[Senate Hearing 116-269]
[From the U.S. Government Publishing Office]
S. Hrg. 116-269
EVALUATING THE RESPONSE AND MITIGATION TO THE COVID-19 PANDEMIC IN
NATIVE COMMUNITIES AND S. 3650
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
JULY 1, 2020
__________
Printed for the use of the Committee on Indian Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
41-422 PDF WASHINGTON : 2020
COMMITTEE ON INDIAN AFFAIRS
JOHN HOEVEN, North Dakota, Chairman
TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska JON TESTER, Montana,
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana CATHERINE CORTEZ MASTO, Nevada
MARTHA McSALLY, Arizona TINA SMITH, Minnesota
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Jennifer Romero, Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on July 1, 2020..................................... 1
Statement of Senator Barrasso.................................... 4
Statement of Senator Cantwell.................................... 25
Statement of Senator Cortez Masto................................ 32
Statement of Senator Daines...................................... 30
Statement of Senator Hoeven...................................... 1
Statement of Senator Lankford.................................... 34
Statement of Senator McSally..................................... 27
Statement of Senator Moran....................................... 9
Statement of Senator Murkowski................................... 5
Statement of Senator Schatz...................................... 6
Prepared statement........................................... 7
Statement of Senator Smith....................................... 8
Statement of Senator Tester...................................... 5
Statement of Senator Udall....................................... 3
Witnesses
Davis, Scott J., Executive Director, North Dakota Indian Affairs
Commission, Office of The Governor, State of North Dakota...... 41
Prepared statement........................................... 42
Elgin, Lisa, Secretary, National Indian Health Board............. 43
Prepared statement........................................... 44
Fenton, Jr., Robert J., Regional Administrator, Region 9, Federal
Emergency Management Agency, U.S. Department of Homeland
Security....................................................... 14
Prepared statement........................................... 16
Weahkee, Hon. Rear Admiral Michael D., Director, Indian Health
Service, U.S. Department of Health and Human Services.......... 10
Prepared statement........................................... 12
Appendix
Allis, Kevin J., CEO, National Congress of American Indians,
prepared statement............................................. 68
Brown, Hon. Coly, Chairman, Winnebago Tribe of Nebraska, prepared
statement...................................................... 62
Cawston, Hon. Rodney, Chairman, Confederated Tribes of the
Colville Reservation, prepared statement....................... 74
Friend, Hon. Billy, Chief, Wyandotte Nation, prepared statement.. 73
Letters, submitted for the record
Lucero, Esther, CEO, Seattle Indian Health Board, prepared
statement...................................................... 69
Papa Ola Lokahi (POL), prepared statement........................ 65
Response to written questions submitted to Robert J. Fenton, Jr.
by:
Hon. Lisa Murkowski.......................................... 83
Hon. Tom Udall............................................... 81
Response to written questions submitted to Hon. Rear Admiral
Michael D. Weahkee by:
Hon. Martha McSally.......................................... 95
Hon Lisa Murkowski........................................... 92
Hon. Jon Tester.............................................. 94
Hon. Tom Udall............................................... 84
Robert Wood Johnson Foundation (RWJF), prepared statement........ 76
Rupnick, Sr., Hon. Joseph, Prairie Band Potawatomi Nation,
prepared statement............................................. 63
Sunday-Allen, Robyn, Vice President, National Council of Urban
Indian Health (NCUIH), prepared statement...................... 61
EVALUATING THE RESPONSE AND
MITIGATION TO THE COVID-19 PANDEMIC IN NATIVE COMMUNITIES AND S. 3650
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WEDNESDAY, JULY 1, 2020
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:36 p.m. in room
562, Dirksen Senate Office Building, Hon. John Hoeven,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. Good afternoon. We will call this oversight
and legislative hearing to order.
Before we begin, I want to remind those members who are
connecting with us remotely to please mute your microphone.
This will cut down on the static feedback in the hearing room.
The Committee will receive testimony today from two
Administration and two tribal witnesses on evaluating the
response and mitigation to the COVID-19 pandemic in Native
communities. The Indian Health Service witness will also
provide testimony on S. 3650, the Coverage for the Urban Indian
Public Health Providers Act. This bill will get us to a total
of eight bills in two weeks that we have taken testimony on in
Committee . I certainly look forward to marking up these bills
and moving them to the Floor in the coming weeks.
Today, tribal communities are experiencing some of the
highest rates of infection for COVID-19 in the Country. The
Indian Health Service recently reported more than 19,000
positive cases in the 12 service areas. Data also shows that at
least five Indian tribes such as the White Mountain Apache, the
Pueblo of Zia, the Pueblo of San Felipe, the Navajo Nation, and
the Kewa Pueblo, have had higher cases per capita, outpacing
States like New York, New Jersey, Massachusetts and some
others.
Additionally, the Centers for Disease Control and
Prevention states that American Indians and Alaska Native are
in a racial and ethnic minority group at an increased risk of
contracting COVID-19 or experiencing severe illness, regardless
of age. American Indian and Native American persons have a
hospitalization rate five times that of non-Hispanic White
persons.
Because of these higher rates, Native communities have
taken needed measures to limit exposure and protect their
people, instating curfews, or shelter in place orders. Opening
drive-through testing locations, closing non-essential
businesses, ceasing tourism and other revenue-generating
activities and switching schools to virtual platforms to
provide necessary education to students are examples of how
tribes are taking action and limiting the spread of infection
from reaching more into their communities.
In my home State of North Dakota, the first reported case
of COVID-19 was on March 11th, 2020. I can say that all the
communities across the State have taken measures to protect
their residents against the coronavirus. One of the larger
reservations in my home State is the Mandan Hidatsa and Arikara
Nation. They have provided a live community impact dashboard
that updates COVID-19 cases found on their lands.
This community ahs experienced 42 confirmed cases, causing
the tribe to take protective measures, such as devising a
policy that penalizes members for violating quarantine orders.
We should take a moment to acknowledge those law enforcement,
first responders, and medical personnel risking their health to
protect and care for those affected by the pandemic. Thank you
all for your tireless work that is helping so many.
As the Country knows, there is no vaccine to protect a
person against this respiratory illness. But work will continue
toward finding one. Congress will continue to fulfill the trust
and treaty obligations to Indians. Through various funding
authorized by Congress so far the Indian Health Service has
allocated approximately $2.4 billion to address COVID-19 needs.
Today's hearing will provide the Committee with an
understanding of what both the Indian Health Service and
Federal Emergency Management Agency is doing to mitigate and
prevent more cases of COVID-19 appearing in Native communities.
Specifically, I am interested to learn what is working well and
where improvements can be made by reaching more rural
communities, especially the tribal communities, who have less
access to resources than may be available in urban areas.
We are also interested in what lessons have been learned
from both IHS and FEMA during this pandemic. The Committee is
committed to understanding how the interactions between the IHS
and FEMA are being coordinated during the COVID-19 pandemic
response.
I am also pleased to see Mr. Scott Davis, Executive
Director of the North Dakota Commission on Indian Affairs here
today, testifying on panel two. Scott works tirelessly for the
five Indian tribes in North Dakota, and is a former All-
American marathon runner at Haskell Indian School. He was also
a great basketball player. I have watched him play basketball.
He was very good at that. Good athlete. And he is an
outstanding Commissioner for Indian Affairs in North Dakota.
Moving on to the legislative agenda of today's hearing, on
May 7th, 2020, Senators Tina Smith and James Lankford
introduced S. 3650, the Coverage for the Urban Indian Health
Providers Act. Senators Udall, McSally, Harris, Feinstein,
Sinema, Moran, Tester, and Warren also have joined as co-
sponsors. This bipartisan bill amends the Indian Health Care
Improvement Act to provide parity to the Indian Health System,
which is made up of the Indian Health Service, tribal health
programs, and urban Indian organizations.
S. 3650 expands the Federal Torts Claim Act coverage to
Urban Indian Organizations. More than 70 percent of American
Indians and Alaska Natives live in urban areas throughout the
Country. Urban Indian Organizations are able to provide
culturally competent care to Natives living in these urban
areas.
Currently, Urban Indian Organizations are not offered
protections that are already provided to the IHS and tribal
health program employees. UIOs spend critical dollars on
malpractice liability insurance for employees and volunteers,
rather than putting these resources toward health care.
Before we move to our witnesses, I want to turn to Vice
Chairman Udall for his opening statement.
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you, Chairman Hoeven, for calling
today's hearing.
Over the last several months, our Nation has faced a
convergence of major and seemingly unprecedented challenges; a
global pandemic and economic crisis and flagrant systemic
injustice. In examining the Federal response to these crises,
it is clear that the Administration ignored the warning
signals.
But for Indian Country and other communities of color, the
lack of Federal public health preparedness and the resulting
economic freefall were not unprecedented. In fact, they were
predictable and they were avoidable. We know that Native
populations in the U.S. experience morbidity and mortality
rates four times greater than non-Native populations in
previous pandemics.
Tribal economies are particularly vulnerable to economic
shocks and downturns in that in matters of housing, health
care, education, and justice, American Indians, Alaska Natives
and Native Hawaiians were too often left behind. We know this
because for years, tribal leaders, Native organizations and
witnesses have testified before this Committee that Federal
policies and failures have exacerbated health disparities,
economic barriers, and institutional inequities.
I understand that this is an uncomfortable truth for us to
grapple with. But we in Congress should not be surprised by
reports that the Indian Health Service, tribe and urban Indian
clinics have faced challenges securing personal protective
equipment and testing supplies when we knew that they did not
have access to the Strategic National Stockpile, and that they
were excluded from most Federal public health emergency
preparedness planning.
We should not be surprised by testimony that Indian Country
has struggled to navigate the bureaucratic maze of COVID-19
programs when we knew that many agencies had little to no
meaningful engagement with tribes prior to this pandemic. And
we should not be surprised that tribes' ability to access
Federal assistance and resources depends largely on how good
their relationship is with their State government, which
Federal official they are working with, or which agency region
they are located in, not when we knew that Federal practices
lack consistency and policies favor State pass-through models.
I have been fighting alongside tribes to address these very
same issues since I first arrived in Congress. Many of you on
this Committee have been fighting right alongside with me. But
as we have been so humbly reminded by this pandemic, there is
much yet to be done. That is why today's hearing is so
important. Congress and the Administration must take a good,
hard look in the mirror and see where we are still falling
short. That includes the Treasury Department, which has barely
got critical tribal CARES Act funding out the door, 50 days
beyond the statutory deadline. That is twice as long as
Congress intended, causing what a court determined to be
irreparable harm to tribal governments in their fight against
coronavirus. Whether it is the IHS or Treasury, the
Administration must do better.
Admiral Weahkee and Administrator Fenton, I hope you will
commit to taking the feedback you receive back to your
departments and work with your leadership to act on it. And I
hope that this Committee can work together to address these
statutory barriers and resource gaps for Native communities
without further delay.
Senator Smith's bill, which we are considering today, is an
excellent example of the type of practical, bipartisan solution
we should all be pushing. This bill not only creates parity
with the IHS system, but also helps urban Indian health
programs reduce operating costs due to COVID-19 related budget
shortfalls. I am proud to be co-sponsor of her work on this
front.
I will close by saying that despite the challenges that
remain before us, I am dedicated to standing with all American
Indians, Alaska Natives and Native Hawaiians. I am hopeful that
the Senate will be able to work together and replicate the
historic wins we have achieved for Native communities in the
first set of coronavirus relief packages.
Thank you again, Mr. Chairman, for this hearing. Thank you
to our witness for joining us for this very important
discussion.
The Chairman. Thank you, Vice Chairman Udall. We do have
some opening statements. We will begin with Senator Barrasso.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Mr. Chairman, for
holding this important hearing today.
As you know, when I was chair of this Committee , I
frequently spoke about my friends in Wyoming, the Wind River
Reservation, the Northern Arapahoe, and the Eastern Shoshone
Tribes. Yesterday I had a chance to visit at length with the
leadership of the Northern Arapahoe Tribe. As Senator Udall
said, there was a delay in getting some of the money out. There
was an initial 60 percent went out, but it took a long time to
get that second amount. The Northern Arapahoe have gotten that
$27 million to which they say they are grateful for what we
have done as part of the CARES Act.
As both of you have said, the impacts of this disease on
our tribes is disproportionately high. In Wyoming, we have had
20 deaths, half of them from the Northern Arapahoe Tribe. So
when you take a look at those numbers and this disproportionate
price that they have paid, I think it is very important for us
to have this hearing today and to hear from our experts and
continue to ask probing questions and see what more we can do.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Barrasso.
Senator Tester will give an opening statement remotely.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thanks for having this hearing, Chairman
Hoeven. Look, Indian Country, it has already been said today,
has been disproportionately impacted by COVID. They face unique
challenges in this pandemic in their communities. That is why
it is so very critical that the Federal Government uphold their
trust and treaty responsibilities and provide Native
communities the resources they need to address this crisis.
As a result, quite frankly, of underfunding and lower
reimbursement levels, many Indian health facilities across
Indian Country have limited their services for caring, and even
individuals impacted by COVID. So being able to refer patients
to another facility during this pandemic has been critical for
Indian health care providers, to be able to provide adequate
care to Native folks.
Having increased revenues as a result of things like
Medicaid expansion has been critical for Indian health care and
the facilities that serve them. Yet quite frankly, the Trump
Administration is moving full steam ahead to dismantle the
Affordable Care Act.
The bottom line is this: there is a big problem in Indian
Country. In Montana, they are seeing COVID infection at about
twice the rate they should, and quite honestly, we need to step
up to make sure that the money we have appropriated is getting
to them, and making sure they have what they need to be able to
come back from this horrible virus.
With that, I look forward to the testimony. I look forward
to the questions thereon.
The Chairman. Thank you, Senator Tester.
We will turn to Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman, and to our Vice
Chairman, thank you for a very important hearing. I think we
look to the impacts of COVID-19 on different sectors. We have
certainly had many hearings in the Energy Committee on how this
pandemic has impacted different parts of our economy and the
people. There is probably nothing more important that we can be
doing here in this Committee than looking to the impacts to our
American Indians, Alaska Native and Native Hawaiians, on
vulnerable populations, and as the statistics have been shared,
they are troubling in terms of how we see the health
disparities reflected when you have something like a COVID
virus impacting.
In Alaska, we have been, I won't say lucky, because luck
has nothing to do with the fact that we have been able to keep
our number of cases very low. What we have done in many of the
communities, primarily our Alaska Native remote communities, is
they have voluntarily shut themselves off from the rest of the
world. They have said, we do not want travelers in here, we do
not want the mail plane to come in here, we don't want the
plane that is going to be delivering fresh goods for the
grocery store, because we are so concerned about how this virus
may repeat history, do a repeat from the 1918 flu, the Spanish
flu, that wiped out many Alaska Native villages. Natives around
the state today remain fearful of just that impact.
So the efforts that have been made to keep the virus out
have been considerable. They have been aggressive, and they
have been expensive. So the funding for the CARES Act to help
offset this is very, very important.
I do think it is also important to recognize that we all
want to see these funds dispersed to the villages, to our
tribes, and do so in a manner that is consistent with what we
outlined in CARES, but also quickly. It was unfortunate that we
saw litigation delay the initial distributions of these funds,
and are still delaying some portions of the CARES Act funding,
all over a dispute that we felt we had made very, very clear
when we enacted CARES, that those who would be eligible for
this CARES Act funding would be our tribes, and the tribes
would include, in Alaska's case, our Alaska Native
Corporations.
With the recognition of the complexity of the laws and
impacts with how Alaska Natives are addressed and treated under
ANSCA, and our Federal laws, we do not have reservations in
Alaska. Our statuses are different when it comes to Alaska
Native peoples. And it is an overlay of organizations, tribal
health organizations, our tribes, our Native villages, our
Native corporations. It is complex. And I think it is important
to understand how all of these entities together, working
together, are pulling the weight to respond to this impact of
COVID.
I didn't intend, Mr. Chairman, to make more than a minute
statement, but I felt it was important to outline to colleagues
that yes, we all share the same goal here. We want to get this
much-needed funding out to our tribes across the Country. We
will do so. But we have to ensure that they are done in a fair
way so that those costs that have been associated with this
pandemic are reimbursed and reimbursed fairly and fully.
With that, I am looking forward to the testimony this
afternoon, and to direct some questions, primarily about where
we are with water and wastewater when it comes to Admiral
Weahkee.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murkowski. Now we will
turn to Senator Schatz.
STATEMENT OF HON. BRIAN SCHATZ,
U.S. SENATOR FROM HAWAII
Senator Schatz. Thank you, Mr. Chairman, and Vice Chairman,
for scheduling this hearing. I want to follow up on what
Senator Murkowski said. It is important for us all to take a
breath and to remember the tradition of the Committee on which
we all serve. It has a tremendous, decades-long tradition of
bipartisanship. But not only about bipartisanship, but a sense
that all Native peoples hang together, that Alaska Natives,
American Indians, and Native Hawaiians hang together.
With the unfortunate situation of the deployment of the
funds to Alaska being delayed as a result of litigation and a
misinterpretation of the statute, we also need to remember that
in the final throes of the negotiation over the CARES Act, that
the dollars we are actually talking about were characterized as
a sort of Democratic ask, something that had to be negotiated
for, on behalf of Democrats. I don't think that is the
tradition of this Committee. I don't think that is the way we
want to move forward.
So as we look at July and we look at another traunch of
Federal funding for keeping people alive and keeping some
semblance of an economy going, including Native people
everywhere across the United States, we should remember that we
all must hang together, Democrat and Republican, Native
Hawaiian, Alaska Native, and American Indian. I am very, very
hopeful that with the Chairman's leadership, we are going to be
able to do just that.
Thank you very much.
[The prepared statement of Senator Schatz follows:]
Prepared Statement of Hon. Brian Schatz, U.S. Senator From Hawaii
Thank you Chairman Hoeven and Vice Chairman Udall for scheduling
this hearing. Bipartisan and bicameral efforts to support native
communities are more important than ever. The COVID-19 outbreak
continues to rage and it's disproportionately impacting the lives of
American Indians, Alaska Natives, and Native Hawaiians.
Today we will receive testimony from the administration, a national
native health organization, and a state commission on Indian affairs.
We are seeking to understand two things:
First, whether the authorizations and supplemental funding provided
to tribes and native communities in previous coronavirus response bills
were effective.
And second, what additional legislative actions are needed to
improve implementation, address urgent needs, and speed recovery.
Chairman Hoeven, I request that the remainder of my opening
statement be entered into the record so that we can move forward to the
witness panels more quickly.
The disproportionate health, economic and social burdens faced by
native communities are not new. But the COVID-19 pandemic is shining a
light on funding deficits and glaring shortcomings in access to health
care, clean water, sanitation facilities, safe housing, and other basic
necessities.
Native Hawaiians are at risk:
They have the shortest life expectancy of the major ethnic
groups in Hawaii;
They are more likely to have an underlying medical
condition, such as coronary disease, diabetes, asthma or COPD,
making COVID-19 a greater health threat; and
Native Hawaiians also make up half of the homeless
population on the island of Oahu alone. They are also more
likely to live in overcrowded housing conditions, making
compliance with social distancing guidelines difficult.
I have attached several documents produced by the Office of
Hawaiian Affairs and Papa Ola Lokahi as an addenda to my remarks to
provide additional data on the status of Native Hawaiians. *
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* The information referred to is in the hearing appendix.
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As one of the United States' indigenous peoples, who formed a
government prior to our own and exercised sovereignty over lands that
are now part of the state of Hawaii, we accord Native Hawaiians a
unique legal and political status. The U.S. has a trust responsibility
to Native Hawaiians and more than 200 laws have been enacted in
furtherance of the special trust relationship.
I fully support S. 3650, a bill introduced by Senator Smith and
other SCIA colleagues to extend Federal Tort Claims Act (FTCA) coverage
for urban Indian health providers, and I also support parity in
treatment for Native Hawaiian Health Care Systems (NHHCS) providers.
Just as the Congress passed the Indian Health Care Improvement Act
to authorize funding and programs for the Indian Health Service,
tribes, and to extend health care services for Native Americans living
in urban areas, the Native Hawaiian Health Care Improvement Act was
enacted to authorize funding and programs for Native Hawaiians.
Extending FTCA coverage to the Native Hawaiian Health Care Systems
would ensure that these health care centers can focus all of their
scarce resources on providing patient care.
According to the American Community Survey of 2017, the Native
Hawaiian population in Hawaii was approximately 300,000, and the
American Indian and Alaska Native population was approximately 36,274.
Given a prospective service population this large, the Native Hawaiian
Health Care Systems need relief from paying expensive insurance
premiums so that they can grow their capacity to serve the health care
needs of more Native Hawaiian families.
The Chairman. Thank you, Senator Schatz. And we will turn
to Senator Smith.
STATEMENT OF HON. TINA SMITH,
U.S. SENATOR FROM MINNESOTA
Senator Smith. Thank you, Mr. Chair and Ranking Member. I
am really glad to have this hearing today.
It is a good time for us to take a look at what has
happened with COVID-19 in Indian Country. I very much
appreciate Senator Schatz's comments as we think about how we
work in a bipartisan way to make sure that our treaty and trust
responsibilities as the Federal Government are upheld
carefully.
Mr. Chair, I have to say that I note, based on the
witnesses that we have today that we won't have an opportunity
to speak with anybody at Treasury today about Treasury's
implementation and disbursement of the funds. I know that this
is an issue that I can tell has been a concern for both my
Republican and my Democratic colleagues. So I hope that we will
have an opportunity to talk with somebody at Treasury and
understand better what happened and how we can make sure that
it doesn't happen in the future, as our American Indians and
Alaska Natives and Native Hawaiians had to wait so long for
these funds that they needed so desperately.
I want to lift up one issue which is very important to
Minnesota tribes, which is as grateful as they are to have this
CARES Act funding, as I know everybody on this Committee
understands, these dollars cannot be used to displace the lost
revenue that tribes have experienced because of their voluntary
decision to shut down tribal enterprises. This has resulted not
only in dramatic increase in unemployment on tribal nations,
but also dramatic decreases in government revenue, as a result.
So I hope this is something that we can all work on
together in this Committee , Republicans and Democrats
together. Because this issue would haunt tribal nations and
people everywhere in this Country unless we are able to address
it.
Thank you, Mr. Chair.
The Chairman. Thank you, Senator Smith.
Now we will turn to our witnesses, beginning with the----
Senator Moran. Mr. Chairman?
The Chairman. Yes?
Senator Moran. It is Senator Moran.
The Chairman. Oh, Senator Moran. Would you like to make an
opening statement? Go ahead.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. I would, thank you. Chairman Hoeven and Vice
Chairman Udall, thank you for conducting this important
hearing. You were kind enough to allow me to make opening
remarks, because I chair the Senate Veterans Affairs which will
begin when I get there, I guess, but begin at 3:00. I did not
want to miss the opportunity to express my view of how
important this hearing is, and how important the topic is to
make certain that we are doing what we should be doing in
regard to tribes and Native Americans.
I also would commend Senator Tina Smith and our colleague
Senator Lankford for the bill that is being discussed today. I
am a co-sponsor of that bill, and I look forward to seeing it
pass the Senate and become law.
I mentioned that I am on my way to chair a Veterans Affairs
committee, and I wanted to highlight the role the Department of
Veterans Affairs plays in regard to Native American health
care, both because many Native Americans are veterans
themselves, but also the fourth mission of the Department of
Veterans Affairs is to assist the rest of the Country, non-
veterans, in times of health care crisis. Senator Tester, the
ranking member of the Committee that I chair, and I have had
weekly telephone conferences with Dr. Stone, the Director of
Health Care at the VA, and the Secretary of the Department,
Secretary Wilkie. In almost every weekly phone call, the
conversation has involved the role that the Department of
Veterans Affairs is playing in caring for the health care and
well-being of Native Americans.
The tribes in Kansas certainly have not been without their
challenges related to COVID-19. But I am greatly concerned by
what is happening in places outside my State as well. I have
advocated to ensure that our tribes are remembered in the
relief packages that are passed by Congress, and I intend to be
active and engaged in the efforts as we look at what a Phase
four package might entail as well.
Mr. Chairman, I will not be here to ask the necessary
questions, but I will pay attention to the results of this
hearing, because it will inform what direction we should
proceed in that regard. If I was present, I would highlight the
importance of broadband and internet for delivering services on
tribal lands and to Native Americans, but to all Americans, as
we have seen COVID-19 demonstrate the importance of tele-health
and tele-education.
I also am remiss in not being able to hear the testimony of
the North Dakota Executive Director of the Indian Affairs
Commission. You highlighted that he is a Haskell graduate.
Haskell of course is in Lawrence, Kansas. Every time I meet or
hear of a Haskell grad, I take great pride in their success and
the time that they spent in my home State.
Mr. Chairman, thank you for the opportunity to join you for
this brief moment. I look forward to hearing the results of
your hearing, so that we can act appropriately on behalf of
tribes and Native Americans.
Thank you.
The Chairman. Thank you, Senator Moran. I will pause for
just a moment, if there is anyone else who is attending
remotely who wants to give an opening statement.
Hearing none, then we will go forward with our witnesses.
First, we have the Honorable Rear Admiral Michael D. Weahkee.
He is the Director of the Indian Health Service, U.S.
Department of Health and Human Services. After he testifies, he
will be followed by Mr. Robert Fenton, Jr., Regional
Administrator, Region 9, Federal Emergency Management Agency,
U.S. Department of Homeland Security, Washington, D.C.
With that, Rear Admiral Weahkee, please proceed.
STATEMENT OF HON. REAR ADMIRAL MICHAEL D. WEAHKEE, DIRECTOR,
INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Weahkee. Good afternoon, Mr. Chairman, Vice Chair
Udall, and members of the Committee . Thank you for the
opportunity to testify on the Indian Health Service's efforts
to respond to and mitigate the coronavirus pandemic, as well as
on S. 3650, Coverage for the Urban Indian Health Providers Act.
Let me start with a few comments on S. 3650. I am pleased
to mention that the IHS endorses the policy to extend Federal
Tort Claims Act coverage to UIOs, which is consistent with our
fiscal year 2021 budget request. However, IHS does prefer
formulating the coverage extension as part of the statutory
section of the Public Health Service Act, where the other
various similar extensions are located. This is noted in my
written statement.
Now I will transition to our COVID-19 response. Over the
past several months, the IHS has worked closely with our tribal
and urban Indian organization partners, with State and local
public health officials, and with our fellow Federal agencies
to coordinate a comprehensive, all of government, public health
response to this pandemic.
Throughout our efforts, our number one priority has been
the health and safety of our IHS patients and our staff. While
the Indian health system is large and complex, we realize that
preventing, detecting, treating, and recovering from COVID-19
requires collaboration and local expertise. We continue to
participate in regular conference calls with our tribal and
Urban Indian Organization leaders from across the Country to
provide updates, answer their questions, and to hear their
concerns and engage in rapid tribal consultation in Urban
Confer sessions, so that we can inform our COVID-19 funding
distributions and meet the needs of Indian Country.
I am grateful to Congress for supporting our efforts
through several supplemental appropriations that have enabled
the Indian Health Service to allocate $2 billion to our IHS,
tribal, and urban Indian health program partners to prepare for
and respond to the Coronavirus. We are detecting COVID-19
through screening and state of the art lab testing.
Through White House-led testing initiatives, we have
distributed, or are in the process of distributing, a total of
470 Abbot ID NOW test analyzers, and hundreds of thousands of
testing supplies for various testing platforms. Our IHS
National Supply Service Center has distributed over 60 million
units of personal protective equipment and other Coronavirus
related supplies, including 1.7 million testing swabs and
transport media.
In my written testimony, I provided data on our resting
statistics as of June 7th, in which we had performed 157,980
tests, which equaled 9.5 percent of our user population,
exceeding the U.S. all races testing rate. But we do have up to
date information that we can provide to the Committee as these
numbers do change on a daily basis.
We are treating each and every patient with culturally
competent, patient-centered, relationship-based care as we look
to recover from COVID-19. The IHS is supporting the emotional
well-being and mental health of our workforce and the
communities we serve, providing services that draw from a long
history of cultural resilience among our American Indian and
Alaska Native communities.
In June, the IHS announced a new critical care response
team of expert physicians, nurses, and other health care
professionals. This mobile team is providing urgent, life-
saving medical care for COVID-19 patients and conducting hands-
on clinical education.
HHS has also provided the Indian Health Service with access
to 20,000 doses of remdesivir, that is being supplied to
patients in both our Federal and tribal hospitals across the
Country. Remdesivir is an investigational anti-viral medicine
that has shown progress in shortening the recovery time in some
people.
In April, the IHS expanded use of an agency-wide video
conferencing platform that allows for tele-health on almost any
device and in any setting, including in our patients' homes.
Since this expansion, the IHS has experienced a greater than
11-fold increase in the use of tele-health from roughly 75
visits to week to now an average of over 907 visits per week.
Our health care professionals are also providing a great deal
of care over the telephone.
We look forward to continuing our work with tribal and
Federal partners as the Country moves forward toward phased
reopening and recovery. We strongly encourage everyone to
continue to follow CDC guidelines and instructions from their
local, State, and tribal governments, to prevent the spread of
COVID-19 and protect the health and safety of our communities.
Before I close, I just wanted to highlight a few recent
trips that I have made to the Navajo, Bemidji, and Phoenix
areas, where I observed powerful and uplifting examples of
collaboration during my visits to several area health
facilities. I met with Navajo Nation President Jonathan Nez,
and Oneida Nation Tribal Chairman Tehassi Hill, to hear
directly about their challenges combating COVID-19. I am
grateful for the strong leadership displayed by our tribal
partners in working alongside Federal and State partners to
ensure the safety and well-being of American Indian and Alaska
Native communities.
In closing, I want to acknowledge and thank our entire
Indian Health Service team, including those on the front lines
treating our patients, and others in supportive roles that have
demonstrated profound commitment in raising the physical,
mental, social, and spiritual health of American Indians and
Alaska Natives to the highest level during this unprecedented
time. I am extremely proud of their hard work to combat COVID-
19. I consider myself fortunate to work alongside such a truly
committed and dedicated workforce.
Thank you again for the opportunity to speak with you here
today. I appreciate your continued partnership and engagement
while we work together to combat the Coronavirus epidemic.
Thank you.
[The prepared statement of Rear Admiral Weahkee follows:]
Prepared Statement of Hon. Rear Admiral Michael D. Weahkee, Director,
Indian Health Service, U.S. Department of Health and Human Services
Good afternoon Chairman Hoeven, Vice Chairman Udall, and Members of
the Committee. Thank you for the opportunity to testify on the Indian
Health Service's (IHS) efforts to respond to and mitigate the
Coronavirus pandemic, as well as on S. 3650, Coverage for the Urban
Indian Health Providers Act.
Responding to and Mitigating the Coronavirus Pandemic
Over the past several months, the IHS has worked closely with our
tribal and Urban Indian Organization (UIO) partners, state and local
public health officials, and our fellow Federal agencies to coordinate
a comprehensive public health response to the pandemic. Throughout our
efforts, our number one priority has been the safety of our IHS
patients and staff.
While the Indian health system is large and complex, we realize
that preventing, detecting, treating, and recovering from COVID-19
requires local expertise. We continue to participate in regular
conference calls with tribal and UIO leaders from across the country to
provide updates, answer questions, and hear their concerns. In
addition, IHS engages in rapid Tribal Consultation and Urban Confer
sessions in advance of distributing COVID-19 resources to ensure that
funds meet the needs of Indian Country.
I am grateful to Congress for supporting our efforts through the
passage of the Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020; the Families First Coronavirus Response Act;
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and the
Paycheck Protection Program and Health Care Enhancement Act. These laws
have provided additional resources, authorities, and flexibilities that
have permitted the IHS to administer nearly $2 billion to IHS, tribal,
and urban Indian health programs to prepare for and respond to
Coronavirus. These resources have helped us expand available testing,
public health surveillance, and health care services. Moreover, they
support the distribution of critical medical supplies and personal
protective equipment in response to the pandemic. In addition, the $500
million distributed by the Department of Health and Human Services
(HHS) from the Provider Relief Fund to IHS, tribal, and urban Indian
health programs will help providers in American Indian and Alaska
Native communities recover lost revenue, and provide Coronavirus-
related health care services. All of these resources make a real
difference in helping to fulfill our IHS mission as we continue to work
with tribal and UIO partners to deliver crucial services during the
pandemic.
The IHS continues to play a central role as part of an all-of-
nation approach to prevent, detect, treat, and recover from the COVID-
19 pandemic. We are partnering with other Federal agencies, states,
tribes, tribal organizations, universities, and others to deliver on
that mission. We protect our workforce through education, training, and
distribution of clinical guidance and personal protective equipment. We
also protect our tribal communities through supporting tribal leaders
in making their decisions about community mitigation strategies that
are responsive to local conditions, and to protect the health and
safety of tribal citizens as those communities make plans to safely
return to work.
We are detecting COVID-19 through screening and state-of-the-art
lab testing. Through White House-led testing initiatives, we have
distributed, or are in the process of distributing, a total of 350
Abbot ID NOW rapid point-of-care analyzers, as well as hundreds of
thousands of testing supplies for various testing platforms. The IHS
National Supply Service Center has also distributed over 60 million
units of personal protective equipment and other Coronavirus response
related products, including 1.7 million testing swabs and transport
media. As of June 7, we have performed 157,980 tests in our American
Indian and Alaska Native communities, which equates to 9.5 percent of
our user population, exceeding the U.S. all-races testing rate, and the
testing rate of most states and foreign nations. Of those tests, 13,165
(9.3 percent) have been positive, with large geographic variation from
as much as 23.3 percent in the hard-hit Navajo Area, to less than 0.3
percent in the Alaska Area.
We are treating each and every patient with culturally competent,
patient-centered, relationship-based care. As we look to recovery from
COVID-19, the IHS is supporting the emotional well-being and mental
health of its workforce and the communities we serve, providing
training, education, and access to treatment that draws from our faith
and traditions and a long history of cultural resilience among American
Indians and Alaska Natives.
Earlier this month, the IHS announced a new Critical Care Response
Team of expert physicians, registered nurses, and other health care
professionals that will be available on an as needed basis.
This team will provide urgent lifesaving medical care to COVID-19
patients admitted to IHS or tribal hospitals. These expert medical
professionals will conduct hands-on clinical education while treating
patients and expanding capacity. They will also train the frontline
health care professionals on the most current information available for
the management of COVID-19 patients, and other critically ill patients.
The critical care response team can be mobilized and at the bedside of
the patient within 24-48 hours' notice.
Earlier in May, we began distributing remdesivir to IHS federal and
tribal hospitals based on requests and current burden of patients with
COVID-19 who are hospitalized or in an ICU. Remdesivir is an
investigational antiviral medicine that has been used under an
emergency use authorization to treat certain people in the hospital
with COVID-19. Remdesivir was shown in a clinical trial to shorten the
time to recovery in some people, although the data was not sufficient
to determine if the drug was associated with lower mortality. HHS has
provided the IHS with access to 8,000 vials of remdesivir, and it is
being supplied to patients at 15 of our IHS and tribal hospitals across
the country.
In April, the IHS expanded use of an Agency-wide videoconferencing
platform that allows for telehealth on almost any device and in any
setting, including in our patients' homes. Since April's telehealth
expansion, the IHS has experienced a greater than eleven-fold increase
of telehealth visits, from roughly 75 telehealth visits per week on
average to now 907 videoconferencing telehealth visits per week on
average. This number does not include other telehealth modalities such
as care provided over the telephone, which is common in the bandwidth-
constrained environments of Indian country.
We look forward to continuing our work with tribal and federal
partners. As we work towards recovery, we are committed to working
closely with our stakeholders and understand the importance of working
with partners during this difficult time. For instance, we are
currently working with other federal partners to provide assistance to
the National Indian Gaming Commission as they work to provide guidance
to tribally owned casino facilities that want to ensure they are doing
all they can to keep employees and customers safe. We strongly
encourage everyone to continue to follow CDC guidelines and
instructions from their local, state, and tribal governments to prevent
the spread of COVID-19 and protect the health and safety of our
communities.
I want to share an update on a trip that I made to the Navajo Area
IHS at the end of May. During my trip, I visited the Navajo Area Office
and Emergency Command Center in Window Rock, Arizona. I met with Navajo
Nation President Jonathan Nez and joined him in the Navajo Nation's
virtual town hall meeting on COVID-19. I am grateful for the strong
leadership displayed by our tribal partners in working alongside
federal and state partners to ensure the safety and well-being of
American Indian and Alaska Native communities. I observed powerful and
uplifting examples of collaboration during my visits to the Gallup
Indian Medical Center, the Shiprock-Northern Navajo Medical Center, and
the Crownpoint Health Care Facility. I would like to thank our entire
Navajo Area IHS team for their continued dedication to our patients. I
also want to acknowledge the rest of our IHS team, including those on
the front lines, and others in supportive roles that have demonstrated
profound commitment to raising the physical, mental, social, and
spiritual health of American Indians and Alaska Natives to the highest
level during this unprecedented time. I am extremely proud of their
hard work to combat COVID-19, and I consider myself fortunate to work
alongside a truly talented and dedicated team.
S. 3650, Coverage for the Urban Indian Health Providers Act
This bill would amend the Indian Health Care Improvement Act
(IHCIA) to extend Federal Tort Claims Act (FTCA) coverage to UIOs as
coverage is currently authorized for Indian Self-Determination and
Education Assistance Act (ISDEAA) contractors.
Congress must specifically authorize, in statute, the extension of
federal tort coverage to certain groups or individuals. Currently,
Federal law extends FTCA coverage to ISDEAA contractors' employees and
personal services contractors [25 U.S.C. 5321(d)]. Federal law does
not provide tort liability coverage for injuries to Urban American
Indian and Alaska Native patients that result from the negligent acts
of employees at UIOs providing health and medical services pursuant to
a contract with or a grant from the IHS.
The IHS enters into limited, competing contracts and grants with 41
501(c)(3) non-profit organizations to provide health care and referral
services for Urban Indians throughout the United States. In calendar
year 2017, 35 UIOs provided 653,614 health care visits for 75,194
American Indians and Alaska Natives, who do not have access to the
resources offered through IHS or tribally operated health care
facilities because they do not live on or near a reservation.
UIOs are purchasing liability insurance with resources that could
be better utilized to expand services available to Urban American
Indian and Alaska Native patients. The rising cost of liability
insurance and the general cost of providing health care services
adversely impact the ability of UIOs to provide needed services. As a
result, certain kinds of staff and health services, such as dental
services, have been substantially reduced or eliminated. UIOs are an
integral part of the IHS health care system. They provide high quality,
culturally relevant health care services and are often the only health
care providers readily accessible to Urban American Indian and Alaska
Native patients.
IHS endorses the policy to extend FTCA coverage to UIOs, which is
consistent with the FY 2021 Budget request. However, IHS prefers
formulating the coverage extension as part of the statutory section in
the Public Health Service Act where the other various similar
extensions are located.
Thank you again for the opportunity to speak with you today.
The Chairman. Thank you, Admiral Weahkee.
Now we will turn to Administrator Fenton.
STATEMENT OF ROBERT J. FENTON, JR., REGIONAL ADMINISTRATOR,
REGION 9, FEDERAL EMERGENCY MANAGEMENT AGENCY, U.S. DEPARTMENT
OF HOMELAND SECURITY
Mr. Fenton. Good afternoon, Chairman Hoeven, Vice Chairman
Udall, and distinguished members of the Committee . My name is
Robert Fenton. I am the FEMA Region 9 Regional Administrator.
