Letter from NCAI, NIHB, NCUIH, et al to House Leadership re: COVID-19 4th Package (April 15, 2020)

Letter from NCAI, NIHB, NCUIH, et al to Senate Leadership re: COVID-19 4th Package (April 15, 2020)

Signatories:

• National Congress of American Indians
• National Indian Health Board
• National Council of Urban Indian Health
• Self-Governance Communication & Education Tribal Consortium
• National Association of Food Distribution Programs on Indian Reservations Native Farm Bill Coalition
• Intertribal Agriculture Council National Indian Education Association
• American Indian Higher Education Consortium National Indian Child Welfare Association
• United South and Eastern Tribes Sovereignty Protection Fund

Letter Text

April 15, 2020

Re: COVID-19 Recovery Legislative Proposal (Phase #4)

This letter is on behalf of the undersigned American Indian and Alaska Native (AI/AN) organizations, which collectively serve all 574 federally recognized AI/AN tribal nations. The recommendations outlined in this letter encompass critical funding and policy needs to help protect and prepare AI/AN communities to effectively respond to the current 2019 novel coronavirus (COVID-19) pandemic.

As the urgency, infection rate, and death toll of the COVID-19 pandemic intensifies, it has become increasingly clear that Indian Country needs significantly more resources to protect and preserve human life and address the grave economic impacts tribal nations face due to the closure of government operations and tribal enterprises to protect the health of their citizens and surrounding communities. AI/AN communities are disproportionately impacted by the health conditions that the Centers for Disease Control and Prevention (CDC) notes increase risk for a more serious COVID-19 illness, including respiratory illnesses, diabetes, and other health conditions. We urge you to include the following recommendations as you work on a phase 4 package to stem the COVID-19 pandemic. In addition to the specific funding and policy requests outlined below, tribal nations are strongly urging maximum flexibility in the use of new and existing funds to be able to comprehensively address COVID-19 response efforts.

This letter is one of three letters addressing: economic development and employment; tribal governance and housing/community development; and health, education, nutrition, and human services. The language included in this letter covers the health, education, nutrition and agriculture, and human service needs for Indian Country. For your convenience, we have created an abbreviated list to coincide with the specific funding and policy requests found later in the letter. This abbreviated list previews how the letter is organized.

Health

Health Section 1: Critical Funding and Access Needs

• Provide $1 billion for Purchased/Referred Care (PRC).
• Provide $1.215 billion for Hospitals and Health Clinics.
• Establish a $1.7 billion Emergency Third-Party Reimbursement Relief Fund for IHS, Tribal Programs, and Urban Indian Organizations.
• Provide $85 million for equipment purchases and replacements.
• Provide $161 million for Urban Indian Health.

Health Section 2: Critical Infrastructure

• Provide $2.5 billion for Health Care Facilities Construction to include support for new and current planned projects, the Small Ambulatory Health Center Program, and the Joint Venture Construction Program.
• Provide $1 billion for Sanitation Facilities Construction.
• Provide $750 million for maintenance and improvement of Indian Health Service and Tribal facilities.

Health Section 3: Technical Medicaid/Medicare Fixes

• Authorize Medicaid reimbursements for Qualified Indian Provider Services and Urban Indian Organizations.
• Provide reimbursements for services furnished by Indian Health Care Providers outside of an IHS or Tribal Facility.
• Ensure parity in Medicare reimbursement for Indian Health Care Providers.
• Include pharmacists, licensed marriage and family therapists (LMFTs), licensed professional counselors, and other providers as eligible provider types under Medicare for reimbursement to IHS, Tribal health programs, and Urban Indian Organizations.

Health Section 4: Technical Amendments Needed

• Expand telehealth capacity and access in Indian Country by permanently extending waivers under Medicare for the use of telehealth and enacting certain sections of the CONNECT to Health Act.
• Make the IHS Scholarship and Loan Repayment Program tax exempt.
• Implement ways to facilitate interagency transfers of funding that tribal nations can access to address COVID-19 and its impacts so that funding can be disbursed to tribal nations quickly.
• Implement ways to disburse funding to tribal nations using existing funding mechanisms already in place when possible.
• Provide Tribal and UIO access to the Strategic National Stockpile.
• Provide Tribal and UIO access to the Public Health Emergency Fund.

