A win from Washington and a funding challenge from the states to Congress

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Sen. John McCoy was the sponsor of Washington State legislation to authorize dental health therapy in tribal communities. (Senate photo)
Mark Trahant / Trahant Reports

We live in odd times. Congress is moving forward with promised legislation that will roll back much of the health care reform enacted during the past eight years. The Trump administration is issuing regulations to do the same. The key here is that President Donald J. Trump and Republicans in Congress have the votes (mostly). But in state capitals there are real debates about public policy. What happens next will be determined by lots of people working together.

The future of the Affordable Care Act is a case in point. Republicans in Congress are eager to ditch the law, but coming up with a replacement or even a fix is a much more difficult task. This is one issue where there are not enough votes in Congress to do anything. Yet.

But in state capitals there is an understanding that a wholesale repeal of the law could be a financial disaster for states that have already expanded Medicaid. So many Republicans at the state level, such as Ohio Gov. John Kaisch, are pushing back. He recently told CNN that that any repeal without addressing Medicaid expansion is a “very, very bad idea.”

But several of the states prefer a real solution, one that doesn’t grab as many headlines, yet would be practical. And that is to continue with current law and then Secretary of Health and Human Services Tom Price would grant states many more waivers to design the programs the way they want.

This makes more sense than a block grant because it keeps in place the idea that if people are eligible for Medicaid, then it will be funded. Under a block grant scenario, it’s likely the total amount would be capped and people who currently get insurance could lose that.  (Perhaps the most difficult problem is this: How do you protect the states that expanded Medicaid and still add funding to those states that said no?)

This is a huge issue for Indian Country because Medicaid could cover even more of the people who currently use the Indian health system.  (Best of all: Money from insurance is supposed to stay at the local healthcare facility.) States also come out ahead with American Indian and Alaska Native clients because the federal government is obligated to pick up the tab. It’s a 100 percent federal “match.”

This is one of those issues that divide Republicans, especially in Congress. The members who are listening to states understand the problem: What happens when you take away people’s health insurance? The answer is not good. And it’s even life or death for some people because without insurance there will be no medical care for ongoing issues.

This week in Washington state there was a victory for health care reform in Indian Country. The Legislature passed, and Gov. Jay Inslee, signed into law, a measure that opens up the practice of dental health therapy.

Dental health therapists are mid-level providers. They work under the supervision of a dentist and offer routine and preventive services, like dental exams; provide fillings; clean teeth; placing sealants; and perform simple tooth extractions. This law is important because it opens up Medicaid funding to pay for dental care. And it expands access making it much easier for patients to get appointments.

“We have one dentist to see more than 6,000 patients on the Colville Indian Reservation,” said Mel Tonasket, vice-chairman of the Colville Confederated Tribes. “This law will help us hire a dental therapist to make sure our people are getting the oral health care they need.”

Most experts in health care reform argue for increasing value in health care by lowering costs and at the same time improving quality. This is that.

This oral health reform was started a decade ago by Alaska Native Tribal Health Consortium. According to The Kellogg Foundation: Since then “45,000 Alaska Natives now have access to dental care and the dental health aide program has generated 76 full time jobs with a net economic effect of $9.7 million, one-third of which is spent in rural Alaska. Now, as a way to replicate the same dramatic oral healthcare improvements in Alaskan villages, i.e., reduced caries disease, healthier teeth and patient satisfaction with culturally competent care given by home-grown providers, tribes are blazing a trail to bring dental therapy to the lower 48 states as a high-quality, cost-effective strategy to reduce dental care shortages. Washington State is on the leading edge of this movement.”

This is a great example of the principle of lead, follow, or get the hell out of the way. A year ago Swinomish President Brian Cladoosby announced that the tribe was using its sovereign powers to hire a dental health therapist in contradiction to federal and state law. The case was clear that the tribe had the authority even while raising questions about Medicaid funding or licensing. (The American Dental Association was successful getting language into the Affordable Care Act that required state action.) But the state of Washington was reasonable and the result is the new law.

The bill was sponsored by Sen. John McCoy, a member of the Tulalip Tribes. “This is a tribal-based solution that will make a tremendous difference for Native people—especially children,” he said.

According to Kellogg: Dental therapists are now practicing in Minnesota, in addition to Native American communities in Alaska and Washington. They’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio are exploring the potential for dental therapists to significantly improve oral health care for many more children and communities.

