Considerations in Government, Tribal, and Military Healthcare Settings

It is highly recommended in the community that clinicians broaden their exposure to clinical case profiles that help them grow in their expertise of these foundational concepts to improve the quality of care. For this reason, this course will explore the impact of foundational concepts in non-profit, academic/research, state, federal, tribal, and military health systems across the United States of America and Native Nations.

Case studies will be provided in this course, specifically geared towards the similarities and differences observed in each of the settings discussed, and the implications of key concepts applied in each setting. The course begins by looking at both for-profit and nonprofit entities. Then, this course will explore the state-based system before contrasting that to federally based healthcare systems. This course goes further by exploring key concepts in the military and veteran healthcare systems, before wrapping up with explorations the health systems of Native American Nations.

It is highly recommended that clinicians study further and grow in their understanding of the varied types of healthcare systems in the United States as they navigate their clinical career. They are more likely to be able to provide a standard of care that honors all their patients.

The present course begins by exploring considerations of working in specific healthcare systems and providing guidance for the aspiring clinician. Settings in the United States that are private, for-profit, investor-owned, or network-owned have unique considerations that a Charge Nurse, Rehabilitation Manager, or other administrative clinicians may need to consider (U.S. News & World Report, 2023).

Some of the largest opportunities for medical and allied health professionals to be employed in the private setting can be found at businesses such as the Hospital Corporation of America®, Tenet®, HealthSouth®, Universal Health Services® (UHS), and CVS®. Interestingly, CVS® is the largest USA healthcare company, but has a limited scope of practice and distribution of medications. Currently, CVS® is only authorized to provide outpatient services in the most fundamental sense. Outpatient services billable under physical therapy (PT), respiratory therapy (RT), or occupational therapy (OT) are not currently offered. CVS® is a major employer of nurses and nurse practitioners across the country (CVS Health, 2021; U.S. News & World Report, 2023).

Considerations in for-profit healthcare settings are well-known and frequently discussed in the community. Other healthcare settings require additional regulations, such as those seen in entities that do not focus on generating profits to deliver care, but instead reinvest their revenue into the healthcare entity to fund additional services.

Aspiring clinicians are likely to work in a variety of for-profit settings. These settings can be investor or network owned. A smaller subsection of the clinical community may choose to work in settings where profit-based approaches to healthcare delivery are not emphasized. In many cases, a non-profit focused setting will be associated with a moral, ethical, or philosophical reasoning for de-emphasizing the sources of funding of the healthcare revenue cycle. Approximately 60% of healthcare settings are non-profit funded settings. Upwards of 20% of healthcare settings are government or military-associated entities; we will discuss military-associated care in subsequent sections (Kaiser Permanente, 2023; U.S. News & World Report, 2023).

The largest non-profit provider in America is Kaiser Permanente, with over 12 million members in its insurance plan across eight states and the District of Columbia. Kaiser Permanente has 39 hospitals and 734 medical offices (Kaiser Permanente, 2023). This example of a non-profit provider differs from many smaller non-profit systems, such as that found at Massachusetts General Birmingham, an integrated academic health center. Massachusetts General Birmingham has 14 academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, and other care sites and services (Massachusetts General, 2023). A clinician working for Kaiser Permanente may experience a work-life they commonly expect (U.S. News & World Report, 2023).

Non-profit healthcare systems have additional regulations that can affect their sources of operating revenue and/or their healthcare revenue cycles. Non-profit health systems must file additional paperwork, such as a Healthcare Administrative Needs Assessment. Clinical personnel are often utilized as review members or other administrative personnel when collecting the data for Needs Assessments and can be an excellent opportunity for career growth (U.S. News & World Report, 2023; Furukawa et al., 2022).

An often overlooked area of healthcare, but one that expands the opportunity for a clinician to grow in their expertise, are religious-based non-profit providers. Just like other non-profit healthcare entities, there can be additional considerations in this setting due to the emphasis on a particular religious viewpoint or philosophy, something to keep in mind when interviewing for those jobs. Depending on their group size, religious-based non-profit providers may need additional authorizations to provide RT, PT, or OT services (U.S. News & World Report, 2023).

The most considerable religious-based non-profit collaboration exists between Catholic Health East and Trinity Health, known as the Trinity Health system® (Trinity Health, 2023). It includes 88 acute-care hospitals, hundreds of other care locations in 25 states, and Medicare’s (PACE) Program of All-inclusive Care for the Elderly, providing billions of dollars in care to more than a million people. In 2021, Trinity Health® began talks with MercyOne’s 16 medical centers and affiliates in Iowa and may be moving into that region (CMS, 2023; U.S. News & World Report, 2023).

