September 24, 2017
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LePage cuts last direct ties with tribes on public health

By Matthew Stone, BDN Staff
Updated:

Gov. Paul LePage’s administration has cut off state funding that the four federally recognized Native American tribes in Maine were using to plan an expansion of addiction treatment and mental health care in their communities.

The move comes six years after Maine started including the tribes in state-funded efforts to combat major health problems. Tribal leaders now worry that recent initiatives to develop an addiction treatment center serving tribal members, improve life for seniors, and tackle other health challenges in the tribal communities in eastern and northern Maine could stall.

The public health work “was beginning to have some positive results, and, now, all of a sudden, it’s gone,” said Theodore Bear Mitchell I, a former Penobscot Indian Nation representative in the Maine Legislature. “We’re used to it. We’ve gone through it for 220 some-odd years. They promised us one thing, and, after a while, they do something else.”

The most recent cut, effective July 1, eliminated the position of a tribal public health liaison whose responsibilities included educating tribal communities about chronic disease prevention and management, representing the tribes on a range of state health boards and committees, and coordinating community efforts to improve the health of the approximately 10,000 tribal members in Maine.

Compared with Maine’s population, tribal members face higher rates of diabetes, obesity and high blood pressure; they have markedly higher smoking and heavy drinking rates; and they have lower life expectancy. But while the state has made major cuts to public health budgets in recent years — including in the state budget that took effect two months ago — it has continued to fund public health liaisons outside of tribal areas.

“I think if there’s one liaison position that should be funded, the tribal liaison should be the No. 1 priority,” said Ed Miller, a longtime public health advocate from Hallowell who spent much of his career working on anti-tobacco efforts and advocated for the 2011 state law to include the tribes in the public health system. “I’d much rather have a public health liaison working with the tribes than working with Falmouth and Cape Elizabeth.”

A 2011 state law, signed by LePage, incorporated the four tribes into the state’s then-nascent network of state-funded public health services. The law also created the tribal public health district and elevated it to the same status as the state’s eight other regional public health districts.

Now, the end of funding for the tribal public health position leaves state-funded liaisons in every state public health district except the tribal district. The Maine Center for Disease Control and Prevention made the cut following minimal communication with tribal officials.

“It’s really, as I see it, breaking the law, not following the legislation,” said Penobscot Nation Chief Kirk Francis. “It’s, to me, just a lack of respect for the tribes when you can’t even have a conversation about, one, cutting something so significantly in an important area, and, two, eliminating it without even a phone call.”

In an email to the BDN, Maine Department of Health and Human Services spokeswoman Emily Spencer wrote, “The tribal district may employ a liaison that would be recognized by the Department.”

But without the state funding they used to receive, the tribes would have to cover the cost themselves.

The end of the state’s funding for locally planned, tribal public health efforts isn’t the only example of a state-tribal health partnership collapsing in recent years. In 2011, the LePage administration included the four tribes in a federally funded program to expand the availability of home visiting services throughout the state.

With federal grant money, the state intended to send more parent educators into the homes of expectant families and families with newborns, to help them ease into parenthood, check their houses for potential hazards to a baby, and show them how to safely put their babies to sleep. Through contracts, the Maine Center for Disease Control issued funds to every tribe in the state in hopes of including tribal members in the expansion of home visiting services, which are voluntary and free of charge to parents.

That collaboration, however, unraveled in 2015, while home visiting contracts remained in place for a range of other agencies across the state. The state ended four of five tribal home visiting contracts that year, citing too few births as the primary reason. According to tribal officials, most of the families receiving home visiting through the tribes stopped receiving the service.

Also in 2015, LePage rescinded an executive order that required state agencies to consult with the tribes on many policy changes; the Penobscot Nation and Passamaquoddy Tribe withdrew their representatives from the Maine Legislature; and the Penobscot Nation lost a federal court case challenging the state’s right to regulate fishing on the Penobscot River.

The loss of state funding for tribal public health, Francis said, “just reinforces people’s mindsets that it’s hard to build trust in this relationship when these things keep happening.”

‘Everyone realized the importance’

The 2011 proposal to incorporate the four Maine-based tribes into the state’s infrastructure for tackling public health problems generated little controversy. It passed the House and Senate unanimously before LePage, then in his first year in office, signed the measure into law.

“Everyone realized the importance of it,” said Mitchell, who served as the Penobscot Nation’s legislative representative at the time.

The legislation enabled the four tribes — the Penobscot Nation, Passamaquoddy Tribe, Houlton Band of Maliseets and Aroostook Band of Micmacs — to start receiving public health funds and, through two tribal public health liaisons, to be involved in statewide public health planning and policy-making.

The law was significant because it called for the four tribes to work together on health challenges, and it represented an example of the tribes and the state setting aside differences to work together on public health, Francis said.

