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NCUIH Submits Comments to IHS on Resource and Patient Management System Replacement and Health Information Technology Modernization Focus Groups

On June 3, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about Health Information Technology (HIT) Modernization Governance regarding the replacement of the Resource and Patient Management System (RPMS). These comments responded to the joint Tribal Consultation and Urban Confer on May 3, 2022 and request for comments. NCUIH thanked the IHS for hosting the joint Tribal Consultation and Urban Confer and for planning two additional Tribal Consultation and Urban Confer sessions in 2022 to address HIT Modernization. Furthermore, NCUIH recommended that IHS ensure HIT Modernization focus groups are representative of the entire IHS/Tribal/Urban Indian Organization (I/T/U) system, identify specific statutes and/or regulations that prevent convening the focus groups before IHS purchases the new Resource and Patient Management System (RPMS), and prioritize interoperability in the RPMS replacement system.

Background

HIT Modernization for the I/T/U system is long overdue. Although HIT is necessary to provide critical services and benefits to American Indians/Alaska Natives (AI/AN) patients, IHS has historically faced challenges in managing clinical patient and administrative data through the RPMS. Initially developed specifically for the IHS, years of underfunding and a resulting failure to keep pace with technological innovation have left the RPMS impractical by current HIT standards. RPMS has been in use for nearly 40 years and has developed significant issues and deficiencies during this time, especially in recent years as HIT systems have rapidly advanced in sophistication and usefulness. As the Department of Health and Human Services (HHS) Office of the Chief Technology Officer (OCTO) and IHS found in the 2019 Legacy Assessment, systemic challenges with RPMS “across all of the IHS ecosystem currently prevent providers, facilities and the organization from leveraging technology effectively.” Because HIT is so critical to modern provision of healthcare services, this in turn makes it difficult for AI/AN healthcare providers to provide continuous, consistent care to the already marginalized AI/AN community. Accordingly, NCUIH appreciates that IHS has chosen to fully replace RPMS. Appropriate implementation of HIT Modernization will be a long-term project requiring consistent communication and collaboration between IHS and the entire I/T/U system.

NCUIH’s Requests to HHS

Accordingly, NCUIH makes the following specific comments, requests, and recommendations to IHS:

  • IHS must ensure that HIT Modernization focus groups are representative of the entire I/T/U system.
    • Inclusion of urban Indian organizations (UIOs) in the HIT Modernization process is consistent with, and required by, the federal government’s trust responsibility and the Indian Health Care Improvement Act (IHCIA). Furthermore, it is sound public policy. The UIO experience with RPMS and their needs from the modernization process must be accounted for, because they will inherently differ from the rest of the I/T/U system.
    • NCUIH urges the IHS IT office to proactively reach out to individual UIOs and NCUIH for recommendations on persons willing and able to serve as UIO representatives on the HIT Modernization focus groups. IHS Headquarters should also use Area Offices to reach out to UIOs, as they will have pre-existing local relationships with relevant UIO IT staff.
    • NCUIH offers its assistance if needed to facilitate communication with UIOs relating to the HIT Modernization focus groups or HIT modernization.
  • NCIUH requests that IHS identify the specific provisions of the Federal Acquisition Regulation, as well as any other relevant statutes and/or regulations, which it believes prevent convening the HIT Modernization focus groups at this time.
    • Based on the May 3 Tribal Consultation and Urban Confer, NCUIH understands that IHS identified legal concerns with convening focus groups prior to purchasing a RPMS replacement system and is seeking to minimize the risk of bid protests.
    • NCIUH asks that IHS identify relevant statutes and/or regulations which it believes prevent convening the focus groups at this time, so that Tribes, UIOs, and relevant national organizations may understand IHS’ concerns and provide pertinent feedback.
    • In addition, NCUIH requests an explanation from IHS on how it will utilize the focus groups if a RPMS replacement system is purchased prior to their convening.
  • IHS must prioritize interoperability in the RPMS replacement system.
    • Advancing interoperability is a key component of the 2020-2025 Federal Health IT Strategic Plan and is critical for creating a longitudinal health record that can be used to provide and improve care to AI/ANs.
    • NCUIH and UIOs are concerned that purchasing a RPMS replacement system without utilizing the interoperability focus group runs the risk of recreating RPMS’ existing interoperability problems.
    • If IHS insists on purchasing a RPMS replacement system prior to convening the interoperability focus group, it must use all data gathering tools at its disposal, including surveying I/T/U providers, hosting further Tribal Consultations and Urban Confers, internal technical analysis, and more, to ensure that the RPMS replacement system will prove to be a comprehensive solution for all I/T/U facilities.