In more urban areas, nearly ⅔ of healthcare entities are non-profit. They often align with academic and/or research providers that abide by certain guidelines for their scope of practice. One of these types of entities will be discussed in later sections: the University of California health system. These relationships are available between some healthcare entities and academic, governmental, military, tribal, or other research-oriented settings (University of California Health, 2023; U.S. News & World Report, 2023).

The U.S. federal government will occasionally waive or cede responsibility for a service or function to the states (Massachusetts General, 2023; Michigan Department of Health and Human Services [MDHHS], 2023a; MDHHS, 2023b; Mishkiki Community Clinics, 2023; University of California Health, 2023). In healthcare, this can happen quite frequently and get complicated. However, clinicians can navigate these different systems and establish a profound and broad-based career that can be stimulating and stabilizing.

An example of a state-funded system that provides primary, secondary, inpatient, and outpatient services is The Healthy Michigan Plan. The Healthy Michigan Plan is executed through the state-level Michigan Department of Health and Human Services (MDHHS) and provides essential care to the most impoverished residents in the area (MDHHS, 2023a; MDHHS, 2023b). Like other state-level departments, MDHHS is a dedicated health division of the state government that works closely with local governments and municipalities to provide public health on the ground. This particular system can have ample career and growth opportunities for medical and allied health professionals that wish to expand their clinical expertise in challenging conditions. Further, it provides a fantastic opportunity to grow in public health while serving a local community that may not otherwise have access to quality healthcare (MDHHS, 2023a; MDHHS, 2023b).

The most common state-funded system is the academic or research system, such as the University of California's statewide system of Medical Centers (University of California Health, 2023). State-funded medical centers and academic clinical research partnerships benefit all aspects of the healthcare revenue cycle. Specifically, the patient intake process and the payment structures in these settings are more streamlined, providing low patient costs and simultaneous cutting-edge healthcare access. Academic and clinical research healthcare settings adhere to the strictest policies of a Just Culture, the Pillars of Healthcare, and the patient-provider relationship.

This system serves California patients under the banner of UC Health (University of California Health, 2023). The University of California Medical Center is an autonomous operating unit of the University of California, separate from the state. These centers are unique from those found at Massachusetts General because the UC Health system must additionally support all other forms of the educational experience at the university level (Massachusetts General, 2023). Additionally, the UC Health system supports five academic medical centers and their associated services, each of which has educational and clinical relationships with several of UC Health’s 20 health professional schools, including UC Davis Medical Center, UC Irvine Medical Center, UCLA Medical Center, UC San Diego Medical Center, and UCSF Medical Center. The last of which also includes Children’s Hospital & Research Center Oakland in its financial statements (University of California Health, 2023).

In the next section, a targeted and specific application of this exploration is provided. The first case study will utilize the lens of mental health disorders and disparities to provide a focused clinical application. In Case Study #1, the healthcare revenue cycle is interrupted, but not due to financial reasons. Federal and state-level research has been conducted and has determined there is a specific need for intervention but demonstrates that the complexity of finding an appropriate solution requires healthcare administrators who are able to see the broader implications of the healthcare revenue cycle. In this case study, those implications affect some of the most at-risk populations in the U.S., children and teens suffering from documented mental health crises (Whitney & Petersen, 2019).

In general, financing healthcare in America involves setting caps on costs and incentivizing cost reduction, lowering the price burden on patients. Much of healthcare financing is driven by CMS, which supports the programs of Medicare and Medicaid. CMS guarantees delivery of a specific level of coverage to people who might not otherwise be able to afford it. Medicare and Medicaid’s administrative overhead remains low compared with private insurance, and its spending per individual has risen more slowly than private insurance (Alzheimer’s Association, 2022; Center for Medicare & Medicaid Services, 2023).

Medicare is one of the US's largest sources of public health insurance, serving the elderly, the disabled, and those with end-stage renal disease (ESRD). CMS offers Medicare and Medicaid at the federal level, but Medicaid can also be available at the state level.

Medicaid, the third-largest source of health insurance in the country, provides coverage for low-income adults, children, the elderly, and individuals with disabilities. This program is also the most significant long-term care provider for older Americans and individuals with disabilities. In 1997, the US government created the Children’s Health Insurance Program (CHIP) to provide insurance to children in uninsured families (Center for Medicare & Medicaid Services [CMS], 2023).

