Remarks from Senators Tom Udall and Tina Smith

July 1, 2020

Today, Senators Tom Udall and Tina Smith spoke on the Senate floor about the importance of providing parity for urban Indian health and providing resources for all of Indian Country

Excerpt from Senator Udall

Watch Clip

70 percent of Native Americans live in urban settings. Yet the Medicaid reimbursement rate for urban Indian health facilities is lower than the federal reimbursement rate. We need to balance the scales and help the 41 urban Indian health facilities across the nation expand their services.

Full Remarks from Senator Udall

We here in Congress must focus our work on helping these communities. We must take on the long standing systemic reasons that these communities entering this crisis are entering at a greater risk and we must enact real reform so that the next time when the next pandemic or economic downturn hits. It’s not these same communities that once again bear the brunt of the disaster.

Today, Mr. President, I want to focus our attention on American Indian and Alaska Native communities, communities where infection and mortality rates are much higher than the overall U.S. population. Communities that can’t escape the economic hardships this pandemic has caused. We already knew that pandemics like this take an awful toll on native communities. This was true 100 years ago during the 1918 flu pandemic when Native Americans died at four times the rate of rest of the country.

This was true a decade ago during the 20, 19, H1N1 outbreak. When Native Americans died at the same high rates, it’s unforgivable that the administration was not better prepared. The underlying reasons that native peoples, whether living on tribal lands, urban settings or elsewhere, are at risk are multifaceted, but they are all rooted in historic, systemic injustice.

First and foremost, many Native Americans do not have ready access to quality health care despite the federal government’s trust and treaty obligations to provide it. Trust and treaty obligations take on taken on by this government in exchange for millions of acres of land and countless lives lost on the large rural reservations and remote Alaskan Native villages, the nearest health care facility might be hours away. And when you get there, if you can get there, they often — there aren’t often doctors enough or nurses or hospital beds enough, these logistical barriers are compounded by the chronic history.

Native communities also face the highest rates of underlying conditions like diabetes, heart and lung disease, asthma and obesity. That result in worse culvert 19 outcomes. Battles over water rights and underinvestment and tribal infrastructure have compounded the problems.

We all know that washing our hands is a critical measure to prevent the spread of culvert 19, yet tribal communities are three point — seven times more likely to lack complete indoor plumbing than other U.S. households. On the Navajo Nation, which is confronting one of the worst corona virus outbreaks in the nation. 18 percent of households don’t have complete indoor plumbing. And so again, it’s no surprise that researchers have already found that covered 19 cases are more likely to occur in tr ibal communities with a higher proportion of homes lacking indoor plumbing.

We also know that social distancing is key to preventing spread of the virus. Yet almost one in six native households are overcrowded, making social distancing not just difficult but physically impossible for many families. All these institutional barriers create and combine to create a perfect storm.

These barriers aren’t the result of chance. They’re the result of policy. It is these institutional barriers that we must acknowledge and finally address so that this pandemic is not one more example of the United States failure to meet our obligations.

This time must be different. We must meet our responsibilities and help build a more just and equitable society. Throughout this crisis.

Native communities have fought back, they are resilient. They have fought back hard. For example in my home state of New Mexico and in Arizona and Utah. The Navajo Nation has imposed strict curfews to spread.

To prevent the spread, they’ve ramped up testing despite the complete lack of testing supplies in the beginning and they have now as of today, tested about 25 percent of their population compared to 10 percent nationally, but tribal responses to the pandemic have been repeatedly. Underfunding of the Indian Health Service, which many of us have fought for years to correct, and while we’ve made progress, the IHS budget still only covers an estimated 16 percent of need and as a result of centuries of discriminatory land, agricultural and environmental policies, Native communities also Face the highest rates of underlying conditions like diabetes, heart and lung disease, asthma and obesity that result in worse culvert 19 outcomes. Battles over water rights and underinvestment and tribal infrastructure have compounded the problems.

We all know that washing our hands is a critical measure to prevent the spread of culvert 19, yet tribal communities are three point — seven times more likely to lack complete indoor plumbing than other U.S. households. On the Navajo Nation, which is confronting one of the worst corona virus outbreaks in the nation. 18 percent of households don’t have complete indoor plumbing. And so again, it’s no surprise that researchers have already found that covered 19 cases are more likely to occur in tr ibal communities with a higher proportion of homes lacking indoor plumbing.

