Joe Finkbonner (RPh, MHA), a member of northern Washington’s Lummi Nation, is the Execu- tive Director of the Northwest Portland Area Indian Health Board (NPAIHB). Tasked with reducing the disparities in health care for American Indian populations in Oregon, Washington and Idaho,NPAIHB’s dedicated staff work under Finkbonner’s leadership to advocate for the interests of 43 Tribal Delegates from the Pacific Northwest, and the communities they represent. This work includes research, legislation and “training the trainers”—providing education for health care providers regarding the specific health issues that are a priority in their communities. NPAIHB also serves as a resource to those providers. The organization’s EpiCenter, where Finkbonner previously served as Director, is one of twelve epidemiology centers around the nation that provide health-related research to improve the health status and life expectancy of native peoples. NPAIHB’s work is a model to tribal communities across the United States.
What are some of the challenges that come with your role?
The challenges involve overcoming the enormous health status battles that face the American Indian populations. There is no shortage of work to be done in regards to the disparity facing American Indians, both reservation-based and urban – everything from oral health challenges to diabetes to cancer rates to cardiovascular disease rates, as well as alcohol/substance abuse rates and suicide rates. But it is an under-re- sourced system – the Indian Health Service (the Federal Health Program for American Indians and Alaska Natives) only funds about 60% of the need, and yet the Federal Government has promised the tribes when they claimed millions of acres of land that they would provide health care to the tribal people. From the tribal leaders’ viewpoint, that obligation hasn’t been met. We are constantly struggling to remind our Congress Members that they have an obligation to make sure the Indian Health Service is still in place and is properly supported, so that it we can continue to make improvements in the health status of our tribal members.
What is most important to you in life?
Making a difference. I don’t choose a path in life simply for my own gratification; I like to feel the work I do is meaningful. Making headway is what motivates me to keep going. It’s not about the acknowledgement or the accolades that go along with accomplishing something—I just want to see results. Those results include having our tribal members able to access health care at a greater rate and with greater ease. Hope- fully, I have contributed to that in the work that I have done, along with the tribal leaders in the Northwest. While I am not an elected leader who steps out in front, I provide information and tools to those elected leaders so they can go out and advocate for more resources for the Indian Health Service.
What do you wish more people knew about American Indian health care?
Many things! One example—I think there is a general misunderstanding that the Indian Health Service is free. What people often don’t fully comprehend is that there are hundreds of treaties that have been signed with tribal leaders in exchange for land that was owned by tribal people. As part of those treaties, the Federal Government promised to provide health care and education. Those promises have not been kept. I am sure there is not a single person living in America today who would feel like it would be okay if that happened to them. You hear people say over and over that this is ancient history and that we should just “get over it”. I seriously doubt if someone was buying a house and they just stopped making payments the bank would just “let it go”. We have mortgaged the United States, and the health care systems and education systems are those payments that the Federal Government is supposed to provide to our tribes and their citizens. There isn’t anyone I know who would let someone else off the hook for promises that were made to that extent.
You are a member of the Lhaq’temish, a part of The Lummi People. What can you tell us about your heritage?
That is a coastal Salish term for our people, our tribal name and a description of the people of that region. There were many villages that were tossed in under the title of the Lummi tribe. As treaties were signed and we were pressed to form a reservation and to establish our roles, many small villages were combined into a larger population and they called us Lummi. That’s typically how it is—if a group is called “The Confederated Tribes of Umatilla,” for example, that means numerous bands were consolidated into one commonly-known tribe.
As far as my own experience of the Lhaq’temish tribe goes, I grew up near Bellingham, WA, on the reservation for a fair part of my life, and I also lived in Bellingham. I was raised by a single mom who did not have a college education. She took clerical jobs and we did not, by any means, live a lavish lifestyle. In fact, we were at poverty level most of the time. What I love about our people and our culture—it’s a sort of tongue-in-cheek joke—it’s said that if you’re part of a Native American tribe you’re never homeless. I have always felt that to be true. That’s really the way our people are. Growing up, we always had extended family who made sure that we had a dry roof over our heads when we were between apartments, when my mom needed to save money to come up with first, last and deposit. We always had a place to stay, whether it was with grandparents, or aunts and uncles, or “family” that is not blood family – the people you grew up with. Anyway, in the tribe, you are all related in one form or another, if you look back far enough in the family tree. This experience has made me who I am today.
What are some examples of common health issues that NPAIHB’s programs address?
There is a lot of emphasis on preventing diabetes, stroke, heart disease and cancer, as well as health maintenance strategies such as managing a healthy weight, staying up to date on immunizations and practicing good oral hygiene. Indian health care is integrated, and the providers talk together about what is best for the patient, rather than just silo-ing an individual’s health care— going here for medical care, going elsewhere for dental care, and going a different place altogether for mental health care or substance abuse management. It’s a system that the United States as a whole could learn from.
How do NPAIHB’s programs interface with Federal health programs, such as the Affordable Care Act?
We worked very hard to ensure that elements and principles that were a part of treaties were included in the Affordable Care Act, and did so successfully. The difficult part has been the implementation of it, because you have 50 states, and ideally all 50 would operate their own exchange, but many do not, for their own philosophical reasons. Oregon and Washington both have their own exchanges.
The Indian Health Service is completely different from the general health care system in the US. It was first established in 1954, and in it the Federal Government took responsibility for making sure tribal peoples are provided with health care. They did it primarily by building health care facilities on the reservations and offering primary care. When tribal members needed specialty care or hospital care, the Federal Government would purchase that from a separate pot of funds that was at that time called “contract health services” and is now called “purchased and referred care”.
We are focused preserving that system. It really is an amazing system, because the bulk of the resources are put into public health and prevention. When you look at the average life expectancy for an American Indian back in 1974, it was 47 years of age. If that were still true today, I wouldn’t be sitting here now! Since that time, through the Indian Health Service system, tribal leaders and health care providers have focused on public health infrastructure, sanitation, housing and immunizations, as well as on providing education about disease prevention and public safety. Now the American Indian life expectancy average is between six and seven years less than the general population. You can see it’s been quite successful! I think it would be even more successful if it weren’t under-resourced. We are at 60% of the spending of the general population. I think if our system was fully funded, we might not only meet the life expectancy of the general public, we might exceed it.
Regarding the Affordable Care Act, we want to protect that system, because we think it’s valuable. Even when tribes began to take over operating that system, they largely continued the same principles. The Indian Health Care Improvement Act is a bill that was first approved in 1976, and it addressed specific aspects of Indian Health Services and what specific services were authorized to spend money on. We have worked a great deal to get that reauthorized and renewed.
We were not very successful during the Bush administration, and when Obama was elected and began talking about developing the Affordable Care Act, we saw that as an opportunity to work on the Indian Health Care Improvement Act. What we thought was important in the Affordable Care Act was to honor some of the elements of the treaties and that Federal obligation.
What are your hopes for the future?
I hope for good health for everyone, but particularly the populations that I work with, our tribes in the Northwest. I’d love to see the health status of the American Indian population improve to be on par or above that of the general population. We have many people working together to produce results, and it is my hope that we will be successful. I’d like to see our tribal populations enjoying longer life and better health—they deserve it!