ALASKA STATE LEGISLATURE  HOUSE SPECIAL COMMITTEE ON TRIBAL AFFAIRS  April 15, 2025 8:01 a.m. DRAFT MEMBERS PRESENT Representative Maxine Dibert, Chair Representative Ashley Carrick Representative Robyn Niayuq Burke Representative Andi Story Representative Jubilee Underwood Representative Elexie Moore MEMBERS ABSENT  Representative Rebecca Schwanke COMMITTEE CALENDAR  PRESENTATION: TRIBAL HEALTH CONTRACTING~ COMPACTING & CONSULTING - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER ALBERTA UNOK, President, CEO Alaska Native Health Board Anchorage, Alaska POSITION STATEMENT: Co-presented the PowerPoint, titled "Alaska Tribal Health Compacting." MONIQUE MARTIN, Vice President Intergovernmental Affairs Alaska Native Health Consortium Anchorage, Alaska POSITION STATEMENT: Co-presented the PowerPoint, titled "Alaska Tribal Health Compacting." JACOLINE BERGSTROM, Executive Director Health Services Tanana Chiefs Conference Fairbanks, Alaska POSITION STATEMENT: Co-presented the PowerPoint, titled "Alaska Tribal Health Compacting." ACTION NARRATIVE 8:01:44 AM CHAIR MAXINE DIBERT called the House Special Committee on Tribal Affairs meeting to order at 8:01 a.m. Representatives Moore, Story, Carrick, and Dibert were present at the call to order. Representatives Underwood and Burke arrived as the meeting was in progress. ^PRESENTATION: Tribal Health Contracting, Compacting & Consulting PRESENTATION: Tribal Health Contracting, Compacting & Consulting    8:03:04 AM CHAIR DIBERT announced that the only order of business would be a presentation on tribal health contracting, compacting, and consulting. 8:03:58 AM ALBERTA UNOK, President, CEO, Alaska Native Health Board, introduced herself, sharing that she is a tribal citizen of the Native Village of Kotlik, located in the Yukon Kuskokwim region. 8:04:12 AM MONIQUE MARTIN Vice President, Intergovernmental Affairs, Alaska Native Health Consortium (ANTHC), introduced herself, sharing that she was born and raised in Wrangell, and she is a tribal member of the Tlingit and Haida Indian Tribes of Alaska. 8:04:23 AM JACOLINE BERGSTROM, Executive Director, Health Services, Tanana Chiefs Conference, introduced herself. 8:04:35 AM MS. UNOK co-presented the PowerPoint, titled "Alaska Tribal Health Compacting" [hard copy included in the committee packet]. She thanked the committee for hearing the presentation and began on slide 2 with an overview. She stated that the presentation would explain the Alaska Tribal Health System (ATHS). She stated that the Alaska Native Health Board (ANHB) is the statewide voice for ATHS, with the mission to promote the spiritual, physical, mental, social, and cultural wellbeing and pride of Alaska Native people. She stated that in 1994 the Indian Health Service (IHS) had approved the Alaska Tribal Health Compact (ATHC). She noted that this was the first multi- party compact in the nation, and it serves all 229 tribes in Alaska. MS. UNOK moved to slide 4 and provided a timeline of the history of Alaska Native health care. She pointed out that Native Alaskans had used traditional healing methods until the U.S. purchased Alaska, and at that time, military doctors began providing some services, along with missionary medical personnel. She stated that in 1931, the Bureau of Indian Affairs took over the responsibility of health care for Native Alaskans, and then the U.S. Public Health Services took over. She stated that this year is the 50th anniversary of the Indian Self-Determination and Education Assistance Act (ISDEAA), which began the work that Native Alaskans are doing today. MS. UNOK moved to slide 5 and spoke about the Alaska Native Services Hospital, which was built to care for Native people suffering from tuberculosis, a huge epidemic around 1953. She directed attention to a picture of the hospital's Alaska Native Health Campus, which is owned by Alaska Natives. She moved to slide 6 and emphasized the importance of tribal self-governance in health care, as it would ensure an effective voice in the implementation of programs that respond to the real needs of the people. She stated that ISDEAA backs the idea that if the people served are involved in the decision-making process, health statistics would improve. She asserted that this reflects the true meaning of self-determination. MS. UNOK explained the difference between contracting and compacting, as seen on slide 7. She stated that contracting is the first step for tribes in exercising self-determination in health care, but this would be limited, while compacting gives tribes' full autonomy on programs and services. She noted that tribes can contract, compact, or do both with the IHS. She noted that the IHS provides less than 50 percent of funding for services, and the tribes provide the rest. 8:09:57 AM MS. UNOK directed attention to the 26 co-signers of ATHC, as seen listed on slide 8. She stated that these represent a single compact covering multiple tribes and tribal organizations. She described ANHB's process in the compact, as it helps set up the negotiations with IHS. This includes looking at funding agreements and common language to create a unified approach. On slide 9, she described ATHS as a statewide coordination of care, forming an integrated statewide network, which