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Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

State/Tribal Partnerships


Mary Kay Smith, M.A.S., Senior Advisor, Indian Health Care, Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services, Baltimore, MD.

Yvette Joseph Fox, M.S.W. (Colville), Executive Director, National Indian Health Board, Denver, CO.

Joseph Finkbonner, R.Ph., M.H.A. (Lummi), Director, Lummi Indian Family Enrichment (LIFE) Center; Chief Executive Officer, Lummi Indian Business Council, Lummi Nation, Bellingham, WA.

Richard Arnold, M.A., American Indian/Alaska Native Liaison, Managed Care Contracts Management Section, Division of Program Support, Medical Assistance Administration, Washington Department of Social and Health Services, Olympia, WA.

Consultation and HCFA

Two Presidential Executive Orders—13084 (published in 1998) and 13021 (published in 1996)—require Federal agencies to consult with tribal governments and work with tribal colleges and universities. Unless specific action is taken to supercede or rescind these orders, they will remain in effect after the current administration ends.

The consultation program of the Health Care Financing Administration (HCFA)—which oversees Medicare, Medicaid, and State Children's Health Insurance Programs (SCHIP) within the U.S. Department of Health and Human Services—emphasizes partnerships between tribes, States, and HCFA regional offices. Urban Indian programs are also invited to participate.

Several consultation models have been developed by States and tribes. Some use an existing consultation structure (e.g., the Indian Health Board is the convening point in Montana); others create a new structure (e.g., Arizona, South Dakota).

Mary Kay Smith acknowledged that including tribes calls for a new way of thinking for HCFA, presenting some challenges.

  • HCFA is working on establishing a solid consultation structure (while allowing the flexibility to use different models).
  • Part of this requires educating Federal staff on sovereignty and other issues; HCFA plans to contract for agencywide training.
  • It also requires standardizing policies, so regional offices are not making policies in isolation.
  • Another challenge involves overcoming legal barriers, such as conflicting policies and policy interpretations within different agencies of the Department of Health and Human Services.

Consultation and the States

Yvette Joseph Fox discussed the consultation processes of nine State Medicaid managed care programs (Arizona, California, Michigan, Minnesota, New Mexico, New York, Oklahoma, Oregon, and Washington) based on a 1998 study. She pointed out that the challenges tribes and States encounter in building successful consultation processes can be complicated by a host of non-health-related issues, such as water rights or gaming. However, given that the Indian Health Service (IHS) per capita appropriation ($1,431) is less than one-half of the national Medicaid per capita expenditure ($3,261), it is critical that these relationships develop.

The study's consultation-related findings included:

  • Different conditions within the States led to different approaches to State/tribal consultation.
  • Early in the process, there was often an adversarial relationship, but as communications continued over time, the parties developed a better mutual understanding and more trust.
  • Tribes operating their own healthcare programs had more expertise in understanding the complexities of healthcare financing and a longer history of negotiating with State governments.
  • Two approaches seemed to lead to greater satisfaction among tribes:
    1. Tribes organized themselves, meeting periodically with tribal leaders setting agendas, to present coordinated responses to State proposals.
    2. The State's Medicaid department had a staff person designated to serve as liaison, offering technical assistance and troubleshooting.
  • Greatest satisfaction for both tribes and States results from using multiple approaches. The more tribal participation, the greater the satisfaction.
  • It takes time to resolve issues. Ongoing intervention works well.

Washington State's Experience: Tribal Perspective

The 28 federally recognized tribes in Washington State use multiple conduits for consultation. Increased tribal control of health systems results in more tribal council members getting involved in consultation over health policy. Joseph Finkbonner pointed out that effective consultation includes both legal/policy and technical/implementation people. The conduits include:

  • Washington State Tribal Leaders Association, in which elected members of tribal councils meet on a regular basis to discuss a variety of issues. The association meets directly with the State Governor twice each year.
  • Indian Policy Advisory Council, which advises the State Department of Social and Health Services on issues including Medicaid, mental health/substance abuse, and public health. Members are appointed by tribal councils. Both policy and program staff often attend.
  • American Indian Health Commission for Washington State, which looks at both healthcare issues and issues that could affect access to healthcare (e.g., welfare reform). Like the Indian Policy Advisory Council, members appointed by tribal councils include both policy and program staff.

Accomplishments resulting from these conduits include:

  • Regularly scheduled meetings—rather than meetings held in response to problems—have increased understanding and trust, and allowed the groups to make steady progress. This model is now being used for discussions in non-health related areas.
  • Tribes have early input into the development of budgets, policies, and programs.
  • The American Indian Health Care Plan, which was assigned by the State legislature in 1993 to the State Department of Social and Health Services. Its 20 recommendations were revised in 1999.

Mr. Finkbonner noted the importance of HCFA in the consultation process. He advised that workshop participants should include HCFA staff early on an issue and keep them informed of the process.

Barriers to effective consultation include:

  • Lack of knowledge—Educating staff unfamiliar with tribal issues is a continuing need as State programs and resources are decentralized to regional and local levels.
  • A commitment by both tribes and the State to devote time and resources to consultation is critical. The success of the process can actually undermine the perception of need for it.
  • Lack of resources, both for implementation and for travel and other costs related to participating in meetings (especially for smaller tribes).

Washington State's Experience: State Perspective

Rick Arnold described Washington's consultation process from the State perspective. The State and the tribes have a shared goal: Because Indian people are also Washington residents and Indians nationwide have some of the worst health-status indicators of any U.S. population, it makes sense to improve access to services in an attempt to improve those indicators. However, it is also important to keep the "big picture" in mind: The State must serve everyone with a certain amount of equity.

Relationships start at the top (e.g., the Governor, Commissioners). In Washington State, a Centennial Accord was developed in 1989 between the Governor and the federally recognized tribes, formalizing their government-to-government relationship; the accord has been signed by each Governor since that time. With support from the top, tribal representatives can craft both formal and informal relationships with State staff. Mr. Arnold stressed the importance of learning "who does what" within State government and developing working relationships with those staffers.

For effective consultation, tribes are proactive in letting their State know the issues important to them. Washington's tribes have health people who are always thinking of ways to improve the care delivery system; they present these ideas and are willing to push to "get the ball rolling" through the political process as necessary. Ongoing education within State agencies, particularly on the importance of the sovereign status of tribes and the fact that Indians are "not just another minority group" is key to effective consultation, and the State staff person serving as tribal liaison may not be able to handle all education efforts alone. Ongoing education for tribal staff on how to work with the State government will also further consultation efforts.


Issue list. Olympia (WA): American Indian Health Commission of Washington State; 2000 Apr.

Purpose. Olympia (WA): American Indian Health Commission of Washington State; 2000 Apr.

Report card from previous summits. Olympia (WA): American Indian Health Commission of Washington State;1999 Aug.

Dixon M. Indian health in nine state Medicaid managed care programs. Denver (CO): National Indian Health Board; 1998 Sep.

Centennial accord between the federally recognized Indian Tribes in Washington State and the State of Washington. Olympia (WA): State of Washington; 1989 Aug.

Executive order 13021: Tribal colleges and universities. Washington (DC): White House, Office of the Press Secretary; 1996 Oct.

Executive order 13084: consultation and coordination with Indian Tribal Governments. Washington (DC): White House, Office of the Press Secretary; 1998 May.

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