Press Release: New NCUIH Report on Urban Third-Party Reimbursement

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Washington, DC (August 27, 2020)— The National Council of Urban Indian Health (NCUIH)  is proud to announce the publication of its report – “Recent Trends in Third-Party Billing at Urban Indian Organizations”. The report provides an overview of billing methods and payment methodologies that Urban Indian Organizations (UIOs) use for third-party reimbursement, data insights, and related policies and issues relevant both in the recent past and in the age of coronavirus.

“We have long known that Urban Indian Organizations do not receive adequate funding from the federal government,” said NCUIH Executive Director Francys Crevier. “This report demonstrates how resilient UIOs have been in spite of this, setting up robust third-party billing arrangements in a complex policy environment.  Unfortunately, the COVID-19 pandemic represents a catastrophic threat to the stability they have built”.

Key Findings Include:

  • Third-party reimbursement is more crucial to the stability of the Urban Indian healthcare system than ever. Between fiscal year (FY) 2010 to FY2018, third-party reimbursement nearly tripled, while funding from IHS appropriations remained relatively unchanged.
  • UIOs were projected to earn a minimum of $212.7 million in reimbursement in FY 2020.  Yet due to the coronavirus pandemic, NCUIH estimates that UIOs lost over a quarter of that expected revenue by June 21, 2020 (between $55.1 to $60.5 million).
  • In FY2018, UIOs received $672 per American Indian and Alaska Native (AI/AN) patient from the Indian Health Service (IHS) budget’s Urban Indian Health line item.
  • The average Medicaid reimbursement rate UIOs receive is around $245 – nearly half the 2020 all-inclusive rate of $479 available to tribal health programs and IHS facilities.  The lowest rate NCUIH has on record was $70 in 2018, and 50% of UIOs currently receive between $170 and $300 per encounter.

The authors of the report – Sunny Stevenson, JD (sstevenson@ncuih.org) and Andrew Kalweit, MPH (akalweit@ncuih.org) – presented initial findings at a Webinar on August 6, 2020 and will also present at the IHS Partnership Virtual Trainings on October 1, 2020.  A recording and slides for the first presentation are available online, alongside training materials.

NCUIH is thankful for the partnership with the Division of Tribal Affairs and Office of Minority Health at the Centers for Medicare and Medicaid Services, as well as NORC at the University of Chicago, which made this project possible. We look forward to continued collaboration as we strive to achieve healthy equity for American Indian and Alaska Native people.

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About the National Council of Urban Indian Health
The National Council of Urban Indian Health (NCUIH) is the national organization devoted to the support and development of quality, accessible, and culturally-competent health services for American Indians and Alaska Natives (AI/ANs) living in urban settings. NCUIH envisions a nation where comprehensive, culturally competent personal and public health services are available and accessible to AI/ANs living in urban communities throughout the United States.  NCUIH is the only organization that represents all 41 Urban Indian Organizations (UIOs) federally funded by the Indian Health Service.

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PRESS RELEASE: National Native Organizations (NCUIH, NCAI, NIHB) Call for Congressional Action in Light of New CDC Report

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FOR IMMEDIATE RELEASE 

Contact: Meredith Raimondi, 202-932-6615, mraimondi@ncuih.org

CDC study finds that COVID-19 has a disproportionate impact on American Indians and Alaska Natives who are 3.5 times more likely to test positive for COVID-19.

Washington, D.C. (August 26, 2020) – Today, the National Council of Urban Indian Health (NCUIH), the National Indian Health Board (NIHB), and the National Congress of American Indians (NCAI) (the National Native Organizations) renewed a call for urgent action by Congress on COVID-19 emergency legislation for Indian Country in light of a new CDC study from August 19, 2020. Previously, the National Native Organizations expressed the need for Congress to immediately reconvene to pass emergency COVID-19 legislation. The last emergency supplement to Indian Country was on March 27, 2020 in the CARES Act, in which Indian Country received just 0.5% of the funding.