I want to thank you for this opportunity to discuss the
actions taken by FEMA to support Native American communities
during the COVID-19 pandemic. But before I begin my remarks, I
would like to provide my condolences to the families and
relatives of the 126,000 Americans who have lost their lives
from COVID-19. Given the scope of this hearing and the
disproportionate impact of the pandemic on Native American
communities, I would like to express my particular condolences
to the families and relatives of Native American victims of
COVID-19. My thoughts and those of FEMA's employees are with
you.
For the first time in FEMA's history, there are 57
concurrent major disaster declarations, encompassing every inch
of our Country and impacting all 574 federally-recognized
tribal nations. This is truly a Whole-of-America response.
The scale of this historic event has required FEMA to adapt
its response practices in order to both respond to COVID-19 and
simultaneously to maintain mission readiness for other
disasters, such as wildfires or hurricanes. As you are aware,
the challenges facing tribal nations are as diverse as the
United States itself. Regardless of the unique obstacles, all
tribal nations face widespread challenges in mitigating the
impacts of this pandemic.
To address these challenges, FEMA headquarters, FEMA's
regional offices, and their tribal liaisons are available to
provide dedicated support to tribes. As previously stated, I am
the Regional Administrator of FEMA's Region 9, which
encompasses 400,000 square miles and includes some of the most
culturally and economically diverse communities in the United
States. Our region includes 157 federally recognized tribes
within California, Arizona, and Nevada.
In Region 9, as well as in other regions, we have dedicated
tribal liaisons and deploy staff to tribes when additional
coordination is needed. An example of one tribe that FEMA
Region 9 has worked with closely during the pandemic is the
Navajo Nation. The Navajo Nation faces particular unique
challenges as it borders three States with higher mobility in
and outside of its borders.
Many Americans are not aware the Navajo Nation experienced
the fastest rate of spread in the Country. I would like to
highlight some of FEMA's experiences in supporting the Navajo
government as well as other Federal agencies.
To address the historic challenges facing the Navajo
Nation, a unified command group was formed by President
Jonathan Nez. It included FEMA and multiple HHS components,
including IHS, to ensure that the right Federal assets are
mobilized at the right time to save lives. Following emergency
declarations, I sent our Type 1 National Team members to the
Navajo Nation to establish a unified command and an incident
action plan to provide interagency coordination at all levels.
This structure remains in place today and it continues the
partnership.
Just yesterday, I visited the Navajo Nation, where I
participated in the Nation's uniformed command meeting and
joined President Nez in a virtual town hall in support of the
messaging on the importance of adhering to mitigation.
President Nez has taken great steps to limit mobility, highly
encouraged the use of masks, enacted curfews, and stay-at-home
orders, and continues to champion ways to leverage CARES Act
funding in a manner that best serves the Navajo Nation.
While the Navajo Nation has faced some unique challenges in
their fight to lessen the impact of COVID-19, they have also
experienced challenges common to all tribal governments. One
area of focus has been intricacies with FEMA's Public
Assistance grant program. There are three paths in which tribal
governments may become recipients of the PA program, as a
direct recipient, as a subgrantee on other States'
declarations, or they may request their own major declaration
from the President.
The Public Assistance program reimburses emergency
protective measures taken by a tribe. FEMA has developed a
process to advance 50 percent of a project's funding to
applicants before the project is completed.
Our office has performed outreach to tribal nations to
explain this process, and continues to work with tribal
governments interested in seeking the expedited reimbursement.
In some cases, we have dedicated FEMA staff who assist tribal
nations in the application process.
I want to highlight some strong partnerships with some of
our State partners that we have worked with to support the
tribes. For example, California sat up a tribal affairs desk in
the State Operations Center to assist tribes and coordinate a
routine weekly conference call with Federal, State and local
agencies as well as any health clinics and has provided
deployment personnel, equipment and commodities to meet
emergency needs of tribal communities.
The State of Arizona has also participated closely with
tribes, including providing a significant number of personal
protective equipment, and delivered specific aid to specific
IHS and 638 facilities, including the use of rotary aircraft to
help expedite PPE, medical training, and other components such
as Strategic National Stockpile clean ventilators.
These are just a few of the efforts FEMA is participating
in with the tribes to respond to COVID-19. I and the entire
FEMA team are committed to ensuring we address the critical
needs of the tribal governments during this challenging time.
The historic response and our preparations for the future will
continue to require a Whole-of-America effort. FEMA looks
forward to coordinating closely with Congress as we work
together to protect the lives of Native Americans.
I would like to thank the Committee for providing FEMA with
the resources to meet these complex mission requirements. I
look forward to answering your questions today.
Thank you.
[The prepared statement of Mr. Fenton follows:]
Prepared Statement of Robert J. Fenton, Jr., Regional Administrator,
Region 9, Federal Emergency Management Agency, U.S. Department of
Homeland Security
Good afternoon, Chairman Hoeven, Vice Chairman Udall, and
distinguished Members of the Committee. My name is Robert Fenton, and I
am the Region Nine Administrator of the Federal Emergency Management
Agency (FEMA). Thank you for the opportunity to discuss FEMA's response
and the actions underway to protect tribal nations during the
coronavirus (COVID-19) pandemic.
I would like to begin today by acknowledging and providing my
condolences to the families and relatives of the 126,000 Americans who
have lost their lives to COVID-19. My thoughts, and those of the men
and women of FEMA, are with you.
For the first time in the United States' history, there are 57
concurrent Major Disaster Declarations encompassing every inch of our
country and impacting all 574 federally recognized Indian tribes: from
the native villages of Alaska, to the pueblos of the Southwest and the
tribal communities of the Northern Plains, Mississippi Valley and
Eastern Seaboard. The scale of this historic event has required FEMA to
adapt its response practices and workforce posture in order to both
respond to COVID-19 and simultaneously maintain mission readiness for
more common disasters such as hurricanes, earthquakes, floods, or
wildfires.
Regardless of the challenges that FEMA continues to confront, the
bedrock of our mission remains constant: helping people before, during,
and after disasters. Although--and indeed because--COVID-19 has changed
our daily lives and the scope of its impact is unprecedented, the
Nation is counting on us to accomplish our mission and we will do so in
accordance with our core values of compassion, fairness, integrity, and
respect. FEMA will continue to leverage the Whole-of-Government
response to serve all of America.
Engaging with sovereign tribal nations is a key component of this
Whole-of-America response, and overcoming the unique challenges
confronting tribes has been a strategic prioritization for FEMA from
the beginning of the response to the pandemic. Many tribes are in
locations with limited transportation, medical, and communications
infrastructure which can complicate response efforts during any
disaster. Within the context of COVID-19, social determinants of health
and disproportionate percentages of chronic illnesses combined with
these infrastructural limitations to create particular challenges for
potentially at-risk tribes.
In direct reflection of the magnitude of this historic event,
FEMA's unprecedented support for tribal governments is measured beyond
financial support or the distribution of personal protective equipment
(PPE). FEMA's response has served to stabilize lives in the most
fundamental ways. For example, when the shelves of grocery stores
became barren and members of two tribes in New York were unable to
purchase scarce supplies, FEMA's emergency food distribution services
were able to fill that critical void. This is one simple example of
FEMA's understanding that emergency management is about putting people
first--both the disaster survivors we serve and those who serve them.
FEMA Headquarters and FEMA Regional Offices have provided expanded
services in support of tribal governments across the country in
response to the pandemic since the National Emergency Declaration was
declared on March 13, 2020. Each of the ten FEMA regional offices have
dedicated Tribal Liaisons within their workforces to coordinate with
tribes located in that respective region. Regional Tribal Liaisons and
Regional Administrators serve as the primary point of contact regarding
FEMA assistance, and serve as the conduit to connect tribes with FEMA
leadership and program subject matter experts, as needed, for
information sharing, technical assistance and resource coordination. As
part of these efforts, FEMA Regions, with the support of our federal
partners, have hosted weekly meetings and conference calls with tribal
leaders and tribal emergency managers to answer any of their questions
during this pandemic response. In Washington, D.C., FEMA has a
dedicated, permanent National Tribal Advisor Desk that further supports
coordinated federal response efforts to support tribes during any major
disaster or emergency activation within FEMA's National Response
Coordination Center (the NRCC)--which is located in FEMA Headquarters.
The NRCC has served as the fulcrum for coordinating the federal
interagency response to the COVID-19 pandemic. The NRCC Tribal Desk, as
is commonly referred to, was activated on March 15th and has been
staffed every day to support response and recovery efforts.
Today's testimony will offer an overview of FEMA's response efforts
and strategies for COVID-19, the types of assistance we have provided,
and the ways in which FEMA has augmented the leading efforts of our
federal partners at Health and Human Services (HHS), including the
Indian Health Service (IHS), to protect the lives of tribal citizens.
Overview of FEMA's Support for Tribal Partners
Public Assistance Category B
On March 13th, 2020, President Trump declared a nationwide
emergency pursuant to section 501(b) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Stafford Act). As a result, FEMA's
involvement in the federal response was vastly expanded. As part of
this unprecedented nationwide declaration, all state, local, tribal,
and territorial (SLTT) partners became immediately eligible for FEMA
Public Assistance (PA) Category B, emergency protective measures as
authorized by section 403 of the Stafford Act and funded by the
Disaster Relief Fund. Such assistance includes, but is not limited to,
funding for tribal medical centers, Alternate Care Facilities, non-
congregate sheltering, community-based testing sites, disaster medical
assistance teams, mobile hospitals, emergency medical care, and the
transportation and distribution of necessary supplies such as food,
medicine, and personal protective equipment (PPE).
Subsequent to the President's emergency declaration, all 50 states,
five territories, the District of Columbia, and the Seminole Tribe of
Florida have been approved for Major Disaster Declarations. As a direct
result of every single state receiving a Major Disaster Declaration,
every single tribal government in the country became covered by a Major
Disaster Declaration.
To provide flexibility, tribal governments have parallel paths
through which they can seek assistance from FEMA. They can either
request to be direct recipients under the nationwide emergency
declaration, or they can seek assistance as a direct recipient or
subrecipient under a State's Major Disaster Declaration. Tribal
governments also have the option to request a specific Major Disaster
Declaration directly to the President through FEMA. Regardless of the
way in which tribal governments pursue FEMA assistance, FEMA Regional
Offices and their Tribal Liaisons are available to provide technical
assistance.
In total, FEMA is working directly with 85 tribes under this
framework including partners such as the Hidatsa and Arikara Nations of
North Dakota, the Choctaw Nation of Oklahoma, and the Mashpee Wampanoag
Tribe of Massachusetts. In keeping with the Stafford Act, FEMA
allocates funding to cover 75 percent of costs, and tribal governments
are responsible for the remaining 25 percent.
Cost Share Adjustments for Public Assistance Category B
Many state and tribal governments have requested adjustments to the
75:25 cost-share ratio due to the economic hardship and loss of tax
revenue associated with the COVID-19 pandemic. As of June 25th, 42
states and 28 tribes have requested a cost share waiver. The Stafford
Act authorizes the President of the United States to make cost share if
warranted.
Tribal government recipients may request cost share adjustments
from the President through their FEMA Regional Administrator.
FEMA will then make a recommendation to the President regarding the
request and the President has the authority to make final cost share
adjustment determinations.
When federal obligations meet or exceed $149 per tribal member FEMA
will recommend the President increase the federal cost share from 75
percent to not more than 90 percent. As part of this calculation, FEMA
will use a tribal government's population on or near tribal lands, as
reported by a tribal government, to determine per capita obligations
for each tribal government that makes a request. FEMA also considers
qualitative factors such as the historical context of recent disasters
within the specified area.
CARES Act Funding for Cost-Share Considerations
To help tribal governments affected by COVID-19, the Department of
Treasury recently announced that Coronavirus Relief Fund dollars,
provided under the Coronavirus Aid, Relief, and Economic Security
(CARES) Act, may be used to pay for FEMA's cost share requirements
under the Stafford Act. This is yet another example of increased
flexibilities offered to tribal governments to nimbly respond to and
recover from COVID-19.
Managing Critical Shortages: FEMA Resource Distributions to Tribal
Partners
On March 19th, FEMA's role in the pandemic response changed. Under
the direction of the White House Coronavirus Task Force, FEMA moved
from playing a supporting role in assisting the U.S Department of
Health and Human Services (HHS), which was designated as the initial
lead federal agency for the COVID-19 pandemic response, to leading the
Whole-of-Government response to the COVID-19 pandemic.
From the outset, a key element of FEMA's response has been managing
shortages of medical supplies needed to combat the pandemic, such as
PPE, ventilators, swabs, and the chemical reagents required for
testing. This effort alone has presented a historic challenge for FEMA
and its federal partners such as IHS and HHS. COVID-19 has been a
global crisis-leaders across over 150 countries have simultaneously
been competing for the exact same medical supplies. We have been
further challenged as most of the manufacturing for PPE occurs in Asia,
where the virus significantly slowed down private sector production
capabilities.
Concurrently, American medical professionals on the front lines of
the pandemic have required an exponentially greater volume of PPE and
other medical supplies. On average, the United States began consuming a
year's worth of PPE in a matter of weeks. FEMA worked closely with HHS
to ensure that locations in danger of running out of supplies within 72
hours received lifesaving equipment from the Federal government's
reserve within the Strategic National Stockpile (SNS), as administered
by HHS.
Many of the earliest shipments to tribal governments and IHS
originated from HHS's SNS. From the beginning, FEMA and HHS understood
and acknowledged that the SNS alone could not fulfill all our Nation's
requirements. The SNS was never designed or intended to fully supply
every state, territory, tribe and locality in the United States
concurrently, and cannot be relied upon as the single solution for
pandemic preparedness. It was principally designed as a short-term
stopgap buffer to supplement state and local supplies during an
emergency.
Expedited international shipments within Project Airbridge
facilitated by FEMA's Supply Chain Stabilization Task Force helped to
supplement IHS and tribal nations' PPE or medical needs until global
supply chains could begin to stabilize. Once flown in via the Air
Bridge, 50 percent of the supplies on each plane were sent by
distributors to customers in areas of greatest need, such as hotspots
within the Navajo Nation.
Although FEMA was never intended to be the primary source of
supplies for any entity, our Agency was able to augment the vast
donations and supplies distributed through our partners at HHS and IHS.
In addition to our federal partner donations, FEMA facilitated the
distribution to tribal governments of 19,400 boot covers. 13,755
coveralls. 65,204 face shields. 1,276,800 gloves. 32,000 goggles.
15,000 KN90 masks. 139,670 KN95 Respirators. 397,030 N95 Respirators.
107,911 gowns. 1,825 Powered Air Purifying Respirators. 1,506 surgical
gowns. 120,450 surgical masks and 1,200 Tevek headcovers.
In addition, FEMA distributed more than 26,880 meals and 17,136
bottles of water to tribal communities and constructed five Alternate
Care Facilities, in partnership with the U.S. Army Corps of Engineers,
to assist the San Carlos Apache Tribe, Hualapai Tribe, and Navajo
Nation.
An Example: FEMA Support for the Navajo Nation
I do not need to remind the Members of this Committee that the
breadth of challenges facing Indian tribes and Alaska Native Villages
are as diverse as the United States itself. For example, certain tribes
within the Yukon territory of Alaska must deal with the difficulties of
being entirely inaccessible by roads and overcome the consequential
challenges of receiving medical aid by small boats or aircraft.
Conversely, other tribes in the continental United States must adapt to
the difficulties of being directly accessible by major highways, and
the exponentially increased risk of exposure to COVID-19 brought by
international travel. To best exemplify the ways in which FEMA has been
able to assist tribal governments and their wide variety of needs, I
would like to share our experiences in supporting one of most impacted
tribal nations within my jurisdiction: the Navajo Nation.
Similar to the challenges faced by other tribal nations across the
country, limited medical infrastructure and high rates of chronic
illnesses combined to create a vulnerable demographic amongst the
Navajo Nation. To further complicate matters, the Navajo Nation is
spread out across Arizona, New Mexico, and Utah. Consistent with other
aspects of the COVID-19 response, a key component of FEMA's efforts to
protect the lives of the Navajo Nation was close coordination with our
federal and state partners as part of the Whole-of-Government response.
To address the immediate shortages of PPE needed to support medical
workers on the front line in the Navajo Nation, FEMA and HHS worked
together to deliver critical PPE such as 159,000 N95 masks, 111,000
gloves, 30,000 face shields and 18,000 Tyvek suits. As part of the
Whole-of-America response, FEMA and HHS were able to further augment
these shipments to the Navajo Nation by facilitating donations of
102,967 gowns and an additional 30,500 gloves. To address ventilator
shortages, FEMA and HHS also facilitated the delivery of 50 ventilators
to Navajo Area IHS and 100 ventilators to the State of Arizona, to be
available to tribal nations, as needed.
Experience has demonstrated that emergency management is most
effective when federally supported, state or tribe managed, and locally
executed. As such, FEMA and Arizona State Health mission sent a
Disaster Medical Task Force to Tuba City Regional Health Care, which
provided subject matter expertise and other assistance. Furthermore,
FEMA has deployed an incident management assistance team to support the
Navajo Nation led response through joint planning, operations and
logistics at the Navajo Nation Health Command Operations Center.
Testing is also an important aspect of the strategy to combat
COVID-19 within the Navajo Nation. In keeping with lessons learned
elsewhere in the country, FEMA supported HHS efforts to prioritize
rapid testing for at-risk populations within the Navajo Nation.
Prioritizing the limited number of rapid tests for populations with
underlying health considerations was key to facilitating a rapid
response and the strategic distribution of scarce supplies. COVID-19
diagnostic platforms with longer turnaround times were found to be more
appropriate in situations with lower risk of rapid spread and
escalation. Rapid testing, as supported by HHS, IHS, and FEMA, has
allowed for increased diagnostic screenings above the national average.
In addition to FEMA's traditional role, we worked in nontraditional
ways as well. Through our relationship with the Department of Homeland
Security HQ, we deployed a ``Tactical Technical Assistance Strike
Team'' into the Navajo Nation during the peak of the crisis there. This
team not only helped with the traditional response, but also vectored
nontraditional NGO partners like The World Central Kitchen and
Community Organized Relief Effort into the Navajo Nation.
Lastly, understanding that emergency management practices must put
people first, FEMA deployed a six-person Incident Support Base (ISB)
team to support staged commodities, if needed or requested by the
Navajo Nation. FEMA staged four 52-foot trailers with cots, blankets,
water, and meals.
I commend our partners at HHS and IHS for working with the Navajo
Nation and using this experience to prepare for future emergencies. For
example, IHS is working with the Centers for Disease Control and
Prevention, also within HHS, and the Navajo Nation to recommend
solutions, identify resources and begin implementing plans to expand
water access on the Navajo Nation. These actions will potentially
assist in reducing the spread of the illness and lessen the burden on
the Navajo Nation's health care delivery infrastructure.
Conclusion
As the Regional Administrator of an area that serves 157 tribal
governments, including the Navajo Nation, I am acutely aware of how
critical FEMA's work is to the lives of Indian tribes, and I, and the
entire FEMA team, am committed to ensuring we address the critical
needs of tribal members during this challenging time.
Finally, I would also like to recognize the men and women of FEMA,
as well as our partner departments and agencies for their adaptability,
hard work, and endurance during this unprecedented response and express
our appreciation to Congress and the President for providing FEMA with
the necessary resources to meet very complex mission requirements and
conditions.
This historic and unprecedented response will continue to require a
Whole-of-America effort, and FEMA looks forward to closely coordinating
with Congress as we work, together, to protect the health and safety of
the American people during the COVID-19 pandemic.
Thank you for this opportunity to testify. I look forward to
answering any questions that you may have.
The Chairman. Thank you, Administrator Fenton.
And we will proceed to five-minute rounds of questions. I
am going to begin with Admiral Weahkee. I know that you have
been using the tele-health services, following CDC guidelines.
I guess my first question for you, Admiral, at IHS, is when do
you see returning to normal operations, and then when you do,
will you still have that tele-health service available?
Mr. Weahkee. Thank you, Chairman Hoeven. I appreciate the
question. We are very excited to have the flexibilities that
have been provided by CMS, both in terms of licensure and the
increased reimbursement for those services. We are very hopeful
that many of those will continue, even beyond the pandemic. I
think that we tested the possibility of that occurring and by
far, our providers have taken to it, our patients have taken to
it. So I really think it is going to be a sea change for the
way that patient care is delivered from this point forward.
That being said, we have a lot of challenges in Indian
Country with broadband access. Not all of our communities have
the ability to obtain services through that mechanism. We have
turned to hand-held telephones. Most Americans have a telephone
available to them. So we are trying to use that platform as a
potential.
In terms of when we will return to normal, I think that is
going to be different for different parts of the Country. We
have operations in 37 different States, 605 different
facilities across that system of care. Some of the locations
will be ready to return back to normal much sooner than others,
just depending on local situations, hospital capacity, local
infection rates.
But we do have a very defined, phased plan to return back
to some semblance of normalcy.
The Chairman. Also, you have lost a lot of third-party
reimbursements. What do you see as far as recouping some of
those third-party reimbursements for procedures that have been
put off because of COVID?
Mr. Weahkee. Thank you, Chairman.
We have assessed within our Federal family and with tribal
entities who are willing to share their information, and our
urban partners, what the third-party losses have been. We have
heard everything from 30 percent to 80 percent. We have good
insight into our Federal operations and what those numbers are.
But depending on the size and type of facility, if you are only
providing residential treatment, alcohol and substance abuse,
those services are for the most part taking a major hit. Dental
services is another line that has taken a significant hit.
But hospital size, part of the Country that you are in,
there is some broad variation. We have been very fortunate
beneficiaries of the Provider Relief Fund. So we thank Congress
for that. But the funding that we have received is not reaching
the entire need out there.
I visited the Phoenix Indian Medical Center this week. They
are projecting a $14 million deficit by the end of this fiscal
year if current situations continue.
The Chairman. IHS has been allocated $2.4 billion from the
CARES Act. How much of that is allocated, and do you anticipate
being able to allocate all of it? Are you going to have some
returned? If so, why?
Mr. Weahkee. Thank you, Chairman. The vast majority of
those funds have been allocated. In fact, all the funding is
out at the area offices. The first three supplements of funding
are in the front lines already in the coffers and being used to
purchase testing equipment, and to continue to pay those
salaries from that lost third-party revenue.
One set of funds that is taking a little bit longer to get
out is the Paycheck Protection Program and Healthcare
Enhancement Act funds. That is $750 million worth of the
funding. We are undergoing bilateral modifications to the
annual funding agreements to ensure that we have testing plans
developed in partnership with the tribes and we have a good
understanding of their needs, estimated testing supply needs,
in the future.
The Chairman. You indicated testing, more than 150,000
tests, 9.5 percent of the IHS user population. That is a rate
that exceeds most States, a lot of them, and most foreign
countries, too. What is your target? That is good. What is your
target for testing?
Mr. Weahkee. Well, Senator, our target, and I will probably
lean back on Dr. Toedt here, the target is to assess at least
10 percent of your population.
Dr. Toedt. [Remark off microphone] testing the positivity
rate.
Mr. Weahkee. The positivity rate. So our current number is
now 272,935 tests that have been completed. That represents
16.4 percent of our user population. So in less than three
weeks' time now, we have seen substantial increases in our
testing rates. We have a high, in Navajo and Phoenix, right at
about 20 percent of their population is being tested. I think
positivity rates for places like Alaska where we have been able
to test 46,772 patients, they have a positive rate of only a
0.3 percent, which is very good.
But we feel like we are doing a great job in terms of
testing capacity and meeting the needs of testing in Indian
Country. That being said, supplies deplete and hot spots
persist in large metropolitan areas and it will be difficult to
get those testing supplies.
The Chairman. For those hot spots, for example, in the
Southwest, including tribes in White Mountain, the White
Mountain Apache, also the Navajo Nation, what are you doing in
terms of coordinating with other agencies to try to make sure
you are meeting their service needs?
Mr. Weahkee. Yes, sir, and that goes to the heart of the
all-of-government approach. It is vitally important that we are
working with the States where our tribes exist. The State of
New Mexico has been a fabulous partner. Governor Lujan Grisham
has done a lot of great work in ensuring that we have testing
capacity. She has contracted isolation sites. But it is
important that we utilize all the resources available to us.
We talked about government support a lot. We have also had
a lot of support coming from non-governmental organizations and
from universities. Johns Hopkins is engaged in both of those
locations, White Mountain and Navajo.
So we are taking advantage of all the resources available
to us in this all-of-nation approach.
The Chairman. Thank you, Admiral Weahkee. We will turn to
Senator Udall.
Senator Udall. Thank you, Mr. Chairman.
Admiral Weahkee, you should know better than anyone that
COVID-19 is hitting Indian Country particularly hard,
especially in the Navajo service area in Arizona and New
Mexico, and you should agree that as doctors and medical
professionals across the Country work on the front lines to
battle this deadly virus, the least we can do is ensure that
they have the right personal protective equipment. That is a
bare minimum.
So you can understand why I am deeply troubled by recent
reports about hundreds of thousands of substandard KN95
respirator masks supplied to IHS hospitals serving the Navajo
Nation on New Mexico and Arizona. I mentioned this concern in a
brief phone call with you in May. I followed up with a May 27th
letter asking for a full report, and posing very targeted
questions to you about what happened there on the circumstances
of the IHS' $3 million Federal procurement contract with Zach
Fuentes LLC.
First, let me state the obvious. It is outrageous that
substandard masks were sent anywhere, let alone to a COVID-19
hotspot. In its haste, IHS contracted for faulty PPE and failed
its responsibility to its patients and caregivers, period.
I understand that the IHS did not use the faulty masks, and
by a stroke of luck, none were actually distributed for use in
IHS facilities. That does not take away from the fact that IHS
potentially put patients and medical personnel in harm's way by
failing to do its due diligence.
To make matters worse, yet another report has surfaced
indicating that the contractor has refused to terminate the
contract, and has demanded his $3 million payment.
Admiral, you are in a world of hurt. How about we start
with your explaining how this happened, for the record?
Mr. Weahkee. Thank you, Vice Chairman. I just want to state
for the record that this situation is procurement sensitive. We
are still working with contract acquisition professionals and
attorneys to go back and forth with this particular vendor on
this purchase.
It wasn't a stroke of luck that kept those supplies from
getting to our front line staff, it was the systems and
controls in place at our area offices and in our receiving, to
ensure that those materials were not distributed to our health
care professionals.
So I am happy that we have been able to identify the
situation and now, because of non-conformance of this
particular vendor in meeting the needs of our PPE, we have the
ability to send those supplies back. There are options
available to him. He can make it good by providing us with
masks that meet the FDA standards and certifications. Or he can
try to come up with a different way of fulfilling his end of
the contract.
He has not been paid. Those masks are all sitting in a
warehouse in Mexico. They are clearly identified that they are
not to go to any of our locations.
In terms of how this occurred, we used Federal acquisition
regulation requirements and the flexibilities that have been
provided to us by the CARES Act. We identified and looked at
seven different vendors for that particular procurement. He had
the best pricing and the delivery options available at the
time. But since you have identified the needs that persist, and
they do, we do need masks, not only in Navajo but throughout
the Country, we are looking at other vendors to help meet that
need.
Our National Supply Service Center immediately shipped
100,000 N95s, not KN95s, but actual N95s, to that location as
this is being resolved.
Senator Udall. I expect a full response to my May 27th
letter with written answers to all my questions. And a staff
briefing is not enough. Your response letter last night I
received at 11:36 p.m. It didn't answer any of the questions.
So I want to ask one of those, or two of those questions
today. What protocols are in place to guard against IHS
procuring substandard PPE?
Mr. Weahkee. Thank you, Senator. The protocols that are in
place are controls and systems for any procurement. So we do
have a receiving that is conducted by procurement
professionals. They review, according to the order, to ensure
that we have received what it was that we ordered. We also have
quality assurance reviewers that sometimes include infection
control nurses. So those items that a materials management
person may not have as much familiarity with as a front line
health care service worker, there would be multiple points to
be able to check and ensure that we are using what it is that
we need to be using in each setting.
So there are multiple checks and balances built into our
system to ensure that the PPE being used meets the quality
control standards in place.
Senator Udall. Will you commit to me to answer my questions
in my May 27th letter to you?
Mr. Weahkee. We will, sir.
Senator Udall. Thank you. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Udall.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
Admiral Weahkee, you heard me mention in my short opening
the impact that we have seen in Alaska as a result of the
pandemic, the tribal providers being forced to shut down
elective procedures in the clinics. The negative financial
consequences I don't think can be overstated.
It is estimated that third-party collections have dropped
by 80 percent in some States. We recognize that the need is
considerable, and you certainly know that.
One of the things that really has helped shine a spotlight
during this time of COVID-19 is when you are telling people to
follow certain safety protocols, like washing your hands
frequently, and you are from a village where you don't have
safe drinking water, you don't have running water in your home,
you don't have the means, really, to keep yourself and your
family clean. This is very, very, very hard. It just highlights
again how essential adequate sanitation is for our communities.
We are seeing not only this play out in our communities,
but we know that other forms of disease also come with lack of
safe drinking water, lack of the ability to clean and
disinfect. Of the 190 Alaska Native communities, 32 are still
not served with in-home water and sewer. Typically, these
communities have a washeteria where you can go and you can wash
your clothes, take a shower, get clean. But in many, many of
these communities, and you know because you have seen them, it
is simply inadequate.
I was out in Wales this past year. Wales has been working
for years now to get their washeteria back. Beyond just one
shower, there is no washing machines that work. It is a Federal
effort to get a washeteria in place.
Not only a Federal effort, it then becomes a media event
when that story is not only played in the Anchorage daily news
but in news publications around the Country. So it speaks to
the issue that so many rural communities lack access to
adequate water. This comes when you have extraordinarily high
construction costs in those communities. IHS has established
cost caps per home that when approached, both decrease the
priority of the project in the scoring system, and limit the
amount of funding available.
So my question to you, Admiral, is whether or not IHS would
be willing to eliminate or at least to raise the cost caps for
projects that provide piped water and sewer into these unserved
communities. We have to be figuring out how we can do more to
be more responsive, to get water and sanitation out there.
Mr. Weahkee. Thank you, Senator Murkowski. I join you in
having seen Wales and Shishmaref myself, and the dire need for
these services. That has been in my conversation with President
Nez on the Navajo Nation, they have a lot of very similar
issues with a lack of available water systems.
Even before the pandemic, we had identified a need of $2.7
billion across our system of care for sanitation and facilities
construction needs. But these problems are now exacerbated as a
result of the pandemic and the inability to wash hands, as you
say, which is one of the public health measures we need to put
in place.
With regard to the caps, we do have three different tiers
in the State of Alaska. As we all know, it costs much more to
construct. We have to barge equipment in and supplies and
condense your construction time frame. All of those add to the
cost.
We are currently collecting actual data to identify whether
or not the caps that are currently in place are meeting
reality. We know that we now have some additional flexibilities
that have been provided to us. President Trump also put in
place an executive order that has enabled us to waive certain
regulations and policies that may be impeding our construction
projects or other infrastructure projects.
So I am definitely open to looking at what flexibilities we
may have available to us to make changes and get these built
once and for all.
Senator Murkowski. I think it is important, you mentioned
the flexibility there and the opportunity to perhaps waive. We
have also seen the need for community public health measures in
terms of how we deal with community contributions in Indian
communities for sanitation projects.
So looking, having the IHS again look to waive the non-
Indian contribution requirements in the Indian communities is,
I think, something that could be helpful. So I would urge you
as you are looking to those authorities that you have, what has
recently been laid out in this executive order.
But I think we have known that we have had this problem for
far too long. When we had Dr. Eastman up to the State just
about six weeks ago or so, his eyes were opened. Even though
this was not something that was in his bailiwick or
jurisdiction, he was starting to think outside the box, how can
we work with FEMA to perhaps use emergency funds. Because this
is an emergency. It has been an emergency for a long, long
time. That has been part of the problem and what has stalled us
out.
So know that we are going to keep working aggressively with
you. While it might not be something that we can direct funding
to now, I think there are flexibilities that we can look to. I
think also when you see the disparities in so many of our
Native villages, our Native communities, following from this
pandemic, there needs to be a greater sense of urgency as to
our purpose and how we address it together.
So I look forward to doing that with both the agencies
here. Thank you, Mr. Chairman.
I do have questions that I will be submitting for the
record if I may.
The Chairman. Very good. Thank you, Senator Murkowski.
Senator Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Mr. Chairman, and thank you,
Vice Chairman Udall, for holding this important hearing.
The Urban Indian Healthcare facilities in Seattle and the
Indian Health Board and the Native Project provide critical
service for Native Americans and Alaska Natives throughout the
Pacific Northwest. The Seattle Indian Health Board serves
around 6,000 patients annually, and at least two-thirds of
those being Native Americans or Alaska Natives. The Native
Project in Spokane also provides a wide array of services to
more than 300 tribes.
However, chronic underfunding of our trust and treaty
obligations across the Indian Healthcare system, in addition to
the deadly COVID pandemic, is threatening Indian health and
wellness of Native Americans and Alaska Native communities. So
this is especially the case in a large percentage of American
Indians and Native Alaskans who live in urban areas. Currently,
Urban Indian health programs typically receive less than 1
percent of the IHS budget, even though approximately 70 percent
of American Indians and Alaska Natives live in urban areas. So
the inequity of Urban Indian health care just has to stop.
The situation is not helped by the fact that the Urban
Indian health programs receive a lower Federal Medical
Assistance Percentage, or FMAP, as other Indian health care
facilities. To me, this inequity does not even make sense.
These providers must have parity, particularly as they have
needed to close their doors, reduce services, stop medicine
delivery due to the lack of resources and capacity of COVID-19.
So Rear Admiral, what are the benefits of extending 100
percent FMAP parity to Indian health programs, and how can we
get that done? How would it impact the IHS budget?
Mr. Weahkee. Thank you, Senator Cantwell. I agree that we
do have many of our American Indian and Alaska Native brothers
and sisters living in metropolitan areas now. You quote 70
percent living there. Active user counts, individuals using our
Urban Indian programs, is about 71,000 per year, last check. So
that contributes partially. Many of our funding formulas are
based on the active users of the programs. That being said, we
know that there are many urban centers across the Country who
really want to participate in that program.
The 100 percent FMAP would benefit those locations, because
then 100 percent of the funding going to those locations is
coming out of the Federal coffers, as opposed to the match
required by the States. So there is a funding amount that
States would need to come up with in that current system that
would all be paid by the Federal Government if 100 percent FMAP
were provided to the Urbans in the same way it is for our IHS
tribal and community health centers.
Senator Cantwell. I am glad you mentioned that part. So now
we are talking about an Indian Health Service facility
somewhere, let's pick Montana, or what have you, they get 100
percent, right?
Mr. Weahkee. Yes, ma'am.
Senator Cantwell. Okay. So if you actually had a physical
hospital facility in downtown Seattle that was on a tribal
land, you would also get 100 percent?
Mr. Weahkee. Depending on the structure of that facility,
if it was true tribal, tribal 638, through a tribe directly
running it or tribal resolutions. I think Phoenix Area Medical
Center is a good example of that, where there are six service
unit tribe and they so get 100 percent FMAP.
Senator Cantwell. So we are only just talking about the
structure of the building, not the obligation to meet Indian
health. So my point is, this is an inequity, we have to fix it.
There is no reason--do you know of a reason for the inequity?
Mr. Weahkee. Other than historical structure, and the
manner that the programs came about.
Senator Cantwell. Right. So I am saying, with so much of
the population in Urban Indian Health, and the fact that it is
in dire pandemic and needing resources, to me, obviously States
are coming to us too and saying, let's have full FMAP, because
of their underwater nature in health care. Now seems the
perfect time to fix this and to move forward.
I don't think that there is any difference, other than the
structure and the building, as you say, in the code. But in
reality, we are talking about serving Indian health. That is
all we are talking about. So to me, we should meet this
obligation.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Cantwell.
At this point we will turn to Senator McSally remotely.
STATEMENT OF HON. MARTHA McSALLY,
U.S. SENATOR FROM ARIZONA
Senator McSally. Thank you, Mr. Chairman, I appreciate it.
It is good to see you gentlemen today. Arizona is home to
22 federally recognized tribes and more than 300,000 Native
American constituents. When the Coronavirus hit, I have been a
tireless advocate for our Native Americans in Arizona, fighting
for the tribal stabilization fund, that $8 billion, also for
tribal parity and engaging with the Administration to ensure
the execution of many parts of the CARES Act was within
Congress' intent in order to help our Native American
communities.
This pandemic has devastated Native American communities
and economies. But I do want to recognize the incredible
response by our tribal leaders, of the health care heroes, of
the first responders. Tribal members and their families have
shown incredible resilience and strength and innovation and
just service to others in this incredibly challenging time.
They are doing an incredible job and we are here to make sure
that they have the resources that they need to fight and defeat
this virus. We will defeat this virus together.
Mr. Fenton, it is good to see you remotely. The Navajo
Nation has garnered national attention and international
attention as one of the hardest hit communities in the world.
While FEMA aid has been flowing since early days, the 25
percent cost share requirement has proven to be burdensome and
seems to unwisely divert funds away from where they are really
needed locally.
On April 2nd, the Navajo Nation formally requested a waiver
for the 25 percent tribal cost share requirement. FEMA
acknowledged receipt of the letter and reported the request was
under review at FEMA Region 9 headquarters. Since nearly three
months have passed since the Navajo Nation submitted the
request, when can President Nez expect a response?
Mr. Fenton. Yes, Senator. There are a couple of different
ways that cost share can be changed. As you know, one is by the
President. So that letter is in process.
In the interim, what has happened is the Administration has
made CARES Act funding available to be used as a cost share
match. So that 25 percent, along with our 75 percent to cover
the whole 100 percent. Then we can also look at a change if
they reach the 90-10 per capita number, which is $149 per
capita.
So no State, tribal nation or territory has received a cost
share change, primarily because of all the funding that is out
there now and trying to leverage that together to provide the
need. I talked to President Nez yesterday, and he understands
that there hasn't been a response yet. That doesn't mean that
there won't be one. And of course, Congress can do that through
a change, too.
Senator McSally. Got it. So just to be clear, they have got
no response yet, but where is it in the process of working its
way up the Administration? So the answer is not no. I know
there are different ways to address this, and one could be in
additional legislation. But through the Administration's
process, where are they in the process and when will they get
an answer?
Mr. Fenton. It is within FEMA, and typically we don't
address cost share waivers until there it goes over $149 per
capita, which we are far short of right now. So that is what
triggers the 90-10 change.
So we have that, we are tracking their cost share right
now, and their spend and need. The majority of the assistance
we have given to the Navajo Nation has been in direct Federal
assistance. So until we build them, there is no cost share for
that. We have reimbursed them less than a million dollars at
this point. So the cost share would be small amounts that they
have been impacted which they can use CARES Act funding, or
non-profit in lieu of that, too.
So there hasn't been a significant impact to them yet from
that cost share. We continue to monitor it and work closely
with them.
Senator McSally. So just to be clear, when you say CARES
Act coming as a second mechanism, are you talking about using
some portion of the Tribal Stabilization Fund, the $8 million?
Mr. Fenton. Of the Treasury money, I think it was $600
million provided to Navajo.
