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Washington State Dental Association

My Grieving Chickasaw Heart

    This year’s reincarnation of the midlevel provider bill has an interesting twist. HB 1027 (Appleton, Gregerson, S. Hunt, Cody, Moscoso, Buys) would allow midlevel providers to practice in federally-recognized tribal dental clinics.
    The bill states, in brief, that American Indians are disproportionately affected by oral health disparities resulting in an access issue and backlog of dental treatment. They believe the tribes are in the best position to design their own dental programs and want “to explore options for the use of trained/certified expanded function personnel in order to increase oral health care services in tribal communities.”
 Further, a dental health aide or therapist may perform only those procedures permitted under standards adopted by the federal Community Health Aide Program (CHAP) or a higher limit set by the tribe.
    CHAP is the Alaska model. Dental Therapists are under a dentist’s general supervision. That supervision can be off site. There is a caveat that the supervising dentist can set limits to the therapist’s scope. Those limits are far more generous than most Washington dentists are comfortable with.
    This bill grieves my Chickasaw dentist heart, because the authors are ever so right and ever so wrong. Let’s talk.
    4.1 million Americans self-identify as being Native American. That is 1.5 percent of the U.S. population. Contrary to U.S Representative Paul Gosar, DDS’s recent comment, Native Americans are not “wards of the Federal Government.” The United States Constitution recognizes Indian Nations as sovereign and self-governing. Our founding fathers treated indigenous tribes as “foreign governments” according to the National Congress of American Indians’ An Introduction to Indian Nations in the United States. Native Americans are not like any other minority. We are indigenous people in a “fundamental contract between Indian Nations and the United States.” The services Native Americans receive are NOT welfare and not need-based. Services are provided by extensive treaty negotiations in exchange for millions of acres of ceded land. Interestingly, Indian lands currently comprise 5 percent of our nation’s total land area and contain 10 percent of our energy reserves…and copper. Don’t forget copper, and salmon, and lumber and…
    There are approximately 566 federally-recognized tribes in the United States, located in 33 states. (Tribes can be added or dropped) Washington State has 29 recognized tribes. The rules, laws and case studies for Native American Sovereignty are complex. Technically, the tribes in our state could hire therapists right this minute. The catch is, Medicaid cannot pay a midlevel without state authorization. 
    So what are the problems facing Indian Country? I shouldn’t, but I do feel a bit sorry for U.S governmental agencies trying to put an often under-funded, one-size-fits-all Band-Aid on completely different tribes facing completely different problems. The pro-midlevel Kellogg Foundation is active in Indian Land. They report that the Pine Ridge Reservation is larger than the state of Connecticut and has three clinics employing nine dentists for 28,797 people. That is clearly not working.
    Some tribes, like mine, have worked hard to build casinos and other businesses to grow billions almost entirely without debt. Rural tribes cannot build giant casinos and other industries to help take care of their own. No one would come. Unemployment statistics on reservations run from a reported 13.6 to 80 percent. One fourth of Native Americans live in poverty with few resources to pull themselves out.
    In spite of the Indian Health Services extensive prevention measures, Early Childhood Caries (ECC) continue to be a serious problem for Native Americans. The ADA 2010 Symposium on ECC in American Indian and Alaska Native Children states that for many AI/AN communities, ECC is approximately 300 percent higher than the U.S. all races prevalence.
    The adult population has a high edentulous rate. Some tribes are rife with periodontal disease that is thought to correlate with the concurrent high rate of diabetes in many Native Americans. 
    In 2012, the Swinomish Tribe received the Children’s Alliance’s Voices for Children Advocacy Award for their efforts in supporting a midlevel bill. Swinomish Programs Administrator John Stephens stated, “We are overcoming generations of poor health and poor experiences…” In 2012, The Swinomish Tribe reported a five- to six-week wait time for appointments and “more need than we can provide care for.”
    There is an obvious and truly great need for improved dental care in Indian Country. But that does not automatically mean a midlevel is the answer. The ADA has released at least six reports questioning the economic viability of midlevel providers. The ADA ‘s systemic review in 2013 found that surgical midlevel providers do not reduce the overall rates of dental decay. It’s just not that simple. 
    To help address these challenges and help identify a long-term solution with Indian Country, the WSDA has hired a firm led by Casey Sixkiller, a Seattle-raised, Washington, DC-based, Cherokee Nation citizen and public policy consultant. He and his partners have extensive experience working with and on behalf of tribes to help solve problems. We hope that with his help, we can reach out to individual tribes in Washington State and see if we can work together to find effective solutions to increase access to dental care in Indian Country and to improve oral health. 
    Kellogg points out that Native Americans want to be treated by their own. Who wouldn’t, especially considering the huge trust issues that have grown over the centuries? Credit must go to the University of Washington Partners In Diversity who has for many years actively sought and helped qualified American Indian students on their journey to become dentists. Talk to UWPID member Dr. Jim McGraw. He is passionate about helping these students and will leave a lasting legacy in Indian Country.
    The thing that kills my dental soul is that I do not want to continue the past, slippery slope of poor care for my people or any other. Article Three of the Northwest Ordinance of 1789 states- “The utmost good faith shall always be observed toward the Indians; their land and property shall never be taken away from them without their consent…but laws founded in justice and humanity shall from time to time be made, for preventing wrong to them.” Well, that didn’t work. It’s time to do something right for Native Americans. 








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