So look for more action and more success stories coming from state capitals.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com

 

 

 

 

 

 

 

 

#NativeVote16 – Alaska Native success story is an innovation for the states

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Vermont Governor Peter Shumlin last week signed S.20 into law, the fourth state in the nation to allow dental therapists to provide dental care. The Alaska Native Tribal Health Consortium began dental health therapy in 2004. (Photo from Vermont Public Interest Research Group or VPIRG.)

 

Just one example of innovation from the Native health system

Mark Trahant / TrahantReports

In the news business, this would be a man bites dog story. That’s the idea that a narrative framework is the opposite of what’s supposed to be. The usual story is that Indian health programs are a disaster and only getting worse. But in the real world if you want to find innovation, efficiency, and ideas that must be borrowed by state governments, then explore some of the many successes found in the Indian health system.

Of course that’s not what we are reading about lately. Most of the news stories about Native health focus on the serious problems in the Great Plains. That indeed is a crisis — and one worth fixing.

But at the same time there are other parts of the Indian health system that are unbelievable success stories.

Consider the data: Just before the Indian Health Care Improvement Act was signed into law in 1976 the average age at death for American Indians and Alaska Natives was 48.3 years. The age at death for White people was 72.3 years. And today? That 20-plus-year difference has been reduced to a gap of less than five years. Today the life expectancy at birth for American Indians and Alaska Natives is 72.3 years, compared to 76.9 for all races.

And that steady progress, imperfect as it is, has been made without the same resources as the general population. Doing more with less is part of the operating framework at tribal health facilities, nonprofits that operate health clinics for a Native community, and, even for the federal Indian Health Service.

The story that still needs to be told is that the U.S. medical system could learn a lot from the Indian health system. The U.S. system is the most expensive in the world, by far, while the Indian health system operates at levels comparable to what other nations spend on health care. Could Indian health use more resources? Absolutely. That’s the frustrating part of the narrative; it’s the option that Congress never seems to consider. (Previous: Paul Ryan’s call for Indian health ‘choices’ would be a disaster.)

So with that context let’s celebrate a success story with roots from the Alaska Native medical experience.

Last week Vermont Gov. Peter Shumlin signed into law a bill that licenses dental therapy in Vermont. Therapists are midlevel providers who will provide dental procedures such as fillings and simple extractions. “This is important because there’s a direct connection between oral health and overall health,” the governor said. “Having dental therapists available to work with dentists and hygienists will make it easier for Vermonters to get the care they need, closer to home and no matter what type of insurance they have.”

More than a decade ago the Alaska Native Tribal Health Consortium experimented with a program to train midlevel oral health providers. It was a community-based program to serve a need because too few dentists were practicing in remote Alaska Native villages.

Almost immediately this was an “aha!” moment as other communities saw this as a smart way to expand dental access. Dental therapy students were hired and trained right out of high school and then were put right to work.

But the innovation was followed by a fight. The American Dental Association sued trying to stop this program, saying that the midlevel providers were practicing dentistry without a license. The Alaska Native Tribal Health Consortium fought back and won, using the Indian Self-Determination Act and the Indian Health Care Improvement Act to trump the state’s licensing regulations.

The data today is clear. The program has been spectacularly successful providing routine dental care to some 40,000 patients every year. As the Pew Charitable Trusts wrote: “Evidence is growing that expanding the dental team to include midlevel providers, often called dental therapists, helps dentists build their businesses while increasing access to high-quality, cost-effective care. A 2014 report from the Minnesota Board of Dentistry and Department of Health evaluated the impact of these providers and found that they expand access to care for vulnerable populations and improve the efficiency of clinics and dental offices.”

Across the country, both in Indian Country, and now in states, the idea of a midlevel dental practice is expanding.

Last summer at the National Congress of American Indians, Brian Cladosby, Chairman of the Swinomish Indian Tribal Community, and president of NCAI, said the tribe would expand dental health therapy using its own sovereign regulatory structure. In recent months tribes in Oregon began their own pilot program to train dental therapists.

This innovation is the future. It expands dental care as well as opportunity for young people who want a career in dental health. It’s important to tell the story and its roots with the Alaska Native Tribal Health Consortium.

Supreme Court Justice Louis Brandeis once called states “the laboratories of democracy.” Tribes, and intertribal organizations, then, might be first test labs.

Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports

Reposting or reprinting this column? Please credit: Mark Trahant / TrahantReports.com