Sheila Hogan

Montana Director of the Department of Public Health and Human Services Sheila Hogan explains the states new medical coverage payment plan in Billings in this July 2016 file photo.

BOB ZELLAR/Gazette Staff

Two new state programs will provide training and up to $64 million in annual funding for tribes to prevent suicide and to offer preventive health care to Native Americans, which Montana’s top health official called “a historic investment.”

The announcements by Department of Public Health and Human Services Director Sheila Hogan came during a Thursday meeting of the Interim State-Tribal Relations Committee in Helena.

She also presented updates about how the agency hopes to improve daily operations to better serve Native Americans, and spoke about the lack of a director for the Office of American Indian Health after its first leader left in protest this spring.

At the heart of discussions was one stark fact: Native Americans, on average, die 20 years sooner than other Montanans.

In recent years, the state has talked about doing more to collaborate with tribes to close that gap. The disparity results from health, social, political and economic factors exacerbated by federal programs built as part of treaty agreements to serve tribal communities separately from other Americans. Those programs, including the Indian Health Service, have historically been underfunded, understaffed and held to lower quality standards.

Perhaps the most robust result of the state discussions to date came in April when Montana secured federal funding for preventive health care by adding a new program to an existing Medicaid waiver. For each of the next two years, Hogan said about $64 million will be available for tribes to spend on offering preventive health care services after developing a plan and negotiating a contract with the state.

“We pay the treatment piece, but we do not have funds to address the prevention piece,” Hogan said, referencing the fact that the federal Indian Health Service, as well as state programs, pay for care after someone is ill. Because Native Americans receive less preventive and routine care, they are more likely to be diagnosed later than other Montanans and are more likely to have minor issues develop into serious conditions.

The Tribal Health Improvement Program will be open to federally recognized tribes with what are commonly called 638 agreements, a type of contract that allows tribes to take over management of some services offered by IHS. The federal funding is likely to continue beyond the initial two years, like other programs supported by the waiver, said DPHHS Medicaid Director Marie Matthews.

It could be endangered, however, if health care reforms proposed by Congress modify parts of the American Indian Health Care Act incorporated into the Affordable Care Act, which includes additional tribal-specific provisions.

The Fort Peck Reservation in northeastern Montana was the first to participate in an early version of the program, whose initial successes since 2009 were critical to securing the new federal funding, Hogan said.

Lesa Evers, tribal relations manager for the department, lauded the program as innovative, not just because it might be the first direct partnership between tribes and the federal Center for Medicare and Medicaid Services. She said it preserves Native autonomy to tailor unique solutions for their communities’ particular needs.

Participating tribes will receive gradual funding increases as they move through three tiers of the program that could range from broad-based prevention services to intensive, one-on-one support for people with the highest levels of Medicaid spending — often a sign of unmet preventive or maintenance health needs.

It is unclear when tribes might begin negotiating to join the program.

“People, in a way, are paralyzed. We as Indian people have never had access to prevention dollars,” Evers said, describing the reaction of tribal leaders upon learning about the new funding opportunity. “People are waiting for a minute to think about what this really could mean …. They’re dreaming right now.”

Hogan also shared an update with the committee about ongoing efforts to prevent suicide in Montana’s Native communities.

The 2015 Legislature dedicated $250,000 to study the issue in Indian Country and to develop an action plan.

Tribal members packed a committee room at the state Capitol in January to present the result, the Montana Native Youth Suicide Reduction Strategic Plan, and to urge legislators to approve funding to implement the plan. The coalition that wrote the 104-page report, with help from a professional consulting firm, left $130,000 unspent to give that effort a jump start.

Hogan said about $50,000 of the 2015 funds will pay for the state to host a Zero Suicide Academy to be attended by four representatives from Montana’s eight tribal governments and five urban health programs. Attendees will apply what they learn at home and teach others. The training is part of a national suicide prevention curriculum.

The remaining $70,000 will be divided among the 13 groups to spend as they see fit on related programs, which breaks down to $5,384 each.

The 2017 Legislature approved an additional $250,000 to spend over the next two years to implement three other parts of the Native Youth Suicide Reduction plan. Legislators also made another $750,000 available to suicide prevention programs serving any population, if they qualify. Tribes and urban health programs also can apply for that money.

Hogan said they hoped to start collecting applications this fall.

Vice Chair Rep. Alan Doane, R-Bloomfield, said he was frustrated that so little of the 2015 funding would be spent directly on services, noting that the committee had previously called on the coalition and its partners to spend less on administrative work.

“I realized it takes a lot to get a program started. I hope out of this next $1 million that more … gets to boots on the ground,” he said. “Government, we can be way more frugal in administration and get the money to people it’s supposed to help.”

Chairman Jonathan Windy Boy, D-Box Elder, agreed, noting all eight committee members had signed the letter.

Sen. Lea Whitford, D-Cut Bank, pushed back to defend the coalition’s work and the final Native Youth Suicide Reduction Plan. She argued that developing a detailed action plan has long-term value and that partnerships formed during the process have strengthened programs throughout the state.

“It opened the door for people to communicate. I realize that you’re looking at the $5,038 some dollars. What you’re missing is the bigger picture,” she said. “This Legislature, the past Legislature had asked, ‘What is your plan? How are you going to go forward?’ That’s what you have in front of you.”

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