On August 19, 2020, the Centers for Disease Control and Prevention (CDC) released the results of a COVID-19 study that examined the impact of COVID-19 on American Indians and Alaska Natives (AI/ANs). The report revealed many concerning details about COVID-19’s impact on AI/ANs, including that, in the 23 selected states CDC studied, AI/ANs were 3.5 times more likely to test positive for COVID-19 than non-Hispanic whites.

“The CDC study proves what we have known for months to be true – American Indians and Alaska Natives are disproportionately contracting and dying every single day from COVID-19. Inaction by the federal government is a failure of the federal trust responsibility to provide health care to Natives in exchange for cessation of our lands. This is not the first time a virus is killing our people while the federal government stands by without any plan for Indian Country. The time is now for our Congressional leaders to take action and provide our people the resources obligated to them by the federal government before more lives are needlessly lost”, said Francys Crevier, Executive Director of the National Council of Urban Indian Health.

“We are grateful that Congress directed nearly $200 million to CDC to support Tribes during the COVID-19 pandemic, but it is evident by the data that more resources and funding are needed. The CDC report highlights serious COVID-19 related challenges faced by American Indians and Alaska Natives, which is information that the National Indian Health Board has been relaying to media, Members of Congress and the Administration for months. Our messages are clear: Native people are disproportionately and negatively impacted by COVID-19; data gaps for Native health persist and need to be addressed; and serious investment is needed for public health infrastructure and health information technology within the Indian health system. Tribes need these resources, so we have a fighting chance to combat COVID-19 and the capacity to track the virus and all disease processes in Indian Country,” Stacy Bohlen, Executive Director of the National Indian Health Board.

“The federal government’s chronic underfunding of American Indian and Alaska Native public health systems has undeniably fueled the disproportionate impacts of COVID-19 on tribal communities,” said National Congress of American Indians CEO Kevin Allis. “Increased resources, including for public health infrastructure, are greatly needed to address these disparities and ensure that the United States upholds its trust and treaty responsibility to provide quality healthcare to tribal nations and their citizens.”

Background

On July 20, 2020, in response to these glaring inequities, NCUIH, NIHB, NCAI, and other organizations representing AI/ANs sent a letter to House and Senate leadership including recommendations for the fourth COVID-19 relief package. On July 27, 2020, the House Native American Caucus also sent a letter echoing the importance of addressing these needs. The recommendations included $2 billion in emergency funding for IHS and at least $1 billion for health infrastructure, Federal Torts Claim Act coverage and 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations, reauthorization of the Special Diabetes Program for Indians, and delivery of funds through preexisting IHS self-determination and self-governance contracts, among other provisions. These policies will provide AI/AN providers with the resources necessary to combat the disproportionate impact that COVID-19 has on AI/ANs.

Study Overview and Limitations

The CDC also found that AI/ANs infected by COVID-19 tended to be younger, with 12.9% of AI/ANs under 18 testing positive for COVID-19 compared to 4.3% of non-Hispanic Whites. The study was unable to identify disparities in COVID-19 disease severity and health outcomes compared to other racial and ethnic groups due to lack of available data for AI/ANs, illustrating the need for further research. Studies from the CDC, including this one, have shown that AI/ANs are among the racial and ethnic minority groups at a highest risk for severe COVID-19 outcomes. Factors contributing to higher rates of COVID-19 infection include historical trauma, preexisting health disparities, multigenerational households, and lack of access to running water.

The report also acknowledged several limitations due to incomplete data for AI/ANs.  First, data is voluntarily reported to CDC, which results in missing data and an incomplete picture of the prevalence of COVID-19 infection among our population. Second, the report included data from only 23 states, and the analysis only included one half of reported COVID-19 cases among AI/ANs during the same time period. Third, the methodology in this report used bridged-races estimates as population denominators which are known to inflate the Hispanic AI/AN population, resulting in an underestimation of mortality rates among AI/AN populations. The federal government must do a better job in meeting its trust responsibility to gather accurate and complete data to assess the true impact of COVID-19 in AI/AN communities.