Senator McSally. To them, that was their portion of the $8
billion, is what you are getting at. Okay, thanks.
So I want to talk about just the tribal initiative. Early
on, many tribes in Arizona expressed frustration about indirect
accessibility structure between FEMA, States, and tribes. This
was in the early days. So how has FEMA worked to improve the
working relationships with the tribes in a way that respects
tribal sovereignty and also improves efficiency?
Mr. Fenton. There are many different mechanisms that
coordinate with the tribes. One is each region has tribal
liaisons that work with the tribes. I have two in California,
for northern and southern California, and one in Arizona and
one in Nevada. In addition to that, during this event, I have
deployed personnel to specific tribes that are heavily
impacted, so I have a team up in the Navajo Nation, I have sent
people over to the White Mountain Apaches. And then I have
individuals within each State that are also coordinating that,
along with the States that are communicating.
There's a number of mechanisms to ensure the communication.
In addition to that, I have dedicated people to help them with
the public assistance reimbursement.
Senator McSally. Okay, great. I can't totally read the
clock; I think I might be over my time. Admiral Weahkee, I am
going to submit some questions for the record specifically
about testing. I am concerned the White Mountain Apache Tribe
now has the highest infection rate per capita in Arizona and
are in need of mobile testing sites. So please look for those
questions for the record on testing.
Mr. Weahkee. Thank you, Senator.
Senator McSally. Thanks.
The Chairman. Thank you, Senator McSally.
We will turn to Senator Schatz.
Senator Schatz. Thank you, Mr. Chairman, Ranking Member
Udall.
My first question is for Director Weahkee. I wanted to
follow up on Chairman Hoeven's question regarding tele-health.
Some of the loosening of restrictions that just happened in the
CARES Act are actually temporary and only apply for the period
of the pandemic. I would like you to speak to the utility of
these changes, the additional flexibility you have now, and
increasingly I hear from patients, from tribal governments,
from Native Hawaiian health care organizations, from providers,
that not only is tele-health working, but it is sort of hard to
imagine going back to the old way. What Congress hasn't quite
realized is that a lot of the changes that we have made
statutorily only apply during this pandemic.
So could you speak to the need to making some of these
changes permanent?
Mr. Weahkee. Yes, and thank you, Senator Schatz, for this
opportunity to speak to tele-health. Definitely, it is a mode
of care that we have turned to in Indian Country for quite some
time. We have seen rapid growth, rapid expansion, an 11-fold
increase in only a short three or four months. We know that
that pales in comparison to many other health systems who have
increased their tele-health hundred-folds.
We have had conversations within HHS. I have heard both
Administrator Verma from CMS and Secretary Azar as the
Secretary speak to the desire to maintain these tele-health
flexibilities long-term. So I am hopeful that we will see that
come to fruition. Again, the challenges in Indian Country are
really around broadband access and our rurality. We have many
of the broadband services that go right around our
reservations. So individuals who may be able to access tele-
health in a neighboring rural city or county can still not
access it on the reservation proper.
So having partnership opportunities with the FCC and the
vendors who provide tele-health services are going to be
vitally important as we move forward. Of course, the necessary
resources to build the cabling and other lines of support.
Senator Schatz. So a couple of other questions. First of
all, I want to make a specific point about tele-health. People
think of as similar to this WebEx where you need a really high-
speed connection. That is certainly true, and it is certainly
the case that we all need to do better about broadband
connectivity in Native communities. But I think it is important
to remember that some of tele-health is storing forward
technology, it is remote patient monitoring technology, which
does not require super-fast bandwidth. Those are the kinds of
things that do not depend on our ability to deploy
infrastructure, but rather depend on our willingness to extend
the flexibility that exists in the CARES Act into the future.
Second question that I have, Director, is, have you seen
any quality of care problems now that some of these services
are being delivered by tele-health rather than in person?
Mr. Weahkee. Thank you, Senator. I have personally not seen
any quality of care items. Let me turn to my chief medical
officer, Dr. Toedt. Anything you have seen or heard?
Dr. Toedt. [Remarks off microphone.]
Mr. Weahkee. Thank you. We have not.
Senator Schatz. And a final question, there was a fair
amount of good conversation in the opening remarks around the
need to help health care providers in order to deliver direct
patient care and not spend too much money on costly malpractice
insurance. I think that is true for Alaska Natives, for
American Indians, and Native Hawaiians. I am wondering if you
could just let us know how important you think it is from a
standpoint of your providers.
Mr. Weahkee. Thank you, Senator Schatz. I think that any
time that you can have the backing of the Federal Government in
an ever-increasing litigious society that it would be
beneficial to our providers. It would buy them a sense of
support.
Any time that you have to take away from precious few
resources to pay malpractice insurance, you are making
decisions, those funds could better be spent additional
providers or nursing support, or other pieces of the health
care system, if you didn't have to pay those high insurance
rates.
Senator Schatz. Thank you very much.
The Chairman. Thank you, Senator Schatz. We will turn to
Senator Daines.
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Chairman Hoeven, and Ranking
Member Udall.
Admiral Weahkee, welcome. As we look at what is happening
in Montana and across our Nation, disasters always seem to hit
harder in Indian Country. This one is no different, with the
current Coronavirus pandemic. That is why I fought alongside
Senator McSally to secure $8 billion, we worked together on
that, to be set aside for tribal governments to respond to this
crisis.
Additionally, we were able to secure tribal eligibility for
an additional $803 billion in grants and loans. This has
provided tribes in Montana with some important tools and funds
needed to help combat this global pandemic.
We have also worked hard to facilitate getting more PPE out
to Montana's tribes, working with the vendors, making sure they
have the resources to purchase the amount necessary.
A question, Admiral, is that not enough seems to be the
most common phrase I hear in regard to PPE in the health care
system. What steps has IHS specifically taken to ensure that
tribes in Montana have enough PPE and testing kits to
accurately and safely track the Coronavirus?
Mr. Weahkee. Thank you, Senator Daines. I appreciate your
question. Specific to both PPE and testing supplies there are
similar processes used to fulfill the needs for both. Early on
in the pandemic, we, just like every other health care system
across the Country, were really scrambling to meet the needs.
Everybody needed the same materials at the same time, and
manufacturing supply was just not where it needed to be to meet
those needs.
We worked closely with FEMA and the Assistant Secretary for
Preparedness and Response in HHS in the early days to fulfill
any supply needs that we couldn't meet through our regular
channels, through the Strategic National Stockpile. We all know
that at some point that Strategic National Stockpile was
depleted and probably, according to many, earlier than it
should have been.
So we have a lot of work to do to prepare for the next
pandemic and the potential second wave coming to ensure that we
are ramping up the par levels and the supplies that we have,
not only in the Strategic National Supply, but within our
agency stockpiles as well. We have within the Indian Health
Service a National Supply Service Center. It is located in
Oklahoma City. It is a warehouse full of supplies as well as
three regional supply centers, one in Anchorage, Alaska,
Gallup, New Mexico, and Nashville, Tennessee. We have had
internal discussions in the same way that they have at the
national about increasing our S and S, about increasing our
stockpiles and potentially even the need to increase by some
additional regional centers, perhaps in the Great Lakes and the
Pacific Northwest.
Senator Daines. In Mille Lac, if I can interject for a
moment, we are seeing an increase in the number of COVID-19
positive test results in Montana, significant spikes and some
of the hot spots have been right there in Indian Country in
Montana. So I think we all need to make sure we don't rest on
our laurels and assume that the storm has passed. It seems like
it is regaining some strength. We just have to keep our eyes on
this very, very dynamic situation going forward.
So I want to thank you for that response. We look forward
to continuing to work together on this to make sure that our
Montana Tribes have enough resources to effectively respond to
this pandemic. Because we are not out of the woods yet. We have
a ways to go.
Mr. Weahkee. Thank you, Senator.
Senator Daines. I want to shift gears, before my time runs
out, Admiral Weahkee. That is, when asked a question about
permanent infrastructure, in Indian Country there seems to be a
lack of that in many of our reservations. Tribes lack emergency
shelters and quarantine facilities to provide shelter and care
for those displaced by the pandemic. Many tribal members live
in multigenerational housing, where social distancing and
isolation are virtually impossible.
My question is, could you elaborate on the effects the lack
of permanent facilities are having on your agency's ability to
effectively respond to this pandemic?
Mr. Weahkee. Thank you, Senator Daines. I would probably
start the response in terms of social determinants of health,
and adequate, stable housing being an item that we have lacked
within Indian Country for many, many years. Many locations
across the Country have the luxury of turning to vacated hotels
as an isolation site. We typically don't have many hotels on
our Indian reservations to be able to use in that way.
So as you note, we have been turning to vacated Bureau of
Indian Education or tribal schools for those isolation sites.
But the kids will need to go to school at some point.
Senator Daines. In terms of doing better, what can IHS and
FEMA be doing to better protect our tribes, and what more can
Congress be doing to support you in these efforts?
Mr. Weahkee. Yes, sir. I feel strongly that in addition to
the housing, we have a queue of health care facility
construction sites, $2 billion on the current grandfathered
list, and $14 billion overall. But if we could open up the
opportunity to enable tribal programs to request other facility
types, outside of hospitals and health centers, they really
want to build residential treatment centers, they want to build
long-term care facilities for their elders. Those are
authorized currently in the Indian Health Care Improvement Act,
but there has not been any funding identified to be able to
pursue those opportunities.
Senator Daines. Admiral Weahkee, I have already run out of
time. Thanks for your responses.
Mr. Weahkee. Thank you, sir.
The Chairman. Thank you, Senator Daines. We will turn to
Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you, Mr. Chairman. Thank you,
gentlemen, for coming today to talk about this important issue.
Let me just start off with Rear Admiral Weahkee. Back in
April, I had sent you a request on behalf of the Duck Water
Shoshone in Nevada. They were seeking an ambulance. I just have
to say thank you because you fulfilled their request very
quickly. You were attentive, and it made a difference for the
tribe. So we really appreciate your response to our tribes in
Nevada.
Let me follow up on the line of questioning from Senator
Daines, that this is really focused on the aging health
infrastructure at IHS. I know, you talked about how you had
allocated the CARES Act money already, about $2.4 billion. My
question is, are you using some of those dollars in the CARES
Act for the infrastructure investment to ensure that tribal
members are well served, with respect to the concerns that I
see, on IHS's aging health infrastructure?
Mr. Weahkee. Thank you, Senator Cortez Masto. As part of
the four waves of funding that we received, we did specifically
target some of the CARES Act funding for infrastructure related
purposes, both sanitation facility construction and some of the
needs within our facilities. So we have been able to put aside
some of the Coronavirus supplements for this purpose
specifically. But we of course have many more needs out there
that can be met with these resources.
On the BEMAR, our Backlog of Essential Maintenance and
Repair, we currently have about $767 million of need in that
one particular line item. Of course, equipment is a big piece
of that as well. We need to continuously update our equipment,
so our providers have the latest and greatest tools to be able
to care for and treat our patients.
Senator Cortez Masto. I would appreciate your sharing al of
that with the Committee . I think particularly we are looking
to go to into another stimulus package to assist our tribes as
we address the health care crisis of COVID-19. We want to make
sure that you have all the resources and you have the
infrastructure that is set up to provide the support that is
necessary through this health care crisis.
I also want to jump back to the traunch of funding that you
did receive. You talked about you still had $750 million from
the CARES Act to allocate to PPE and health care enhancement.
What is your time frame for getting that money allocated?
Mr. Weahkee. Thank you, Senator. The $750 million of the
Paycheck Protection Program and Health Care Enhancement Act has
been 100 percent allocated, we have just not had the
opportunity to obligate all those funds yet. About 40 percent
of that fund is currently obligated. We are working directly
with tribes to pursue these bilateral modifications to the
annual funding agreements, which is taking the time. Tribes are
putting together their tribal-specific testing plans and
identifying the resources that they need, because the detailed
budget was a requirement. We are actually managing this pot of
funding on behalf of HHS. The funds were appropriated to them,
yet we are managing them.
So we weren't able to, in the same way we did supplement
one and put it out through a unilateral modification, and the
process is just taking us a little bit longer.
We do anticipate, just as quickly as we can get signatures
on both sides of the paperwork, having those funds obligated.
It is underway across the Country as we speak.
Senator Cortez Masto. Thank you. I appreciate that.
Mr. Fenton, welcome, and thank you so much for your good
work in Region 9, which is a region that is very important to
the State of Nevada. I have heard from the FEMA's Crisis
Counseling Program, which provides emotional support, crisis
counseling, and connection to community support systems, as
being hugely helpful through this pandemic. Do those counselors
that serve greater Nevada also serve the tribes? The question I
have along with that is, or does FEMA have a process for
providing more culturally competent services to Indian Country?
Mr. Felton. I couldn't hear the second part of your
question, the last sentence, ma'am, if you could repeat it.
Senator Cortez Masto. Sure. Do you serve the tribes, and if
you do, do you provide culturally competent services for our
tribes?
Mr. Fenton. With regard to our crisis counseling programs,
there are currently right now, within Region 9, we don't have
any tribes that have their own declaration. So those crisis
counseling programs are run through the State. Definitely they
could go ahead and provide assistance to tribal governments
through that mechanism and their resources.
Navajo Nation is in the process of requesting their own
declaration, and if they want to use their resources through
their own declaration and submit a crisis counseling grant,
they could go ahead and do that.
Then as far as, I think the second part of your question,
do we have competent----
Senator Cortez Masto. Culturally competent. Culturally
competence sensitive to our tribes and their needs.
Mr. Fenton. So one of the things that we is we provide not
only training to our staff to work with tribal governments, but
also our territorial partners on the cultural needs, and have a
specific cadre within FEMA that works with our tribes, so that
we build relationships and have leveraged people from the
tribal community that participate within that cadre to help
with communications and better understand the cultural needs.
Senator Cortez Masto. Thank you. I know I have gone over my
time. Thank you very much, Mr. Chairman. Thank you, gentlemen.
The Chairman. Thank you, Senator Cortez Masto.
We will turn to Senator Lankford.
STATEMENT OF HON. JAMES LANKFORD,
U.S. SENATOR FROM OKLAHOMA
Senator Lankford. Mr. Chairman, thank you very much. To
both our witnesses, I really appreciate your engagement for
being here today and for all the work that you continue to do.
You have had very, very busy schedules here of late, with a lot
that is going on. I very much appreciate that.
Admiral Weahkee, I also wanted to be able to thank you for
some of your technical assistance and your help as we have gone
through this process. Senator Smith and I have a bill, The
Urban Indian Health Providers Act, that helps provide some
quality on tort reform, and trying to deal with the basics to
make sure that all our of our tribal health facilities are
treated the same.
As you know full well, some Urban Indian Health care
providers have a different level of malpractice coverage than
others. Senator Smith and I are trying to be able to fix that,
to make sure everybody has quality in this coverage. We have
several Senators that are on board on this Committee , and
others that are welcome to be able to join. We are grateful for
the help and the insight that you have. We look forward to
trying to get that passed and get that implemented in the days
ahead. I just wanted to be able to say thank you specifically
to you, Admiral, for your help through this process as we go
through.
Can I ask a question? We have been through a lot at this
point. And there is a lot that is happening. For every single
one of us, this is on the job training, because none of us has
been through a pandemic before. Are you collecting a kind of a
lessons learned as you are going through this process to make
sure if we have weakness, if we had strength in this area, this
is something that needs to be fixed in the future, so while the
heat of the battle is going on right now, we are able to serve
as many places as you can, is there an ongoing list that you
have in your office of things to fix long-term, or lessons to
be learned for next time?
Mr. Weahkee. Thank you, Senator Lankford. I appreciate your
leadership in Congress. We have stood up a structure, an
incident command structure, within the agency. We have a
headquarters team. Dr. Michael Toedt, who is behind me, is the
Operations Section Chief. But we also have a planning section
chief, which is headed by our Quality Director, Jonathan
Merrell. We are compiling all the lessons learned as we
progress. We have a revised concept of operations, which is
updated on a regular basis.
Most recently, as a result of some of my visits to Navajo
and Phoenix and Bemidji, we have identified the need for health
care team support. Many of our caregivers are very much
fatigued. They are facing death on a daily basis, not only at
work, but also at home in their communities with friends and
family members impacted.
So looking to resources through the UNM TeleECHO program to
provide caregiver fatigue training, and other mental health and
behavioral health services, is just one example of, as we learn
these lessons, implementing them into our response. We will be
sure that our pandemic response documents are updated in the
hot wash when we get to that point.
Senator Lankford. That would be very helpful.
Quickly, I want to be able to mention this to you as well.
There is sometimes inequity among tribes as well. Some tribes
are very well organized and have good connections, are able to
read the documents and know where to be able to get help. Some
smaller tribes do not have the same structure to be able to
know where to get help. That help is available to them, they
just don't know to be able to ask for it and where that is.
What is your office doing at this point to make sure we are
reaching out to smaller tribes to make sure they are very aware
of the help that is available to them?
Mr. Weahkee. Thank you, Senator. One of the things that we
are doing is focus on communications. We do have a weekly call
with tribal and Urban Indian Organization leaders. We have
actually decreased that tempo to once every two weeks. But that
is a call in which we have been bringing together our partners
from across the Federal agency. White House Intergovernmental
Affairs is brokering and facilitating along with HHS
Intergovernmental Affairs.
We brought in the BIA, we have brought in FEMA, we brought
in various other partners from VA to really speak to the
Coronavirus-specific resources they have available to them. Our
partners at the Department of Interior in the Bureau of Indian
Affairs does have the capacity to help tribes develop tribal-
specific emergency response plans. So that is something that we
have connected many tribes to. We are happy to continue to do
that work.
Senator Lankford. Thank you. I just wanted to make sure no
one is overlooked in this process, that we have opportunities
for help, and they just don't know who to call or where to dial
in and get that.
Mr. Fenton, let me ask a quick question as well. Is there
any administrative flexibility or form that you see at this
point just to streamline tribes' interaction with FEMA?
Specifically I am thinking about things like the Public
Assistance Administrative Claim requirements, other areas that
as we go through this you see, we need some reforms, we need
some streamlining?
Mr. Fenton. I appreciate the question, Senator. One of our
goals in our strategic plan is to lessen the complexity at
FEMA. One of those areas that we have been working on is the
Public Assistance program.
One of the things we have done in this event has been able
to, up front, 50 percent of the cost for projected costs, and
being able to expedite that. Usually we are turning those
around in two to three weeks. So we continue to get better. We
have the after action process that focuses on these events. We
have already had calls with not only our tribes, State and
territories to talk about SNS 2.0, and get ready for the fall,
and other events, whether it be hurricanes or the fires that
will come as we get later into the summer and into this fall.
Senator Lankford. Okay. Well, if there are ways that we
need to help in that process, this Committee stands ready to be
able to help in that. Obviously, Homeland Security, if we can
do more, it would be great to be able to great to help. I am
also on that committee, and so if there are ways that we need
to help in streamlining we are glad to be able to do that to
make it more effective and less paperwork in the process.
Thank you both very much.
The Chairman. Thank you, Senator Lankford. We will turn to
Senator Smith.
Senator Smith. Thank you, Chair Hoeven and Vice Chair
Udall. Thanks to our folks here today testifying before us.
I want to start where Senator Lankford started, which is to
just talk a little bit about the FTCA coverage for urban health
clinics. It is great to have so many of our colleagues on the
Committee supporting this proposal. I am glad to have the
endorsement that you have provided, Admiral Weahkee.
I am wondering, this is just such an inequity between
organizations serving Urban Indian populations versus IHS
facilities and tribal health programs that we are trying to
correct here. It can make a big difference in terms of the
amount of money that Urban Indian Organizations have to provide
the services needed so badly.
So Admiral Weahkee, would you just comment for me briefly
about the role that Urban Indian Organizations are playing
right now in the COVID pandemic, and why this is such an
important issue to address?
Mr. Weahkee. Yes, thank you, Senator Smith. Definitely, our
Urban Indian Organization partners are the third leg of our
Indian health system stool, along with our IHS federally
operated and our tribally operated programs. We have 41 urban
programs located across the Country. Many of those providing
vital ambulatory health care services.
One of the earliest hit locations was San Jose, California,
our Santa Clara Health System. As noted earlier, our Seattle
Indian Health Corps program, they were early in the response to
COVID-19, as the Country's first cases really emerged there on
the West Coast.
So we have had the opportunity to learn from their response
efforts, not only the treatment protocols and the supplies that
were going to be needed, but as things progressed and they were
further along in their journey in combatting Coronavirus,
having the regular calls so that those best practices can be
shared to tribal leaders and other urban programs was vitally
important.
We have been able to see and hear how they have patched
together funding, not only from Indian Health Service but from
other Federal agencies and States, to be able to meet the needs
of their communities. So I really can't over-stress the value
and importance, as we have many of our American Indian and
Alaska Natives living in metropolitan areas, my own family
included, down in the Phoenix area, where we have family
members obtaining services from an organization called Native
Health.
So definitely valuable partners in our approach to
providing care and treatment.
Senator Smith. Thank you for that. I have seen the same
thing. In the early days of the pandemic I convened a
conversation with the urban indigenous community in Minneapolis
and heard a lot about the struggle that they are having to
provide health care to elders, particularly in the community.
We talk a lot about broadband and access to technology being an
issue in rural tribal communities. But it is also an issue in
urban tribal communities, where there is so much poverty and
lack of ability to pay for broadband, or even to have the
technology. The phone that you held up earlier, even lacking
that technology. If you can't go to the local library or cafe
to get your tele-health, then you are in a world of hurt when
you are trying to get access to care. So I think these issues
apply to urban Indian populations as well.
I want to, before I run out of time, I want to just follow
up on this testing question that several of my colleagues have
asked about. In Minnesota, my staff and I are part of a weekly
conversation with Minnesota's tribal nations. Every week they
ask, where are those testing dollars? They are so concerned
about this. They are quite concerned about managing outbreaks
on tribal lands.
Of course, being able to do the occupational and
surveillance testing that is so important to be controlling the
spread of the virus as they reopen tribal enterprises is
extremely important right now. So what should I tell my tribal
leaders in Minnesota about when they can expect to see those
testing dollars, so they can move forward with what they know
they need to do?
Mr. Weahkee. Thank you, Senator Smith. I think that the
best response would be to take a look at the Paycheck
Protection Program and Healthcare Enhancement Act. That traunch
of funds was specifically meant to increase testing capacity,
contact tracing, and surveillance. So as they receive the
request to negotiate that bilateral modification, that those
funds are specifically meant to meet that need that you just
articulated.
Senator Smith. What they are telling me is that it is
extremely hard to figure out how to get access to the kids to
get connected. So can I just ask if we can follow up separately
to try to resolve this problem for them? It is one of the
biggest issues that they have right now.
Mr. Weahkee. Yes, ma'am, happy to do so.
Senator Smith. Thank you.
The Chairman. Thank you, Senator Smith. And I do have a few
more questions for Administrator Fenton. The Vice Chair may
have some questions as well.
Senator Udall. I have more.
The Chairman. So, Administrator Fenton, FEMA spent a
considerable amount of time updating its tribal consultation
policy, which was published in July, 2019. The policy
acknowledges the special government-to-government relationship
between the Federal agency and the tribes.
So understanding that that process can be complex for
tribes as well as States and territories, what training and
technical assistance or resources are available to tribes
applying for public assistance relief directly from FEMA?
Mr. Fenton. Throughout the year, we provide training to our
tribes, even before disasters, and have a number of workshops
that we schedule before disasters. With regard to this event
specifically, we had discussions with all the tribes across the
United States. For example, myself and Region 9 held a call
with our State partners in each State to let them know about
the options they have as far as being a subgrantee underneath
the State and what that meant administratively and effort wise,
being a direct recipient of FEMA, or requesting their own
declaration.
Then we gave time for the tribes to make that selection.
Then what do is reach out to them to officially apply to the
Public Assistance program. As part of that process, we have a
kind of discussion with them of the application process, which
to use as far as documentation, what is eligible. Then we
assign them someone to help them with the grant process.
So we are working through that with all the tribes. We do
have people dedicated to each State that are working with our
different tribes to reimburse them costs from this event, as
far as coordinating other types of assistance outside the PA
program that may come from the different Federal agencies. So
we are coordinating that, things like hoteling for isolation
purposes. We have given out tents to some tribes that want to
isolate people at home, food, PPE, water, other supplies that
are needed as a result of combating COVID.
So we are doing that across the Country, and then there is
also coordination calls at the national level, both with the
White House and our headquarters, to different tribal members
so that we can make sure we are helping and addressing their
issues.
The Chairman. All right. As we have discussed, two of the
hardest hit tribes fall within Arizona, the White Mountain
Apache and also the Navajo Nation. In your time in Arizona,
what preparedness and response has FEMA undertaken to try and
control the spread of COVID-19 in these hot spots? And what are
your experiences in terms of coordinating with other Federal
agencies and also IHS to that?
Mr. Fenton. This event, as I said in my opening comments,
is really an all-of-nation or all-of-America event. So it
really takes coordination to happen at multiple levels. Not
only are we out at those locations and with our State partners
coordinating the Federal interagency and all the different
departments and agencies that are bringing resources, whether
it be IHS and their mission, CDC, ASPR from HHS and others, to
include the Corps of Engineers that provided alternate care
sites, or VA that is providing nurses out at White Mountain
Apache and Navajo Nation.
So our job is to coordinate that overall Federal relief.
That includes not only at the Federal level, but to States,
local governments, private sector, and non-profits. So by
bringing that in to coordinate with tribal entities to address
their issues is kind of what has been our focus.
As far as issues, I think that any time you have an event
that is a new event like this, that brings complexities and
maybe entities that are not used to working together and don't
understand each other's authority. So there is a period that we
have gone through to understand not only authorities but
resources and capabilities to make sure that we are able to
address in a timely manner the needs of Native American tribes.
The Chairman. Admiral Weahkee, same question.
Mr. Weahkee. Thank you, Senator. I think that the key is
that cross-entity relationship. The VA nurses are a great
example. We were able to work with them to bring in critical
care nurses, not only to meet the surge capacity but also our
nurses that have been seeing patients non-stop working very
long hours for the past four months. They need a spell and they
need some support.
We now have our contractors asking for hazard pay on top of
their contract amounts, so they are asking to increase our
rates. But that coordination has been key. And we have, in the
same way that have updated our con ops, or concept of
operations, we have also updated our guidance for tribes on how
to use the FEMA route. So we have asked tribes to go to our
area emergency management points of contact. We look within the
agency if we can meet that need. If we can't, then we will
elevate it to FEMA and the Strategic National Stockpile. We put
that into a protocol, it is in writing. It has been shared
broadly. It will be there and available to us next time around
when we need it, so we don't have to recreate this wheel.
The Chairman. Thank you. Vice Chairman Udall.
Senator Udall. Thank you, Mr. Chairman.
Administrator Fenton, I would like to ask you about
interagency coordination when it comes to tribes and Urban
Indian health programs and accessing Federal channels for
testing supplies and PPE. FEMA has led much of the procurement
and distribution through the National Response Coordination
Center, acquiring testing and PPE supplies for the NRCC from
sources like the DOD stockpile, the HHS Strategic National
Stockpile, and by other means.
But after several months of calls, briefings, and letters,
both from Congress and the tribes, the process for requesting
emergency medical supplies remains confusing at best. At one
point, I believe the NRCC promised to produce some flow charts
on the topic. But I don't believe we have seen anything on that
front yet.
This confusion is leading to delays in delivery of these
supplies and creates uncertainty related to cost shares for
other Federal agencies, for tribes, and for Urban Indian health
programs. We need to know that supplies are reaching the ground
expeditiously. And we need to know whether any costs will be
coming out of IHS, tribal or Urban Indian health program
budgets.
Under what circumstances would IHS, a tribe, or an Urban
Indian health program have to reimburse FEMA, in full or in
part, for supplies it receives during the COVID-19 crisis?
Mr. Fenton. Senator PPE and testing supplies have been a
challenge on this event. Any time you have a demand that is 400
percent over what is available through manufacturing, it causes
a strain on the whole system. FEMA has done a number of things
to improve that process, to expediting movements of resources
from private sector medical suppliers, to establishing and
working with private sector to established new manufacturing to
making sure that there is not price gouging or hoarding of
supplies.
Senator Udall. Mr. Fenton, the question is about
reimbursement, will they have to reimburse FEMA in full or in
part for this.
Mr. Fenton. With regard to reimbursement, there is a number
of ways that a tribe could get supplies. They are getting them
directly from either the Strategic National Stockpile, which is
not cost shared, that HHS is providing full reimbursement
through that. And we have an interagency agreement between us
and them to do that. IHS is providing resources to them for
their hospitals.
In addition to that, some States are providing resources,
for example, California, I know has provided 7 million N95
masks, over which they are not charging them a cost share for
that, or any type of EMAC agreement.
When a tribe does not have a resource, it specifically
comes to FEMA and puts a request in. That is the only time that
something is cost shared. Or if a tribe goes out and procures
it on their own, then it would be cost shared, and then they
could also use the 75-25, as I said earlier, they could use the
CARES Act funding that they received to go ahead and offset
that 25 percent cost share.
Senator Udall. Are there any circumstances where the IHS,
tribes or Urban Indian programs are asked to pay a
reimbursement when other government or health systems are not?
Mr. Fenton. I am not aware of us charging IHS for masks.
Senator Udall. Will the NRCC publish any flow charts or
guidance on the methods for accessing Federal emergency
supplies as promised?
Mr. Fenton. I will circle back with them and make sure that
we submit something after this.
Senator Udall. Thank you very much.
This question is to both Administrator Fenton and Admiral
Weahkee. Will you both commit to working together to simplify
and clarify how tribes can access medical supplies during
disasters and public health emergencies?
Mr. Fenton. Yes, sir.
Mr. Weahkee. Yes, sir, absolutely.
Senator Udall. Thank you. Thank you both. Thank you, Mr.
Chairman.
The Chairman. Thank you, Vice Chairman Udall. I would like
to thank both of our witnesses for being here, and also for the
very important work that you are doing.
If there are no more questions for this first panel,
members may also submit follow-up questions. We know there are
going to be some follow-up questions already, as Senator
Murkowski indicated. So other members may submit follow-up
questions for the record as well.
So with that, again, thank you to our first panel. We
appreciate very much both of you being here. Thank you.
With that, we move right away to our second panel. Today
our second panel includes two tribal witnesses. As mentioned
earlier, Mr. Scott Davis is a member of the Standing Rock Sioux
Tribe and a descendant of the Turtle Mountain Band of Chippewa.
He has many years of experience working with tribes and tribal
organizations and was appointed to be the Executive Director of
the North Dakota Indian Affairs Commission in April of 2009.
In his capacity as Executive Director, Mr. Davis
coordinates the State to tribal government relationship,
together with addressing issues affecting Native communities in
North Dakota. Today's hearing provides a great opportunity to
discuss how States and tribes are reducing and preventing
Coronavirus at the local level.
Our second witness, Ms. Lisa Elgin, is Secretary of the
National Indian Health Board. She will be joining us virtually.
Again, we appreciate both of you joining us. With that, I would
turn to Mr. Davis and welcome your opening comments.
STATEMENT OF SCOTT J. DAVIS, EXECUTIVE DIRECTOR, NORTH DAKOTA
INDIAN AFFAIRS COMMISSION, OFFICE OF THE GOVERNOR, STATE OF
NORTH DAKOTA
Mr. Davis. Thank you, Chairman Hoeven and respective Vice
Chair Udall, thank you.
[Greeting in Native tongue], greetings again on behalf of
myself, Scott Davis, a proud member of the Standing Rock Sioux
Tribe, and also a descendant of the Turtle Mountain Band of
Chippewa. My Lakota name is Oksate' Tawa'. I would definitely
bring a good warm handshake if I could. I come here with a good
heart. Thank you for the invitation today.
Today I was given permission by both of our tribes, in
partnership with our Governor Burgum to provide testimony today
regarding the working relationship between the five tribal
nations in North Dakota and the State of North Dakota, and also
our full partners regarding COVID-19 pandemic. Since the start
of the COVID-19 pandemic, I immediately reached out to our five
tribal leaders and asked them how they were going to respond to
the pandemic in declaring a state of emergency.
As you know, tribes do have the authority to declare on
their own through the Sanford Act or to declare with the
governor. In this case, the tribes chose to declare with
Governor Burgum and by doing so, it opened up a lot of
resources to the tribes.
Since then, we have committed to weekly calls from Governor
Burgum, my office, and to the five tribal chairs, tribal
councils, tribal clinics, and also to the Indian Health
Service. The majority of these calls entail discussion about
Protective Personal Equipment, PPE, testing kits and supplies,
and also discussions that entail guidance on opening
businesses, schools, and tribal colleges.
But most importantly, we have partnered with the five
tribal nations in conducting mass testing events. Two weeks ago
we finished our first round in testing all five tribes. Today,
we are continuing those partnered testing events and making
sure that all North Dakota tribal communities and members get
tested on a regular basis, as requested from tribal leadership.
These events at times are led by our National Guard in
partnership with the tribal incident command staff, tribal
health staff, Indian Health Service, and local county public
health offices.
As a result, we have strong working relationships in
testing thousands of tribal members. By doing this, we are
seeing very low positive testing results from COVID-19 in each
of our tribal nations. We attribute this to the resources
available that we have developed with the tribes. Examples are
the PPE, the testing kits, surge plans, data sharing and
consistent communications.
This partnership is a direct result of the commitment
Governor Burgum and my office has made with the five tribal
nations in North Dakota since he took office. Tribal engagement
is one of the five initiatives under the Burgum administration.
Prior to the pandemic, Governor Burgum's office and my office
have had countless meetings with the tribes, and have held
three large conferences entitled Strengthening Tribal, State,
and Federal Relations. Each conference has had over 300
attendees from the tribes, States and Federal leaders and their
agencies.
Mr. Chairman, this concludes my testimony. I will stand for
any questions.
Wopila, Che'Migwetch. Thank you.
[The prepared statement of Mr. Davis follows:]
Prepared Statement of Scott J. Davis, Executive Director, North Dakota
Indian Affairs Commission, Office of The Governor, State of North
Dakota
Greetings Chairman Hoeven and members of the U.S. Committee on
Indian Affairs. My name is Scott J. Davis, a proud member of the
Standing Rock Sioux Tribe and descendent of the Turtle Mt. Band of
Chippewa. My Lakota name is Oksate' Tawa'--His Celebration. I greet you
all today with a warm handshake and good heart.
I was given to permission from our North Dakota (ND) Tribal Nations
to provide testimony today regarding the working relations between our
5 ND Tribal Nations, ND State-Governor's Office and Federal Partners
regarding the COVID 19 pandemic.
Since the start of the Covid19 Pandemic, I immediately reached out
to the 5 ND Tribal Leaders in asking them how they are going to respond
to the pandemic in declaring a State of Emergency. As you now, Tribes
have the authority to Declare on their own, through the Sanford Act, or
to Declare with the Governor. In this case, the Tribes chose to Declare
with Governor Doug Burgum. By doing so, it opened a lot of resources to
the Tribes.
Since then, we have committed to weekly calls from Governor Burgum
to the 5 Tribal Chairs, Tribal Councils, Tribal Clinics and the Indian
Health Service. Majority of the calls entail discussion about
Protective Personal Equipment (PPE) and Testing Kits/Supplies.
Discussions also entail guidance on opening businesses, schools and
Tribal Colleges.
Most importantly, we have partnered with the 5 ND Tribal Nations in
conducting Testing Events. Two weeks ago, we finished our first round
in testing all 5 ND Tribes. Today, we are continuing those partnered
Testing Events in making sure that all ND Tribal communities and
members get tested on a regular basis as requested from Tribal
leadership. The events, at times, are led by the ND National Guard in
partnership with the Tribal Incident Command Staff, Tribal Health
Staff, Indian Health Service and local County Public Health offices.
As a result of strong working relations and testing thousands of
Tribal members, we have seen low positive COVID 19 cases on each of the
5 ND Tribal Nations. We attribute this to resources available and
delivered to the Tribes, e.g. PPE, Testing Kits, surge plans, data
sharing and consistent communications.
This partnership is a result of the commitment Governor Burgum has
made with the 5 ND Tribal Nations since he took office. Tribal
Engagement is one of five initiatives under the Burgum administration.
Prior to the pandemic, Governor Burgum's office and my office have held
countless meetings with the Tribes and have held 3 conferences
entitled, Strengthening Tribal, State and Federal Relations. Each
conference has had over 300 attendees from Tribal, State and Federal
leaders and agencies.
This concludes my testimony; I will stand for any questions.
Wopila, Che'Migwetch--Thank you.
The Chairman. Thank you, Mr. Davis. We will turn to Ms.
Elgin.
STATEMENT OF LISA ELGIN, SECRETARY, NATIONAL INDIAN HEALTH
BOARD
Ms. Elgin. Good afternoon, Chairman Hoeven, Vice Chairman
Udall and members of the Committee . Thank you for inviting me
to testify at today's oversight hearing.
My name is Lisa Elgin, and I am the Secretary and
California area rep to the National Indian Health Board, or
NIHB. I am also tribal administrator for my tribe, which is the
Manchester-Point Arena Band of Pomo Indians, and I chair the
California Rural Indian Health Board.
I would like to start by thanking the Committee for the
work it has done so far to address COVID-19 in Indian Country.
This includes over $1 billion for IHS under the CARES Act, and
the $750 million tribal set-aside for testing under the
Paycheck Protection and Healthcare Enhancement Act. These were
necessary investments but not sufficient to stem the tide of
the pandemic in tribal communities.
As sovereign governments, many tribal nations have set
their own timelines for reopening, which may or may not align
with their State. For instance, of the 109 tribal nations in
California, 70 percent continue to have tribal emergency and
shelter in place orders still in effect, even though the State
of California continues to reopen.
What I would first like to focus on in my remarks is how
this crisis has devastated Indian Country, the factors that
made us more vulnerable, what needs to be done to mitigate the
impacts on our people. Just like every public health crisis
before it, COVID-19 has disproportionately impacted our people.
Here are a few data points I will share to demonstrate this.
According to CDC, our people have the highest COVID-19
hospitalization rate nationwide. Our people are experiencing
the second highest COVID-19 death rate nationwide. In New
Mexico, our people account for 8 percent of the population, but
over 53 percent of all COVID cases. In Montana, our people
equal about 6 percent of the population, but over 13 percent of
all cases.
None of this is by accident, but the direct result of the
United States' ongoing failure to fully honor its treaty
obligations for healthcare. Here are a few stats that highlight
this truth. Our people suffer more than any population from
nearly all the underlying health conditions that CDC noted
increase risks of COVID-19, including diabetes, respiratory
illness, kidney disease and obesity.
In 2018, per capita health spending was the lowest at IHS
$3,779 compared to over $8,000 under Medicaid, over $9,500
under the BIA, and over $13,000 under Medicare. The average age
of an IHS hospital is four times the average age of mainstream
hospitals. In fact, an IHS hospital built today could not be
replaced for 400 years under current spending figures.
Yet in California, we don't have a single tribal or IHS
hospital. I repeat, not one hospital. We had an average of 25
percent provider vacancy rate before the pandemic hit,
including four physicians, nurses, pharmacists, and nurse
practitioners. Nearly 6 percent of our people live in
households without running water, compared to less than 1
percent in the Nation.
