Brent Simcosky, health services director for the Jamestown S'Klallam Tribe, looks out from the Jamestown Healing Clinic in Washington state’s Olympic Peninsula, on May 24.Nathan Vanderklippe/The Globe and Mail
An artificial stream wends a tinkling chatter past banks of newly landscaped plants toward the exposed beams and enormous glass windows that make up the Jamestown Healing Clinic.
It could be a resort, situated on a sunny lot on the outskirts of town, its soaring lobby decorated with outdoor scenes from Washington state’s rugged Olympic Peninsula and art from the local Jamestown S’Klallam Tribe. It is, instead, an opioid treatment centre, built in a county that has seen more overdose deaths per capita than any other in the state.
Over the last few months, the Healing Clinic has offered a response, providing methadone treatment, mental-health counselling, dentistry, transportation and even child care for those seeking care.
“People say, ‘God, this is like a spa. It doesn’t need to be this fancy,’” said Brent Simcosky, the tribe’s health-services director. A lot of other opioid clinics, he said, “look like they’re in sheds.”
Across Washington state, however, the architecturally sculpted contours of the tribally run care clinic are becoming more common.
Seven of Washington state’s 37 opioid-treatment programs are now run by tribal nations, with two others exploring the idea. Nearly a third of those opened since 2017 have been tribally owned or operated. By next year, half of the state’s mobile methadone units will be operated by tribes.
It is a remarkable riposte to history. Despite federal treaty obligations to provide health care to Native Americans, the country’s Indigenous people have some of its worst health outcomes. Indigenous Americans are second only to Black Americans in incidence of opioid deaths.
But through the entrepreneurial moxie of several small groups in Washington state and a twist of U.S. regulations, tribal nations are embarking on a new effort to be a balm to an opioid epidemic that the spread of fentanyl has made far more severe. Clallam County experienced 15.7 overdose deaths per 100,000 people from 2013 to 2017. By 2021, it had more than tripled.
Responding is not “rocket science,” said Mr. Simcosky. “But it takes money and resources.”
Tribes have discovered a unique ability to access both.
A nontribal provider might be able to bill Medicaid, the publicly funded U.S. health care program, $30 per opioid patient per day, to provide methadone. For tribes, the reimbursement rate is far higher, up to $600 per patient per service, rates created as a response to underfunding of Indigenous health care, which must often be delivered in remote settings. Those services can include substance use disorder treatment, dental, daily dosing and mental health.
Critically, tribes can access higher rates for nontribal citizens, too. About 85 per cent of the patients at the Jamestown clinic are not Indigenous. What it means is the tribes have discovered a way to deliver a raft of publicly funded services to those most in need.
“It’s setting the gold standard for recovery,” said Jeremy (JJ) Wilbur, vice-chair of the Swinomish Tribal Senate. And it “comes from Indian country,” added Leon John, outreach director for didgʷálič Wellness Center, (pronounced deed-gwah-leech), the Swinomish opioid clinic.
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The Swinomish, located near Anacortes, Wash., are progenitors of the model. They began with a small wellness facility that provided treatment to tribal members, only to discover this was inadequate. Someone living with nontribal members might return home to others whose addictions were not eligible for treatment.
“They were only treating half of the home,” said Mr. John. He advocated for a much larger clinic that could treat everyone. No one could stop the trafficking of drugs onto the reservation. But it might be possible, he argued, to reduce demand in the surrounding community, “and we’ll never know how many lives we save doing that.”
It was no small task. Building a full opioid-treatment program required going through eight different regulatory processes, many with uncertain outcomes and high costs. For the Jamestown, the Drug Enforcement Agency mandated a secure room for the storage of pharmaceuticals, with earthquake alarms, steel-plated walls and a massive safe.
It was “$30,000 just for the safe to store the methadone,” Mr. Simcosky said. “Which, by the way, is delivered in a FedEx truck.”
But the didgʷálič clinic was at capacity soon after it opened in 2017 and has expanded several times since. Tribes from across the U.S. have taken notice, with delegations from Alaska, Colorado, North Carolina, Oklahoma and Oregon studying what the Swinomish have built.
Providing health services, they have found, can nurture broader change. By law, any excess revenue – profit – can only be spent on health, education or social services. As a result, the Swinomish opioid centre now funds more than $1-million a year in full-ride scholarships for tribal members. The 13-bus transportation network created to bring people for treatment has also been used to build a local transit service.
The Jamestown, meanwhile, operates a primary care clinic that serves about 18,000 patients, most of them non-native. The tribe’s health care department is its biggest revenue generator, eclipsing its casino.
The Jamestown opioid centre, which opened last year, is expected to pay back its construction costs in five to 10 years. The tribe has already begun plans for a 16-bed evaluation and treatment psychiatric hospital after receiving $26-million in funding from the state.
That model suggests health care could become a major business for U.S. tribal nations.
For now, however, opioid treatment has been embraced more quickly.
“As an employee and as a client in these clinics, I don’t think you can get any better,” said Dawn Lee, a substance use disorder professional who operates a small consultancy. “I have a couple of nontribal clinics right now, and their reimbursement rate is really low. So it’s really hard to keep providers and keep staff.”
Not so with the tribes, who have continued to add services. One new tribal clinic provides kennels for dogs. Security personnel are trained to know each patient by name. Providing multiple services under one roof means patients aren’t waiting for treatment, and don’t go missing in between appointments at different locations.
Obstacles remain, particularly in securing regulatory approvals. The Jamestown project was only built after a costly court battle against local opponents who contended that the opioid centre would bring a wave of addicts to their community.
But tribal treatment centres tend to be located away from major population centres, which has been a boon to the state. “Our biggest push right now is to find ways to reach out to more of the rural communities,” said Misty Challinor, president of Washington State Opioid Treatment Providers, an industry group.
What’s not clear is how well those tribally run treatment centres work. Most are too new to generate reliable statistics, and the ubiquity of fentanyl has created a worsening backdrop. Last year, Washington state measured a 17-per-cent increase in opioid deaths.
The didgʷálič clinic, however, has counted just one client overdose in the past two years, and Swinomish tribal members say the difference is tangible.
Compared to the past, “we are not attending nearly the amount of funerals for opioid overdoses,” said Mr. Wilbur.
“It’s almost rare now,” added Mr. John.