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About the National Council of Urban Indian Health

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.A

About the National Congress of American Indians 

Founded in 1944, the National Congress of American Indians is the oldest, largest, and most representative American Indian and Alaska Native organization in the country. NCAI advocates on behalf of tribal governments and communities, promoting strong tribal-federal government-to-government policies, and promoting a better understanding among the general public regarding American Indian and Alaska Native governments, people, and rights. For more information visit www.ncai.org.

About the National Indian Health Board

Established by the Tribes to advocate as the united voice of federally recognized American Indian and Alaska Native Tribes, the National Indian Heatlh Board (NIHB) seeks to reinforce Tribal sovereignty, strengthen Tribal health systems, secure resources, and build capacity to achieve the highest level of health and well-being for our People.

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NCUIH, NIHB, and NCAI Send Joint Letter Urging Congress to Prioritize Indian Country in COVID-19 Vaccine Efforts

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On July 30, 2020, the National Council of Urban Indian Health (NCUIH), the National Indian Health Board (NIHB), and the National Congress of American Indians (NCAI) sent a letter to the leadership of the House and Senate Appropriations committees requesting a 5% direct set aside to the Indian health service, Tribal Nations, and urban Indian organization (I/T/U) system for vaccine distribution, administration, monitoring, and tracking in the next COVID-19 relief package. This set aside is vital because in previous pandemics American Indians and Alaska Natives (AI/ANs) had death rates four times higher than the national average, yet were some of the last to receive access to a vaccine. During this current pandemic AI/ANs have the highest COVID-19 hospitalization rate. This vaccine set aside will help ensure that history does not repeat itself during the coronavirus pandemic. The 5% set aside is reflective of the size of the AI/AN population and will ensure equitable access to any future COVID-19 vaccine.

Letter

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Re:  COVID-19 Vaccine Distribution

Dear Chair Shelby, Chair Lowey, Ranking Member Leahy, and Ranking Member Granger:

On behalf of the undersigned national organizations collectively serving all 574 sovereign federally-recognized American Indian and Alaska Native (AI/AN) Tribal Nations and all 41urban Indian organizations (UIOs), we write to strongly urge you to ensure that the next COVID-19 pandemic relief package includes direct set-aside funding to Indian Health Service (IHS), Tribal Nations, and urban Indian organizations (collectively “I/T/U”) for COVID-19 vaccine distribution, administration, monitoring, and tracking.

Under both the 1918 Spanish Flu pandemic, and the 2009 H1N1 pandemic, AI/AN people had death rates four times higher than the nation. Unfortunately, under each of those public health crises – and despite their profound impact on Tribal communities and AI/AN People – access to and/or a distribution plan for vaccines were afforded last, if at all, to AI/AN communities. This is because under both of those previous pandemics, Congress failed to enact direct set-asides for the I/T/U system for vaccine access and distribution and the Administration failed to create specific plans to safeguard Tribes or their citizens. Neither Congress nor the Administration did any planning around vaccination, health promotion, disease prevention or other impacts in Indian Country during the H1N1 pandemic and other previous pandemics. Congress has the opportunity to ensure this sordid history does not repeat itself with the COVID-19 pandemic. Congress can achieve that by including a minimum 5% direct, statutory set-aside in funds for the entire I/T/U system for COVID-19 vaccine distribution. A 5% set-aside is reflective of the size of the national AI/AN population, and of numerous statutory funding set-asides Congress has previously enacted for issues like the opioid crisis, suicide, chronic disease, and many others. We strongly urge you to ensure that a statutory set-aside for COVID-19 vaccine distribution is included for the full I/T/U system in this next COVID-19 pandemic relief package.

