The United States has a legal responsibility to provide health care to American Indian and Alaska Native (AI/AN) people who are members or descendants of federally recognized Tribes based on the treaties, laws, and Supreme Court rulings that define the federal trust responsibility. Federal law mandates that sovereign Tribal nations are recognized as distinct and independent political communities that oversee the well-being of their own citizens. As such, federal and state governments must engage Tribes as equal peers and negotiate with them as one government to another government, known as a government-to-government relationship. This includes formal consultations with Tribal leaders or their delegates on policy or program changes affecting Tribal members. It also includes state and federal requirements for Tribal consultation on Medicaid policies that may impact Tribal members who are eligible for and enrolled in Medicaid.¹

Effective collaboration to improve health care and outcomes for AI/AN people, however, goes beyond meeting the minimum standards of consultation. While consultation is a strong starting point, it is important for state and Tribal governments to cultivate mutual respect and trust. This foundation will enrich their government-to-government relationships and help them work together on shared goals.

Washington State sits on the ancestral territories of 29 Native nations. This profile explores how Washington State’s Medicaid agency has worked to build stronger relationships with the governments of these 29 federally recognized Tribes. It focuses on two organizations that lead this work: the Office of Tribal Affairs (OTA) in Washington State’s Health Care Authority, which oversees the state’s Medicaid and public employee insurance programs, and the American Indian Health Commission (AIHC), a Tribal-led entity that works with Washington State to develop policies supporting AI/AN communities. While states and Tribes across the country have their own unique contexts, the practical steps taken in Washington State can inform, and hopefully help improve, government-to-government relationships in other states.

Background

Working effectively with the governments of Native nations requires an understanding that Tribes are sovereign nations within the boundaries of the United States. Native nations — whose traditional lands and waters intersect with state boundaries across the country — are governed by elected Tribal government officials and have established governments to legislate, enforce Tribal laws, and support Tribal citizens.

About 3.5 percent of the population of Washington State, or 270,000 people, identifies as AI/AN (alone or in combination with another race). Nationally, about one-third of AI/AN people under 65 are covered by Medicaid. Native people in Washington State also face significant health disparities. Recognizing the importance of serving these populations well and honoring a true government-to-government relationship, Washington State has strengthened and standardized Tribal consultation. These changes are based directly on collaboration with and feedback from Tribal leaders.

Lead Organizations Driving Tribal-State Relationships in Washington State

In Washington State, the Office of Tribal Affairs (OTA) and the American Indian Health Commission (AIHC) are leading efforts to strengthen government-to-government relationships between the 29 Tribes and the State of Washington, with a focus on Medicaid and health care policy.

OTA, part of Washington State’s Health Care Authority (HCA), advises and improves HCA’s work with Tribes, promoting government-to-government relationships. OTA works with Tribal leaders and their delegates from each Tribe, AIHC, and Indian health care providers, including the two Urban Indian Organizations (UIOs) in the state. With 17 full-time staff, many of whom are Native, OTA has worked to enhance its capacity to work proactively and directly with Tribal partners.

AIHC, formed in 1994 by the Tribal governments who have shared geography and treaty protected interests within and beyond Washington State, supports Tribal sovereignty and highlights unmet Tribal needs, particularly related to health and health care. AIHC is comprised of delegates from each federally recognized Tribal government sharing geography with Washington as well as at-large delegates representing UIOs and AI/AN individuals who may be affiliated with non-federally recognized Tribes or part of Tribes in other states. AIHC’s efforts help Tribes work together and coordinate their work with state officials.

Approaches to Support Collaboration on Shared Policy Priorities

Building upon the landmark agreements and key state laws in Washington State, the Office of Tribal Affairs and other state staff have taken a number of steps to collaborate more closely with Tribes on Medicaid and other health policy, outlined below.

Meet Regularly to Build Relationships

Building effective relationships requires time, including regular meetings to stay updated on priorities held by each Tribe and UIO, and to work through solutions together. OTA staff meet weekly with AIHC counterparts and hold regular informal meetings with Tribal staff and leaders, alongside formal consultation and confers,³ to ensure Tribal leaders receive new information about policy and program updates promptly and state staff are aware of emerging health-related issues impacting Tribes. Timely sharing of updates or new ideas allows Tribal leaders and staff to request additional information, schedule opportunities to work together, or set up a formal consultation. OTA and AIHC also work routinely with legislators and participate in meetings with the Governor’s Office of Indian Affairs to understand and address legislative or executive barriers.

How the state meets with Tribal leaders and their delegates is as important as how often. OTA staff understand the value of meeting Tribes in person and on a personal level. In-person meetings provide opportunities for state staff to meet Tribal delegates and members, share meals and stories, strengthen bonds, and, ultimately, enjoy working together. State staff and Tribal leaders and delegates co-create meeting agendas, ensuring the state is aware of and addresses Tribal needs. It is also important for OTA to meet with Tribes individually, not solely in group settings or through AIHC.

