Policy Blast: Tribal Nations Summit Highlights Funding Needs for Indian Health including Urban Indian Health

Administration leaders discussed new initiatives to address the needs of Indian Country, a memorandum of understanding to support Native languages, advance appropriations for IHS, and additional funding for urban Indian health

 

Last week, the White House convened for the 2021 Tribal Nations Summit for the first time since the Obama Administration. During the summit, remarks encompassed an array of topics all linking back to the health, wellness, and progression of Indian Country. This year’s summit brought together officials and leaders from the Federal government and federally recognized Tribes, to discuss ways to invest and continue to strengthen the Nation-to-Nation relationship.

 

  • During the live broadcast President Biden announced five new initiatives:
  1. Development of 17 departments and agencies to protect Tribal treaty rights in the work of the Federal government;
  2. Increase Tribal participation in management and stewardship of Federal lands;
  3. Institute the Biden Administration as the first to work to achieve comprehensive Tribal ecological knowledge into the Federal governments scientific approach in the fight of climate change;
  4. Take action to protect the greater Chaco landscape in northwestern New Mexico further protecting the area from new oil and gas leasing;
  5. Lastly, signed executive order “Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People”. This order has a heavy emphasis on policy and directs the departments of Justice, Interior, Homeland Security, and Health and Human Services to create and implement strategies that improve safety; additionally, addressing the ongoing crisis of missing or murdered Indigenous people. Strategies identified in the order call for support on enforcement strategies with prevention and response to violence; improved data collection, analysis, and information sharing; early intervention and victim survivor services; and increased consultation and engagement with Indigenous communities.

During the summit, acknowledgement was paid to the profound impact of COVID-19 to Indian country and the devastating consequences. Highlighting the lack of infrastructure, gaps in efficient health insurance access, high rates of unemployment, lack of foundational preschool education for children, and several other critical measures. Janet Yellen, U.S. Secretary of the Treasury, addressed that the goal is not to return Indian country to its pre-covid economic situation, that was already not efficient, but to truly “build back better. Several mentions were made to the direct promotion of Urban Indian Organization (UIO) capacity and the health status of their patients. Secretary Xavier Becerra, U.S. Department of Health and Human Services, noted that “as of this week, IHS has administered over 1.78 million doses of the COVID-19 vaccine in Indian Country, through Tribal and urban Indian programs”. American Indians and Alaska Natives have an over three times higher infection rate than non-Hispanic whites, are four times more likely to be hospitalized, and have higher rates of mortality at younger ages, yet modeled with resilience in testing and prevention planning, Indian Country now leads the nation for having the highest vaccination rate!

 

First Lady Jill Biden announced a new memorandum of agreement on Native language, bringing governments together to promote and support the instruction and preservation of Native American languages. This investment will bring millions of dollars to enable the revitalization of many languages that are in danger of being forgotten due to the loss of elders during this pandemic. Such loss urges the need for protection of language and tradition more than ever.

Susan Rice, Director of the Domestic Policy Council, covered President Biden’s request for $29 billion for Indian Programs in the next year budget, indicating a 14% increase over last year’s request. Including for the first time, advance appropriations for Indian Health Service (IHS).

As the summit came to a close, IHS announced $9.34 million in funding, enhancing opportunities to support Tribal self-governance and urban Indian health. The Urban Indian Health Programs 4-in-1 Grant Program is for $8.5 million and aims to enhance capacity when developing programs that achieve the highest possible health status for urban Indians. Funding will be used to support four health program objectives:

  • Health promotion and disease prevention services
  • Immunization services
  • Alcohol and substance abuse related services
  • Behavioral health services

There are a total of 33 awards expected to be afforded, lasting the span of 5-years. Applications are due by February 8, 2022. Individual award amounts for the first year will be between $160,000 and $650,000. New applicants can apply for funding up to $200,000. This funding is only open to UIOs that are currently administering a contract or receiving a grant.

 

 

Background

The progress report, published in partnership with the Tribal Nations Summit, was released in advance of last week’s Summit and included the need to meet the obligations to urban Indians. In the report, it addressed that over 70 percent of AI/ANs live off reservation in an urban area. The report reinforces the Biden Administration’s commitment to elevating the voice of urban Indians, including UIOs, in Tribal listening sessions with topics pertinent to health, education, funding, housing, voting, and more, as well as addresses Urban Indian Health Organizations inclusion in 100 percent Federal Medical Assistance Percentages (FMAP).