We also know that social distancing is key to preventing spread of the virus. Yet almost one in six native households are overcrowded, making social distancing not just difficult but physically impossible for many families. All these institutional barriers create and combine to create a perfect storm.

These barriers aren’t the result of chance. They’re the result of policy. It is these institutional barriers that we must acknowledge and finally address so that this pandemic is not one more example of the United States failure to meet our obligations.

This time must be different. We must meet our responsibilities and help build a more just and equitable society. Throughout this crisis.

Native communities have fought back, they are resilient. They have fought back hard. For example in my home state of New Mexico and in Arizona and Utah. The Navajo Nation has imposed strict curfews to spread.

To prevent the spread, they’ve ramped up testing despite the complete lack of testing supplies in the beginning and they have now as of today, tested about 25 percent of their population compared to 10 percent nationally, but tribal responses to the pandemic have been repeatedly. I’ve fought hard for funding targeted for tribes when the administration offered nothing for tribes. We secured over 10 billion in the care sector. When the administration fumbled distribution of tribal funding?

Missing the statutory deadline for distribution by almost two months Congress and the tribes pushed back because tribes are in crisis days matter. It took a lawsuit in a federal court order for tribes to get their share of the 8 billion set aside for them under the care Sec. And today, the Senate Indian Affairs Committee will hold an oversight hearing on implementation of federal programs to support tribal culvert, 19 prevention containment and response efforts. Tribal witnesses will testify tha t policies and practices at FEMA. The CDC herself and a number of other federal agencies have made tribal access to federal culvert 19 resources much harder, whether it’s denying tribes access to corona virus surveillance data, creating a confusing business team bureaucracy for requesting emergency medical supplies or delaying access to grant funds.

This administration continually makes the decisions that disadvantage Native communities. Decisions that threaten native lives and prolong this country’s legacy of systematic, systemic injustice, the administration must do better and Congress must do much more. Each day, we fail to act to advance policies.

To address the disparities faced by Indian Country is the day we fail to uphold our oath of office. The Republican Senate majority has delayed far too long infections are on the rise. The U.S. has surpassed every other nation in the world in the spread and death and destruction of this virus.

20 million Americans are out of work, the highest unemployment level since the Great Depression. State, local and tribal. Governments and health care systems across the nation are shuttering essential services and furloughing essential workers. None of this should come as news to the Republican majority inaction in the face of this disaster is unconscionable.

This body must get down to business that we’re here and we’re elected to do. It’s long past time we pass another. Hamstrung by this administration and Congressional inaction as vice chair of the Senate Indian Affairs Committee. I’ve fought hard for funding targeted for tribes when the administration offered nothing for tribes.

We secured over 10 billion in the care sector when the administration fumbled distribution of tribal funding. Missing the statutory deadline for distribution by almost two months Congress and the tribes pushed back because tribes are in crisis days matter. It took a lawsuit in a federal court order for tribes to get their share of the 8 billion set aside for them under the care Sec. And today, the Senate Indian Affairs Committee will hold an oversight hearing on implementation of federal program s to support tribal culvert, 19 prevention containment and response efforts.

Tribal witnesses will testify that policies and practices at FEMA. The CDC and a number of other federal agencies have made tribal access to federal culvert 19 resources much harder, whether it’s denying tribes access to corona virus surveillance data, creating a confusing business team bureaucracy for requesting emergency medical supplies or delaying access to grant funds. This administration continually makes the decisions that disadvantage Native communities. Decisions that threaten n ative lives and prolong this country’s legacy of systematic, systemic injustice, the administration must do better and Congress must do much more.

Each day, we fail to act to advance policies. To address the disparities faced by Indian Country is the day we fail to uphold our oath of office. The Republican Senate majority has delayed far too long infections are on the rise.

The U.S. has surpassed every other nation in the world in the spread and death and destruction of this virus. 20 million Americans are out of work, the highest unemployment level since the Great Depression. State, local and tribal. Governments and health care systems across the nation are shuttering essential services and furloughing essential workers.

None of this should come as news to the Republican majority inaction in the face of this disaster is unconscionable. This body must get down to business that we’re here and we’re elected to do. It’s long past time we pass another.

We must infuse IHS with additional funding for tribal healthcare and ensure it has parity in accessing federal programs. We must provide tribal governments with the resources they need to keep their communities up and running safely. By providing 20 billion in additional targeted funding within the Treasury’s corona virus Relief Fund, the Senate should pass bills I’ve introduced that have already been adopted by the House of Representatives and its heroes package which was passed over six weeks ago.