CMS is a major player in the healthcare sphere (Alzheimer’s Association, 2022; CMS, 2023). Medicare and Medicaid’s policies affect more than healthcare delivery. They drive many of the financial standards for delivering healthcare because they are heavily woven into the fabric of all other forms of American healthcare financing. Healthcare financing is a major factor driving patients' access to necessary services. The most significant effect of state vs. federal funding of Medicaid is the variability in access to services depending on where a person lives and which state they reside in (CMS, 2023). In Case Study #4, access to Medicaid services is explored through the lens of individuals who are at risk of self-harm, substance abuse, and mental health crises (Rahman, 2022).

The present course has discussed Medicaid at the state level more than issues related to the federal level (CMS, 2023). At the federal level, Medicare and Medicaid are more heavily regulated by CMS. Medicare has different parts that help cover specific services (Alzheimer’s Association, 2023; CMS, 2023):

1. Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (SNFs). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people do not pay a premium for Part A because they or a spouse already paid it through their payroll taxes while working.
2. On the other hand, Medicare Part B helps cover medically appropriate physician’s services and outpatient care. It also covers healthcare to prevent illness or detect it at an early stage when treatment is most likely to work best. Most people pay a monthly premium for Part B.
3. Medicare Part C is a managed care plan and is associated with many of the considerations discussed in the previous course content.
4. Medicare Part D prescription drug coverage is available to everyone with Medicare. Most people pay a monthly premium for Part D.

Medicaid provides health coverage to millions of Americans in the inpatient and long-term care settings discussed above, beyond the state contributions (CMS, 2023). Some programs and benefits include special protections—such as provider networks and payment methods—that help ensure services are accessible. Preventive care and other services help people stay healthy and avoid more costly care. CMS offers materials and toolkits, so beneficiaries can learn about these services and how to access them. CMS also supports many efforts to measure access, share the results, and promote progress (Alzheimer’s Association, 2022; CMS, 2023).

Medicare has some fundamentally different considerations compared to other settings described in the present course. “Mental health” in Medicare beneficiaries is often associated with cognitive impairments and/or dementia (Alzheimer’s Association, 2022; CMS, 2023). Exploring the abundance of clinical case profiles among Medicare beneficiaries would necessitate a course much longer than this one! To that end, the present course provides a fictional case study that will explore a general early onset amnestic Mild Cognitive Impairment (aMCI) case profile in a female.

The U.S. social safety net was discussed in previous material and is the only source of local government-owned medical facilities open to the general public. While there are millions of men and women serving as active and retired military personnel, even individuals who are not members of the armed services can work as contractors or independent providers in the military health system. Below, the present course will highlight just a few of the clinical case profiles a professional is likely to encounter in the military healthcare setting. Competent clinicians are desperately needed in military and veteran settings, to treat the complex issues suffered by our nation’s most patriotic citizens (U.S. Department of Defense [DOD], 2023).

The U.S. Department of Defense (DOD) operates field hospitals and permanent hospitals via the Military Health System (MHS) to provide military-funded care to active military personnel (DOD, 2023). Specifically, the 2017 US National Defense Authorization Act called for the creation of military-civilian partnerships for training and sustaining essential trauma knowledge points and skills for deployment ready medical force (DOD, 2023). The American College of Surgeons (ACS), in partnership with the MHS, has been working to define the information points and skills for the combat casualty care team and develop the criteria for choosing and evaluating military-civilian partnerships formed to provide this training (DOD, 2023).

One example of an MHS direct-care facility is found at Womack Army Medical Center (WAMC). WAMC provides care to more than 200,000 Tricare® beneficiaries at a medical complex located at Fort Bragg in North Carolina. WAMC is a fully accredited 110-bed, evidenced-based regional medical center serving Fort Bragg, home to the legendary 82nd Airborne Division, XVIII Airborne Corps, U.S. Army Special Operations Command, U.S. Army Forces Command, and U.S. Army Reserve Command (Womack Army Medical Center [WAMC], 2023). By population, Fort Bragg is the largest Army installation in the world, home to nearly 10% of the Army’s active component forces (DOD, 2023; Tricare, 2023; WAMC, 2023).

WAMC provides opportunities for medical and allied health professional employment to service personnel and civilian healthcare staff (WAMC, 2023). WAMC offers a soldier recovery unit and a state-of-the-art hospital. There are several clinics currently providing service: Byars Health Clinic, Clark Health Clinic, Executive Medicine Clinic, Family Medical Residency Clinic, Hope Mills Medical Home, Joel Pediatric Clinic, Linden Oaks Medical Home, and Robinson Health Clinic. WAMC affords MHS beneficiaries access to bereavement support, a component of mental health and behavioral treatments that are overlooked in this population. Former and current military personnel and their loved ones are disproportionately affected by loss and suffering. There are widespread opportunities for providing care to this at-risk population (DOD, 2023; Tricare, 2023; WAMC, 2023).

