1. History and Application of the Alaska Tribal Health Compact with the Indian Health Service Rose Tepp, Tribal Lead Negotiator, Kenaitze Indian Tribe Carolyn Crowder, Crown Consulting & Management Christopher Mandregan, Jr., Alaska Area Director, Indian Health Service

2.  Introduction & History of Alaska Tribal Health System  How the One Alaska Compact Evolved  Inter-Tribal Relationships & Cooperation  Impact on the Federal System

3.  1900-1970: Health care for Alaska Natives was provided by the U.S. government  1970-1998: Alaska Native tribes organized health care organizations under Self- Governance legislation and gradually assumed ownership of health services at regional and tribal levels  1998-2015: All Alaska Native health care is provided by Alaska Native organizations  Represents 229 Tribes  Serves 147,000 Alaska Natives/American Indians  586,412 square miles of predominantly road-less land

4. HISTORY OF ALASKA TRIBAL HEALTH SYSTEM  Alaska Native Health Board established (1968) Representing 26 member Tribal Health Orgs & Independent Tribal P. L. 93-638 Compactors/Contractors  Alaska Tribal Health Directors  Technical Advisors Forum to address all Statewide Health Issues Created & Co-managed Statewide Services i.e. Community Health Aide Program, Sanitation & Safe Water Services Recognized Federal & State Health Advocacy Voice for Alaska Natives

5.  1968 Formation of the Alaska Native Health Board  1970 First regional health organizations (YKHC and NSHC)  1975 AFN’s Alaska Native Health Care Policy Statement  1994 Alaska Tribal Health Compact agreement  1997 New Alaska Native Medical Center  1998 Formation of ANTHC  1999 ANMC ownership transferred to ANTHC/SCF  2002 ANHB Statewide Native Health Plan  2004 ATHS Memo of Understanding

6.  Shared advocacy lead by Alaska Native Health Board  One compact with Indian Health Service  Co-Manage ANTHC statewide services & statewide AK Native Medical Center w/open access to urgent care statewide  Strong Inter-tribal Health Network  ATHS organizations collectively spend almost $4 million per day  ATHS employs over 8,000 full and part-time staff statewide ~ 70% Native Hire  ATHS expenditures $1.4 billion; $1.7 billion by 2020  ATHS serves 147,000 people; 160,000 people by 2020 (9% increase)

7.  Alaska Native Medical Center: tertiary care  6 regional hospitals  4 multi-physician health centers  25 subregional mid-level care centers  180 small community primary care centers  Purchased/Referred Care to private medical providers and other specialty services

8.  Alaska Tribal Health System proposed Single State-wide Agreement under the Title III of the ISDEAA Tribal Self Governance Demonstration Project (1988-early 1990s)  Congress Authorized statewide organization: 3 THOs + 2 Unaffiliated Reps designated to manage ANTHC statewide services and co-manage ANMC, through ANTHC Consortium Board of Directors (1998)  Made Permanent by Title V Legislation: 22 Co-signers to the Alaska Tribal Health Compact; Tribal authority delegated through Authorizing Resolutions (2000)  Funding Agreements are entered into by a Tribe or Co-Signer on behalf of member Tribes  Foundation is Respect for Strong Government-to-Government Relationship

9.  Alaska Tribal Caucus Structure:  All co-signers are members  Election of Co-lead negotiators : one Tribal Governance Leader, one Administrative Leader  ANHB serves as facilitator  Sets Agenda for Compact Negotiations  Caucuses (Tribal & Federal)  Review of Common Open Items Issues & Updates  Pre-negotiations – new issues & new co-signers  Common Negotiations – Preserves Tribal Right to Opt out of commonly negotiated items  Individual Tribal Funding Agreement Negotiations (drawing to determine order)  Opportunity to share local concerns and issues  Negotiation of Tribal-specific terms, language & issues

10.  Co-signer Common Negotiations Cooperative Process  Tribal Shares Committee (Open to All Co-signers)  Legal Language Committee (Open to All Co-signers & Legal Counsel)  Open Tribal Discussion of National Issues of Importance to Co-signers  Open Items List Recorder: All Co-signers Agree on Documentation of Tribal Shares, Legal language, Issues among Co-signers  Agreement on Ground Rules  Decision making Process  Closed Caucus before Pre- & Final-negotiations & as needed  Co-signer discussion of Agency Lead Negotiator positions/decisions in other negotiations  General Agreement of Common Issues among Co-signers  Documentation & Agreement on Caucus position on Open Items List of Issues  Principles:  Shared Vision for the Greater Good  Do No Harm  Do Not Made Concessions which has potential to erode Tribal rights to Self Govern  Consensus Decision-making & Process for Conflict Resolution  Tribes retain right to opt out of commonly negotiated language during individual negotiations

11.  Alaska paved the way for Tribes to assume Area Office Assume non-residual programs, functions, services and activities  Transfer of Area pfsa’s to ANTHC radically changed relationship with Alaska Area Office  Role of Alaska Area Office shifted from providing health services to performing inherently federal functions, i.e., functions that cannot be contracted to Tribes under the ISDEAA.

12.  1994 – 274 Area FTEs/1,200 S/U FTEs2016 – 34 Area FTEs  Comprehensive state-wide programs including:  Alaska Native Medical Center  Office of Community Health Services  Office of Environmental Health & Engineering  Community Health Aide Training  Title III Self-Governance Demonstration Project prompted downsizing to pay Area Tribal Shares (RIF Avoidance & Budget)  1999 - ANMC & Area state-wide PSFAs Transferred to Tribal Management

13. The Mission of the Alaska Area Native Health Service, IHS is To Make Tribal Self-Determination Work for All.

14.  Assumptions created at the national level drove Area decisions (e.g., IT & centralization)  Tribal decisions also drive decisions about Area staffing and functions (e.g., T1 v T5, HR, procurement, & finance)  What functions are (really) inherently federal?  Budget constraints are more acute in the absence of 3 rd party revenues (Pay Act)  Statutory changes since 1994 affect ability to perform with existing model

15. ResidualTransitional “Residual”Buy-Back Surcharge OD - Executive Direction (inc. OGC Legal Counsel) OAPM – Acquisition & Property Management OEHE – Environmental Health & Engineering OFM – Financial Management OHR – Human Resources Administrative Support OEHE – Environmental Health & Engineering OFM – Financial Management OHR – Human Resources OTP – Office of Tribal Programs Administrative Support OFM – Financial Management DCPS – Commissioned Corps Personnel

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