We must make our strategic stockpile available to tribes. Tribes should be able to access PPE ventilators and other necessary medical equipment just as states can. We must make sure that tribes have equal access to the Centers for Disease Control and their resources to prepare for public health emergencies like this pandemic.

70 percent of Native Americans live in urban settings. Yet the Medicaid reimbursement rate for urban Indian health facilities is lower than the federal reimbursement rate. At other IHS facilities, we need to balance the scales and help the forty three urban Indian health facilities across the nation expand their services and as so much of our lives move to the Internet.

We must make sure that native schools, health care facilities and government services are not left on the wrong side of the digital divide. All tribes must have access to high speed broadband. Mr. President, this public health and economic crisis has hit us all hard, but we shouldn’t deny that some communities have been hit harder. We need to send immediate relief to those communities that have been so severely hurt, including Native communities and we need to set our sights on genuinely taking on this systemic and institutional barriers these communities have faced for far too long.

We can — we should — we must do better. Mr. President, I yield the floor and notice absence of a quorum.

Full Remarks from Senator Smith

I rise today with my colleague, the Senator from New Mexico, Tom Udall to call for urgent action by Congress to respond to the needs of tribal nations and urban Indigenous communities. During the COVID-19 pandemic, we have not done enough.

We have not lived up to our shared trust and treaty obligations and in this moment, we are called upon to respond to the historic injustice and systems of oppression and institutional violence that are harming communities of color and Indigenous people. Over the last month, people in Minnesota and across our country have focused our attention on the deep, systemic inequities that black and brown and indigenous people face, and this injustice is not new. It is as old as the colonization of our country by colleagues.

This is a unique moment. This public health crisis presents us with an opportunity to show that we are serious about repairing the damage done by our broken promises to sovereign, tribal nations and urban Indigenous communities. Some have said that COVID-19 is the great equalizer, but we know that covered hits hardest.

Those without a safe place to call home, those struggling with low wages and poverty and lack of health care and black brown and indigenous people living with the trauma of having their identity and their very humanity called into question even before this virus spread. The impact of covered on Native communities has been devastating. Native people have been hospitalized for COVID-19 it at five times the rate of white people.

In mid-May, the Navajo Nation reached a higher per capita infection rate than any other hotspot in the country. So why is it that cove? It is hitting tribal nations so hard well, despite repeated calls from tribal leaders and urban Indigenous leaders.

Over the past few decades, the federal government has stood by and allowed the budget for Indian health services to dwindle. We’ve neglected Indian housing programs and we’ve ignored growing health inequities. The federal institutions dedicated to serving Indian Country are not broken.

Unfortunately, these institutions have never been adequate to live up to our trust and treatment responsibilities and they represent a broken promise. The federal government’s failure has life and death consequences for native people, for their health and for their. Think of this striking statistic, unemployment in the Indigenous community in the Twin Cities is at a terrible Forty seven percent higher than any other group in our state. Within tribal nations, the economic impact of the corona virus is equally devastating. Early this spring, tribal governments in Minnesota and all around the country made the difficult decision to voluntarily close tribal enterprises in order to protect public health.

As a result, they lost significant government revenue and also experienced massive unemployment not only for their members, but for members. From the surrounding communities and this lost revenue meant that tribal governments were forced to scale back essential services like nutrition assistance, nutrition assistance for elders public safety and education programming. So in the cares act, Congress agreed to eight billion dollars in emergency relief to help tribes respond to coated even after Congressional action though tribal governments have had to continue fighting to get their fair share of those dollars, the Trump administration argued that some of this relief Should go to for profit, Alaska native corporations.

And then it took the Treasury Department 40 days to distribute just the first 60 percent of the funds to tribes and not until two weeks ago, almost three months after passage of the CARES Act did tribal governments receive the rest. To be clear, these funds cannot be used to replace lost revenue. So Mr. President, we have so much work to do to fulfill our commitment to Indigenous people and the simple proposition that Native families should have equal access to health care and housing and opportunity.

As white Americans when I speak to tribal leaders in my state about this cycle of historic underinvestment and inequity and broken promises, I mean, I share their frustration. I don’t know how anybody couldn’t.