Health Section 5: Legislative Amendments and Reauthorizations

• Move Contract Support Costs to mandatory appropriations.
• Move 105(l) lease agreements to mandatory appropriations.
• Permanently reauthorize the Special Diabetes Program for Indians with automatic annual adjustments tied to medical inflation, and permit tribes and tribal organizations to receive funds through Self-Determination contracts or Self-Governance compacts.
• Provide mandatory appropriations for Village Built Clinics.

Education

Education Section 1: K-12 Educational Needs

• Authorize Tribally Controlled Grant Schools to access Federal Employee Health Benefits (FEHB).
• Ensure that a tribal state of emergency is included in the definition of aqualifying emergency.
• Ensure access to healthy meals for all students that are impacted by school closures andhave no other means to get these meals.

Education Section 2: K-12 Education Infrastructure and Broadband Needs

• Provide $115 million for wireless hotspots for BIE students and teachers as animmediate solution to school closures.
• Provide $60 million for laptops for BIE students and teachers as an immediate solution to school closures.

Education Section 3: Higher Educational Needs

• Provide an additional $7 million in the Interior-Bureau of Indian Education account to meet the immediate and critical needs of Tribal College and Universities (TCUs).
• Authorize Tribal Colleges and Universities as eligible to participate in the E-Rate program.
• Establish a $16 million TCU set-aside in the USDA-Rural Utilities Service Program using existing funds.
• Provide at least $500 million in the Interior-BIE account for a TCU Deferred Maintenance & Rehabilitation Fund, as authorized under the Tribally Controlled Colleges and Universities Assistance Act.

Education Section 4: Education Infrastructure and Broadband Needs

Nutrition and Agriculture

Nutrition and Agriculture Section 1: Critical Funding and Access Needs

• Clarify CARES Act Food Distribution Program on Indian Reservations (FDPIR) funding covers administrative costs, reimbursement of emergency food purchases, and authorizes FDPIR Indian Tribal Organizations to procure food locally and regionally; waive the non- federal cost share requirements; and allow for necessary administrative flexibility for verifications, certifications, and service.
• Temporarily waive the prohibition on dual use of the Supplemental NutritionAssistance Program (SNAP) and FDPIR during the same month.
• Provide assistance to Farm Service Agency (FSA) borrowers for relief andimplementation of policies to provide support for tribal producers and entities.
• Increase the SNAP maximum benefit available to all households by 15 percent andthe minimum benefit from $16 to $30 and delay implementation of the proposed and final SNAP rules.
• Provide parity and eligibility for tribal governments and Indian Tribal Organizations inthe Emergency Food Assistance Program (TEFAP).
• Adequately Fund the Federally Recognized Tribes Extension Program (FRTEP) at $30 million.
• Provide for agriculture lending through Community Development Financial Institutions (CDFIs).
• Create a COVID-19 Perishable Products Loss Fund due to market disruption.

Nutrition and Agriculture Section 2: Infrastructure Funding and Broadband Needs

• Create a 15 percent tribal set aside in the USDA ReConnect Broadband program and Distance Learning and Telemedicine Grant Program to enhance broadband access and long- distance healthcare in Indian Country.
• Increase funding for tribal-specific projects under all USDA Water and Environmental Grant Programs by $200 million.
• Expand the use and increase funding for the Rural Development (RD) Community Facilities Programs.
• Provide tribal specific funding for the Local Access Market Programs (LAMP).
• Expand USDA RD programs Substantially Underserved Trust Area (SUTA) designationto all programs at RD to support tribal priority.
• Enhance Natural Resources Conservation Service (NCRS) programing for tribal producers, including: full advanced payments for socially disadvantaged producers; remove/waive requirements of one year prior control, the need for a Conservation Stewardship Program technical service provider, and compensation to former lessees of tribal lands for the installation of existing conservation practices; and ease requirements for beginning farmers/ranchers.

Human Services

Human Services Section 1: Temporary Assistance for Needy Families (TANF)

• Appropriate funding in the amount of $2 billion to the TANF Contingency Fund (TCF) and allow tribal nations access in order to meet the significant needs of Tribal TANF recipients.
• Create and provide $5 billion to a TANF Emergency Fund similar to the fund created in the American Recovery and Reinvestment Act (ARRA) with a waiver of non-federal contribution for tribal nations and flexibility for tribal nations to spend in areas specific to each tribal grantee.

