NCUIH Testifies Before Congress on First-Ever COVID-19 Oversight Hearing with IHS

Executive Director Francys Crevier stressed the need for the federal government to uphold the trust responsibility to Indian Country.

Washington, DC (June 11, 2020) – Today, the House Committee on Appropriations Subcommittee on Interior, Environment and Related Agencies held a hearing on the Indian Health Service (IHS) Covid-19 Response. The first panel included Rear Admiral Michael Weahkee, Director of IHS. The second panel started with Stacy Bohlen, CEO of the National Indian Health Board and finished with Francys Crevier, Executive Director of the National Council of Urban Indian Health (NCUIH). The hearing brought attention to the disparate impacts of the COVID-19 pandemic on Indian Country and the response by the Indian Health Service.

“On behalf of the National Council of Urban Indian Health (NCUIH), which represents 74 urban Indian facilities across the country, we are grateful for your tireless efforts in ensuring all of Indian Country has the resources needed to protect and care for our relatives. This disease, like the federal obligation to Native people, does not stop at the borders of a reservation. This pandemic has exacerbated the long-standing behavioral health disparities due to decades of historical trauma and will have lasting impacts for years to come. We thank you for including urban Indians in COVID-19 legislation. We urge Congress and the Administration to honor the federal trust obligation by providing the whole IHS System with all the resources necessary to serve the families who need them most,” said Francys Crevier, Executive Director of NCUIH in her testimony.

“The United States government has a trust responsibility to Indian tribes and signed treaties promising to provide health care and other services. Hundreds of years later, the failure to meet these treaty and trust obligations continues…The federal government has not been able to overcome the historical neglect and meet the true needs of Indian Country,” said Chair Betty McCollum in her opening remarks.

“All of the resources [from Congress] make a real difference in helping to fulfill our IHS mission as we continue to work with tribal and urban Indian organization partners to deliver crucial services during the pandemic,” said Rear Admiral Michael Weahkee in his remarks.

Hearing Information

• Recording

Chair Betty McCollum

• Statement

Rear Adm. Michael D. Weahkee  Director, Indian Health Service

• Testimony

Stacy Bohlen Chief Executive Officer, National Indian Health Board

• Testimony

Francys Crevier Executive Director, National Council of Urban Indian Health

• Testimony PDF

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NCUIH Testimony Highlights

• NCUIH requests that funds appropriated to UIOs by Congress are swiftly appropriated.  “COVID-19 funds have been needlessly tied up for weeks – and in more than instance months – by other agencies, thereby creating unnecessary barriers to pandemic response at UIOs”.
• NCUIH requests that “UIOs have avenues for direct communication with agencies charged with overseeing the health of their AI/AN patients, especially during the present health crisis.” “Only IHS has a statutory requirement to confer with UIOs, which has enabled other agencies to ignore the needs of urban Indians and neglect the federal obligation to provide health care to all AI/ANs – including the more than 70% that reside in urban areas.”
• NCUIH requests that Congress and federal agencies continue to act to ensure that UIOs can access PPE and testing equipment. During the pandemic “UIOs were not allocated any Abbott Rapid Response tests from IHS or FEMA. We have had to fight every step of the way for any testing capabilities”.
• NCUIH requests that the federal government remedy longstanding inequities that UIOs face including
  • 100% Federal Medical Assistance Percentage (FMAP) reimbursement for UIOs
  • Federal Tort Claims Act coverage for UIOs
  • Reimbursement from the VA for services provided to Native Veterans
  • Including UIOs in the national Community Health Aide Program and Indian Health Care Improvement Fund
• NCUIH requests that “the federal government ensures our frontline heroes receive the same protections as all other public health employees and provides adequate resources to UIOs to enable the continued provision of high quality and essential services. UIOs need equal access to programs like the Community Health Aide Program and community health workers to get to high risk patients.”
• NCUIH requests that UIOs are given access to facilities funding through at least an $80 million urban facilities line item. “Some facilities are located in 50+ year old buildings that already required expensive repairs and these needs have been significantly exacerbated by the pandemic.” UIOs need funding “in order to include necessary improvements like physical separations to enable safe distancing, air purification systems, and negative pressure rooms to control viral spread.”
• NCUIH requests that IHS release previously appropriated funds for UIOs to build telehealth capacity.
• NCUIH appreciates that the HEROES Act includes $1 billion for third party reimbursement relief, however NCUIH “urges Congress to include the full amount of $1.7 billion as recommended by the coalition of national Native American organizations.”
• NCUIH requests $7.3 million in annual appropriation for behavioral health at UIOs for the next three years to address the previous unmet need for behavioral health funding and account for the increase in behavioral health services due to COVID-19 that will remain for years to come.