The MHS has an additional task that other settings do not: they must maintain a certain level of “medical readiness” for the USA’s most patriotic citizens. Many individuals are waiting in reserve, and it is not uncommon for veterans to come out of retirement and reenlist. To that end, past, current, and aspiring military personnel must adhere to a level of physical readiness that the general population does not (DOD, 2023; Tricare, 2023; WAMC, 2023). This aspect of working in the complicated MHS setting is explored further in Case Study #6 where the utilization of services is elucidated. Case Study #6 documents the impact of service utilization in the healthcare revenue cycle and provides perspective on some aspects that may need to be improved to increase the volume of patient intake. Sometimes, the utilization of services by a patient population can be increased, increasing the access to care, and improving the quality of the patient intake process for those seeking services, currently. Healthcare administrators, charge nurses, rehabilitation managers, and other personnel may focus on considerations shown in Case Study #6 in their own buildings, in order to improve care.

The federal Veterans Health Administration (VHA) operates the Veterans Association’s (VA) hospitals, as discussed in previous course content (Veterans Association, 2023). The missions of the MHS are complex and interrelated (DOD, 2023). There are currently 152 VA Medical Centers and approximately 1,400 community-based outpatient clinics in the United States. In this setting, a veteran can receive treatment for a medical condition associated with their active duties without cost or other forms of medical treatment for a fee. The treatment of soldiers began under emergency circumstances in the Civil War, and significant reformations occurred during World War I and II.

Around the second war, the U.S. Executive Branch was reorganized. The DOD was formed as a unifying presence among the Army, Navy, and Air Force (Meffert, 2019; Tricare, 2023; U.S. Government Accountability Office, 2023; Veterans Association, 2023).

Consequently, the separate medical divisions were never really unified and remained a point of tension within the MHS community (DOD, 2023). Ultimately, active duty members and civilian contractors can work together to provide comprehensive care to the nation’s most patriotic citizens. Previously, Tricare® was discussed and provides veterans with health insurance coverage. Recently, Tricare® began to process Medicare Parts A & B beneficiary claims (Centers for Medicare & Medicaid Services [CMS], 2017; Tricare, 2023; Veterans Association, 2023).

There are some important points to note when contracting or working as active duty personnel in an MHS facility. In many cases, females and female dependents of active duty service members pay out of pocket or additional costs for contraceptive access or reproductive services. The emphasis on women’s health in MHS has been lacking and is a major area where civilian contractors can provide additional education and remedy to an underserved population (Meffert, 2019; Tricare, 2023; U.S. Government Accountability Office, 2023; Veterans Association, 2023).

Overall, all recipients complain of issues with Tricare® not qualifying as “minimum essential coverage” and the financial impacts of this misclassification (Tricare, 2023). It can impact their ability to make appointments due to financial constraints imposed by an over-complicated and slow system. In the wake of the global pandemic, MHS personnel and service members are at an increased risk of depression and other mental health concerns that necessitate medical intervention (Meffert, 2019; U.S. Government Accountability Office, 2023; U.S. Department of Veteran Affairs, 2023).

In the present course, explorations of the for-profit, non-profit, state, and federal health systems of the United States have been explored. The U.S. has a complicated history, especially when it comes to healthcare delivery because this country grew on top of an already existing culture with specific methods for addressing healthcare needs. As clinicians work in midwestern or western settings, they are more likely to work in a federally recognized Native American health system. These health systems have many similar considerations to those explored so far. In the remaining topics and case studies, those similarities are shown and help clinicians in the midwestern and western regions of the U.S. explore care in at-risk populations who desperately need healthcare.

The interaction between the United States and Native American peoples is the subject of years of education for American students. The present course will not provide a dense history of all Native American people of the United States. However, the present course will utilize a specific example from the author’s Native American federally recognized tribal affiliation, the Pokagon Band of Potawatomi. The Pokagon Band of Potawatomi were among the earliest Native American tribal groups to be federally recognized and have a long history in the Midwest (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

The telling of history is also a culturally sensitive component of working in tribal settings. For this reason, the present course includes a quoted history of the Pokagon Band of Potawatomi, to show respect to the Neshnabék culture and tell their story. Showing cultural sensitivity in Native American Tribal settings is essential to providing quality care (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

To that end, the Pokagon Band of Potawatomi’s history will be shown in this section (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

