health care reform

Characteristics of Indigenous primary health care service delivery models: a systematic scoping review

Year

Indigenous populations have poorer health outcomes compared to their non-Indigenous counterparts. The evolution of Indigenous primary health care services arose from mainstream health services being unable to adequately meet the needs of Indigenous communities and Indigenous peoples often being excluded and marginalised from mainstream health services. Part of the solution has been to establish Indigenous specific primary health care services, for and managed by Indigenous peoples. There are a number of reasons why Indigenous primary health care services are more likely than mainstream services to improve the health of Indigenous communities. Their success is partly due to the fact that they often provide comprehensive programs that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health. However, there are gaps in the evidence base including the characteristics that contribute to the success of Indigenous primary health care services in providing comprehensive primary health care. This systematic scoping review aims to identify the characteristics of Indigenous primary health care service delivery models.

Resource Type
Citation

Harfield, S. G., Davy, C., Mcarthur, A., Munn, Z., Brown, A., & Brown, N. (2018). Characteristics of Indigenous primary health care service delivery models: A systematic scoping review. Globalization and Health, 14(1). doi:10.1186/s12992-018-0332-2

Honoring Nations All-Stars Profile: Tohono O’odham Nursing Care Authority

Year

For many years, due to the Tohono O’odham Nation’s location in the Sonoran Desert of Arizona and the sparse population, Nation members did not have ac-cess to reservation-based long-term or post-hospital care services. This was particularly true for O’odham elders. Elders admitted to the Sells Area Indian Health Service Hospital for acute care who subsequently required follow up long-term skilled nursing care or a place for post-hospital recovery were discharged to nursing home facilities in the Tucson, Arizona area. For most O’odham families, a visit to elder family members required a drive of ninety minutes or more—if trans-portation was available at all. Language and cultural barriers in these urban settings also became a major concern. The facility caregivers could not speak to these residents in the O’odham language, and O’odham residents were not offered traditional foods to eat, could not easily seek the assistance of medicine people, and were not able to spend their remaining days in the desert environment to which they were accustomed. While statistics are not readily available, it is not hard to conclude that placing an ill and frail O’odham elder in a foreign and isolating facility hastens further debilitation and death.Seeking change, the Tohono O’odham community members asked their government to find a way to provide good, culturally appropriate, and local care so that they could bring their elders home

Native Nations
Resource Type
Citation

Stout, Francis and Judith Dworkin. Honoring Nations All-Stars Profile: Tohono O’odham Nursing Care Authority. Harvard Project on American Indian Economic Development, John F. Kennedy School of Government, Harvard University. Cambridge, Massachusetts. 2013.

Honoring Nations: Jodi Gillette: A New Era of Governmental Relations

Producer
Harvard Project on American Indian Economic Development
Year

White House Native American Affairs Senior Policy Advisor Jodi Gillette discusses a new era of governmental reform, the result of a new executive branch administration in the federal government. She elaborates on how this change in administration will effect Native nations, particularly with respect to the provision of health care services.

People
Native Nations
Resource Type
Citation

Gillette, Jodi. "A New Era of Governmental Relations." Honoring Nations symposium. Harvard Project on American Indian Economic Development, John F. Kennedy School of Government, Harvard University. Cambridge, Massachusetts. September 17, 2009. Presentation.

"[Lakota greeting] Really honored to be here. Thank you very much for giving me the opportunity to address this wonderful program. I'm humbled and blessed by this honor and being able to address such a dazzling audience. I've always been very impressed and inspired by the work that takes place here, both in my position at the tribal government when I worked for the Standing Rock Sioux Tribe -- my own tribe -- and then also for the non-profit, the Native American Training Institute. I've been really thinking about what kinds of work happens here. I just really want to acknowledge and thank all of the incredible efforts that the John F. Kennedy School of Government here at Harvard -- through the efforts and the thoughts of Manley Begay, Joseph Kalt and Stephen Cornell in their pioneering ways -- to try to look at the ways that we can help our own people. Looking at new, I say new old ways, because we have some pretty tangled challenges that we deal with on a regular basis, multiple levels of bureaucracy, multiple levels of compounding problems that are interrelated and I think that this program -- Honoring Nations and the board -- continues to provide the direction and wisdom that it takes to maintain and grow a rich body of information built upon the core values that you use to evaluate who can be honored here at this program -- the effectiveness, significance to sovereignty, transferability, and sustainability.