While Tribal governments often have shared interests, each is also advocating for its own citizens and needs. The OTA demonstrates its understanding of inter-Tribal relationships, showing Tribal leaders and delegates that the state sees them as equal and individual government-to-government partners. Putting this level of understanding into practice is essential for progress.

OTA is also working to make Tribal consultation more uniform across health departments in Washington State. A consistent and streamlined process will help Tribal leaders, delegates, and staff know what to expect from consultation and what their roles and authority are within this structure.

Focus on the Priorities of Tribal Governments

As part of its commitment to building relationships, OTA works to understand and support the concerns of Tribal leaders and communities, rather than solely focusing on state priorities. This approach ensures knowledge-sharing goes both ways — Tribal members, staff, and leaders share their expertise with Medicaid staff, while Medicaid staff share information about the opportunities and limitations of the Medicaid program. In Washington State, health care priorities vary across Tribes, encompassing a breadth of topics. Tribal leaders are concerned about access to care, especially access to behavioral health and substance use treatment during the current opioid addiction crisis. There are also concerns about unequal access to care for Medicaid recipients compared to those covered by Medicare or commercial insurance and for Medicaid recipients who may have different experiences if they are enrolled in Medicaid managed care compared to fee-for-service (FFS) Medicaid.⁴ Additionally, Indian health care providers of all types are interested in opportunities to increase reimbursement and investment, including by pursuing an 1115 waiver in partnership with the state that would allow Washington Medicaid to reimburse the provision of Tribal traditional healing practices.

The state is working with Tribes to explore how to address some of these priorities through policy change. For instance, OTA has been working with Tribes to improve mental and behavioral health services for Native people. As part of 988 implementation,⁵ Washington State worked with Tribes to create the Native and Strong Lifeline, a crisis hotline designed for AI/AN people. Tulalip Tribes worked with HCA to name a Tribal Designated Crisis Responder for their community — someone who can offer culturally attuned care for Tribal members experiencing behavioral health crises. (For more policy collaborations, see the sidebar on the state’s 1115 waiver.)

State staff can also assist Tribes on issues outside the state’s purview by connecting Tribal delegates to Medicaid experts and federal policymakers, or others who can address non-Medicaid health-focused issues. Summer Hammons, Legislative Policy Analyst for Treaty Rights & Government Affairs for the Tulalip Tribes, explains that she worked with OTA to obtain background information and connect with federal Medicaid officials while exploring issues related to Medicaid eligibility and income from Tribal general welfare. Although this issue is outside Washington State’s control, it significantly impacts AI/AN people served by Medicaid. Hammons says that Tribes can often feel taken advantage of because they do not always receive the federal or state support they should receive — but working with OTA Administrator Aren Sparck and his team feels different, thanks to their ongoing relationship and the support she receives in meeting the needs of members of the Tulalip Tribes.

Provide Training to State Staff

The Office of Tribal Affairs also works with colleagues throughout HCA to help them develop competencies to better work with Tribes. While OTA staff act as experts and advisors when needed, Sparck explains, “My goal is that HCA staff do not have to bring all Tribal issues to OTA.” He hopes to see staff across the agency build capacity and become familiar and comfortable with topics like Tribal consultation, Medicaid coverage for AI/AN people, and the relevance of specific policy areas to Tribes.

One way to build competency in managing government-to-government relationships and understanding when and how policy change might impact Native nations is through staff education and training. Under (RCW) 43.376 Government-to-government relationship with Indian Tribes, the American Indian Health Commission provides comprehensive training on these topics for state agency employees, along with the governor’s office and state legislators and their staff. These trainings are offered regularly to account for turnover among state employees and elected officials.

Vicki Lowe, Executive Director of the AIHC, explains that the trainings have two key goals: (1) ensuring state staff understand their responsibility to treat Tribal governments as equal partners; and (2) clarifying that the state’s obligations to Tribes are based on their status as sovereign nations under federal treaties and laws. For instance, a training on the Indian health care system explores the history of the United States’ obligation to provide health care to AI/AN people, the current organization of this health system, and the basics of a government-to-government relationship. “Trainings are not about ‘believing in’ the rights of Tribes and the state’s obligations,” notes Lowe, “but about being aware of and following the law.”

Support Tribal-State Policymaker Dialogue

OTA and AIHC also support meetings between Tribal delegates and state legislators. Successful meetings, especially in person, can change the tenor of conversations and break down barriers. AIHC also works to highlight the political power of Tribes for state agency staff, legislators, and other policymakers. Tribal governments and members contribute to the state’s economy by creating jobs, spending on goods and services, paying state and local taxes, voting in elections, and contributing to regional growth, especially in rural areas. State officials can better focus on Tribal issues and work as equal governments when they understand the power and influence of Tribal governments as sovereign nations and contributors to the public good, with growing populations and effective advocacy groups.