OMB Urges Passage of Appropriations Bills as a Priority for Indian Health

On November 12, 2021, The Office of Management and Budget (OMB) released a fact sheet urging Congress to pass their appropriations bills for 2022. The fact sheet includes 17 top priorities around pandemic response and other public health initiatives, national security and American leadership, education, and core citizen services. Of the 17, inclusion of Indian Health Service (IHS) funding and addressing American Indians and Alaska Natives health disparities was in the top 3 priorities:

 

  • Address health disparities among American Indians and Alaska Natives. The President’s Budget and the House and Senate appropriations bills provide funding for thousands more inpatient admissions and millions more outpatient visits at Indian Health Service (IHS) facilities, compared to continuing 2021 funding levels, and would allow IHS to fill hundreds of open medical and other staff positions.

 

Appropriation Bills Status

 

The House fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill (H.R. 4372), which includes $200.5 million for urban Indian health and $8.1 billion for IHS, was part of a seven-bill package the House passed on July 29.

 

The Senate Appropriations Committee released its FY 2022 Interior, Environment, and Related Agencies bill, which includes $92.7 million for urban Indian health, $7.61 billion for IHS, an additional $6.58 billion in advance appropriations to IHS for FY23, and a facilities fix to allow urban Indian organizations to use existing IHS funding for facilities improvement and renovations. However, the Senate has yet to pass their appropriations bill.

OMB Urges Passage of Appropriations Bills as a Priority for Indian Health

On November 12, 2021, The Office of Management and Budget (OMB) released a fact sheet urging Congress to pass their appropriations bills for 2022. The fact sheet includes 17 top priorities around pandemic response and other public health initiatives, national security and American leadership, education, and core citizen services. Of the 17, inclusion of Indian Health Service (IHS) funding and addressing American Indians and Alaska Natives health disparities was in the top 3 priorities:

 

  • Address health disparities among American Indians and Alaska Natives. The President’s Budget and the House and Senate appropriations bills provide funding for thousands more inpatient admissions and millions more outpatient visits at Indian Health Service (IHS) facilities, compared to continuing 2021 funding levels, and would allow IHS to fill hundreds of open medical and other staff positions.

 

Appropriation Bills Status

 

The House fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill (H.R. 4372), which includes $200.5 million for urban Indian health and $8.1 billion for IHS, was part of a seven-bill package the House passed on July 29.

 

The Senate Appropriations Committee released its FY 2022 Interior, Environment, and Related Agencies bill, which includes $92.7 million for urban Indian health, $7.61 billion for IHS, an additional $6.58 billion in advance appropriations to IHS for FY23, and a facilities fix to allow urban Indian organizations to use existing IHS funding for facilities improvement and renovations. However, the Senate has yet to pass their appropriations bill.

Policy Blast: House Passes Budget Reconciliation Which Includes Long Needed Infrastructure Funds for Urban Indian Health

The Build Back Better Act maintained $100 million for UIO facilities and extension of key Medicaid parity provision for UIOs.

On November 19, 2021, the House passed President Biden’s Build Back Better (BBB) Act with a 220-213 vote. The BBB Act, allocates $2.347 billion to the Indian Health Service (IHS), $100 million for Urban Indian Health facilities, and extension of an additional 8 fiscal quarters of 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) beginning April 1, 2021. As Congress negotiated the Reconciliation bill from $3.5 trillion to $1.75 trillion, funding for Indian Country was significantly reduced from the original reconciliation instruction allocation of $20.5 billion. Earlier this week, the President signed into law the bipartisan infrastructure bill which allows UIOs to use existing resources to fund infrastructure projects.

“Adequate funding for Indian Country is crucial now more than ever, especially as the COVID-19 pandemic has, and continues to be, the deadliest for American Indian and Alaska Native communities. We are grateful for our House champions who ensured that urban Indian health was a priority. We cannot build back better without Indian Country and encourage the Senate to retain these critical provisions.” said Francys Crevier, CEO of NCUIH (Algonquin).,

Background and Advocacy

UIOs, which are a fundamental, inseverable component of the Indian Health Service/Tribal Health Program/UIO (I/T/U) system, face chronic underfunding. The National Council of Urban Indian Health (NCUIH) has long advocated for adequate funding for ALL three parts of the I/T/U system to better serve the American Indian/Alaska Native (AI/AN) population.

NCUIH initially advocated for $200 million dollars on August 1, 2021. The draft reconciliation bill released on September 27 included $100 million for UIO facilities. Since 1986, $13.3 billion in facilities funding has been allocated to IHS, however UIOs are not eligible for the IHS Facilities or Sanitation line items. The allocation of $100 million for UIO facilities in BBB is historic and long overdue.