NCUIH looks forward to the upcoming listening sessions and is confident that UIOs will be valuable subject matter experts in the HIT Modernization focus groups.

NCUIH Submits Comments to HHS about Missing and Murdered Indigenous People and Violent Crime Against Native People

On May 19, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to Health and Human Services (HHS) about Executive Order (EO) 14053— Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. These comments responded to correspondence, dated April 4, 2022, initiating a Tribal Consultation on the policy directives outlined in EO 14053. NCUIH outlined recommendations for HHS including communication and collaboration with UIOs, engagement with UIOs as critical stakeholders in HHS’ comprehensive plan to address the MMIP Crisis and violent crime, and the establishment of an agency-wide Urban Confer policy.

History of MMIP and EO 14053

According to the National Missing and Unidentified Persons System (NamUs), as of August 1, 2021, data demonstrates that most missing and unidentified cases involving AI/AN persons occur off tribal land. Still, relevant data on violence and crime in urban AI/AN communities is significantly lacking. What data does exist demonstrates a troubling situation for urban AI/AN communities. At least seventy percent (70%) of violent victimization experienced by AI/ANs is committed by persons not of the same race – a substantially higher rate of interracial violence than experienced by white or black victims. Furthermore, a 2019 report from the Minnesota Statistical Analysis Center found that AI/AN persons made up twenty percent (20%) of all victims of sex trafficking in Minnesota in 2017. Additionally, according to the California Consortium of Urban Indian Health’s Red Women Rising initiative, sixty-five percent (65%) of urban Indian women experienced interpersonal violence, forty percent (40%) experienced multiple forms of violence, and forty-eight percent (48%) experienced sexual assault. An October 2021 report by the Government Accountability Office (GAO) on the Missing or Murdered Indigenous Women noted that “tribal organization officials told [GAO] that AI/AN individuals who leave rural villages to move to urban, nontribal areas are at a higher risk of becoming victims to violent crime, including human trafficking, which they stated is a serious concern related to the MMIP crisis.”

NCUIH has consistently advocated for violent crime perpetrated against AI/ANs and the MMIP crisis to be treated as more than solely criminal justice or public safety issues.  Crime and violence are key Social Determinants of Health (SDOH) that both affect the immediate victims and cause negative health impacts throughout AI/AN communities.  Also, according to HHS, “[a]ddressing exposure to crime and violence as a public health issue may help prevent and reduce the harms to individual and community health and well-being.” A 2019 NCUIH survey found that sixty-six percent (66%) of UIOs said the most significant risk factors leading to AI/AN patients missing in their communities are: homelessness, foster system transitioning, domestic violence, substance misuse, and human trafficking, among others.  In turn, the federal government’s trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians” requires it to address violent crime against AI/ANs and the MMIP crisis through a holistic and inter-agency approach that supports and improves the health of AI/AN communities and individuals

EO 14053 is a landmark pledge “to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.” In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” EO 14053 specifically directs the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.” In addition, EO 14053 directs the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”  Pursuant to Section 5 of EO 14053, HHS must “develop a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors, as well as their families and advocates.”

