of the IHS.
one of the things that I mentioned, obviously, Medicare, Medicaid, is a patch, right? It doesn’t it doesn’t actually get us to where it needs to be.
But what you have is you have decades of chronic underfunding, kronick neglect.
And I’d give an example of what that means on the ground.
The deficit, the rate at which facilities are a place within IHS is, so it’s it’s so backlogged and produced this underfunding that it would take, I don’t know the exact number, but I know it’s a couple of hundred years.
McCurry scheduled for a facility to be replaced, right.
So you have a backlog and facilities replacement?
You have also the challenge that tribes have is that when the modern public health apparatus was being created in a modern public health infrastructure of being created, it was created at the state level. Just created a local level. Right. But it wasn’t created at the tribal level of tribes really had to kind of figure that out on their own.
So, tribes are still working through how you create this system, as they’re getting years of neglect and years of not having support in doing so.
But I think the best most concrete example is just that lack of resources, lack of attention, and just a severe backlog and just replacing basic facilities that we see with the Indian Health Care System.
And I mean, the per capita spending is low for, you know, within IHS compared to other, you know, healthcare programs, it’s, you know chronically underfunded. And I think we see that when we look at the facilities and access to resources across the system.
Thanks, Christopher. So just just bridging off, then doctor Molina and thinking about you know, what policymakers could be or should be advocating for and thinking about when it comes to the future of reform. In indigenous health broadly what are some things that, you know, you would say or you would hope to see policymakers support as we move forward what are sort of those top top key issues?
Well, first of all, I think that policy makers should look at the experience of what’s going on with tribally managed programs. When they 638 programs.
We’ve seen remarkable success stories like my tribe, the San Carlos Apache, who took over the management of their hospital, has done an amazing job to be able to expand their resources, increase our services, provide culturally based care. I mean, I think that that itself as a model. Now, what, what does that make?
It happen is the business model that they have that the Indian Health Service does not offer with the Indian Health Service proper like Phoenix Indian Medical Center, or in the IHS facility. It’s a very bureaucratic system, that very cumbersome.
You know, innovation is slow to move because of workflows.
And, you know, when I was CEO at P IMC, and we wanted to re-organize our executive team and re-organize departments in the private sector, this wouldn’t take, but weeks or months, to happen.
My experience of the Phoenix, a medical center, it took 1.5 years to run it through headquarters.
Because there’s such a level of governance of bureaucratic government that makes it very, very difficult and understand why, because the government must have some kind of oversight.
But I think as far as a matter of policy, we should begin to look at some of these workflows that needed to make change, to make it more nimble.
That’s one thing that needs to be re-evaluated. As, first of all, look at policies, especially, around hiring.
It takes months to hire somebody into the Indian Health Service.
We’re in the private sector, takes us a few days.
No, that needs to be changed.
The other thing that has made it difficult for Indian Health Service facilities, proper, is its ability to be able to partner with other governmental agencies. Whether it’s a county, with its city, whether it’s a state, Because there’s so many rules around the federal government that it makes it very difficult to be able to develop these relationships.
And now, more so, in this time and age, as opposed to 50 years ago, there’s much more resources out there that that IHS facilities can make use up to be able.
2, 2, 2, 2 to bring in.
Another experience I had with Indian Health Service. And I will see you at the hospital 10 years ago. I had an offer from a private company to come in and put solar panels to reduce our electrical expenditures.
Well, in a private sector, that’s a great idea.
But unfortunately, the eri office did not approve it, because it was not within their policy.
So, there’s some of the antiquated policies that really need to get looked at again, and I think it’s the responsibility of each area office, like the Phoenix area, the California area, to begin to evaluate these policies and find opportunities for change.
But then, again, you know, we’re dealing with a leadership mentality.
Know, do we want to keep doing things the way it’s always been done, which is sort of a response that I’ve heard when I asked, well, why do why, why do we do it that way, Because it’s always been done that way.
That unfortunately really leads to a lot of bumps and challenges and people could be able to get access to care or even be able to upgrade our facility. You know, it really is a big effort, and I think people who are in leadership positions and administrative positions find it very difficult to be able to manage change, because it’s a very cumbersome system to manage change within Indian Health Service.
The other thing, too, that, I think, as a matter of policy that needs to be looked at, it’s a wages for healthcare providers within the Indian Health Service.