Interior Appropriations Subcommittee Testimony National Council of Urban Indian Health

Francys Crevier, Executive Director

June 11, 2020

The National Council of Urban Indian Health (NCUIH) is the national non-profit organization devoted to the support and development of quality, accessible, and culturally-competent health and public health services for American Indians and Alaska Natives (AI/ANs) living in urban areas. NCUIH is the only national representative of the 41 Title V Urban Indian Organizations (UIOs) under the Indian Health Service (IHS) in the Indian Health Care Improvement Act (IHCIA). NCUIH strives to improve the health of the over 70% of the AI/AN population that lives in urban areas, supported by quality, accessible health care centers.

Chair McCollum, Ranking Member Joyce and Members of the Subcommittee, thank you for inviting me to speak on the impacts of the COVID-19 pandemic on urban Indian health. On behalf of the National Council of Urban Indian Health (NCUIH), which represents 41 urban Indian organizations (UIOs) that serve American Indians and Alaska Natives (AI/ANs) at 74 facilities across the country, we would like to express our gratitude for your tireless efforts in ensuring all of Indian Country has the resources needed to protect and care for our relatives during this pandemic. We also appreciate your commitment to ensuring that the 70% of AI/ANs residing in urban areas have access to critical health care. There is more work to be done and we look forward to working with Congress on ensuring that future emergency legislation provides urban Indian organizations resources to address this crisis. To that end, today I am going to testify with respect to the need for additional resources for UIOs to respond to the pandemic, including at least $80 million in facilities and infrastructure funding, coverage for significant losses in third-party reimbursement dollars, behavioral health funding, and parity for UIOs among the I/T/U system.

Decades of underfunding of the Indian Health Service (IHS) system, coupled with added burdens of chronic disease, put AI/ANs at higher risk of poor outcomes due to COVID-19. The disproportionate impact COVID-19 has on AI/ANs, like the federal obligation for the provision of health care to AI/AN people, does not stop at the borders of a reservation. For instance, AI/ANs are 3 times more likely to have diabetes, more than 1.5 times more likely to have been hospitalized for respiratory infections in the past, and more than 1.5 times more likely to have coronary heart disease than non-Hispanic whites. The Centers for Disease Control and Prevention has identified these conditions as specific risk factors for more serious illness due to COVID-19. Disparities in other social determinants of health also contribute to a disproportionate impact of the novel coronavirus on AI/AN people. During the H1N1 outbreak of 2009, AI/ANs were 4.1 times more likely to die than non-AI/AN people. It is thus essential to continue to provide essential resources to the IHS system – comprised of IHS facilities, tribal facilities, and UIOs – which has been hard hit by the pandemic as facilities shift their operations to prepare for, prevent, and respond to increases in COVID-19 among their patient populations. For instance, one UIO facility in San Jose, California recently reported a 13% positive test rate – higher than the national average.

