American Indians and Alaska Natives (AI/AN) experience higher rates of many mental health and substance use disorders than other Americans. Disparities in mental health outcomes stem from the role of intergenerational trauma, as well as high rates of poverty and associated barriers to nutrition, educational and economic opportunities, and other social determinants of health (SDOH). In addition, delivery of high-quality behavioral health services for AI/AN people are often complicated by the rural nature of most reservations, provider shortages, and a lack of culturally responsive health care. In response to these challenges, Tribal Nations are increasingly taking on management of the behavioral health services delivered to their members.
To help strengthen behavioral health services for AI/AN people, some states are working with Tribes to ensure that their needs and interests are considered in programs and that Tribes receive adequate resources to expand services and supports that integrate cultural practices. A NASHP webinar provided an overview of the behavioral health delivery system for AI/AN people and outlined strategies used in Oregon and Oklahoma to partner with Tribes to deliver culturally responsive services and supports, along with considerations and takeaways for states seeking to strengthen partnerships with Tribes to deliver behavioral health services.
American Indian and Alaska Native Behavioral Health Needs
AI/AN people live in a unique cultural context that influences their behavioral health outcomes and access to services and supports. Studies indicate that AI/AN people have disproportionately higher rates of mental health challenges such as suicide, post-traumatic stress disorder, violence, and substance use disorders. AI/AN people experience the highest rates of suicide of any population within the U.S., and these rates have been increasing since 2003. AI/AN people have also faced disproportionate harms related to the opioid crisis and substance use, including higher rates of alcohol-related deaths and overdose deaths than other populations. Behavioral health challenges are particularly pressing for Indigenous youth; some studies show that alcohol and other drug use for AI/AN youth begins at younger ages and at higher rates than for other populations, and suicide rates for AI/AN adolescents are over double the rate of white adolescents.
These data emphasize the need for holistic and community-led solutions that are integrated within Tribal continuums of services. Webinar presenters noted that, as states work to improve access and delivery of behavioral health services, it is important to consult with and integrate Indian health care providers in care delivery, ensure these providers receive adequate funding, and acknowledge traditional practices when delivering care. These improvements rely on ongoing collaboration between Tribal and state policymakers.
Understanding the Indian Health Service’s Role in Delivering Behavioral Health Care to American Indian and Alaska Native Communities
The Indian Health Service (IHS) is the federal agency responsible for providing federal health services, including behavioral health services, to AI/AN people. It delivers services through a three-part system of IHS-operated facilities, Tribal facilities operating under a compact with the IHS, and Urban Indian Organizations operating with IHS funding. IHS reports that in the past decade, Tribes have increasingly chosen to enter into compacts with IHS that enable them to assume funding and control of the behavioral health services delivered to their members. Currently, more than 50 percent of the mental health programs and over 90 percent of the substance use treatment and recovery programs for AI/AN communities are Tribally operated.
The IHS’s Division of Behavioral Health (DBH) is the nation’s primary administrator of behavioral health, alcohol and substance use, and family violence prevention programs for AI/AN people. The DBH’s TeleBehavioral Health Center of Excellence (TBHCE) branch works to provide and promote culturally responsive telebehavioral health services delivered in facilities operated by IHS, Tribes, and Urban Indian Organizations (I/T/Us) across the country. TBHCE services are available to AI/AN people of all ages and include an array of mental health and substance use treatment services. TBHCE also provides technical assistance to I/T/U behavioral health programs and offers culturally sensitive education and training to health care providers through the TBHCE Tele-Education program.
Oregon’s Direct Support to Tribal Nations for Behavioral Health Services
The Oregon Health Authority (OHA) has dedicated significant resources to improving the delivery of behavioral health services to AI/AN people. OHA’s work is guided by state law (Oregon Revised Statutes 182.162 – 182.168), which directs all state agencies to develop and implement programs that affect Tribes and to promote communication and positive government-to-government relationships with Tribes, as well as OHA’s Tribal Consultation and Urban Indian Health Program Confer Policy. The policy promotes “open, continuous, and meaningful consultation” to ensure Tribal input on all relevant OHA programs, policies, and activities. Building on a foundation of trust and mutual respect between the state and Tribes, the policy aims to promote the participation of AI/AN people in Oregon’s health and human service programs to eliminate disparities in access to services, enhance health outcomes, and adjust state programs to accommodate Indian health programs.
In this effort, OHA has collaborated with Tribes and the Urban Indian Health Program in the state to support AI/AN behavioral health. In 2019, the OHA developed its Tribal Behavioral Health Strategic Plan, which includes several strategic goals aimed at reducing disparities in behavioral health outcomes and improving access to services for AI/AN people. For example, OHA provides Tribes and the Urban Indian Health Program with funding to strengthen Tribal behavioral health programs and expand service delivery according to community needs. Funding is non-competitive and set aside to ensure that Tribes receive “adequate, flexible funding” for behavioral health services and supports.