Indigenous leaders in Minnesota know that a lack of housing on tribal lands leads to overcrowding, which increases the risk of contracting covered and tribes have asked over and over again for sufficient funding for an enhanced housing programs and they shouldn’t have to ask any more indigenous leaders Know a lack of access to health care and substance abuse disorder treatment leads to chronic health conditions like diabetes and heart disease and asthma, which worsen covered symptoms. Tribes have asked over and over again for sufficient funding to address these health inequities and they shouldn’t have to ask anymore. Indigenous leaders know that a lack of access to credit and capital prevents urban Indigenous households and folks living on tribal land from building wealth like their white neighbors who can more easily.

Therefore, weather the storm of unemployment Native communities have asked over and over again to enforce fair lending laws and to ensure act. Thank you Mr. President, I yield the floor.

On June 25, the Centers for Disease Control and Prevention (CDC) held the first virtual listening session for Urban Indian Organizations (UIOs) to express their needs and identify gaps related to the COVID-19 response. The purpose of the session was for the CDC to hear about the needs of UIOs during this pandemic. This event was coordinated by CDC and the National Council of Urban Indian Health (NCUIH).

The CDC officials that participated were Dr. José Montero, Director of the Center for State, Tribal, Local, and Territorial Support, and Captain Carmen “Skip” Clelland, Director of the Office of Tribal Affairs and Strategic Alliances. The session was facilitated by NCUIH’s Sunny Stevenson, Senior Manager of Federal Relations, and Jamie Ishcomer-Aazami, Deputy Director.

UIOs expressed concern about distribution of and access to vaccines once they are developed; the need for flexible funding in order to make infrastructure improvements to accommodate social distancing requirements and coronavirus testing; and the need for Urban Indians to be included in data about the coronavirus. Often American Indians and Alaska Natives (AI/ANs) are labeled as “others” and AI/AN data cannot be distinguished. UIOs requested that CDC and other agencies institute an urban confer policy with UIOs. They also requested recurring listening sessions with CDC. Captain Clelland confirmed that CDC will work with NCUIH to coordinate a second listening session.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act provides that “not less than $125,000,000 shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes” for “CDC-Wide Activities and Program Support”. The law states that the funding shall be for grants or cooperative agreements to carry out surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities.

CDC has yet to disseminate any CARES Act funds to UIOs, or announce an opportunity for UIOs to apply for them, even though the CARES Act was signed into law on March 27, 2020.

On June 18, 2020 the Center for American Progress, a Washington DC based think tank, released a report on the COVID-19 response in Indian Country. The detailed report focuses on 7 key areas for addressing health inequities in Indian country during the pandemic: inclusion in COVID-19 data; addressing bureaucratic barriers; supporting tribal economies; addressing the underfunded Indian health system; developing critical infrastructure; funding tribal public safety and justice needs, and restoring tribal homelands. The report highlighted how underfunded the Indian health system was prior to COVID-19 and elaborated on how much stress Urban Indian Organizations (UIOs) have been under since the pandemic began.

The report included recommended policy solutions for better funding and supporting Indian Health Service (IHS). Topping the list of solutions is increasing funding for IHS and prioritizing urban Indian health. The other solutions mirror those UIOs have been asking for: access to the Strategic National Stockpile; reauthorization of the Special Diabetes Program for Indians (SDPI); to include pharmacists; licensed marriage and family therapists, and licensed counselors as eligible providers for Medicare reimbursement; extending Medicare telehealth waivers; and removing restrictions and barriers for UIOs. Most importantly, the report calls for the inclusion of UIO-specific language in all Indian health system related legislation to ensure UIOs receive the resources intended.

Key Highlights

Recommendation: Address the chronic underfunding of the Indian Health Service system

The IHS is the federal agency that oversees and provides health care to AI/AN communities through Indian tribes, tribal organizations and urban Indian organizations, together known as the I/T/U system. Before COVID-19, the IHS was already so underfunded that expenditures per patient were just one-fourth of the amount spent in the veteran’s health care system and one-sixth of what is spent for Medicare.³³ IHS facilities are, on average, understaffed by 25 percent.³⁴ Now, the IHS is scrambling to provide crisis services to a vulnerable and hard-hit constituency with its stretched-thin staff, inadequate facilities, and severe lack of funds.

