April 6, 2018
Mapping the Trust Responsibility for
Public Health Services

The federal government took on the obligation to provide healthcare, public health and other services to Tribes (the federal Trust Responsibility) as part of the treaties negotiated with Tribes. Those solemn promises were later re-affirmed in Supreme Court case law, legislation and executive orders. Although certain federal agencies have been specially tasked with upholding the Trust Responsibility (like the Indian Health Service), this duty runs from the entire federal government to the Tribes. 

In mapping the Trust Responsibility for public health (which emphasizes disease prevention and health promotion), a number of operating divisions in the US Department of Health and Human Services (HHS) stand out and are important potential sources of funding and support for Tribal public health and community health programs.

Indian Health Service
The Indian Health Service (IHS) is responsible for providing federal health services to American Indians and Alaska Natives (AI/AN) with the goal "to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level." IHS provides health services for AI/AN people through direct and contracted services. Despite the mission and charge of the agency, IHS has been chronically underfunded and struggles to provide all of the health care services needed. As a result, little funding is available for disease and injury prevention programs. However, where those programs do exist, we see success stories that can serve as models for the nation.

Community Health Representatives (CHR)
The CHR program has been critical in providing access to healthcare, wellness programs, and public health education in Tribal communities. CHR's are culturally competent health professionals who provide a variety of public health services, including increasing access to health care through transportation of people and health products, educating the community on health and wellness, and providing case management for a variety of health conditions, including assisting people in monitoring chronic diseases.

CHR Budget Fast Fact:
CHR's are an important investment in Tribal public health, however, the Fiscal Year (FY) 2019 President's Budget recommends that the CHR program be eliminated. Tribal Leaders across Indian Country have shared the loss of this program would reduce people's access to health services and wellness programs, and reduce their ability to prevent poor health outcomes.

Special Diabetes Program for Indians (SDPI)
An extremely successful program in Indian Country, SDPI works to reduce the rate of diabetes in AI/ANs, which is currently the highest of any race/ethnicity in the US. Since the program begin in 1997, SDPI programs have improved wellness and chronic disease prevention across Indian Country. Specifically, diabetic eye disease rates have decreased 50% and kidney failure rates have decreased 54%, the highest decrease of any race/ethnicity. Approximately 780,000 Native people are served by this program each year.

SDPI Budget Fast Fact:
SDPI is currently funded through FY 2019 at $150 million per year. Tribal advocates have called for a long term renewal and an increase in SDPI funding, which has remained at the same level since 2004. However, the President's budget request for FY 2019 proposes SDPI move from "mandatory" funding to "discretionary," which would allow Congress to make changes to the funding annually.

Centers for Disease Control and Prevention (CDC)
The CDC is the largest national public health agency in the U.S., whose mission is "...to protect America from health, safety, and security threats, both foreign and in the U.S." To achieve this goal, CDC aims to: detect and respond to new and emerging health threats; tackle the biggest health problems causing death and disability; put science and advanced technology into action to prevent disease; promote healthy and safe behaviors, communities and environment; develop leaders and train the public health workforce; and take the health pulse of our nation. 

CDC offers some important public health resources to Indian Country, including: workforce support (for example - CDC assignees to Tribal governments and organizations), data that can be used to make public health decisions, and grant funding, including the Good Health and Wellness for Indian Country (GHW).

Funded through CDC's National Center for Chronic Disease Prevention and Health Promotion, GHW grants go out to 12 Tribes, 11 Tribal Organizations and all 12 Tribal Epidemiology Centers. The grants support a variety of health strategies including reducing commercial tobacco use, increasing breastfeeding, revitalizing healthy traditional foods, and providing patient / community health education, and public health surveillance (Public health surveillance involves tracking, or monitoring disease and other health conditions, is the cornerstone of public health practice. CDC has defined public health surveillance as the regular collection, analysis, use, and sharing of data to prevent and control disease and injury).

Good Health and Wellness in Indian Country Budget Fast Fact:
For FY 2018, GHWP will receive just under 16 million dollars. This funding has been an important resource for Indian Country, and one that many Tribal advocates wish to see expanded so that more Tribes can get funding. Despite the need for greater CDC investment in Tribal public health, the President's FY 2019 budget request zeros out this funding.

Substance Abuse and Mental Health Services Administration (SAMSHA)
SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. SAMHSA works towards this goal by increasing awareness and understanding of mental and substance use disorders; promoting emotional health and wellness; promoting prevention of substance abuse and mental illness; increasing access to effective treatment; and supporting recovery.

SAMHSA offers support for Tribal public health and behavioral health with: grants and cooperative agreements for Tribal and Tribal organizations; a specialized team that coordinates across the agency to increase AI/AN access to resources and services; a Tribal Training and Technical Assistance (TTA) Center that is available to support Native communities build capacity and plan and implement programs; and a National Tribal Behavioral Health Agenda (TBHA), which supports the development, coordination, and funding of programs and resources for Tribes. 

Block Grant Fast Fact:
SAMHSA's Community Mental Health Services Block Grant is a substantial and sustained investment in behavioral health in the US and funds all 50 states, 6 territories, Puerto Rico, the U.S. Virgin Islands, and Washington, DC. The President's FY 2019 budget proposed $562,571,000 for the program. Unfortunately, the funding excludes Tribal Nations as eligible entities, despite the great level of need seen in Indian Country.

Using the Map, Taking Next Steps
This provides just a small glimpse of the community and public health work that US Department of Health and Human Services does through some of its operating divisions. Advocates across Indian Country have called on not only IHS, but all of its sister agencies to assist in carrying out the Trust Responsibility for health and public health services to Tribes. As we have seen policy makers and federal agencies begin to respond, we know much more work is needed.

To Learn More
Please join NIHB in the final event of National Tribal Public Health Week with a webinar on:
Advocacy 101: Gaining Congressional Support for Tribal Public Health
When: Friday, April 6, 2:00 pm - 3:00 pm Eastern time
To register, visit here.
How can Congress support Tribal public health? By creating a system where there can be a substantial, sustained, and scaled investment in public health for Indian Country with existing funding streams set aside for Tribes. Learn more about this important topic, advocacy, and how you can get involved - presented by NIHB's Congressional Relations staff. 

National Indian Health Board | www.nihb.org
910 Pennsylvania Avenue SE | Washington, DC 20003 | Phone: 202-507-4070
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