I also want to take some extra time to talk about cultural relevance, which is also a core value, but these kinds of efforts serve as a beacon for many tribes wanting to do better as they advance their governance and the way that they govern inside with their tribal members. Without this important light shown on these programs, it's difficult to imagine where we would be today. And I think that we can have successes in our own communities, and we know that some things do work there and that not all is lost, because we have things that operate. But what this program does is it provides a vehicle to transfer and spread that word of what's effective and that other Nations can benefit from that. And I know it's really hard for a lot of our people to sort of 'toot their own horn' and it's a value to be humble, but through this program it's offering a way to be generous with that knowledge with other Nations and to show that generosity with other people so that they can learn and they don't have to go through a lot of the trials and errors that it takes to build these programs.

I'm honored to be invited by the board and the program, but I'm mostly honored because I think it's so, so important to address that these are great institutions and these are great programs, but we can talk and praise all these efforts and all it is is an idea without having the actual work take place. That work is only successful in the communities as you implement. You can talk and you can think and you can over-think and you can suppose and you can conjecture and all it is is talk. It takes a certain class of people, a certain special someone to take those ideas and try them and put them into use. We can talk but how much are we going to get done? How much are we going to do? This program recognizes those efforts, those -- as the President [Obama] always talks about -- the unsung heroes in our communities that get up every day and try it, try to make things better in the community with all of the challenges, with all of the socioeconomic challenges, with all of the...and we say these things, I can say these things in a way that is more distant, but all of the relatives that are suffering, that's what it comes down to and you feel it and you're there every day. And I think that's quite a difference than going out and trying to think and build these ideas.

And with our leaders, I think that the tribal leaders and the leaders that are being honored here today, you inspire me. I think that mostly what it takes to become an honoree is to take that core value of cultural relevance and make most of what you're doing in a day meaningful to the people that you're trying to help. And I think that in the beginning of my road to the White House, I don't think that anything was more important to me than trying to make sure that in 50 years, in a hundred years that we're still here. And the things that make us different are our cultural values. And I don't think that people put enough stock into how that plays into governance. Because in governance it seems like you have to talk a certain or become something else in your programs, because that's how you get funding. But where the real innovation takes place is when you're able to transfer what works in your communities.

And we have a lot of successful things going on in our communities, and I always say our communities because I am Standing Rock Sioux Tribe and I grew up in Kyle, South Dakota first. But in our communities there are things that work and people are very, we have best practices but they're not always looked at as the processes that get funding or recognition. We have ceremonies, we have events, we have gatherings, we have a rich history of cultural resiliency and those things aren't still here today because we weren't able to figure out what's important to our communities and what's important to maintaining our future as Native peoples. What we have there are some things that work for us. And being able to take what is important and what is relevant and resonates with our people and turn them into something that can also help us and also be a part of our governing structure is what is exciting to me about the Honoring Nations program. This is a unique opportunity for people on the ground level to really be highlighted and praised for that kind of work.

And I think that, as you look at what the President has been talking about, and you listen to his speeches, he often talks about successes beyond the Beltway. Beyond the Beltway is outside of D.C., beyond -- what is it -- 495. I think that with this kind of an era we're really paying attention to how this looks and how these kinds of successes take shape and work in the communities. I don't think that many people know me very well. I know a few people from North Dakota, I know a few people in the dance world as I'm a powwow dancer. And I think the main reason that I'm here is that I always wanted to make a difference and that's kind of just how I was raised. And I didn't really feel like the policy and the politics, the national politics, were talking about me. I felt like that I'm a government major, I have a degree in public administration, I understand all of that, but I just never really thought that it made a difference to participate at that level. But with this President, thanks to people that are sitting in the room here today -- JoAnn Chase and Heather Kendall-Miller, a number of other folks that worked on the campaign -- I heard some things that I had not heard from another candidate, a national presidential candidate and those things caught my ear, caught my attention and I felt like, 'This is really different.' And my story isn't something that is unique with the people that I work with. I spent a number of years trying to do things at the community level and that's the kind of people that the President has chosen. He really looks at people that were fighting for civil rights, he looks for people that have paid attention to what is working and what is not working at the community level. And so I'm working with a number of people that get it. They get some of those basic things that, yeah, the tribes want to be included. They don't want to just be included; they want to be considered as we move forward on the larger policy initiatives that are taking place.

