The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
"Advisory council" means the governor's Indian health advisory council established in RCW 43.71B.020.
"Advisory plan" means the plan described in RCW 43.71B.030.
"American Indian" or "Alaska Native" means any individual who is: (a) A member of a federally recognized tribe; or (b) eligible for the Indian health service.
"Authority" means the health care authority.
"Board" means the northwest Portland area Indian health board, an Oregon nonprofit corporation wholly controlled by the tribes in the states of Idaho, Oregon, and Washington.
"Commission" means the American Indian health commission for Washington state, a Washington nonprofit corporation wholly controlled by the tribes and urban Indian organizations in the state.
"Community health aide" means a tribal community health provider certified by a community health aide program of the Indian health service or one or more tribes or tribal organizations consistent with the provisions of 25 U.S.C. Sec. 1616l, who can perform a wide range of duties within the provider's scope of certified practice in health programs of a tribe, tribal organization, Indian health service facility, or urban Indian organization to improve access to culturally appropriate, quality care for American Indians and Alaska Natives and their families and communities, including but not limited to community health aides, community health practitioners, behavioral health aides, behavioral health practitioners, dental health aides, and dental health aide therapists.
"Community health aide program" means a community health aide certification board for the state consistent with 25 U.S.C. Sec. 1616l and the training programs and certification requirements established thereunder.
"Fee-for-service" means the state's medicaid program for which payments are made under the state plan, without a managed care entity, in accordance with the fee-for-service payment methodology.
"Historical trauma" means situations where a community experienced traumatic events, the events generated high levels of collective distress, and the events were perpetuated by outsiders with a destructive or genocidal intent.
"Indian health care provider" means a health care program operated by the Indian health service or by a tribe, tribal organization, or urban Indian organization as those terms are defined in 25 U.S.C. Sec. 1603.
"Indian health service" means the federal agency within the United States department of health and human services.
"New state savings" means the savings to the state general fund that are achieved as a result of the centers for medicare and medicaid services state health official letter 16-002 and related guidance, calculated as the difference between (a) medicaid payments received from the centers for medicare and medicaid services based on the one hundred percent federal medical assistance percentage; and (b) medicaid payments received from the centers for medicare and medicaid services based on the federal medical assistance percentage that would apply in the absence of state health official letter 16-002 and related guidance.
"Reinvestment account" means the Indian health improvement reinvestment account created in RCW 43.71B.040.
"Reinvestment committee" means the Indian health improvement reinvestment committee established in RCW 43.71B.020(4).
"Tribal organization" has the meaning set forth in 25 U.S.C. Sec. 5304.
"Tribally operated facility" means a health care facility operated by one or more tribes or tribal organizations to provide specialty services, including but not limited to evaluation and treatment services, secure detox services, inpatient psychiatric services, nursing home services, and residential substance use disorder services.
"Tribe" means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native claims settlement act (43 U.S.C. Sec. 1601 et seq.) which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
"Urban Indian" means any individual who resides in an urban center and is: (a) A member of a tribe terminated since 1940 and those tribes recognized now or in the future by the state in which they reside, or who is a descendant, in the first or second degree, of any such member; (b) an Eskimo or Aleut or other Alaska Native; (c) considered by the secretary of the interior to be an Indian for any purpose; or (d) considered by the United States secretary of health and human services to be an Indian for purposes of eligibility for Indian health services, including as a California Indian, Eskimo, Aleut, or other Alaska Native.
"Urban Indian organization" means an urban Indian organization, as defined by 25 U.S.C. Sec. 1603.