Some creation stories tell that the Potawatomi have always been around. Additional stories tell of migration from the Eastern seaboard with the Ojibwe and Odawa Nations. There were three tribes. The three tribes were loosely organized as the Three Fires Confederacy, with each serving a crucial role (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021):

1. The Ojibwe were said to be the Keepers of Tradition
2. The Odawa were known as the Keepers of the Trade
3. The Potawatomi were known as the Keepers of the Fire

The Potawatomi migrated from north of Lake Superior and Lake Huron to the shores of the mshigmé, or Great Lake. This location, in what is now Wisconsin, southern Michigan, northern Illinois, and northern Indiana, is where European explorers in the early 17th century first met the Potawatomi. These people called themselves “Neshnabék”, meaning the original or true people (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

As the United States frontier border moved west, boundary claims and land cessions became the focus for Native Americans. In 1830, the United States Congress passed the Indian Removal Act and ordered that all American Indians be transferred to lands west of the Mississippi River, leaving the Great Lakes region open to the further development of non-Indian peoples (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

The Treaty of Chicago of 1833 determined the circumstances for the elimination of the Potawatomi from the Great Lakes area. When Michigan became a state in 1837, more tension was put on the Potawatomi to continue moving west. The dangerous trip killed 10% of the approximately 500 Potawatomi involved (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). As the news of the dreadful trip dispersed, some bands, consisting of small groups of families, escaped to northern Michigan and Canada. Some individuals also tried to hide in the swamps and forests of southwestern Michigan. The U.S. government sent soldiers to collect the Potawatomi they could find and forced them to leave at gunpoint and relocate to the reservations in the west. This imposed eradication is now called the Potawatomi Trail of Death, much like the more familiar Cherokee Trail of Tears (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

However, a small group of Neshnabék, with Leopold Pokagon as one of their leads, earned the right to stay in their homeland, in part because they had exhibited a compelling attachment to Catholicism. It is the successors of this minor group who constitute the Pokagon Band of Potawatomi Indians (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

When the American immigrants first came to southwestern Michigan in the beginning of the 19th century, they found Leopold Pokagon and his settlement in what is known now as Bertrand Township in Niles, Michigan. In the year 1838, Leopold and his group from the St. Joseph Valley visited the Odawa at L’Arbre Croche to try to find a place to stay. For a while, the Treaty of 1833 allowed them to remain in Michigan (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). They were supposed to relocate to the L’Arbre Croche area with the Odawa within five years. The Treaty of Washington of 1836 was struck between the Odawa and Ojibwe and relinquished much of the lands in the north. Basically, they were all told there would be no room for them to move there (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

Upon returning to Michigan, Leopold procured land in Silver Creek Township using annuity funds amassed through several previous treaty negotiations, including the Treaty of 1833 (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). Pokagon and various other groups then moved communally to Silver Creek Township, near present-day Dowagiac, Michigan.

After a short passage of time, Brigadier General Hugh Brady warned about his intentions to push Pokagon’s Band out of Michigan. Pokagon, who by then was an old man in deteriorating health, traveled to Detroit to get a written ruling from Epaphroditus Ransom of the Michigan Supreme Court to remain on their land (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

Nearly a century later, during the Great Depression, the federal government passed the Wheeler-Howard Act, also known as the Indian Reorganization Act of 1934. This legislation would provide tribes with resources to work to reestablish their own tribal governments. Even though the Pokagon Band applied for recognition, the Bureau of Indian Affairs had restricted funding and persons to fully implement the Indian Reorganization Act. Therefore, the Bureau of Indian Affairs decided to recognize only one Indian tribe in the lower peninsula of Michigan. The one recognized tribe was the Saginaw Chippewa Indian Tribe (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

It took until September 21, 1994, for the federally recognized standing of the Pokagon Band of Potawatomi to be reaffirmed by an act of Congress (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). After decades of work by hundreds of Pokagon Band citizens, the Pokagon Band’s authority was restored on that day in a signing ceremony with President Bill Clinton. This day is celebrated as Sovereignty Day by citizens of the Pokagon Band (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). This Act did not mean that the Pokagon Band instantly became an Indian tribe, but rather that the federal government reaffirmed that they were a tribe (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

In the subsequent section, the present course will include real-world tribal health system applications based on access to the health system of the Pokagon Band of Potawatomi. There are more than 570 federally recognized Native American Tribal Nations (e.g. “Band,” “Nation,” or “Tribe”). Some variation among tribal health systems is found. Focusing on an applicable tribal health system affords the present course to provide foundational content to a clinician hoping to work in a tribal health system in the future (Mshkiki Community Clinics, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