And what I wanted to talk about today is that there's a couple of ways that we can kind of step up a little bit more. Because I got here by caring and participating in the campaign, the election part of the policy cycle, but we also have a number of other things that are continuing to take place. And one of them is the way that we bring our messages to Washington, D.C., the solutions that we're looking for, the examples that we're looking for are extremely important. But not only that, as we continue to have a dialogue and engage with the different people in this new administration, that we have a way that we bring our message that provides those solutions.

And this is, after meeting with lots of people and lots of Nations and a lot of diplomats that have been coming to D.C. for a number of years, we're not having to make, as Indian nations you're not having to make the argument of why we should be there. It's not about the challenges that you face, it's not about...there's a number of people that spend a lot of time describing the issue. What I'm really interested in knowing is how do we address those issues? The how part. You can spend half of the time that you get with the high levels of leadership describing the problem but it's so much easier, it's so much faster... they're already, 'Okay, what do you want? How can we change this? What are your ideas? How can we address this?' And the solutions have to be better thought out. We have to look at the existing laws. We have to look at the existing structures. The administrative things that we can do, the legislative things, but we also know that there's no way that one or two people can address these things alone, that it requires a consistent and meaningful partnership that I think that tribes can bring and have been bringing. And this new diplomacy or this...and people are doing this, for the most part; people want to bring solutions. But just having it in a form that's easily digestible so that we can just take it and say, 'These are the priorities, these are the things that they want to do to address this issue,' is very helpful.

So no matter what you're talking about -- like with land and water, safety, health, education -- people aren't talking about that we need to have our nation-to-nation relationship. That's a given. We had a lot of groundwork laid by leaders for a number of years and we understand that there is a federal trust responsibility, that we don't need to...with this administration we don't have to keep going over those points. We also know that the administration has taken special effort to appoint people as a foundation to include not only tribal governments in some of the decision making, putting people in place that can have...we can fast forward to the solution part and we don't have to really be an advocate and change somebody's mind or inform them or educate them at the different presidential appointment level, but we can already get to work.

And different people like the Assistant Secretary Larry Echo Hawk or the IHS [Indian Health Service] Director Yvette Roubideaux, Mary McNeil at USDA [U.S. Department of Agriculture] and Mary Smith at the Department of Justice. And then we also have, I'm not the only person in the White House, we also have Kim Teehee at the Domestic Policy Council. And these are some wonderful advances. And that position was actually a cornerstone of the campaign and that's been filled. Another cornerstone has been the White House Conference with Indian Nations that's taking place this fall. I can't say when because it's a moving fluid event right now, but we are going to have that this year. And all of those, those are great presidential priorities and we haven't forgotten about them. We also know that it's frustrating sometimes because it feels like things haven't been moving quickly enough, that we haven't felt that change. It was supposed to be night and day. He got into office, inaugurated, the sun started shining, but that's a lot easier said than done because we have a lot of work. There's an eight-year history that we're trying to try to address in terms of what was happening with various agencies and the budgets and all of those things.

