Supporting Government to Government Relationships


Trust Responsibility

Prior to the formation of the United States Government, Tribal Nations negotiated treaties with Great Britain and Spain, establishing them as nations on the global level. Tribal sovereignty is inherent, existing before the United States Government existed. 

Through Supreme Court cases, statutes and regulations, agreements made through treaties between Tribes and the United States Government have created a “trust responsibility.” Trust responsibility is a legally enforceable obligation of the United States to protect tribal self-determination, tribal lands, assets, resources, and treaty rights, as well as carry out the directions of federal statutes and court cases. 

Tribal governance is based on trusted systems, policies, and environments—governance that empowers our people, is culturally competent, and promotes health equity.


Tribes with ceded land in Washington State signed treaties with the United States before Washington became a state. Today, Tribes and the State of Washington work together in a government-to-government relationship. 

The Centennial Accord, which was executed on August 4, 1989, ensures the paramount authority for both Tribal governments and Washington State governments to exist and to govern, and establishes the respect for the values and cultures represented by Tribal governments. 

The Millennium Agreement, which was signed in 1999, frames the terms and principles of the State/Tribal relationship required to cement the government-to-government relationship. The principles include partnership and collaboration related to economic, social/cultural issues, and natural resources. It also established a commitment to improved communication, cooperative education, and the development of a consensus-based, lasting, and respectful relationship. 

Government-to-government work also includes holding the federal government accountable to fulfilling treaty obligations regarding health. This becomes particularly important when setting state policies and procedures that have a mix of federal and state funding and directly impact Indian Health Care Providers, both at Tribal Clinics and Urban Indian Health Organizations.

See the Governor’s Office of Indian Affairs for how the Centennial Accord and Millenium Agreement are being implemented on an ongoing basis.

Governor's Indian Health Advisory Council (GIHAC)

Background on the Governor’s Indian Health Advisory Council

Tribal Leaders, Urban Indian Health Program Leaders and their staff have been working with the State to address issues from the implementation of managed care in the Medicaid system in Washington State. Issues were identified through the 2013 Tribal Centric Behavioral Health Report to the Legislature and Tribal consultation for the 1915 b and 1115 Medicaid waivers that change the way Medicaid services are provided in this State.

Through this process, a Tribal Issues Grid was jointly developed by the state and tribal representatives to track resolution of issues.  From the fall of 2015 until July 1, 2017, issues identified as program or operational were addressed through workgroups, round tables and consultation.  The remaining issues were identified as needing “a legislative fix.”

The Washington Indian Health Care Improvement Act (WIHCIA) was developed to resolve these legislative issues. This is also part of a three-year plan (insert link to 3-year plan) to improve the Medicaid Fee for Services system that has been adversely impacted by the changes made to the Washington State Medicaid Program through waivers and use of managed care entities and to enhance the 100% FMAP savings in the state.

A proviso in the 2019 budget funds $200,000 to the Washington State Health Care Authority to further develop how these issues will be addressed.  The proviso includes the convening of the Governor’s Indian Health Advisory Council. Council membership consists of:

  • Representation from each tribe in Washington state, designated by the tribal legislative body, who is either the Tribe’s American Indian Health Commission (AIHC) delegate or the Tribes designee;
  • Tribal Liaison from the Health Care Authority (HCA), Department of Children, Youth and Families (DCYF); Department of Commerce; Department of Corrections; Department of Health (DOH); Department of Social and Health Services (DSHS); Office of the Insurance Commissioner (OIC); Office of the Superintendent of Public Instruction (OSPI); and Washington Health Benefit Exchange (WAHBE);
  • CEO of the Indian Health Service Portland area office and each service unit in Washington state or his or her designee;
  • CEO of each Urban Indian Health Program (UIHP) in Washington state or his or her designee who may be the urban Indian health program’s American Indian health commission for Washington state delegate;
  • Executive Director of AIHC or his or her designee;
  • Executive Director of the Northwest Portland Area Indian Health Board (NPAIHB) or his or her designee;
  • One member from each of the two largest caucuses of both the House of Representatives and Senate, appointed by the speaker of the House of Representatives or Senate, or his or her designee;
  • Two individuals representing the governor’s office.