In Montana, the life expectancy for Native American people is 19 to 20 years shorter than for whites. The median age at death for Native men here is 56. It's 62 for Native women.
Those statistics, in part, motivated Governor Steve Bullock last year to create a new position in the state health department: Director of American Indian Health.
The woman he appointed to the job this spring is Mary Lynn Billy-Old Coyote, who's from the Rocky Boy's reservation. She's well aware of the difficulty many Native American people have getting health care.
"You are oftentimes just happy to get your doctor’s appointment after waiting for eight hours in the waiting room," she says.
In the 19th century, the federal government promised to take care of Native American health needs, as part of the compensation for tribes giving up almost all of their homelands. But the Indian Health Service that's supposed to do that has been historically underfunded and unable to meet the health needs of tribal members.
"The current budget is $4.9 billion," she says, "and it really, truly should be sitting at $29.9 billion, because of accounting for health care inflation. That's a dramatic gap."
That gap means that Native Americans who need healthcare are often told that it's not available unless they're at immediate risk of losing their life or a limb. Billy-Old Coyote says that's commonly misunderstood, both inside and outside Native communities.
"Indian Health Service is not insurance," she says. "Therein is a myth that I actually continually run into, that Indian Health Service is insurance, it's not."
Health insurance has long been out of reach for many people in Indian Country, either because it's been prohibitively expensive, or because insurance companies were allowed to deny people coverage entirely if they had pre-existing health conditions. Nor was Medicaid generally available to anyone who wasn't a child, pregnant or disabled.
The Affordable Care Act, which some people call “Obamacare,” changed that. Subsidies are now available to help lower-income people buy private coverage. And in January, Montana implemented the health law's option to expand Medicaid. That means nearly anyone making less than $16,000 a year can now get coverage. Billy-Old Coyote says that creates huge opportunities for someone in Indian Country.
"Now I have access to a system that's not rationed. I can go to a specialist, I can actually obtain care that I normally would not have normally obtained before," she says.
Billy-Old Coyote calls herself an evangelist for the HealthCare.gov marketplace that offers subsidized private insurance, and a connection to expanded Medicaid. Lee Newspapers recently estimated that fewer than a third of Native Americans in Montana who are eligible for subsidized or free health coverage have signed up for it at this point.
"We've got to get folks enrolled," Billy-Old Coyote says. "We've got to get them where they're participating in the system. The second part of that is understanding how this coverage works. How do I understand how Medicaid works? And how do I understand that this is of importance to my health? So we have to educate on how to use a consumer product. It's difficult for anybody overall, but what if you've never had access to private health care, Medicaid? You don’t necessarily have the tools to even understand how to navigate it. So that’s the other part that we need to do: Increase numbers, and we also have to increase education and support of how to use it."
Billy Old Coyote says Montana is one of six states where the Indian Health Service is making a special effort to boost enrollment in Affordable Care Act coverage. Meanwhile, she says, she talks about it with people she meets all the time, like a man she ran into outside a tribal council meeting recently.
"I know for a fact that this person is going to go home, talk to their mom, talk to their dad, talk to their grandma, talk to their aunt, or they're going to Facebook," she says. "I know that that's how it happens, the word of mouth is so strong in Indian Country, that communication is so strong. And I do it every single day, including weekends."
But Billy-Old Coyote's evangelism for getting people signed up for health coverage goes beyond helping them meet their individual health needs. More people with health coverage means that they'll get and be able to pay for more healthcare in tribal clinics, and hospitals both on and off Montana's reservations. And that means those facilities will need to, and be able to, hire more staff - medical staff and back office administrators to process all the new payments. Healthcare, Billy-Old Coyote says, is an engine for job creation. It's a message she brought to a recent meeting.
"And the tribal president said, 'where do we find these people?' And I said, they're right here. They're right here in this community.
"We just need to build them," Billy-Old Coyote says. "We need to give them the skills, and we need to give them the opportunity. And we can do that through tribal colleges, and we can do that through giving mentoring and internships. And, they're certainly professional positions, they’re jobs we can be proud of, and they're jobs that impact their community. So to me, there’s opportunity there not only to build healthcare, but there's opportunity to build your entire community, and build jobs."
Billy-Old Coyote emphasizes that she has no desire to tell tribal leaders what to do. She declined to be interviewed about her goals and priorities until after she'd had a chance to consult with all of Montana's tribal health leaders.
"American Indian Health is not just medical, dental, vision," she says. "So, I'm very much focused on a greater community effort. And one of my core foundation elements of my approach is: The solution is in the community. It's there; we just have to figure out how to get it, how to resource it, how to build it."
Billy-Old Coyote is excited about a new effort underway at the Indian Health Service that would give tribes more control over IHS funding.
The idea is to make IHS funding stretch further by giving tribes the option to use it to purchase private health insurance coverage directly.
It could lead to tribes being able to use IHS funds to pay health insurance premiums for their members, or create their own, new tribal health plans.
Six months into her job as Montana's first American Indian Health director, Mary Lynn-Billy Old Coyote has a pretty long list of things she wants to accomplish. Things as specific as all tribes having well-equipped ambulances, and tribal members having access to wellness programs, -- and things as abstract as Indian health no longer being an afterthought when healthcare decisions are made in Montana. She says she's reminded of why all that's important when she heads home to her family's ranch on the Rocky Boy's reservation nearly every weekend.
"Success will be, when I don’t have to worry when I see that ambulance coming down the road when I’m in Rocky Boy and worry that somebody didn’t get health care," she says.