provides health care services at village clinics, regional hubs, and the Alaska Native Medical Center (ANMC). She pointed out some of the regional and local providers listed on the slide, and she noted the partnerships. MS. UNOK, on slide 10, displayed a map of the regional tribal organizations. She stated that the tribal management of health care prioritizes local decision making, as each region has its own challenges. She moved to the next slide and displayed a map showing the specific referral pattern of tribal care. She addressed the "hub and spoke" model, which keeps care "as close to home as possible." She noted that telehealth is highly used in ATHS. She pointed out that the map emphasized the size of Alaska compared to the contiguous U.S. She added that it shows ATHS covering the entire state. She moved to slide 12 and emphasized the importance of ATHS, both economically and culturally. She pointed out that ATHS is a large part of the state's economy, as it is larger than the retail trade, construction industry, and manufacturing. She stated that ATHS is responsible for over 24,000 jobs in the state. In conclusion, she stated that this is all guided by the voice of Alaska Native people, who set the direction of programs and services. She expressed appreciation to the committee. 8:15:49 AM MS. UNOK, in response to a question from Representative Story, explained that IHS covers 50 percent of the need; therefore, ATHS must seek additional revenue to provide the full spectrum of services. She pointed out that IHS has had some funding cuts to its budget, with not many increases. She stated this would be discussed later in the presentation. In response to a follow-up question, she pointed out that the national need from IHS is $60 billion, and it is only funded at $6 million. She stated that she would follow up to the committee with the numbers statewide. 8:18:19 AM MS. MARTIN added to Ns. Unok's response, stating that ANMC is required to seek third party reimbursement. On average at the ANMC, Medicaid makes up about 40 percent of the revenue at the center. She stated that IHS provides about 12 percent of the revenue. She noted the different third-party entities that could be billed for reimbursement. She stated that the Southcentral Foundation has been able to help connect people to services. MS. MARTIN co-presented the PowerPoint and moved to slide 13. She explained the uniqueness of ANTHC, which was created in 1998. She noted that ANTHC supplies many of the statewide services. She pointed out that 99 percent of functions that normally would have fallen under IHS, have been assumed by tribal health organizations through compacting, which is unique in the state. MS. MARTIN moved to the next slide and stated that ANTHC is divided into four areas: support services, community health, environmental health, and ANMC. On slide 15, she overviewed the consortium's business support services, as it has enabled ANTHC to support many different programs. On slide 16, she overviewed ANTHC's Community Health services, and labeled it a "prevention arm." She noted that it provides preventative care and is almost entirely grant funded. She stated that ANTHC provides training programs for health aides through its Community Health services. She added that these services also include prevention and research. 8:24:16 AM MS. MARTIN, in response to a question from Representative Burke concerning federal funding, stated that because of the funding freezes, ANTHC's Community Health services is facing issues. She noted that ANMC has been affected, along with some of the water and sanitation projects. She explained that there has been a lack of communication and information from the federal government, and this has created angst for staffing who work in grant-funded positions. She stated that as an organization, it is navigating this uncertainty by taking steps to continue to provide services and secure employees. MS. MARTIN moved to slide 17 and continued to overview ANTHC's Community Health services. She spoke about the first Integrated Health Aide Forum, stating that this was important because it brought aides together to speak about their different issues. She noted the creation of the Alaska Tribal Cancer Advisory Network and the sixth annual Alaska Indigenous Research Program. MS. MARTIN, in response to a question from Chair Dibert, expressed uncertainty concerning the dates of the first Integrated Health Aide Forum. She stated that she would follow up with this information. 8:29:20 AM MS. MARTIN moved to slide 18 and slide 19 and discussed ANTHC's "construction arm." She stated that, in partnership with rural communities, ANTHC's Department of Environmental Health and Engineering builds a variety of sanitation systems. She discussed ANTHC's utility management support. She highlighted some of the department's successes in 2024, including the utilization of local hires, the installation of septic systems, and water testing. MS. MARTIN transitioned from slide 20 to slide 23 and discussed ANMC. She explained that it is Alaska's first level two trauma center, and it treats non-beneficiary patients, such as non- Natives. She explained that this is because it is a trauma center, providing care to burn patients, for example. She discussed the post-COVID-19 pandemic return of services. She concluded by pointing out that part of ANMC's mission is to serve traditional food to patients and in the cafeteria. She noted that this helps with the healing process. 