Governor signing Windy Boy community health bill

A bill by a local legislator intended to improve health care on Indian reservations that split local legislators' votes is being signed into law today by Gov. Steve Bullock.

Rep. Jonathan Windy Boy's Community Health Aide Program bill is scheduled for signing today in Helena.

The bill sets standards for people to be certified, without being licensed, to provide some dental, behavioral health and community health services in a location operated by U.S. Indian Health Services or a tribal health program.

"This is going to be a win-win situation for everybody," Windy Boy said.

The bill, House Bill 599, was amended by the Senate and sent back to the House, then went to a conference committee after the House did not approve the amended version, voting 83-17 to not approve the amendments.

After coming out of the conference committee, the House voted 73-23 to adopt the amended version and the Senate passed it 28-22.

Local legislators were divided on support for the bill, with votes divided half-and half.

Along with Windy Boy, Reps. Joshua Kassmier, R-Fort Benton, and Kasey Knudsen, R-Malta, and Sen. Frank Smith, D-Poplar, voted for the bill.

Rep. Jacob Bachmeier, D-Havre, and Sens. Russ Tempel, R-Chester, and Mike Lang, R-Malta, voted against the bill.

Windy Boy said the issue was first brought to his attention by Fort Belknap Indian Community staff and attorney, he said. They said the Indian Health Services director told the tribes other states have been utilizing a CHAP program since the 1960s, he said. It was originally established to bring health awareness to the community and transport patients to see specialty doctors.

Alaska and Washington state are the only other states in the country with the community health aid programs, he added.

After the bill is passed, Montana will set certification for dentist health, mental health and behavioral health aid technicians for tribal and Indian Health Services facilities. The certified professionals will be able to assess patients for preventative care and be able to refer patients to specialists who can treat them.

Windy Boy said that while the bill was in the Legislature, it had some opposition from the dental industry, which feared unqualified people would be authorized to provide surgical care. He added that these claims are misinformed and the aids would only provide precautionary preventative care.

Many children on the reservations need specialty care because their teeth are growing in incorrectly and sometimes can cause issues, he said. The dental health aid technicians would do screenings to catch those issues with children's teeth and "red flag" the patients and notify the dentist to put them at a higher priority.

Dental health aid technicians and the other technicians authorized in the program would be certified and trained on the state level, he said. He added that dentists who are authorized for surgical extractions are classified as level four, the dental aid technicians would be classified as a level one.

The Community Health Aid Program would be overseen by a board made up of health care professionals in the specific areas of mental, behavioral and dental health, he said. He added that the board will make sure the health aid technicians are compliant with all of the requirements by the state.

Mental and behavioral health care is critically important, Windy Boy said. Montana has one of the highest rates of suicide in country, he said, and Indian Country in Montana is ranked higher than state average. The mental and behavioral health aid technicians, once they are implemented, will be addressing those specific issues, screening patients and pushing them to local psychologist specialists.

Windy Boy added that the bill will federally "force (the state's) hand" to address the needs on reservations.

"People are afraid of change," he said, adding that the program needs to be established to pull health care on the reservations out of the "dark ages."

The bill has no fiscal note, he said. The program will be run off of third party billing and is eligible for IHS funding. Patient who receives the services will also be able to use private insurance, medicaid, medicare other insurances which are available.

IHS has also proposed $20 million in the CHAP program, he said.

"Which is huge because we are one of only three states that has this capability," he said.

Indian health care has been underfunded for decades, since its conception, Windy Boy said, but having third-party billing capabilities increase revenue and the effectiveness of the program.

The bill was originally scheduled to sunset in 2021, he said, but during the conference committee he was able to have it extended to 2024.

"It's going to take a year or two to get everything in place," he said. "... We want to do this right."

Once the board is put into place and they are able to start implementing regulations they will have the blueprints to move on to the next step, he said.

Local legislative support - and opposition

Lang and Knudsen did not respond to multiple requests for comments on the bill.

Bachmeier said he voted for the bill when it first came to the floor of the House, but after it passed and he found out more about it, he reversed his position.

His concern is that the bill dramatically expands the scope of practice and could put patients at risk, he said. The Senate made some amendments which may make the bill more on line with the intent of the bill, but he had not had a chance to consult with medical professionals about the amendments.

 He said that various boards oversee behavioral health, medical and dental licenses and have developed ethical, legal and educational standards that are in line with others across the country.

"When any of us walk into a clinic, we can assume that our providers have been educated, credentialed, and that they have appropriate oversight from a medical board," he said. " ... I understand reservations struggle to find providers and I have empathy for those communities struggling to find providers. However, I also believe that we have standards in place for medical professionals for a reason. Everyone should receive a certain quality of care."

Tempel said that the bill shouldn't have made it out of the Legislature.

"All I can say is, I cannot believe some of the bills that get passed," he said. "This was one that should not have cleared either house."

Smith said that although he is not an expert on the bill, other states and public health services are using a similar program

"It isn't certified by the state, but it can be," he said.

All the bill does is make certification for community health aid technicians so public health units can use them, he said, adding that the final decision is up to the supervisors at each health care facility if they want to utilize the program.

"I'll do anything that supports health care," he said.

Reservations have a shortage of medical services across the state and the bill helps address the issue, he said. He added that the main opposition of the bill was coming from big hospitals, because they are the ones that receive the referrals.

He said that if the program is successful on the reservations it could be expanded statewide.

Kassmier said he supported the bill because it increases care. The bill was aimed for communities that are trying to get help, he said, adding that more people will be able to be seen by the community health aides and, if further action needs to be taken with the patients, the aides can refer them to a specialist, cutting down the time it takes for people to get the help they need.

"It's hard to get qualified people in everywhere," he said. "The more help we can get, somehow, I think, it does benefit people's health care."

Kassmier said that the community health aide program does not cost as much as hiring more licensed health care professionals and will be easier for people to access on reservations. People will be able to be seen quicker and the technicians will be able to identify problems faster. He added that the program doesn't mean the technicians are not qualified, but will be working on preventative health care and identifying issues before they get worse.

He said that because the bill does have a sunset, if issues arise with the program they will be able to revisit it.

"I think it's going to improve health care all the way around," Kassmier said.