“This is one of the only areas where we receive any state funding,” he said. “We don’t have this big fiduciary relationship with the state. This was really one area where we felt we could put all the politics aside. We could find a way forward in what we see as a top priority and one of the most important issues facing the tribes.”

The legislation also allowed the tribes to direct their own public health efforts, and it specified that the public health liaisons working with the tribes would be tribal employees. The public health liaisons to the state’s other eight public health districts are Maine CDC employees.

“A local response to these issues is why you create these districts in the first place,” Francis said. “Simply housing them in some central location, I will tell you, as pre-2011 will show you, the tribes will get very little attention.”

Losing momentum

Following the 2011 law’s passage, the tribes started receiving state money to pay for two public health liaison positions, along with other public health funds, and the newly formed tribal public health district started tackling tribal members’ public health challenges. (Between 2008 and 2011, before the tribal public health district formed, the Maine CDC used a patchwork of federal funds to pay for two tribal liaisons.)

While health care provided by medical professionals is geared toward individual patients, public health involves a wide range of activities aimed at improving the health of whole populations, from law and policy changes to public awareness campaigns to vaccination clinics.

Using the results of a detailed assessment of tribal members’ health status, the tribal public health district had worked in recent years to identify the most pressing health challenges facing tribal members and strategies for tackling them.

Earlier this summer, the council that oversees the tribal district — with the tribal public health liaison coordinating the efforts — began planning to expand culturally sensitive addiction treatment services, said Clarissa Sabattis, chief of the Houlton Band of Maliseets.

Council members from the four tribes signed a resolution agreeing to pursue the development of a treatment center, and they had met with treatment experts and with federal officials to discuss funding, said Kristi Ricker, who served as the tribal public health liaison.

Without the liaison organizing the work, Sabattis said, tribal officials are worried the treatment expansion efforts could stall.

“Each tribe has its own set of priorities, so having that entity that was there for all of us and move these efforts forward was big,” she said.

“It’s not the same kind of energized movement forward as there was before, because there’s nobody dedicated to do that,” said Ricker, a registered nurse who has since started working at Acadia Hospital in Bangor. Members of the tribal health district council “all have other jobs. For the tribal chiefs, they’re very busy. They’re pulled in a hundred different directions.”

‘No connection’

Tribal public health efforts have sustained other funding cuts over the past five years as the Legislature and LePage administration shrank state public health budgets.

In 2012, the state cut funding for Healthy Maine Partnerships statewide, including for the tribes, by more than a third — to $4.7 million annually from $7.5 million. (The Healthy Maine Partnerships were small, regional coalitions of health care providers, local governments, law enforcement and others that oversaw local public health initiatives and aided in public health emergency responses. They were funded with a pot of money Maine receives each year as part of the Tobacco Master Settlement Agreement with the nation’s largest tobacco companies.)

But even with less funding, the state renewed its contract with the tribes each year to fund two tribal public health liaisons and the tribal Healthy Maine Partnership, according to a BDN review of the contracts.

Last year — the same year the LePage administration dissolved all 27 Healthy Maine Partnership coalitions — the state cut the tribes’ public health contract by more than half, funding only one tribal liaison instead of two.

The funding for the one remaining liaison, Ricker, ended June 30.

About six weeks before, on May 17, all five tribal chiefs received a letter from the Maine CDC notifying them that the agency would no longer pay for the tribes to employ a public health liaison. Instead, the CDC was “willing to add an additional District Liaison position within Maine CDC to replace this contracted position,” read the letter from James Markiewicz, the CDC’s deputy chief of district public health and emergency preparedness.

The 2011 law that incorporated the tribes into the state’s public health network states that the tribal liaisons “are tribal employees,” not state employees. It makes the tribal public health liaisons tribal employees for a reason, said Francis, the Penobscot Nation chief.

“We do know that the very complex and unique history of the tribes is one of the key contributing factors” to health disparities between tribal members and the rest of Maine’s population, he said. “Those deserve specific attention, and some centralized, state-run situation is going to cookie-cutter their approach to everything, and it’s not going to be effective, if we get the attention at all.”

Spencer, the Maine DHHS spokeswoman, said the CDC attempted to end the tribal liaison contract and move the position to the CDC staff in an effort to “formalize the position and allow the Department to secure on-going funding — meeting both the needs of the Department and the tribal governments.”

Sabattis, the Houlton Band of Maliseets chief, met with LePage in mid-June to request that the state reinstate the contracted position. But Sabattis heard nothing from state officials after that meeting, she said, despite sending multiple requests for information about their decision on reinstating the contract.

Then, in mid-August, Ricker, who had worked as a tribal liaison for five years, received an email from a Maine CDC staff member asking her to return her state-issued computer. That confirmed the end of funding for the position, Ricker said. Tribal officials received no other notification or explanation, they said.