So as far as what we're working on are of course the budgets, the FY11 now, 2011. We're also looking at the presidential priorities for this year and that is the reason that I was appointed in this intergovernmental affairs [position]. It's actually a part of the Office of Public Engagement, which formerly was known as Office of Public Liaison. Office of Public Liaison was the place where they call it the front door of the White House, where governments or if you're Office of Public Engagement then it would be an organization or a non-profit. And Mr. [Joseph] Kalt was right when he said that this position was specially crafted to exist in intergovernmental affairs, things to work like NCAI [National Congress of American Indians] and Joanne Chase back during the Clinton administration. There's a given that tribes should be treated as governments, not as a public organization that serves minorities. And that's the, our sister organization is the Office of Public Engagement. So the reason that I bring that up is because my position wasn't a part of any kind of pre-campaign discussion or pre-election discussion. It was just kind of like a logical thing to do and that's how this was in place and it's the first of its kind. Office of Public Engagement is very important to the President. His senior advisor Valerie Jarrett is in charge of my office, so that's basically my boss. I have another boss, Cecilia Muñoz, who is the director of Office of Intergovernmental Affairs and they're both tremendously, tremendously supportive. They have a great understanding of what it means to be left out of discussions, to be not a part of the decision-making process and having to catch up afterwards. And so people like that in very good places make a difference in my job. And so that's why, it's not just me and it's not just the Domestic Policy Council, Kim Teehee, but it's a number of people all over the White House.

And so that's why I say it's so important to bring those solutions and bring the how. How are we going to address this? And part of that is bringing best practices to the table and showing those kinds of things. And I just am so honored and I keep saying that I'm inspired because I really am by the work that has taken place by the honorees. It feels like, sometimes when it gets really tough, it feels like it doesn't matte,r but in reality the President has put forth a new kind of leadership that I appreciate because of my years of studying tribal governance. And that's the principle that the people at the top, and this is from my own understanding of how my leadership works, the Lakota word for leader is [Lakota language] and that means 'cane.' And that means basically that the leader is at the bottom and everybody else is at the top, the most pitiful and the most, people that are having the hardest time are at the top. And that's...it's opposite of the European contact model where you have the king or the monarch at the top and everybody else is below them. The tribal leaders, I really feel that they get that, that they are in that position to bear the difficulties and bear the challenges that our communities face to move forward. And that's why they're called a cane because people lean on them. And I think that this President really gets that and you'll see that as not just in what he says, but how he's put people into place and how he talks about change.

And with the whole idea, the second thing that I wanted to talk about is continuing that participation. Second thing I wanted to talk about is health insurance reform and that is a way that the President has put forward...most people are covered by insurance and they like their health care plan. And so that's something different when you're going to try to convince a large group of, the majority of the Americans are happy with their health care but there's still about 12 percent of the people that aren't happy with that. And so he's trying to help the people that are not, are suffering basically. And this was his number-one priority and sometimes it seems like, 'Well, how do Indians fit in there? How do we relate to this issue? How am I supposed to stay engaged with something like this?' But I just wanted to assure you that the Indian voice and the concerns of Indian nations has not been lost in this discussion. We've been monitoring it and we have a really good idea, thanks to a lot of the organizations like NCAI and NIHB [National Indian Health Board] and tribal leaders that have voiced what is concerning them about this. And so having that kind of information and that dialogue on this specific issue but other issues going forward like energy, public safety, sacred lands, all the different things that affect our communities is critical to how we do our work.

And having that support, that's still important, much like a lot of people came out during the campaign. It's still important to voice that support for something this important. And they're calling it the test of the President and so I encourage you, if you haven't already thought about how this affects you, health care affects everybody. And daily, people are losing their health insurance because of the escalating costs. Since 2000, there's been a doubling of insurance premiums. And this might not seem like it resonates with Indian communities, but the rising costs of health care effects everybody including Indian Health Service. And it seems like contract health services is always running out of money but if you look at why it's running out of money, being flat-lined for the past eight years compounded by the health care costs rising at an unprecedented rate, there's no wonder why. There's no wonder why we haven't been able to keep pace with that. But we also know that there's an effort. He really wants to strengthen the health insurance system and this is to get everybody covered, to get costs under control and to improve quality.

