When Healthcare Funding on Reservations Dries Up

The Penobscot Indian Reservation, established through a settlement with the state of Maine in 1980, begins about 12 miles north of Bangor at the foot of a bridge that stretches across the Penobscot River. Technically, the boundaries of the tribal territory stretch in a thin line 60-odd miles up the river from there. But the reservation’s technical area is tiny: just over seven square miles. Last year a Maine appeals court ruled that only the islands, and not the water surrounding them, belonged to the tribe.

On Indian Island, where tribal infrastructure is housed, there is a small museum—shuttered on a Monday morning in May—and a beige warehouse that’s home to one of the oldest high-stakes bingo games run by an indigenous nation. A few yards down the road, the Penobscot health department, a low building with a playground out back, provides family services, substance abuse counseling, and dental services. The four chairs in its bright, air-conditioned clinic waiting area are all full. The lights behind the window where a receptionist would sit are turned off.

In this small compound, Penobscot tribal members can receive a variety of services from a staff of about two dozen. There is drug counseling and a nutritionist “diabetes coordinator” on staff, as well as two nurses, a doctor, and a dentist. According to Census data, a little over 600 people live on the Penobscot reservation, but the tribe says this tiny health department saw 2,505 individual patients in the last fiscal year.

In the ‘70s, the Penobscot Nation and the Department of Justice sued the state of Maine, compiling documentation laying claim to about two-thirds of the state’s land on behalf of the state’s tribes. The out-of-court reparations settlement of some $81.5 million was used to purchase some of these lands. But provisions in the Maine Indian Claims Settlement Act limit the tribes’ sovereignty, and the relationship between the government and the tribes is so strained that in 2015 tribal leaders withdrew their representatives from the state legislature. In recent years health care initiatives intended to decrease the disparities between indigenous populations and the rest of the state have been routinely implemented before being hastily shut down.

The United States government subsidizes health care for federally recognized tribes, but Congress routinely underfunds Indian Health Services, an agency within the Department of Health and Human Services. And small tribal health departments like the one on the Penobscot reservation are already understaffed: When I started contacting native health departments in Maine, I found that a handful of numbers were disconnected. Numerous messages went unreturned. Many messages sent to official email addresses at Maine Indian Health Services immediately bounced back.

In the last few years, several positions intended to improve the health of Maine’s tribes have been eliminated, even as tribal members are twice as likely to suffer from some chronic diseases like diabetes than the rest of the state. And further changes that may soon be coming to Maine, and the country at large, worry people like Candy Henderly, the director of the Penobscot Nation Health Department. Governor Paul LePage, one of the country’s most vocal supporters of work requirements for Medicaid funding, could force tribes to submit to administrative hurdles in order to retain already thin funding. It’s a “strain on an already strained resources,” Henderly tells me on the phone.

If you’re interested in the current administration’s attitudes towards social services, Maine is a good place to visit.

In January, the Trump administration told tribes nationwide that it would not exempt indigenous populations from sweeping changes to federal health care programs, including Medicaid work requirements, endangering already thinly funded systems and raising serious questions about the independence of supposedly sovereign nations. While some states, like Utah, have preemptively exempted recognized tribes from such mandates, the Trump administration has suggested federal exemptions would bring up civil rights issues, suggesting an interpretation that considers tribes a race rather than independent governments. On many reservations, unemployment is more than twice as high as the national average, and life expectancy for tribal members is generally much lower—in some places, it’s lower by about 20 years.

Ron Allen, a member of the Tribal Member Advisory board, wrote to the head of the Department of Health and Human Services earlier this year: “Without supplemental Medicaid resources, the Indian health system will not survive.” Penobscot Nation chief Kirk Francis is concerned that his members, unable to qualify for other health care, might flood an already overwhelmed system.

Maine’s five tribal health centers, most of which are concentrated in the northernmost reaches of the state, provide free healthcare to around 10,000 members of Maine’s four recognized tribes. According to data compiled by a group of senators last month, Medicaid billing accounts for about half of all patients in some tribally operated health systems, and 40 percent of patients at federally operated Indian Health Service centers. About one-quarter of all these indigenous Americans are receiving care at least partially funded by Medicaid. This past September, the state of Maine pulled some of its last direct funding for tribal health care.

If you’re interested in the current administration’s attitudes towards social services, Maine is a good place to visit: Governor LePage, a talk radio fixture and the former manager of a chain of discount stores, has described himself as “Donald Trump before Donald Trump.”

LePage, like the president, is fond of styling his bigoted outbursts as an opposition to “political correctness.” In 2016, he left a long voicemail message for a female Democratic opponent, telling her “I’m after you” after she criticized his assertion that “90 percent” of drug dealers in his state are “black or Hispanic.” He has also lobbied to re-christen “Medicaid” as “welfare” in state legislation, as LePage is very much like the president in his unwavering belief, bolstered by his own mythologically amplified success in business, that people who use social services are ungrateful drags on the system.

Years before the Trump administration rewrote its Health and Human Services guidelines to favor work requirements for Medicaid recipients, and long before individual states began to put those requirements on the books, LePage implemented 20-hour-a-week work requirements for food stamps after three months of use. For years, he has proposed that Medicaid recipients disclose property records and financial assets, as well as pay monthly premiums and fees for emergency room visits that are deemed “non-emergency.” The governor is currently being sued for refusing to pass the Medicaid expansion approved by voters.

Meanwhile, in the years since work requirements were implemented for food stamp recipients in his state, federal data shows measurements for “food insecurity” have increased by almost 10 percent. LePage’s health care policy has also been ruinous for the state’s handful of native tribes, who have been dropped from nearly all other sources of support.

When care is deferred long enough they’ll either pay out of pocket or start looking for other ways to mitigate the pain.

Last year, LePage abruptly cut ties between Maine’s tribes and a state-funded effort to combat major health problems, like opioid addiction and chronic illness management. (Nationwide, native Americans have among the highest overdose rates of any group.) In 2011, Maine tribes were also dropped from a federally funded program to provide home visits to new families. And in 2015, LePage signed an executive order cutting out the state’s four tribes’ right to be consulted on major policy changes that affect them: Even now, people like Henderly and her clinical staff don’t know exactly what the state is up to, since “there isn’t a formalized set of criteria” for how tribes and the state government consult.

Right now, Henderly says, her department does the sorts of things you would expect any other federally subsidized health care center serving a large population to do: prenatal care, the filling of prescriptions, preventative medicine. The problem, as she sees it, will be when she and her staff are forced to provide the same level of care with far less money to work with.

And the Penobscot system, like other tribal health care systems in Maine, isn’t equipped to perform surgeries or other, more complicated procedures. The way the system works now, she says, patients are referred to outside specialists, which is funded through the Indian Health Services program. Already, patients are put on waiting lists for, say, knee surgery, and when they’re deferred long enough and are in pain they’ll either have to pay out of pocket or start looking for ways to mitigate their physical distress.

Henderly worries that less funding and longer wait times “can actually can contribute to the opioid crisis…What you end up doing is accessing long-term pain management and waiting for those services.” That last bit of state funding that was cut a few years ago had been intended to expand drug counseling for the tribes.

And if the Medicaid work requirements are enacted in Maine, she says, the tribe will have to expend more resources to comply with whatever the state requires. The administrative burden of enrolling every able-bodied tribal resident in a work program, likely created by the tribe, will be immense.

And that’s just to keep the reimbursements they’re already getting, which aren’t really enough, she points out. Not after virtually every other source of support has been pulled.