The federal government has treaty obligations to fully fund health services in Indian Country in perpetuity. These obligations were established through the over 350 Treaties signed between sovereign Tribes and the United States, and reaffirmed in our U.S. Constitution, Supreme Court case law, and federal legislation and regulations. These obligations must be honored under the COVID-19 pandemic and beyond. To that end, we greatly appreciate the $1.032 billion allocated to IHS under the CARES Act, and $750 million Tribal and urban Indian set-aside for COVID-19 testing under the Paycheck Protection Program and Health Care Enhancement Act. These were critical, but not nearly sufficient, investments to stem the tide of the pandemic in Indian Country. As Congress negotiates funding for COVID-19 vaccine distribution, it must ensure direct funding and access to vaccines reach the full I/T/U system.

Indeed, Indian Country has been disproportionately impacted by this pandemic. This is a systemic reality rooted in large part in the chronic underfunding of IHS, including a long term shocking lack of investment in health and public health infrastructure.  Per capita spending for those utilizing the I/T/U system reached only 40% of national health spending in 2018 ($3,779 vs $9,409), and, unsurprisingly, AI/AN people experience among the starkest disparities in the underlying conditions that increase the risk for a more serious COVID-19 illness. These include Type 2 diabetes, liver disease, heart disease, cancer, obesity and asthma.  According to the Centers for Disease Control and Prevention (CDC) AI/AN People have the highest COVID-19 hospitalization rate at 281 per 100,000 – a rate 5.3 times higher than for non-Hispanic Whites.[1] Aggregated national data on death rates show that AI/AN People are experiencing the second highest COVID-19 death rate, at 60.5 deaths per 100,000.[2]

In closing, we thank the Committee for the continued commitment to Indian Country and urge you to prioritize Indian Country in COVID-19 vaccine distribution and access. We patiently remind you that federal treaty obligations to the Tribes and AI/AN People exist in perpetuity, and must not be forgotten during this pandemic.   We urge you to make a commitment and follow through on it: determine that American Indians and Alaska Natives will receive the vaccine, will have funds sufficient to acquire and distribute it and the full faith and confidence of the United States Government will ensure distribution to this nation’s first citizens will be reliable, swift and early. As always, we stand ready to work with you in a bipartisan fashion to advance health in Indian Country.

Sincerely,

National Indian Health Board

National Congress of American Indians

National Council of Urban Indian Health

CC:

Lisa Murkowski, Chair, Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies

Tom Udall, Ranking Member, Senate Appropriations Subcommittee on Interior, Environment, and Related Agencies

Betty McCollum, Chair, House Appropriations Subcommittee on Interior, Environment, and Related Agencies

David Joyce, Ranking Member, House Appropriations Subcommittee on Interior, Environment, and Related Agencies

[1] Centers for Disease Control and Prevention. COVID-19 Data Visualization. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

[2] APM Research Lab. The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S. https://www.apmresearchlab.org/covid/deaths-by-race

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NCUIH Bills on FTCA for UIOs Advance Out of House and Senate Committees

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On July 29, H.R. 6535 passed the House Natural Resources Committee. “Urban Indian organizations like the ones that serve my constituents in Phoenix are already working off shoestring budgets and shouldn’t have to sacrifice patient care to shell out millions for liability coverage,” said Rep. Ruben Gallego, who introduced H.R. 6535. The bill has also been referred to the House Energy and Commerce and Judiciary Committees where it awaits further action.

On July 29, the Senate Committee on Indian Affairs advanced their companion bill S. 3650 with an amendment to extend FTCA to Native Hawaiians.  The link to the hearing can be found here. The bill awaits further action for consideration before the full Senate, however, due to a full calendar including COVID-19 relief funding and FY21 Appropriations, passage looks unlikely.

