By Lee Egerstrom
Minnesota and the federal Medicaid program need to recognize American Indian culture and practices with traditional healing and better define health and wellbeing to serve America’s original citizens.
This is among findings and three important “Call to Action” recommendations emerging from an exhaustive study of health care services conducted by the Minnesota Department of Human Services (DHS).
The report, Pathways to Racial Equity in Medicaid: Improving the Health and Opportunity of American Indians in Minnesota, was released in December following research that found great racial inequalities in the delivery and accessibility of America’s largest health care system.
Three calls for taking new action emerged after statewide meetings with tribal and urban American Indian health leaders and providers.
The first call identified a need for Minnesota to “Invest in Traditional Healing,” recognizing its importance to the mental and overall health and wellbeing of the state’s American Indian population. This means DHS will need to stay engaged with tribal nations, urban American Indian clinics and organizations, and the federal Centers for Medicaid and Medicare Services (CMS) to find ways to cover traditional healing costs under Medicaid.
Questions need to be resolved. These include how to set a monetary value to traditional healers’ services, do they need a license or certification of some sort, and how will tribal data sovereignty be upheld?
A second “Call to Action” requires complex social, medical and political cooperation. It states its goal as “Reframe what defines health and wellbeing and the evidence used to make decisions.”
To do so, the report said DHS will need to continue work with tribes and urban community clinics to define health and wellbeing for American Indians, to work with federal partners on Medicaid rules and regulations, and with other state officials and lawmakers to create, propose, implement and evaluate care and payments for related services.
This effort will interact with the federal Indian Health Service (IHS), which is described as often “underfunded” by Congress. The authors cite a painful old joke from Northern Minnesota that warns American Indians to get sick, if they must, by June before IHS’ funds run out.
The third “Call to Action” is to “Create a Pathways to American Indian and Tribal Health Integration Team” (PATH-I) at DHS.
This may need legislative approval or at least Legislature-approved funding, said Dr. Nathan Chomilo, the lead author of the Pathways report. The team is envisioned as a source of community information for DHS staff, and for sharing information about available Medicaid resources. The team would work with all involved state and community groups and Indian health systems to integrate cultural approaches to health and for Medicaid to lead or participate in systems integration.
Some of these goals could lead Minnesota to seek waivers from the federal Medicaid program to conduct experimental implementation programs. Within the past year, these so-called “1115 waivers” were granted for experimental programs in Arizona, California, New Mexico and Oregon.
“Improving how we administer Medicaid is crucial as we collectively work toward achieving health equity with American Indian communities in Minnesota,’’ Chomilo told The Circle.“The time for action is now. There remains much DHS can learn from, and create together with, American Indian communities and Tribal Nations to realize a health care system that is truly responsive and culturally inclusive for all people in Minnesota.”
Chomilo is the medical director for the state of Minnesota’s Medicaid program. He is also a pediatrician doctor and hospital internist, an adjunct assistant professor of pediatrics at the University of Minnesota Medical School, was a founder of the Minnesota Doctors for Health Equity group. He also holds other state and University positions in support of medical and childhood health and development.
An important colleague on the Pathways report was Takayla Lightfield, who was a perinatal program consultant on the Population Health Innovation team at DHS. Her main work at DHS has been co-managing the Integrated Care for High-Risk Pregnancies grant program. From the Cheyenne River Sioux Tribe, she has long been involved with relevant health care work and traditional healing.
Since the Pathways report was released in December, Lightfield has taken on a new job at DHS. “I am now the Tribal Policy Consultant in DHS’ Office of Indian Policy (OIP),” she said. She will work with Dr. Chomilo to disseminate the report, assist in follow-up work and pursue the Calls to Action in seeking legislation and other governmental permissions.
With her work in perinatal programs at DSH, Lightfield has dealt with child health issues for the American Indian community. That includes gaining access to Medicaid, to the SNAP (formerly called Food Stamps) and TANF (Temporary Assistance for Needy Families) and other food and nutrition education benefits for families and for “doula” care.
Doulas are certified helpers for pregnancies and delivery. She is one herself. They, and medical professional midwives, may well serve as role makers for traditional healers in the months and years ahead.
“Doulas are already able to become registered providers and bill Medicaid for their services,” she said. But so far, she added, certifying traditional healers “is one of the main concerns we have heard from tribes regarding the 1115 traditional services waiver.”
Going forward, Lightfield said she will promote and help integrate the Pathways report into DHS actions. And she plans to continue gathering input from tribes, urban directors and community groups on how DHS can move this process forward together with its partners.
Although not cited here in this news report, the DHS Pathways report provides various studies and U.S. Census Bureau data showing problem Minnesota’s American Indians, their families and communities face in accessing Medicaid and health care.
The Calls for Action were assembled from community-led efforts to identify ways others “can help us increase access to traditional healers, ceremonies, sacred medicines, Indigenous foods and teachings,” she said.
“This is how we can save those Native babies.”
Participants in the research and discovery for this project included:
Tribal agency staff from Fond du Lac, Lower Sioux, Red Lake and Bois Forte reservations. Urban American Indian clinics and organizations included the Native American Community Clinic, Indian Health Board of Minneapolis, Division of Indian Work, Metro Urban Indian Directors (MUID) and St. Paul Indians in Action.
Other American Indian and Tribal Affiliated Organizations participants included the Great Lakes Inter-Tribal Epidemiology Center, American Indian Cancer Foundation, Great Lakes Area Tribal Health Board and Johns Hopkins Center for Indigenous Health.
And other American Indian community members included Karina Forrest Perkins from the mental health and wellbeing group Vail Communities, and Dr. Deana Around Him from the Child Trends research organization with operations in Washington, D.C., Minnesota and North Carolina.
This massive research effort involved at least 382 people from across the state with virtual and in-person sessions in Bemidji, Duluth and Minneapolis.
1115 Waivers – The four states receiving 1115 waivers in the past year are launching demonstration projects.
The Oregon Health Plan waiver might be useful for what Minnesota might pursue. It seeks to provide reimbursement for tribal-based healing practices approved by Oregon’s Tribal-Based Practice Review Panel that currently involves prevention, substance use, and mental health services.
The report is available online at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-8209C-ENG.