Because the wages are very low comparable to the private industry, can we tend to lose a lot of good providers, because they’ve got families to work to take care of? They got kids to go to school, and, unfortunately, it’s a very competitive market out there.
I’ve seen in the Indian Health Service when we would train certified coders and billers when we get them certified and trained to be able to enhance our funding to the IHS facility by third party payers.
They got offered other jobs, higher pace when they left the Indian Health Service providers leaving that health service because there’s other opportunities for better pay and environments. Now we do get a lot of people that come to the Indian Health Service to do their payback, or either to get student loans repaid.
And unfortunately, that’s good, but after the loans are paid up, they leave because there’s other opportunities.
So, I think, as a matter of policy, we should begin to look at clinicians, wages as a way to keep, retain, and recruit qualified providers to come into the system, You know, We all have the unfortunate experience. a few years back when we saw that there were some providers that are, fortunately, we’re doing illegal things with Indian Health Service.
And that had to do with background checks.
You know, there was not a good system of background checks, and unfortunately, you know, we hired providers that didn’t have the best moral responsibilities.
Patients get impacted.
So I agree with Chris, also, that, you know, it’s really a matter of funding, you know, that we need to put into this system, otherwise it stays intact antiquated.
We’re not able to compete in the private sector, and we’re losing a lot of good people. So, thank you.
Thanks for that perspective. And I think, you know, it’s an important consideration going forward. And, you know, post similar thing to Christopher. You know, thinking, building off the ACA, improving our systems, you know, what kinds of things do we need to be advocating for? And thinking about in our tribal communities, there’s often this debate, even in academic circles between you, do we centralized services. Is it a single payer system?
Or, you know, as doctor Molina was saying ensuring that there’s an independent sovereign nations operating their health systems but improving integration and collaboration. How do we move forward? What did we do building on the CCA? What do you see in the key points?
I think fundamentally, we need to get full funding for IHS.
I think that will help us begin to solve a lot of the issues that we’re seeing, and obviously the next question is, how do you move towards full funding? Right? What is the best way to do that?
And you know, we’ve advocated in ISP for tribally driven study on that.
Were they trying to try to come together and figure out what the full funding actually look like?
Worship funding be allocated.
What are the pressing needs of any country?
So I think a tribally driven study, I think something that we’re advocating for And we think could help answer that question of what is full funding look like in terms of building off the ACA. I think you can look at some of the policy proposals that are out there right now.
And I think it gets juxtapose that on top of, what does that look like, in regards to a fully funded and, in health care system, right. Do we still need a third party payers, right.
And, that’s an open question. I don’t have the answer to that question. I think that’s why you would want to do a study. Again, tribally driven study in order to figure out the answer to that question.
But I think any discussion about improving Indian health care starts and ends with fully funding the Indian Health Service, making sure that funding is available to address somebody’s longstanding needs.
And, as I said earlier, keep our people in the Indian Health Care System and keep them from going to private private entities, and, you know, you, because you think about, you know, some of the things that Indian Health Care System should be doing. Right? Traditional healing, culturally competent health care, and all that, it would, you know, it’s, it’s, it’s possible, it can be expanded upon for funding of IHS.
You brought up an important point. You know, I think we’ve had thousands of years of health systems within this, this continent, and in our traditional healing services were very much foundation on community values regional, of course with that. You know, doctor Molina, how do you see that being incorporated from a policy perspective within our tribal communities or even in the urban indigenous organizations?
Yeah, absolutely. Thank you, Chris, for touching on that.
Because, you know, I think the Western based model of care has had a devastated impact on Indigenous health and Wellness, because it’s a totally different model of care, based on just, no, the, the mind and the body.
And the thing about, about the Western based Medicine of Care, they don’t really always incorporate what was so important to indigenous people.
The spirituality part of health and well-being, which is what traditional medicine is really all about, incorporating the holistic impact, or the holistic approach of mind, body, spirit, emotion, family.
Everything that comes together to provide that health care, that’s the way our people’s DNA.
Thanks. And it’s all about, it’s always been that way.
And I think that’s probably one of the reasons why we see so much disparities and Indian health, because we, as indigenous people, need that holistic approach to care. It’s always been that way. And I think, unfortunately, the Western based model of care doesn’t really embrace that yet.
It has, in some respects what I’ve seen happen, like with the San Carlos Apache Healthcare Corporation, they’re embracing that model of care at the Alaska System embraces that model of care. Because they understand the importance that it means to indigenous people.