NCUIH and UIO advocacy to Congressional leadership helped retain provisions in the BBB Act affecting UIOs that were at risk of cuts during Congress’ negotiations to reduce the cost of the budget reconciliation bill. However, the overall stark decrease in the funding commitment for Indian Country is disappointing for AI/ANs and does not uphold the trust and treaty obligations of the federal government. This past week, NCUIH sent a letter to Speaker Pelosi’s office urging the passage of the BBB Act with support for Indian Country.

 

Next Steps

The Reconciliation bill will now be sent to the Senate for consideration. NCUIH will also be requesting that the Senate retain the $100 million for UIO facilities and extension of 100% FMAP.

 

Budget Reconciliation Bill Highlights

Committee on Natural Resources

Indian Health Service

  • “MAINTENANCE AND IMPROVEMENT.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $945,000,000, to remain available until September 30, 2031, for maintenance and improvement of facilities operated by the Indian Health Service pursuant to a self-determination contract (as defined in subsection (j) of section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304(j))) or a self-governance compact entered into pursuant to subsection (a) of section 404 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5364(a)).”
  • “MENTAL HEALTH AND SUBSTANCE USE DISORDERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $123,716,000, to remain available until September 30, 2031, for mental health and substance use prevention and treatment services, including facility renovation, construction, or expansion relating to mental health and substance use prevention and treatment services.
  • “PRIORITY HEALTH CARE FACILITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for projects identified through the health care facility priority system established and maintained pursuant to subparagraph (A) of paragraph (1) of subsection (c) of section 301 of the Indian Health Care Improvement Act (25 U.S.C. 1631(c)(1)(A)).”
  • “SMALL AMBULATORY.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $40,000,000, to remain available until September 30, 2031, for small ambulatory construction.”
  • “URBAN INDIAN ORGANIZATIONS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until September 30, 2031, for, notwithstanding the restrictions described in section 509 of the Indian Health Care Improvement Act (25 U.S.C. 1659), the renovation, construction, expansion, equipping, and improvement of facilities owned or leased by an Urban Indian organization (as defined in item (29) of section 4 of that Act (25 U.S.C. 1603(29))).
  • “EPIDEMIOLOGY CENTERS.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until September 30, 2031, for the epidemiology centers established under paragraphs (1) through (2) of subsection (a) of section 214 of the Indian Health Care Improvement Act (25 U.S.C. 1621m(a)(1)–(2)).”
  • “ENVIRONMENTAL HEALTH AND FACILITIES SUPPORT ACTIVITIES.—In addition to amounts otherwise available, there is appropriated to the Director of the Indian Health Service for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $113,284,000, to remain available until September 30, 2031, for environmental health and facilities support activities of the Indian Health Service.”

Committee on Education and Labor

Grants to Support the Direct Care Workforce

  • “GRANTS AUTHORIZED.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $1,000,000,000, to remain available until September 30, 2031, for awarding, on a competitive basis, grants to eligible entities to carry out the activities described in subsection (c) with respect to direct support workers.
    • Urban Indian Organizations are listed as eligible entities for this grant to “provide competitive wages, benefits, and other supportive services, including transportation, child care, dependent care, workplace accommodations, and workplace health and safety protections, to the direct support workers served by the grant”

Committee on Energy and Commerce

Extension of 100 Percent Federal Medical Assistance Percentage for Urban Indian Health Organizations and Native Hawaiian Health Care Systems

  • “The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) is amended— (1) by striking ‘‘for the 8 fiscal year quarters beginning with the first fiscal year quarter beginning after the date of the enactment of the American Rescue Plan Act of 2021’’ and inserting ‘‘for the period of the 16 fiscal year quarters that begins on April 1, 2021’’; and (2) by striking ‘‘such 8 fiscal year quarters’’ and inserting ‘‘such period of 16 fiscal year quarters.”

Funding for Palliative Care and Hospice Education and Training

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $25,000,000, to remain available until expended, to support the establishment or operation of programs that— (1) support training of health professionals in palliative and hospice care (including through traineeships or fellowships); and (2) foster patient and family engagement, integration of palliative and hospice care with primary care and other appropriate specialties, and collaboration with community partners to address gaps in health care for individuals in need of palliative or hospice care.”
    • UIOs are mentioned as eligible applicants for funding

Funding for Local Entities Addressing Social Determinants of Maternal Health

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other nonprofit organizations working with a community-based organization, or consortia of any such entities, operating in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding to Grow and Diversify the Doula Workforce

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the doula workforce, including through improving the capacity and supply of health care providers.”