Human Services Section 2: Veterans

• Require the Veterans Health Administration (VHA) to reimburse IHS and tribal nations for services under PRC.
• Exempt Native veterans from copays and deductibles at VHA facilities.
• Authorize UIOs as eligible for VA reimbursement.

Human Services Section 3: Indian Child Welfare Services

• Provide $30 million for tribal governments under Title IV-B, Subpart 1 of the Social Security Act.
• Provide $45 million for tribal governments under Title IV-B, Subpart 2 of the Social Security Act to be divided as follows:
  • $20 million to mandatory funding for tribal nations.
  • $20 million to discretionary funding for tribal nations.
  • $5 million to the Tribal Court Improvement Project.
• Provide $20 million for tribal governments under Title IV-E Chafee funds.
  • Authorize language allowing tribal nations to directly access the Social Services Block Grant Program by establishing a 5 percent tribal nation set aside in the statute.

Thank you for your consideration of the recommendations outlined in this letter. We look forward to working with you to ensure that Indian Country’s concerns and priorities are comprehensively addressed, as we respond to the COVID-19 pandemic.

Sincerely,

• National Congress of American Indians
• National Indian Health Board
• National Council of Urban Indian Health
• Self-Governance Communication & Education Tribal Consortium
• National Association of Food Distribution Programs on Indian Reservations
• Native Farm Bill Coalition
• Intertribal Agriculture Council
• National Indian Education Association
• American Indian Higher Education Consortium
• National Indian Child Welfare Association
• United South and Eastern Tribes Sovereignty Protection Fund

Example from CARES Act without specified funding amount for UIOs:

The bill provides $1.032 billion to the Indian Health Service (IHS) in critically needed resources to support the Indian Health System during the pandemic, including expanded support for medical services, equipment, supplies and public health education for IHS direct service, tribally operated and Urban Indian Organizations; expanded funding for purchased/referred care; and new investments for telehealth services, electronic health records improvement, and expanded disease surveillance by tribal epidemiology centers. Not less than $450 million shall be distributed through Tribal shares and Urban Indian Organizations.

Example from CARES Act if it had specified funding for UIOs:

The bill provides $1.032 billion to the Indian Health Service (IHS) in critically needed resources to support the Indian Health System during the pandemic, including expanded support for medical services, equipment, supplies and public health education for IHS direct service, tribally operated and Urban Indian Organizations; expanded funding for purchased/referred care; and new investments for telehealth services, electronic health records improvement, and expanded disease surveillance by tribal epidemiology centers. Not less than $450 million shall be distributed through Tribal shares; and not less than $94 million to Urban Indian Organizations.

Democrats seek hazard pay for health workers amid pandemic

By Tucker Doherty, Rachel Roubein

04/08/2020 08:14 PM EDT

Congressional Democrats are trying to add $13 per hour hazard payments for frontline health care workers up to a total of $25,000 in the next coronavirus relief package, along with $15,000 incentives for people who join the medical workforce surge during the pandemic.

Senate Minority Leader Chuck Schumer said a so-called Heroes Fund could compensate nurses, EMTs and other workers for unanticipated risks as they confront a flood of new cases. Some workers have unsuccessfully sought payments from cash-strapped hospitals and other employers experiencing a downturn in business from lockdowns and cancelations of nonessential procedures.

“No proposal will be complete without addressing the needs of our essential workers by giving them hazard pay,” Schumer said on a call this week with reporters.

But no Republican has signed on to the plan, an indication that bipartisan buy-in might be elusive as congressional Republicans race to send billions of dollars more to small businesses hit hard by the crisis. The White House didn’t comment for this story, and Senate Majority Leader Mitch McConnell’s office didn’t respond to a request for comment.

The proposed hazard payments would be limited for health professionals earning above $200,000, but even workers above the cutoff could receive up to $5,000. Schumer also proposed extending the payments to workers in other industries, including grocery store workers, truck drivers, drug store workers and pharmacists.

Some doctors and nurses have described staying in hotels to ensure they don’t inadvertently pass the virus to their families. Others have said they fear they’ll get infected, in part because of a severe shortage of specialized protective equipment.

