The idea of “tribal sovereignty” is not static. It’s always a test, a back and forth contest between those who believe in indigenous self-government versus those who like the idea of Someone Official dictating rules.
Usually that Someone Official works for a government, a state, a county, or the federal government. These are well-intentioned people who passionately believe they are doing the right thing. But Someone Official doesn’t always have to be a government; the same disregard for tribal sovereignty is found in business, nonprofits, and in professional associations.
And so it is with the story about dental health care in Indian country.
Alaska, like much of Indian country, was facing an oral health epidemic with tooth decay (and pain) being the norm for nearly every child. A number of studies reached the same conclusion: "Lack of access to professional dental care is a significant contributor to the disparities in Indian health that exist in the American Indian/Alaska Native population."
So more than a decade ago the Alaska Native Tribal Health Consortium experimented with mid-level oral health providers, dental health therapists. The design of the program was to train and hire community-based providers right out of high school who would serve patients at the village level. The dental health therapists carry out basic dental services such as fillings and simple extractions. Their primary role is preventative and educational.
However the American Dental Association sued to stop this program, saying that the mid-level providers were practicing dentistry without a license. The Alaska Native Tribal Health Consortium fought back, using the Indian Self-Determination Act and the Indian Health Care Improvement Act to trump the state's licensing regulations. Now more than a decade later, the program has been spectacularly successful providing routine dental care to some 40,000 patients every year.
You'd think that kind of success would bring a smile to the members of the American Dental Association. Nope. Instead the dentists' trade group is lobbying to make sure that the dental health therapists program is limited to Alaska (and now Minnesota).
This is where the dentists took on the role of Someone Official. The ADA decided that tribes in the lower 48 should not even have the opportunity to experiment with mid-level providers unless authorized by a state authority. The ADA did this by inserting language into the Indian Health Care Improvement Act (which is rolled into the Affordable Care Act) that says the Indian Health Service must have state approval before expanding dental health therapists.
This is where the next chapter in this story starts. At the National Congress of American Indians mid-year conference last week, President Brian Cladoosby, Chairman of the Swinomish Tribe in Washington state, announced that his tribe will enroll a student in a two-year training program to become a dental health therapist.
"We as Indians have long faced an oral health crisis, and the crisis is only growing," Cladoosby said. "There just aren't enough dentists in Indian country to address this crisis. The Swinosmish dental clinic sees more than twice the number of patients per provider as the national average. That's why we are expanding the Swinomish dental team through the proven solution of training and employing dental health aide therapists."
This is tribal sovereignty in action. Current law might prevent the Indian Health Service from investing in better oral health care delivery; but it does not say anything about a tribal health program. This is one of those historical pushes against the status quo that write the rules for what can be done.
The extraordinary thing about this whole story is that it should be a non-issue. Dentists and their trade group should be cheering the success of reaching so many Native people with a path forward for better oral health. Nearly every clinic in Indian country is understaffed – and I only use "nearly" because there might be one outlier out there. Fact is that there are not enough dentists in this country to serve the general population, let alone underserved communities such as Indian country. (And in the decade following the success of the Alaska dental health therapists program, it's significant that the dentists' trade group has proposed another solution to improve access to dental health in Indian country.)
A couple of years ago I had the chance to visit Bethel, Alaska, with dentists in a trip sponsored by the W.K. Kellogg Foundation. At one point, the dentists asked one of the dental health therapists about his practice in a series of rapid fire questions. One by one he answered correctly. And the dentists walked away impressed because the people were being served.
One more test, one answered by sovereignty in action.
Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.