So, I think that, as a matter of policy, you know, the Federal government Congress, IHS really needs to look at this important aspect of bringing back that model of care by funding that model of care by providing resources to be able to address that.
Because going back to that 25 USC 602, the highest possible health status.
That is a goal, The highest possible health status, and we’re still missing that goal.
Because, perhaps, need to incorporate not only more funding, and be able to capture the real element of what Indigenous health and wellness has all about, as a matter of policy, But, also, as a matter of a sovereign, right, You know, It’s, it’s a sovereign, right.
Thank you. I appreciate that. perspective. It’s such an important component is you note, and, you know, one of the strongest preventative health care systems that just don’t get a lot of space for discussion within these these policy arenas. So, just as we think about wrapping up, you know, one of the questions that came from the audience, which I think is an important one is, you know, can you discuss how to respectfully interact with tribal health officials with communities. You know, if you, if you’re thinking about advocating or working on this level of Christopher, you want to tackle that one first?
So, I think fundamentally recognizing that tribes are sovereign nations, that tribes are sovereign governments, and that tribes have an inherent right to govern their, govern their people, their territory, as as they see fit. So I think acknowledging that, tribes exist within the American legal framework, you know, along with the federal government. And along with states, I think having that kind of grounding is very important going in.
Secondly, I would know it encourage folks to reach out with tribal leadership before engaging with a tribe or tribal members. Right, Again, it’s a sovereign nation.
You want to make sure you’re approaching this work in a way that’s respectful of the tribes and tribal leadership, which I think is very important. It’s also important to recognize that each tribe, each area, has different health care needs in a different culture. So I think that’s also important, as well. And just being mindful of tribes are sovereign nation, and also that each tribe in each area, or region, has different needs. And I think, going in with that mindset, I think, will be a huge asset and being an Ally.
Anything that you want to add on that, definitely, Lena, in terms of the perspective of engagement?
Sure, maybe on the relationship side, what’s critically important, I think it’s also that people understand importance of intent and building trust, because, again, our indigenous people have not had a good history with the government.
So, you know, there’s still a lot of sense of distrust.
People coming into indigenous communities, too.
Try to do good if you will. Especially with research studies. A lot of our communities have been hit with proposal for research studies, especially in light of the pandemic and other things coming up.
But what’s important is that, although there’s, there’s good intends behind Western medicine, to improve health care in the community, it’s also important, know, where the factors at Chris, by then, but also, to develop a real, meaningful relationship, engagement with the leadership.
Know, something that’s built-in trust.
Some something for the minds come together, well, not even more than minds, but the spirit, because, again, our Indigenous people think different, you know, in the Western world, you know, your MD, your JD credentials, mean a lot, or you MPH, or your PHD credentials in the Western world mean a lot, but not so much an indigenous community, but means more than the indigenous community.
Is your spirit?
Is your heart, is your intent for the wellness of the people.
And then I think is critically important, because then you can be, can develop that spirit of trust and relationship with the community.
And the thing about it is two, is to, then come good on your promises, What you intend to do, and what you’ll want to do, you know, and continue that work in a good way.
Not just come in and do what you gotta do, that leap again, but continue that relationship with the tribe.
Or perhaps, other opportunities that may come up. Because I think the relationship building results are really critical.
Well, I think, what a wonderful way to close some of the questions today, and bring us back to the, the spirit in the Worldview of our Indigenous communities across our, are great land, and I really want to thank you both for your insights on this important topic. And I know we’ve only just scratched the surface. It’s such a huge and deep area of consideration. And unfortunately, this is all the time we have today. John and Christopher, I’d really like to thank you so much, messy, show.
Thank you, with Honor. We appreciate you being here with us today. And I’d encourage the audience members to please take the time to complete this brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via e-mail later today. And this was the closing event for the Alliance for Health Policies, 20 21 programs, calendars.
So, keep an eye on your inbox and on your website, for announcements about their plans for 2022, recording of this webinar. But also, additional materials will be available on the Alliance website. I noted, noted. Of course, that, Christopher mentioned a few videos that are posted on the National Indian Health Board website, with more information on his topic area, and I’m sure both speakers would be more than happy to entertain questions afterwards, as well. And this concludes today’s presentation, Christopher and John, Thank you so much again for joining us today, and I hope everyone has a good rest of your day, and also a good rest of your week.
Thank you, all.