Story by Zachariah Bryan, photos by Jamie Drysdale
It was Friday, the end of a busy week for Loren BirdRattler, Blackfeet Nation’s agricultural resources manager. He was driving around the Blackfeet Indian Reservation in his banged-up 2001 Buick LeSabre. His attire stood in sharp contrast against the rugged terrain around him: a purple collared shirt with a matching purple patterned tie, pinstripe slacks, a black overcoat.
He was showing off the many projects he had gotten involved in since starting his new job in June 2016: a new water compact that he helped pass through tribal council vote in May, a conservation district, a noxious weed cleanup and plans to support Blackfeet farmers and producers. He also chairs the state Youth Suicide Prevention Commission, which recently helped pass a bill in the legislature that would allocate $1 million to the cause.
This is where he’s comfortable. He has a long resume with a smorgasbord of organizational development, policy and advocacy positions, taking him to Washington, D.C. and back. He lists positions with high profile organizations like the Smithsonian Institute, Department of Defense and, most recently, as inaugural executive director of Western Native Voice and Montana Native Vote.
Those last two positions ended four years ago. He became sick and then homeless, leaving a gap in his resume from 2013-2016. He picked up trash, bartended and slept on benches and in abandoned houses in Washington state, having fallen through the cracks of both the state and tribal health care systems in Montana.
He was rebuilding his life in Spokane, where he received health care through Washington’s Medicaid expansion, which Montana, at the time, had failed to pass itself.
It saved his life.
State officials believe that a little less than half of Montana’s population of 70,000 Native Americans live in urban areas. Urban American Indians are described as the “invisible tribes,” a group of people who are poorly understood, experience greater health disparities and are often ignored in the national conversation on American Indian health.
Treaty obligations require the federal government to fund health care for Native Americans, a responsibility that is fulfilled by the Indian Health Service. However, most of that money is concentrated on reservations. Less than 1 percent of the nation’s IHS budget goes toward a smattering of Urban Indian health centers, $44 million out of $5.7 billion nationwide, according to the U.S. Department of Health and Human Services 2016 budget.
That scant funding comes in the form of grants and contracts, which often come with strings attached and specific parameters, such as diabetes or tobacco prevention programs. According to the Urban Indian Health Commission, there is no uniform national policy regarding Urban American Indian health care.
IHS does not focus on tribal members living in urban areas because those communities are not part of sovereign nations, said Aren Spark, government affairs director for the Seattle-based Urban Indian Health Institute.
“(It) is an easy out for them because then they don’t have to spend as much money,” Spark said. “That way you don’t have to pay attention to all the Native people, which would be a much larger sum of money.”
Just two out of the five urban Indian health centers in Montana have a clinic with limited primary care and other services, while the others act mostly as referral centers. Before Montana expanded its Medicaid program, many fell into a gap where they made too much money to qualify for Medicaid, and made too little to afford the high premiums of private health insurance. It was common for urban Indians seeking treatment from IHS to drive back to the reservation.
BirdRattler opted out of health insurance when he was executive director of Western Native Voice in Billings. He figured he was healthy, he said, and if something ever arose, he could just drive to the IHS hospital on the Crow reservation.
In 2011, the same year he started working at Western Native Voice, he began a new medication prescribed by RiverStone Health, a Billings-based public health nonprofit, for a chronic illness he declined to disclose.
While the medication worked, he started developing side effects. Specifically, psychosis. It was gradual at first, enough for him to convince himself that nothing was wrong.
BirdRattler said he didn’t let his growing inner struggles affect his work.
“I’m very meticulous about how things appear. I’m a perfectionist. I wanted perfect results. That drive (for my work) never stopped during that slow degradation,” he said.
His problems persisted, culminating in spring 2013. He quit his position at Western Native Voice and went back home to the Blackfeet reservation.
He started having suicidal and homicidal thoughts.
“I justified in my mind that it was OK to take another life,” he said. “There were times I felt I was ready to pick up a gun and begin to take people’s lives.”
One morning, he woke up and knew something wasn’t right. He decided he needed to leave, before he actually hurt the people he loved the most: his friends, his family and his lover. He packed up his suitcase with three changes of clothes and his mother drove him to the train station. He was off to Spokane.
“I got on the train with no intention of ever coming back here, no intention of ever having ties with my family,” he said. “That’s how bad my state of mind was at the time.”
It was a choice that saved his life, he said.
Washington passed Medicaid expansion three years before Montana did, and BirdRattler fit perfectly into its parameters.