With the end of funding for the liaison, no tribal liaison on the CDC’s staff, and the end of other sources of state public health funding, “There’s no connection between the CDC and the tribes anymore,” Ricker said.

The tribal public health district continues to receive some state public health funds, but indirectly through statewide contractors working on specific public health problems, such as smoking and obesity.

For medical care, the tribes’ health centers receive federal funds through the Indian Health Service, an agency that the Government Accountability Office has called “ineffectively administered” and underfunded.

In a report last year, the GAO noted that the agency “is unable to pay for all eligible services, and that these gaps in services sometimes delay diagnoses and treatments, which can exacerbate the severity of a patient’s condition and necessitate more intensive treatment.”

As far as public health planning work in the tribal public health district, “at this point, really, there’s zero work” happening, said Ricker.

Same thing ‘all over again’

Ricker and Sabattis draw parallels between the end of funding for local public health efforts and the end of funding for the tribes to provide home visiting services to young tribal families.

“Does it feel like it’s the same thing happening all over again? Yes,” said Sabattis. “There’s definitely some similarities as far as the communication that’s happened and the people overseeing these things.”

In 2011, Maine DHHS applied for and received a four-year, $5.7 million federal grant to expand home visiting. In the grant application — led by Sheryl Peavey, who oversaw home visiting at the time and today is the Maine CDC’s chief operating officer — the state pledged to work on expanding home visiting to tribal families in the first year of the four-year grant.

Home visitors, through a state program called Maine Families, work with new and expectant parents to help them cope with their babies’ crying, check their homes for potential child hazards, help with breastfeeding, and show them how to safely put a baby to sleep. Research has shown that such home visits can reduce the likelihood of child maltreatment, contribute to improved parenting practices, and boost children’s development and school readiness.

Soon after Maine received the home visiting expansion grant, the state issued contracts to each of the five tribal communities (the Passamaquoddy Tribe has two reservations in Washington County) to fund home visiting services.

The contracts required that each full-time home visitor enroll and regularly visit at least 25 families each year, but tribal officials expressed concerns to state home visiting officials early on that they couldn’t meet those numbers, given their small populations, low numbers of births each year, and the reality that not every expectant or postpartum family would enroll. Not meeting those numbers would render the tribes out of compliance with their state contracts, putting them at risk for termination and the services in jeopardy.

“That was a big concern, and we had told them that we don’t have the numbers to meet the requirements,” Ricker said.

Ricker and Sabattis said the state officials agreed to be flexible. But, Ricker said, “when it came right down to it, that was not what happened.”

By the time the four-year grant had run its course, only one tribe — the Houlton Band of Maliseets — still had a direct contract with the state for home visiting. The state ended that contract early in 2016, Ricker and Sabattis said, just before the state shifted management of the home visiting program to the non-profit Maine Children’s Trust, awarding the trust a $23 million, 2½ -year contract without requiring that the trust compete for the contract award.

Tribal families are still eligible for home visiting services provided by the nonprofit organizations that provide the services in designated areas of the state under contract with the Maine Children’s Trust. But, according to tribal officials, the number of tribal families receiving home visiting services dropped when the state ended the contracts it held with the tribes.

Tribal parents were more likely to enroll in home visiting services provided through their tribal governments, Sabattis said. Having home visitors “right here in the community made a huge difference,” she said. “They worked within our health department. They were in our community.”

In a 2016 application to the federal government for a new round of home visiting funds, Maine DHHS acknowledged that, after the state ended its home visiting contracts with the tribes, home visits continued only for “some” of the families that were previously receiving them.

Spencer, the DHHS spokeswoman, wrote in her email to the BDN that DHHS provided technical assistance to the tribes on implementing their home visit programs and, in some cases, extended the length of corrective action plans before ending contracts. The caseload requirement for home visitors, she noted, was a requirement tied to the federal home visiting funds the state was receiving.

“The Department fulfilled its pledge as outlined in the [2011] expansion grant application,” Spencer wrote. “…With only 5-20 births per year in each Tribe, home visiting caseloads in the tribal communities were below the required levels.”

Ricker said she suggested that the state switch the funding source for tribal home visiting: Tribes would receive state funds, and the state would reallocate their federal funds, since state money permits more flexibility. Tribal health staff members also suggested different staffing and supervision arrangements to meet the required ratios, Ricker said. The state never changed the funding source or organizational structure.

Maine DHHS pledged to use the four-year, $5.7 million federal grant to expand home visiting services to more families across the state, but an expansion of the size the state proposed in its federal grant application never materialized.

Maine DHHS estimated it would reach 1,700 additional families by the end of the fourth year of funding, which would be a 72 percent increase. But the home visiting program reached just 150 more families in that time: 2,520 families in 2015, up from 2,368 in 2011, according to the KIDS Count database assembled by the Maine Children’s Alliance.

The year after, in 2016, the number of families dropped back to 2,341.

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com.


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