Roughly 22 percent of our people are uninsured, the highest
percentage of any population in the Country. And to clarify,
access to IHS is not the same thing as health insurance. In
fact, by law, having access only to IHS means you are still
uninsured.
Across the 24 federally operated IHS hospitals, there are
only a total of 33 ICU beds. Less than half of all IHS and
tribal hospitals have operating rooms and only there is only
one hospital, a level 3 trauma center in Alaska, that has
capacity for more than 40 inpatients per day.
On top of this, our third-party collections from payers
like Medicaid and private insurance has plummeted by as much as
$5 million per tribe per month. Admiral Weahkee testified
before the House earlier this month that, he reported the IHS
has seen third-party collections drop 30 to 80 percent below
this time last year, that it would take years to recoup those
losses.
In short, the challenge are astronomical. Here is what
Congress must do moving forward to address COVID-19. We invite
you to review our written testimony for additional insight and
recommendations on what needs to be done.
We urge you to maintain all tribal provisions in the House-
passed Heroes Act. These are tribally vetted and bipartisan
measures that are need to alleviate the worst impact of the
crisis on our communities.
Ensure timely passage of fiscal year 2021 appropriations
for IHS. We cannot afford another continuing resolution or a
shutdown during this pandemic.
Pass the bipartisan S. 3937 STIP Reauthorization Act of
2020. We thank Senator McSally and Senator Murkowski on that
committee for championing this critical bill that would provide
five years of guaranteed funding at an increase of $200 million
overall. We are also very pleased that this bill includes
language authorizing tribes to receive these funds as 638
contracting and compacting agreements.
Provide at least $1 billion for water and sanitation
infrastructure. Thousands of our people from Alaska and Navajo
Nation lack running water. Handwashing continues to be the
number one way to protect against COVID. To speak plainly, we
need running water to do that.
In closing, I would like to leave you with a final thought.
During both the 1918 Spanish flu pandemic and the 2009 H1N1
pandemic, our people died at four times the rate of all other
races combined. Our treaties were not fully honored back then;
the same inexcusable reality is true today.
Once again, I thank you for holding this important hearing,
and inviting NIHB to testify. I look forward to your questions.
[Phrase in Native tongue.] Thank you.
[The prepared statement of Ms. Elgin follows:]
Prepared Statement of Lisa Elgin, Secretary, National Indian Health
Board
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
thank you for holding this critical oversight hearing to ``Evaluate the
Response and Mitigation to the COVID-19 Pandemic in Native
Communities.'' On behalf of the National Indian Health Board and the
574 federally-recognized sovereign American Indian and Alaska Native
(AI/AN) Tribal Nations we serve, I submit this testimony for the
record.
Our nation is gripped by the most unprecedented public health
crisis in generations. As of June 28, 2020 there are over 2.5 million
COVID-19 cases nationwide and over 125,000 COVID-19 deaths, according
to the Centers for Disease Control and Prevention (CDC). Public health
data continues to demonstrate that not only are new cases not
subsiding, they are dangerously increasing in countless jurisdictions
nationwide. According to the CDC, on Thursday June 25, the United
States recorded 40,588 cases--the highest number of cases reported in a
single-day since April 6. In a data analysis from Kaiser Family
Foundation, from June 11 to June 25 a total of 26 states reported
increased COVID-19 cases including many with large AI/AN populations
including Arizona, Oklahoma, Michigan, Nevada, Wisconsin, Washington,
Wyoming, Montana, California, and Oregon. \1\
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\1\ Kaiser Family Foundation. 2020. States with Upward of 14-Day
Trends in COVID-19 Cases and Positivity Rates. https://www.kff.org/
coronavirus-covid-19/slide/states-with-upward-of-14-day-trends-in-
covid-19-cases-and-positivity-rates/
---------------------------------------------------------------------------
But similar to every prior public health crisis, there are
disparate and disproportionate impacts on underserved and marginalized
communities, and Indian Country is at the epicenter. According to CDC,
people with chronic obstructive pulmonary disease (COPD), type 2
diabetes, and chronic kidney disease are at higher risk for a more
serious COVID illness. AI/AN populations are disproportionately
impacted by all three of these underlying health conditions. In 2017,
CDC reported that age-adjusted percentages of COPD were highest among
AI/ANs (11.9 percent vs 6.2 percent across all populations). \2\ While
rates of End Stage Renal Disease have dropped by 54 percent among AI/
ANs as a result of the Special Diabetes Program for Indians (SDPI), AI/
ANs continue to experience a significant burden of kidney disease.
Similarly, in 2017 it was reported that AI/ANs experienced the highest
diabetes prevalence at 15.1 percent, at more than double the percentage
for non-Hispanic Whites. \3\
---------------------------------------------------------------------------
\2\ Wheaton AG, Liu Y, Croft JB, et al. Chronic Obstructive
Pulmonary Disease and Smoking Status--United States, 2017. MMWR Morb
Mortal Wkly Rep 2019;68:533-538. DOI: http://dx.doi.org/10.15585/
mmwr.mm6824a1external_icon
\3\ Department of Health & Human Services, Centers for Medicare &
Medicaid Services. 2018. LTSS Research: Diabetes in Indian Country
Annotated Literature Review.https://www.cms.gov/Outreach-and-Education/
American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/pdf/Emerging-LTSS-
Issues-in-Indian-Country-Diabetes-in-Indian-Country-Annotated-
Literature-Review.pdf
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Despite alarming gaps nationwide in population-specific COVID-19
health disparities data, available information clearly demonstrates
that Tribal communities are facing the brunt of this public health
crisis. The federal government has treaty and trust obligations to
fully fund healthcare in perpetuity for all Tribal Nations and AI/AN
Peoples, and it is imperative that this obligation be met in the face
of the COVID-19 pandemic.
To that end, we are pleased that each previous COVID-19 relief
package has included important Tribal health provisions, such as the
$64 million in funding for Indian Health Service (IHS) under the
Families First Coronavirus Response Act; $1.032 billion in funding for
IHS under the CARES Act; and the baseline $750 million Tribal set-aside
in testing under the Paycheck Protection and Healthcare Enhancement
Act. But despite these meaningful investments, it is clear that they
have been insufficient to address the grave impacts of COVID-19 in
Indian Country.
Recommendations
On June 2, 2020 NIHB submitted a letter to Senate Majority Leader
McConnell and Minority Leader Schumer urging that as the Senate began
negotiations on the next relief package, that all of the Tribally-
specific funding and legislative provisions outlined in the House-
passed HEROES Act be maintained and built upon by addressing critical
areas of unmet need. To that end, NIHB has outlined several top
priorities--some of which fall squarely under the Committee's
jurisdiction, and others that we urge Committee members to work on in
lockstep with colleagues serving on Interior Appropriations, Finance,
and Health, Education, Labor and Pensions. NIHB also strongly supports
the bipartisan S. 3650 and urges the full Committee to pass this
important bill.
1.Ensure timely passage and meaningful increases to the overall Indian
Health Service (IHS) budget for Fiscal Year 2021 in line with
the Tribal Budget Formulation Workgroup Recommendations
Without an enacted FY 2021 IHS budget that is passed on-
time, the Indian health system will be left significantly
unprepared to tackle a potentially stronger wave of infections
in the fall and winter months ahead.
--Therefore, it is imperative that IHS not be subject to
another continuing resolution or face the threat of another
government shutdown.
While we appreciate the $1.032 billion appropriated to IHS
under the CARES Act, and the additional $2.1 billion proposed
under the House-passed HEROES Act, these investments do not
replace the need for strong and meaningful investments in the
annual appropriated IHS budget.
--The IHS Tribal Budget Formulation Workgroup (TBFWG) has
outlined the need for $9.1 billion for IHS in FY 2021 to be
able to effectively address healthcare needs.
AI/ANs continue to face significant health disparities,
especially for conditions like diabetes and respiratory
illnesses, which increase the risk of a COVID-19 infection.
Without a bold and substantive FY 2021 IHS budget to equip the
Indian health system with the tools to address these
disparities, they will continue to go unaddressed, leaving
Indian Country more vulnerable to COVID-19 outbreaks.
2. Pass the bipartisan S. 3937--Special Diabetes Program for Indians
Reauthorization Act of 2019--with slight changes to the new
``Delivery of Funds'' language to ensure Tribes and Tribal
organizations are able to receive awards through P.L. 93-638
self-determination and self-governance contracts and compacts
According to the CDC, diabetes is one of the strongest risk
factors for a more serious COVID-19 infection. AI/AN
communities are diagnosed with diabetes at more than double the
rate for Whites, and higher than any other population
nationwide.
The Special Diabetes Program for Indians (SDPI) is the only
program that has effectively reduced incidence and prevalence
of diabetes, and is responsible for a 54 percent reduction in
rates of End Stage Renal Disease and a 50 percent reduction in
diabetic eye disease. In a 2019 federal report, SDPI was found
to be largely responsible for $52 million in savings in
Medicare expenditures per year.
--Despite its documented success, since September 30, 2019,
SDPI has gone through four short-term extensions, with the most
recent extension occurring under the CARES Act. SDPI is
currently set to expire on November 30, 2020.
The bipartisan S. 3937, introduced by Senator McSally, and
supported by Senator Murkowki and Senator Sinema, would provide
5-years of guaranteed funding for SDPI at an increase to $200
million per year overall. This represents the first increase to
SDPI in over sixteen years, and the longest reauthorization in
over a decade.
Significantly, S. 3937 would also authorize Tribes and
Tribal organizations to receive SDPI awards through P.L. 93-638
self-determination and self-governance contracting and
compacting agreements, thus allowing for greater local Tribal
control over the life-saving program.
--However, Tribes and NIHB are requesting slight technical
tweaks to the new language in S.3937 to further clarify the
authority and prevent any potential administrative delays in
implementation. We urge the Committee to pass S.3937 with the
requested changes below.
``(2) DELIVERY OF FUNDS.- On request from an Indian tribe
or tribal organization, the Secretary shall award diabetes
program funds made available to the requesting tribe or tribal
organization under this section as amounts provided under
Subsections 106(a)(1) and Subsection 508(c) of the Indian Self-
Determination Act, 25 U.S.C. 5325(a)(1) and
5388(c), as appropriate.''
3. Provide minimum $1 billion for water and sanitation development
across IHS and Tribal facilities
In order to stem the tide of the COVID-19 pandemic in Indian
Country, it is essential that Congress make meaningful
investments in water and sanitation development across IHS and
Tribal facilities.
The HEROES Act only outlined $30 million overall for water
and sanitation development in Indian Country ($10 million
within IHS, and $20 million within Bureau of Indian Affairs).
This is severely below the level of need to protect and
preserve health in AI/AN communities.
--According to the 2018 IHS Sanitation Facilities
Infrastructure Report, roughly $2.67 billion is needed to bring
all IHS and Tribal sanitation facilities to a Deficiency Level
1 designation.
4. Provide meaningful increases to the IHS budget for telehealth,
electronic health records and health information technology
(IT) infrastructure development
Limitations in the availability of AI/AN specific COVID-19
data are contributing to the invisibility of the adverse
impacts of the pandemic in Indian Country within the general
public. Senior IHS officials, including Chief Medical Officer
Dr. Michael Toedt, have stated publicly that existing
deficiencies with the IHS health IT system are inhibiting the
agency's ability to adequately conduct COVID-19 disease
surveillance and reporting efforts.
--Lack of health IT infrastructure has also seriously
hampered the ability of IHS and Tribal sites to transition to a
telehealth-based care delivery system. While mainstream
hospitals have been able to take advantage of new flexibilities
under Medicare for use of telehealth during the COVID-19
pandemic, IHS and Tribal facilities have not because of
insufficient broadband deployment and health IT capabilities.
The TBFWG has previously outlined the need for a roughly $3
billion investment to fully equip the Indian health system with
an interoperable and modern health IT system. It is critical
that Congress provide meaningful investments in health IT
technologies for the Indian health system to ensure accurate
assessment of AI/AN COVID-19 health disparities and equip
Indian Health Care Providers with the tools to seamlessly
provide telehealth-based health services.
5. Eliminate the sunset provisions under Section 30106 of HEROES so
that removal of the ``four walls'' Medicaid billing restriction
and extension of 100 percent FMAP to urban Indian organizations
are made permanent; Clarify the four walls language to ensure
that the fix to the billing restriction is made both for
services provided by an Indian Health Care Provider outside the
four walls, and those services on the basis of a referral
Currently, IHS and Tribal providers are largely restricted
from billing for medical services outside the four walls of a
clinic. This means that home visits, telehealth, and other
necessary outpatient COVID response services can't be
reimbursed, leading to serious gaps in accessibility of care.
In March 2020, in an effort to improve access to services
during the COVID-19 pandemic, the Centers for Medicare and
Medicaid Services (CMS) announced that it would not review
claims for compliance with the four walls restriction before
January 30, 2021.
--This means that if Section 30106 of HEROES were to be
enacted as is, the fix to the four walls restriction would only
be in effect for five months. In addition, the four walls
language under Section 30106 only fixes the four walls billing
restriction for services on the basis of a referral, not those
services provided by Indian Health Care Providers (IHCPs)
outside the four walls--such as in patient's homes, schools,
jails, or other locations. Not only is it critical that the
four walls fix be made permanent, it is equally critical that
the fix to the four walls billing restriction be made for both
services provided by IHCPs outside the four walls, and those
services on the basis of a referral.
Delaying the four walls issue does not solve it. In
addition, there is very little incentive for states to work
with Tribes to amend their Medicaid programs for only a five
month fix to the four walls issue, especially given the
resources that go into that process.
--However, Tribes and NIHB are vehemently opposed to
extending 100 percent FMAP to non-Indian Health Care Providers
as part of the legislative fix to the four walls restriction.
6. Authorize Indian Health Care Providers (IHCPs) to receive Medicaid
reimbursement for all medical services authorized under the
Indian Health Care Improvement Act (IHCIA)--called ``Qualified
Indian Provider Services''--when delivered to Medicaid-eligible
American Indians and Alaska Natives
Currently, IHCPs only receive reimbursement for health
services authorized for all providers in a state. Therefore,
although IHCIA authorizes medical services such as long-term
care and mental/behavioral services that are crucial for Tribal
communities to respond to COVID-19, an IHCP will not be
reimbursed for these services if they are not covered by the
state Medicaid program.
Because of chronic underfunding of IHS, many Tribes utilize
third party collections from payers like Medicaid to constitute
up to 60 percent of their healthcare operating budgets. But
without the authority to bill for services already authorized
under federal law, it is further straining Tribal COVID
response efforts.
--This provision reinforces the direct relationship between
Tribes and the federal government by ensuring that IHCPs are
reimbursed at 100 percent FMAP for all services authorized
under IHCIA, at no cost to the states.
7. Enact Certain Sections of the Bipartisan CONNECT to Health Act
The bipartisan Creating Opportunities Now for Necessary and
Effective Care Technologies (CONNECT) for Health Act of 2019
(S. 2741) was introduced in October 2019 and has the broad
support of over 100 health organizations.
--Section 3 of the CONNECT to Health Act would provide the
U.S. Department of Health and Human Services (HHS) with the
ability to waive certain telehealth restrictions outside of the
national emergency context. These waivable restrictions include
limitations on provider types, technology, geographic area, and
services. These are critical authorities to ensure flexibility
in delivery of mental and behavioral care.
--Section 8 of the CONNECT to Health Act would eliminate
originating site requirements with respect to facilities
operated by IHS, a Tribe or Tribal organization which make it
very difficult to deliver mental and behavioral health care.
Originating site requirements currently mandate that a
patient be in a particular location such as a physician's
office, hospital, or other specified clinical setting. These
requirements prevent patients from being able to receive mental
and behavioral health services from their homes, community
centers, or other non-clinical locations.
--In addition, Sections 4, 5, 7, and 14 of the CONNECT Act
affect use of telehealth for mental health services, emergency
care, rural health clinics, and Federally Qualified Health
Centers (FQHCs); and also expands the list of health
professionals who may provide services through telehealth--all
of which have immediate and long-term benefits to the Indian
health system.
8. Include Pharmacists, Licensed Marriage and Family Therapists
(LMFTs), Licensed Professional Counselors, and other providers
as eligible provider types under Medicare for Reimbursement to
Indian Health Care Providers
There is a severe, longstanding, and well-documented
shortage of healthcare professionals in Indian Country. Because
of this shortage, Indian healthcare programs rely extensively
and increasingly on the services of other types of licensed and
certified non-physician practitioners, including Licensed
Marriage and Family Therapists (LMFTs), Licensed Professional
Counselors (LPCs), Certified Community Health Aides and
Practitioners (CHAPs), Behavioral Health Aides and
Practitioners (BHAPs), and Pharmacists
--LMFTs, LPCs, and higher-level BHAPs are qualified to
furnish many of the same services that psychiatrists, CSWs, and
psychologists do. Among other services, pharmacists in Indian
programs deliver clinic-based, protocol-driven care on behalf
of physicians, including tobacco cessation, and medication-
assisted treatment (MAT) for substance use disorders.
All these providers furnish essential, effective, and high-
quality care that is covered by many Medicaid programs, yet
Medicare does not cover them, nor do the many non-governmental
healthcare plans and health insurers that follow Medicare's
lead.
This deprives Indian Health programs of critically needed
federal reimbursement for vital healthcare services to AI/ANs,
which is critical to an effective COVID-19 response.
9. Permanently Extend Waivers under Medicare for Use of Telehealth
COVID-19 has dramatically increased the need to connect
patients to their providers through telehealth for medical and
behavioral health services. In response, CMS has temporarily
waived Medicare restrictions on use of telemedicine.
Yet for many Tribes that lack broadband and/or telehealth
capacity and infrastructure, it is not financially feasible to
purchase expensive telehealth equipment for a short-term
authority.
--Making permanent the telehealth waivers for both video
and audio-based telehealth services would ensure that the
telehealth delivery system remains a viable option for delivery
of essential medical, mental and behavioral health services in
Indian Country, and helps close the gap in access to care.
The Numbers: COVID-19 in Indian Country
As of June 24, IHS has reported 18,240 positive cases, with roughly
67 percent of positive cases being reported out of the Phoenix and
Navajo IHS Areas alone. However, IHS numbers are highly likely to be
underrepresented because case reporting by Tribal health programs,
which constitute roughly two-thirds of the Indian health system, are
voluntary. According to data analysis by APM Research Lab, AI/Ns are
experiencing the second highest aggregated COVID-19 death rate at 36
deaths per 100,000. \4\ The CDC reported that from March through June
13, 2020 age-adjusted COVID-19 hospitalization rates among AI/ANs were
higher than any other ethnicity, at 221.2 per 100,000. \5\ Reporting by
state health departments has further highlighted disparities among AI/
ANs.
\4\ APM Research Lab. The Color of Coronavirus: COVID-19 Deaths by
Race and Ethnicity in the U.S. https://www.apmresearchlab.org/covid/
deaths-by-race
\5\ Centers for Disease Control and Prevention. COVID-19 Data
Visualization. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/racial-ethnic-minorities.html
In New Mexico, AI/ANs represent roughly 8 percent of the
population, yet account for over 53 percent percent of all
COVID-19 cases. \6\
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\6\ New Mexico Department of Health. COVID-19 in New Mexico.
https://cvprovider.nmhealth.org/public-dashboard.html
As of this writing, the Oyate Health Center in South Dakota
has conducted 544 COVID-19 tests, with 114 confirmed positive
case results (20.9 percent). Of those 114 cases, 13 were
reported between June 10 and June 16. \7\
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\7\ Great Plains Tribal Chairman's Health Board. CEO Update: Oyate
Health Center To Host Mass Testing, New Website Launches. https://
gptchb.org/news/ceo-update-oyate-health-center-to-host-mass-testing-
new-website-launches/
In Wyoming, AI/ANs account for over 27 percent of all COVID-
19 cases statewide despite representing only 2.9 percent of the
state population. \8\
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\8\ Wyoming Department of Health. COVID-19 Map and Statistics.
https://health.wyo.gov/publichealth/infectious-disease-epidemiology-
unit/disease/novel-coronavirus/covid-19-map-and-statistics/
Similarly in Montana, where AI/ANs constitute about 6.6
percent of the state population, over 13 percent of confirmed
COVID-19 cases are among AI/ANs. \9\
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\9\ Montana Department of Public Health and Human Services. https:/
/dphhs.mt.gov/publichealth/cdepi/diseases/coronavirusmt/demographics
In Arizona where AI/ANs account for roughly 5 percent of the
state population, as of June 28, 2020 they represented 15
percent of those hospitalized for COVID and roughly 9 percent
of all COVID cases statewide. \10\
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\10\ Arizona Department of Health Services. COVID Data Dashboard.
https://www.azdhs.gov/preparedness/epidemiology-disease-control/
infectious-disease-epidemiology/covid-19/dashboards/index.php
Most poignantly, in a data visualization of COVID-19 case rates per
100,000 by Tribal Nation created by the American Indian Studies Center
at the University of California Los Angeles, it was found that if
Tribes were states, the top five infection rates nationwide would all
be Tribal Nations. \11\
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\11\ University of California Los Angeles. American Indian Studies
Center. Coronavirus in Indian Country: Latest Case Counts. Retrieved
from https://www.aisc.ucla.edu/progression_charts.aspx
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The COVID-19 pandemic has further exposed the vast deficiencies in
health care access, quality, and availability that exists across the
Indian health system. Prior to COVID-19, the Indian health system was
beset by an average 25 percent clinician vacancy rate, \12\ and a
hospital system that remains over four times older than the national
hospital system. \13\ Limited intensive care unit (ICU) capacity to
address a surge of COVID cases across many IHS and Tribal facilities
has strained limited Purchased/Referred Care (PRC) dollars, creating
further challenges that are contributing to rationing of critical
health care services. Overall, per capita spending within IHS ($3,779)
is at only 40 percent of national health spending ($9,409), making IHS
the most chronically underfunded federal health care entity nationwide
and thus severely ill-equipped to respond to COVID-19.
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\12\ Government Accountability Office (GAO-18-580). https://
www.gao.gov/products/GAO-18-580
\13\ Indian Health Service. 2016. IHS and Tribal Health Care
Facilities' Needs Assessment Report to Congress. https://www.ihs.gov/
sites/newsroom/themes/responsive2017/display_objects/documents/
RepCong_2016/IHSRTC_on_FacilitiesNeedsAssessmentReport.pdf
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For example, while CDC has noted that hand-washing is the number
one way of protecting against a COVID-19 infection, water and
sanitation infrastructure in Indian Country is significantly
underdeveloped. Approximately 6 percent of AI/AN households lack access
to running water, compared to less than half of one percent of White
households nationwide. \14\ In Alaska, the Department of Environmental
Conservation reports that over 3,300 rural Alaskan homes across 30
predominately Alaskan Native Villages lack running water, forcing use
of ``honey buckets'' that are disposed in environmentally hazardous
sewage lagoons.
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\14\ US Water Alliance. 2019. Closing the Water Access Gap in the
United States. Retrieved from http://uswateralliance.org/sites/
uswateralliance.org/files/
Closing%20the%20Water%20Access%20Gap%20in%20the%20United%20States_DIGITA
L.pdf
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Because of the sordid history of mineral mining on Navajo lands,
groundwater on or near the Navajo reservation has been shown to have
dangerously high levels of arsenic and uranium. As a result, roughly 30
percent of Navajo homes lack access to a municipal water supply, making
the cost of water for Navajo households roughly 71 times higher than
the cost of water in urban areas with municipal water access. \15\ In
fact, in a new peer-reviewed study of 287 Tribal reservations and
homelands, COVID-19 cases were found to be 10.83 times more likely in
homes without indoor plumbing. \16\
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\15\ Ingram, J. C., Jones, L., Credo, J., & Rock, T. (2020).
Uranium and arsenic unregulated water issues on Navajo lands. Journal
of vacuum science & technology. A, Vacuum, surfaces, and films : an
official journal of the American Vacuum Society, 38(3), 031003.https://
doi.org/10.1116/1.5142283
\16\ Rodriguez-Lonebear, Desi PhD; Barcel cents, Nicol s E. MD;
Akee, Randall PhD; Carroll, Stephanie Russo DrPH, MPH American Indian
Reservations and COVID-19, Journal of Public Health Management and
Practice: July/August 2020--Volume 26--Issue 4--p 371-377 doi: 10.1097/
PHH.0000000000001206
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Gaps in COVID-19 AI/AN Public Health Data
These existing capacity and resource shortages meant that the
Indian health system was woefully unprepared to prepare, prevent, and
respond to the COVID-19 pandemic. Available data on AI/AN COVID-19
health disparities reaffirms this central point. Unfortunately, because
of high rates of misclassification and undersampling of AI/AN
populations in federal, state, and local public health disease
surveillance systems, available data likely significantly
underrepresents the scope of the impact in Indian Country. To be clear,
misclassification of AI/ANs on disease surveillance systems is not
unique to COVID-19.
Previous studies have found significantly higher rates of
misclassification outside of IHS Contract Health Service Delivery Areas
(CHSDA); \17\ for all-cause mortality rates in states like Oklahoma;
\18\ for HIV infections among AI/ANs across five states; \19\ and on
death certificates reported to CDC. \20\ However, the issue has taken a
new level of urgency given the unprecedented devastation of this
pandemic on underserved communities.
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\17\ Jim, M. A., Arias, E., Seneca, D. S., Hoopes, M. J., Jim, C.
C., Johnson, N. J., & Wiggins, C. L. (2014). Racial misclassification
of American Indians and Alaska Natives by Indian Health Service
Contract Health Service Delivery Area. American journal of public
health, 104 Suppl 3(Suppl 3), S295-S302. https://doi.org/10.2105/
AJPH.2014.301933
\18\ Dougherty, Tyler M. MPH, CPH; Janitz, Amanda E. PhD, BSN, RN;
Williams, Mary B. PhD; Martinez, Sydney A. PhD; Peercy, Michael T. MPH,
MT(ASCP)H; Wharton, David F. MPH, RN; Erb-Alvarez, Julie MPH, CPH;
Campbell, Janis E. PhD, GISP Racial Misclassification in Mortality
Records Among American Indians/Alaska Natives in Oklahoma From 1991 to
2015, Journal of Public Health Management and Practice: September/
October 2019--Volume 25--Issue--p S36-S43 doi: 10.1097/
PHH.0000000000001019
\19\ Bertolli, J., Lee, L. M., Sullivan, P. S., & AI/AN Race/
Ethnicity Data Validation Workgroup (2007). Racial misidentification of
American Indians/Alaska Natives in the HIV/AIDS Reporting Systems of
five states and one urban health jurisdiction, U.S., 1984-2002. Public
health reports (Washington, D.C. : 1974), 122(3), 382-392. https://
doi.org/10.1177/003335490712200312
\20\ Centers for Disease Control and Prevention. 2016. The Validity
of Race and Hispanic-Origin Reporting on Death Certificates in the
United States: An Update. https://www.cdc.gov/nchs/data/series/sr_02/
sr02_172.pdf
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Multiple states with large AI/AN populations including but not
limited to Minnesota, Michigan, New York and California are reporting
thousands of COVID cases without any information on patient ethnicity,
or categorizing cases as ``other'' on demographic forms. In California
for instance, the state has noted that race/ethnicity data is missing
for nearly 30 percent of reported cases. Multiple studies have
demonstrated that AI/ANs are more likely to be misclassified as
``other'' or are omitted from surveillance systems entirely.
Thus, these structural challenges in data reporting only serve to
render invisible the disparate impact of COVID-19 in Indian Country.
Relatedly, Tribal Epidemiology Centers (TEC) continue to face
significant barriers in exercising their statutory public health
authorities by facing major hurdles in accessing federal and state
public health surveillance systems, including for COVID-19 data. \21\
These issues continue to have a direct negative effect on health
outcomes for AI/AN Peoples, and are exacerbating the impact of COVID-19
in Indian Country.
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\21\ Centers for Disease Control and Prevention. Issue Brief on
Tribal Epidemiology Center Legal Authorities. https://www.cdc.gov/phlp/
docs/tec-issuebrief.pdf
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Unfortunately, the adverse impacts of COVID-19 in Indian Country
extend far beyond these sobering public health statistics. Tribal
economies have been shuttered by social distancing guidelines that have
also severely strained Tribal healthcare budgets. Because of the
chronic underfunding of IHS, \22\ Tribal governments have innovatively
found ways of maximizing third party reimbursements from payers like
Medicare, Medicaid, and private insurance. For many self-governance
Tribes, third party collections can constitute up to 60 percent of
their healthcare operating budgets. However, because of cancellations
of non-emergent care procedures in response to COVID-19, many Tribes
have experienced third party reimbursement shortfalls ranging from
$800,000 to $5 million per Tribe, per month. In a hearing before House
Interior Appropriations on June 11, 2020, IHS Director Rear Admiral
(RADM) Weahkee stated that third party collections have plummeted 30-80
percent below last year's collections levels, and that it would likely
take years to recoup these losses.
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\22\ Per capita spending at IHS in FY 2018 equaled $3,779 compared
to $9,409 in national health spending per capita; $9,574 in Veterans
Health Administration spending per capita; and $13,257 per capita
spending under Medicare.
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These funding shortfalls have forced Tribes across the lower 48 and
Alaska to furlough hundreds of workers, curtail available healthcare
services, or close down clinics entirely. For example, Tribes in the
Bemidji Area reported that nearly 20 percent of their healthcare system
and 35 percent of their government services staff were forced to be
furloughed due to revenue shortfalls. Meanwhile, Tribal business
closures have compounded the devastation of the COVID pandemic in
Indian Country. According to the Harvard Project on American Indian
Economic Development (HPAIED), before COVID-19 hit, Tribal governments
and businesses employed 1.1 million people and supported over $49.5
billion in wages, with Tribal gaming enterprises alone responsible for
injecting $12.5 billion annually into Tribal programs. During the six
week period (through May 4, 2020) whereby all 500 Tribal casinos were
closed in response to COVID-19 guidelines, Tribal communities lost $4.4
billion in economic activity, with 296,000 individuals out of work and
nearly $1 billion in lost wages. \23\
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\23\ Meister Economic Consulting. Coronavirus Impact on Tribal
Gaming. Retrieved from http://www.meistereconomics.com/coronavirus-
impact-on-tribal-gaming
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Extrapolated across the entire U.S. economy, collectively $13.1
billion in economic activity was lost during the same time period, in
addition to $1.9 billion in lost tax revenue across federal, state and
local governments. In a new visualization created by NIHB, over 193,000
AI/ANs have become uninsured as a result of COVID-19 job losses, with
the vast majority of these individuals (72 percent) lacking access to
IHS as well. \24\
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\24\ National Indian Health Board. Estimating Covid-19 caused
increases in Uninsured AIANs due to job loss. https://
public.tableau.com/profile/edward.fox#!/vizhome/EstimatingCovid-
19causedincreasesinUninsuredAIANsduetojobloss/
EstimatingIncreaseinAIANUninsuredduetoCOVID-19JobLoss
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Such astronomical losses in Tribal healthcare and business revenue
are exacerbating the already disproportionate impact of COVID-19
infections in Indian Country, and are further reducing available
resources for Tribes to stabilize their health systems and provide
critical COVID-19 and related health services to their communities. As
such, we urge the Committee to work on the recommendations outlined at
the top of this letter, and stand ready to work with you in a
bipartisan manner to secure their passage.
Thank you for your consideration of the recommendations outlined in
this letter. We look forward to working with you to ensure that Indian
Country's health care concerns and priorities are comprehensively
addressed, as we respond to the COVID-19 pandemic.
The Chairman. Thank you, Ms. Elgin.
At this point, we will turn to questions. I am going to
start with Mr. Davis. I know Governor Burgum has an excellent
working relationship with the tribes in North Dakota, and that
you are a very important part of that.
Can you tell the Committee how testing within the five
tribal communities in the state is going? What are lessons
learned? Any recommendations you have that could be useful
elsewhere?
Mr. Davis. Good question, Senator Hoeven, thank you.
That is correct; Governor Burgum has a very good
relationship with the tribes. It is not by chance, it has been
from hard work, I will just say that. It has been a lot of work
go into those relations. I think in times like this, you kind
of see the, I hate to use the word, the fruits of it, but in
times of this pandemic, in this case, it has shown its fruits,
because our tribal members are tested daily, weekly.
We just wrapped up a large testing event up in Turtle
Mountain yesterday, the largest tribe in North Dakota. We
tested about 250 yesterday in partnership with our county
partners, who tested another part of the tribe, and also IHS
tested the businesses.
So you will see a unified, partnered strategy here,
Senator, and members of the Committee . When I think about this
virus, it obviously does not see jurisdiction. So what affects
my tribe will affect the county, will certainly affect the
State and vice versa. So we are being very, very dedicated to
the testing events upon request from the tribes, and exercising
the National Guard in partnership with IHS and the health
departments and the counties.
So these testing events are very large. I have been to
every one of them. I think I missed one. But they are very
long, there is a lot of planning involved. But it goes back to
the partnerships, the communications we have had. I go back to
the weekly calls, Chairman, and the weekly calls that we have
with our partners, the feds, obviously the IHS, a part of that,
the tribal college presidents, the tribal councils, obviously,
and the tribal chairs of where we are.
Also, now we are looking at data. We do have data sharing
agreements with the tribes that are a legal document. But now
we are trying to home in on the results of these tests, of
streamlining where they are by region, also by address. Age and
gender is obviously included in that, as well.
So these are the shared data agreements that tribes may
have, a data dashboard, if you will. But we do have that, as
you know, Governor Burgum is a pretty techie guy, so this data
stuff is really important to him.
These are the good things, the tools that we have that we
are sharing with the tribe. The PPE stuff, just had two
shipments delivered to the tribes today. Those are upon
request, whether masks, gloves, you name it, we deliver that,
and also testing kits.
So right now, where I am from in Standing Rock, we are
trying to work with the State of South Dakota and doing another
unified, joint testing event, hopefully down in the South
Dakota side this time, and making sure that my tribal members
from Standing Rock are all tested as well.
The Chairman. Recently, there has been an outbreak, I
think, on the MHA Nation Reservation. To address community
spread, what are you doing in your position with contact
tracing and that kind of thing, in order to try to curtail
that? Whether in this case it is MHA, or one of the other
reservations.
Mr. Davis. Chairman Hoeven, another good question there.
Yes, that is another big part of the portfolio, if you will,
for COVID. Contact tracing is a big piece of this. Again, I go
back to jurisdiction.
So we deploy our contact tracing teams, whether it is
through the Department of Health or the university systems, or
even sometimes our private hospitals. We make sure that we work
in unison with the tribes, in this case, MHA, making sure that
that information is shared, but also when the calls are made to
the people who are under-investigated, and that is a good word,
I guess, in this case, of who that person has been around with
a positive test, making sure those folks are tested immediately
within one or two days. Then we go from there.
Also, Chairman, at least the homeless shelters. Because as
we all know in this room, housing and placing people who have
limited water, that was talked about earlier, we are going
through one right now back home at Cannonball, we have a family
that tested positive there that doesn't have running water. So
we deployed our resources, State resources with the tribe, to
make sure that there was a hotel room that was available for
that family who tested positive.
But that time is running out. We are looking at a deadline
of July 11th where that facility will be backing out of that
and resuming business. But my call again this morning with FEMA
ensures us that that funding will be available for those
homeless shelters. It is up to us to find that facility or a
private motel of some sort to make sure that tribal members are
safe during the quarantine process.
So one thing that I did want to share, Chairman, some of
the Federal facilities that the tribes are requesting, I am on
these calls with Interior, is that it takes a little bit longer
time to get the okay from Interior to get that facility or that
building switched over to a homeless shelter or a quarantine
area. So you probably see or hear inquiries from tribes, not
just from the Great Plains, but I am assuming across Indian
Country, on possibly streamlining some of those Federal
properties regarding, in this case, Interior, that could be
opened for homeless shelters and also the quarantine process.
The Chairman. Thank you. Vice Chairman Udall.
Senator Udall. Thank you, Mr. Chairman.
In the House hearing last month, IHS Director Weahkee
indicated that IHS facilities have lost 30 to 80 percent of
their normal revenue from third-party billing collections due
to the COVID-19 pandemic. He also acknowledged that the
payments to IHS facilities from the Provider Relief Fund have
not fully offset these losses.
Ms. Elgin, is it fair to say that a number of IHS
facilities are still feeling the consequences of the revenue
shortfalls caused by COVID-19?
Ms. Elgin. Absolutely. Just two weeks ago, Admiral Weahkee
told the House Interior Appropriations Subcommittee that the
agency is experiencing third-party revenue shortfalls at 30 to
80 percent, like you said, below collections this time last
year, and that it will take years to recoup those losses. The
House-passed Heroes Act allocated $1 billion to address revenue
shortfalls.
But this was back in mid-May. Since then, COVID cases in
Indian Country have only continued to increase, and the need is
more likely higher than $1 billion. We urge the Senate to
increase the funding for the tribes as you work on your next
COVID relief package.
Senator Udall. Thank you very much. We are doing that. I am
working with a number of colleagues to address these
operational funding shortfalls in the next COVID-19 relief
package. It is clear that IHS facilities need direct access to
supplemental funding. But I believe that there are also policy
corrections Congress can enact to further address this issue.
The bill on today's legislative hearing agenda, S. 3650,
the Coverage for Urban Indian Health Providers Act, is one such
example. It would address a longstanding imbalance within the
IHS for Urban Indian health programs, and help reduce their
operating costs at a time when many programs would otherwise
face furloughs and belt-tightening.
Ms. Elgin, what further policy corrections could Congress
enact to alleviate operation funding shortfalls for IHS
facilities?
Ms. Elgin. At the very least, we urge the Senate to
maintain the $1 billion outline for revenue shortfalls within
IHS tribal and Urban Indian facilities in the House-passed
Heroes Act as the adverse impacts of this pandemic carry on, or
likely even more relief funding to replenish third-party
revenue shortfalls will be needed.
Senator Udall. Ms. Elgin, I have heard concerns from tribal
leaders and Urban Indian health programs about decisions other
HHS agencies have made regarding administration of Indian
Country's specific COVID-19 health resources, particularly
related to administration of funding and grants. Can you
provide some examples of grant or resource administration
practices within HHS or FEMA that have hamstrung tribal and
Urban Indian response and mitigation efforts during the
Coronavirus pandemic?
Ms. Elgin. Yes, there have been significant challenges.
Number one, Federal treaty obligations cannot be fulfilled
through competitive grants. Even though COVID, like many tribe
didn't have dedicated grant writers. When they do, those grant
writers are more likely to be wearing multiple hats.
Tribes had limited capacity before COVID. And with the
furloughs and reduced hours, capacity is even lower now. Many
of HRSA's and CDC's grant application reporting requirements
are very onerous, some requiring 20 pages per application and
hours upon reporting.
Unfortunately, this has led some tribes to forego applying
for some grants to begin with, because they don't have the time
to write these long grants. That is a very difficult decision
to make, because the tribes absolutely need the money. No tribe
should be put in this position. CDC needs to make sure that it
is funding every tribe for public health, not just some of
them.
To be fair, we are very appreciative of the fact that CDC
added an additional $40 million on top of the $40 million
Congress set aside for the tribes. And in the Corona
Preparedness and Response Act, they also were receptive to the
feedback to make the grants non-competitive, which they did
with the additional $40 million they allocated to the tribes.