8:34:34 AM MS. BERGSTROM co-presented the PowerPoint and moved from slide 25 to slide 28. She pointed out to the committee that the presentation began at the state level, with the focus narrowing to the regional perspective. She stated that the Tanana Chiefs Conference (TCC) provides health and social services for members in its region. It is a tribal consortium with 42 members, and it strives to advance tribal self-determination, while enhancing Native unity. She stated that it is one of the 26 co-signers on ATHC, serving around 12 percent of the total Alaska Native population. She directed attention to TCC's vision of having healthy people across generations and its mission of partnering with the people it serves, as seen on the slide. She explained that in 2019 the board adopted the guiding Athabaskan principle of ch'eghwtsen', which means "true love." She stated that the corporate values are based on this principle, as seen on the next slide. This slide showed a picture of Andy Jimmie, who was the second traditional Chief for TCC. She expressed gratitude for Mr. Jimmie's dedication. 8:38:50 AM MS. BERGSTROM transitioned to slide 29 that displayed a map of TCC's region in Alaska, which covers more than one third of the state. She continued that 39 regions are covered, and this represents 37 federally recognized tribes. She noted that it is divided into six subregions. She stated that because of the vastness of the region, different partnerships have come about. She moved to slide 30 and discussed TCC's board structure. She explained the board structure and funding for TCC, stating that every tribe has one seat on the board of directors. She stated that TCC is partially funded through IHS, and it relies on state and federal grants. She noted that IHS is the "payer of last resort" after third party collections, such as Medicaid, Medicare, and private insurance. She expressed the understanding that around 30 percent of TCC's budget comes from IHS and 40 percent comes from Medicaid. MS. BERGSTROM moved to slide 31 and discussed TCC's Board of Directors. She stated the tribal leadership oversees the organization, and the executive board and chief chair provide oversight. She noted that Brian Ridley is the chief/chairman and noted his guidance, as seen on slide 32. She discussed the remote communities, as seen on slide 33. She stated that there are 11 remote communities with limited road access. She noted that many of the rural patients rely on airplane travel for a higher level of care. She pointed out that there are 13 communities with limited sanitation facilities and no running water in the homes. She noted that limited broadband in the rural communities has implications on rural telehealth capabilities. MS. BERGSTROM moved from slide 34 to slide 36 and discussed the challenges of the TCC region. For social determinants of health, she listed water and sanitation needs and food security. She noted the salmon crisis and the climate crisis. She pointed out the effects of historical trauma, such as the loss of language, culture, and the experience of boarding schools, as Elders are now "opening up" about this. She added that the limited access to education security also effects health. She pointed out the lifestyle indicators of health, such as tobacco and substance use, obesity and diabetes rates, and cancer rates. She noted the high rates of colon cancer among Alaska Natives. MS. BERGSTROM moved to slide 37 and slide 38 and reiterated that TCC is tribally driven. Looking at strategic planning initiatives, she stated that there is significant input from tribes, patients, staff, and data. She pointed out that the elder population has been growing, and it will not plateau until 2045. She noted the use of data concerning the population, as the birthrate for Alaska Natives is higher than the rest of the state; however, life expectancy for Alaska Native people is 10 years less than the average Alaskan. She expressed this is because of the COVID-19 pandemic and the death from drug overdoses. She addressed the concerns of tribal communities, noting drug usage, violence, food security, and others. 8:50:04 AM MS. BERGSTROM transitioned to slide 39 and explained the strategic initiative to increase health care within Alaska Native communities. She pointed out that this includes finishing the Chief Andrew Isaac Health Center, improving wellness, prevention, and behavioral health, addressing water and sanitation needs, and achieving the re-accreditation of all services. MS. BERGSTROM moved from slide 40 through slide 42, and she pointed out that there are still health care impacts from the COVID-19 pandemic. She noted that TCC learned to be adaptable on delivering services during the pandemic, such as with telehealth; however, the challenges from the pandemic continue to affect the workforce, supply chain, and inflation. She pointed out that many people in remote Alaska have been leaving the workforce, and the cost to hire a new workforce has risen. She discussed medical inflation