1. DHAT’s and Tribal Sovereignty A Snapshot of Problems and Potentials Northwest Portland Area Indian Health Board Presentation

2. Swinomish-Upper Skagit Dental Clinic-Background The Swinomish Indian Tribal Community is the federally recognized entity comprised of the aboriginal Swinomish, Lower Skagit, Kikialus and Samish tribes. The Swinomish Indian Tribal Community has a 10 square mile reservation, created as a result of the Treaty of Point Elliot in 1855, which was signed in exchange for giving up land title to over 500 square miles of Northwest Washington

3. Location of Reservations in the State of Washington

4. Swinomish Canoe Family

5. Swinomish Dental Clinic Systems Overview Part of the Indian Health System of Dental Clinics There are 29 I/T/U Dental Clinics in the State of Washington In 2012 Indian Health Service I/T/U’s are currently serving 106,372 Official Users out of In 2012 Indian Health Service I/T/U’s are currently serving 106,372 Official Users out of 192,114 Native Americans living in the State. Only 55% of Native Americans have access or are accessing these Clinics Clinics are operated directly by the Indian Health Service or by the Tribes or Urban Indian organizations through Contracts or Self Governance Compacts The SITC Dental Clinic is operated by the Swinomish Indian Tribal Community through a Self Governance Compact

6. Oral Health in Indian Country American Indian and Alaska Native children between the ages of 2 and 4 have the highest rate of decay in the United States—five times the national average… -U.S. Department of Health and Human Services From the Last National Oral Health Survey in 1999

7. Old I.H.S. Provided Dental Trailer Swinomish Indian Tribal Community

8. Swinomish Dental Clinic after Self Governance -Exercising Sovereignty

9. Swinomish Dental Clinic Typical small I/T/U Dental Clinic within the Portland Area Office and located in northwest Washington state Current Staffing consists of 1 Full time Dentist, 1 Part time Dentist, 1 Dental Hygienist, 2 Dental Assistants, 1 Support staff

10. Indian Health Service Overview General U.S. population has an average of 1,500 Patients per Provider/Dentist Typical I.H.S. Provider/Dentist availability is 2,800 Patients per Provider Typical I.H.S. Provider is expected to service 86% more patients than the U.S. Dental average

11. Indian Health Service User Count and Service Deficiencies Indian Health Service provides only 22% of current program funding from Dental Program funds –balance comes from the Tribal general fund and 3 rd Party billing, mainly Medicaid Program is dependent upon soft money from 3 rd party collections, especially Medicaid reimbursements Indian Health Service is a dramatically underfunded system, both in how it counts Users and how Congress funds its operations. Rule of thumb-Indian Health Service gets 60% of Level of Need Funding, actually a little lower in I.H.S.

12. ...BECAUSE WE’VE ALWAYS DONE IT THAT WAY ! Why no DHAT’s in the lower 48 states? “Organized dentistry does agree with the proponents of DHAT on one issue: some people with significant oral health needs do not have access to dental care, and something needs to be done.... The ADA’s proposed solutions have been both vague and irrelevant to the access barriers, and they have not be followed up with action.”

13. Solution Provided by DHAT Procedure review for FY 2012 and 2013 for Swinomish- Upper Skagit Dental Clinic showed that over 50% of procedures and services could have been provided by trained Dental Health Aide Therapists under the Alaska model DHAT Licensure Authorization would help I/T/U Clinics fill a huge gap in service demand across the Indian Health Service system for Native patients Work Force Development based in the Community assures longer term benefits

14. Swinomish People in Regalia for Canoe Journey Welcome July 2011

15. Dental Capacity Pyramid Swinomish Upper Skagit Dental Clinic with Patient Flow with DHAT’s as a Vital Piece ` Other Dental Support Staff Dental Assistants Dental Health Aide Therapist Dental Hygienist Dentist

16. Dental Capacity Pyramid Swinomish Upper Skagit Dental Clinic with Patient Flow without DHAT’s as a Vital Piece ` Other Dental Support Staff Dental Assistants Dental Hygienist Dentist

17. Medical Care System in the 1970’s -Imagine when Primary Care could only be provided by an MD, ie No Physician’s Assistants Or Nurse Practitioners- In the 21 st Century the Primary Care System is reliant on Mid-Level Providers -Dental Practices are operating under the similar model that Medical was under in the 1970’s

18. Alaska DHAT Scope of Practice DHAT[----]-------------------------------------------------- < 50 Billable Procedures DDS[------------------------------------------------------] >500 Billable Procedures Source: Dr. Louis Fiset, BA-DDS- University of Washington

19. Alaska Native Oral Health Solution : DHATS Providers with cultural awareness and understanding of community needs Provide routine care – overburdened Dentists can now prioritize complex cases Saving health systems money Creating a new educational/employment field for AI AN students Improved pediatric care Alleviate burden IHS faces Alaskan DHAT’s in 10 years are the Most studied health professional in the history of oral medicine!

20. Why a 2 Year DHAT Program Competency reached with 2 years for the <50 Billable Procedures Curriculum fits a 2 Year structure Training Costs lower Graduates return to their Communities sooner Cost of social commitments for trainees lower

21. Decay of Tribal Sovereignty under the ACA Via lobbying from groups as the American Dental Association, The Affordable Care Act Title X Reauthorization of the Indian Health Care Improvement Act stipulates: Via lobbying from groups as the American Dental Association, The Affordable Care Act Title X Reauthorization of the Indian Health Care Improvement Act stipulates: Community Health Aide Program “shall exclude dental health aide thera­pist services from services covered under the program.” UNLESS – “an Indian tribe or tribal organization lo­cated in a State (other than Alaska) in which the use of dental health aide therapist services or midlevel dental health provider services is authorized under State law to supply such services in accordance with State law.” UNLESS – “an Indian tribe or tribal organization lo­cated in a State (other than Alaska) in which the use of dental health aide therapist services or midlevel dental health provider services is authorized under State law to supply such services in accordance with State law.” With Thanks to Dr. Terry Batliner

22. Worcester v. Georgia (1832)-Indian Nations are distinct political communities with inherent sovereign rights free from interference from states Worcester v. Georgia (1832)-Indian Nations are distinct political communities with inherent sovereign rights free from interference from states Indian reservations borders are protective barriers from states and their citizens Indian reservations borders are protective barriers from states and their citizens Clearly established that state law and jurisprudence did not reach into the confines of a reservation Clearly established that state law and jurisprudence did not reach into the confines of a reservation The Affordable Care Act has allowed the legitimacy of Indian Nations as self-determining governments to be chipped away With Thanks to Dr. Terry Batliner DHATS: A Legal and Political Health Issue

23. Swinomish Dental Clinic Our analysis shows that over 50% of procedures could have been provided by DHAT’s rather than a Dentist Analysis shows that the same procedures could have been covered with 50% Personnel cost savings-replace Dentist time with DHAT time Analysis shows that Dentist time could have been significantly re-oriented to more complex Dentist only procedures, ie such as prosthodontic, advanced restorative and surgical procedures, etc..

24. Our Current Political Solution Swinomish Tribal Community worked with the Northwest Portland Area Indian Health Board and the Washington State House and Senate to craft a Tribal Specific DHAT Authorization Bill-HB 2466 consistent with the limitations under the ACA http://apps.leg.wa.gov/documents/billdocs/2013- 14/Pdf/Bill%20Reports/House/2466%20HBA%20CDHT%2014.pdf

25. Thanks for Listening and Appreciate your Time John Stephens Programs Administrator Swinomish Indian Tribal Community jstephens@swinomish.nsn.us 360-466-7216