But much more needs to be done and the issues continue. For
instance, we still do not know what CDC is doing with the $125
million in tribal funding allocated under the CARES Act. We
have demanded answers, but have yet to receive them. Tribes
need that money to be released as quickly as possible and it
must cover every single tribe. If the Federal government can't
get away with funding on State and not another, it should not
get away with only funding some tribes.
A major issue is lack of technical assistance given tribes
on how to spend the COVID money, the timelines for spending it,
the restrictions on spending it and eligibility. We need grant
administration TA. NIHB is filling in this gap and trying to
provide TA to the tribes, but Congress needs to provide HHS
with dedicated funding to assist tribes with grant management.
With FEMA, tribes have consistently urged the
Administration to waive cost-sharing requirements. We just need
a statutory fix to this problem.
Senator Udall. We really appreciate that.
Mr. Chairman, I have one more question, with your
permission.
The Chairman. Certainly.
Senator Udall. In 2010, Congress designated tribal
epidemiology centers as public health authorities and granted
them access to CDC's disease surveillance data bases. But a
decade later, when the Coronavirus pandemic struck, the CDC
still hadn't worked with Indian Country to implement these
important pieces of tribal public health infrastructure. This
is a longstanding issue for Indian Country. Access to real-time
accurate health data is critical to a successful COVID-19
response.
Ms. Elgin, in NIHB's opinion, can IHS, tribes, and Urban
Indian health programs accurately monitor COVID-19 activity
using their existing public health surveillance and health IT
systems?
Ms. Elgin. We are trying our best, but there are
significant barriers. Chief Medical Officer Michael Toedt has
publicly stated that the IHS antiquated health IT system is
seriously limiting their ability to engage in COVID
surveillance. Many of the tribes have purchased their own
commercial, off the shelf, EHR systems. In California, for
instance, tribes use NextGen, but one big problem is lack of
interoperability, our systems aren't talking to each other as
well as they need to be. And that is negatively impacting our
patients' health. Through the IHS tribal budget formulation
workgroup, the tribes have recommended $3 billion to ensure the
full Indian Health system has a well-functioning health IT
system. To this end, we absolutely need parity with the VA.
To give one example, under the CARES Act, Congress gave the
VA $3.1 billion just for health IT. In comparison, IHS only got
$65 million. With IHS relying on the VA system, we need parity
in investment. Otherwise, Indian Country will be left behind.
Just a related issue that has received media attention is
the fact that the tribes and tribal epicenters have faced
serious challenges in accessing public health data from the CDC
and from the States. Tribes and tribal epicenters are public
health authorities under law.
Yet CDC continues to deny tribes access to CDC's
surveillance systems, despite readily giving this to the
States. Many States incorrectly cite HIPAA concerns, or flat-
out refuse to share data with the tribes. We are sovereign
governments and we have the same authority as States to access
public health data.
While tribes have tried working with their States in good
faith to access data that rightfully belongs to us, we continue
to encounter many barriers. We urge Congress to ensure
meaningful funding for health IT for the tribes. One way we can
address the problem with access to State data is by having
Congress require States to share public health data with tribes
and tribal epicenters as a condition of receiving the CDC
surveillance funding.
We remain committed to working with all of you in these
solutions.
Senator Udall. Thank you very much, Ms. Elgin. Mr.
Chairman, just let me say, I think this has been a very
important hearing. We have had two panels. We have looked at
oversight in a serious way, and I think it has given us a lot
of issues we should be working on.
Congress must do everything in its power to keep every IHS
facility up and running during this pandemic. I hope we can
work in a bipartisan fashion to expeditiously enact provisions
to close some of these policy loopholes and secure more direct
funding for the Indian Health Service.
Thank you, Mr. Chairman.
The Chairman. Thank you, Vice Chairman Udall.
We do have Senator Smith who has some questions for the
witnesses. Senator Smith?
Senator Smith. I know it has been a long afternoon and Ms.
Elgin has waited to speak with us. So I am grateful just to ask
two things I was really anxious to hear your perspective on,
Ms. Elgin.
The first has to do with mental health issues and the
special mental health issues with tribal youth. This is
something I am so concerned about, about all of our youth not
being in school, not having access to the nutrition that they
are used to, the structure that they are used to, potentially
not having a safe place to be during the day, the schools not
being open.
I also know that the Bureau of Indian Education, as I
understand it, didn't get CARES Act funds out to schools before
the end of the year. Many schools in Minnesota haven't received
those dollars yet.
My question is, could you give us some advice about how we
should think about meeting the mental and behavioral health
needs of Native students in the midst of this pandemic?
Ms. Elgin. Thank you. Yes, I will try. It is a good
question highlighting one of the key detriments that have
happened around mental health. We heard that from the
Administration, that drug overdoses have increased this year,
likely as a result of the greater social isolation. Our people
and Native youth are definitely being impacted. We have the
second highest opioid overdose deaths and experienced the
highest increase in drug ODs between 1999 and 2015. Because of
that, the tragedy of suicide does continue.
It goes back, many tribal communities struggle with food
insecurity. According to USDA, roughly 28 percent of our Native
households with children are food insecure. In some areas,
rates of food insecurity are higher than 40 percent. Only 25
percent of our people living on the reservation are within one
mile of the supermarket compared with 60 percent of the general
population.
We are all looking at ways to fix this. I just want to say,
too, we didn't talk too much about homelessness. But I think
this comes into play as well. We know that can happen, even on
the reservation, the gentleman talked about homes being
overcrowded sometimes, and you have to move away from your
family. With that comes this mental anguish and stress, again,
that is not just faced by tribal or Native youth, but elders
and the whole family in general.
I think tribes are working their best, trying to get
measures in place to secure an emergency housing situation that
they may need. Speaking for my own tribe, we put things and
measures in place that if we have to move a family away, it is
going to be somewhere near, and not going to really put them in
danger of going to a bigger city. I am two hours away from the
biggest town near me, and just trying to get the food
stockpiles there, and all the supplies you need, everything, it
all comes with this stress and anguish going on now.
So I along with our neighboring tribes here are working
together just to come together and a plan that will help and
work with the mental health issues surrounding this COVID.
Senator Smith. I think COVID happens in the context of
historic trauma, this is layered on that historic trauma,
especially the trauma around an illness and sickness and
disease that is brought to Indian Country. I really think this
is an area where we have a shortage of mental health services
and substance abuse services generally. It is exacerbated in
Urban Indian communities and also on tribal land. It is very
important for us to think of this now.
I want to just say as I close, Mr. Chair, that the comments
you were making, Ms. Elgin, about the challenges that tribes
faced dealing with grant-based programs all the time really
resonate with me, because that is often our solution. And then
it not only puts additional pressure and stress on tribal
governments and their leadership and those Urban Indian
Organizations, but it also puts tribes in a position of having
to compete against one another when that is not at all the
spirit of our trust and treaty obligations, when it comes to
our relationships with tribal governments.
In exchange for the land, we had promised health care. As a
promise, it should not be broken.
I thank you very much, Mr. Chair. I will close, and thank
you for the opportunity to be a part of this hearing today.
The Chairman. Thank you, Senator Smith.
Just a couple of quick questions I have in wrapping up.
First, for Mr. Davis, as we work on this, and I know you are
involved, you said both from the State side, I think from the
Federal side, also from the tribes, as we continue to work on
this, what costs do you see as the most in need for
reimbursement? As we move forward, what costs are most in need
for reimbursement?
Mr. Davis. That is a good question, Senator Hoeven.
I know the tribes are counting their costs as we speak, as
well as the State. It is very costly. Hopefully, that will be
all 100 percent reimbursable from the feds.
As far as the high costs, I think it is the personnel, the
time. When I look at the doctors and health care providers and
law enforcement, even just leadership, there are a lot of
people that I see that I work directly with that are just
working day in, day out.
So I think the overtime cost, Admiral Weahkee talked about
the hazard pay. I have been in those discussions as well. The
testing kits, the PPE, the infrastructure, those are things
that I see as well. As we all know, infrastructure is very
costly. Some of my tribes back home don't have the
infrastructure to handle the cases, so they have to be referred
out to Bismarck and Fargo and so forth. So those are the costs
I see, Senator, that are coming down the pipeline.
I would also mention, too, with businesses I know, this
body has worked diligently on a bipartisan bill for
reimbursements for businesses, casinos, all those things. I am
so appreciative of that, with Treasury, I have been on those
calls as well. But as we all know, it is at times not enough.
I want to go back to what Senator Smith said, when she
talked about mental health. For me personally, I have been in
recovery for 16 years. What I see back home, we could use
treatment centers, every tribe needs one, needs two of them. I
think a conduit of that is the workforce in regard to
licensing. That is one thing that I see as really, barrier, I
kind of hate to say it, the regulation. Maybe it is regulation.
I would rather see innovation in regard to mental health on
tribal lands. Because we all know that we have a number of
cultural providers, if you will, that can provide services for
our members, for our youth, for whoever, who are going through
this pandemic, who are going through historical trauma. That
could and should be reimbursable through Federal dollars.
So I see that as a barrier, Chairman, as far as mental
health services go, those reimbursement costs to those. Most
times, when you are working back home in the treatment centers,
for mental health, you have to have a license of some sort. I
understand that, I agree with that. But also, I think there has
to be a way to be innovative of that. Sometimes I look at those
licenses as red tape, quite honestly. That red tape leads to
poor services, because you are shown to teach mental health a
certain way, and when you are trying to teach it culturally to
my people, it is different. And it kind of doesn't work.
So I would urge you and your staff, Chairman Hoeven, to
look into that, how it can be innovative with similar licensing
when it comes to mental health on tribal lands.
The Chairman. Thank you, Mr. Davis.
Ms. Elgin, does the National Indian Health Board have
educational outreach or training that they think has been
particularly effective in helping Native communities battle
COVID-19?
Ms. Elgin. Yes. There have been significant challenges, of
course, but we have been doing this, they provide the TA that
they can. Many of the grant application reporting requirements
are always a concern when we try to outreach to tribes that we
need to.
Since March, NIHB has had a public health team that has
conducted 12 national webinars for tribes to provide education
on COVID that connect with tribes regarding resources and
unanswered technical questions. They have created 35 one-
pagers, fact sheets and infographics on everything from how to
conduct a sweat lodge during COVID to how to do home-based
COVID testing, the vaccines, how to stay safe in
multigenerational housing and addressing the mental and
behavioral health challenges resulting from this distancing and
sheltering in place orders. They are doing everything they can
to make sure that tribes have all this information and the
resources needed during this pandemic.
The Chairman. Thank you.
I would like to thank both Mr. Davis and Ms. Elgin for
testifying on our second panel. There may be additional
questions submitted for the record. We would ask that if there
are, you would respond.
With that, again, we want to thank both of you for being
here and for the work you are doing.
With that, our hearing is adjourned.
[Whereupon, at 5:11 p.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement of Robyn Sunday-Allen, Vice President, National
Council of Urban Indian Health (NCUIH)
My name is Robyn Sunday-Allen and I am the Vice President of the
National Council of Urban Indian Health (NCUIH), which represents the
41 Urban Indian Organizations (UIOs) across the nation who provide
high-quality, culturally-competent care to Urban Indians, constituting
over 70 percent of all American Indians/Alaska Natives (AI/AN). I also
serve as the Chief Executive Officer of the Oklahoma City Indian
Clinic, a permanent program within the IHS direct care program and a
UIO, which provides culturally sensitive health and wellness services
including comprehensive medical care, dental, optometry, behavioral
health, fitness, nutrition, and family programs to our patients. I
would like to thank both Chairman Hoeven and Vice Chairman Udall for
holding this legislative and oversight hearing during this
unprecedented pandemic, which has especially impacted Indian Country.
My testimony is regarding S. 3650, Coverage for the Urban Indian Health
Providers Act, and how it would improve health care outcomes for
Oklahoma City's Urban Indian community.
S. 3650, Coverage for the Urban Indian Health Providers Act, was
introduced by four Senators of this Committee--Lankford, McSally,
Udall, and Smith, who have recognized the essential nature of this
technical fix and that it is not a partisan issue. S. 3650 will close a
major disparate gap in the Indian Health Service (IHS) system by
extending Federal Tort Claims Act (FTCA) coverage to UIOs. FTCA for
UIOs was also included in President Trump's FY 2021 budget and the
Tribal Budget Formulation Workgroup's FY 2021 and FY 2022 budget
recommendations. Both in this esteemed Chamber and in the House of
Representatives, the Coverage for Urban Indian Health Providers Act has
enjoyed broad support, both geographically and across political
parties. This extensive support shows that one thing is clear across
the board: FTCA coverage must be extended to UIOs, especially at a time
when it is needed most.
At the Oklahoma City Indian Clinic, we spend approximately $200,000
annually on malpractice insurance, money which we would rather invest
in our services. If UIOs were covered under the FTCA, we would put
every one of these dollars back into services to include preventative
care, such as: mammograms, pap smears, immunizations (adult and
children), and dental sealants, among other services.
We are not alone in needing these funds even more during the COVID-
19 pandemic. Many UIOs fear for our staff and have been forced to
institute hiring freezes as we stretch every dollar as far as it will
go. In fact, 83 percent of UIOs initially reported they had been forced
to reduce their services, and 9 UIOs have reported hiring freezes.
Extending FTCA coverage to UIOs is a simple legislative fix, but
the benefits would be significant. A single UIO may pay as much as
$250,000 annually in medical malpractice insurance, funds which could
instead be used to invest in better health outcomes for their
communities or to prepare for public health emergencies like the one we
are currently facing. By freeing up federal funding for UIOs, they
would be better able to serve their communities with high-quality
health care. For instance, some UIOs have reported to NCUIH that they
are hesitant to hire additional providers or provide additional
services as they cannot cover the costs of additional medical
malpractice insurance, even as they are prepared to cover the new
salaries and related costs. This directly and substantially limits the
services UIOs can provide to their patients as the cost of adding
providers or new services to malpractice insurance policies can be the
sole prohibition to service expansion.
The federal government maintains a trust obligation to tribes and
AI/ANs, which originates in treaties wherein the U.S. promised certain
duties to Native populations in exchange for the lands which make up
this great Nation; included among these duties is the provision of
health care services. The Indian Health Care Improvement Act recognized
that the federal trust responsibility to provide health care to AI/AN
people does not end at the borders of a reservation and that it extends
to AI/ANs who reside in urban areas. It was also under this Act that
Congress formally recognized UIOs as the entities to further the
fulfillment of the federal government's responsibilities to Urban
Indians. UIOs are an integral component of the IHS system, which
facilitates the provision of essential health care services through its
three components: Indian Health Service facilities, Tribal Health
Programs, and UIOs, commonly referred to as the ``I/T/U'' system. Each
component of the I/T/U system has a significant role to play in
providing AI/ANs with high-quality, culturally-competent care. UIOs not
only offer a wide range of critical services, which include clinical
and behavioral health services, but they are also often the only places
in urban settings where Urban Indians can receive traditional care
services and function as centers for cultural activities in inter-
tribal settings.
Although UIOs are an integral component of the IHS system, UIOs
still have to fight to receive parity with the other two components of
the I/T/U system. If UIOs are not explicitly included in Indian health
care legislation, they are most often implicitly excluded, with the
ultimate result that UIOs do not receive the resources they need to
provide care to their communities. This is a failure of the trust
responsibility.
As it stands, all employees and eligible contractors at IHS and
tribal facilities are treated as federal employees for the purpose of
medical malpractice liability. This is true for Community Health Center
employees and volunteers as well. Unlike these similarly-situated
health centers, UIOs must use their limited federal funding to purchase
expensive medical malpractice insurance out-of-pocket.
Even absent the current Public Health Emergency, UIOs face
disproportionate hardship as they attempt to stretch every dollar to
care for a population with higher risks of chronic disease. AI/ANs face
significant health disparities, including diabetes, cancer, and heart
disease. \1\ Many of these disparities place AI/ANs at a higher risk
for serious COVID-19 complications. With over 70 percent of AI/ANs
living in urban areas, and with the highest rates of COVID-19 taking
place in areas of high population density, many UIOs are the central
care delivery sites for communities with compounded risks. UIOs receive
direct funding from only one line item--and are not eligible for other
critical IHS funding, including Health Care Facilities, Sanitation,
Purchased/Referred Care, and Equipment, to name a few. Facing a
pandemic with decades of underfunding made it clear in the earliest
stages of the pandemic that UIOs would need a substantial amount of
emergency resources in order to meet the needs of Urban Indians.
Congress acted swiftly to support UIOs and the entire IHS system
through emergency supplemental appropriations. We are grateful for the
support, and cannot emphasize enough how essential these resources have
been to positive health outcomes for Urban Indians.
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\1\ National Center for Health Statistics. Health, United States,
2015: With Special Feature on Racial and Ethnic Health Disparities.
Hyattsville, MD. 2016.
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In order to both maximize the value of the money Congress has
appropriated to UIOs, and to ensure other critical needs are met, it is
imperative that UIOs have access to critical cost-saving measures like
FTCA coverage. UIOs have reported that they would use their medical
malpractice savings for additional Personal Protective Equipment,
infrastructure improvements to ensure proper distancing between
patients and staff, hiring additional providers, and expanding
available services. All of these are imperative to help UIOs prevent
and treat COVID-19 among their patients and communities, while
preparing for future Public Health Emergencies.
We thank Congress for your support of UIOs during this Public
Health Emergency and we urge you to keep FTCA coverage for UIOs front
of mind as your work diligently on the next COVID-19 package. We are
grateful for the Committee's continued support of Urban Indians and
dedication to improving the health outcomes of Indian Country.
______
Prepared Statement of Hon. Coly Brown, Chairman, Winnebago Tribe of
Nebraska
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
thank you for the opportunity to offer the Winnebago Tribe of
Nebraska's perspectives on the COVID-19 pandemic. I am writing to
discuss my tribe's experience with the Coronavirus Aid, Relief and
Economic Security Act (``CARES Act'').
My tribe makes our home on an Indian reservation along the banks of
the Missouri River in Northeastern Nebraska and Northwestern Iowa. We
have over 5000 tribal members and numerous tribal enterprises that
employ thousands of employees in a five-county area, Nebraska, Iowa and
around the world. The Tribe formed Ho-Chunk, Inc., the economic
development corporation of the Tribe, in 1994. Ho-Chunk, Inc. is now
the largest minority-owned company in Nebraska and has received
numerous awards for its innovative approaches to tribal economic
development. The Tribe also operates two small gaming operations in
Nebraska and one relatively modest sized gaming operation in Iowa which
provide approximately 40 percent of the Tribal government revenues that
are integral to support tribal government operations and programs.
To protect our people, we declared a public health emergency on
March 24, 2020. That same day we created the Winnebago Pandemic Task
Force to ensure the health, safety and welfare of Tribal members during
the public health emergency. The Tribe provides critical health
resources and operates social services, law enforcement, education and
numerous other important services to our Tribal citizens. Further, we
are responsible for protecting our invaluable workforce who provide
these services and protections through our Tribal government and Tribal
enterprises. We made the difficult decision to close our government and
gaming operations on March 17, 2020. We also implemented a curfew on
April 15, 2020 and a mandatory face mask policy on April 27, 2020. We
have experienced 68 positive cases of COVID-19 of which there have been
three tragic losses of life and 63 people have recovered. Currently we
have five active cases.
On March 27, 2020, Congress passed the CARES Act which established
the Coronavirus Relief Fund (CRF) for state, local and tribal
governments to respond to the public health emergency with respect to
the Coronavirus Disease 2019. The CARES Act required that amounts to
tribal governments ($8 billion) be distributed not later than 30 days
of enactment (April 26, 2020). Relief funds are to be used for
expenditures incurred March 1--December 30, 2020.
To date, the $8 billion fund has not been fully distributed to
Tribal governments. These critical relief funds remain the subject of
litigation. Instead of what should have been one payment in full by
April 26, my tribe received three partial payments of varying amounts
in early May and mid-June. Depending on the outcome(s) of multiple
lawsuit(s), there is potential for the remainder of the fund to be paid
to tribal governments in yet another payment. We had no insight into
the formula that the U.S. Department of the Treasury used despite
several tribal leader calls with Treasury on the issue. Even when
Treasury made what became the first, second and third payments and
described the different formulas used, tribes were unable to determine
how such amounts were calculated by Treasury.
As a result, our tribe had no ability to properly plan for an
unknown amount of CRF funds that our tribe would receive and therefore,
no ability to plan for how to allocate CRF funds among the numerous
priorities we have in response to the COVID-19 public health emergency.
In addition, since the payment of CRF tribal relief funds was
significantly delayed by almost two full months, all tribes, including
my own, lost critical time to implement preparedness and response
efforts. By the time we received the most recent payment on June 18,
positive COVID cases on our reservation totaled 66 and all three of the
COVID related deaths we have experienced in our community thus far, had
already occurred.
As we continue to respond to the pandemic, there is no end in
sight. The Tribe asks Congress to extend the use of CRF funds for
necessary expenditures to respond to the public health COVID-19
emergency to September 30, 2021. We further ask that Congress allow
Tribes to use relief funds to replace lost revenue and for governmental
operations during the pandemic. Unlike state and local governments,
Tribes do not have a tax base to draw upon during these trying times to
support our governmental functions. Thank you very much for your
attention.
______
Prepared Statement of Hon. Joseph Rupnick, Sr., Prairie Band Potawatomi
Nation
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee
on Indian Affairs:
The following statement is submitted on behalf of the Prairie Band
Potawatomi Nation (``Prairie Band'') to be included in the record of
the Committee's hearing.
Like all Federally-recognized tribal nations, the Prairie Band has
been affected by the COVID-19 pandemic and our Tribal government has
declared a disaster, imposed stay-at-home orders on our people, closed
our enterprises, and provided direct services and support for our
people under quarantine during the last four months. This has resulted
in tremendous hardship to our people, our families, and the people we
employ in our region in Kansas.
As you know, the CARES Act provided for an $8 billion Coronavirus
Relief Fund for Tribal governments (``Tribal CRF''). Payments from the
Tribal CRF were to be paid within 30 days of enactment (March 27, 2020)
and that such funds could only be used to cover costs that:
Were necessary expenditures incurred due to the public
health emergency with respect to the Coronavirus Disease 2019
(COVID-19);
were not accounted for in the budget most recently approved
as of March 27, 2020 for the affected government; and
were incurred during the period that begins on March 1,
2020, and ends on December 30, 2020.
The Treasury Department, which was given responsibility for
distributing the Tribal CRF monies, has diverged wildly from this
Congressional mandate. The Prairie Band and over 200 Tribes were not
treated fairly by the Treasury Department in the distribution of Tribal
CRF monies.
Background. To implement the CARES Act, the Treasury and Interior
Departments held two consultation sessions with Tribal leaders to
solicit input on how to distribute the CRF monies. In early April, the
Treasury Department (which has the obligation to disburse the funds)
requested information from Tribal governments for purposes of
developing a distribution formula to allocate 60 percent of the Tribal
CRF, or $4.8 billion (``Round 1''). This data request included a
request for our Tribal enrollment population, as well as our land base,
number of employees, and total expenditures.
Inexplicably, the Treasury Department then proceeded to ignore all
of the requested data--including tribal enrollment figures--and instead
adopted a formula used to distribute Indian Housing Block Grants
(``IHBG''). This was despite its acknowledgment that ``Tribal
population is expected to correlate reasonably well with the amount of
increased expenditures of Tribal governments related directly to the
public health emergency.'' See U.S. Department of Treasury, Coronavirus
Relief Fund Allocations to Tribal Governments, May 5, 2020 (see
attached). * And also despite the fact that not one Tribal leader
during the consultation process asked for the IHBG formula to be
applied. The offered explanation by Treasury officials was that the
IHBG ``formula area corresponds broadly with the area of a Tribal
government's jurisdiction and other areas to which the Tribal
government's provision of services and economic influence extend.'' Id.
Based on Treasury's Round 1 formula, the Prairie Band received
$2,456,891.27. Our first impression was that this was a low figure,
given our tribal population of 4,561 members. However, our suspicions
were affirmed when a report analyzing the distributions was issued by
the Harvard Project on American Indian Economic Development. See R.
Akee, E. Henson, M. Jorgensen, & J. Kalt, Dissecting the US Treasury
Department's Round 1 Allocations of CARES Act COVID-19 Relief Funding
for Tribal Governments, May 18, 2020 (``Harvard Report'') (see
attached). *
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* The information referred to has been retained in the Committee
files.
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Gross Error by the Treasury Department Revealed. The Harvard Report
revealed that, if the Treasury Department had utilized the Tribal
enrollment data as originally requested, the Prairie Band would have
received $10,327,948, or $7,631,673 more than we actually received! Id.
at 10. Indeed, the Harvard Report indicated that the Prairie Band was
in the ``top 25'' tribes that were ``under-represented'' by the
Treasury's use of the IHBG formula. We don't consider what Treasury did
as ``under-representing'' the Prairie Band; we consider it as once
again an action by the U.S. government to arbitrarily and unfairly
treat us as Indian people by disregarding the one verified measure used
to identify us to the federal government--our Tribal enrollment
figures.
The Harvard Report also revealed even harsher results for many
other Tribes, with Treasury recording ``zero'' Tribal population for
some, thus allocating only the minimum $100,000.00 to those Tribes to
assist their people.
Why the reason for such unfairness? The Harvard Report explains
that the IHBG formula used by Treasury is based on self-identified
racial data derived from the U.S. Census. This racebased data includes
both individuals who self-identify as American Indian/Alaska Native as
``single race'' and those who identify as ``mixed race''. Based on
known distributions, it appears that Treasury utilized the ``mixed
race'' data in distributing the CRF monies. Because the foundation of
the IHBG formula is race based, HUD rarely incorporates Tribal
enrollment data and so its formula generates wildly divergent
allocations of housing dollars despite the growth in a particular
Tribe's population or its lack of HUD-funded housing. Id. at 12-13.
The Prairie Band falls into the latter category. Because of our
economic success and our community philosophy regarding housing--we do
not rely heavily on federal HUD monies to provide housing to our
people. The Prairie Band has only 17 HUD-funded housing units! And
because of this fact, the Treasury Department underfunded us by 75
percent of the amount of money we would have otherwise received to help
our people address the COVID-19 pandemic.
It flies in the face of fundamental principles of federal Indian
law and policy that the U.S. Treasury would disregard Tribal enrollment
data as a barometer of a Tribal government's service obligation to its
people in favor of wildly inaccurate race-based housing data. But that
is what happened. And it was arbitrary, capricious, and wrong.
Judicial Relief Not Available. Because of our frustration and anger
at Treasury's actions, the Prairie Band filed a lawsuit in Federal
District Court to remedy the consequence of Treasury's misconduct and
to prevent further arbitrary distributions of remaining Tribal CRF
monies. (See U.S. D. Ct. D.C. Civil No. 20-cv1491, Jun. 11, 2020).
Ultimately, the District Court denied our request for a temporary
restraining order. However, the Treasury Department conceded that there
was sufficient litigation risk associated with its position and
notified the Court it intended to withhold $679 million for the Prairie
Band and the 260 other Tribes that were shorted by Treasury's use of
the IHBG data.
Following the litigation, Treasury has since distributed the
remaining 40 percent of the Tribal CRF monies and relied upon a formula
utilizing employment and expenditure data (see attached). The Prairie
Band received an additional $7,355,949 associated with this Round 2
distribution.
Request for Relief. Despite the lack of judicial remedy, I bring to
your attention the Prairie Band's experience because Congress should be
aware of how poorly the Treasury Department administered the Tribal CRF
monies. Hundreds of Tribes received far less than they would have
received had Treasury utilized Tribal enrollment data. And that means
that hundreds of Tribes received far less support to help their people
than Congress intended when it enacted the CARES Act and appropriated
the Tribal CRF monies.
We ask for the Committee's assistance in (i) examining why Treasury
utilized a funding formula that ignored Tribal enrollment data and
seriously underfunded 261 Tribes and (ii) appropriating additional
funds to provide restitution to the Tribes adversely affected by
Treasury's action to allow us to fully respond to the COVID-19
pandemic.
We are willing to assist you in any way that you may find necessary
to address our concerns. Thank you for your consideration.
______
Prepared Statement of Papa Ola Lokahi (POL)
Dear Chairman Hoeven, Vice Chairman Udall, Senator Schatz, Senator
Smith, and the Members of the U.S. Senate Committee on Indian Affairs:
Mahalo (thank you) for your leadership during the Novel Coronavirus
Disease (COVID-19) pandemic in ensuring that Americans from all walks
of life survive these challenging times. Papa Ola Lokahi (POL) is a
community-based non-governmental entity that serves as the body with
whom federal agencies consult on Native Hawaiian health policy and
health care and that coordinates services between the Native Hawaiian
Health Care Systems (NHHCS or the Systems). The five Systems provide
invaluable direct health care services to the Native Hawaiian
community. The Office of Hawaiian Affairs (OHA) is a semi-autonomous
state agency tasked with the mission to serve and advance the well-
being of Native Hawaiians. On behalf of our organizations and the
community we serve, we request parity for POL and the NHHCS with the
urban Indian organizations (UIOs) by including POL, the Systems, and
their employees as part of the Public Health Service in the expansion
of the Federal Tort Claims Act in S. 3650, the Coverage for Urban
Indian Health Providers Act, which was introduced by Senator Tina Smith
(D-MN).
The federal government, through actions of the U.S. Congress, must
honor its trust responsibility to all Native Americans, including
American Indians, Alaska Natives, and Native Hawaiians. This trust
responsibility extends beyond the trust lands and includes ensuring our
native people receive health care and related services wherever they
live. Over the past century, the U.S. Congress has repeatedly
recognized this responsibility to the Native Hawaiian people in
hundreds of legislative actions, including statutes addressing the
health challenges faced by the Native Hawaiian community.
Native Hawaiian Health Disparities
Like our native relatives on the continental United States, Native
Hawaiians face disproportionate threats to our physical and mental
health, including poverty, \1\ suicide and depression, \2\ infant
mortality, \3\ alcohol abuse, \4\ homelessness, \5\ and prejudices
against natives. Native Hawaiian infants are twice as likely to die
(infant mortality rate of 7.9 per 1,000 live births) than their White
peers (infant mortality rate of 3.5 per 1,000 live births) in the State
of Hawai`i. \6\ Native Hawaiians are more likely to suffer from
coronary heart disease, diabetes, and asthma than non-Native Hawaiians
in the State. \7\ Nearly 16,000 Native Hawaiians suffer from diabetes
and more than 36,000 suffer from asthma. \8\ These diseases are the
result of many factors such as social determinants like housing.
Indeed, many Native Hawaiians face homelessness-making up nearly half
of the homeless population on the Island of O`ahu, \9\ which houses
approximately two thirds of the State's total population.
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\1\ Anita Hofschneider, Poverty Persists Among Hawaiians Despite
Low Unemployment, HONOLULU CIVIL BEAT (Sept. 19, 2018), https://
www.civilbeat.org/2018/09/poverty-persists-among-hawaiians-despite-low-
unemployment/.
\2\ NATIVE HAWAIIAN MENTAL HEALTH AND SUICIDE, OFFICE OF HAWAIIAN
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
\3\ Ashley H. Hirai et al., Excess Infant Mortality Among Native
Hawaiians: Identifying Determinants for Preventive Action, AM. J. OF
PUB. HEALTH (Nov. 2013), https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3828695/pdf/AJPH.2013.301294.pdf.
\4\ NATIVE HAWAIIAN HEALTH STATUS, OFFICE OF HAWAIIAN AFFAIRS 22
(July 2019), http://www.ohadatabook.com/NHHS.html.
\5\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF
HAWAIIAN AFFAIRS 2 (2020).
\6\ Hirai, supra note 3.
\7\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF
HAWAIIAN AFFAIRS 1 (2020).
\8\ Id. at 1-2.
\9\ Id. at 2.
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Mental health is also a serious concern for the Native Hawaiian
community. More than twenty percent of Native Hawaiian adults reported
that they frequently feel their mental health is ``not good.'' \10\
Although Native Hawaiians make up only 27 percent of all youth in the
State between the ages of ten and fourteen, they constitute 50 percent
of the completed suicides. \11\ These factors contribute to the fact
that Native Hawaiians, despite being the indigenous peoples of the
Hawaiian Islands, have the shortest life expectancy of any major
population in the State. \12\
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\10\ NATIVE HAWAIIAN MENTAL HEALTH AND SUICIDE, OFFICE OF HAWAIIAN
AFFAIRS (Feb. 2018), http://www.ohadatabook.com/HTH_Suicide.pdf.
\11\ David M.K.I. Liu & Christian K. Alameda, Social Determinants
of Health for Native Hawaiian Children and Adolescents, HAW. MED. J.
(Nov. 2011), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3254224/pdf/
hmj7011_suppl2_0009.pdf
\12\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF
HAWAIIAN AFFAIRS 2 (2020).
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The History of the Native Hawaiian Health Care Improvement Act
To respond to the health care needs of the Native Hawaiian people,
the U.S. Congress created a Commission and ordered a Needs Study to
assist in understanding the status of Native Hawaiian health. The
Native Hawaiian Health Care Improvement Act, as it is known today,
passed into law in 1988 and created a permanent program to address the
health disparities faced by the Native Hawaiian community. As a result
of this legislation, POL contracts with the Health Resources and
Services Administration at the U.S. Department of Health and Human
Services to create, update, and implement a comprehensive health care
master plan that promotes health and prevents disease in the Native
Hawaiian community.
Papa Ola Lokahi and the Native Hawaiian Health Care Systems
POL coordinates and assists health care programs and service
delivery within the NHHCS. The NHHCS is comprised of five separate
Systems with unique service areas. They are Ke Ola Mamo on O`ahu;
Ho`ola Lahui Hawai`i on Kaua`i; Hui Malama Ola Na `Oiwi on Hawai`i
Island; Hui No Ke Ola Pono on Maui; and Na Pu`uwai on Moloka`i, which
also serves clients on Lana`i. The Systems play a critical role in the
delivery of health care services to the Native Hawaiian community. More
than 300,000 Native Hawaiians residing in the State, and approximately
615,000 Native Hawaiians across the entire country, are eligible to
receive health care services through the Systems. Additionally, as the
sole Indian Health Service (IHS)-contracted health care provider in the
State, Ke Ola Mamo in partnership with the Systems and other
facilities, also provide health care for the 37,751 American Indians
and Alaska Natives who reside in the State and the many thousands more
Native American visitors who come to our islands each year.
Each of the five Systems offer unique services to their patients.
The Systems as a whole provide primary health care, behavioral health,
and dental services as well as health education to manage disease and
transportation to attend appointments. The Systems provide preventative
care to improve diabetes management and cardiac health, as well as
screenings for diseases such as breast and cervical cancer. Further,
the Systems provide traditional Native Hawaiian healing through
practices such as Lomilomi massage therapy to improve circulation and
range of motion and Ho`oponopono, a traditional healing art to promote
physical, mental, and emotional health and wellness for individuals,
families, and communities. For Native Hawaiians seeking to overcome
substance abuse challenges, the Systems offer smoking cessation
programs and substance abuse counseling. The Systems also provide their
clients with culturally enriching wellness and fitness programs, such
as Hula for Health and nutrition classes.
The Systems are working to address the health and well-being of
Native Hawaiians at all stages of life. To that end, the Systems
provide prenatal support to expectant mothers and offer newborn care.
For our older keiki (children), the Systems provide immunizations and
school physicals to students and athletes. The Systems also provide
health services and nutritional support to teenagers. Finally, Native
Hawaiian Kupuna (Elders) are eligible to receive support through adult
day care, aging in place programs, and in-home care services.
The Systems ensure access to health care for Native Hawaiians, as
well as American Indians and Alaska Natives living in or visiting
Hawai?i. They directly serve more than 23,000 clients annually. \13\
Each year, the Systems provide more than 4,700 clients with Native
Hawaiian traditional healing services; provide more than 8,500 dental
services; teach over 2,000 hours of disease and complication prevention
classes; transport more than 1,000 clients to health care appointments;
and instruct more than 20,000 participants in physical fitness classes.
\14\ The critical role the Systems play in the Native Hawaiian
community is undeniable. Since the COVID-19 pandemic began, the Systems
have provided urgent care, telehealth, and telemedicine services that
have proven critical during the Stay in Place and quarantine orders in
the State. Additionally, POL and some of the Systems performed COVID-19
testing, delivered meals to seniors, and collected information on
critical Native Hawaiian community health needs. The Systems have
turned to innovation to continue to offer their valuable services
during this time.
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\13\ Native Hawaiian Health, Papa Ola Lokahi (2020).
\14\ Id.
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The Need for Parity for the NHHCS and UIOs in FTCA Coverage
While POL and the Systems are successful in their missions to
provide health care services to the Native Hawaiian community, the
Systems are forced to spend a significant portion of their budget on
malpractice insurance rather than spending those funds on the provision
of health care and related services to patients. Including the POL and
the Native Hawaiian Health Care Systems' employees under the expansion
of the Federal Tort Claims Act (FTCA) found in S. 3650, Coverage for
Urban Indian Health Providers Act, will provide parity for the Systems
alongside the UIOs, which play a parallel role in the urban Indian
communities. FTCA coverage will free an estimated $220,000 annually to
provide quality health care services in response to the effects of the
COVID-19 pandemic, not only for those infected by the disease but also
for individuals who no longer receive employer-based insurance due to
loss of employment or reduced hours. This would help the Systems to
continue providing services to patients who are most at risk of
contracting COVID-19 and who may not have any other means to receive
health care in the aftermath of this pandemic.
The high costs of malpractice insurance during the pandemic imposes
limitations on the types of services the Systems can provide and
creates barriers to retention and recruitment. Further straining the
Systems, the provision of health care to American Indians and Alaska
Natives in Hawai?i adds roughly twice as much in health costs compared
to the level of funding the Systems receive from IHS to provide these
services, including serving as the payor of last resort for patients in
need, each year. With FTCA coverage, the Systems would be able to
provide an estimated 25,000 additional encounters for up to 2,000 more
patients and to provide expanded services, including primary care and
behavioral health services, additional transportation to appointments,
and increased traditional healing practices to cope with the stress
placed on families facing increased hardships during the pandemic,
among other things.
Significantly, this expansion of coverage would also mean that the
NHHCS can more effectively recruit and retain high-caliber medical
professionals with specializations. For example, although some of the
Systems already provide pediatric care, an expansion would allow the
remaining Systems who do not offer such services to recruit a
pediatrician to provide our keiki health services at the same place
that their parent receives care. Additionally, the Systems could
increase their collaboration between Systems by recruiting different
types of specialists to provide care across the Systems and decrease
patient travel. The Systems also project the ability to offer 25
percent more events addressing the social determinants of health while
integrating relevant traditional practices and culture.
The COVID-19 pandemic has exacerbated and will widen the health
disparities Native Hawaiians face. Unemployment in Hawai`i has
skyrocketed, with many organizations reporting Hawai`i as the second
worst state in terms of unemployment levels. \15\ We do not expect
unemployment to lower significantly in the foreseeable future because
one of our biggest industries, tourism, is almost completely shut down
and many small business have permanently closed as a result. Our
economy will likely not begin to see growth again until the last stages
of the COVID-19 pandemic recovery. Native Hawaiians will continue to be
disproportionately affected by this fact because nearly one in four
Native Hawaiians are employed in the service industry closely tied to
tourism in Hawai'i. \16\ This pandemic threatens the continued success
and survival of the NHHCS. The inclusion of the NHHCS in the extension
of the FTCA protections will address some of the most urgent needs
facing the NHHCS and help provide parity in carrying out the federal
government's trust responsibility to Native Hawaiians.