While the CARES Act provided $1 billion to the IHS, unmet needs are estimated at $32 billion.³⁵ Federal assistance during the pandemic has not been forthcoming; the Sault Ste. Marie Tribe of Chippewa Indians, for example, received only two test kits for a tribe of 44,000 people.³⁶ The Oyate Health Center, a major health provider in Rapid City, South Dakota, which transitioned into tribal management in 2019, received almost no tests, PPE, or cleaning supplies.³⁷ The Seattle Indian Health Board was sent body bags when it asked for more medical supplies to fight COVID-19.³⁸ Urban Indian organizations are some of the worst hit, with 83 percent forced to reduce services and almost half unable to deliver medicine.³⁹ Overwhelmed facilities are forced to fly patients into larger cities for treatment and must foot the transportation bill.⁴⁰

The I/T/U system requires an urgent injection of funds and investment in capacity, but the likelihood of a prolonged COVID-19 pandemic lasting months or years necessitates that the federal government not renege on its duties to support the treatment of diabetes, asthma, substance abuse, and other immunocompromising diseases that are increasing the AI/AN fatality rate.

Immediate policy solutions:

• Increase immediate funding to the IHS and prioritize urban Indian health, including access to the national service supply center for essential testing equipment; equipment purchases and replacements; and IHS hospitals and health clinic on-site treatment capacity
• Expedite the reauthorization of the IHS Special Diabetes Program for Indians (SDPI) and other programs that deal with immunocompromising conditions that require uninterrupted care
• Provide all I/T/U facilities access to the Strategic National Stockpile and Public Health Emergency Fund
• Include pharmacists, licensed marriage and family therapists, licensed counselors, and other providers as eligible provider types under Medicare for reimbursement to I/T/U facilities in order to lessen the burden of mental health on immunity
• Extend waivers under Medicare for the use of telehealth in Indian Country
• Remove restrictions and barriers on care provision through urban Indian health organizations

Long-term policy solutions:

• Increase funding for the IHS and strengthen coordination among federal, tribal, state, and local health agencies
• Fund job-training programs to address staff shortages through the Indian Health Care Improvement Act
• Provide a tax incentive for IHS professionals similar to other public sector health workers
• Ensure an explicit mention of urban Indian organizations in I/T/U-related legislation to combat the invisibility of urban AI/AN suffering

https://www.americanprogress.org/issues/green/reports/2020/06/18/486480/covid-19-response-indian-country/

Executive Director Francys Crevier stressed the need for the federal government to uphold the trust responsibility to Indian Country.

Washington, DC (June 11, 2020) – Today, the House Committee on Appropriations Subcommittee on Interior, Environment and Related Agencies held a hearing on the Indian Health Service (IHS) Covid-19 Response. The first panel included Rear Admiral Michael Weahkee, Director of IHS. The second panel started with Stacy Bohlen, CEO of the National Indian Health Board and finished with Francys Crevier, Executive Director of the National Council of Urban Indian Health (NCUIH). The hearing brought attention to the disparate impacts of the COVID-19 pandemic on Indian Country and the response by the Indian Health Service.

“On behalf of the National Council of Urban Indian Health (NCUIH), which represents 74 urban Indian facilities across the country, we are grateful for your tireless efforts in ensuring all of Indian Country has the resources needed to protect and care for our relatives. This disease, like the federal obligation to Native people, does not stop at the borders of a reservation. This pandemic has exacerbated the long-standing behavioral health disparities due to decades of historical trauma and will have lasting impacts for years to come. We thank you for including urban Indians in COVID-19 legislation. We urge Congress and the Administration to honor the federal trust obligation by providing the whole IHS System with all the resources necessary to serve the families who need them most,” said Francys Crevier, Executive Director of NCUIH in her testimony.

“The United States government has a trust responsibility to Indian tribes and signed treaties promising to provide health care and other services. Hundreds of years later, the failure to meet these treaty and trust obligations continues…The federal government has not been able to overcome the historical neglect and meet the true needs of Indian Country,” said Chair Betty McCollum in her opening remarks.

“All of the resources [from Congress] make a real difference in helping to fulfill our IHS mission as we continue to work with tribal and urban Indian organization partners to deliver crucial services during the pandemic,” said Rear Admiral Michael Weahkee in his remarks.