NCUIH’s Requests to HHS

NCUIH issued the following comments and recommendations regarding the creation of HHS’ comprehensive plan and its implementation of EO 14053:

  • NCUIH requests that HHS honor EO 14053 through consistent and clear communication, as well as collaboration, with UIOs.
    • In EO 14053, the federal government committed to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.” This includes working with Tribal leaders and UIOs to drive meaningful prevention and intervention efforts.
    • Communication and collaboration with UIOs is not only required by EO 14053, but also sound public policy. Working with UIOs will help HHS make local connections, source, share, and analyze data, better understand the extent and causes of violent crime against AI/ANs and the MMIP epidemic, and evaluate the adequacy of research and data collection efforts at CDC and NIH.
    • NCUIH is ready, willing, and able to assist HHS communicate with UIOs and develop ongoing relationships to support this work.
  • NCUIH requests that HHS engage UIOs as critical stakeholders in its comprehensive plan to support prevention efforts that reduce risk factors for the victimization of Native Americans and increase protective factors.
    • NCUIH is appreciative that IHS recently held an Urban Confer on EO 14053 with UIOs. However, NCUIH emphasizes that it is the responsibility of the Secretary, and HHS as a whole, not just IHS, to work with urban AI/AN communities to reduce violent crime and address the MMIP epidemic.
    • UIOs are already engaged in culturally focused, community-based prevention efforts such as projects funded through the Domestic Violence Prevention Program, partnerships to provide services for victims of crime, and direct services for substance abuse disorders, mental health, and behavioral health.
  • NCUIH requests that HHS establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs.
    • Urban Confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in 70 percent of AI/AN people living outside of Tribal jurisdictions. Urban Confers are integral to addressing the care needs of most AI/AN persons and fulfilling the government’s trust responsibility.
    • Developing and implementing an Urban Confer policy for HHS is sound public health policy. Given the gravity of MMIP and violence against AI/ANs, it is imperative that HHS as a whole address these problems holistically and agency-wide, not solely at the IHS level. Urban Confers would enable UIOs to share feedback, recommendations, and testimony on the unique needs of their UIOs.

NCUIH will continue to closely follow HHS’ implementation EO 14053 and advocate for the resources needed to address the MMIP crisis and violent crime against AI/ANs, regardless of where victims live.

NCUIH Submits Comments to IHS on the Special Diabetes Program for Indians for Fiscal Year 2023

On May 16, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Special Diabetes Program for Indians (SDPI). These comments responded to the Dear Urban Indian Organization Leader correspondence initiating Area Urban Confers on the SDPI, dated April 15, 2022. In the comments, NCUIH emphasized the importance of SDPI and its impact in reducing health disparities related to diabetes for AI/AN populations. NCUIH also proposed recommendations for fiscal year (FY) 2023 including an increase in funding to at least $250 million with built-in automatic annual medical inflationary increases and additional support for UIOs seeking supplemental funding sources for diabetes-related care.

SDPI and Its Importance to Indian Country

As a grant program inclusive of all three components of the IHS/Tribal Health Program/Urban Indian Organization (I/T/U) system, SDPI has been a resounding and demonstrable success in reducing diabetes and diabetes-related illnesses in Indian Country. The National Indian Health Board has called SDPI “the nation’s most strategic, comprehensive and effective effort to combat diabetes and its complications.” SDPI remains a critical program to continue to address disparately high rates of diabetes among AI/ANs.

SDPI has directly enabled UIOs to provide critical services to their AI/AN patients, in turn significantly reducing the incidence of diabetes and diabetes-related illnesses among urban Indian communities. As of 2022, 30 out of the 41 UIOs received SDPI funding. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

NCUIH’s Requests to IHS

NCUIH made the following comments and recommendations about the SDPI:

  • SDPI should be permanently reauthorized and funding increasing to $250 million, with built-in automatic annual medical inflationary increases
    • SDPI funding has been stagnant at $150 million since 2004. Due to inflation and increases in health care costs, the level of funding has effectively reduced over the past nearly twenty years. This places the onus on Indian Health Care Providers to make up the funding difference to ensure the continued success of SDPI.
    • The federal government’s trust responsibility to AI/ANs requires that the government provide services and resources to improve the health of AI/AN citizens and the United States has pledged to provide all resources necessary to eradicate the health disparities between AI/ANs and the general population of the United States. Because AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, SDPI falls well within the federal government’s trust responsibility to AI/ANs, and it is the duty of the United States, not Tribes and UIOs, to reconcile funding concerns with programmatic need.
    • In addition, NCUIH urges the federal government to collaborate with other federal agencies to create or identify supplemental funding sources and communicate the availability of these funds to UIOs.
  • NCUIH requests that IHS ensure that SDPI remains inclusive of UIOs, especially if IHS is considering structural changes to SDPI.
    • NCUIH asks that IHS communicate any potential recommendations to UIOs as soon as possible and hold proper and timely Urban Confer sessions, as is required by the federal trust responsibility and the Indian Healthcare Improvement Act, prior to making any formal recommendations to Congress.

NCUIH will continue to closely follow IHS’s progress and policies with SDPI and advocate for future of this vital program.

NCUIH Submits Comments on Fiscal Year 2023 Appropriations Priorities to the Office of Management and Budget

On May 18, 2022, NCUIH submitted written comments and recommendations in response to the Office of Management and Budget (OMB) Dear Tribal Leader letter seeking Tribal consultation on appropriations priorities for programs and services that serve Tribal governments, organizations, and peoples in Fiscal Year (FY) 2023. Though NCUIH noted recent investments in the Indian Health Service (IHS) discretionary budget, the comments highlighted evidence that funding falls far short of documented need and fails to address inflation in the cost of medical care, particularly for the 70 percent of American Indians/Alaska Natives living in urban areas. NCUIH made six key recommendations to fully fund and support health services for Native organizations and communities, including urban Indian organizations (UIOs).

Background

OMB serves as a clearinghouse for budget formulation by developing overarching presidential priorities, coordinating across agencies, and publishing the annual President’s Budget. Last year’s Presidential Memorandum on Tribal Consultation and Strengthening Nation-to-Nation Relationships established an ongoing priority to uphold the federal trust responsibility through tribal engagement and consultation. Consistent with this memorandum, the OMB initiated a Tribal consultation to promote tribal priorities in the FY 2023 President’s Budget on April 25, 2022. Officials sought comment on programs that serve Tribal governments, organizations, and communities. In particular, the agency noted interest in feedback on shifting funding for IHS from discretionary to mandatory and reclassifying 105(l) Lease costs.

Current Action

NCUIH made six recommendations to improve delivery of health services to AI/ANs living in urban areas through the FY 2023 budget, including:

  1. Fully Fund Urban Indian Health at $949.9 million for FY 2023.
    As of FY 2018, the average health care spending is $11,172 per person, however, Tribal and IHS facilities receive $4,078 per IHS-eligible patient. UIOs receive just $672 per AI/AN patient from the IHS budget, significantly below federal per capita spending levels. This forces UIOs to operate on very slim margins, causing significant difficulty during unforeseen events.
  1. NCUIH supports the President’s FY 2023 Budget proposal for mandatory funding for the IHS.
    Since 1997, IHS has only once received full-year appropriations by the start of the fiscal year (FY 2006). This leaves the IHS subject to government shutdowns, automatic sequestration cuts, and continuing resolutions, which negatively impact patient care. For instance, during the 35-day government shutdown at the start of FY 2019, UIOs were forced to lay-off staff, reduce hours, reduce services, and some, unfortunately, had to temporarily close their doors due to the lack of funding. Mandatory funding for IHS is necessary and long overdue to ensure stable and predictable funding for AI/AN healthcare that is exempt from the political process.
  1. NCUIH requests that OMB hold a separate urban confer with UIOs to discuss the budget request for urban Indian health programs.
    IHS is the only federal agency with an Urban Confer Policy—no other agency, including agencies under the Department of Health & Human Services (HHS) that oversee programs for UIOs, has an established mechanism for dialogue with UIOs. Outside of the IHS Urban Confer process, urban AI/ANs have no specific representation with federal agencies regarding health care matters that affect them, leaving them on the margins of critical conversations on AI/AN health care that occurs across the Executive Branch.
  1. Create a Tribal Office and a Tribal Advisory Committee with UIO Representation
    During the recent virtual OMB consultations, Tribal leaders asked for a permanent position within OMB dedicated to AI/AN health care, a liaison between Indian Country and OMB, and/or an Office of Tribal Affairs within OMB. This new position or office would help coordinate communication and facilitate outreach to address budgetary shortfalls. NCUIH supports this request and stresses that UIO consultation and involvement is imperative to fulfill the President’s vision to improve health equity for AI/ANs. NCUIH also supports the request that OMB establish an OMB Tribal Advisory Committee with UIO representation.
  1. NCUIH requests that OMB provide an exception apportionment that is inclusive of the entire I/T/U system.
    In the absence of an exception apportionment, if Congress does not reach a budget agreement in time and the federal government must shut down, UIOs are subject to the shutdown. Federal shutdowns require UIOs to lay off staff, reduce hours and services, and even shut their doors, ultimately leaving their patients without adequate health care. During the 2019 shutdown, multiple patients died while an East Coast UIO was closed.
  1. Improve data accuracy for urban AI/ANs
    OMB’s Office of Information and Regulatory Affairs (OIRA) oversees the implementation of federal government-wide policies in the areas of information policy, privacy, and statistical policy. In this field of practice, the establishment of statistical standard practices is a critical government function. When searching for and comparing health indicators, assessing the health status of entire AI/AN communities, testing academic research using vital statistics, and conducting epidemiological studies in support of public health, it is very common to wrestle with misclassifications of race for AI/AN people. This is due, at least in part, to the fact that tribal membership or descendancy is a political status classification, not a racial category.  .NCUIH requests that OMB consult with NCUIH and UIOs to ensure that OIRA’s statistical standard practices appropriately account for urban AI/ANs. Additionally, NCUIH requests that OMB commit to continuously consulting and working with NCUIH and UIOs to improve OIRA’s data accuracy for urban AI/ANs

NCUIH will continue to monitor the FY 2023 budget formulation process and report developments across federal agencies and in Congress.

DOJ Consultation Meeting on the Public Safety and Criminal Justice Needs of Native Americans

On January 14, 2022, the U.S. Department of Justice (DOJ) Office of Tribal Justice (OTJ) issued a Dear Tribal Leader letter inviting Tribal leaders to a two-day government-to-government consultation on March 16 and 17, 2022. The purpose of this two-day consultation is to discuss “DOJ’s efforts to address the unacceptably high rate of violent crime in Native communities, including the rates of missing or murdered indigenous persons.” Deputy Attorney General Lisa Monaco directed this consultation in her November 15, 2021  memorandum establishing the DOJ’s Steering Committee to address the crisis of missing and murdered indigenous persons (MMIP). The OTJ is also welcoming written comments via email to OTJ@usdoj.gov until April 15, 2022. The meetings will be held from 3:00 p.m. – 4:30 p.m. EST on both days.

On November 15, 2021, during the White House Tribal Nations Summit, President Biden signed Executive Order 14053 (E.O.) “Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People,” which directed the Administration to work together with Tribes to “build safe and healthy Tribal communities and to support comprehensive law enforcement, prevention, intervention, and support services.”  The E.O. also recognizes that because “approximately 70 percent of American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas, we must continue that work on Tribal lands but also build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans.”  To that end, in her November 15, 2021 memorandum, Deputy Attorney General Monaco directed DOJ’s Steering Committee to seek and consider the views of stakeholders including Urban Indian Organizations.