in detail. Concerning the workforce challenges, she stated that TCC is looking to "grow our own," and she noted the health aide-training center. MS. BERGSTROM moved to slide 43 and slide 44 and discussed the Chief Andrew Isaac Health Center expansion project. She stated that existing services are being expanded, along with the addition of other services, such as an ambulatory surgery center, cancer care infusion center, audiology services, and ophthalmology services. She moved to slide 45 and discussed the challenge and opportunities concerning behavioral health. She noted that there has been an increased need for these services; however, there has been a reduction in funding. She added that other challenges include provider enrollment delays and authorization requirements. She stated that recent legislation could reduce the administrative burdens. MS. BERGSTROM moved to slide 46 and provided positive examples of improvement in Alaska Native health care. She pointed out that the collaborative element with state and federal partners is strong. She noted that there is a 100 percent match for those who receive Medicaid services. She maintained that IHS health care is not free, as it is a federal obligation to repay for the past. Contrary to some beliefs, she asserted that tribal health services are of the same quality or better, compared to other entities. She maintained that tribal health organizations provide quality health care, with strong quality assurance policies and procedures in place. She discussed the opportunity to expedite the patient and the provider enrollment process and streamline the travel reimbursement process. MS. BERGSTROM moved from slide 47 to slide 50. She pointed out that in 2022 the TCC Cancer Care Committee received an award for its work on colon cancer detection. It also received the Patient Experience Award for timely response by staff and a national award for a quality improvement study that focused on accelerated Hepatitis C screening of patients. She stated that the TCC pharmacy was recognized for its rapid response with vaccines during the COVID-19 pandemic. She added that TCC's clinical pharmacist specialist are providers with full prescriptive authority. She noted that the Alaska Pharmacist Association presented two awards to TCC pharmacists in 2023. In conclusion, she noted the long-term staff who sit on state and national committees. 9:04:05 AM MS. BERGSTROM, in response to a question from Representative Story concerning funding, stated that TCC gets its base funding from compacting with IHS, which covers roughly 30 percent of the need. She stated that the rest of the funding comes from federal grants. She mentioned that there is a small amount of funding from the state, but overtime grant funding has dwindled. She added that for those with alternate insurance, that insurance would be billed. In response to a follow-up question, she stated that compacting consists of different groups coming together. For the IHS compact, she stated that all the co- signers are in one compact, but each would have its individual funding agreement, and TCC would receive 12 percent of the total share. She stated that TCC has existed for 30 years, so the organization is strong, but it has not happened overnight. She stated that TCC is a consensus-based organization, as 26 out of the 29 co-signers must agree, and this is how it is able to function. MS. BERGSTROM, in response to a question from Representative Carrick concerning access to more colonoscopy screenings, stated that TCC would remind patients when they are on the 5-year interval for screenings. She stated that if a family has a positive history for polyps, the screening begins at age 40. She expressed concern over the possible lack of federal funding to continue this program. REPRESENTATIVE CARRICK commented that not having federal funding for preventative health care would cost the state, as the state already has some of the highest colon cancer rates in the world. 9:13:01 AM MS. UNOK, in wrap up, stated that even though a large amount of information was presented, there is much more in the tribal health story. She noted that many third-party sources do not reimburse for preventative services, and the lack of funding for preventative services is a major issue. MS. BERGSTROM thanked the committee. She stated that with further questions, the dialogue could be continued at another time. MS. MARTIN discussed the importance of prevention, emphasizing that the barrier of travel plays into the issue. She suggested that there should not be a centralized campus in Anchorage, but a distributed healthcare network, so health care is "closer to home." CHAIR DIBERT commented on the quality of services provided at ANMC, especially the pulmonology department. She commented on ANMC's expansion project. MS. MARTIN invited the committee members to visit ANMC and tour the expansion project. She stated that ATHS serves 70,000 more people than before compacting, and ANMC reflects this. CHAIR DIBERT expressed appreciation for the traditional foods served at ANMC. She thanked the presenters. 9:20:07 AM ADJOURNMENT  There being no further business before the committee, the House Special Committee on Tribal Affairs meeting was adjourned at 9:20 a.m.