”If you’re putting your life and your health on the line, or you come home to your family and you’re risking their health, that seems to me like something that should be compensated for,” said a resident physician from Cleveland, who asked to remain anonymous because he wasn’t authorized to speak to the press.

The recently passed CARES Act, H.R. 748 (116) , allows patients to get tested for coronavirus without out-of-pocket costs in most cases, but sick workers could be left with thousands of dollars in medical bills for subsequent treatment. According to the Kaiser Family Health Foundation, an average hospital admission for pneumonia with major complications costs more than $20,000 in total, including $1,300 in out-of-pocket costs.

Some doctors have also expressed frustration that they are ineligible for the law’s $1,200 stimulus checks, which are reduced for workers with incomes above $75,000. The labor market analytics firm Emsi found 41 percent of health practitioners are eligible for the full amount, compared to 83 percent of the labor market overall. In New York, a high wage state that has become the epicenter of the crisis, just 29 percent of health practitioners are fully eligible.

Democratic lawmakers and labor unions have pushed in the last week for hazard pay for health personnel and other essential workers. At an SEIU press event, Sen. Bob Casey (D-Pa.) called for legislation that would treat health workers as “soldiers coming off the battlefield.”

President Donald Trump floated the idea of hazard pay during an appearance of Fox News last week and said his administration was asking hospitals to consider bonuses for their front-line workers. But the $2.2 trillion stimulus bill’s hospital bailout fund is likely going to other needs. Hospitals say they’re desperate for more cash, as they work to buy much-needed equipment and grapple with revenue they’re losing from canceling elective surgeries.

Congress gave HHS wide latitude to determine how to divvy up those funds — and announced the first, $30 billion tranche, based on how providers bill Medicare, would go out to hospitals within days. The next batch will focus on health providers who get very few Medicare dollars, such as nursing homes, pediatricians and children’s hospitals.

Vice President Mike Pence has touted the announcement of a “special pandemic pay program” for the 40,000 employees of HCA Healthcare, one of the country’s largest hospital chains. But the company’s program is focused on maintaining pay for furloughed and quarantined employees.

Labor leaders say they’ve pushed for hazard pay alongside other worker priorities, such as adequate protective equipment. But with traditional revenues in collapse and costs increasing, they say even those employers receptive to the idea haven’t offered much.

“We’re attempting to get, in nursing homes in particular, time-and-a-half pay,” said Rob Baril, an SEIU regional president, “but ultimately, if there’s not additional federal or state money that comes down, it becomes very difficult for employers to meet those needs.”

Baril said essential workers were also being asked to make other sacrifices, such as quitting part-time jobs they rely on to make ends meet. A CDC report on the initial wave of deaths in Washington state nursing homes in March identified shared staff as a major cause of the spread between facilities. In response, some local health departments have banned the practice.

Some hospital operators and physician staffing firms have responded to funding shortfalls by cutting pay, benefits and hours. Envision Healthcare, a major private equity-backed provider scrutinized by Congress last year over surprise billing, is withholding pay and cutting salaries. Alteon Health, a major ER staffing firm, rolled back announced cuts to vacation and retirement benefits following critical media coverage.