During the course of the pandemic, 4 programs had to close their doors due to lack of resources and personal protective equipment (PPE) necessary to keep staff and patients safe from this deadly virus and only serve some patients remotely. Thankfully, PPE has become more available and emergency funds have started to flow into UIOs, which has allowed at least 1 program to reopen. At the beginning, however, delays in funding were extremely troublesome. Now, IHS is hosting weekly calls with our leaders and that has been invaluable to ensuring our programs can continue to serve the patients who need them most. We commend IHS for the agency’s invaluable partnership and tireless efforts to disseminate resources to Tribes and UIOs as expeditiously as possible. Unfortunately, funds have been needlessly tied up for weeks – and in more than instance months – by other agencies, thereby creating unnecessary barriers to pandemic response at UIOs. Compounding on this, only IHS has a statutory requirement to confer with UIOs, which has enabled other agencies to ignore the needs of urban Indians and neglect the federal obligation to provide health care to all AI/ANs – including the more than 70% that reside in urban areas. In fact, NCUIH has been unsuccessful at facilitating dialogue between numerous federal agencies and UIO-stakeholders, despite several attempts. This is not only inconsistent with the government’s responsibility, but is contrary to sound public health policy. Agencies have been operating as if only IHS has a trust obligation to AI/ANs, and that causes an undue burden to IHS to be in all conversations regarding Indian Country in order to talk with agencies. It is imperative that UIOs have avenues for direct communication with agencies charged with overseeing the health of their AI/AN patients, especially during the present health crisis.

In addition, the COVID-19 pandemic has highlighted the urgency of rectifying the long-standing inequities UIOs face. Everyone in the country has been fighting for PPE and testing kits. However, those sudden challenges compound the difficulty providing care when combined with the chronic funding and infrastructure gaps UIOs already experience. UIOs were not allocated any Abbott Rapid Response tests from IHS or FEMA. We have had to fight every step of the way for any testing capabilities, meanwhile, at least in two areas UIOs have been leading the way in getting testing available for the counties in which they are located. UIOs are a strong partner in their communities, and yet many have been forced to significantly ramp up facilities and infrastructure and pay premium prices for scarce supplies. These excess costs cascade on top of the extremely limited federal funding UIOs receive, as UIOs receive primary funding from only one line item of IHS – urban Indian health – funded at just below $58 million in FY 2020. Congressional and Administrative action has proved essential to enable UIOs to respond to the pandemic – and must continue as UIOs continue to face this crisis, the response to which mandates additional resources that are also flexible.

For instance,  all of this compounds on the inequities UIOs already face – for instance, the federal government does not reimburse states for 100% of the cost of Medicaid services at UIOs like it does for IHS and tribal facilities and UIOs are forced to expend millions of dollars each year in malpractice insurance because they do not receive Federal Torts Claims Act coverage like employees at IHS and tribal facilities (and both employees and volunteers at Community Health Centers). And, UIOs have been interpreted as ineligible for other essential programs or cost-saving measures – including reimbursement from the VA for services to Native Veterans, the national Community Health Aide Program, and Indian Health Care Improvement Fund, to name just a few. All of these factors have contributed to the novel coronavirus’s devastating impacts on UIOs. As our health workers are risking their lives every day, we need the federal government to ensure our frontline heroes receive the same protections as all other public health employees and provide adequate resources to UIOs to enable the continued provision of high quality and essential services. UIOs need equal access to programs like CHAP and community health workers to get to high risk patients.

