Editor's note: Dr. Kain has worked at a tribal clinic for the past nine years. There is great interest among the tribes in expanding access to chiropractic for their tribal members; however, there is confusion as to how to do it; as well as a lack of knowledge in the greater chiropractic community of the need and process. This article is intended to help bring awareness to the issue and be a guide for those interested in working in this arena.
There are 574 federally recognized Native American tribes in the U.S. representing approximately 10 million people self-identifying as American Indian/Alaska Native on 334 reservations and in many urban centers. There are 2.9 million tribal members being treated by tribal clinics.
The Indian Health Service, or IHS, is the government agency under the Department of Health and Human Services charged with fulfilling health care treaty obligations of the federal government to Native American tribes. The tribes are legally sovereign domestic dependent nations and have diplomatic relations with the U.S. on a state-to-state level, similar to the individual states, and are self-governing within their reservation borders. They follow federal law and negotiate with both the federal and state governments on an equal basis.
The Bureau of Indian Affairs and the Bureau of Indian Education are also involved as well: as tribal liaisons and consulting with most federal agencies that may impact tribal affairs.
The Current Status
The IHS traditionally offers very basic services at most tribal clinics and does not employ or pay for chiropractic services. Due to historically consistent underfunding and outdated policies, the IHS has resisted calls from the tribes to add chiropractic since at least 2015, although it has listed DCs as eligible providers for its loan repayment program if they work for a tribe.
The Indian Self-Determination and Education Assistance Act of 1975 (Public Law 93-638) authorized the secretary of the interior and other government agencies to enter into contracts with, and make grants directly to, federally recognized Indian tribes. This allowed tribes to exercise more tribal sovereignty and choose to take control of various functions previously controlled by the federal government, such as their health clinics.
Such self-determining or “638” tribes can then modify or add the services they perform for their own members instead of the limited services offered by the IHS. Some of these clinics operate as Federally Qualified Health Centers (FQHC) under HRSA.
The Need
The Native American population has the highest rate of substance use disorders and highest death rate by drug overdose and suicide of any ethnic group in the U.S. Native Americans are more likely to experience chronic pain than the general population, and suffer from undertreatment due to Indigenous determinants of health disparities and other biopsychosocial factors. Historically, the IHS clinics were some of the highest opioid prescribers in the nation. Thus, there is a great need for non-pharmacological musculoskeletal care such as chiropractic.
In response, some “638” tribes are adding chiropractic services to their clinics, especially in response to the opioid crisis to address pain and function. To do so, they must petition and negotiate an updated contract or compact with the IHS.
The Challenges
There are barriers due to lack of knowledge of the value of adding chiropractic services or the problems it can help address. There is a lack of knowledge on how to add chiropractic or how to hire a DC or how to bill for it. There are consultants and resources available to aid tribes looking to go through this process and it is very doable, as numerous tribes have successfully integrated DCs into their clinic.
Most tribal clinics are medically integrated with primary care, behavioral health and dental as the core. Some clinics also have physical therapy and/or podiatry or have visiting specialists such as cardiology or nephrology. One barrier is to understand the difference between chiropractic and physical therapy. A credentialing process and peer-to-peer education will likely be necessary.
Working in tribal clinics is similar to working in FQHCs or other community-based clinics. There is often a higher complexity of patients with multiple comorbidities, requiring a team approach to health care. There are barriers to payment. It requires good communication and interprofessional skills to work with the attending MD, PA or NP and medical staff and administrators. It requires a certain comfort level working in a medical setting and as part of a team, rather than clinic owner.
Other challenges include educating the billers and administrators, and using a medical EHR not intended for chiropractic. Long care plans, pre-pay plans and high volume are strongly frowned upon in the medical environment; you may have to adapt to shorter trial care plans with specific goals and co-management with their PCP down the hall who may have other ideas of how to treat or refer. You will likely be expected to stay in your lane professionally, with a neuromusculoskeletal emphasis.
The flipside of this is you can often have the PCP down the hall order any necessary imaging for Medicare or other insurance-restricted patients to avoid the patient having to pay out of pocket. You will need to be able to explain chiropractic and care plans and discuss cases with the other providers using their language. They often know nothing about different techniques or the differences in chiropractic other than what they have heard (good and bad).
The Reality
This will likely be a pain practice, with wellness guidance if you have time. Just remember that you are part of a team of professionals, all there for the patients according to your individual and unique training. As you earn the trust of the patients and providers, it gets easier.
There are opportunities for professional collaboration, expanding perspectives on chiropractic of the medical staff, and often educating and training medical students and residents. It can be very rewarding to help those patients who otherwise would not have access or choose to see a chiropractic physician.
There will likely be a cultural learning curve to working with the Native American population. The Native American culture and experience is unique in the U.S., and it strongly colors their perspectives. There is strong (earned) distrust of non-natives. You will have to educate yourself about generational trauma, the boarding school travesty, land allotment and broken treaties.
There is a high level of emotional, physical and chemical abuse on the reservations. According to the IHS, one in three native women have been sexually abused. All of this directly affects how you talk and care for patients. There is training available to help prepare you for connecting with and assisting these incredible people on their journey to healing.
You will often be treated as an outsider at first and may be questioned how long you are going to stay as the IHS clinics are known for having a high turnover rate. Remember, you are there to help them exercise their tribal sovereignty by taking control of their health, as such you are working beside them, not there to fix their culture. The tribes all have their own culture. Practice cultural humility and listen.
Generational trauma is real and is specifically being addressed on a larger scale now by the tribes. The show “1923” helped open a lot of people’s eyes to the history as experienced by Native Americans. The broken treaties, stolen lands and abuse are recent in native memory, with aunts, grandparents and great grandparents having lived through these traumas.
Research shows that generational trauma can persist and affect lives for up to 14 generations, but it also shows it can be undone in as little as one generation when properly addressed. It can directly affect care.
The Opportunity
Integrative care is the future of health care, and chiropractic is uniquely qualified to provide more effective care more efficiently and more affordable for patients who have been denied guideline-adherent care at tribal clinics. The tribes need and are looking for alternatives to opioids, and chiropractic often fits better with traditional native medicine practices.
The tribes who can – those that have taken steps to practice tribal sovereignty and become self-determining – are taking responsibility and doing something to help their tribal members and communities. They are choosing to bypass the system and hire their own chiropractic physicians to fill a specific role within their medical clinics. Are you in an area or position to help meet that need?