Key Takeaways: Strategies to Improve Tribal-State Health Partnerships

Washington State has worked hard to build a solid partnership with Tribes to support Medicaid and other health-related goals. States across the country can similarly improve their relationships with the federally recognized Tribal governments with whom they share geography, and Indian health care providers who receive Medicaid support to care for AI/AN people. State staff, governors, and legislators can use the strategies employed in Washington State, adapting them to their own settings and contexts in partnership with Tribal leaders and delegates. These strategies include:

• State legislation: Changes to state law can clarify state staff roles and responsibilities in government-to-government relationships with Native nations and governments, including efforts to strengthen and standardize Tribal consultation. The Centennial Accord and Millenium Agreements in Washington State created shared understanding around these relationships, and additional state laws codified these frameworks, focusing specifically on improving health care for AI/AN communities.

• Executive orders and initiatives: Directives from the Governor’s Office can support formal Tribal engagement and enforce best practices. Engagement from the governor’s office is important to facilitating conversations between Tribal leaders and the state. The Centennial Accord and Millenium Agreement mandate accountability and oversight actions from the Governor’s Office.

• Organizations to promote partnership: Organizations within and outside of state government can push for stronger government-to-government relationships and bring policy expertise to the table. Washington State created the Office of Tribal Affairs to better support state-Tribal partnerships related to Medicaid and health care policy. Tribal governments created the American Indian Health Commission to advocate for Tribal sovereignty and needs, including promoting the collective interests of Tribes in working with the state.

• Training for state staff: State staff may not always be aware of the specific requirements for working with Tribes or may be unsure how to meet these requirements. AIHC educates state employees and elected officials about their role in upholding Tribal sovereignty and promoting government-to-government relationships through Tribal consultation and other partnership opportunities.

• Collaborative meetings and consultations: Regular meetings between state staff and Tribes help maintain communication, stay updated, and collaboratively address ongoing issues, in addition to the legally mandated Tribal consultation process. OTA meets regularly with Tribal leaders and their delegates, AIHC, and Indian health care providers across the state to collaborate on Medicaid and health policy issues.

• Sufficient and specialized state staffing: Managing government-to-government relationships with Tribal governments requires sufficient staffing and time to build policy expertise and understand each Tribe’s unique needs and perspectives. In Washington State, adequate funding and support for Tribal liaisons, OTA staff, and other relevant state staff are necessary to sustain deep and ongoing work with Tribes.

• Knowledge sharing: State staff can support Tribal leaders, delegates, and staff as they work with the Medicaid program or other state agencies that impact their goals and priorities. OTA supports the variety of needs and issues brought up by their partners in Tribal government.

• Policy innovation: Tribes and states can collaborate to develop innovative policy solutions to issues raised by Tribes, using Medicaid levers including 1115 waivers, state plan amendments, and other policy and practice changes. In Washington State, OTA and other HCA staff collaborated with Tribal governments on their 2023 1115 waiver, leading to the development of the Native Hub.

Conclusion

Through the practical strategies outlined in this profile, partnerships between Washington State and the 29 federally recognized Tribes whose ancestral homelands intersect with the state have improved significantly. The close and ongoing government-to-government relationship between OTA, Tribal leaders and delegates, and AIHC has resulted in innovative Medicaid and health policies aimed at improving health outcomes for AI/AN communities. Despite some challenges, mutual trust and respect — including respect for the sovereign status of Native nations — help all parties push through challenges and seek solutions together. While each of the 575 federally recognized Tribes across the United States are unique, as are the UIOs and Tribal organizations providing health care to Tribal citizens, many strategies implemented between the Tribes and Washington State can be adapted to strengthen government-to-government relationships elsewhere.

*Armelle Casau is a former associate director at the Center for Health Care Strategies.

1. AI/AN people become eligible for Medicaid through the same pathways as non-AI/AN people: based on income and/or categorical eligibility. Some forms of income related to Tribal membership are not counted toward Medicaid’s income limit. In recognition of the federal trust responsibility, states receive a 100% federal match for Medicaid services delivered to AI/AN people through the Indian Health Service or Tribal health care organizations. At this time, Urban Indian Organizations do not receive a 100% match.
2. 28 of the Tribes that share geography with Washington State have signed the Centennial Accord. One Tribe has chosen not to sign the accord, citing that their government-to-government relationship is with the federal government, not the state.
3. In Washington State, “consultation” refers to the federal mandate to meet with Tribal leaders and their delegates in a formal process to collaborate on policy change that will impact Tribal members. “Confer” refers to the formal process Washington State uses to meet with UIOs on policy changes that will impact these organizations.
4. While citizens of Native nations can receive free health care through the Indian Health Service (IHS), most AI/AN people also have health insurance. Insurance coverage allows for third party payments to be made to Indian Health Care Providers, which can bolster Indian Health Service funding; it also provides coverage for AI/AN people to receive care outside of IHS, which can bolster access to services not provided at local IHS or Tribal sites of care.
5. 988 is the federally mandated crisis number. It was implemented in 2022, as a way for people experiencing a mental health crisis to have immediate access to telephone- or text-based crisis care and referral to additional support. 988 implementation was supported by federal funding, but 988 lines are largely managed and funded on an ongoing basis by state and local governments.