COVID-19 Resource Center

Resources from Past Events

• IHS COVID-19 Webinar: Impact of COVID-19 on childhood immunizations services at IHS (June 30 @1pm ET)
• CDC COVID-19 Partner Update: Planning Considerations for Events and Gatherings (June 29 @ 3pm ET)
• IHS Covid-19 Webinar: “Supporting the Mental Health of Healthcare Workers” (May 28 @ 10a MT)
• Joint Commission | COVID-19 Q&A Webinar for Behavioral Health Care (May 29 @ 12:30 ET)
• Generalized Anxiety Disorder and COVID-19 | NIHB (May 28th @ 3pm ET)
• Sheltering In Place, Intimate Partner Violence, and the Healthcare Response (May 20 @ 3pm ET)
• Telehealth Models in PrEP Delivery: From Barriers to Benefits  | Health HIV (May 19 @ 3p ET)
• IHS Covid-19 Webinar: “Compassion Fatigue” (May 18 and 21 @ 12 MT)
• “After COVID-19: What Telehealth Stays, What Goes?”: Center for Connected Health Policy (Video | Slides)
• Webinar: Operating Isolation and Quarantine Facilities and Providing Medical, Behavioral Health, and Substance Use Treatment: Lessons from King County, USICH (May 12, recording)
• AMA: Coding for Telemedicine & COVID-19 (May 6, 2020)
• IHS Advancements in Diabetes Webinar:Managing Diabetes through the COVID-19 Crisis (April 2, 2020)
• Telehealth & COVID-19: Implications for HIV Care & Treatment (April 3, 2020)
• Telepsychiatry in the Era of COVID-19- webinar on governance and recommendations for implementation (March 20, 2020 recording)
• Managing the Mental Health Effects of COVID-19 – (March 24, 2020 recording)
• IHS Considerations for Tribal and Urban Programs Wanting to Transition to Telebehavioral Health (March 24, 2020 recording)
• Webinar: Implementing Assessment and Recovery Centers and Providing Transportation to Isolation and Quarantine Facilities: Lessons from Seattle/King County (April 13, 2020 recording)
• Telehealth Learning Series for SUD Tx and Recovery Support Providers (March 30-April 27, 2020 recordings and resources)
• CDC Guidance for Certifying Deaths Due to Coronavirus Disease 2019 (COVID-19) (April 16, 2020 recording)
• NIHB Suicide Prevention Resource Center Webinar Treating Suicidal Patients During COVID-19: Best Practices and Telehealth (April 14, 2020)
• NICOA Weekly COVID-19 Call with Title VI Grantees (Every Friday)
• COVID-19: The Health Consequences of the Consequences (April 16, 2020)
• CCHP State Telehealth Policy & COVID-19 (April 9, 2020 recording)
• APA COVID-19 and Mental Health: Caring for the Public and Ourselves (March 21, 2010)
• SMIAdviser Serious Mental Illness and COVID-19: Tailoring ACT Teams, Group Homes, and Supportive Housing (April 9, 2020)
• Pain & Opioid Use Disorder Webinar Series: Assessment and Treatment of Pain and Co-occurring Opioid Use Disorder in Individuals with Serious Mental Illness (March 30, 2020 recording page)
• IHS COVID-19 Response Webinar Series: Behavioral Health Integration and COVID-19 Response (April 9, 2020 recording page)
• CMS Coronavirus COVID-19 Stakeholder Calls (Audio Only, March-April 2020)
• Ask a Native Physician: Town Hall with the NIHB and the Association of American Indian Physicians (April 8, 2020)
• Ask a Native Physician: Town Hall with Association of American Indian Physicians and NIHB (April 15, 2020)
• Noncompetitive Grant: Supporting Tribal Public Health Capacity in Coronavirus Preparedness and Response (CDC-RFA-OT20-2004) (April 8, 2020)
• CMS COVID-19: Telehealth Video, Coinsurance and Deductible Waived, ASC Attestations, Ambulance Modifiers, Lessons From Front Lines, MLN Call Today (April 7, 2020)
• TLPI Tribal Healing to Wellness Court Webinar during the Pandemic (April 10, 2020, article)
• National ACT Virtual Meetings to Address Impact of COVID-19 (April 6, 2020)
• What Peer Support Specialists Need to Know about Telehealth in the Current Crisis – Part 1 (April 6, 2020)
• NRDems Forum: Coronavirus Response in Indian Country (April 17, 2020 recording)
• Ask a Native Physician Provider Town Hall with Association of American Indian Physicians and NIHB (April 19, 2020)
• HRSA Telehealth Learning Series: Telehealth in the Time of COVID-19 (April 20, 2020)
• ADAP Coping with COVID-19 Virtual Patient Support Meeting (April 28, 2020)
• CDC Psychological First Aid: Addressing Mental Health Distress During Disasters (April 22, 2020)
• Coronavirus Virtual Town Hall: Improving Health Within Our Communities (April 22, 2020)
• Ask a Native Physician COVID-19 Town Hall (April 22, 2020)
• COVID-19 Testing: Possibilities, Challenges, and Ensuring Equity (NAM-APHA COVID-19 Conversations Series) (April 22, 2020)
• COVID-19 in Indigenous Populations: Not Repeating the Past (April 22, 2020)