The Role of Provinces, States, and Territories in Shaping Federal Policy for Indigenous Peoples’ Health

ABSTRACT

Under both Canadian and United States law, the availability and quality of healthcare and health services to Indigenous peoples are primarily a federal responsibility. Nevertheless, sub-national authorities—most importantly provinces, states, and territories—play a crucial role by virtue of covering (often through federal mandate) services, and regulating health facilities and health personnel off-reserv(ation). While both federal governments have undertaken efforts to transfer, within their fiduciary obligations, their responsibilities for Indigenous peoples’ health to the management of Indigenous peoples themselves, that transfer has considered or included provincial, state, and territorial authorities and resources unevenly, and, in some cases, in tension with the objectives of respecting standards for quality and access. This article applies the methodology used by Canadian researchers of the sub-national health authority issue to the health transfer experience in the United States. The article summarizes findings that demonstrate similar deficiencies as those present in the Canadian transfer process. The article further outlines the experiences of Hawai`i and Ontario as offering models through which to address some of these deficiencies. The article finally suggests that there is a positive relationship between greater participatory models adopted by provinces, states, and territories and better health outcomes among Indigenous groups so included.

KEYWORDS:

• “638 compact”
• Aboriginal
• American Indian
• first nations
• health policy
• Native American

Acknowledgments

The author thanks the editors and the anonymous reviewers, Yvonne Boyer, Colleen Flood, and Brenda Macdougall. Research assistance was provided by Alison Matusofsky.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. As with Canada, there are populations specifically committed to the federal government such as its employees, members of armed forces, and Indigenous peoples.

2. The Children’s Health Insurance Program, established in 1997, is similarly jointly administered. For purposes of the analysis provided herein, the same problems that apply to Medicaid broadly apply to CHIP although some states maintain special programs with respect to the health and welfare of Native American children. The welfare of Native American children is similarly affected by the Indian Child Welfare Act, although the relationship of that federal law to the issues addressed by this article is generally distinct.

Additional information

Funding

This Article was completed with support from the Foundation for Educational Exchange Between Canada and the United States as part of its Fulbright Scholars program.

Notes on contributors

Sam Halabi

Sam Halabi is an Associate Professor at the University of Missouri School of Law as well as a Scholar at the O’Neill Institute for National and Global Health Law at Georgetown University. During the 2017–2018 academic year, he served as the Fulbright Canada Research Professor in Health Law, Policy, and Ethics at the University of Ottawa, Ontario. He is the editor (with Larry Gostin and Jeff Crowley) of Global Management of Infectious Disease after Ebola (OUP 2016). He holds a JD from Harvard Law School, an MPhil from the University of Oxford (St. Antony’s College) and a B.S., summa cum laude, from Kansas State University.