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\15\ Dave Segal, Hawaii's Unemployment Rate Remains High at 22.6
percent, STAR ADVERTISER (June 19, 2020), https://
www.staradvertiser.com/2020/06/19/hawaii-news/hawaiis-unemployment-
rate-remains-high-at-22-6/.
\16\ ISSUE BRIEF: COVID-19 AND NATIVE HAWAIIAN COMMUNITIES, NATIVE
HAWAIIANS OVER-REPRESENTED IN COVID-19 AT-RISK POPULATIONS, OFFICE OF
HAWAIIAN AFFAIRS 3 (2020).
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Mahalo again for your leadership during this difficult time in our
nation. We understand that the pandemic has negatively affected the
health and economic well-being of all native communities across the
nation, and the Native Hawaiian community is no different. During this
public health crisis, we are confident you will support providing all
native health care providers with equal treatment and the necessary
protections to continue caring for the health of our people despite the
many hardships resulting from this pandemic.
______
Prepared Statement of Kevin J. Allis, CEO, National Congress of
American Indians
Dear Chairman Hoeven and Vice-Chairman Udall:
On behalf of the National Congress of American Indians (NCAI),
thank you for holding this hearing on ``Evaluating the Response and
Mitigation to the COVID-19 Pandemic in Native Communities'' and on S.
3650, Coverage for Urban Indian Health Providers Act. Founded in 1944,
NCAI is the oldest and largest representative organization serving the
broad interests of tribal nations and communities.
As the infection rate and death toll of the COVID-19 pandemic
intensifies, it is clear that American Indian and Alaska Native (AI/AN)
communities are disproportionately impacted due to a chronic
underfunding of the federal trust and treaty responsibilities. While we
are grateful for Congress' support of Indian Country in the Coronavirus
Aid, Relief, and Economic Security (CARES) Act, greater aid is needed
in addition to addressing the numerous issues, barriers, and delays
that tribal nations encountered in accessing congressional COVID-19
relief. On July 14, 2020, we submitted extensive testimony to the
United States Commission on Civil Rights on this topic and made short-
term and long-term recommendations. To aid this Committee's work, we
enclose that testimony for your consideration and record. *
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* The information referred to has been retained in the Committee
files and can be found at http://www.ncai.org/resources/testimony/
written-testimony-of-president-fawn-sharp-at-the-hearing-on-covid-19-
in-indian-country-the-impact-of-federal-broken-promises-on-native-
americans.
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Additionally, with regard to S. 3650, Urban Indian Organizations
(UIOs) are an essential part of the Indian healthcare delivery system
alongside the Indian Health Service (IHS) and tribal health programs
(I/T/U). Currently, both IHS and tribal health programs receive Federal
Tort Claims Act (FTCA) coverage but UIOs do not. As a result, UIOs are
forced to spend their limited resources on tort claim coverage, which
has negatively impacted the scope of services that they can provide. S.
3650, addresses this gap by expanding FTCA coverage to UIOs. NCAI
supports extension of FTCA parity which will enable UIOs to increase
the delivery of services to urban AI/ANs at a time when those services
are most needed.
______
Prepared Statement of Esther Lucero, CEO, Seattle Indian Health Board
Dear Chairman Hoeven and Vice Chairman Udall:
The Seattle Indian Health Board (SIHB) would like to thank you and
the Senate Committee on Indian Affairs for holding the Oversight
Hearing on ``Evaluating the Response and Mitigation to the COVID-19
Pandemic in Native Communities and Legislative Hearing to Receive
Testimony on S. 3650''. We appreciate the opportunity to provide
written comments on our experiences mitigating the COVID-19 pandemic at
SIHB, and our research division, the Urban Indian Health Institute
(UIHI) and express our support of S. 3650.
SIHB is one of 41 Urban Indian Health Programs (UIHP) that assist
the federal government in fulfilling their trust responsibility to
provide healthcare for the American Indian and Alaska Native citizens
living in urban areas. UIHPs are a critical component of the Indian
Health Service (IHS) Direct/Tribal 628/UIHP (I/T/U) system of care and
offer culturally attuned health services to the 1.5 million American
Indians and Alaska Natives who live in 117 counties across 24 states.
UIHI is an IHS designated Tribal Epidemiology Center (TEC) and
public health authority which conducts data, research, and evaluation
services for over 62 urban Indian organizations nationwide. These
health, social, and cultural service agencies provide culturally
attuned health services to urban Indian communities. Of the twelve
TECs, UIHI is the only one with a national purview, the other eleven
operate regionally, serving tribal nations.
Indigenous Resilience in Confronting COVID-19
SIHB is one of the thousands of frontline health care organizations
that is actively working to limit the spread of COVID-19 our
communities. As a UIHP and Federally Qualified Health Center, we have
remained open for business throughout the COVID-19 pandemic. We are
adapting our service delivery models to ensure continued access to care
for of our clients, for example:
Within weeks, our clinic operationalized a COVID-19 testing
site at our main clinic and within two months were operating a
low-barrier community-based testing site at our satellite
site--Chief Seattle Club. Over the course of three months, our
staff reconfigured physical spaces and adjusted clinical
workflows to increase social distancing and implement safety
measures for patients, staff, community members, and vendors.
Notably, due to internal adjustments and supplemental funding,
SIHB did not experience mass furloughs or layoffs like many of
our healthcare partners.
Over the course of several months, we have operationalized
expanded telehealth options for medical, dental, behavioral
health, and traditional Indian medicine. Today, the majority of
our appointments are telehealth visits. To orient our patients
to this new service delivery model, we developed the ``Call Our
Relatives Home'' initiative to outreach past and present
patients and encourage reconnecting to care.
To offer telehealth services to our patients experiencing
homelessness, we were able to create ``telehealth kiosks''--
private rooms on site that maintain social distance and are set
up for telehealth appointments.
Through flexible supplemental HRSA funding, we were given
the ability to finance modest infrastructure changes that
improved telehealth, facility security, and sanitation
measures. For example, new features like keyless entry,
automatic doors, and plexiglass protections will work to limit
the spread of the virus.
Through supplemental SAMHSA funding, we are in the process
of standing up an intensive outpatient program where we can
offer a higher level of care for our behavioral health
patients. This program will begin to address a longstanding
community need. These funds combined with new federal and state
telehealth waivers that allowed for increased flexibilities and
payment parity have proven to be successful policy changes.
To meet the preventative health care needs of our pediatric
and prenatal patients, we created a Saturday clinic--open
exclusively to pediatrics and prenatal patients and staffed
with integrated care teams for wrap around health and social
services.
Each of these efforts demonstrate the adaptive and innovate
approaches UIHPs take to support the health and well-being of urban
American Indian and Alaska Native people.
As a TEC, UIHI immediately began producing newsletters, fact
sheets, and webinars focused COVID-19 impacts for tribes, UIHPs, and
urban Indian communities. To date, UIHI has disseminated 20 factsheets
and resources for clinics, workplaces, and community members. Topics
range from best practices for American Indian and Alaska Native data
collection, to COVID-19 information tailored for urban Native
homelessness service providers. UIHI has partnered with the National
Council on Urban Indian Health (NCUIH) to create an urban Indian
organizations national surveillance system. As of June 28, 2020:
75 percent of UIHPs submitted data to the surveillance
system;
19 of the participating UIHPs report screening a total of
37,476 patients for COVID-19;
A total of 5,636 patients were tested for COVID-19 with 6
percent testing positive;
-- Among the positive COVID-19 patients where age was
submitted, 87 percent are age 18-64 in comparison to 74 percent
in national surveillance data; \1\
\1\ ``Cases in the U.S.'' Centers for Disease Control and
Prevention, Centers for Disease Control and Prevention, 23 June 2020.
Retrieved from: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-
in-us.html.
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-- Among the positive COVID-19 patients where race/ethnicity
was submitted, 49 percent are American Indian or Alaska Native;
-- Among the positive COVID-19 patients where gender was
submitted, 64 percent are female, in comparison to 51 percent
in national surveillance data; \2\ and
\2\ Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease
2019 Case Surveillance--United States, January 22-May 30, 2020. MMWR
Morb Mortal Wkly Rep. ePub: 15 June 2020.DOI: http://dx.doi.org/
10.15585/mmwr.mm6924e2external icon
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-- Among the positive COVID-19 patients where home status was
submitted, 94 percent live in multigenerational homes.
This national UIO surveillance data is the only data that
specifically looks at the experience of UIHPs in detail and is
therefore critical to understanding the prevalence of COVID-19 and
supporting data-driven decisionmaking among urban American Indian and
Alaska Native communities.
These are just a few examples of the work that UIHPs and TECs are
undertaking to ensure the health and well-being of American Indian and
Alaska Native people. Despite the remarkable successes of Indian
healthcare providers in response to COVID-19, there continues to be
notable challenges with monumental implications for American Indian and
Alaska Native people. The following sections outline three areas of
concern on the federal response to COVID-19 in urban Native
communities. We share these continued challenges with the intent of
working in partnership with Congress and federal agencies to overcome
these barriers and support the health and well-being of urban American
Indian and Alaska Native people.
Health Disparities Increase COVID-19 Risk Among American Indians and
Alaska Natives
The IHS continues to be the most chronically underfunded healthcare
system in the United States, despite federal promises to tribes dating
back to the 1800s. As a result of this chronic underfunding of trust
and treaty obligations, American Indian and Alaska Native communities
around the country suffer from disproportionate rates of diabetes,
heart disease, asthma and cancer, as compared to other racial or ethnic
groups \3\--all of which are COVID-19 risk factors. Very recent studies
seem to show that some of the most common comorbidities in fatal COVID-
19 cases were diabetes or heart disease.
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\3\ Urban Indian Health Institute. (2018). Urban Indian Health Data
Dashboard. Retrieved from: https://www.uihi.org/urban-indian-health/
data-dashboard/
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In a factsheet entitled: Special Diabetes Program for Indians
(SDPI): Mitigating COVID-19 Risk, UIHI outlines that individuals with
diabetes are at a higher risk for severe complications of COVID-19 and
potentially at a higher risk for fatality. Given that American Indian
and Alaska Native people currently have the highest rates of diabetes
compared to other racial or ethnic groups, there is an increased
concern that American Indian and Alaska Native people are at a
disproportionately higher risk for severe complications and possibly
fatal outcomes related to COVID-19. Currently, SDPI is the only
national public health intervention that has been shown to improve
diabetes related outcomes including treatment and prevention and has
the potential to help mitigate the high risk of COVID-19 for American
Indian and Alaska Native people with diabetes.
Incomplete Data on COVID-19 Impacts Among American Indians and
Alaska Natives
Recent CDC data show that ``. . .age-adjusted hospitalization rates
[for COVID-19] are highest among non-Hispanic American Indian or Alaska
Native and non-Hispanic black persons, followed by Hispanic or Latino
persons.'' \4\ Even with the release of this data, our understanding of
the impacts of COVID-19 on American Indian and Alaska Native people is
limited. As we have seen throughout the COVID-19 response, incomplete
demographic data complicates our understanding of health disparities
and impacts in tribal and urban Indian communities.
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\4\ Centers for Disease Control and Prevention. (2020). COVID-19 in
Racial and Ethnic Minority Groups. Retrieved from: https://www.cdc.gov/
coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-
minorities.html
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Data collected on tribal and urban Indian communities by local,
state, and federal governments has historically misrepresented,
misclassified, and omitted American Indian and Alaska Native
populations in their analysis and reports. The incorrect and inaccurate
data ultimately affects the overall health and well-being of the
American Indian and Alaska Native population. Since the COVID-19
outbreak, we are seeing that American Indian and Alaska Native data is
often not being reported or has been included in the ``other'' data
category by non-Indigenous entities.
Efforts led the twelve Tribal Epidemiology Centers, have shed light
on the data gaps for American Indian and Alaska Native people. In May
2020, UIHI released a set of best practices for American and Alaska
Native data collection to ensure state and local public health agencies
work collaboratively with tribal and urban Indian communities,
including Tribal Epidemiology Centers, who are adept and proficient
with data collection and analysis of the American Indian and Alaska
Native population.
Continued Administrative Barriers for Urban Indian Organizations
The federal trust responsibility is a legal obligation and
cornerstone of relations between the U.S. federal government and
tribes; it was created by hundreds of treaties and centuries of court
decisions. The IHS fulfills the federal trust responsibility to deliver
healthcare to American Indian and Alaska Native citizens through the I/
T/U system of care. Nationwide, over 70 percent of the American Indian
and Alaska Native population live in urban areas, yet UIHPs receive
less than one percent of the IHS budget, and TECs have been chronically
underfunded since their inception in 1996. On average, an IHS contract
or grant is $281,128 for a UIHP and $338,675 for a TEC, but the need is
much greater. As a result, many UIHPs rely on third-party
reimbursements from Medicaid, Medicare, and private health insurance
and grants to provide basic services, while TECs seek out additional
public and private funding through grants and contracts.
Recent federal investments are contributing to an increasingly
integrated health care system. Yet, there is much to be done to address
decades of chronic underfunding. As a result of legislative education
and outreach and congressional champions, urban Indian organizations
are increasingly included in federal legislation as a part of the I/T/U
system of care. All four federal COVID-19 bills (Pub.L. 116-123, Pub.L.
116-127, Pub.L. 116-136, and Pub.L. 116-139) included urban Indian
organizations as defined by title V of the Indian Health Care
Improvement Act.
While the congressional intent was to fund urban Indian
organizations, administrative challenges persist. The following bullet
points summarize common barriers for urban Indian organizations:
Exclusionary grant eligibility--Public policies and federal
grant eligibility requirements are often restricted to tribes
and tribal organizations, thereby excluding urban Indian
organizations. While federal legislation is increasingly
inclusive of urban Indian organizations as part of the I/T/U
system of care, there can be a disconnect when funding is
allocated through certain federal agencies. For example, CDC's
COVID-19 funding strategy included a grant opportunity open to
only 11 of the 12 IHS TECs because grant eligibility criteria
were limited to tribes and tribal organizations. This
effectively eliminated UIHI from epidemiology and surveillance
funds. This is a significant gap given that not only is UIHI
the sole TEC that operates on a national level, but 70 percent
of the American Indian and Alaska Native population live in
urban areas.
Limited contracting with urban Indian organizations--Level
of experience and engagement working with the I/T/U system of
care varies across HHS. Some agencies have limited contracts or
grants with urban Indian organizations thereby complicated
expeditious funding. For example, when the CDC announced a $80
million investment in tribes, tribal organizations, and urban
Indian organizations in March 2020, dissemination of funds
across the I/T/U system of care was delayed. \5\ Due to CDC's
limited existing contracts with urban Indian organizations,
NCUIH was awarded funds to establish grants to UIHPs. As an
unintended consequence, it took three months for SIHB to access
$190,000. To date, this is the only CDC funding SIHB has
received of at least $205,000,000 set aside by CDC for the I/T/
U system of care.
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\5\ Health and Human Services. (2020). HHS announces upcoming
action to provide funding to tribes for COVID-19 response. Retrieved
from: https://www.hhs.gov/about/news/2020/03/20/hhs-announces-upcoming-
action-to-provide-funding-to-tribes-for-covid-19-response.html
Lack of Urban Confer policies across HHS agencies--IHS is
the only HHS agency with an Urban Confer policy. Urban Confer
policies allow federal agencies and urban Indian organizations
to engage in an open and free exchange of information and
opinions that leads to mutual understanding and comprehension,
and emphasizes trust, respect, and shared responsibility. \6\
These policies do not substitute for, nor do they invoke, the
rights of a tribal nation, rather they allow urban Indian
organizations to represent the needs of urban American Indian
and Alaska Native citizens as an Indian Health Care Provider.
Without an Urban Confer policy, HHS agencies have no formal
mechanism for gathering feedback from urban Indian
organizations and vice versa. As a result, submitting feedback
to HRSA, SAMHSA, and CDC was a significant barrier for urban
Indian organizations.
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\6\ Indian Health Service. Indian Health Manual: Ch. 26--Conferring
with Urban Indian Organizations. Retrieved from: https://www.ihs.gov/
ihm/pc/part-5/p5c26/. Accessed (2020).
Limited understanding of the public health authority status
of Tribal Epidemiology Centers--SIHB and UIHI are committed to
understanding the impacts of COVID-19 in urban American Indian
and Alaska Native communities. As a TEC and public health
authority, UIHI supports the epidemiological needs of 62 urban
Indian communities nationwide. Thanks to recent Congressional
oversight, TECs now have access to CDC COVID-19 Case
Surveillance. Yet, barriers persist for other HHS data access.
UIHI continues to be denied access to the National Notifiable
Disease Surveillance System (NNDSS) by CDC. A failure to grant
data access perpetuates systemic health inequities in American
Indian and Alaska Native communities. Timely analysis of NNDSS
data is critical to supporting tribal and urban Indian
organizations as they prevent, prepare, and respond to a second
surge of COVID-19. To fully operate as public health
authorities alongside local, state, and federal entities, the
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roles and authorities of TECs must be upheld.
Recommendations
We applaud the committee on your efforts to support the I/T/U
system of care to address longstanding and emergent racial and ethnic
health disparities in American Indian and Alaska Native Communities. As
a result of your advocacy, tribal and urban Indian communities continue
to innovate and demonstrate the resilience of Indigenous communities in
the face of a global pandemic. As we work together to address
historical and current disparities and promote the well-being of
American Indian and Alaska Native communities, we ask that the
committee:
Continue to include tribes, tribal organizations, and urban
Indian organizations in legislative language when intending to
support the I/T/U system of care.
Extend 100 percent Federal Medical Assistance Percentage
(FMAP) to urban Indian organizations to ensure payment parity
for Indian Health Care Providers and reduce the burden on
states responding to COVID-19.
Extend the IHS Urban Confer policy to all HHS agencies to
encourage mutual understanding and strengthen relationships
between HHS agencies and urban Indian organizations.
Support investments in Tribal Epidemiology Centers to
provide culturally competent support and services to tribes and
urban Indian communities responding to COVID-19 including
resources for emergency response planning, training and
technical support, communications, outreach and education, and
other public health surveillance activities.
Leverage Congressional oversight authority to ensure HHS
agency compliance with data sharing requirements.
Support a $1.7 billion Emergency Third-Party Reimbursement
Relief Fund for the I/T/U system of care to submit claims for
relief funding based on health care service needs or losses
related to COVID-19.
Permanently Reauthorize the Special Diabetes Program for
Indians (SDPI) to ensure continued access to culturally attuned
and tribally-driven diabetes prevention and treatment.
Permanently extend telehealth waivers under Medicare to
ensure expanded telehealth services across the I/T/U system of
care.
Support S. 3650--Coverage for the Urban Indian Health
Providers Act to extend Federal Tort Claims Act coverage to
Urban Indian Health Program Employees.
Thank you for your continued advocacy to address the health and
wellness of our American Indian and Alaska Native communities. If we
can provide any additional information in support of this request,
please contact us by phone or email.
______
Prepared Statement of Hon. Billy Friend, Chief, Wyandotte Nation
Thank you Chairman Hoeven, Vice Chairman Udall, and Members of the
Committee for the oppo1iunity to submit testimony on S. 2165, the
Safeguard Tribal Objects of Patrimony (STOP) Act of2019. The Wyandotte
Nation strongly supports swift passage of the STOP Act.
My name is Billy Friend and I am the Chief of the Wyandotte Nation.
The struggle to protect tribal cultural heritage from illegal
trafficking is a tragically common challenge for communities across
Indian Country. The Wyandotte Nation is no exception. International
markets have become a safe harbor for trafficking federally protected
tribal cultural heritage items, and they will remain this way until
Congress enacts federal law to address this issue. We firmly believe
the STOP Act will make tremendous strides in preventing international
trafficking of federally protected tribal cultural heritage items and
securing their return home to their tribal communities.
I. The Wyandotte Nation Has Fought to Protect Our Tribal Cultural
Heritage
Items of tribal cultural heritage are as unique as the tribal
nations to whom they belong. These items share the common
characteristics of being of deep intangible and tangible significance
to a tribal nation. Many people view our cultural heritage as beautiful
works of art, as talismans of a past culture they would like to own, or
as items to trade for profit. Whatever intrinsic beauty these items
possess, that is not their intended purpose.
Our items of cultural heritage have significant roles to play
within our cultures, our traditional calendars. our families, and our
ways of life. Our cultural heritage also helps us honor and uphold our
values and teach those values to our community members, particularly
our young people. So important are these items of cultural heritage
that they belong to the community as a whole- as our shared inheritance
and as our shared responsibility to honor and protect for present and
future generations.
The Wyandotte Nation has first-hand experience in fighting to
prevent the loss of our cultural heritage due to theft, trafficking,
and illegal sales. Many of our tribal artifacts are now in museums
abroad or in private collections outside the jurisdiction of the United
States, due to fact that we for many years did not have the financial
means or the ability to track down and acquire the items that were
historically ours.
II. Support for the STOP Act to Close Gaps in Existing Federal Law
The Wyandotte Nation fully supports the passage of the Safeguard
Tribal Objects of Patrimony (STOP) Act of 2019, S. 2165. Gaps in
existing federal law have enabled dealers and collectors to operate in
the shadows when it comes to items of tribal cultural
heritageespecially once exported abroad. The STOP Act illuminates these
dark corners.
There is an already-existing international mechanism through which
countries can request the return of cultural property from other
countries. The Convention on the Means of Prohibiting and Preventing
the Illicit Import, Export and Transfer of Ownership of Cultural
Property is a 1970 international treaty that the United States signed.
France, now a safe harbor for those seeking to sell federally protected
tribal cultural heritage items, is also a signatory. When a signatory
prohibits export of particular cultural patrimony items and introduces
an accompanying export certificate, that signatory can call on other
signatories to control imports of those items and help with
repatriation. The United States has not explicitly prohibited export of
tribal cultural heritage items otherwise protected under federal laws
like the Native American Graves Protection and Repatriation Act
(NAGPRA) and the Archaeological Resources Protection Act (ARP A).
Instead, when we try to regain our sacred items from an auction block
abroad, we are told these gaps in United States law prevent government
action to facilitate return.
The STOP Act places an emphasis on facilitating the return of
protected cultural heritage items trafficked internationally. The STOP
Act sets out to accomplish the two main goals of: (1) stopping the
export and facilitating the international repatriation of tribal
cultural heritage items already prohibited from being trafficked under
federal law; and (2) facilitating coordination among federal agencies
in protecting and repatriating such items and in aiding the voluntary
return of tribal tangible cultural heritage more broadly.
The STOP Act is designed to meet these very narrow goals. But NAGRA
and ARPA have other serious limitations that make even their domestic
implementation difficult, including restrictive provenance
requirements. While the STOP Act works to prevent the export of items
already protected under NAGPRA and ARPA and to secure their return, we
hope to see larger changes to NAGPRA and ARP A in the future meant to
resolve these other limitations.
We understand the STOP Act has been developed with significant
expert feedback, including from seasoned agency officials. We welcome
this expert feedback to strengthen the STOP Act so that it best meets
its goals.
We need the STOP Act now. Without it, we will continue to see our
tribal cultural heritage trafficked just out of our reach and in front
of our very eyes. The Wyandotte Nation urges you to act swiftly to
enact the STOP Act into law.
______
Prepared Statement of Hon. Rodney Cawston, Chairman, Confederated
Tribes of the Colville Reservation
On behalf of the Confederated Tribes of the Colville Reservation
(the ``Colville Tribes'' or the ``Tribes''), I thank you for this
opportunity to provide written testimony for the record on the
Committee's oversight hearing on the federal government's response and
mitigation to the COVID-19 pandemic in Native communities.
After more than three decades of trying to construct a new clinic
in Omak, Washington, the Colville Tribes was fortunate for the Omak
clinic to have been one of the five projects that the Indian Health
Service (IHS) selected earlier this year for the Joint Venture (JV)
Facility Construction Program. COVID-19, however, has affected the
ability of the Colville Tribes and other JV awardees to build their
facilities due to the precipitous decline in third party revenue.
The Colville Tribes joins the National Indian Health Board, the
National Congress of American Indians, and the Northwest Portland Area
Indian Health Board in requesting that the Senate include funding to
cover the construction costs of the eligible JV projects as part of any
infrastructure bill that it may consider this year.
By way of background, the Confederated Tribes of the Colville
Reservation is, as the name states, a confederation of twelve
aboriginal tribes and bands from across eastern Washington state as
well as parts of Oregon, Idaho, and British Columbia. The Colville
Reservation encompasses approximately 1.4 million acres and is in north
central Washington state. The CCT has nearly 9,600 enrolled members,
making it one of the largest Indian tribes in the Pacific Northwest.
About half of our tribal members live on or near the Colville
Reservation.
I. The Colville Tribes' Health Facility Needs and Joint Venture
Application
In 2019, for the second time in the past decade, the Colville
Tribes applied to replace its temporary modular building in Omak,
Washington, with a new clinic through the IHS's JV program. The IHS
solicits applications for the JV program very infrequently--every six
or seven years--and the program is extraordinarily competitive. When
the IHS selects a tribal project for the JV program, the tribe agrees
to construct and, in most cases, equip the facility, and the IHS agrees
to pay for 80 percent of the recurring staffing costs for at least 20
years.
For decades, the Colville Tribes and its citizens have lacked a
tribal health care facility in Omak, the largest population center on
the Colville Reservation. In September 2007, the CCT, out of
desperation, used tribal funds to modify a small modular office
building for use as a temporary clinic in Omak and redeployed resources
from its already understaffed operations in Nespelem, Washington, in an
effort to provide at least some health care to Omak residents.
The temporary Omak modular building is so cramped that it barely
allows for wheelchair access in its main hallway. The lack of square
footage has inhibited the Colville Tribes' ability to add and retain
health care providers in Omak, which has resulted in long wait times
for patients and fewer billable patient encounters. The Colville
Service Unit has been operating under historically low staffing ratios
since its inception in the late 1930s, so the Colville Tribes were
already facing a critical shortage of providers in its health delivery
system. The reduction in patient encounters caused by the lack of
providers has had the domino effect of eroding the Colville Tribes'
user population count and negatively impacting the Colville Service
Unit's base funding.
When the IHS solicited applications in 2009, the Colville Tribes
intended to apply, but was unable to do so because of a lack of
available tribal funds due to the downturn in the timber market
associated with the housing market crash. At that time, the CCT heavily
relied on income from the sale of on-reservation timber. In recent
years, as its economy has diversified, the Colville Tribes have been
able to utilize tribal resources to develop plans for a new Omak clinic
and secure financing for that facility.
The Colville Tribes applied in 2014, but its application did not
progress beyond the pre-application phase. Since then, the Colville
Tribes also engaged with the IHS on ways to improve its application
when the IHS once again solicited applications. The Colville Tribes
appreciates the cooperation and assistance that IHS officials and staff
provided as it prepared its 2019 application.
Early last month, the IHS finally announced the five projects it
selected for the JV program out of the 10 nationwide finalists and 34
total applicants, and the CCT was extremely grateful to be one of those
selected. A bipartisan group of the northwest congressional delegation
weighed in with the IHS with letters of support. The selection of the
Omak clinic by the IHS represents just the second JV project ever
awarded to an Indian tribe in the IHS's Portland Area, the geographic
region of the IHS that includes more than 60 Indian tribes in
Washington, Oregon, and Idaho.
II. Impact of COVID-19 on the Colville Tribes and Its JV Project
The COVID-19 outbreak has impacted Indian country in a multitude of
ways and the Colville Tribes is no exception. Since the outbreak, our
health care system has struggled to obtain personal protective
equipment, to treat tribal member patients with COVID-19 and others
with chronic conditions, and with decreased budgets due to an abrupt
decline in third party revenue.
A significant portion of the Colville Tribes' business plan to
repay the funds needed to build the Omak clinic hinges on collection of
third-party revenue, most notably Medicaid. As of this writing, the
Governor of Washington has instructed state agencies to incorporate 15
percent cuts for the remainder of the current budget biennium. While
Washington state has a comparatively generous Medicaid program, it also
has many options to cut its Medicaid costs, including implementing
provider cuts, freezing inflation increases, or not allowing rebasing
of payments. Washington's Medicaid program also provides eligibility
for individuals whose income exceeds the federal poverty level and
could easily reduce eligibility thresholds down to just the minimum
required levels, thereby reducing the number of Medicaid eligible
beneficiaries.
For the Colville Tribes' Omak JV project, any reduction in the
number of Medicaid eligible patients or services will affect the
Tribes' revenue forecasts and its ability to service debt for the
construction of the clinic. This is coupled with the COVID-19 related
decreases in third party revenue in the Indian health system generally,
which Director Weahkee testified at the June 11, 2020, House
Subcommittee on Interior and Related Agencies oversight hearing to be a
30-80 percent reduction for IHS-operated facilities. We understand that
other JV project awardees, specifically those in Alaska, are facing
similar challenges to the viability of their construction plans.
III. Include Funding for the Eligible JV Project Finalists as Part of
any Infrastructure Bill the Senate may Consider
The Colville Tribes requests that the Committee support including
funding for the eligible JV projects in any infrastructure legislation
that it may consider on its own or negotiate with the House. Because
the JV program has a highly competitive and rigorous application
process, the most recent awardees represent the best evidence of true
health facility needs in all of Indian country.
Also, unlike some projects on the legacy IHS Priority Construction
list, the JV projects are truly ``shovel ready'' in that the IHS
weighed construction planning heavily in the final selection process
and successful applicants were required to provide comprehensive
construction details in their applications. The Colville Tribes will be
able to break ground as soon as the IHS approves our construction
plans.
Most significantly, there is no more important investment in
infrastructure for Indian country than health care facilities when
considering the myriad of health problems that affect Native Americans
on a disproportionate basis. To the extent the Committee can recommend
investments in Indian country in any infrastructure package that the
Senate assembles or negotiates, we encourage you to include funding to
construct the JV program awardees.
______
Prepared Statement of the Robert Wood Johnson Foundation (RWJF)
The Robert Wood Johnson Foundation (RWJF) is the nation's largest
philanthropy dedicated to improving health and health care in the
United States. Since 1972, we have worked with public and private-
sector partners to advance the science of disease prevention and health
promotion; train the next generation of health leaders; and support the
development and implementation of policies and programs to foster
better health across the country, including high-quality health care
coverage for all. RWJF is working alongside others to build a national
Culture of Health that provides everyone in America a fair and just
opportunity to live the healthiest life possible.
On May 28, 2020, RWJF issued these Health Equity Principles for
State and Local Leaders in Responding to, Reopening, and Recovering
from COVID-19:
COVID-19 has unleashed a dual threat to health equity in the United
States: a pandemic that has sickened millions and killed tens of
thousands and counting, and an economic downturn that has resulted in
tens of millions of people losing jobs-the highest numbers since the
Great Depression. The COVID pandemic underscores that:
Our health is inextricably linked to that of our neighbors,
family members, child- and adult-care providers, co-workers,
school teachers, delivery service people, grocery store clerks,
factory workers, and first responders, among others;
Our current health care, public health, and economic systems
do not adequately or equitably protect our well-being as a
nation; and
Every community is experiencing harm, though certain groups
are suffering disproportionately, including people of color,
workers with low incomes, and people living in places that were
already struggling financially before the economic downturn.
For communities and their residents to recover fully and fairly,
state and local leaders should consider the following health equity
principles in designing and implementing their responses. These
principles are not a detailed public health guide for responding to the
pandemic or reopening the economy, but rather a compass that
continually points leaders toward an equitable and lasting recovery.
1. Collect, analyze, and report data disaggregated by age, race,
ethnicity, gender, disability, neighborhood, and other sociodemographic
characteristics.
Pandemics and economic recessions exacerbate disparities
that ultimately hurt us all. Therefore, state and local leaders
cannot design equitable response and recovery strategies
without monitoring COVID's impacts among socially and
economically marginalized groups.1 Data disaggregation should
follow best practices and extend not only to public health data
on COVID cases, hospitalizations, and fatalities, but also to:
measures of access to testing, treatment, personal protective
equipment (PPE), and safe places to isolate when sick; receipt
of social and economic supports; and the downstream
consequences of COVID on well-being, ranging from housing
instability to food insecurity. Geographic identifiers would
allow leaders and the public to understand the interplay
between place and social factors, as counties with large black
populations account for more than half of all COVID deaths, and
rural communities and post-industrial cities generally fare
worse in economic downturns. Legal mandates for data
disaggregation are proliferating, but 11 states are still not
reporting COVID deaths by race; 16 are not reporting by gender;
and 26 are not reporting based on congregate living status
(e.g., nursing homes, jails). Only three are reporting testing
data by race and ethnicity. While states and cities can do
more, the federal government should also support data
disaggregation through funding and national standards.
2. Include in decisionmaking the people most affected by health and
economic challenges, and benchmark progress based on their outcomes.
Our communities are stronger, more stable, and more
prosperous when every person, including the most disadvantaged
residents, is healthy and financially secure. Throughout the
response and recovery, state and local leaders should ask: Are
we making sure that people facing the greatest risks have
access to PPE, testing and treatment, stable housing, and a way
to support their families? And, are we creating ways for
residents-particularly those hardest hit-to meaningfully
participate in and shape the government's recovery strategy?
Accordingly, policymakers should create space for leaders from
these communities to be at decisionmaking tables and should
regularly consult with community-based organizations that can
identify barriers to accessing health and social services, lift
up grassroots solutions, and disseminate public health guidance
in culturally and linguistically appropriate ways.
People of color (African-Americans, Latinos, Asian Americans,
American Indians, Alaska Natives, and Native Hawaiians and
other Pacific Islanders), women, people living in congregate
settings such as nursing homes and jails, people with physical
and intellectual disabilities, LGBTQ people, immigrants, and
people with limited English proficiency.
For example, they could recommend trusted, accessible
locations for new testing sites and advise on how to diversify
the pool of contact tracers, who will be crucial to tamping
down the spread of infection in reopened communities. They
could also collaborate with government leaders to ensure that
all people who are infected with coronavirus (or exposed to
someone infected) have a safe, secure, and acceptable place to
isolate or quarantine for 14 days. Key partners could include
community health centers, small business associations,
community organizing groups, and workers' rights organizations,
among others. Ultimately, state and local leaders should
measure the success of their response based not only on total
death counts and aggregate economic impacts but also on the
health and social outcomes of the most marginalized.
3. Establish and empower teams dedicated to promoting racial equity
in response and recovery efforts.
Race or ethnicity should not determine anyone's opportunity
for good health or social well-being, but, as COVID has shown,
we are far from this goal. People of color are more likely to
be front-line workers, to live in dense or overcrowded housing,
to lack health insurance, and to experience chronic diseases
linked to unhealthy environments and structural racism.
Therefore, state and local leaders should empower dedicated
teams to address COVID-related racial disparities, as several
leaders, Republican and Democrat, have already done. To be
effective, these entities should: include leaders of color from
community, corporate, academic, and philanthropic sectors; be
integrated as key members of the broader public health and
economic recovery efforts; and be accountable to the public.
These teams should foster collaboration between state, local,
and tribal governments to assist Native communities; anticipate
and mitigate negative consequences of current response
strategies, such as bias in enforcement of public health
guidelines; address racial discrimination within the health
care system; and ensure access to tailored mental health
services for people of color and immigrants who are
experiencing added trauma, stigma, and fear. Ultimately,
resources matter. State and local leaders must ensure that
critical health and social supports are distributed fairly,
proportionate to need, and free of undue restrictions to meet
the needs of all groups, including black, Latino, Asian, and
Indigenous communities.
4. Proactively identify and address existing policy gaps while
advocating for further federal support.
The Congressional response to COVID has been historic in its
scope and speed, but significant gaps remain. Additional
federal resources are needed for a broad range of health and
social services, along with fiscal relief for states and
communities facing historically large budget deficits due to
COVID. Despite these challenges, state and local leaders must
still find ways to take targeted policy actions. The following
questions can help guide their response.
Who is left out? Inclusion of all populations will strengthen
the public health response and lessen the pandemic's economic
fallout for all of society, but federal actions to date have
not included all who have been severely harmed by the pandemic.
As a result, many states and communities have sought to fill
gaps in eviction protections and paid sick and caregiving
leave. Others are extending support to undocumented immigrants
and mixed-status families through public-private partnerships,
faith-based charities, and community-led mutual aid systems.
Vital health care providers, including safety net hospitals and
Indian Health Service facilities, have also been disadvantaged
and need targeted support.
Will protections last long enough? Many programs, such as
expanded Medicaid funding, are tied to the federal declaration
of a public health emergency, which will likely end before the
economic crisis does. Other policies, like enhanced
unemployment insurance and mortgage relief, are set to expire
on arbitrary dates. And still others, such as stimulus checks,
were one-time payments. Instead, policy extensions should be
tied to the extent of COVID infection in a state or community
(or its anticipated spread) and/or to broader economic measures
such as unemployment. This is particularly important as
communities will likely experience re-openings and closings
over the next six to 12 months as COVID reemerges.
Have programs that meet urgent needs been fully and fairly
implemented? All existing federal resources should be used in a
time of great need. For example, additional states should adopt
provisions that would allow families with school-age children
to receive added Supplemental Nutrition Assistance Program
(SNAP) benefits, and more communities need innovative solutions
to provide meals to young children who relied on schools or
child care providers for breakfast and lunch. States should
also revise eligibility, enrollment, and recertification
processes that deter Medicaid use by children, pregnant women,
and lawfully residing immigrants.
5. Invest in strengthening public health, health care, and social
infrastructure to foster resilience.
Health, public health, and social infrastructure are
critical for recovery and for our survival of the next
pandemic, severe weather event, or economic downturn. A
comprehensive public health system is the first line of defense
for rural, tribal, and urban communities. While a sizable
federal reinvestment in public health is needed, states and
communities must also reverse steady cuts to the public health
workforce and laboratory and data systems. Everyone in this
country should have paid sick and family leave to care for
themselves and loved ones; comprehensive health insurance to
ensure access to care when sick and to protect against medical
debt; and jobs and social supports that enable families to meet
their basic needs and invest in the future. As millions are
projected to lose employer-sponsored health insurance, Medicaid
expansion becomes increasingly vital for its proven ability to
boost health, reduce disparities, and provide a strong return
on investment. In the longer term, policies such as earned
income tax credits and wage increases for low-wage workers can
help secure economic opportunity and health for all. Finally,
states and communities should invest in affordable, accessible
high-speed Internet, which is crucial to ensuring that
everyone-not just the most privileged among us-is informed,
connected to schools and jobs, and engaged civically.
Conclusion
These principles can guide our nation toward an equitable response
and recovery and help sow the seeds of long-term, transformative
change. States and cities have begun imagining and, in some cases,
advancing toward this vision, putting a down payment on a fair and just
future in which health equity is a reality. Returning to the ways
things were is not an option.
______
National Council of Urban Indian Health
July 17, 2020
The Honorable Mitch McConnell,
Majority Leader;
The Honorable Charles Schumer,
Minority Leader,
United States Senate,
Washington, DC.
Dear Leader McConnell and Leader Schumer:
On behalf of the National Council of Urban Indian Health (NCUIH),
which represents 41 urban Indian organizations (UIOs) and the American
Indian and Alaska Native (AI/AN) populations they serve, we write to
express our gratitude for your tireless efforts in protecting our
Nation during this pandemic. We appreciate your commitment to ensuring
urban Indians have access to the critical health care they need by
including UIOs in the COVID-19 emergency response packages.