Funding to Grow and Diversify the Maternal Mental Health and Substance Use Disorder Treatment Workforce

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $75,000,000, to remain available until expended, for carrying out a program to award grants or contracts to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, or other appropriate public or private nonprofit entities (or consortia of any such entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the maternal mental health and substance use disorder treatment workforce, including through improving the capacity and supply of health care providers.”

Funding for Maternal Mental Health Equity Grant Programs

  • IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $100,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, Native Hawaiian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other nonprofit organizations, schools, or programs determined appropriate by the Secretary, or consortia of any such entities, to address maternal mental health conditions and substance use disorders with respect to pregnant, lactating, and postpartum individuals in areas with high rates of adverse maternal health outcomes or with significant racial or ethnic disparities in maternal health outcomes.”

Funding for Expanding the Use of Technology-Enabled Collaborative Learning and Capacity Building Models for Pregnant and Postpartum Individuals

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education 15 programs, residency or fellowship programs, or other 16 schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes, to evaluate, develop, and expand the use of technology-enabled collaborative learning and capacity building models (as defined in section 330N of the Public Health Service Act (42 U.S.C. 254c–20)).”

Funding for Promoting Equity in Maternal Health Outcomes Through Digital Tools

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $30,000,000, to remain available until expended, for carrying out a program to award grants or contracts to community-based organizations, Indian Tribes and Tribal organizations, Urban Indian organizations, health care providers, accredited medical schools, accredited schools of nursing, teaching hospitals, accredited midwifery programs, physician assistant education programs, residency or fellowship programs, or other schools or programs determined appropriate by the Secretary, or consortia of any such entities, that are operating in health professional shortage areas designated under section 332 of the Public Health Service Act (42 U.S.C. 254e) with high rates of adverse maternal health outcomes or significant racial and ethnic disparities in maternal health outcomes to reduce racial and ethnic disparities in maternal health outcomes by increasing access to digital tools related to maternal health care.”

Funding for Community Violence and Trauma Interventions

  • “IN GENERAL.—In addition to amounts otherwise available, there is appropriated to the Secretary, for fiscal year 2022, out of any money in the Treasury not otherwise appropriated $2,500,000,000, to remain available until expended, for the purposes described in subsection (b):
    • (b) USE OF FUNDING.—The Secretary, acting through the Director of the Centers for Disease Control and Prevention, and in consultation with the Assistant Secretary for Mental Health and Substance Use, the Administrator of the Health Resources and Services Admin1istration, the Deputy Assistant Secretary for Minority Health, and the Assistant Secretary for the Administration for Children and Families, shall use amounts appropriated by subsection (a) to support public health-based interventions to reduce community violence and trauma, taking into consideration the needs of communities with high rates of, and prevalence of risk factors associated with, violence-related injuries and deaths, by—
      • (1) awarding competitive grants or contracts to local governmental entities, States, territories, Indian Tribes and Tribal organizations, Urban Indian organizations, hospitals and community health centers, nonprofit community-based organizations, culturally specific organizations, victim services providers, or other entities as determined by the Secretary (or consortia of such entities) to support evidence-informed, culturally competent, and developmentally appropriate strategies to reduce community violence, including outreach and conflict mediation, hospital-based violence intervention, violence interruption, and services for victims and individuals and communities at risk for experiencing violence, such as trauma-informed mental health care and counseling, social-emotional learning and school-based mental health services, workforce development services, and other services that prevent or mitigate the impact of trauma, build appropriate skills, or promote resilience”

CMS and OSHA Issue New Rules and Standards Around COVID-19 Vaccination Requirements

On November 5, 2021, the Occupational Safety and Health Administration (OSHA) under the U.S. Department of Labor announced new emergency temporary standards to protect nearly 85 million workers from the spread of COVID-19. These standards come in alignment with the Administration’s previous policies requiring federal employees and contractors to be fully vaccinated, as well as the recent Centers for Medicare and Medicaid Services (CMS) rule that health care workers at facilities participating in Medicare and Medicaid be fully vaccinated. 

OSHA’s COVID-19 Vaccination and Testing Emergency Temporary Standard (ETS) will follow the same time frame as both the CMS rule and the Administration’s previously implemented policies – by January 4, 2022 all contractors and employees covered under these vaccination rules must have completed a full series of vaccinations or have received a single dose vaccination. These rules take precedent over any state or local ordinances, and OSHA further clarifies that their standard does not preempt the CMS rule. 