With health insurance, BirdRattler was able to see a team of doctors in Spokane. They quickly identified that it was his medication causing the psychosis, and put him on a different medication. He worked with the providers on a plan to put him on the road to recovery. He had a whole team on his case: a physician, a physician’s assistant, a pharmacist and a nutritionist. The experience was “eons ahead” of what he saw at IHS, which didn’t have the resources to pay such close attention to his health.
His mind began to clear, he said, but it took time to heal fully.
“I think about those times and I often equate it to an LP record, when you put a scratch in it,” he said. “Every time that needle comes around, it’s going to hit that scratch. It takes a while to buff out those scratches, to not go back to where you were.”
When the Affordable Care Act rolled out, it came with much promise and fanfare, and there was no shortage of initiatives targeting Native Americans for enrollment. Yet many Native Americans who are eligible for insurance in Montana remain uninsured.
Of the roughly 70,000 Native Americans eligible for reduced coverage in Montana, only about 17,000 have signed up. Another roughly 22,000 appear to have insurance through their employers, according to an analysis of state and federal employment records by the Billings Gazette in September, 2016.
Helena Indian Alliance, one of the two Urban Indian Health Centers in Montana that have a clinic, has been on the front lines. When the ACA marketplace first rolled out, Executive Director Tressie Smith said there were a number of challenges: higher premiums, application glitches with the Affordable Care Act website and a long, complicated process.
Julie Burrows, enrollment coordinator, said it could take up to three visits, each two to three hours long, to guide a person through the process. And big enrollment events, no matter how well-advertised, proved to be ineffective, Smith said.
“Most of those were failures,” she said. “What we really needed to do was target people and get one-on-one with them.”
Medicaid expansion, which was enacted in 2015 after the state legislature passed the Health and Economic Livelihood Partnership, or HELP Act, has succeeded where the ACA private insurance marketplace faltered. So far, nearly 10,000 Native Americans have enrolled in Medicaid, and more sign up every day, according to a February report from the Montana Department of Health and Human Services.
Helena Indian Alliance has been an especially effective partner in the rollout. In 2011, when the organization first started tracking insurance numbers, 80 percent of their patients were uninsured, 9 percent had private insurance and almost 6 percent were on Medicaid.
In the first quarter of 2017, the numbers have changed dramatically: 39 percent of patients were uninsured, 17.6 percent had private insurance and39 percent of patients had Medicaid. Overall, from 2015 to 2016, the clinic saw 25 percent more patients, which Smith largely attributed to Medicaid expansion.
“That’s a big thing. Every one of those (people) matters,” said Lesa Evers, tribal relations manager for the state Department of Health and Human Services. “Every one of those now have access to preventive care, to dental care, to eyeglass, to mental health and substance abuse services, this whole myriad of coverage they didn’t have before.”
Evers explained that Medicaid opens up a whole new world of options for Native Americans, many of whom aren’t used to having private health insurance. Where before, if they went to IHS, they could be turned away if their health condition wasn’t life threatening, now they can seek the treatment and operations they need. And if a patient needed care that couldn’t be provided at an IHS facility, there were only so many dollars available to refer them to outside hospitals.
Having insurance could be critical in closing the life expectancy gap between Native Americans and other races, Evers said. According to a 2013 report, “The State of the State’s Health,” on average white men in Montana live 19 years longer than Native American men, and white women live 20 years longer than Native American women.
“That’s a big deal,” she said. “If we would’ve had access to preventative care, if we understood what it is, if we knew what it meant to prolong life—to stopping disease or slowing disease—if we understood all that, maybe we wouldn’t have this 20-year difference in lifespan,” Evers said.
There will always be challenges in providing health insurance to Native Americans, she said. Health insurance is a new concept for most in Indian Country, and it’s complicated, especially for a group of people who historically have received health care without having to worry about medical bills. There’s a whole world of lingo that needs to be mastered: premiums, copays, deductibles and more.
“I think, for most people, it seemed out of reach, so they would just continue to use the limited services they have available to them,” Evers said.
Lisa LaMere, 35, who lives in Billings, is a Chippewa Cree descendant and qualifies for enrollment in the federally unrecognized Little Shell Chippewa Tribe. She has eight prescriptions. She uses them to treat a number of ailments: depression, anxiety, diabetes, high cholesterol, chronic heart burn and a kidney that has been losing function over the past year.
Before she qualified for Medicaid under Montana’s HELP Act, she had to scramble this cocktail of pills together in an unorthodox fashion. She got the majority of her medicine at the Billings Indian Health Board. But they didn’t have everything, so she went to RiverStone Health to pick up two others through a discount program.
Sometimes, the Costco Pharmacy would be cheaper. Other times, she made the 90-mile trip to the Crow reservation IHS facility, but she didn’t like the way they treated her. As an outsider, she felt unwelcome, like the staff expected her to seek treatment at her home reservation.