On July 22, Robyn Sunday-Allen, NCUIH Vice President and Chief Executive Officer of the Oklahoma City Indian Clinic, testified in front of the House Subcommittee for Indigenous Peoples of the United States. Ms. Allen testified in support of H.R. 6535, the Coverage for Urban Indian Health Providers Act. H.R. 6535 would extend Federal Tort Claims Act (FTCA) coverage to urban Indian organizations (UIOs). Passage of H.R. 6535 would ensure that UIOs achieve parity with the rest of the IHS/tribal health providers/urban Indian organizations system (I/T/U system). Currently, UIOs are the only part of the I/T/U system that do not receive FTCA coverage. This Act, if passed, would save UIOs up to $250,000 a year on medical malpractice insurance-money that could be used to hire additional providers, provide additional programs, and to respond to COVID-19 and future public health emergencies.

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NUIFC Press Release: The National Council of Urban Indian Health Joins An Unprecedented National Coalition For Census & Civic Engagement Work In All Native Communities

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SEATTLE, WA — The National Urban Indian Family Coalition (NUIFC) is excited to welcome the National Council of Urban Indian Health (NCUIH) to a national coalition of Native organizations working collaboratively on a robust, unprecedented civic engagement initiative focused on ensuring an accurate Census count and empowering hundreds of thousands Native voters in communities on and off the reservation.

“We have so much at stake and we’re taking extraordinary efforts to make sure our voices are heard in the most important election and Census of our lifetime,” says Janeen Comenote, NUIFC Executive Director. “The addition of NCUIH to our already powerful coalition of urban Indian organizations both locally and nationally strengthens our collective ability to impact the body politic in the U.S.”

“It is of paramount importance that we ensure that American Indians and Alaska Natives (AI/AN) living in urban settings are civically engaged, exercising their rights and raising their voices. As this is the first time ever that NCUIH has been awarded funds to focus on Census and Voting initiatives at the national level, we are encouraged to see attention given to urban AI/AN mobilization to positively impact and educate decision makers and the general public on our reality and challenges especially amid a global pandemic that is ravaging our communities.”

— FRANCYS CREVIER, NCUIH’S EXECUTIVE DIRECTOR

NCUIH joins an impressive list of national Native organizations including, the National Congress of American Indians, the Native American Rights Fund, Urban Indian Health Institute, the Center for Native American Youth, and the NUIFC. The addition of the NCUIH rounds out a full geographic footprint both on and off the reservation in Indian Country.

“NCUIH is thrilled to partner with the National Urban Indian Family Coalition (NUIFC) and the Wallace H. Coulter Foundation on a critically important census and civic engagement initiative for Urban Native Americans,” says Alejandro Bermudez Del-Villar, NCUIH’s Programs & Development Director. “It is of paramount importance that we ensure that American Indians and Alaska Natives (AI/AN) living in urban settings are civically engaged, exercising their rights and raising their voices. As this is the first time ever that NCUIH has been awarded funds to focus on Census and Voting initiatives at the national level, we are encouraged to see attention given to urban AI/AN mobilization to positively impact and educate decision makers and the general public on our reality and challenges especially amid a global pandemic that is ravaging our communities.”

NCUIH was formed in 1998 to support the development of quality, accessible, and culturally competent health services for American Indians and Alaska Natives living in urban communities. Today, NCUIH works in partnership with more than 40 urban Indian organizations offering quality, accessible, and culturally sensitive health care programs in their community and are a trusted institution in Indian country.

To this end, NCUIH will conduct online civic education through multiple platforms, invest into Urban Indian Health Organizations to engage in community engagement around the Census and election, and work directly with its youth council to foster civic participation among young Natives.

In 2018, the NUIFC launched the first ever national urban American Indian & Alaska Native Civic Engagement initiative, which was an overwhelming success and contributed to the election of the country’s first two Native American Congresswomen. This year NUIFC has steadily grown this national coalition with the primary goal of supporting an even larger network of Urban Indian organizations as they build political power and ensure an accurate Census count. With more than 70 percent of all American Indians and Alaska Natives residing in metropolitan centers, it is vital that our work include as many urban stakeholders as possible.

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