The OHSA COVID-19 Vaccination and Testing (ETS) for employers with 100 or more employees is as follows: 

  • Require full vaccination of employees by Jan 4, 2022. If an employee is not fully vaccinated by then, employees must provide a negative COVID test on at least a weekly basis. The ETS does not require an employer to cover the cost of the tests but they may be required to do so through other agreements or laws. 
  • Pay employees for the time taken to get vaccinated. If needed, employers must also give sick leave to those who need to recover from side effects. Compliance for this must be met by December 5, 2021. 

The CMS COVID-19 Omnibus Vaccine Rule (IFC-6) is as follows: 

  • By December 5, 2021, all facilities must have processes and plans in place for vaccinating staff, providing exemptions and accommodations and tracking and documenting staff vaccinations. All eligible staff must also have received at least one dose of a multi-dose vaccination, or the single dose vaccination by this date. 
  • By January 4, 2022, all covered staff at eligible facilities must have completed a multi-dose series of vaccination or be fully vaccinated. For this rule, CMS considers fully vaccinated to be 2 weeks post completion of either the single or multi-dose inoculations. 

  

For more information, please see:  

Fact Sheet: Biden Administration Announces Details of Two Major Vaccination Policies 

OSHA Publication 4162: Summary of COVID-19 Emergency Temporary Standard 

FAQ: CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule 

FEMA Public Assistance Funds Available to UIOs for COVID-19 Vaccine Administration Activities

On November 5, 2021, in response to the Centers for Disease Control and Prevention (CDC) recommendation that children ages 5-11 receive the Pfizer COVID-19 vaccine, the Federal Emergency Management Agency (FEMA) announced that its Public Assistance program will reimburse 100% of eligible costs associated with administering vaccines to children and adults until December 31, 2021. The funding will continue after December 31, but the reimbursement percentage may change. Urban Indian Organizations (UIOs) operating medical facilities are eligible for this FEMA funding that will be provided on a reimbursement basis for eligible vaccination activities, including:

 

  • Vaccination facilities including community vaccination centers, mass vaccination sites and mobile vaccinations including necessary security and other services for sites.
  • Medical and support staff including contracted and temporary hires to administer vaccinations.
  • Training and technical assistance specific for individuals storing, handling, distributing, and administering of COVID-19 vaccinations.
  • Personal protective equipment, other equipment, supplies, and materials required for storing, handling, distributing, and administering COVID-19 vaccinations.
  • Transportation support such as refrigerated trucks and transport security, for vaccine distribution as well as reasonable transportation to and from the vaccination sites for children and families with limited or no mobility to get to a vaccine site.
  • Onsite infection control measures and emergency medical care for children and families at vaccination sites.
  • Communication efforts that keep the public informed including public messaging campaigns, public service announcements, flyers, newspaper advertisements, websites, translation services, in-person community engagement, and call centers or websites to assist with scheduling appointments or answering questions for children and their families.

 

 

NCUIH worked with FEMA’s Public Assistance Division early in the pandemic to get questions answered about the agency’s available resources for UIOs and open the lines of communication with FEMA officials.

MOU Between the VA and IHS Updated to Improve the Health Status of AI/AN Veterans and Include UIOs

MOU VA/HIS

MOU Between the VA and IHS Updated to Improve the Health Status of AI/AN Veterans and Include UIOs.

On October 1, 2021, the U.S. Department of Veteran Affairs (VA) Veterans Health Administration (VHA) and the U.S. Department of Health and Human Services (HHS) Indian Health Service (IHS) signed a new Memorandum of Understanding (MOU) aimed at improving the health status of American Indian and Alaska Native (AI/AN) Veterans. This MOU establishes a framework for coordination and partnership to leverage and share resources as well as investments in support of each organization’s mutual goals. The new MOU replaces and supersedes the MOU signed in October 2010.

The MOU is being updated because in 2019, the U.S. Government Accountability Office (GAO) published a report that contained a recommendation for IHS and VHA to revise the MOU and related performance measures so that they reflect best practices for successful performance measures, including the identification of measurable targets. GAO’s recommendation served as the catalyst for initiation of tribal consultation by VHA and Urban Confer by IHS regarding updates to the MOU.

BACKGROUND

In 2003, the VHA and the IHS initially entered an MOU to improve access and health outcomes for AI/AN Veterans. They then implemented a revised MOU in 2010 to further establish mutual goals to advance collaboration, coordination, and resource sharing. UIOs were explicitly mentioned in the MOU language.. However, the VA’s position was that UIOs were not identified in 25 U.S.C. §1645(c) as one of the organizations it could reimburse.