LaMere couldn’t pick up all her prescriptions at the same time. They came on different days. If she missed a pickup, and didn’t take certain medications for even a day, she experienced debilitating headaches.
Just talking about the process made her feel tired. LaMere is a working single mother of two, so taking hours, sometimes full days, off of work multiple times a month to pick up prescriptions or to see the doctor to get a new prescription, was unsustainable.
“I’m only 35 years old,” she said, lamenting she was too young to have so many health problems. “To be on all those medications is a huge hassle to begin with, and then the time and energy it took to wait everywhere you go, any services that are for low income, you just have to wait for an extra long time.”
Medicaid changed that. Now, LaMere can see her doctor and pick up her prescriptions all at the same place, the Billings Clinic, which is right next to where she works. No more scavenger hunts for pills.
“I don’t know what I would do without Medicaid in my life,” she said. “I wouldn’t have the same level of life as I do now.”
Many Native American leaders and advocates were on the edge of their seats when Donald Trump was elected president and Republicans took over both houses of the Legislature. The administration has made it a top priority to repeal the Affordable Care Act, which would likely include cuts to Medicaid.
The House of Representatives failed to pass a replacement program, the American Health Care Act, in March. In late April, a new version of the act narrowly passed the House, although experts are skeptical the bill has enough support in the Senate to follow suit.
“They don’t have the votes (to roll back Medicaid),” said Mark Trahant, an independent columnist who has been writing almost daily about the health care debate on his website Trahant Reports. “You see a lot of conservative states decide that the numbers worked out.
That includes Sen. Lisa Murkowski (R-Alaska), who said she would not vote for cutting down Medicaid expansion so long as state leaders still embraced it, despite her criticism of the ACA.
As for Montana, Sen. Steve Daines has said he supports cutting back Medicaid.
In this administration, nothing is safe, Trahant said. In March, he said he had heard rumors that Republicans were already working on another attempt to repeal and replace ACA, and Indian health could be on the chopping block.
“They’re all in the target sights, the question is, can you get consensus? That’s the challenge now, they can’t get consensus,” Trahant said at the time, noting that the debate over healthcare has revealed deep divisions in the Republican party. Montana health care leaders are listening closely to the national debate, but at least for the time being, all they can do is keep operating like Medicaid expansion and other provisions of the Affordable Care Act are here to stay.
“I don’t think people should become paralyzed or stifle what they’re doing,” DPHHS Tribal Relations Manager Evers said. “We have it today. Let’s use it today, let’s continue like it’s going to stay in place for a while.”
On Christmas Eve of 2015, BirdRattler returned to the Blackfeet reservation. He reconnected with his family, found old friends and helped his uncle out on the family ranch in Birch Creek.
He decided to stay.
In the spring of 2016, Verna Billedeaux, ex-officio member of the Natural Resources Conservation District, encouraged him to apply for the newly created agricultural resource manager position.
“I love his energy, love his passion, love his vision,” she said over the phone.
So, he applied. He was interviewed and hired and he’s been going 90 miles per hour ever since. Working a policy and organizational development job is like riding a bike, he said.
Thinking on it, BirdRattler said he likely would have never made it back to this kind of position, back to his home, without that break in Spokane when he was able to receive insurance through Medicaid expansion. It was a slow climb up, he said, but he made it.
“To be patient was a hard lesson for me,” he said. “To be patient and allow things to fall into place. I’m spiritual. I do have a relationship with the Creator, I knew the Creator had me on a path and that I just needed to be patient and things would manifest. And they did.”
BirdRattler still visits Spokane every now and then. It’s like a second home, he said. On a recent sunny April day, he clambered down a slope of rocks under the bridge overlooking the Spokane Falls. He found the spot where he had camped out so many times when he was homeless. He looked out onto the Spokane River, which, fueled by snow melt from a good winter, was higher than he had ever seen it.
The water was raging, constant, boiling foam white. Spray wetted the rocks and the litter where he had once slept.
He thought of other Urban Indian Americans, who perhaps didn’t have the same resume and support system as he did.
“When you’re really talking about the impacts (of Medicaid expansion) on urban Indians, they’re profound,” he said. “You’re really talking about a population that’s in this gray area, that doesn’t get direct health care from Indian Health Service, that doesn’t have access to health care on the reservation, that doesn’t have access to health care off the reservation, in the urban areas where they reside.”
“That is just egregious. I think as an industrial, advanced society, we can do a helluva lot better in coming up with solutions to raise them up and provide adequate health care for them.”
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