Hearing Information

• Recording

Chair Betty McCollum

• Statement

Rear Adm. Michael D. Weahkee  Director, Indian Health Service

• Testimony

Stacy Bohlen Chief Executive Officer, National Indian Health Board

• Testimony

Francys Crevier Executive Director, National Council of Urban Indian Health

• Testimony PDF

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NCUIH Testimony Highlights

• NCUIH requests that funds appropriated to UIOs by Congress are swiftly appropriated.  “COVID-19 funds have been needlessly tied up for weeks – and in more than instance months – by other agencies, thereby creating unnecessary barriers to pandemic response at UIOs”.
• NCUIH requests that “UIOs have avenues for direct communication with agencies charged with overseeing the health of their AI/AN patients, especially during the present health crisis.” “Only IHS has a statutory requirement to confer with UIOs, which has enabled other agencies to ignore the needs of urban Indians and neglect the federal obligation to provide health care to all AI/ANs – including the more than 70% that reside in urban areas.”
• NCUIH requests that Congress and federal agencies continue to act to ensure that UIOs can access PPE and testing equipment. During the pandemic “UIOs were not allocated any Abbott Rapid Response tests from IHS or FEMA. We have had to fight every step of the way for any testing capabilities”.
• NCUIH requests that the federal government remedy longstanding inequities that UIOs face including
  • 100% Federal Medical Assistance Percentage (FMAP) reimbursement for UIOs
  • Federal Tort Claims Act coverage for UIOs
  • Reimbursement from the VA for services provided to Native Veterans
  • Including UIOs in the national Community Health Aide Program and Indian Health Care Improvement Fund
• NCUIH requests that “the federal government ensures our frontline heroes receive the same protections as all other public health employees and provides adequate resources to UIOs to enable the continued provision of high quality and essential services. UIOs need equal access to programs like the Community Health Aide Program and community health workers to get to high risk patients.”
• NCUIH requests that UIOs are given access to facilities funding through at least an $80 million urban facilities line item. “Some facilities are located in 50+ year old buildings that already required expensive repairs and these needs have been significantly exacerbated by the pandemic.” UIOs need funding “in order to include necessary improvements like physical separations to enable safe distancing, air purification systems, and negative pressure rooms to control viral spread.”
• NCUIH requests that IHS release previously appropriated funds for UIOs to build telehealth capacity.
• NCUIH appreciates that the HEROES Act includes $1 billion for third party reimbursement relief, however NCUIH “urges Congress to include the full amount of $1.7 billion as recommended by the coalition of national Native American organizations.”
• NCUIH requests $7.3 million in annual appropriation for behavioral health at UIOs for the next three years to address the previous unmet need for behavioral health funding and account for the increase in behavioral health services due to COVID-19 that will remain for years to come.

Interior Appropriations Subcommittee Testimony National Council of Urban Indian Health

Francys Crevier, Executive Director

June 11, 2020

The National Council of Urban Indian Health (NCUIH) is the national non-profit organization devoted to the support and development of quality, accessible, and culturally-competent health and public health services for American Indians and Alaska Natives (AI/ANs) living in urban areas. NCUIH is the only national representative of the 41 Title V Urban Indian Organizations (UIOs) under the Indian Health Service (IHS) in the Indian Health Care Improvement Act (IHCIA). NCUIH strives to improve the health of the over 70% of the AI/AN population that lives in urban areas, supported by quality, accessible health care centers.

Chair McCollum, Ranking Member Joyce and Members of the Subcommittee, thank you for inviting me to speak on the impacts of the COVID-19 pandemic on urban Indian health. On behalf of the National Council of Urban Indian Health (NCUIH), which represents 41 urban Indian organizations (UIOs) that serve American Indians and Alaska Natives (AI/ANs) at 74 facilities across the country, we would like to express our gratitude for your tireless efforts in ensuring all of Indian Country has the resources needed to protect and care for our relatives during this pandemic. We also appreciate your commitment to ensuring that the 70% of AI/ANs residing in urban areas have access to critical health care. There is more work to be done and we look forward to working with Congress on ensuring that future emergency legislation provides urban Indian organizations resources to address this crisis. To that end, today I am going to testify with respect to the need for additional resources for UIOs to respond to the pandemic, including at least $80 million in facilities and infrastructure funding, coverage for significant losses in third-party reimbursement dollars, behavioral health funding, and parity for UIOs among the I/T/U system.

Decades of underfunding of the Indian Health Service (IHS) system, coupled with added burdens of chronic disease, put AI/ANs at higher risk of poor outcomes due to COVID-19. The disproportionate impact COVID-19 has on AI/ANs, like the federal obligation for the provision of health care to AI/AN people, does not stop at the borders of a reservation. For instance, AI/ANs are 3 times more likely to have diabetes, more than 1.5 times more likely to have been hospitalized for respiratory infections in the past, and more than 1.5 times more likely to have coronary heart disease than non-Hispanic whites. The Centers for Disease Control and Prevention has identified these conditions as specific risk factors for more serious illness due to COVID-19. Disparities in other social determinants of health also contribute to a disproportionate impact of the novel coronavirus on AI/AN people. During the H1N1 outbreak of 2009, AI/ANs were 4.1 times more likely to die than non-AI/AN people. It is thus essential to continue to provide essential resources to the IHS system – comprised of IHS facilities, tribal facilities, and UIOs – which has been hard hit by the pandemic as facilities shift their operations to prepare for, prevent, and respond to increases in COVID-19 among their patient populations. For instance, one UIO facility in San Jose, California recently reported a 13% positive test rate – higher than the national average.