NCUIH and UIO leaders have been testifying before Congress for years regarding the MOU not being fully implemented for UIOs. Between 2012 and 2015, the VA reimbursed over $16.1 million for direct services provided by IHS and Tribal Health Programs covering 5,000 eligible Veterans under the IHS-VA MOU.

On December 27, 2020, the Consolidated Appropriations Act, 2021 was signed into law, providing authority for UIO reimbursement from VA. This critical piece of legislation (Health Care Access for Urban Native Veterans Act) included in the Consolidated Appropriations Act, 2021 will make a meaningful difference in the funding for health care services provided by UIOs to improve healthcare to AI/AN Veterans. Passage came after advocacy from NCUIH and other national organizations serving AI/ANs. On July 15, 2019, the National Congress of American Indians( calling on the United States Congress to enact legislation requiring the VA to reimburse UIOs for health care provided to AI/AN Veterans. Following the resolution, NCUIH testified before Congress on Native Veterans’ access to healthcare, asking the VA to “fully implement the VA and Indian Health Services’ Memorandum of Understanding (VA-IHS MOU) and Reimbursement Agreement for Direct Health Care Services.” On December 4, 2020, NCUIH, the National Congress of American Indians (NCAI), and National Indian Health Board (NIHB) wrote a letter urging Congress to ensure the passage of H.R. 4153 – Health Care Access for Urban Native Veterans before the end of the year.

 

In a letter[1] sent to IHS in March 2021, NCUIH emphasized the need for VA and IHS to approach their common issues of statutory interpretation on provisions related to Native Veteran eligibility, copay exemption, and reimbursement with the requisite flexibility to ensure practical implementation and consistency with the Indian Health Care Improvement Act. NCUIH also made recommendations to assist IHS in making improvements to areas collaboration, including requesting that IHS work with the VA to revise the VA and to specify that UIOs have access to the CMOP through the National Supply Service Center (NSSC). Additionally, NCUIH continued to advocate for better access to broadband/information technology wherever AI/AN Veterans reside.

The new MOU reflects many of the recommendations, requests, and comments NCUIH expressed in the most recent comment period and mentioned that the VHA recognizes the importance of coordinated and cohesive efforts on a national scope, while acknowledging that the implementation of such efforts requires local adaptation through an agreement to meet the needs of Veterans and their families as well as UIOs.

Importance of Including UIOs in the new MOU

Veterans often choose to visit UIOs, either as their primary providers or as parts of their care teams, and these partnerships need to be seamless to promote access to quality care for Veterans based on their needs, rather than expecting the Veterans to conform to a fragmented . According to a recent Tribal Consultation Listening Session Summary Report, it was noted that the VA has stated that they will work to cultivate relationships at the local and national levels. Through these partnerships, the VA has suggested that outreach events are held to help Veterans enroll in benefits and file claims. However, as one commenter noted, “UIOs [had] largely been left out of this agreement until recent legislation made it clear that UIOs should be treated as full partners in the MOU.” Several respondents urged VA to continue to be inclusive of these programs and treat them as full partners within the language of the MOU.

 

 

[1] FINAL NCUIH VA_IHS MOU Confer Comment.pdf

Native American Heritage Month UIO Spotlight: All Nations Health Center

Native American Heritage Month is more than just a 30-day celebration, it’s a reminder that important work is happening every day to ensure Native communities everywhere have equitable access to services and representation.

NCUIH would like to introduce an Urban Indian Organization (UIO) and NCUIH member, All Nations Health Center in Missoula, Montana, who are at the frontlines of this important work and are representative of the imperative efforts of over 40 Urban Indian Organizations across the country.

We asked Executive Director, Skye McGinty (Little Shell Chippewa), MA, MBA, a few questions about their experiences in the UIO community, through the lens of All Nations, and what are some important things to keep in mind during Native American Heritage Month for both Native and Non-Native community members.

A picture of the All Nations team at their 3rd Annual 5K Fun Run and Walk.

 

Q: What do you wish the public knew about your services? Are there any misconceptions?

A: In late 2020, we changed our name from Missoula Urban Indian Health Center to All Nations Health Center to better reflect the culture of our clinic and our mission to provide holistic health services to the communities who live in and around Missoula. The biggest misconception in our community is that our services are only for Native people. While we do have an Indigenous perspective on the delivery of health services and our primary focus is on the Native population, we serve non-Natives, too. We hear time and time again from our non-Native clients that the kinds of services we provide and the way we deliver them is special and different compared to what you might experience in a Western medicine setting. If we could clear up any misconceptions, it’s that we provide services to truly all nations, and our Indigenous providers and services are for everyone.