In continuation of this commitment, NCUIH is asking you to include
necessary supplemental funding as well as critical legislative fixes
for UIOs in the next Coronavirus legislative package to ensure UIOs can
protect their urban Indian communities.
IHS--Urban Indian Health--$64 million (in HEROES Act)
Medicaid--Extension of the Full (100 percent) Federal
Medical Assistance Percentage (FMAP) to UIOs Permanently (H.R.
2316/S. 1180) (in HEROES Act)
Health Care Access for Urban Native Veterans Act (H.R. 4153/
S. 2365) (in HEROES Act)
Parity in Medical Malpractice Liability for UIOs (H.R. 6535/
S. 3650)
IHS--Urban Facilities Line Item--$80 million and Amend
Facilities Renovation to Remove Unnecessary Limitations on
Accreditations so UIOs can make COVID-19 Renovations (25 U.S.C.
1659)
IHS--UIO Behavioral Health--$7.3 million for 3 years
IHS--UIO Health Information Technology--$20 million
Confer Policy for HHS with UIOs
Inclusion of UIOs in Advisory Committees with Focus on
Indian Health
These requests are essential to ensuring urban Indians are properly
cared for, both during this crisis and in the critical times following.
Thank you for your continued partnership. Communications on this matter
may be directed to Meredith Raimondi, Director of Congressional
Relations for NCUIH.
Sincerely,
Francys Crevier, Executive Director *
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* Francys Crevier's Interior Appropriations Subcommittee Testimony
on June 11, 2020 has been retained in the Committee files.
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______
May 21, 2020
Hon. Charles E. Schumer,
Senate Democratic Leader,
U.S. Senate,
Washington, DC;
Hon. Frank Pallone,
Chairman,
House Committee on Energy & Commerce,
U.S. House of Representatives,
Washington, DC;
Hon. Tom Udall,
Vice Chairman,
Senate Committee on Indian Affairs,
Washington, DC.
Re: Including Native Hawaiian Health Care Systems in
Parallel Urban Indian Health Organization Measures
Dear Leader Schumer, Chairman Udall, and Chairman Pallone:
Mahalo (thank you) for your leadership during the Novel Coronavirus
Disease (COVID-19) pandemic to ensure that Americans from all walks of
life survive these challenging times. We are a group of Native Hawaiian
organizations that provide health, educational, cultural, community
development, and other services to the Native Hawaiian community. On
behalf of our organizations and the community we serve, we request
parity for Papa Ola Lokahi (POL) and the Native Hawaiian Health Care
Systems (NHHCS) with the urban Indian health organizations in the
upcoming COVID-19 response package(s).
In the interest of parity, we request that you include POL and the
NHHCS in any relief provision that benefits urban Indian health
organizations. Specifically, we support including these five
provisions--similarly requested by a consortium of tribal
organizations--in the next package:
1. Extend full Federal Medical Assistance Percentage coverage
for Native Hawaiians receiving care at the NHHCS;
2. Classify NHHCS and its employees as part of the Public
Health Service under the Federal Tort Claims Act;
3. Provide reimbursements for primary health care services to
Native Hawaiians during this and any future health crisis;
4. Reimburse the NHHCS for health services provided to Native
Hawaiian veterans otherwise eligible for treatment at a
Veterans Health Administration facility and exempt Native
Hawaiian veterans from any cost sharing requirements; and
5. Clarify that the NHHCS could receive reimbursement for
services provided outside a physical clinic.
This pandemic threatens the continued success and survival of the
NHHCS, and these provisions will address the most urgent needs facing
the NHHCS. The above five Native Hawaiian Health Care Improvement Act
amendments would most efficiently address these needs and provide
parity in carrying out the federal government's trust responsibility to
Native Hawaiians. If parallel urban Indian health organization measures
are not yet included in this response package, we also request your
consideration to include those provisions as well.
Mahalo again for your leadership during this difficult time in our
nation. We understand that the pandemic has negatively affected the
health and economic well-being of native communities across the nation,
and the Native Hawaiian community is no different. We are confident
that you will ensure the Native Hawaiian community does not face
greater health disparities as a result of this pandemic by providing
parity for the Native Hawaiian Health Care Systems with the urban
Indian health organizations.
Attachments:
(1) Native Hawaiian Health Care Improvement Act amendment language
to address the five provisions mentioned above;
(2) Senator Schatz's Native Hawaiian Health Care Improvement Act
language summary and background information; and
(3) April 15, 2020 Letter from American Indian and Alaska Native
organizations. *
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* The attachments have been retained in the Committee files.
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______
U.S Senate,
1,070 people have signed a petition on Action Network telling you
to Petition to Provide Adequate Support for Indian Country in Phase IV
Stimulus Package: a Citizen-Led Initiative.
Here is the petition they signed:
May 21, 2020
Dear U.S. Senators,
Petition to Provide Adequate Support for Indian Country in Phase IV
Stimulus Package: a Citizen-Led Initiative The COVID-19 pandemic is
highlighting the disparities this country has endured for centuries.
Indian Country has always endured the greatest burden after disastrous
events, but we always emerge stronger. As of May 18, there have been
5,626 confirmed cases of COVID-19 in the Indian Health System and 174
total deaths. Right now, tribal citizens from across the continent are
disproportionately feeling the pandemic's impacts: they have lost jobs
and health care, resources are stretched thin, youth cannot attend
school, broadband Internet access is disproportionately lacking, and so
many elders are in need of food and financial support.
We will not accept being an afterthought in federal relief efforts
made in this country-the country where Native people have been for
centuries.
And yet, an afterthought is exactly how we have been treated
throughout this crisis. Indian Country has been undersupported by
federal relief efforts. Tribes and tribal entities received $8 billion
in the Phase III stimulus package, but this support fell far short of
the $20 billion for which the National Congress of American Indians
initially advocated to cover the true needs of Indian Country.
Moreover, the current administration was extremely slow getting the
funds out the door, delaying the resources meant for Native
communities. Now the HEROES Act recently passed by the U.S. House of
Representatives includes $20 billion more for Tribal governments--
urgently needed forward progress. We ask the Senate to maintain this
level of funding in any Phase IV stimulus package. These funds will be
used to feed tribal citizens, aid health care work, and jump start our
economic recovery plan. Tribal nations and communities contribute not
just to their enrolled members, but to people from other tribes and to
non-Native people, too. Our contributions should be recognized, and our
people should be acknowledged and adequately supported!
We must ensure Indian Country is accounted for in the Phase IV
stimulus package. Specifically the Senate must do the following:
Maintain the appropriations for tribal governments and entities in
the HEROES Act of $20 billion, consistent with the needs of Indian
Country. In addition, require that the administration get the funds out
the door in a timely manner, so they are not held up in the same way
that the CARES Act funding was.
Provide tribal set-asides from the Federal Reserve, the U.S.
Treasury, and other department lending, guarantees, and forbearance
programs to ensure that Tribal governments and entities can access
these programs without burdensome restrictions.
As citizens of our respective Tribal Nations and the United States,
we will continue to hold our representatives accountable for including
us in the ongoing efforts to fight and survive this pandemic. The lives
of millions of our people are on the line. We look forward to the day
this has passed and to the new lessons that emerge from it.
Sincerely,
Isabel Coronado, Tribal affiliation: Muscogee (Creek)
Nation
Owen L. Oliver, Tribal affiliation: Quinault/Isleta Pueblo
Christie J. Wildcat, Tribal Affiliation: Northern Arapaho/
Euchee/Navajo/Cherokee
Jazmine B. Wildcat, Tribal Affiliation: Northern Arapaho/
Euchee/Navajo/Cherokee
Mikah Carlos, Tribal Affiliation: Salt River Pima-Maricopa
Indian Community
Adam J. Soulor, Tribal Affiliation: Mohegan Tribe
Sam Schimmel, Tribal Affiliation: St. Lawrence Island
Siberian Yupik/Kenaitze Indian
______
Response to Written Questions Submitted by Hon. Tom Udall to
Robert J. Fenton, Jr.
Question 1. You testified that FEMA's role in the pandemic response
changed on March 19, 2020 when the agency moved from playing a
supporting role in assisting the U.S. Department of Health and Human
Services (HHS), which was designated as the initial lead agency for
COVID-19 pandemic response, to leading the ``Whole-of-Government
response'' to the COVID-19 pandemic. This new role includes managing
shortages and distributing medical supplies across agencies like the
Indian Health Service (IHS) and to Tribal governments directly. But
FEMA's ``Whole-of-Government response'' has led to confusion on payment
of cost-shares associated with the medical supplies being provided to
other federal agencies and Tribal governments. For instance, Tribal
governments report that it is unclear whether the 25 percent non-
federal cost-share under Robert T. Stafford Disaster Relief and
Emergency Assistance Act (Stafford Act) emergency disaster assistance
grants applies to medical supplies. Please answer for the record the
following questions on FEMA's ``Whole-of-government'' response. Does
the 25 percent non-federal cost-share under the Stafford Act apply to
the procurement and distribution of medical supplies to Tribal
governments?
Answer. Eligible emergency protective measures taken at the
direction or guidance of public health officials, and not provided or
funded by the authorities of another federal agency, may be reimbursed
under the Federal Emergency Management Agency (FEMA) Public Assistance
(PA) program. Reimbursable activities for the COVID-19 pandemic fall
under Category B of the FEMA PA program-Emergency Protective Measures.
Summary of COVID-19 Emergency Protective Measures
Medical Care
Emergency and inpatient clinical care
Purchase, lease and delivery of specialized medical
equipment
Purchase and delivery of Personal Protective Equipment
(PPE), durable medical equipment and consumable medical
supplies
Medical waste disposal
Certain labor costs associated with medical staff
Temporary Medical Facilities
Leasing, purchasing, constructing, mobilizing, operating,
and maintaining temporary and expanded medical facilities
Non-Congregate Sheltering to Isolate or Quarantine Populations Such as:
Those who test positive for or have been exposed to COVID-19
and do not require hospitalization but need isolation
(including those exiting from hospitals)
Healthcare workers and first responders who require
isolation
Provision and Distribution of Food
Purchasing, packaging, and/or preparing food
Delivering food to distribution points and/or individuals
Leasing distribution and storage space, vehicles, and
necessary equipment
Other Measures to Reduce Immediate Threats to Life, Property, and
Public Health and Safety
Operating state or tribal Emergency Operations Centers
related to COVID-19 responses
Disseminating public health and safety information
Technical assistance and training to state and local
governments on disaster management and control
The amount of non-federal cost share applied to Stafford Act
assistance for COVID-19 declarations depends on the type and timing of
the request. Tribal recipients may request reimbursement for emergency
protective measures. Additionally, tribes that do not have the
resources to procure their own equipment, supplies, or services may
request Direct Federal Assistance (DFA). DFA is applicable when FEMA
purchases goods and services directly and provides them to state,
territories or tribes, or directs another federal agency through a
mission assignment to directly provide these goods or services directly
to a state, territory, or tribe. Both of these request types--
reimbursement and DFA--are subject to a 25 percent non-federal cost
share.
However, for COVID-19 related declarations, FEMA and the U.S.
Department of Health and Human Services (HHS) signed a reimbursable
agreement for certain medical supplies. DFA requests for these supplies
made within the April 14--June 13, 2020 time period will be paid in
full by HHS (i.e., without a non-federal cost share) when the $1.383
billion national cap has not been reached. Eligible requests under this
agreement include, but are not limited to, PPE, hygiene and infection
control products, portable mechanical ventilators and testing supplies,
including the transport, storage and tracking of these items.
For requests that fall outside the FEMA/HHS reimbursable agreement,
a tribal recipient would be subject to the 25 percent non-federal cost
share. Tribal subrecipients would be subject to the portion of the 25
percent non-federal cost share that state recipient chooses to pass on
to its subrecipients. Some State recipients choose to cover some or all
of the non-federal cost share for their subrecipients.
During COVID-19-related declarations, tribes may use federal
funding from the U.S. Department of the Treasury's CARES Act
Coronavirus Relief Fund or the U.S. Department of Housing and Urban
Development's Community Disaster Block Grant and Indian Community
Development Block Grant programs to meet the non-federal cost share
required for Public Assistance.
Question 2. Are there any circumstances in which a Tribal
government must reimburse FEMA for medical supplies?
Answer. Tribal recipients are required to reimburse FEMA for the
non-federal cost share of DFA requests. When DFA requests meet the
eligibility requirements as described above under the FEMA/HHS
reimbursable agreement, tribes will not be asked to reimburse FEMA or
HHS.
Additionally, tribes could be required to reimburse FEMA if
benefits have been duplicated by another federal agency. Section 312 of
the Stafford Act prohibits all federal agencies from duplicating
benefits for disaster relief. Multiple agencies having authority to
expend funds for the same purpose is not, by itself, a duplication of
benefits under Section 312. However, all federal agencies are
prohibited by Section 312 from paying state, local, tribal and
territorial governments for the same work twice. FEMA is coordinating
closely with other federal agencies to provide information about the
eligible use of various COVID-19 funding resources. Recipients and
subrecipients are ultimately responsible for ensuring that they do not
accept payment for the same item of work twice. FEMA applicants will
certify in the PA application process that assistance is not being
duplicated.
If a tribal government received duplicative assistance for medical
supplies--e.g., it requested reimbursement for medical supplies it
received from another source and/or it accepted funding from two
sources for the same medical supplies, FEMA may deobligate funding to
avoid a duplication of benefits.
Question 3. How is the procurement and distribution of medical
supplies to agencies like IHS budgeted and accounted for, e.g., are
these expenses FEMA or IHS budget line-items?
Answer. Procurement and Distribution of PPE to agencies like Indian
Health Service (IHS) is through an Inter-Agency Agreement (Form 7600
A&B). These expenses are not FEMA budget line-items.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Robert J. Fenton, Jr.
Question 1. In Alaska, so many Native people have grown up hearing
stories of devastation from the 1918 flu. This traumatic event looms
over the current response efforts at a generational scale. Some
communities have still not recovered from the 1918 epidemic. The memory
of this almost unfathomable loss, where 82 percent of all deaths in the
state were Alaska Natives--this motivates a lot of our tribal health
system's response in Alaska.
Alaska Natives face a combination of chronic health conditions,
delayed access to care, inadequate housing, and limited water and
sanitation services, which all contribute to the alarmingly
disproportionate impact epidemics have on Alaska Native communities.
FEMA's role in addressing the public health crisis is critical.
We have heard from Tribal Health Organizations that there is a need
for FEMA to preauthorize Category B expenditures (which include all
COVID-19 disaster declaration expenses). Currently Tribal Health
Organizations have to spend funds and have to wait months for a
determination of what might be allowable to be reimbursed. Would FEMA
support preauthorizing these expenditures?
Answer. As with most federal grants, FEMA's PA Program already
allows the award of subgrants, including for Category B expenditures,
prior to the work being started. FEMA refers to these as ``Standard''
projects. Additionally, unlike many other federal grants, FEMA also
allows the award of subgrants for work that was already completed prior
to requesting assistance, as long as it is directly related to the
response or recovery from the disaster event and would be otherwise
eligible under the program, and refers to these as `work completed'
projects. Once awarded, for both types, funds are generally made
available within 1-3 days to the Recipient (typically the state,
tribal, or territorial emergency management agency), which can then
provide the funds to their subrecipients in accordance with their own
procedures and the general guidelines of 2 CFR Subpart D (which does
allow for the advancement of funds prior to the work being completed).
As a result, FEMA already routinely approves funds prior to the work
being completed, however it is not uncommon for the Recipient to hold
the funds under their own procedures.
In addition to the standard request for assistance, FEMA also
allows recipients and subrecipients to make an expedited funding
request, referred to as an `Expedited' project based on limited
information. These projects are awarded at half of the expected costs
to provide immediate funding, with the remainder of funds being made
available during a later reconciliation. These projects can be
processed in as little as a few days and are provided as an option
specifically for applicants that have an immediate need for funding.
Question 2. We heard that tribes in Region 9 were not able to get
access to the FEMA grants portal (and that it took months) but other
Regions took only 2-3 days to get tribes access to the grants portal--
can you tell me why this process isn't consistent across all FEMA
Regions?
Answer. Each FEMA Region has unique geographical differences that
can affect the timing of assistance. One such difference is the number
of federally-recognized tribes within a Region. During this
unprecedented public health emergency, every Region had to work with
each tribe and with FEMA headquarters to determine the best path for
providing tribes assistance in accordance with the options available to
tribes under the Tribal Declarations Pilot Guidance, as well as under
the President's March 13, 2020 nationwide emergency declaration for
COVID-19.
The backdrop for these discussions was one of record setting
disaster declaration and operations activity across every corner of the
nation.
Receiving access to FEMA's Grant Portal platform is just one step
in a series of administrative and programmatic requirements that tribes
must take to receive Public Assistance (PA). Each step in the process
may take more or less time depending on the nature of the event, the
capacity of the tribe, the activity in the FEMA region and across the
Nation, and the choices the tribe makes on how to request assistance.
Tribal governments typically have three options for FEMA's PA
program under a major disaster or emergency declaration; as a
subrecipient under a state, as a recipient under a state, or as a
direct recipient. Under the President's March 13, 2020 nationwide
emergency declaration for COVID-19, a tribal government could choose to
receive FEMA PA under the nationwide emergency declaration without
submitting a declaration request.
In Region IX, all 48 tribal governments elected to be recipients
under a state. When a tribal government requests to be a recipient
under a state, each request must be processed manually and for new
recipients this can take 2-3 days to process. Once the FEMA-Tribe
Agreement has been signed, the regional office submits a request to the
Grants Portal administrator at FEMA HQ to create a new recipient
profile under the state's declaration number. The Grants Portal
administrator must then create a change request with the Grants Portal
developer to duplicate the state declaration number for the tribal
government.
Question 3. We heard there was confusion on processing resource
requests from tribal clinics and IHS facilities and that some of
requests were delayed due to this confusion--what is IHS and FEMA doing
to avoid this issue in the future?
Answer. Resource requests from IHS or tribal clinics were screened
by an IHS representative to ensure sourcing and distribution were
aligned properly. FEMA has added IHS in its customer profiles as a
drop-down section (instead of a manual write-in) in the Web Emergency
Operation Center software. (screen shot has been retained in the
Committee files).
______
Response to Written Questions Submitted by Hon. Tom Udall to
Hon. Rear Admiral Michael D. Weahkee
Question 1. On May 27, 2020, I sent you a letter requesting
additional information concerning reports that private company had
provided IHS with substandard personal protective equipment (PPE) under
a $3 million federal procurement contract. \1\ On June 30, 2020, you
sent a letter in response to my May 27 letter that did not answer the
questions I posed. \2\ You committed to answering these questions at
the hearing. Please answer for the record, under what circumstances did
IHS become aware of and enter into the contract referenced in my May 27
letter? What safeguards did IHS deploy to ensure that this new
contractor was qualified and able to meet the terms of the contract?
---------------------------------------------------------------------------
\1\ Letter from Sen. Tom Udall, Vice Chairman, S. Comm. on Indian
Affairs, to Michael Weahkee, Director, Indian Health Service, Dep't of
Health and Human Services (May 27, 2020) (letter on file with S. Comm.
on Indian Affairs).
\2\ Letter from Michael Weahkee, Director, Indian Health Service,
Dep't of Health and Human Services, to Sen. Tom Udall, Vice Chairman,
S. Comm. on Indian Affairs (June. 30, 2020) (letter on file with S.
Comm. on Indian Affairs).
---------------------------------------------------------------------------
Answer. In early April, IHS was conducting market research into a
variety of sources of PPE. An IHS contract physician was contacted by a
third party regarding a possible source of N95 or KN95 masks. The
contract physician forwarded the information to several individuals in
IHS, who then forwarded the information to the IHS contracting team.
This market research was conducted in accordance with Part 10 of the
Federal Acquisition Regulation. Notwithstanding, this matter has been
reported to the Department of Health and Human Services (HHS), Office
of Inspector General (OIG). No payment has been made to Zach Fuentes
LLC, and depending on the outcome of the OIG investigation, additional
administrative actions may be warranted
Question 1a. Did IHS verify the KN95 masks supplied by this
contractor met all Food and Drug Administration standards?
Answer. The question of whether the KN95 masks supplied by the
contractor met all Food and Drug Administration standards has been
raised and referred to the HHS, OIG for an investigation.
The IHS supply centers utilize quality assurance coordinators to:
work with subject matter experts to determine requirements; verify that
products involved in procurement meet technical and/or clinical
specifications; approve products moving forward for procurement;
inspect products upon receipt for worthiness and effectiveness; and
develop processes for routine evaluation and quality control. Each IHS
supply center is responsible for ensuring quality assurance processes
are in place as intended to ensure patient safety.
IHS contracting personnel ensure technical reviews are conducted
for each proposed product, as presented by the contractor, prior to
award. After IHS technical evaluations and the contracting personnel
documents determination of fair and reasonableness, the contract/order
is issued. Upon IHS receiving the products, inspections occur and if a
discrepancy or defect is found then the subject matter experts will
conduct a quality review and present findings to the contracting
personnel. The contracting personnel will then notify the contractor of
discrepancy or defect and will request the contractor to correct. If
the contractor cannot correct, then the entire order will be cancelled
in its entirety.
Question 1b. What measures did IHS take to ensure PPE provided
under this contract was not faulty before distribution and use?
Answer. The personal protective equipment (PPE) (KN95 masks)
provided under this contract were not distributed or used.
Question 1c. What portion of the masks sent to IHS under this
contract has the IHS distributed to date? Has IHS recalled those masks
or determined if any masks resulted in the potential exposure of IHS or
Tribal medical personnel?
Answer. None of the masks delivered under the contract have been
distributed or used, therefore no recall was necessary.
Question 1d. What protocols are in place to guard against IHS
procuring substandard PPE? How does IHS generally prevent against
substandard PPE from entering the field?
Answer. The IHS supply centers utilize quality assurance
coordinators to: work with subject matter experts to determine
requirements; verify that products involved in procurement meet
technical and/or clinical specifications; approve products moving
forward for procurement; inspect products upon receipt for worthiness
and effectiveness; and develop processes for routine evaluation and
quality control. Each IHS supply center is responsible for ensuring
quality assurance processes are in place as intended to ensure patient
safety.
IHS contracting personnel ensure technical reviews are conducted
for each proposed product, as presented by the contractor, prior to
award. After IHS technical evaluations and the contracting personnel
documents determination of fair and reasonableness, the contract/order
is issued. Upon IHS receiving the products, inspections occur and if a
discrepancy or defect is found then the subject matter experts will
conduct a quality review and present findings to the contracting
personnel. The contracting personnel will then notify the contractor of
discrepancy or defect and will request the contractor to correct. If
the contractor cannot correct, then the entire order will be cancelled
in its entirety.
Question 1e. How will IHS ensure that the Navajo Service Area has
sufficient PPE to replace the unsuitable masks? What is IHS
headquarters doing more generally to meet current PPE demand with
sufficient and quality supplies?
Answer. The IHS is actively engaged in finalizing an Interagency
Agreement (IAA) with the Assistant Secretary for Preparedness and
Response (ASPR) to provide assisted acquisition support for the
acquisition of supplies, including but not limited to, PPE, hygiene and
infection control products, portable mechanical ventilators, testing
supplies, nasopharyngeal Swabs/UTM and pharmaceutical drugs. IHS is
also part of the HHS Testing At Scale Workgroup which includes
representatives from multiple HHS agencies and programs. HHS Office of
the Assistant Secretary for Health currently provides IHS with Abbott
ID Now Analyzers, test kits, QC kits, nasal swabs, nasopharyngeal
swabs, and transport media.
Question 2. In your June 30 letter regarding the substandard PPE
procurement issue referenced in question one, you stated, ``the
contractor refused [to enter into a no-cost termination of the
contract] and submitted a certified claim for payment.'' What steps
will the Service take in response to the contractor's request for
payment? Please specifically confirm whether or not IHS will issue
payment to the contractor.
Answer. Due to questions concerning the contractor's
misrepresentation of fact in contract formation, a referral was made to
the HHS Office of Inspector General. In the meantime, the contractor
has not and will not be paid for items that did not meet the contract
requirements. Depending on the outcome of the OIG investigation,
additional administrative actions may be warranted.
Question 3. During a briefing with my Committee staff on March 18,
2020, IHS personnel indicated that the Service was not certain how many
intensive care unit (ICU) beds, negative pressure rooms, or ventilators
exist within the network of IHS federally-operated, Tribally-operated,
and urban Indian organization operated facilities (i.e., ITU system).
This uncertainty raises questions about IHS's preparedness to respond
to public health emergencies, especially outbreaks of infectious
respiratory diseases. How many ICU beds, negative pressure rooms, and
ventilators did the ITU system have prior to the President's
declaration of a national emergency concerning COVID-19 on March 13,
2020?
Answer. The IHS has the ability to report on various metrics within
the IHS, Tribal, and UIO (I/T/U) community including the number of
intensive care unit (ICU) beds, negative pressure rooms, and
ventilators that exist within the network of the IHS system. IHS can
currently only report on the sites that send data to the centralized
data store, so data may be incomplete.
IHS began collecting daily data from IHS direct facilities,
manually, on March 11, 2020, prior to the President's declaration of a
national emergency concerning COVID-19 on March 13, 2020. The table
below reflects additional data collected from Tribal and Urban
facilities on March 18, 2020. IHS can provide the information collected
by I/T/U operated facilities that submit data to our centralized data
store on the number of ICU beds, negative pressure rooms, and
ventilators. IHS did not experience ICU/Negative pressure room capacity
issues early on in the pandemic. As most hospitals have limited
capabilities for severely ill patients, many were referred to outside
facilities which could provide higher levels of care for critically ill
patients.
I/T/U Hospital Data for March 18, 2020
------------------------------------------------------------------------
# of
Negative Ventilators/ Hospital
I/T/U ICU Beds Pressure Available Beds
rooms Ventilators
------------------------------------------------------------------------
Federal (I) 27 102 70/58 482
Tribal (T) 6 15 9/9 772
Urban (U) 0 0 0 0
------------------------------------------------------------------------
Question 3a. How many ICU beds, negative pressure rooms,
ventilators, and temporary hospital beds did IHS facilities (federally-
operated, Tribally-operated, and urban Indian organization operated)
have as of the date of this hearing?
Answer. IHS is able to track and report on various metrics around
ICU beds, negative pressure rooms, ventilators and hospital beds at I/
T/U operated facilities. IHS began collecting data, manually, on March
11, 2020 and enabled data collection via a web based application on or
about April 14, 2020. Although tools were developed to streamline data
collection, the reporting, data accuracy, completeness, and integrity
is contingent upon each I/T/U site. Although IHS, to date, has over 789
I/T/U sites/facilities reporting, only a subset provide data on the
aforementioned metrics and the accuracy of the data is contingent upon
the site entering the data into the IHS web portal.
I/T/U Hospital Data for July 1, 2020
------------------------------------------------------------------------
# of
Negative Ventilators/ Hospital
I/T/U ICU Beds Pressure Available Beds
rooms Ventilators
------------------------------------------------------------------------
Federal (I) 27 123 123/122 603
Tribal (T) 28 48 123/112 533
Urban (U) 0 0 0 0
------------------------------------------------------------------------
Note: this data reflects the manual information reported
pending validation at the individual site level. Most of the
change in the tribal ICU bed data and ventilator counts
reported over time in this period reflects the vast improvement
over time in reporting from tribal sites. The change in federal
data between March 18 and July 1 is due to the increased number
of negative pressure rooms, ventilators, and hospital beds at
individual facilities. Individual facilities increased the
available hospital beds by staffing previously unstaffed beds
and creating temporary beds.
Question 3b. Prior to the declaration of the COVID-19 national
emergency on March 13, 2020, what steps did IHS take to prepare for
potential public health emergencies, including pandemics?
Answer. In January and February 2020, the IHS Chief Medical Officer
sent reports and information regarding the novel Coronavirus infection
(2019-nCoV) to IHS Areas, facilities, and providers. This information
was provided to advise and prepare health care facilities for the
potential impact to patients and the delivery of care in Indian
Country.
On March 6, 2020, RADM Weahkee activated the IHS Incident Command
Structure (ICS). The ICS was activated to mitigate negative impacts of
COVID-19 outbreak responses on IHS operations. The IHS senior
leadership used resources available from the Federal Emergency
Management Agency for development of the IHS ICS. Shortly after
activating the ICS, the IHS finalized the COVID-19 Concept of
Operations that guides clinical and administrative actions from
headquarters.
Prior to the COVID-19 national emergency, IHS had previously
developed a Provider Influenza Resources webpage that included several
documents developed for 2009 H1N1 and included a Resource Guide for
American Indian and Alaska Native Governments. See the following
websites: https://www.ihs.gov/flu/resources/providerinfluenza/ and
https://www.cdc.gov/h1n1flu/statelocal/DTLL_H1N1_Guide_10-7-09.pdf. IHS
also utilized the Office of the Assistant Secretary for Preparedness
and Response 2017 Update to the HHS Pandemic Influenza Plan, available
at https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-
2017v2.pdf. In addition, IHS created the IHS Headquarters Continuity of
Operations Special General Memorandum (SGM No. 16-01) for the
implementation and sustainment of responsibilities, as well as the
headquarters' office building Occupant Emergency Plan: Evacuation and
Shelter-in-Place Procedures.
Question 4. During a recent hearing before the House Subcommittee
on the Interior, Environment, and Related Agencies, \3\ you indicated
the ITU system has experienced an estimated third-party revenue loss of
30 to 80 percent due to the COVID-19 pandemic. You stated:
---------------------------------------------------------------------------
\3\ Indian Health Service COVID-19 Response: Hearing before the H.
Subcomm. on the Interior, Environment, & Related Agencies, 116th Cong.
(2019) (statement of Michael Weahkee, Director, Indian Health Service,
Dep't of Health and Human Services).
---------------------------------------------------------------------------
``It will likely take several years to make up for the loss of
third-party revenue collected previously . The initial allocation that
we received [from the CARES Act Provider Relief Funds]--the $500
million that went out from HHS to all of our federal, Tribal, and urban
sites--did help to offset some of those costs. But, we still have many
sites concerned about needing to furlough or even close their doors.''
Is IHS aware of any ITU facilities that have closed, reduced
operations, furloughed staff, reduced staff, or reduced services as a
result of third-party revenue losses caused by the COVID-19 pandemic?
If so please provide the number and service area location of the
facilities that have experienced these impacts.
Answer. IHS is aware of tribal and urban programs that have had to
reduce operations, furlough staff, and reduce staff and services due to
the impact of the COVID-19 pandemic. In addition to a nation-wide
reduction in non-essential surgeries, and in inpatient and outpatient
visits, almost all I/T/U facilities have reduced services for Dental
and Optometry to emergency only. However, a variety of factors have
gone into the decisions to implement short-term and long-term workforce
and operation reductions and other cost saving strategies due to the
economic and operational impacts of the COVID-19 emergency. For
example, a temporary furlough may be required due to a temporary lack
of revenue, risk reduction, an increase in costs for PPE, telehealth,
and staff pay, or reduction in work due to reduced patient visits
during the COVID-19 emergency.
Question 4a. What steps has IHS taken to ensure the ITU system can
participate equitably within the CARES Act Provider Relief Fund
allocation structures set up by HHS?
Answer. The IHS provided technical assistance, data, and other
support to HHS and operating divisions such as the Health Resources and
Services Administration in determining the allocation of $500 million
for I/T/U programs from the Provider Relief Fund. Full details of the
allocation are available here.
Question 4b. How much money would Congress need to provide for IHS
to fully address the third-party revenue shortfalls experienced by the
ITU system as a result of the COVID-19 pandemic?
Answer. It is difficult to say exactly how much funding would be
needed to address shortfalls as a result of COVID-19 given Tribes and
UIOs' third party revenue reporting requirements. I/T/U programs have
anecdotally reported losses ranging from 30--80 percent. \4\ Like
health care facilities across the country, revenues declined as health
facilities restricted the provision of routine care to prevent the
spread of Coronavirus. For example, some IHS facilities depend on
third-party revenue for up to 60 percent of their operating budget to
expand health services and pay staff.
---------------------------------------------------------------------------
\4\ For more information specific to UIOs, see the National Council
of Urban Indian Health's report ``Recent Trends in Third-Party Billing
at Urban Indian Organizations'' available at https://www.ncuih.org/
reimbursement.
Question 5. The CARES Act provided $1.032 billion in additional IHS
funding. Of that amount, Congress directed the Service to reserve up to
$65 million for electronic health record stabilization and support.
Please describe all activities related to electronic health record
stabilization and support IHS has undertaken with these funds.
Answer. The IHS will establish a project management office for
Electronic Health Record (EHR) modernization, support acquisition
planning, and stabilize the current technology environment and IHS
electronic health record system, the Resource and Patient Management
System (RPMS), in FY 2020. The project management office will focus on
governance, acquisition, program planning, Health IT design, and
organization change management. The funding is being used for some
federal positions and tribal stakeholder and engagement. Additionally,
the IHS is also piloting an eHealth Exchange connection to support
interoperability with the VA, DOD, Tribes, and other certified health
systems in the current and future Health IT infrastructure.
Question 5a. Using its current electronic health record systems, is
IHS able to track and report data on hospitalizations or adverse health
outcomes for COVID-19 patients in federally-operated IHS facilities or
within the ITU system as a whole?
Answer. The EHR provides for applications and utilities for
tracking of Hospital Adverse Events (Emergency Department and Hospital
Admissions) and population health data at each site. These results are
reported to the agency Incident Response team, aggregated and presented
in an agency dashboard for continuous monitoring.
The IHS is able to track and report data on hospitalizations or
adverse health outcomes for COVID-19 patients in federally operated IHS
facilities or within IHS, Tribal, Urban health care systems as a whole.
IHS leverages its Business Intelligence framework, which consists of a
centralized data store, or National Data Warehouse, that enables the
ability to collect, integrate and posture data for data reporting and
analytics. To date, IHS has over 789 I/T/U sites/facilities, within 198
service units, across 12 geographical areas are participating in daily
data collection and reporting of COVID-19 related metrics.
Question 5b. How do the ITU system's electronic health record
systems impact the ability to accurately monitor COVID-19 activity?
Answer. While every effort was made to adapt the IHS EHR to provide
adequate direct care capabilities to address COVID-19 for hospitals and
clinics, its decentralized design is not well suited for nationwide
surveillance and reporting to monitor COVID-19 activity. A standardized
EHR graphical user interface template and note titles were created to
electronically document COVID-19 patient visits. Training was provided
to the critical care teams for this COVID-19 template and the note
titles. Specific Document and Note Titles can be searched as part of
the EHR Community Alerts due to this standardized approach. Each
clinical site must make this update to their local EHR to utilize the
COVID-19 template.
Question 6. According to a recent Politico article, \5\ the
Department of Health and Human Services (HHS) and the Centers for
Disease Control and Prevention (CDC) are limiting or denying Tribal
epidemiology centers (TECs) access to federal public health databases,
including infectious disease surveillance databases. This limitation
appears to be in violation of the Indian Health Care Improvement Act
(IHCIA), which designates TECs as public health authorities under the
Health Insurance Portability and Accountability Act Privacy Rule, and
specifies that HHS must grant TECs access to ``data, data sets,
monitoring systems, delivery systems, and other protected health
information in the possession of the Secretary \6\.'' \7\
---------------------------------------------------------------------------
\5\ Darius Tahir & Adam Cancryn, American Indian Tribes Thwarted in
Efforts to Get Coronavirus Data, Politico (Jun. 11, 2020),
www.politico.com/news/2020/06/11/native-american-coronavirus-data-
314527.
\6\ 25 U.S.C. 1621m(e)(1).
\7\ 25 U.S.C. 1621m(e)(2).
---------------------------------------------------------------------------
How is IHS working with other agencies within HHS to ensure Tribes
and Native public health entities have equitable access to federal
public health data resources, including disease surveillance data, to
combat coronavirus spread within Native communities?
Answer. The IHS has longstanding cooperative agreements used to
fund the Tribal Epidemiology Centers (TECs). Since the beginning of the
COVID-19 response, the IHS has actively engaged on weekly calls with
TECs along with colleagues from the Centers for Disease Control and
Prevention (CDC). These calls are coordinated and led by the TECs and
include sharing best practices and group problem solving related to
national and regional COVID-19 response.
IHS is working with federal agencies, Tribes, and tribal programs
to ensure that tribal public health authorities receive the information
they need for public health planning and contact tracing. The IHS
remains committed to advocacy for such access to data as permitted by
law.
IHS has several ongoing coordinating efforts with CDC, including a
number of weekly operational coordination calls with CDC at various
organizational levels. The CDC is working with TECs to provide access
to needed data. CDC participated on an All TECs conference call on June
30, 2020 to discuss the process of transferring and receiving COVID-19
case data for all TECs. Data were transferred to the TECs on July 15,
2020 and will be updated every 2 weeks.
CDC met with the Urban Indian Health Institute (UIHI) on June 18,
2020 to discuss how to transfer and receive the COVID-19 data and
followed up on June 23, 2020 to provide technical assistance on
connecting via a secure server. CDC sent COVID-19 data to UIHI on June
24, 2020. As with the other TECs, CDC will continue to send the most
up-to-date COVID-19 data set to UIHI every two weeks.
Additionally, CDC worked with UIHI on a recent Morbidity and
Mortality Weekly Report (MMWR) on COVID-19 among AI/AN in selected
states: COVID-19 Among American Indian and Alaska Native Persons--23
States, January 31-July 3, 2020 (available at https://www.cdc.gov/mmwr/
volumes/69/wr/mm6934e1.htm
?s_cid=mm6934e1_w). CDC invited all TECs to participate in drafting
this MMWR. CDC is engaged with UIHI in other ways as well. For example,
they are discussing a second MMWR about COVID-19 among urban Indians
with UIHI.
CDC is working to address access to other data and will continue to
work with tribal and other involved stakeholders to do so. The IHS will
continue to support such data access through partnership with CDC.
Question 7. The IHS and Department of Veterans Affairs (VA) have
informed the Committee that they are drafting an inter-agency agreement
(IAA) to allow VA to treat non-Veteran IHS patients during public
health emergencies. The agencies involved have committed to keeping
Congress updated on the negotiations related to this IAA, including how
the IAA would address repayment for VA's costs to provide care for
uninsured non-veteran IHS patients. What is the current status of the
IAA?
Answer. The IHS continues to work with VA to execute an interagency
agreement for bed space, healthcare, resources, and staff.
Question 7a. What information about this agreement has IHS provided
to Indian Tribes and urban Indian organizations? And, has IHS sought
feedback from Indian Tribes or urban Indian organizations regarding the
structure of the IAA?
Answer. The IAA is between IHS and VA as Federal agencies. The IHS
has notified Indian Tribes and UIOs about the goals and intent of the
IAA, but has not actively sought feedback regarding the structure. For
example, the IHS has shared the lifesaving benefit of an IAA as
demonstrated through the coordination that occurred, when the Gallup
Indian Medical Center experienced a critical clinical issue. The
facility had four critical COVID-19 patients, all requiring mechanical
ventilation for life support. GIMC was unable to find any accepting
transfer beds. Without hospital decompression for these critical
patients, GIMC would not have been able to accept any subsequent
critical patients. The VA came through in this crisis, accepting the
patients at the Albuquerque VA Medical Center, allowing for
decompression of GIMC, and allowing GIMC to remain available for
additional critical patients.