It is important to include in this course the history of the Pokagon Band of Potawatomi. It is included in the present course because it demonstrates that although there is a complicated history between the indigenous culture of the Pokagon Band of Potawatomi when it comes to healthcare, all people wish to work together towards a common improved health outcome (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

As the present course acknowledges the complexities of working in a disjointed military health system, it is important to acknowledge the cultural sensitivity needed to work in a tribal health system (Mshkiki Community Clinic, 2023). Maintaining cultural sensitivity is key because, before 1924, Native Americans were not recognized as “human” and were not able to vote. In the late 1960s, Native Americans were beginning to fight for the right to practice their religious beliefs openly, and in 1978 the American Indian Religious Freedom Act was officially enacted (Samra, 2021).

In the ancestry of the Pokagon Band of Potawatomi, a rich historical and complex society existed before the existence of Wisconsin, Illinois, Indiana, and Michigan, as states (Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b). The state and federal systems discussed so far were not established when the Potawatomi began to thrive in their respective society. That society proliferated throughout all of U.S. history and is still functional today. The author of this course, Jeanna Winchester, Ph.D., is a proud federally recognized Native American Tribal member. Native Americans are proud of who they are and hope to achieve respect and consideration when they seek medical care (Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

A major clinical focus of working in Native American populations has been addressing trauma, mental and behavioral health, substance abuse, and suicide prevention (Samra, 2021). Trauma and other atrocities occurred in Native American populations even up to the end of the previous millennium. Many Native American families were relocated and placed on a reservation or abducted, enslaved, sold, and/or erased through the southern Slave Trade, the Indian Boarding School program, and the Indian Removal Act (Indian Health Services [IHS], 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

The National Native American Boarding School Healing Coalition (NHABSHC) was formed in the last decade in partnership with the Navajo, Canadian, and U.S. nations to help heal traumatized people in the wake of genocide, enslavement, and erasure (NNABSHC, 2023). There is a real need for mental and behavioral health interventions in Native American populations, as these people are desperate for change (IHS, 2023; NNABSHC, 2023).

One major consideration when working in tribal health systems is understanding that Native Americans have a “dual citizenship” status. Native nations are considered "domestic dependent nations," which causes tension between tribal sovereignty and its relationship with the United States. Other key points to consider include (IHS, 2023, p. 1; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021):

1. Assorted United States and tribal laws/policies
2. Everyone in the United States has fundamental rights, and Native Americans have additional rights beyond those protections given to everyone
3. There is a myriad of tribal issues spanning education, health, and the environment that require cultural sensitivity
4. Overall, the prevalence of illicit drug use of any kind (prescription or nonprescription) was 15% for Native Americans, 13% for African Americans, 11%for Caucasian Americans, 10% for Native Hawaiian and Pacific Islander Americans, 9% for Non-Indigenous Hispanic or Latino Americans, and only 4% for Asian Americans
5. Like many tribal health systems, the Pokagon Band of Potawatomi works closely with the Bureau of Indian Affairs
6. The Bureau of Indian Affairs (BIA), the US Department of the Interior (DOI), the U.S. Department of the State, and Indian Health Services (IHS) are essential agencies for every Native American
7. The relationship of IHS to the Native American nations was established in 1787 and is based on Article I, Section 8 of the U.S. Constitution
8. IHS’s Mission is to “Raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level”
9. There are two types of IHS facilities: Ones that are directly operated by IHS and others that are more of a collaboration with the tribal government

The Pokagon Band of Potawatomi has a partnership with IHS, known as Pokagon Health Services (PHS). PHS has clinics, e.g., the Mshkiki Clinics, which serve Indigenous peoples in Northern Indiana and Southwest Michigan (IHS, 2023; Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b). Its main Accredited Healthcare Facility located in Dowagiac, Michigan, aids over 2500 patients, offering an integrative care approach that includes dental, pharmacy, medical, and behavioral health services (IHS, 2023; Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b). PHS endeavors to attend to the healthcare disparities in Native and other communities (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

Cultural sensitivity drives much of tribal health systems and is a unique component of working in this setting. For example, “Mshkiki” was chosen as the name of the tribal health system because it is the Potawatomi word that means medicine (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023ab; Samra, 2021).

In many midwestern Native American tribal cultures, such as the Potawatomi, Ojibwey, and Odawa, “medicine” is given a special status from a cultural perspective (Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b). Therefore, Native Americans in this region are very serious and involved in their healthcare treatments. This is not always true. There are some Native American cultures in the U.S. that are more focused on isolationism and a distrust of U.S. medicine. Understanding the culture associated with the facility one is working in helps deliver a higher quality of care. In Midwestern regions, families and communities are emphasized, along with the usage of their Native American languages (Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b).