Recently, you've seen a lot of sort of I guess they're myths out there about Indian health care and it's made national headlines in media in different places and this is an effort. What they've been doing is calling, comparing Indian Health Service to health insurance. And so this is not an accurate comparison because we know that Indian Health Service is a system itself, it's not health insurance. Health insurance provides a guarantee to an individual of a defined set of benefits for a price. Indian Health Service accepts insurance payments for the care it provides but it is not an insurance plan itself. Health reform isn't going to dismantle Indian Health Service and that's something else that's kind of buzzing around and it's not going to. It is true that there isn't one proposal in the health reform that will do anything to discontinue Indian Health Services. President Obama supports strengthening and modernizing Indian Health Service and American Indians and Alaska Natives will continue to have access to their Indian Health Service facilities -- that will not change. If you want to just think about health insurance reform in a way that if you're covered and you like what you have, you can keep it. If you're not covered, this is what we're trying to address and we're trying to do it through an exchange. And so if you're in the IHS system and you might not like everything about it, but we are going to start looking at addressing an Indian Health Service reform with the leadership of Yvette Roubideaux. But the people that aren't covered, and that includes American Indians that aren't living in service areas, and so this provides a more affordable insurance package or options that they can choose to participate in. And then if, the other thing is that this isn't a government takeover of health insurance reform, of health insurance. What it's trying to do is provide those options.

And we were just, we just want to reiterate that this isn't a replacement or it's not a way that we're going to stop Indian health services. And we know that some of these reports have been saying that Indian Health Service is a bad example of government-run health care. We know that despite the historic under funding of Indian health, many of the tribal entities have developed innovative and award-winning approaches to healthcare. And places like Alaska, Oregon, Oklahoma, North Carolina serve as successful models for other rural health programs. And these programs that are successful are good examples of doing more with less. But we're not going to say that IHS is a perfect entity. President Obama has recognized that IHS is underfunded and that's why he proposed a 13 percent increase in the 2010 budget and the largest increase in 20 years where he invested $590 million of recovery act funds for the Indian Health Service. He also knows that the funding increases don't make up for past deficiencies, but it does reflect his support and commitment to the Indian Health Service system. We also just like to say that we want to address this crisis, this health insurance crisis. Many people lose their health insurance every week. And as Indian nations you think, 'Well, how does that affect me? What does that mean to me?'

Well, in the big, big, giant picture of it all, this is the number one thing that he wants to get accomplished. And if he can't accomplish this, this is going to have repercussions for the individual and specific needs that we have in our community and the ability to get those things done as well. And so the big push is to try and get this larger issue addressed and this priority. And then we can move to the things that are important to our communities. And we have a finger on the pulse. We know what the priorities are in Indian Country. One of the scares is that there's a mandate for coverage in the proposals where everybody has to have health insurance, otherwise they'll get penalized. And we've heard loud and clear from tribes that that's not something that will work for Indian Country given the federal trust responsibility. And I can just imagine tribal leaders having to respond to their voters who have been, who are getting these bills in the mail for not having health insurance. This exemption from penalties is something that the White House has weighed in on on the health side and that's very critical.

We're doing our best to make sure, President Obama is making sure that this isn't going to add to the deficit and he wants to make sure that people are comfortable with the fact that revenues from drug companies, drug and insurance companies, and savings from existing health programs are how they're going to pay for this. And then also of course the myth that Medicare is going to be affected and that's not true. And we understand that the Medicare, people that Medicare serves are feeling like their services are going to be affected but that's not true. We know that our communities deserve the truth and that we have a lot at stake in this health reform debate but we are working closely with the experts and the technicians on how this is going to affect our communities and we are paying close attention to that.

And so I guess my main point is that this does effect us because the overall ways that the health industry is just really costly and whether or not...our tribes have different situations all across the country. Some of them operate their own clinics, some of them have contracted the full services, full array of services, others still continue to have direct services but overall we intersect with the private industry and the health system on a regular basis -- the price of drugs, the price of doctors, all of that. And so this is just a way that tribes and American Indians and people can stay engaged in this to see how it really affects us. And so this is the ways... the things that I'm working on are the presidential priorities like health care. We really would like to hear from you as you go back to your communities and think about the different successes and the models and best practices that are being developed there and we appreciate the work that is being done here at Harvard to recognize those efforts. I'm leaving. I wish I could spend more time with many of you and visit. I have an engagement in Denver tomorrow and we're meeting with the Denver Indian Center and a number of different organizations. But we have a lot of work to do and we need your help and so we appreciate the chance and the opportunity to address you. Thank you."