[ 2020 c 256 § 102; 2019 c 282 § 2; ]
The governor's Indian health advisory council is established, consisting of:
The following voting members:
One representative from each tribe, designated by the tribal council, who is either the tribe's commission delegate or an individual specifically designated for this role, or his or her designee;
The chief executive officer of each urban Indian organization, or the urban Indian organization's commission delegate if applicable, or his or her designee;
One member from each of the two largest caucuses of the house of representatives, appointed by the speaker of the house of representatives;
One member from each of the two largest caucuses of the senate, appointed by the president of the senate; and
One member representing the governor's office; and
The following nonvoting members:
One member of the executive leadership team from each of the following state agencies: The authority; the department of children, youth, and families; the department of commerce; the department of corrections; the department of health; the department of social and health services; the office of the insurance commissioner; the office of the superintendent of public instruction; and the Washington health benefit exchange;
The chief operating officer of each Indian health service area office and service unit, or his or her designee;
The executive director of the commission, or his or her designee; and
The executive director of the board, or his or her designee.
The advisory council shall meet at least three times per year when the legislature is not in session, in a forum that offers both in-person and remote participation where everyone can hear and be heard.
The advisory council has the responsibility to:
Adopt the biennial Indian health improvement advisory plan prepared and amended by the reinvestment committee as described in RCW 43.71B.030 no later than November 1st of each odd-numbered year;
Address current or proposed policies or actions that have tribal implications and are not able to be resolved or addressed at the agency level;
Facilitate better understanding among advisory council members and their support staff of the Indian health system, American Indian and Alaska Native health disparities and historical trauma, and tribal sovereignty and self-governance;
Provide oversight of contracting and performance of service coordination organizations or service contracting entities as defined in RCW 70.320.010 in order to address their impacts on services to American Indians and Alaska Natives and relationships with Indian health care providers; and
Provide oversight of the Indian health improvement reinvestment account created in RCW 43.71B.040, ensuring that amounts expended from the reinvestment account are consistent with the advisory plan adopted under RCW 43.71B.030.
The reinvestment committee of the advisory council is established, consisting of the following members of the advisory council:
With voting rights on the reinvestment committee, every advisory council member who represents a tribe or an urban Indian organization; and
With nonvoting rights on the reinvestment committee, every advisory council member who represents a state agency, the Indian health service area office or a service unit, the commission, and the board.
The advisory council may appoint technical advisory committees, which may include members of the advisory council, as needed to address specific issues and concerns.
The authority, in conjunction with the represented state agencies on the advisory council, shall supply such information and assistance as are deemed necessary for the advisory council and its committees to carry out its duties under this section.
The authority shall provide (a) administrative and clerical assistance to the advisory council and its committees and (b) technical assistance with the assistance of the commission.
The advisory council meetings, reports and recommendations, and other forms of collaboration described in this chapter support the tribal consultation process but are not a substitute for the requirements for state agencies to conduct consultation or maintain government-to-government relationships with tribes under federal and state law.
[ 2019 c 282 § 3; ]
With assistance from the authority, the commission, and other member entities of the advisory council, the reinvestment committee of the advisory council shall prepare and amend from time to time a biennial Indian health improvement advisory plan to:
Develop programs directed at raising the health status of American Indians and Alaska Natives and reducing the health inequities that these communities experience; or
Help the state, the Indian health service, tribes, and urban Indian organizations, statewide or in regions, improve delivery systems for American Indians and Alaska Natives by increasing access to care, strengthening continuity of care, and improving population health through investments in capacity and infrastructure.