During the course of the pandemic, 4 programs had to close their doors due to lack of resources and personal protective equipment (PPE) necessary to keep staff and patients safe from this deadly virus and only serve some patients remotely. Thankfully, PPE has become more available and emergency funds have started to flow into UIOs, which has allowed at least 1 program to reopen. At the beginning, however, delays in funding were extremely troublesome. Now, IHS is hosting weekly calls with our leaders and that has been invaluable to ensuring our programs can continue to serve the patients who need them most. We commend IHS for the agency’s invaluable partnership and tireless efforts to disseminate resources to Tribes and UIOs as expeditiously as possible. Unfortunately, funds have been needlessly tied up for weeks – and in more than instance months – by other agencies, thereby creating unnecessary barriers to pandemic response at UIOs. Compounding on this, only IHS has a statutory requirement to confer with UIOs, which has enabled other agencies to ignore the needs of urban Indians and neglect the federal obligation to provide health care to all AI/ANs – including the more than 70% that reside in urban areas. In fact, NCUIH has been unsuccessful at facilitating dialogue between numerous federal agencies and UIO-stakeholders, despite several attempts. This is not only inconsistent with the government’s responsibility, but is contrary to sound public health policy. Agencies have been operating as if only IHS has a trust obligation to AI/ANs, and that causes an undue burden to IHS to be in all conversations regarding Indian Country in order to talk with agencies. It is imperative that UIOs have avenues for direct communication with agencies charged with overseeing the health of their AI/AN patients, especially during the present health crisis.

In addition, the COVID-19 pandemic has highlighted the urgency of rectifying the long-standing inequities UIOs face. Everyone in the country has been fighting for PPE and testing kits. However, those sudden challenges compound the difficulty providing care when combined with the chronic funding and infrastructure gaps UIOs already experience. UIOs were not allocated any Abbott Rapid Response tests from IHS or FEMA. We have had to fight every step of the way for any testing capabilities, meanwhile, at least in two areas UIOs have been leading the way in getting testing available for the counties in which they are located. UIOs are a strong partner in their communities, and yet many have been forced to significantly ramp up facilities and infrastructure and pay premium prices for scarce supplies. These excess costs cascade on top of the extremely limited federal funding UIOs receive, as UIOs receive primary funding from only one line item of IHS – urban Indian health – funded at just below $58 million in FY 2020. Congressional and Administrative action has proved essential to enable UIOs to respond to the pandemic – and must continue as UIOs continue to face this crisis, the response to which mandates additional resources that are also flexible.

For instance,  all of this compounds on the inequities UIOs already face – for instance, the federal government does not reimburse states for 100% of the cost of Medicaid services at UIOs like it does for IHS and tribal facilities and UIOs are forced to expend millions of dollars each year in malpractice insurance because they do not receive Federal Torts Claims Act coverage like employees at IHS and tribal facilities (and both employees and volunteers at Community Health Centers). And, UIOs have been interpreted as ineligible for other essential programs or cost-saving measures – including reimbursement from the VA for services to Native Veterans, the national Community Health Aide Program, and Indian Health Care Improvement Fund, to name just a few. All of these factors have contributed to the novel coronavirus’s devastating impacts on UIOs. As our health workers are risking their lives every day, we need the federal government to ensure our frontline heroes receive the same protections as all other public health employees and provide adequate resources to UIOs to enable the continued provision of high quality and essential services. UIOs need equal access to programs like CHAP and community health workers to get to high risk patients.