When it comes to care and scope of practice, overall, IHS and its related facilities will provide meaningful information for Native citizens to use to receive care (IHS, 2023). Patients who live far from their homelands can receive direct care services or Purchased/Referred Care (PRC), also known as contract services, for up to 180 days once the individual leaves a particular homeland. Sometimes there is reciprocity among the Tribal Nations where Natives can receive services at their facilities. The Pokagon Band of Potawatomi has reciprocity with many tribes and groups, so patients can receive services through various avenues while living near their homelands. It is harder once the patient moves away, but it is possible under some conditions (Mshkiki Community Clinic, 2023). Native American nations employ both Native American and non-Native American contractors in many clinics (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

Sadly, access to mental health, behavioral health, substance abuse, and other suicide prevention measures was significantly reduced during the pandemic, especially among Native nations with a higher incidence rate of these cases than other groups (Samra, 2021). Studies have shown that American Indian/Alaska Natives are 60% more likely to encounter the feeling that everything requires extra effort, all or most of the time, as compared to non-Hispanic whites. Suicide rates, violent deaths, unintentional injuries, homicide, and overall death rates are higher for Native Americans than non-Hispanic Caucasians of the same age group (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021).

If a professional seeks to be an independent contractor working at a tribal facility and is not a federally recognized tribal member, IHS and its related facilities follow standards of care consistent with the U.S. scope of practice. Specifically, each facility can have different Patient Rights & Responsibilities, but all minimally include the following (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021):

1. Rights with respect to being informed regarding the nature of the treatment plan, including benefits expected, the risks involved, and participation in the creation of the treatment plan
2. The right to refuse treatment
3. The right to preserve confidentiality
4. The right to be treated with full recognition of their personal dignity, individuality, and need for privacy
5. The right to obtain services inadequate facilities
6. The right to know the qualifications of the employees providing the services
7. If the patient is found ineligible for services, the right to receive a written explanation stating their rights for an appeal, if any
8. IHS facilities ensure that patient consent to participate in treatment programs as presented to them or pursuant to their treatment plan is to be documented

Further, it is recommended that clinicians become familiar with the cultural background of the Tribal Nation that needs their skills. It would be best if that clinician asked the facility about their policies on HIPAA, Scope of Practice, Compliance Procedures, and other critical foundational concepts. Direct work in this setting has indicated that there can be inconsistencies across settings and buildings, but they are primarily minor, and teams are available to resolve the issue (IHS, 2023; Mshkiki Community Clinic, 2023; NNABSHC, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b; Samra, 2021). In the subsequent topic, the present course integrates the foundational concepts discussed in the Medicaid section previously but applies them here and documents the important role of Medicaid in Native American healthcare delivery.

An integral focus of economic and health policy for Native American healthcare is Medicaid because Native Americans benefit from expanding coverage. IHS is underfunded, so Medicaid is essential to supplement services (IHS, 2023). If a state does not authorize Medicaid expansion, Native nations are deleteriously affected. It is helpful to check the local area to see if that state has expanded coverage. If so, there may be opportunities in the nearby Tribal Nation or IHS facility (CMS, 2017; IHS, 2023).

Native Americans are worried, though, because coverage seems insufficient, costs too much, is underfunded, and is hard to access (IHS, 2023). Native nations are often rural. Native nations have a higher incidence of cancer, diabetes, and kidney disease. Ultimately, a lack of access to personnel puts IHS and Native nations at risk of further health decline. IHS has shown that 85% of the 34 IHS respondents had continuous physician coverage (CMS, 2017; IHS, 2023). Of the 34 locations, only four utilized telemedicine, while a median of just 13% of physicians were board-certified in emergency medicine (CMS, 2017; IHS, 2023). About half of the clinics included in the study identified that their remote location was a significant obstacle for hiring and retaining staff (CMS, 2017; IHS, 2023). Native Americans are often considered to live in “medical deserts” with very little access to care (CMS, 2017; IHS, 2023).

