2. 1. DESCRIBE the Self Governance Negotiation Process 2. SHARE Best Practices Learned from Experiences in other Areas

3. 1) Pre-negotiations -issues identified during planning -review draft Compact, Funding Agreement, and funding tables 2) Final Negotiations -negotiation teams reach agreement on final Compact, Funding Agreement & funding tables -2 final copies signed by Tribe & provided to ALN 3) Post Negotiations -Tribe/Tribal Health Organizaiton signs final documents and returns to ALN -ALN reviews documents & sends with supporting documents to HQ for processing and signature by IHS Director or designee -Once signed. Compact and Funding Agreement are legally binding and enforceable

4.  Network with other SG Compacting Tribes  Attend other negotiations if possible OR share results through legal team  Participate in TSGAC meetings  Work through TSGAC/SGCE to bring issues to national SG Annual Strategy Session (Fall) & Annual Conference (Spring)  Participate in National Workgroups i.e. CSC, ISAC, NTAC, PRC, etc.  Participate in Area & National Budget Formulation Process  Be aware of what is happening nationally – I/T/U “Unity”

5.  Form an Area-Wide SG Caucus  Review Area Tribal Shares, Inherent Federal Functions/Residuals  Evaluate and consider Future re-design & support of Tribal delivery of care system  Shared Services Delivery models  Continued participation in IPC Learning Network (Indian Medical Home Model)  Continued participation in GPRA or other national reporting  Take advantage of & leverage innovative new models learned from national health systems (HRSA, Rural Health, VA, Private Sector, etc.)

6.  Alaska Native Medical Center: tertiary care  6 regional hospitals  4 multi-physician health centers  25 subregional mid-level care centers  180 small community primary care centers  Purchased/Referred Care to private medical providers and other specialty services

7.  1900-1970: Health care for Alaska Natives was provided by the U.S. government  1970-1998: Alaska Native tribes organized health care organizations under Self- Governance legislation and gradually assumed ownership of health services at regional and tribal levels  1998-2015: All Alaska Native health care is provided by Alaska Native organizations  Represents 229 Tribes  Serves 147,000 Alaska Natives/American Indians  586,412 square miles of predominantly road-less land

8.  1968 Formation of the Alaska Native Health Board  1970 First regional health organizations (YKHC and NSHC)  1975 AFN’s Alaska Native Health Care Policy Statement  1994 Alaska Tribal Health Compact agreement  1997 New Alaska Native Medical Center  1998 Formation of ANTHC  1999 ANMC ownership transferred to ANTHC/SCF  2002 ANHB Statewide Native Health Plan  2004 ATHS Memo of Understanding

9.  Shared advocacy lead by Alaska Native Health Board  One compact with Indian Health Service  Co-Manage ANTHC statewide services & statewide AK Native Medical Center w/open access to urgent care statewide  Strong Inter-tribal Health Network  ATHS organizations collectively spend almost $4 million per day  ATHS employs over 8,000 full and part-time staff statewide ~ 70% Native Hire  ATHS expenditures $1.4 billion; $1.7 billion by 2020  ATHS serves 147,000 people; 160,000 people by 2020 (9% increase)

10.  Alaska Tribal Health System proposed Single State-wide Agreement under the Title III of the ISDEAA Tribal Self Governance Demonstration Project (1988-early 1990s)  Congress Authorized statewide organization: 3 THOs + 2 Unaffiliated Reps designated to manage ANTHC statewide services and co-manage ANMC, through ANTHC Consortium Board of Directors (1998)  Made Permanent by Title V Legislation: 22 Co-signers to the Alaska Tribal Health Compact; Tribal authority delegated through Authorizing Resolutions (2000)  Funding Agreements are entered into by a Tribe or Co-Signer on behalf of member Tribes  Foundation is Respect for Strong Government-to-Government Relationship

11.  Alaska Tribal Caucus Structure:  All co-signers are members  Election of Co-lead negotiators : one Tribal Governance Leader, one Administrative Leader  ANHB serves as facilitator  Sets Agenda for Compact Negotiations  Caucuses (Tribal & Federal)  Review of Common Open Items Issues & Updates  Pre-negotiations – new issues & new co-signers  Common Negotiations – Preserves Tribal Right to Opt out of commonly negotiated items  Individual Tribal Funding Agreement Negotiations (drawing to determine order)  Opportunity to share local concerns and issues  Negotiation of Tribal-specific terms, language & issues

12.  Co-signer Common Negotiations Cooperative Process  Tribal Shares Committee (Open to All Co-signers)  Legal Language Committee (Open to All Co-signers & Legal Counsel)  Open Tribal Discussion of National Issues of Importance to Co-signers  Open Items List Recorder: All Co-signers Agree on Documentation of Tribal Shares, Legal language, Issues among Co-signers  Agreement on Ground Rules  Decision making Process  Closed Caucus before Pre- & Final-negotiations & as needed  Co-signer discussion of Agency Lead Negotiator positions/decisions in other negotiations  General Agreement of Common Issues among Co-signers  Documentation & Agreement on Caucus position on Open Items List of Issues  Principles:  Shared Vision for the Greater Good  Do No Harm  Do Not Made Concessions which has potential to erode Tribal rights to Self Govern  Consensus Decision-making & Process for Conflict Resolution  Tribes retain right to opt out of commonly negotiated language during individual negotiations

13.  Alaska paved the way for Tribes to assume Area Office Assume non-residual programs, functions, services and activities  Transfer of Area pfsa’s to ANTHC radically changed relationship with Alaska Area Office  Role of Alaska Area Office shifted

14. The Journey Continues…..

15. Qagaasakung Aleut Taikuu! Inupiaq Háw'aa Haida ‘ Awa'ahdah Eyak Igamsiqanaghhalek Siberian Yupik Tsin'aen Ahtna Athabascan Way Dankoo Tsimshian Gunalchéesh Tlingit Quyana! Yup’ik Благодарите Вас Dena’ina Athabascan