OHA currently distributes funding for services that include alcohol, tobacco and other drug prevention, problem gambling prevention, substance use treatment, intoxicated driver programs, mental health services, workforce development, residential and housing support, opioid response, veterans’ programs, suicide prevention, Tribal Behavioral Health Resource Networks (BHRNs), and care coordination and support for youth and families through System of Care grants. These services are informed by Tribal expertise and use traditional healing practices tailored to meet each community’s unique needs, leading to increased access and early interventions to support mental health care. The Tribal BHRNs provide an example of a set aside. Created with legislative support, Oregon’s BHRNs are designed to expand access to comprehensive, community-based services and supports for substance use treatment. In 2022 the state dedicated $265 million in grant funding to create BHRNs, with $11.4 million of that amount set aside for the nine federally recognized Tribes to use for Tribal BHRNs.
Integrating Tribal Practices and Supports into Substance Use Disorder Treatment and Recovery
The Confederated Tribes of Grand Ronde, one of the nine federally recognized Tribes in Oregon, have used OHA funding to expand the behavioral health program, particularly for workforce and substance use treatment programs. The Tribes offer a variety of services and supports — including mental health and peer recovery, services and nutrition, clothing, career training, and housing supports — at Great Circle Recovery clinics in Salem and Portland, with an emphasis on integrating Tribal spiritual and cultural practices in all health and wellness programs. For example, in 2021, the Tribes created an opioid addiction treatment program that is administered at both sites and offers medication, counseling, and peer support services. In 2023 the Tribes began offering shelter housing for people who are unhoused, which has been significantly impactful in connecting this population with services. The Tribes are also using OHA funding for housing and residential treatment to open a facility for substance use treatment and recovery services and are developing a detoxification facility at the Salem site, which will launch in 2025.
Recent Developments in American Indian and Alaska Native Health Care
Oregon, in addition to Arizona, California, and New Mexico, recently gained approval for a section 1115 demonstration amendment that will allow Medicaid and Children’s Health Insurance Program (CHIP) coverage of traditional health care practices provided by I/T/U facilities. This unique initiative, developed in Oregon with input from the nine federally recognized Tribes, is designed to improve access to culturally appropriate health care and improve the quality of care and health outcomes for AI/AN communities. As noted by Julie Johnson, Tribal affairs director of the Oregon Health Authority, this is an important step taken by federal and state programs to support and invest in Tribal efforts to address AI/AN behavioral health needs by using their traditional healing knowledge.
Federal, State, and Tribal Coordination in Oklahoma’s 988 Implementation
The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) has worked to ensure that the needs of AI/AN communities are considered in the implementation of its Comprehensive Crisis Response system. The system is designed to assist individuals experiencing mental health crises at multiple levels of severity by providing immediate services.
Along with the national roll out of the 988 implementation, ODMHSAS partnered with Solari Crisis & Human Services to launch the 988 Mental Health Lifeline in July 2022. The 988 lifeline replaced the state Suicide Prevention Lifeline to better serve individuals experiencing all forms of mental health crises. Following implementation of the lifeline, 13 Tribal Nations in Oklahoma were awarded SAMHSA Tribal 988 grant funding to increase awareness about the resource and bridge gaps in the Tribal crisis care continuum. To assist with implementation of the 988 Tribal response grants, Oklahoma state officials worked to build relationships with Tribal Nations to promote the lifeline within Tribes through various marketing initiatives. ODMHSAS reports that coordination with Tribes has supported engagement with the lifeline.
988 Tribal Response funding has also supported the development of various Tribal programs designed to deliver additional behavioral health services to members. For example, the Choctaw Nation of Oklahoma has developed a referral program that connects members with the Nation’s mental health providers for mental health assistance and services such as interim counseling, case management, suicide care pathways assistance, and mobile response team support.
ODHMHSAS and the Tribes continue to work together through a Tribal 988 workgroup created from this partnership. The workgroup prioritizes input from Tribes on the focus and administration of ODMHSAS programs. It hosts monthly meetings with grantees to discuss ODMHSAS programs, health concerns among Tribes, and further opportunities for collaboration.
Takeaways for States
To address ongoing health challenges and improve access and delivery of behavioral health services for AI/AN communities, Tribal Nations are increasingly taking on management of their own behavioral health care programs. New authorities in Medicaid, such as recently approved section 1115 demonstration amendments, provide further tools for states to invest in behavioral health services using traditional healing knowledge.
As shown in Oregon and Oklahoma, community-led improvements in care and service delivery that draw on traditional knowledge and cultural strengths are particularly impactful. States can support these efforts by fostering and maintaining positive government-to-government relationships with Tribal Nations to ensure that Tribes are consulted to provide input on relevant activities. With guidance from Tribes, states can implement a range of programs and policies that, for example, provide direct funding for Tribes to support their own initiatives, or leverage strong partnerships to promote federal or state programs. NASHP will continue to support states in their efforts to partner with Tribal Nations to improve the health care delivered to AI/AN people.
Acknowledgments
The authors thank Chris Fore, director of the Indian Health Services Telebehavioral Health Center of Excellence; Julie Johnson, Tribal affairs director of the Oregon Health Authority; Josh DeBartolo, senior manager of community integration of the Oklahoma Department of Mental Health and Substance Abuse Services; Rosanna Tallbear, Oklahoma 988 project coordinator; and Kelly Rowe, executive director of health services of the Confederated Tribes of Grand Ronde, for presenting in the webinar this blog is based on.
The webinar and presentations are available on NASHP’s website.