In 2022 and 2023, it was identified that there were significant levels of lead found in the water supply for Berrien Springs and Benton Harbor, Michigan (MDHHS, 2023a; MDHHS, 2023b). These areas of southwestern Michigan are where Tribal, Medicare, and pediatric Medicaid facilities are located for the Pokagon Band of Potawatomi, at the Mshkiki Community Clinics (CMS, 2017; IHS, 2023; MDHHS, 2023a; MDHHS, 2023b; Mshkiki Community Clinic, 2023; Pokagon Band of Potawatomi, 2023a; Pokagon Band of Potawatomi, 2023b). President Biden and Vice-President Harris have initiated a program to reduce the lead content in the water supply and other areas of the country. Michigan is an area hit very hard by a persistent presence of lead that causes harmful effects in children and adults. The tribal nations, along with state and federal agencies, must battle this public health crisis in the local water supply, still, in 2023 (MDHHS, 2023a; MDHHS, 2023b).

The present course explored for-profit, non-profit, state, federal, military, and Native American health systems in the United States. Case studies were provided, geared towards documenting the similarities and differences observed in each of the settings discussed, and the implications of key concepts were applied in each setting. Major themes and take-away points from the course content are summarized below:

1. Settings in the United States that are private, for-profit, investor-owned, or network-owned have unique considerations that a Charge Nurse, Rehabilitation Manager, or other administrative clinicians may need to consider.
2. Approximately 60% of healthcare settings are non-profit funded settings. Upwards of 20% of healthcare settings are government or military-associated entities.
3. In more urban areas, nearly ⅔ of healthcare entities are non-profit. They often align with academic and/or research providers that abide by certain guidelines for their scope of practice.
4. The United States federal government will occasionally waive or cede responsibility for a service or function to the states. In healthcare, this can happen quite frequently and get complicated.
5. The principal finding from a case study was that half of the estimated 7.7 million U.S. children with a treatable mental health disorder did not receive the treatment they needed from a mental health professional. This estimate varied considerably by state.
6. In another case study, Puerto Rico’s territorial status and its relationship to the United States’ healthcare system impeded aspects of the healthcare revenue cycle. The case study explored how systemic racism and the vague territorial status of Puerto Rico affects healthcare interventions and frontline emergency support for the island which suffered high-intensity hurricanes regularly. The case study indicated that austerity measures, governmental instability, and an exodus of Puerto Rico residents following major hurricanes contributed to extended instability of the healthcare revenue cycle in the Puerto Rico healthcare system.
7. For patients undergoing standard outpatient surgical procedures at a large public university-affiliated hospital in Florida, the rate of prescriptions for opioids were substantially reduced within 6 months after the implementation of state legislation limiting the duration of opioid prescriptions.
8. Medicare is one of the United States’ largest sources of public health insurance, serving the elderly, the disabled, and those with end-stage renal disease (ESRD).
9. CMS offers Medicare and Medicaid at the federal level, but Medicaid can also be available at the state level. Medicaid, the third-largest source of health insurance in the country, is the system that provides coverage for low-income adults, children, the elderly, as well as individuals with disabilities. In 1997, the US government created the Children’s Health Insurance Program (CHIP) to provide insurance to children in uninsured families.
10. The MHS has an additional task that other settings do not: they must maintain a certain level of “medical readiness” for United States’ most patriotic citizens.
11. The need for military specific requirements highlight the value of maintaining training programs in the MTFs as opposed to civilian institutions. In addition, training should include all members of the uniformed healthcare team because of the differences in the scope of practice.
12. In the United States, state-based military personnel are known as the National Guard. Each state supplies its funding, and each National Guard is a separate Army militia based in each state of the Union.
13. In many cases, females and female dependents of active duty service members pay out of pocket or additional costs for contraceptive access or reproductive services. The emphasis on women’s health in MHS has been lacking and is a major area where civilian contractors can provide additional education and remedy to an underserved population.
14. The Bureau of Indian Affairs (BIA), the US Department of the Interior (DOI), the US Department of the State, and Indian Health Services (IHS) are essential agencies for every Native American.
15. The relationship of IHS to the Native American nations was established in 1787 and is based on Article I, Section 8 of the United States’ Constitution.
16. There are two types of IHS facilities: Ones that are directly operated by IHS and others that are more of a collaboration with the tribal government.
17. Native Americans are often considered to live in “medical deserts” with very little access to care.

The present course elucidated clinical case study applications of many foundational concepts in healthcare by going further and broadening the knowledge of course participants. Specifically, this course provided more details about state, federal, military, and tribal health systems while viewing these details through the lens of mental health, substance abuse, and related issues prevalent in the healthcare community, today. Specific suggestions on how to navigate these complex healthcare settings were provided and additional detail emphasizing cultural sensitivity were provided. Overall, lessons from the healthcare revenue cycle help guide participants through the advanced detail and enhance their ability to grow in their scope of practice.

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