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

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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

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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

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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

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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

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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

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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

House Passes Infrastructure Bill with Urban Indian Health Facilities Fix

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The bill includes an amendment to allow Urban Indian Organizations to use existing funds for necessary infrastructure projects.

On November 5, 2021, the House of Representatives passed the bipartisan infrastructure bill with a vote of 228-206. The bipartisan infrastructure bill, which passed the Senate in August, includes the Padilla-Moran-Lankford amendment, which will allow Urban Indian Organizations (UIOs) to use existing resources to fund infrastructure projects to better serve patients and families. The urban Indian health amendment was the first amendment in the infrastructure package to get voted on in the Senate back in August, and it passed with overwhelming support. The package does not include the $21 billion Native health infrastructure ask but does include $11 billion for Native communities with $3.5 billion for the IHS sanitation facilities construction program (UIOs are not eligible for this program).

“We applaud leaders in Congress who supported the bipartisan infrastructure bill with our amendment championed by Senators Padilla, Lankford and Moran. This technical fix will be critical to expanding health care infrastructure for Native communities who have been devastated by the COVID-19 pandemic. While no new funding for urban Indian health was provided in this bill, we are hopeful that Congress will soon pass Build Back Better, which would provide additional resources for urban Indian communities,” said Francys Crevier, CEO of NCUIH (Algonquin).

Background and Advocacy

Urban Indian Organizations 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 and Alaska Natives.

Section 509 of the Indian Health Care Improvement Act (IHCIA) currently permits IHS from providing UIOs with funding for minor renovations by mandating that funding only be provided to UIOs that meet or maintain compliance with the accreditation standards set forth by The Joint Commission (TJC). These restrictions on facilities funding have ultimately prevented UIO facilities from obtaining the funds necessary to improve the safety and quality of care provided to AI/ANs in urban settings. The Padilla-Moran-Lankford amendment included in the Infrastructure bill removes this restriction to allow UIOs to use existing federal dollars on necessary facility needs. NCUIH has worked closely on a bipartisan basis for the past year on the technical legislative fix to support health care for tribal members who reside off of reservations.

Next Steps

The Infrastructure bill will be sent to the President’s desk for signature. The rule to consider the Build Back Better bill also passed and will await further consideration by the House of Representatives.

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

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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

Policy Blast: House Releases Draft of President Biden’s Reconciliation Bill with Historic Investment in Urban Indian Health Program Facilities and Additional Extension of 100% FMAP to UIOs

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The bill includes $100 million for the renovation, construction, expansion, equipment, and improvement of facilities owned or leased by an Urban Indian Organization and an extension of 100% FMAP for UIOs for another 8 fiscal quarters.

On October 28, 2021, the House Rules Committee released their draft bill of President Biden’s Build Back Better agenda with a decrease in funding for Indian Country from the original reconciliation instruction allocation. The reconciliation package allocates $2.347 billion to the Indian Health Service (IHS) and, for the first time, prioritizes renovations, construction, and expansion of facilities for Urban Indian Organizations (UIOs) with the allocation of $100 million for Urban Indian Health facilities. Another key provision of the bill is the extension of an additional 8 fiscal quarters of 100% Federal Medical Assistance Percentage (FMAP) for UIOs beginning April 1, 2021.

NCUIH and UIO advocacy to Congressional leadership helped retain and increase these provisions that were at risk of cuts during this week’s negotiations to reduce the cost of the budget reconciliation bill. However, the overall stark decrease in the funding commitment for Indian Country is devastating for American Indians and Alaska Natives (AI/ANs) and does not uphold the trust and treaty obligations of the federal government.

“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 welcome Congress’s commitment to urban AI/ANs with the investment of $100 million for urban Indian health in the budget reconciliation package and hope for increased funding for the whole of Indian Country. True change requires true investments, and without full funding for the Indian Health Service and Indian Country, Congress still has work to do,” said Francys Crevier, CEO of NCUIH (Algonquin).

Background

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

Next Steps

As the bill awaits Senate agreement, it is still unknown at this time what the final funding of the reconciliation package will look like for all of Indian Country. NCUIH will continue to fully analyze the bill in the coming days.

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 or an Indian Tribe or Tribal organization.”
  • “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.”
  • “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 the renovation, construction, expansion, equipping, and improvement of facilities owned or leased by an Urban Indian organization.”
  • “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.”
  • “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 16-quarter period that begins on April 1, 2021’’; and (2) by striking ‘‘such 8 fiscal year quarters’’ and inserting ‘‘such 16-quarter period’’.”
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, $30,000,000, 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”

NCUIH Endorses Bills Providing Advance Appropriations for IHS

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On October 12, 2021, Representatives Betty McCollum (D-MN-04) and Don Young (R-AK-1) introduced a pair of bipartisan bills that would amend the Indian Health Care Improvement Act (IHCIA) to provide advance appropriations to the Indian Health Service (IHS).

 

The Indian Programs Advance Appropriations Act of 2021 (H.R. 5567), introduced by Rep. McCollum, authorizes advance appropriations authority for certain accounts of the Bureau of Indian Affairs, Bureau of Indian Education, and IHS. The Indian Health Service Advance Appropriations Act (H.R. 5549), introduced by Rep. Young, authorizes advance appropriations authority for IHS.

 

NCUIH has long advocated for advance appropriations for IHS to insulate Indian health care providers from shutdowns and allow for long-term planning. A companion Senate bill, Indian Programs Advance Appropriations Act of 2021 (S. 2985), was introduced by Senators Ben Ray Luján (D-NM) and Martin Heinrich (D-NM) on October 7.

 

NCUIH welcomes the Members of Congress’ legislation to provide budget stability for IHS and strengthen the federal government’s commitment to uphold its trust and treaty responsibilities to American Indians and Alaska Natives.