 

Q: Why do you think organizations specific to serving Native communities are important?

A: It’s vital that Native people have access to services where their lived experiences are honored, they are reflected in the makeup of the staff, and strengthening their resiliency is at the top of the list of priorities. Native organizations provide that safety and honoring in ways that other organizations can’t. Good allyship from non-Native organizations is critical to moving the needle on issues that most deeply impact our Indigenous communities, but Native organizations already have the knowledge to reach our communities and make lasting, positive impacts. It’s imperative that we as Native people are leading the services that we provide to our communities.

 

Q: What’s the biggest challenge you face as an organization?

A: Aside from the obvious answer of COVID, our organization struggles with consistent levels of federal and state funding. Like many UIOs, our budget largely consists of a patchwork of different federal, state, and local grant initiatives. It’s hard to plan for sustainability when continuation applications, reporting requirements, and new grants are all due. Combined with the fact that UIOs have largely been left out of language in legislation that impacts our ability to be self-sustaining, finding reliable funding sources remains our largest challenge.  

 

Q: What excites you about the future of your facility?

A: I am most excited about having a truly integrated model of care for our patients in our new facility. Right now, our services are spread out among three facilities, and with the launch of our capital campaign, we’ll be able to consolidate all services in one brand new patient-centered medical home. I’m excited to bring on new providers to complement our current service offerings and to expand into new services that are comprehensive, holistic, and informed by Indigenous knowledge.

 

NCUIH is excited to share the experience of All Nations and recognize the many other essential UIOs providing vital services to their communities across the country. You can check out the full list of UIO NCUIH Members here. We hope this Native American Heritage Month, we can all re-center the needs of our urban Native communities across Indian Country. Sharing challenges, celebrating how far we’ve come, and looking forward to the future are all incredible ways to stay involved this month and always.

 

Looking for a way to engage with NCUIH and help raise awareness and much-needed funds towards social health equity? Register today for the #MoveWithNCUIH Native American Heritage Month Virtual 5k! Together we will walk, run, bike, swim (or however you choose to move) from a safe distance and celebrate our efforts virtually with one another.

 

Sign-up to #MoveWithNCUIH today!

House Passes NCUIH Urban Indian Health Confer Bill

FOR IMMEDIATE RELEASE 11.3.2021

Media Contact:
National Council of Urban Indian Health
Meredith Raimondi, Director of Congressional Relations
MRaimondi@ncuih.org
651-470-1857

WASHINGTON, D.C. (November 3, 2021) – On November 2, 2021, the House passed the Urban Indian Health Confer Act (H.R. 5221) with a 406-17 recorded vote. This bipartisan bill introduced by Rep. Raúl Grijalva (D-AZ-3), Rep. Betty McCollum (D-MN), Rep. Tom Cole (R-OK), Rep. Don Young (R-AK), Rep. Karen Bass (D-CA), and Rep. Eleanor Holmes Norton (D-DC) would require agencies within the Department of Health and Human Services (HHS) to confer with urban Indian organizations (UIOs) on policies related to healthcare for urban American Indian/Alaska Natives (AI/ANs).

“We are thankful for the passage of the Urban Indian Health Confer Act in the House today and particularly for the leadership of Congressman Raul Grijalva, Don Young, Betty McCollum and Tom Cole. Establishing proper urban confer policies across all HHS agencies has been long overdue and exacerbated amid the current public health crisis ravaging Indian Country. We welcome the federal government’s effort to further fulfill their trust and treaty obligation for all American Indians and Alaska Natives, including those residing in urban areas,” said Walter Murillo (Choctaw Nation of Oklahoma), Chief Executive Officer of NATIVE HEALTH and President of NCUIH.

“As an original cosponsor of this legislation, I believe this bipartisan bill will benefit Native peoples, particularly those who live and seek health care outside of tribal jurisdictions. This legislation will establish direct lines of communication for UIOs across all of HHS and ensure that urban Indian communities are aware of health care policy changes,” said Representative Young (R-AK).

“HHS’ failure to communicate with UIOs about healthcare policies that impact urban Indian communities is inconsistent with the federal trust responsibility and contrary to sound public health policy. The Urban Indian Health Confer Act will establish direct communication for UIOs across the entire department and ensure that urban Indian communities are aware of healthcare policy changes,” said Chairman Raúl M. Grijalva (D-AZ).

Background

The National Council of Urban Indian Health (NCUIH) has long advocated for the establishment of formal dialogue between HHS agencies and UIOs and has tirelessly worked with Congressional leaders to put forth a legislation to address this parity issue.

