On June 18, 2020 the Center for American Progress, a Washington DC based think tank, released a report on the COVID-19 response in Indian Country. The detailed report focuses on 7 key areas for addressing health inequities in Indian country during the pandemic: inclusion in COVID-19 data; addressing bureaucratic barriers; supporting tribal economies; addressing the underfunded Indian health system; developing critical infrastructure; funding tribal public safety and justice needs, and restoring tribal homelands. The report highlighted how underfunded the Indian health system was prior to COVID-19 and elaborated on how much stress Urban Indian Organizations (UIOs) have been under since the pandemic began.
The report included recommended policy solutions for better funding and supporting Indian Health Service (IHS). Topping the list of solutions is increasing funding for IHS and prioritizing urban Indian health. The other solutions mirror those UIOs have been asking for: access to the Strategic National Stockpile; reauthorization of the Special Diabetes Program for Indians (SDPI); to include pharmacists; licensed marriage and family therapists, and licensed counselors as eligible providers for Medicare reimbursement; extending Medicare telehealth waivers; and removing restrictions and barriers for UIOs. Most importantly, the report calls for the inclusion of UIO-specific language in all Indian health system related legislation to ensure UIOs receive the resources intended.
Recommendation: Address the chronic underfunding of the Indian Health Service system
The IHS is the federal agency that oversees and provides health care to AI/AN communities through Indian tribes, tribal organizations and urban Indian organizations, together known as the I/T/U system. Before COVID-19, the IHS was already so underfunded that expenditures per patient were just one-fourth of the amount spent in the veteran’s health care system and one-sixth of what is spent for Medicare.33 IHS facilities are, on average, understaffed by 25 percent.34 Now, the IHS is scrambling to provide crisis services to a vulnerable and hard-hit constituency with its stretched-thin staff, inadequate facilities, and severe lack of funds.
While the CARES Act provided $1 billion to the IHS, unmet needs are estimated at $32 billion.35 Federal assistance during the pandemic has not been forthcoming; the Sault Ste. Marie Tribe of Chippewa Indians, for example, received only two test kits for a tribe of 44,000 people.36 The Oyate Health Center, a major health provider in Rapid City, South Dakota, which transitioned into tribal management in 2019, received almost no tests, PPE, or cleaning supplies.37 The Seattle Indian Health Board was sent body bags when it asked for more medical supplies to fight COVID-19.38 Urban Indian organizations are some of the worst hit, with 83 percent forced to reduce services and almost half unable to deliver medicine.39 Overwhelmed facilities are forced to fly patients into larger cities for treatment and must foot the transportation bill.40
The I/T/U system requires an urgent injection of funds and investment in capacity, but the likelihood of a prolonged COVID-19 pandemic lasting months or years necessitates that the federal government not renege on its duties to support the treatment of diabetes, asthma, substance abuse, and other immunocompromising diseases that are increasing the AI/AN fatality rate.
Immediate policy solutions:
- Increase immediate funding to the IHS and prioritize urban Indian health, including access to the national service supply center for essential testing equipment; equipment purchases and replacements; and IHS hospitals and health clinic on-site treatment capacity
- Expedite the reauthorization of the IHS Special Diabetes Program for Indians (SDPI) and other programs that deal with immunocompromising conditions that require uninterrupted care
- Provide all I/T/U facilities access to the Strategic National Stockpile and Public Health Emergency Fund
- Include pharmacists, licensed marriage and family therapists, licensed counselors, and other providers as eligible provider types under Medicare for reimbursement to I/T/U facilities in order to lessen the burden of mental health on immunity
- Extend waivers under Medicare for the use of telehealth in Indian Country
- Remove restrictions and barriers on care provision through urban Indian health organizations
Long-term policy solutions:
- Increase funding for the IHS and strengthen coordination among federal, tribal, state, and local health agencies
- Fund job-training programs to address staff shortages through the Indian Health Care Improvement Act
- Provide a tax incentive for IHS professionals similar to other public sector health workers
- Ensure an explicit mention of urban Indian organizations in I/T/U-related legislation to combat the invisibility of urban AI/AN suffering