Question 7b. Will the IAA be fully compliant with federal law
governing IHS patient balance billing prohibitions and IHS payer-of-
last resort provisions?
Answer. Yes, the IHS and VA must comply with Federal law. The IHS
is the payer of last resort by statute, 25 U.S.C. 1623(b). This
authority prohibits IHS from paying for care when there are alternate
resources. The IHS would not consider VA to be an alternate resource
for IHS beneficiaries who are non-Veterans, unless those non-Veterans
are eligible for care through VA. Based upon our conversations with VA,
we understand that VA has certain authority to provide care to non-
Veterans. However, those non-Veterans would not be eligible for
services from VA and VA would be required to charge. This includes care
provided to non-Veteran IHS beneficiaries at the request of IHS. The
IHS would defer to VA for a further explanation of VA's authorities and
requirements.
Question 7c. How many patients has the ITU system sent to VA
facilities for COVID-19 related care?
Answer. The information below is reported by the IHS Area offices.
Tribes and UIOs are not required to report this data to IHS, and the
data below may not be representative of all patients transferred to the
VA by Tribes or UIOs.
------------------------------------------------------------------------
Number of
IHS Area Facility patients
------------------------------------------------------------------------
Albuquerque Zuni Service Unit 1
Navajo Gallup Service Unit 14
Phoenix Colorado River Service Unit 1
------------------------------------------------------------------------
Question 7d. To the best of IHS's knowledge, has VA attempted to
bill IHS or any uninsured COVID-19 IHS patients sent to VA facilities
for treatment for the cost of providing this care?
Answer. IHS has currently received three bills from the VA for
patients referred to the VA in Albuquerque from the IHS Navajo Area.
Question 8. Congress directed CDC, the Substance Abuse and Mental
Health Services Administration, the Health Resources and Services
Administration, and the Administration for Community Living to reserve
over $200 million in COVID-19 resources for Indian Tribes, tribal
organizations, and urban Indian health organizations in the Coronavirus
Preparedness and Response Supplemental Appropriations Act, the Families
First Coronavirus Response Act, and the CARES Act. However, I've heard
concerns from Tribal leaders and urban Indian health program directors
relating to the administration and allocation of these funds. As IHS
Director, you are co-chair of the HHS Intradepartmental Council on
Native American Affairs (ICNAA) and a member of the White House's
Indian Country COVID-19 response team--roles that should allow to
monitor and advocate for changes to Tribal-specific COVID-19 programs
within HHS agencies. What kind of technical assistance or guidance is
IHS providing to these other agencies about best practices when
administering Tribal and urban Indian organization specific funding
during the coronavirus pandemic?
Answer. The IHS provides support to our sister agencies in
distributing COVID-19 funds for tribes and UIOs as needed. For example,
the IHS provided technical assistance to the CDC on the funding
methodology for the $40 million for Component A of CDC's new non-
competitive grant for tribal nations, consortia, and organizations.
Question 8a. How can Congress, the Administration, Tribes, and
urban Indian organizations work together to make sure future COVID-19
legislation addresses any administrative barriers or challenges
uncovered through implementation of previous COVID-19 related
legislation?
Answer. The IHS has unique funding authorities and mechanisms,
including the Indian Self-Determination and Education Assistance Act
(ISDEAA), which allow for streamlined distribution of funds. Our sister
agencies, which are not authorized to transfer funds under the ISDEAA,
often rely on grant mechanisms to award funds, which generally take
longer to award because they require the agency to post a solicitation
and review applications. Our sister agencies, like CDC, worked hard to
alleviate potential administrative burdens associated with grant
mechanisms and shorten the timeline as much as possible. However, when
bill language appropriates the funds to these agencies, or directs
funds to be awarded by grant or cooperative agreement, the agencies
must abide by that requirement and their other authorities. Tribal
leaders have long voiced opposition to the use of grant mechanisms due
to the administrative burden that comes along with this award type.
Question 9. The Committee has received reports from Direct Service
Tribes (DST) that the service units in their communities are not
coordinating appropriately with the Tribes' COVID-19 responses efforts.
In particular, several DSTs have noted that their IHS facilities
developed CARES Act spend plans in isolation without soliciting input
from the Tribes' and without regard for the resource needs identified
by each community. Please describe the policies and practices IHS has
implemented to ensure robust COVID-19 response coordination between IHS
service units and the Tribes they serve, including DSTs.
Answer. It is the policy of the IHS that consultation with Tribes
will occur to the extent practicable and permitted by law before any
action is taken that will significantly affect Tribes. Such actions
refer to policies that have Tribal implications and substantial direct
effects on one or more Tribe(s) regarding the relationship between the
Federal Government and the Tribe or Tribes, or on the distribution of
power and responsibilities between the Federal Government and the Tribe
or Tribes. The IHS tribal consultation policy can be found here:
https://www.ihs.gov/ihm/circulars/2006/tribal-consultation-policy/.
Question 9a. Did IHS require service units to consult with DSTs
regarding development of CARES Act spend plans? Please also describe
how federally-operated IHS facilities developed their CARES Act funding
spend plans.
Answer. The IHS tribal consultation policy addresses consultation
at the Service Unit level. All IHS Service Units have a process to
ensure that full consultation with all Tribes within the service unit
is coordinated, and that process may vary depending on the unique needs
and preferences of the Tribal communities served.
Question 10. On April 24, 2020, and again on May 11, 2020,
Committee staff requested information from IHS regarding its use of
volunteers in IHS facilities during the COVID-19 pandemic. Does IHS
have a way to track the total number of volunteers working within the
ITU system? If so, please provide an estimate of the number and service
area location of volunteers currently working within the IHS.
Answer. The information below is reported by the IHS Area offices.
Tribes and UIOs are not required to report this data to IHS, and the
data below does not include all volunteers that may be currently
working for Tribes or UIOs.
------------------------------------------------------------------------
IHS Area Facility Volunteers
------------------------------------------------------------------------
Great Plains Pine Ridge Service Unit 9
Navajo Chinle Service Unit 8
Navajo Gallup Service Unit 12
Navajo Kayenta Service Unit 10
Navajo Shiprock Service Unit 5
Navajo Winslow Service Unit 11
(Tribal)
Phoenix Whiteriver Indian 1
Hospital
Phoenix Urban Indian Center of 10*
Salt Lake
Portland Yakama Service Unit 3
------------------------------------------------------------------------
*Volunteers per month.
Question 10a. How does IHS ensure that all medical volunteers
seeking to work in an IHS facility are appropriately credentialed and
privileged?
Answer.It is the IHS policy to credential and privilege all
providers, whether they are employees, contractors, or volunteers.
Providers are credentialed and privileged according to the facility's
bylaws, policies, and accreditation standards. Each facility also
performs regular provider performance reviews and continuous credential
verification through the IHS Centralized Credentialing System.
Question 10b. Have provider vacancies within each IHS service area
grown or decreased during the course of the COVID-19 pandemic?
Answer. IHS's overall vacancy rate in February was 21 percent, and
the vacancy rate in May was 21 percent. At this point it does not
appear that COVID-19 has impacted vacancy rates.
Question 11. On April 23, 2020, IHS announced its allocation plan
for CARES Act funding--including reserving $10 million to support
sanitation and potable water needs. \8\ Please provide the Committee
with details of the recipients, including award amounts, of the $10
million included in the CARES Act to support sanitation and potable
water needs.
---------------------------------------------------------------------------
\8\ Press Release, Indian Health Service, Dep't of Health & Human
Services, IHS Statement on Allocation of Fiscal $367 million from CARES
Act (Apr. 23, 2020), available online at https://www.ihs.gov/newsroom/
pressreleases/2020-press-releases/ihs-statement-on-allocation-of-final-
367-million-from-cares-act/.
---------------------------------------------------------------------------
Answer. See attachment, CARES Act Project PDS List. *
---------------------------------------------------------------------------
* The information referred to has been retained in the Committee
files.
Question 12. In responses to a question for the record I posed last
year to ICNAA Co-Chair and Administration for Native American
Commissioner Jeannie Hovland regarding ICNAA's plans to discuss the
findings for the National Climate Assessment, she stated the Council
would address the assessment during the Council's next meeting in late
May 2019. \9\ Please provide an update on the status of discussions
within HHS, IHS, or the ICNAA regarding the findings in the National
Climate Assessment.
---------------------------------------------------------------------------
\9\ 45th Anniversary of the Native American Programs Act and the
Establishment of the Administration for Native Americans: Hearing
Before the S. Comm. on Indian Affairs, 116th Cong. 46 (2019) (statement
of Jeannie Hovland, Commissioner, Admin. for Native Americans, Admin.
for Children & Families, Dep't of Health & Human Services).
---------------------------------------------------------------------------
Answer. At the May 22, 2019 meeting of the Secretary's
Intradepartmental Council on Native American Affairs (ICNAA) Director
Patrick Breysse of the CDC National Center for Environmental Health/
Agency for Toxic Substances and Disease Registry (NCEH/ATSDR) outlined
the wide variety of environmental issues affecting Indian Country.
These issues include uranium mining in the Southwest, indoor air
pollution from dirty fuel types, and the contamination of water due to
mining. Funding to address environmental concerns was also discussed as
the Administration for Children and Families Administration for Native
Americans offers funding to American Indians, Alaska Natives, Native
Hawaiians, Pacific Islanders, and Native non-profits. Environmental
Regulatory Enhancement grants can be used to address environmental
concerns within Native communities.
The ICNAA also identified environmental issues as one of its
priority areas for collaboration across HHS operating divisions. The
ICNAA Chair and Vice Chair were able to raise this issue as a priority
area when addressing the Secretary's Tribal Advisory Committee (STAC)
in September of 2019. At the November 2019 ICNAA liaison meeting a
representative of the CDC NCEH/ATSDR office provided an update on the
upcoming Chlorinated Substances Conference that included coverage of a
national study on water and sanitation for Native communities. A
potential collaboration between CDC NCEH/ATSDR and the National
Institutes of Health (NIH) National Institute of Environmental Health
Sciences (NIEHS) on a 2020 conference was also discussed.
The question of addressing environmental issues collaboratively was
discussed among the ICNAA liaisons and the CDC outlined their plan to
host regional summits with tribes. The Tribal Environmental Health
Summit was one of these events, coordinated by the CDC National Center
for Environmental Health, to be held in March of 2020. However, due to
the COVID-19 outbreak, this event had to be cancelled. The CDC NCEH/
ATSDR's also had a presentation on addressing environmental health
concerns in Indian country planned for the National Indian Health Board
Tribal Public Health Summit in late March. This event was also
cancelled due to the COVID-19 pandemic.
______
Response to Written Questions Submitted by Hon. Lisa Murkowski to
Hon. Rear Admiral Michael D. Weahkee
Rear Admiral Weahkee, the impact that the pandemic has had on the
Alaska tribal health system is unprecedented. With tribal providers
forced to shut down elective procedures and clinics, the negative
financial impact cannot be overstated. It is estimated that third party
collections have dropped by 80 percent in some cases. More resources
are needed to sustain the Alaska Tribal health system, which is the
only provider in the vast majority of rural Alaska. Adequately
resourcing and removing unnecessary regulatory barriers are essential
for the Alaska Tribal health system to effectively limit the outbreak
of COVID-19 in Native communities and to properly treat Native
individuals that become infected. Water and sewer service in Alaska
Native communities have long been lacking, but the pandemic has
highlighted how essential adequate sanitation is for communities.
The importance of adequate water and sewer to prevent `water wash'
disease is very clear. CDC studies document skin and respiratory
infections in rural Alaska communities without water service to homes
that are 5 to 11 times higher than the national average. This is
especially critical now, since COVID-19 is a respiratory disease whose
spread can be prevented by hand washing, avoiding close contact with
others, and cleaning/disinfecting surfaces. Lack of water service in
these rural Alaska villages creates extreme challenges in practicing
two of these three basic prevention techniques.
Of the 190 Alaska Native communities, 32 are still not served with
in-home water/sewer. These communities typically have a washeteria
building (that is a combination water treatment plant, laundromat,
toilets and showers) that the entire community uses. Most of these
communities haul their water from the washeteria to their home in a 5-
gallon bucket, and haul their sewage from their home in a different 5-
gallon bucket.
Question 1. Many rural communities do not have access to adequate
water due to the high construction costs of projects in those
communities, particularly in Alaska. The IHS has established cost caps
per home that when approached both decrease the priority of the project
in the scoring system and limits the amount of funding available.
Would IHS be willing to eliminate, or at least raise, the cost caps
for projects that provide piped water and sewer into these unserved
communities?
Answer. The process for developing and updating allowable unit
costs is being reviewed with IHS Area staff. A proposal was developed
to move the program toward the use of more local, actual cost data
collected by IHS, Tribes, and tribal organizations. Until such time
that we have the data necessary to adjust the methodology, the current
approach will continue to be used.
When a project exceeds the allowable unit costs it is flagged as
economically infeasible. If other funding partners are willing to fund
portions of a project that is deemed economically infeasible, the IHS
is willing to provide funding for that project up to the allowable unit
costs amount.
The allowable unit costs are developed for each State, with the
exception of Alaska, which has three regional allowable unit costs to
account for geographical differences that impact costs of construction
within Alaska. The three regions are separated as follows: Northern
Region: $235,500; Southern Region: $169,000; and Central and Western
Regions: $197,500. IHS developed the total allowable unit costs (also
known as threshold costs) to provide a basis for developing overall
project economic feasibility. The allowable unit cost represents the
cost to construct all water, sewer, and solid waste facilities for a
typical home. The methodology used to develop these costs is based on
cost indices used by the IHS facilities program and the Department of
Housing and Urban Development.
Question 2. This pandemic has highlighted the need for community
public health measures, the most basic and important being access to
running water and sanitation. You've expressed willingness in past
hearings to work with tribal organizations in Alaska on overcoming the
issues of community contributions in ``Indian communities'' for
sanitation projects. With the current emergency situation, is IHS
willing to waive the non-Indian contribution requirement in ``Indian
communities?"
Answer. Since the inception of the IHS Sanitation Facilities
Construction (SFC) program nearly 61 years ago, the IHS has consulted
with and encouraged the participation of Tribes, States, other federal
agencies, local governments, non-profits and other potential
stakeholders in all phases of SFC projects. Collaborative sanitation
projects among IHS, Tribes, project participants, contributors and
other stakeholders is the original tenet for the SFC program. All SFC
projects are collaborative projects initiated by tribal request and
requiring participation by, contributions from, and coordination among,
the stakeholders. This approach helps ensure that communities are
jointly engaged in the development of projects and that the limited
funds appropriated for the program expressly benefit Tribal homes in
need of sanitation improvements. Advance planning prior to the
appropriation of federal resources is essential to ensure prorated
contributions for all ineligible units are received/confirmed prior to
the allocation of federal funds.
The SFC program works with a variety of funding partners and
assists communities with identifying potential sources of
contributions. The contribution requirement is premised on and
consistent with 42 U.S.C. 2004a(3). SFC CARES Act funds will be
administered as part of the IHS Facilities Appropriation and as such
are bound by P.L. 86-121, IHCIA, and the IHS policy/guidelines
developed through these two pieces of legislation.
Question 3. Testing Needs: Tribal health needs access to Cepheid
GenXpert testing kits. The Cepheid GenXpert analyzers are available at
regional hospitals, but the ATHS does not have adequate access to the
testing kits needed. These kits have been supplied to commercial
enterprises in Alaska, such as fishing. Will you work to provide equal
access for proper testing for COVID-19 to prevent its spread to rural
Alaska?
Answer. IHS Division of Acquisition Policy (DAP) established an
indefinite delivery, indefinite quantity (IDIQ) (ordering) contract
with Cepheid. This contract has numerous line items for various
molecular laboratory analyzer types, associated warranty and
maintenance agreements as well as the needed COVID-19 testing kits. IHS
Area Offices now have the ability to issue funded orders against this
contract once IHS senior leadership approves the order. The delivery
dates for orders will be dependent on availability due to global
demand. On August 12, 2020, DAP hosted an IHS-wide call to answer
questions about the contract and ordering process.
On August 20, 2020, IHS met with Cepheid representatives to discuss
COVID-19 testing kit supply allocations for IHS facilities, production
capacity for additional molecular laboratory analyzers, and the need to
continue a steady supply of testing kits for facilities with active
analyzers. A follow-up meeting was held on August 25, 2020, with IHS
Leadership and Cepheid representatives. This meeting covered IHS
expectations and Cepheid supply chain realities in regard to supporting
active analyzers with a steady supply of testing kits. Commitments were
made from Cepheid regarding the ongoing support of all active I/T/U
analyzers in the field, including those in rural Alaska through their
direct contract with the Alaska Native Medical Center. DAP intends to
have another IHS-wide call during the week of August 31, 2020 to
address any remaining questions or issues. Additionally, weekly
recurring meetings have been set up with Cepheid representatives to
discuss testing kit supply volumes, any increased capacities, and
outstanding logistics or administrative action items.
IHS has been successful in receiving the Abbott ID NOW COVID-19
point of care analyzers from HHS, which has an active contract with
Abbott. This contract has allowed IHS to receive analyzers and an
ongoing supply of test kits which are distributed through the IHS
National Services Supply Center to I/T/U Indian Health programs. To
date, the Alaska Area has received and distributed 31 Abbott ID
analyzers and tests kits in support of those 31 analyzers. Both Cepheid
and Abbott have confirmed they will work to increase production
capacity so as to allow further allocations to IHS of both analyzers
and test kits to be made available to I/T/U programs including those in
rural Alaska.
______
Response to Written Questions Submitted by Hon. Jon Tester to
Hon. Rear Admiral Michael D. Weahkee
Question 1. IHS acted swiftly to include funding for the newly
recognized Little Shell Chippewa Tribe in the FY 2021 Budget
Justification. However, the placeholder request of $2.6 million is
inadequate. Based on the Tribe's projected user population and the IHS
average per capita expenditure, the Tribe should receive an allocation
of roughly $8-10 million. Can you commit to updating IHS's initial
request in order to adequately reflect the true costs of providing
services to Little Shell?
Little Shell is also in the process of purchasing and renovation a
facility in hopes that its IHS allocation will be used to staff the
facility with IHS personnel. Can you ensure that the Tribe's allocation
is placed under the appropriate IHS account?
Answer. The IHS requested $2.6 million in the FY 2021 Budget
Justification for New Tribes funding for the Little Shell Band of
Chippewa Tribe. This funding level is an estimate, and the IHS has been
working with the tribe to finalize the necessary data to update the
amount. These funds are requested as New Tribes funding, consistent
with the IHS policy for newly federally-recognized tribes, outlined in
the Indian Health Manual.
We understand that the tribe plans on opening its own health care
facility in the near future. If that is the case, the tribe could
ultimately seek to operate its own program under the ISDEAA, and use
the New Tribes funding in support of that facility.
Question 2. The Rocky Mountain Tribal Epidemiology Center provides
support and information to Tribes in Montana and Wyoming yet they have
experienced significant roadblocks to accessing critical COVID data
from the IHS. How does IHS partner with TECs to make sure they can
access the IHS public health surveillance data they need to be
resources to Tribes?
Answer. Rocky Mountain Tribal Epidemiology Center (RMTEC) has an
active Epidemiology Data Mart (EDM) sharing agreement with the Indian
Health Service. Supported by this agreement, RMTEC receives routine
access to fresh, limited data sets several times a year. On July 30,
2020, the IHS technical managers of the EDM hosted a conference call
including RMTEC to review the elements of the EDM that are relevant for
COVID response.
Since the coronavirus pandemic began, the IHS has also worked to
expand data access for Tribal Epidemiology Centers (TECs) to aid their
response efforts. The IHS began sharing influenza-like illness
syndromic surveillance reporting with TECs, and is currently working to
develop standalone reporting to TECs for daily COVID-19 testing data
reported nationally to IHS Headquarters. In addition, the Oklahoma City
Area Office of IHS recently developed an agreement with the Southern
Plains Tribal Epidemiology Center to disclose certain IHS data
(including Protected Health Information in accordance with law) to
carry out specific activities directly related to the novel COVID-19,
including contact tracing efforts. On July 27, 2020, IHS Headquarters
sent notice of the finalized agreement to the remaining IHS Area
Offices to inform and support them in considering similar agreements
and partnership with TECs.
______
Response to Written Questions Submitted by Hon. Martha McSally to
Hon. Rear Admiral Michael D. Weahkee
Question 1. While early outbreaks were clustered in the northeast
part of the state, unfortunately we are now seeing more and more
hotspots in other tribes. For example, the White Mountain Apache Tribe
now has the highest infection rate per capita in Arizona. Rural tribes
in Arizona like White Mountain are in need of mobile test sites.
What is IHS doing to deploy mobile testing in rural areas? Does IHS
have enough employees and healthcare workers to conduct the necessary
amount of testing and provide treatment to these hard hit communities?
What steps could be taken to increase resources in these areas?
Answer. IHS continues to work with HHS and testing analyzer/kit/
swab/media suppliers to acquire testing materials for IHS and tribal
health programs. The IHS is not always able to immediately supply all
testing analyzer/kit/swab/media orders requested due to the lack of
supplies. Testing strategies vary by location and state. Several Tribes
are working with federal and state partners to conduct mass testing
events for their communities. From the onset of the pandemic, and
continuing into the future, the IHS will work with federal and Tribal
programs to support the availability of as many tests as possible. This
work will continue as determined by epidemiological factors (e.g.,
decreased number of cases), transmission, population immunity, and/or
through the availability of safe and effective vaccines which could
eliminate the need for broad scale testing. As of June 29, the IHS had
performed 272,935 tests, equating to 16 percent of the IHS User
Population, and exceeding the U.S. all races testing rate of 10.8
percent. As of August 29, the IHS had performed 650,223 tests, equating
to 39.1 percent of the IHS User Population, compared to the U.S. all
races testing rate of 25.4 percent. Also as of August 29, 36.8 percent
of reported tests completed have been done with the Abbott ID NOW
COVID-19 analyzer.
Question 2. As states begin to reopen, many are providing free
testing to any individual who requests it. This allows businesses to
open with confidence and have employees tested on a regular basis to
ensure safe operation. Are tribal members able to utilize IHS or 638
contract facilities to get free testing on demand?
Answer. Yes. Tribal members should contact their IHS or 638
contract health care facilities for specific information pertaining to
the testing programs available.
Question 3. Tribal communities in Arizona are among the least
digitally connected communities in the country. How has the lack of
access to broadband hindered the IHS in moving forward with
telemedicine opportunities throughout IHS facilities across the
country?
Answer. IHS significantly expanded telehealth capabilities across
the U.S. during the COVID-19 pandemic. The most successful telehealth
programs are those that provide video conferencing services within IHS
facilities. These types of telehealth visits are primarily physician-
to-physician or remote specialists to patients within an IHS facility.
IHS is able to expand telehealth between our facilities despite the
lack of broadband access to many tribal communities. Our primary
challenge is conducting patient-to-provider telehealth visits while the
patient is at home. The IHS has recognized the challenges with lack of
access to patient due to broadband connectivity. Some rural patients do
not have the necessary equipment such as a smart phone or laptop with
adequate signal or broadband connectivity in their home or community.
The IHS has supported telephonic telehealth visits to mitigate
these issues. Also, IHS plans on using the $95 million CARES Act funds
for central program management and services to provide a solid
foundation which supports long-term sustainability of telehealth
infrastructure and services. The literature has shown that system-level
planning and support for telehealth, as opposed to a fragmented
approach, improves continuity of primary care, access management,
economies of scale, and platform standardization.
Question 4. In my conversations with tribal leaders and healthcare
administrators, they have expressed concern about the loss in revenue
as ``elective procedures'' are put on hold to focus on coronavirus
response. Are IHS facilities or Urban Indian Health Organizations being
told to cancel elective procedures to address the pandemic? If so, has
the effect of the loss of revenue from the procedures been accounted
for when calculating the overall needs for IHS facilities?
Answer. The IHS has not advised tribal or urban Indian health
programs to cancel any procedures or patient appointments. However,
some tribal and urban Indian health programs have done so. I/T/U
programs have anecdotally reported third party revenue losses ranging
from 30--80 percent. \10\
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\10\ For more information specific to UIOs, see the National
Council of Urban Indian Health's report ``Recent Trends in Third-Party
Billing at Urban Indian Organizations'' available at https://
www.ncuih.org/reimbursement.
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In some IHS Areas, due to the need to preserve patient bed capacity
for COVID-19 patients and to prevent the spread of the COVID-19 virus,
elective surgeries were place on hold or rescheduled. The effect of the
loss of revenue from elective procedures has been accounted for when
calculating the overall needs at IHS. For example, in one Area due to
delaying elective surgery procedures, there has been a decline in third
party revenues and the Provider Relief Funds have been applied to the
hospitals' budgets to cover portions of revenue gaps in FY 2020. In
addition, other areas of the hospitals' budgets have been adjusted to
decrease expenses such as travel, training, equipment replacement, and
medical supplies used for elective surgeries.
Question 5. Among the factors that have contributed to higher
transmission rates on the Navajo Nation is lack of access to running
water in as many as 30 percent of homes on the Nation. This is
unacceptable. It has been reported that the Indian Health Service
Navajo Area has $620,000 to deploy water and sanitation facilities
projects on the Navajo Nation. It is my understanding that a survey of
all 110 chapters are complete and there are crews on the ground working
on a few identified projects.
Can you tell me how IHS is prioritizing which water projects to
pursue? Can you provide a list of the identified water projects, their
cost, and the status of each project?
Answer. The SFC Program developed guidance to ensure that priority
is given to homes without access to piped water. The priorities were
established to identify the immediate need as it relates to COVID-19
response activities:
Priority 1: Intent is to increase access to temporary water points
at no charge to homeowners with failed individual water systems,
cistern systems, and other tribal homes without access to piped water.
Priority 1 also provided public outreach information to increase
community knowledge about the availability of temporary water access
points, safe water hauling practices, and avoidance of septic tank
effluent.
Priority 2: Intent is to provide PPE for solid waste and wastewater
utility operators to ensure reduced work related virus exposures.
Priority 3: Intent is to provide emergency project funding to
address failed or non-operational individual water or sewer systems to
ensure that all tribal homes have access and subsequently to reduce
risk of coronavirus spread and basic needs such as hygiene. Also,
intent is to provide emergency project funding to address failed
treatment/distribution equipment and ensure that treatment chemicals
are available for continued operation of water supply and waste
disposal systems during the COVID-19 outbreak.
Based on these three priorities, Area SFC Programs were directed to
reach out to their tribal contacts to identify potential projects.
Projects were submitted to HQ Division of Sanitation Facilities
Construction for review and if they fit into these priorities the Area
received funding for the project.
The IHS has provided $5.15 million in CARES Act funding to the
Navajo Nation to fund a single project. This project will install
transitional water point in approximately 58 Chapters, support the
water fees from all Chapter operated water points for the duration of
the Navajo Nation COVID-19 Public Health Emergency (budgeted for two
years), offer Chapters up to 37,000 five gallon water storage
containers, and up to 3.5 million in water disinfection tablets for
distribution to residents of homes with no piped water. The project
will include development of public communication platform that will
contain information about the location, Chapter contact information,
operational hours, and public health messages about the benefits of
safe water collection at the water points and in-home safe water
storage. The map below shows the locations of the existing permeant
water points and transitional water points and their construction
status as of August 24, 2020. A summary of these status is also
provided in the table below. *
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* The information referred to has been retained in the Committee
files.
Question 6. It has been reported that the Tsehootsooi Medical
Center, or TMC, in Fort Defiance, Arizona still doesn't not have enough
testing capabilities to test everyone that requires a COVID-19 test. In
fact, Tsehootsooi Medical Center has reported to directing people to
Gallup Indian Medical Center for testing. This is due to TMC having a
limited number of testing cartridges for the Abbott ID NOW COVID-19.
Though TMC also has the Cepheid GeneXpert analyzer, which is more
reliable than Abbott ID NOW COVID-19, TMC has a limited number of
testing cartridges and swabs to be able to test at the rate needed for
the community and surrounding areas. Additionally, the Abbott ID NOW
COVID-19is notorious for providing false negatives, which results in
providers needing to double-check the Abbott ID NOW COVID-19by either
using the GeneXpert or sending the specimen to a commercial laboratory,
overusing the limited supply of swabs and cartridges.
Does IHS have a plan to improve testing capacity at the P.L. 93-638
health care facilities? If so, please share this plan with the
Committee. If not, when can IHS provide a plan to the Committee?
Answer. IHS continues to work with Tribes, Tribal organizations,
HHS, and testing analyzer/kit/swab/media suppliers to acquire testing
materials for I/T/Us. The IHS is not always able to immediately supply
all testing analyzer/kit/swab/media orders requested due to the lack of
supplies. Testing strategies vary by location and state. Several Tribes
are working with Federal and state partners to conduct mass testing
events for their communities. From the onset of the pandemic, and
continuing into the future, the IHS will work with Federal, Tribal, and
UIO programs to support the availability of as many tests as possible.
This work will continue as determined by epidemiological factors (e.g.,
decreased number of cases), transmission, population immunity, and/or
through the availability of safe and effective vaccines which could
eliminate the need for broad scale testing. As of June 29, the IHS had
performed 272,935 tests, equating to 16 percent of the IHS User
Population, and exceeding the US all races testing rate of 10.8
percent. As of August 29, the IHS had performed 650,223 tests, equating
to 39.1 percent of the IHS User Population, compared to the U.S. all
races testing rate of 25.4 percent. Also as of August 29, 36.8 percent
of reported tests completed have been done with the Abbott ID NOW
COVID-19 analyzer.
With regards to testing analyzers, the Gallup Indian Medical Center
performed a correlation study comparing the accuracy of the Abbott ID
NOW COVID-19 analyzer with that of the Cepheid GENEXPERT analyzer. The
Abbott COVID instrument has been found by IHS to be acceptable for
patient testing. The ABBOTT instrument tested at 98.9 percent accuracy
to that of the Cepheid instrument. Independent correlation testing done
by the Oklahoma City Area IHS also found the Abbott to be acceptable
for use.
On May 14, 2020, the Food and Drug Administration (FDA) released
notice to the public of possible concerns with the accuracy of test
results obtained on the Abbott ID NOW analyzers for COVID-19. Early
data had suggested the potential inaccuracies of results, specifically
false negatives. IHS provided awareness and guidance for interpretation
of data per FDA recommendations on May 15, 2020. IHS also shared among
its users, technical documents that were provided by Abbott following
the FDA news release of validity of test results on the Abbott ID NOW
analyzers. On June 11, 2020, Abbott released updated technical
documents supporting these changes; IHS also shared this information
with its Abbott users. Current product data and manufacturers updates
can be found here: https://www.abbott.com/IDNOW.html.
We agree that a negative test should be treated as presumptive and,
if inconsistent with clinical signs and symptoms or necessary for
patient management, should be tested with an alternative molecular
assay. Negative results do not preclude SARS-CoV-2 infection and should
not be used as the sole basis for patient management decisions.
Negative results should be considered in the context of a patient's
recent exposures, history, presence of clinical signs and symptoms
consistent with COVID-19.
However, many IHS federal and tribal sites still find the test
highly useful, as a positive test result is returned in under 15
minutes, and can allow for definitive management in that case. Negative
results should be treated as presumptive and tested with an alternative
FDA authorized molecular assay, if necessary for clinical management,
including infection control.
Cepheid testing supplies are in very short supply globally, and it
is expected that the situation for the scarce availability of those
supplies will likely persist.
Question 7. It is my understanding that the Navajo Area IHS is
operating isolation units at Shiprock, Chinle, and Gallup for
individuals to safely self-isolate. How is IHS communicating to
individuals who wish to self-isolate at the IHS controlled Isolation
Units and what is the process for a patient to access those services?
What is the occupancy rate of the Alternative Care Sites and Isolation
Units in Shiprock, Chinle, and Gallup? Could you share with the
Committee the occupancy rate of the care Sites and Isolation Units from
the date of initial operation?
Answer. In the Navajo Area, IHS patients can be referred to non-
congregate isolation sites by health care providers or public health
nurses after receiving confirmation of COVID-19 positive testing. A
Patient Mobilization Center at the Navajo Area Office refers patients
to non-congregate isolation sites and assists with patient transfers.
Isolation site Operational Managers have been assigned on the west and
east sides of the Navajo Nation. The managers oversee admissions to the
non-congregate isolation sites. In addition, a patient can also choose
to use an isolation kit to stay on their own property to effectively
isolate. The kits include water, food, cleaning supplies, and a tent.
Currently, patients are not being referred to congregate alternative
care sites (ACS).
As of July 7, 2020, the occupancy rate at the congregate ACS sites
and non-congregate isolation sites are as follows:
Congregate ACS
-- Chine, AZ: 12 patients, opened on May 14, 2020 and now
converted to a congregate isolation site in standby status.
This site will need support services (e.g., food service, waste
removal, security, cleaning, and laundering services) in place
before the site reopens for isolation services. The Navajo
Nation Unified Coordination Group (UCG) is presently pursuing a
contract for the support services.
-- Gallup, NM: 35 patients, opened on April 25, 2020 and
closed on June 17, 2020.
-- Shiprock, AZ: no patients, opened on May 15, 2020 and now
demobilizing.
Non-congregate Isolation Site
-- Aztec, NM hotel: 45 patients, received first patient on
May 9, 2020.
-- Chinle, AZ hotel: 102 patients, received first patient on
May 20, 2020.
-- Farmington, NM hotels: 6 patients, received first patient
on June 7, 2020.
-- Gallup, NM hotels: 800 patients, received first patient
on March 24, 2020. These hotels were leased by the State of New
Mexico for COVID-19 isolation purposes. The Gallup Indian
Medical Center and the Navajo Area Patient Mobilization Center
were approved by the State of New Mexico to place isolation
patients in an isolation hotel room as needed.
-- Kayenta, AZ hotel: Navajo Nation UCG is presently
pursuing a contract for this site.
Question 8. The Navajo Nation views the Navajo Area Indian Health
Service (NAIHS) as a valuable partner in the delivery of health
services to the Navajo people. The IHS has a federal responsibility to
support the Navajo Nation and our P.L. 93-638 health facilities and
tribal health programs during this pandemic.
On March 13, 2020, shortly after the first reported case on the
Navajo Nation, the Navajo Health Command Operations Center was
activated to coordinate and oversee the directions, instructions, and
policies coming from the Navajo Department of Health related to COVID-
19. Nearly two (2) months after the detection of the initial positive
COVID-19 cases on the Navajo Nation, on May 14, 2020, the Navajo Nation
created a Unified Command Group (UCG) to coordinate COVID-19 response
activities and efforts.
The purpose of the UCG is to provide a unified, interactive
approach to delivering services to individuals and families impacted by
COVID-19. The UCG medical and public health branches are co-led by the
Navajo Nation, NAIHS, and P.L. 93-638 representatives.
Why did it take Navajo Area IHS two months to establish coordinated
approaches to the Navajo Nation?
Answer. The Navajo Area IHS stood up its Emergency Operations
Center on February 25, 2020 in preparation for COVID-19 activities.
Additionally, the Navajo Area IHS Leadership was in immediate contact
with the Navajo Nation President and Vice President and joined the
Navajo Nation's COVID-19 Task Force on February 28, 2020. The purpose
of the Task Force was to begin interagency communication, coordination
and planning in preparation for the possibility of COVID-19 cases on
the Navajo Nation. The Navajo Area IHS Leadership participated in
multiple Task Force meetings beginning in March and attended Navajo
Nation-sponsored Logistics Section meetings three days per week
beginning on March 27, 2020 and continues to participate in these
coordination meetings to date.
On April 6, 2020, at the request of the Navajo Nation, the Navajo
Area IHS began serving as a member of the Nation's incident command
structure. On May 7, 2020, the Navajo Nation, in coordination with FEMA
representatives and the Navajo Area IHS representatives, established a
Unified Coordination Group (UCG) structure to incorporate the various
Tribal, state, federal, volunteer, and other organizations into the
command structure. The draft UCG structure underwent reviews by several
Tribal and federal programs and the final structure was officially
released on May 14, 2020. Since that time, the Navajo Area IHS
continues to support the Navajo Nation and participates as an active
member of the UCG.
Question 9. The Hopi Tribe is landlocked directly in the middle of
the Navajo Reservation so when the pandemic flared at the Navajo Nation
it completely surrounded Hopi. During those early days I heard from the
Hopi Tribe that they could not obtain real time test and infection
information from the IHS. This information was crucial for Hopi
leadership to make appropriate decisions including quarantining
individuals, closing villages, and similar actions. Even more
disturbing is that without this information Hopi first responders were
placed in unnecessary danger. What has the IHS done to aid in the flow
of information from its facilities to the communities they serve,
including the Hopi?
The Hopi clinic continues to struggle with maintaining an adequate
supply of PPE and testing kits. Governor Ducey has helped the Hopi
Chairman secure supplies recently but it is an ongoing problem. How is
IHS working with Hopi to ensure the clinic has the supplies that it
needs?
Answer. The IHS is the primary provider of public health services
for the Hopi Tribe. Prior to the COVID-19 response, the Hopi Tribe did
not have formal recognition as the Public Health Authority and
therefore was not receiving direct data communication from IHS. Hopi
Tribe requested formal recognition by the IHS as the Public Health
Authority for the COVID-19 response on April 15, 2020. Since that time,
the tribe has received the necessary information needed to serve the
public health purpose. The IHS Phoenix Area has established a Public
Health Authority process to streamline additional requests from Tribes
throughout the region, thereby ensuring timely communication of
information needed to streamline decisionmaking processes.
The IHS has been given priority access to rapid point-of-care
COVID-19 test systems as part of White House efforts to expand access
to testing in rural communities. The IHS received 250 ID NOW COVID-19
rapid point-of-care test systems which were distributed to federal and
tribal health care facilities throughout Indian Country in 31 states.
This test allows for medical diagnostic testing at the time and place
of patient care, can provide COVID-19 results in under 13 minutes, and
expands the capacity for coronavirus testing for individuals exhibiting
symptoms, as well as for healthcare professionals and the first
responder community. Additionally, this will save personal protective
equipment and ensure our critical workforce is safe and able to support
the response, as only gloves and a facemask are necessary to administer
this rapid point-of-care test.
IHS facilities generally have access to testing for individuals who
may have COVID-19; however, there are nationwide shortages of supplies
that may temporarily affect the availability of COVID-19 testing at a
particular location. In addition to using rapid point-of-care testing
systems, clinicians, including those at IHS, collect samples with
standard synthetic fiber specimen collections swabs and access
laboratory testing through public health laboratories in their
jurisdictions. The IHS also utilizes commercial and other approved
laboratories to test specimens as those services are available.
Regarding the supply of resources, there are nationwide shortages
of PPE. The Phoenix Area coordinates with the IHS NSSC center for PPE
orders and allocations for the Hopi Health Care Center, as well as
coordinating approvals of PPE donations from outside sources. When PPE
is not readily available through regular direct purchase mechanisms,
the Phoenix Area procures PPE internally through the Strategic National
Stockpile in coordination with the ADHS/FEMA.
The Phoenix Area works closely with facility supply chain managers
to monitor PPE inventory and mobilize procurement strategies when burn
rates indicate less than a 4-week PPE for gowns, face masks, gloves,
N95 respirators, and face shields. As of July 24, 2020, the Hopi Health
Care Center was >28 days for all monitored PPE elements.