Next Steps

The bill now awaits action in the Senate.

Executive Order – Access to Affordable Life-Saving Medications Rescission of Regulation

Implementation of Executive Order on Access to Affordable Life-Saving Medications; Rescission of Regulation

On October 1, 2021, the U.S. Department of Health and Human Services (HHS) issued a final rule rescinding the previously issued final rule entitled “Implantation of the Executive Order on Access to Affordable Life-Saving Medications.(2020), The rationale behind rescinding the 2020 Rule was that the overall impact of the additional administrative cost and burden that the 2020 Rule would have placed on health centers would have harmed the centers and the patients they serve. This rule is effective on November 1, 2021.

 

Background

The 2020 Rule established a new requirement directing all H receiving grants under section 330(e) of the Public Health Service Act that participate in the 340B Program, to the extent that they plan to make insulin and/or injectable epinephrine available to their patients, to provide assurances that they have established practices to provide these drugs at or below the discounted price paid by the health center or subgrantees under the 340B Program. This extension applied to health center patients with low incomes, who have high cost sharing requirements for either insulin or injectable epinephrine; have a high unmet deductible; or who have no health insurance.

On March 22, 2021, the effective date of the “Implementation of Executive Order on Access to Affordable Life-Saving Medications” rule was delayed to July 20, 2021 (86 FR 15423), to allow HHS an additional opportunity to review and consider further concerns raised by the rule, including whether revision or withdrawal of the rule may be warranted. The 2021 Notice of Proposed Rulemaking (2021 NPRM) provided for a 30-day comment period, and HHS received 332 comments. Approximately 316 commenters expressed concern that the impact of implementing the 2020 Rule would be a reduction in access to care for underserved populations and the costs allocated in the 2020 Rule would reduce resources available to provide essential primary care for patients. 300 commenters expressed concerns that the 2020 Rule would divert health center resources away from the COVID-19 pandemic response and 301 commenters stated that implementing the Rule would only improve medication access for a small group of people, ultimately resulting in a loss of 340B savings. Out of all the comments, only 12 commenters opposed the proposed rescission of the 2020 Rule, many of whom are pharmaceutical manufacturers.

This year, many contract pharmacies experienced the effects when several drug manufacturers stopped honoring 340B discounts. Such discounts are a critical resource across several health systems, including Tribal and Urban health programs. In response, HHS issued an advisory opinion that opposed the drug manufacturers decision and sent six letters to drug manufacturers addressing the issue. Advocacy efforts at NCUIH and the voice of Tribal leaders during the February 2021 Secretary’s Tribal Advisory Committee (STAC) contributed to HHS’s awareness and action to resolve the issue.

“…HRSA found that six drug manufacturers, including AZ, Ely Lily, and others, were in violation of the 340B program rule, by “knowingly and intentionally charg[ing] a covered entity more than the ceiling price for a covered outpatient drug may be subject to a Civil Monetary Penalty (CMP) not to exceed $5,000 for each instance of overcharging.” Adding that, “the manufacturers must refund or credit the covered entities for any over-charges and begin charging no more than the ceiling price immediately to covered entities.”

 

Current Action

HHS agreed with commenters’ concerns regarding the reduced access to care resulting from the additional burden required of health centers to implement the 2020 Rule and shared their concerns that this rule would result in a loss of 340B revenue. Loss in revenue along with an increased administrative burden would reduce resources available to support critical services to health center patients.

HHS notes the concerns expressed by majority of commenters that the “low income” definition of 350 percent of the Federal Poverty Guidelines (FPG) applicable to patients receiving these two classes of drugs (insulin and/or injectable epinephrine) would have created significant administrative challenges for health centers. HHS’s consideration of the 2020 Rule’s impact was informed, in part, by the demands on health centers resulting from the COVID-19 pandemic. As Executive Order 13937 remains in effect, HHS is exploring non-regulatory options to implement the Executive Order.

 

NCUIH will continue to closely monitor and track the 340B issue and 2020 Rule-related issues, concerns, and comments.

 

When talking about health centers that are getting 330 grants/participate in the 340B program, I like to capitalize it but you don’t necessarily have to. HRSA’s Health Center Program co-opted the term “health center” so in my mind if it’s not capitalized, I wonder if whoever’s using the term is referring to the HRSA designation or not. Here’s some info on the Health Center Program and the statute about it: https://bphc.hrsa.gov/about/what-is-a-health-center/index.html and Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. §254b)

Health Center Program Regulations: 42 CFR 51c and 42 CFR 56.201 – 56.604