A March 2020 NCUIH survey found that 83 percent of UIO-respondents have been forced to reduce their services, with 48 percent reporting no capacity for medicine delivery, and 28 percent reporting no capacity for triage space. Distancing guidelines tell us more than ever that proper capacity in essential facilities, such as health care facilities, is necessary. Just because UIOs do not receive funding under other line items does not mean the costs do not exist. UIOs do not have access to facilities funding under the IHS facilities budget line item and also don’t have access to the COVID-19 funding designated for facilities appropriated to the IHS. Now with the pandemic, it is an urgent priority to adequate fund an urban facilities line item to fund the renovations with accreditation restrictions and construction needed to protect our providers as well as their patients. Some facilities are located in 50+ year old buildings that already required expensive repairs and these needs have been significantly exacerbated by the pandemic. Without any federal funding for facilities, UIOs are forced to use their limited resources such as third party revenue that has drastically declined for essential infrastructure fixes – which during the pandemic include necessary improvements like physical separations to enable safe distancing, air purification systems, and negative pressure rooms to control viral spread. Residential Treatment Centers are faced with how to keep their patients housed within their programs, but also safe from the threat of COVID-19, which also means less patients receive care due to social distancing. They need modular buildings and funding for facilities renovation to ensure patients are not exposed to COVID-19 while seeking treatment. In addition, a recent NCUIH survey found that 26% of UIO-respondents needed a new urgent care facility, 26% needed a new infectious disease area, 31% require new modular facilities, and 20% require a new non-emergent care facility. For these reasons, a minimum of $80 million facilities appropriation for UIOs is absolutely vital to maintain the high quality provision of health care to AI/ANs residing in urban areas. Because each UIO is a unique organization with different capacities, patient populations, and community needs, as well as differing degrees of severity in local COVID-19 outbreaks, these funds must be flexible for use in facilities renovation and infrastructure. IHS received over $900 million in facilities funding last year, and Congress allocated $125 million for facilities in the CARES Act and proposed $366 million in the HEROES Act. IHS continues to be underfunded and we fully support desperately needed funding for Tribes. UIOs are eligible for $0 for facilities funds; it is imperative that this is remedied immediately to ensure access to care for our patients.

As UIOs have shifted to respond to the pandemic, telehealth and telemedicine capacity has become an essential component of health care delivery and something for which UIOs must expend considerable resources. IHS has allocated $95 million for telehealth capacity building at I/T/U facilities – but UIOs have not yet seen this funding, despite the immediate need. For instance, one facility has resorted to the purchase of old phones for patients to enable them to access telemedicine visits offsite. This funding is needed now to address these immediate concerns in the middle of the crisis and to prepare for the additional waves of the virus in the immediate future, as public health officials predict.

By being forced to cancel much of the routine care UIOs conduct, billable services have significantly declined, eliminating or severely reducing third-party reimbursement. That source of funding is critical to maintain UIOs’ operations, facilities and staffs. We support the inclusion in the HEROES Act funding of $1 billion for third-party relief, however, we urge Congress to include the full amount of $1.7 billion as recommended by the coalition of national Native American organizations, including the organizations you’re hearing from today. It is of the utmost importance that these funds be available to UIOs and that this does not create yet another lack of parity in the IHS system.

Finally, it is imperative that Congress appropriate funds for the significantly increased need for behavioral health services at UIOs. UIOs do not receive direct funds from the Mental Health, or Alcohol and Substance Abuse line items and instead must use the urban Indian health line item to account for these essential services. The COVID-19 pandemic and its unprecedented impacts on society have already led to an increased need for behavioral health services. Even before the pandemic, AI/ANs residing in urban areas faced significant behavioral health disparities – for instance, 15.1% of urban AI/ANs report frequent mental distress as compared to 9.9% of the general public and the AI/AN youth suicide rate is 2.5 times that of the overall national average. Congress must appropriate funds to not only address the previous unmet need but account for the increase in behavioral health services that is now critical and will remain so for years to come. TO that end, we respectfully request a $7.3 million in annual appropriation for behavioral health at UIOs for the next 3 years.

It is the obligation of the United States government to provide these resources for AI/AN people residing in urban areas. We thank Congress for the inclusion of UIOs in prior COVID-19 legislation and urge Congress to continue to take this obligation seriously by providing UIOs with all the resources necessary to protect the lives of their AI/AN patient populations. We request Congress continue to explicitly include UIOs in legislation where the whole Indian Health Care delivery system, I/T/U, is meant to benefit. Finally, we respectfully request that, as the FY 2021 appropriations process is underway, Congress keep in mind the significant and devastating strain unforeseen emergencies like the present pandemic and government shutdowns have on the underfunded Indian health system – and the additional stress that UIOs are faced with due to lack of inclusion in critical programs. As you know, Black and Brown lives matter and this committee has the opportunity to be the change we wish to see in this country. We are grateful for you for holding for this hearing today and for making sure our tribal members living in urban areas are not left behind.