Indian Community's View; it's about the Gap in funding our programs

  • Indian health care delivery has improved a great deal since the 1950s and the establishment of the Indian Health Service.
  • Comprehensive Health Programs are now more often run by tribes themselves and they typically integrate behavioral health, dental and medical, and social services including transportation and patient navigators (we call them community health representatives)
  • Western Medicine is now the foundation of Indian Health Programs, but traditional ways continue with the attention to the 'whole' person, the whole family, and the whole community.
  • The Gap is in access to referred care to specialists and hospitals.
  • ​Full funding of the Indian Health Service Budget would provide most of what is needed to close the gap, but health care reform has the promise to provide additional funds and lowered CHS spending.
  • The administrative and IT infrastructure to support a comprehensive program is incomplete in some tribes (information technology is underfunded although for most the implementation of electronic health records/practice mangement has started).
  • Each tribe (but not Urban Indian Programs) has an appropriation of funds to 'buy' health care that they can't provide within the four walls of their facilities (and sometimes primary care or insurance)
  • Priorities and budgets are set to try to make the funds last through the year 
  • When the money runs out, care is rationed or postponed.
  • Community members know whether or not they are 'CHS-eligible' and it is true that if they don't know they probably are not eligible.  This is not to say community members fully understand this complex program and all it's rules (see FAQs).
  • Not all programs run out of money every year-some have not for 20 years and these are the program that best access "ALTERNATIVE RESOURCES"

  • CHS requires CHS-eligible patients to access any alternative resource that is no cost to the patient.  The resource most often accessed is Medicaid.  Some tribes also pay for Medicare and require enrollment in Part B (and or C or D).
  • How does a typical citizen of a tribe, living on or near their own tribe's reservation view their health care program?
  • They feel they operate their own primary care programs and that program has a responsibility for their health care.
  • They understand the program is underfunded (in nearly every case), despite the trust responsibility for federally provided health care.
  • They know their reservation-based program has to interact with the larger medical community to provide the care they want and expect for their families.
  • Insurance is at best a 'necessary evil' not the foundation of services.
Alternate Resource Rule and Health Care Reform
  • Washington's Indian health programs are already experts at Medicaid enrollment-they will enroll more when Medicaid expansion increases eligibilty and relaxes rules.
  • Washington's Indian health programs already contract with health care plans and will likely contract with Qualified Health Plans (if not, payment is still required from QHPs)
  • Indian health program patients are familiar with the requirement that for care outside their facility they are required to 'access alternative resources'-mainly Medicaid
Alternate Resource Rule and Tribal Sponsorship
  • Washington's Indian Health Programs understand that they cannot require patients enroll in Qualified Health Plans if there is a premium or any cost sharing UNLESS the health program is willing to pay all of these costs UNLESS the patient is willing to pay for some of the cost of the Qualified Health Plan.
  • Washington's Indian health programs are already experts at Medicaid enrollment-they will enroll more when Medicaid expansion increases eligibilty and relaxes rules and they could become EXPERTS at enrolling in Qualified Health Plans too.
  • Washington's Indian health programs already contract with health care plans and will contract with Qualified Health Plans so patients they enroll in QHPs can be seen at their own health program and that program can be paid.
  • It is not clear and needs to be determined how IHPs can access the specialist and hospitals in the QHPs network of providers.  For example, will a patient need to repeat their IHP diagnosis and tests with another provider before accessing specialists?
  • Indian health program patients are familiar with the requirement that for care outside their facility that are required to 'access alternative resources'-mainly Medicaid, and they could become familiar and accept enrollment in qualified health plans if a tribe sponsored their premiums (and paid for any or most cost sharing), but only if they can access their own Indian health program.
  • At least 15 Washington Tribes have begun to study the option to sponsor health insurance.  Less than 500 were sponsored as of August 1, 2014.
  • The Gap
Alternate Resource Rule and Health Insurance
  • Indian health program patients are familiar with the requirement that for care outside their facility they are required to 'access alternative resources'-mainly Medicaid
  • IHPs cannot require a tribal member to purchase private health insurance for themselves or their dependents.
  • Although the rate of workforce participation of citizens of most tribes is similar to all races rates in Washington, few add their dependents to their employer offered health plans since they have access to the IHP.
  Washington's Indian health programs (IHP) are primary care programs

  Typical clinic has fewer than 10 primary care providers, many with 2 or 3 FTE primary care providers, but some do have more than 20 providers in their health clinics and many have over 30 providers when all services are included (behavioral health, dental, medical).

  There are also challenges in supporting IHP's primary care programs with staffing the number one issue
Traditional Medicine 
Wild Choke Cherry, Devil's Glove, Bark of Crabapple Trees, Seaweed (in childbirth), Cascara Bark and Alder Leaves are medicines familiar to the Port Gamble S'Klallam Tribe.
The Strong People:  A History of the Port Gamble S'Klallam Tribe'
An important milestone for an infant is when they are given their first cockle (for teething)
Suggested Citation: Website,  Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2014
105 Maple Park Ave SE Olympia,WA 98501
Free and unlimited use granted, citation appreciated
edfox_phd@yahoo.com  360 790 1164
Free and unlimited use granted, citation appreciated
October 4, 2014