Tribal Self-Governance and Foundational Public Health Services

Tribal nations have a unique relationship with the U.S. government, having ceded vast stretches of land and resources in exchange for specific treaty rights, one of which is health care services. The history of how this treaty obligation has been honored by the federal government is largely a shameful one, characterized by political corruption, institutional neglect, and culturally destructive practices. The arc of this history began to change with the passage of the Indian Self-Determination and Education Assistance Act of 1975 (Public Law (PL) 93-638). Prior to this Act, a smattering of medical care and public health services were offered to tribal communities by the Indian Health Service (IHS) and Bureau of Indian Affairs. After Public Law 93-638, the incremental process of self-governance began with the responsibility for providing health services, shifting from federal agencies to sovereign tribal governments (Tribal Self-Governance Timeline – Tribal Self-Governance [asamonitor.pub/3Nct9qd]).

I graduated from medical school in 1975, the year PL 93-638 was enacted, and by 1979 had relocated to the Olympic Peninsula of Washington State, where I have lived and worked ever since. My first job on the peninsula was in Neah Bay for the Makah Tribe at a federal IHS clinic staffed with federally employed health care workers. Physicians rarely stayed for more than a year or two and were widely distrusted by the community. The 1980s saw an expansion of “638” contracts, where tribal governments subcontracted with the IHS to provide services previously supplied by the federal agency. Challenged by the regional IHS medical director, I accepted the job of starting up a “638” clinic for the Lower Elwha Klallam Tribe in 1986. Over the next three decades, I served as the health officer for two rural counties, medical director for three different tribes, and a variety of positions on state boards and commissions. Forging partnerships between tribal health care programs and their counterparts in the nontribal community became a major focus of my medical career.

During these four decades, I was privileged to witness a profound change in how health care services were delivered to tribal communities. 638 clinics gave tribal governments an expanded role in delivering health care services, but tribes were still subject to federal controls and erratic congressional funding. Federal support varied from year to year, and it was common for the funds that paid for specialty services and hospital-based services to run out with several months remaining in the fiscal year. This triggered the dreaded “category 1” funding restriction – only services necessary to prevent immediate loss of life or limb would be covered. This amounted to a brutal form of rationing. Conditions that were merely painful or disabling did not qualify for coverage unless loss of life or irreversible organ damage was imminent.

Far greater changes came in the 1990s, when “self-governance demonstration projects” were authorized. These projects involved a tribe-by-tribe negotiation of a “self-governance compact” that transferred complete responsibility (and its associated funding) from the IHS and Bureau of Indian Affairs to the tribal government. The high-wire act of providing medical care to the community on a limited budget was now lacking a net. The release from federal restraints and the determined leadership of tribal officials at a state and federal level opened up new sources of funding. Tribal health programs aggressively pursued third-party reimbursement from Medicare, Medicaid, and private insurance companies. Tribes pursued cost-based reimbursement, at first using the systems developed for rural health clinics and federally qualified health centers, and eventually developing a nationally negotiated encounter rate for all Medicaid-sponsored services. This allowed tribal health programs to not only fully fund services for tribal citizens but also open their clinics to nontribal community members.

Over the course of several decades, implementation of this self-governance model in Washington state has been transformative. When I started working with isolated coastal tribes in the late 1970s, their government-supplied health services were comparable to what was seen in developing countries. Today, they have modern facilities, a broad range of services, and delivery systems that not only respect cultural values but actively utilize these values as part of a holistic, wellness-oriented approach to primary care and the treatment of substance use disorders. The vision of health care as patient-centered, community-directed, and outcome-oriented has become a reality for a growing number of tribal communities.

The COVID-19 pandemic served as a dramatic stress test of these systems. I spent the pandemic serving as both a county health officer and tribal public health and safety officer. A decade-long effort to build partnerships between counties, tribes, and public hospital districts paid big dividends as the pandemic raged. Scarce supplies were shared, emergency response systems were coordinated, and primary care systems took on an increasing burden of care as hospital systems became overwhelmed with the first surge of COVID cases. Sophisticated systems for infection control, mass testing, contact tracing/case management, and the rapid deployment of antiviral treatments kept case rates and mortality remarkably low. The pandemic also underscored the extraordinary importance of public health capabilities at a community level.

All governments – federal, state, local, and tribal – have a fundamental duty to ensure a basic set of capabilities known as foundational public health services (asamonitor.pub/47ZBGVp). Washington state has long prided itself on its public health innovation. In 1989, on the 100^th anniversary of statehood, Washington state entered into a Centennial Accord with the 29 federally recognized tribes that shared boundaries with the state (asamonitor.pub/3R83gZU). In 1995, the state legislature enacted a public health improvement plan which, among other actions, established tribal health jurisdictions as co-equal partners with the other official components of that system – the State Department of Health, the State Board of Health, and the 35 local health jurisdictions. The combination of two initiatives has led to a sustained, good faith effort to develop public health systems that regard tribal governments as an essential pillar of a fully functional public health system.

Starting in 2017, the Washington State Legislature began making small investments in expanding foundational public health services across all aspects of the public health system. Responding to lessons learned in the pandemic, this funding has been substantially increased for the current 2023-24 biennium, with promises of a long-term legislative commitment to maintain this effort.

While tribes have long provided a wide range of population services, the development of more formal foundation services like epidemiology, emergency response, and comprehensive communicable disease control is a more recent phenomenon. Rather than replicating the fragmented structure of nontribal medical care and public health systems, tribes have the opportunity to create a health care system that seamlessly integrates personal and population health services across all health service areas. The Jamestown S’Klallam Tribe’s Healing Clinic is an example (asamonitor.pub/3uIv6o2). Responding to the ever-worsening opiate epidemic, the tribe opened an innovative opiate treatment program that merges substance abuse treatment (methadone and buprenorphine) with behavioral health, primary care, dental services, social services, and childcare. Tribal cultural values provide an overarching vision of the healing journey necessary to escape the ravages of opiate addiction and rejoin the community as a healthy, productive member.

At a time when health care workers are suffering unprecedented levels of burnout and depression, hope for a reformed health care system grows increasingly dim. The recent history of Tribal Nations developing innovative models for health care delivery is inspiring and instructive. The key to this process has been a vision of community self-determination and the emergence of the leadership to pursue this vision. As we approach the end of 2023, medical care systems are increasingly controlled by the health insurance industry, hedge fund profiteers, and regional hospital conglomerates. We have become a nation that spends the highest percentage of GDP on health care services but ranks at the bottom of the list of developed countries for health access, equity, and outcomes. The American public health system, judged prepandemic to be the best prepared in the world, had one of the worst performance records with respect to COVID mortality of any developed nation. New models are desperately needed. Those who would like to see an inspiring story of community resilience and what is possible in health care when cultural values are merged with (rather than purged from) health care systems are well advised to study what sovereign tribal nations have accomplished in the past three decades.