The advisory plan shall include the following:
An assessment of Indian health and Indian health care in the state;
Specific recommendations for programs, projects, or activities, along with recommended reinvestment account expenditure amounts and priorities for expenditures, for the next two state fiscal bienniums. The programs, projects, and activities may include but are not limited to:
The creation and expansion of facilities operated by Indian health services, tribes, and urban Indian health programs providing evaluation, treatment, and recovery services for opioid use disorder, other substance use disorders, mental illness, or specialty care;
Improvement in access to, and utilization of, culturally appropriate primary care, mental health, and substance use disorder and recovery services;
The elimination of barriers to, and maximization of, federal funding of substance use disorder and mental health services under the programs established in chapter 74.09 RCW;
Increased availability of, and identification of barriers to, crisis and related services established in chapter 71.05 RCW, with recommendations to increase access including, but not limited to, involuntary commitment orders, designated crisis responders, and discharge planning;
Increased access to quality, culturally appropriate, trauma-informed specialty services, including adult and pediatric psychiatric services, medication consultation, and addiction or geriatric psychiatry;
A third-party administrative entity to provide, arrange, and make payment for services for American Indians and Alaska Natives;
Expansion of suicide prevention services, including culture-based programming, to instill and fortify cultural practices as a protective factor;
Expansion of traditional healing services;
Development of a community health aide program, including a community health aide certification board for the state consistent with 25 U.S.C. Sec. 1616l, and support for community health aide services;
Health information technology capability within tribes and urban Indian organizations to assure the technological capacity to: (A) Produce sound evidence for Indian health care provider best practices; (B) effectively coordinate care between Indian health care providers and non-Indian health care providers; (C) provide interoperability with state claims and reportable data systems, such as for immunizations and reportable conditions; and (D) support patient-centered medical home models, including sufficient resources to purchase and implement certified electronic health record systems, such as hardware, software, training, and staffing;
Support for care coordination by tribes and other Indian health care providers to mitigate barriers to access to care for American Indians and Alaska Natives, with duties to include without limitation: (A) Follow-up of referred appointments; (B) routine follow-up care for management of chronic disease; (C) transportation; and (D) increasing patient understanding of provider instructions;
Expanded support for tribal and urban Indian epidemiology centers to create a system of epidemiological analysis that meets the needs of the state's American Indian and Alaska Native population; and
Other health care services and public health services that contribute to reducing health inequities for American Indians and Alaska Natives in the state and increasing access to quality, culturally appropriate health care for American Indians and Alaska Natives in the state; and
Review of how programs, projects, or activities that have received investments from the reinvestment account have or have not achieved the objectives and why.
[ 2019 c 282 § 4; ]
The Indian health improvement reinvestment account is created in the custody of the state treasurer. All receipts from new state savings as defined in RCW 43.71B.010 and any other moneys appropriated to the account must be deposited into the account. Expenditures from the account may be used only for projects, programs, and activities authorized by RCW 43.71B.030. Only the director of the authority or the director's designee may authorize expenditures from the account. The account is subject to allotment procedures under chapter 43.88 RCW, but an appropriation is not required for expenditures.
Beginning November 1, 2019, the new state savings as defined in RCW 43.71B.010, less the state's administrative costs as agreed upon by the state and the reinvestment committee, shall be deposited into the reinvestment account. With advice from the advisory council, the authority shall develop a report and methodology to identify and track the new state savings. Each fall, to assure alignment with existing budget processes, the methodology selected shall involve the same forecasting procedures that inform the authority's medical assistance and behavioral health appropriations to prospectively identify new state savings each fiscal year, as defined in RCW 43.71B.010.
The authority shall pursue new state savings for medicaid managed care premiums on an actuarial basis and in consultation with tribes.
[ 2019 c 282 § 5; ]
This chapter may be known and cited as the "Washington Indian health improvement act."