A March 2020 NCUIH survey found that 83 percent of UIO-respondents have been forced to reduce their services, with 48 percent reporting no capacity for medicine delivery, and 28 percent reporting no capacity for triage space. Distancing guidelines tell us more than ever that proper capacity in essential facilities, such as health care facilities, is necessary. Just because UIOs do not receive funding under other line items does not mean the costs do not exist. UIOs do not have access to facilities funding under the IHS facilities budget line item and also don’t have access to the COVID-19 funding designated for facilities appropriated to the IHS. Now with the pandemic, it is an urgent priority to adequate fund an urban facilities line item to fund the renovations with accreditation restrictions and construction needed to protect our providers as well as their patients. Some facilities are located in 50+ year old buildings that already required expensive repairs and these needs have been significantly exacerbated by the pandemic. Without any federal funding for facilities, UIOs are forced to use their limited resources such as third party revenue that has drastically declined for essential infrastructure fixes – which during the pandemic include necessary improvements like physical separations to enable safe distancing, air purification systems, and negative pressure rooms to control viral spread. Residential Treatment Centers are faced with how to keep their patients housed within their programs, but also safe from the threat of COVID-19, which also means less patients receive care due to social distancing. They need modular buildings and funding for facilities renovation to ensure patients are not exposed to COVID-19 while seeking treatment. In addition, a recent NCUIH survey found that 26% of UIO-respondents needed a new urgent care facility, 26% needed a new infectious disease area, 31% require new modular facilities, and 20% require a new non-emergent care facility. For these reasons, a minimum of $80 million facilities appropriation for UIOs is absolutely vital to maintain the high quality provision of health care to AI/ANs residing in urban areas. Because each UIO is a unique organization with different capacities, patient populations, and community needs, as well as differing degrees of severity in local COVID-19 outbreaks, these funds must be flexible for use in facilities renovation and infrastructure. IHS received over $900 million in facilities funding last year, and Congress allocated $125 million for facilities in the CARES Act and proposed $366 million in the HEROES Act. IHS continues to be underfunded and we fully support desperately needed funding for Tribes. UIOs are eligible for $0 for facilities funds; it is imperative that this is remedied immediately to ensure access to care for our patients.

As UIOs have shifted to respond to the pandemic, telehealth and telemedicine capacity has become an essential component of health care delivery and something for which UIOs must expend considerable resources. IHS has allocated $95 million for telehealth capacity building at I/T/U facilities – but UIOs have not yet seen this funding, despite the immediate need. For instance, one facility has resorted to the purchase of old phones for patients to enable them to access telemedicine visits offsite. This funding is needed now to address these immediate concerns in the middle of the crisis and to prepare for the additional waves of the virus in the immediate future, as public health officials predict.

By being forced to cancel much of the routine care UIOs conduct, billable services have significantly declined, eliminating or severely reducing third-party reimbursement. That source of funding is critical to maintain UIOs’ operations, facilities and staffs. We support the inclusion in the HEROES Act funding of $1 billion for third-party relief, however, we urge Congress to include the full amount of $1.7 billion as recommended by the coalition of national Native American organizations, including the organizations you’re hearing from today. It is of the utmost importance that these funds be available to UIOs and that this does not create yet another lack of parity in the IHS system.

Finally, it is imperative that Congress appropriate funds for the significantly increased need for behavioral health services at UIOs. UIOs do not receive direct funds from the Mental Health, or Alcohol and Substance Abuse line items and instead must use the urban Indian health line item to account for these essential services. The COVID-19 pandemic and its unprecedented impacts on society have already led to an increased need for behavioral health services. Even before the pandemic, AI/ANs residing in urban areas faced significant behavioral health disparities – for instance, 15.1% of urban AI/ANs report frequent mental distress as compared to 9.9% of the general public and the AI/AN youth suicide rate is 2.5 times that of the overall national average. Congress must appropriate funds to not only address the previous unmet need but account for the increase in behavioral health services that is now critical and will remain so for years to come. TO that end, we respectfully request a $7.3 million in annual appropriation for behavioral health at UIOs for the next 3 years.

It is the obligation of the United States government to provide these resources for AI/AN people residing in urban areas. We thank Congress for the inclusion of UIOs in prior COVID-19 legislation and urge Congress to continue to take this obligation seriously by providing UIOs with all the resources necessary to protect the lives of their AI/AN patient populations. We request Congress continue to explicitly include UIOs in legislation where the whole Indian Health Care delivery system, I/T/U, is meant to benefit. Finally, we respectfully request that, as the FY 2021 appropriations process is underway, Congress keep in mind the significant and devastating strain unforeseen emergencies like the present pandemic and government shutdowns have on the underfunded Indian health system – and the additional stress that UIOs are faced with due to lack of inclusion in critical programs. As you know, Black and Brown lives matter and this committee has the opportunity to be the change we wish to see in this country. We are grateful for you for holding for this hearing today and for making sure our tribal members living in urban areas are not left behind.