[ 2019 c 282 § 6; ]
The legislature finds that:
As set forth in 25 U.S.C. Sec. 1602, it is the policy of the nation, in fulfillment of its special trust responsibilities and legal obligations to American Indians and Alaska Natives, to:
Ensure the highest possible health status for American Indians and Alaska Natives and to provide all resources necessary to effect that policy;
Raise the health status of American Indians and Alaska Natives to at least the levels set forth in the goals contained within the healthy people 2020 initiative or successor objectives; and
Ensure tribal self-determination and maximum participation by American Indians and Alaska Natives in the direction of health care services so as to render the persons administering such services and the services themselves more responsive to the needs and desires of tribes and American Indian and Alaska Native communities;
According to the northwest tribal epidemiology center and the department of health, American Indians and Alaska Natives in the state experience some of the greatest health disparities compared to other groups, including:
Disproportionately high rates of premature mortality due to chronic diseases and unintentional injury;
Disproportionately high rates of asthma, coronary heart disease, hypertension, diabetes, prediabetes, obesity, dental caries, poor mental health, youth depressive feelings, cigarette smoking and vaping, and cannabis use;
A drug overdose death rate in 2016 in this state that is three times higher than the national American Indian and Alaska Native rate and has increased thirty-six percent since 2012 and almost three hundred percent since 2000 in contrast to a relatively stable rate for the state overall population. Over seventy-two percent of these overdose deaths involved an opioid;
A suicide mortality rate in this state that is more than one and four-fifths times higher than the rate for non-American Indians and Alaska Natives. Since 2001, the suicide mortality rate for American Indians and Alaska Natives in this state has increased by fifty-eight percent which is more than three times the rate of increase among non-American Indians and Alaska Natives. Nationally, the highest suicide rates among American Indians and Alaska Natives are for adolescents and young adults, while rates among non-Hispanic whites are highest in older age groups, suggesting that different risk factors might contribute to suicide in these groups; and
A rate of exposure to significant adverse childhood experiences between 2009 and 2011 that is nearly twice the rate of non-Hispanic whites;
These health disparities are a direct result of both historical trauma, leading to adverse childhood experiences across multiple generations, and inadequate levels of federal funding to the Indian health service;
Under a 2016 update in payment policy from the centers for medicare and medicaid services, the state has the opportunity to shift more of the cost of care for American Indian and Alaska Native medicaid enrollees from the state general fund to the federal government if all of the federal requirements are met;
Because the federal requirements to achieve this cost shift and obtain the new federal funds place significant administrative burdens on Indian health service and tribal health facilities, the state has no way to shift these costs of care to the federal government unless the state provides incentives for tribes to take on these administrative burdens; and
The federal government's intent for this update in payment policy is to help states, the Indian health service, and tribes to improve delivery systems for American Indians and Alaska Natives by increasing access to care, strengthening continuity of care, and improving population health.
The legislature, therefore, intends to:
Establish that it is the policy of this state and the intent of this chapter, in fulfillment of the state's unique relationships and shared respect between sovereign governments, to:
Recognize the United States' special trust responsibility to provide quality health care and allied health services to American Indians and Alaska Natives, including those individuals who are residents of this state; and
Implement the national policies of Indian self-determination with the goal of reducing health inequities for American Indians and Alaska Natives;
Establish the governor's Indian health advisory council to:
Adopt a biennial Indian health improvement advisory plan, developed by the reinvestment committee;
Address issues with tribal implications that are not able to be resolved at the agency level;
Provide oversight of the Indian health improvement reinvestment account; and
Draft recommended legislation to address Indian health improvement needs including, but not limited to, crisis coordination between Indian health care providers and the state's behavioral health system;
Establish the Indian health improvement reinvestment account in order to provide incentives for tribes to assume the administrative burdens created by the federal requirements for the state to shift health care costs to the federal government;
Appropriate and deposit into the reinvestment account all of the new state savings, subject to federal appropriations and less agreed upon administrative costs to maintain fiscal neutrality to the state general fund;
Require the funds in the reinvestment account to be spent only on costs for projects, programs, or activities identified in the advisory plan;
Address the ongoing suicide and addiction crisis among American Indians and Alaska Natives by:
Including Indian health care providers among entities eligible to receive available resources as defined in RCW 71.24.025 for the delivery of behavioral health services to American Indians and Alaska Natives;
Strengthening the state's behavioral health system crisis coordination with tribes and Indian health care providers by removing barriers to the federal trust responsibility to provide for American Indians and Alaska Natives; and
Recognize the sovereign authority of tribal governments to act as public health authorities in providing for the health and safety of their community members including those individuals who may be experiencing a behavioral health crisis.
[ 2020 c 256 § 101; 2019 c 282 § 1; ]