Letter to CMS in re: Waiver for Minnesota Urban Indian Health Board 1115 Demonstration

June 21, 2017

The Honorable Seema Verma
Centers for Medicare and Medicaid Services
200 Independence Ave, SW
Washington, DC 20201

In re: Waiver for Minnesota Urban Indian Health Board 1115 Demonstration

Dear Administrator Verma:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents over forty urban Indian health programs (UIHPs) across the nation which provide high-quality, culturally-competent health care to urban Indians, I urge the Centers for Medicare and Medicaid Services (CMS) to approve the Section 1115 waiver request (Indian Health Board of Minneapolis 1115 Demonstration) which has been submitted by Minnesota’s (MN) Department of Human Services (DHS). This waiver request would allow organizations in Minnesota that are dually certified as UIHPs and Federally Qualified Health Centers to be eligible for the maximum Federal Medical Assistance Percentage (FMAP) and receive the encounter rate for Medicaid services provided to AI/AN people and for MN.

“Urban Indian” refers to American Indian/Alaska Native (AI/AN) people who do not live on reservations, often because of forced government relocation or lack of economic opportunity. In fact, more than 70% of AI/AN now live in urban areas, as compared with 45% in 1970 and 8% in 1940. NCUIH was established to represent the interests of UIHPs before the legislative and executive branches, and the organization serves as an educational and training resource for UIHPs.

Urban Indian Health Program Funding

There are 43 UIHPs across 19 states, and while the general urban Indian population exceeds well over 70% of the AI/AN population, UIHPs only receive funding from a single IHS line item- the urban Indian line item, roughly only 1% of the IHS budget.

Because of the lack of resources UIHPs receive through IHS, they must fight for other sources of funding in order to keep their doors open and continue the trust responsibility that the federal government has. IHS funds only make up about 30% of the average UIHP budget. Therefore, it is imperative to provide a path to support UIHPs in receiving more resources to provide quality care and additional services for their AI/AN patients.

Devastating Health Outcomes in Indian Country

The health care needs of urban Indians addressed by NCUIH members are complicated by economic disadvantage. Almost twice as many AI/AN people live in poverty as Americans generally, and in many large cities AI/AN people experience poverty at levels comparable to and even in excess of the poorest reservations. According to the Indian Health Service (IHS), “(u)rban AI/AN people have lower incomes, with 41.2% of urban AI/AN people with incomes under 200 percent of the Federal Poverty Level compared to 28 percent of all races…” Compounding the issue, reports IHS, urban AI/AN people “are less likely to access preventive care, do not have culturally competent options, and do not have adequate health insurance coverage.”

Urban AI/AN people experience a multitude of serious challenges to their physical and mental health—alcoholism, suicide, high unemployment, behavioral health issues, and racial prejudice. According to IHS, “(a)lcohol- induced death rates are 2.8 times greater for urban AI/AN people than all races in urban areas”, and they “have greater mortality for chronic disease compared to all races in urban areas…Nationally, infant mortality is higher among AI/AN people compared to the urban all race population…Urban AI/AN youth are at greater risk of suicide…Urban AI/AN people have higher rates of HIV-mortality in certain (areas)…Urban AI/AN people are more likely to engage in health risk behaviors…”

In asking DHS to go forward to CMS with its waiver request, the Indian Health Board of Minneapolis (IHBM) has provided ample statistical evidence of significantly adverse health disparities experienced by the AI/AN people it serves in MN’s Hennepin and Ramsey counties. In fulfilling its Trust Responsibility to provide health care to AI/AN people, the federal government uses IHS, more specifically an I/T/U system by which services are provided by the agency, Tribes, and UIHPs. However, IHS is significantly under-resourced, usually funded at between 50% and 60% of need; sometimes, the agency runs out of money in the middle of the fiscal year, which can force patients to forego serious care and delay basic care. While health care spending per capita across the nation was more than $9,990 in 2016, IHS spending on health care per user was just $2,834.

There are other factors that influence health, but there’s no denying the overarching importance of money. IHS has told the Office of Management and Budget that “the alarmingly inadequate access to health services by AI/AN (is) due to underfunding of IHS”.

Medicaid and Indian Country

Medicaid, the federal government’s program to provide health care to low- income Americans, is of particular importance to AI/AN people. At least one- fifth of the more than five million AI/AN people in the United States are enrolled in Medicaid. AI/AN people are disproportionately reliant on Medicaid as a population even though they are a fraction of a percent of the Medicaid budget. It is vital to ensure AI/AN have access to quality and culturally competent health care pursuant to the trust obligation. Enrollment of AI/AN people in Medicaid helps to relieve the financial burden on IHS and promotes compliance with the Trust Responsibility.

In recognition that the Trust Responsibility for the provision of health care to AI/AN people belongs to the federal government, not the states, the federal government reimburses states for Medicaid services received through IHS and tribal facilities, and pays all of the costs, i.e., 100% FMAP.

The following chart illustrates the number of AI/AN who receive Medicaid from each state with UIHP(s), and the number of AI/AN eligible for Medicaid but remain uninsured based on 2015 Census Bureau Data.


100% FMAP for UIHPS can greatly improve health outcomes for the AI/AN population

While the federal government reimburses states for services received through IHS and tribal facilities for Medicaid services the agency provides to AI/AN people, the FMAP for AI/AN people treated by UIHPs is much less, with an average of 57%. There is no reasonable justification for this inequity. It has been acknowledged by both the legislative and executive branches that the Trust Responsibility to provide health care to AI/AN people follows them off of reservations and into urban areas.

It is also understood that this inequity could be corrected legislatively, either by explicitly adding UIHPs to the law, or administratively, as requested by DHS in this instance for certain qualified providers.

Extending 100% FMAP coverage to UIHPs would, according to IHS,

“help both the State and the UIHP access more federal dollars to support health care. While these federal dollars would initially do nothing more than supplant existing state contributions for care, in the longer term, the increased FMAP could allow UIHP…to negotiate with the State for higher rates of payment. The higher rates of payment could support the expansion of UIHP service offerings and improve patient care.”

The cost impact would be slight--as little as $2.3 million per annum, according to IHS, for all UIHPs combined. For a minimal investment—100% FMAP for all AI/AN people—CMS or Congress could significantly improve health care for urban Indians, help to replenish IHS’ depleted coffers, and reaffirm that the Trust Responsibility must be borne by the federal government, not the states.

Compliance with DHS’ waiver request would not completely address the inadequate Medicaid reimbursement experienced by UIHPs. However, it would begin to address the problem in a particular area with significant numbers of urban Indians, who are very ably served by IHBM.

UIHPs like IHBM are eminently deserving of more support. UIHPs are public- private partnerships, which usually derive no more than one-third of their budget from IHS appropriations. Instead, they must raise revenues from a variety of public, private, and non-profit sources, while still managing to provide high-quality, culturally competent health care. UIHPs provide health care and other services that meet the needs of the patients in their communities. Although they obviously experience ebbs and flows from having to fend for themselves, it should be noted that UIHPs strive while under great pressure and financial restraints. IHBM deserves the support and encouragement it would receive if CMS complies with DHS’ waiver request so that it can receive the Medicaid encounter rate. Indeed, the over forty other UIHPs also deserve the same support and encouragement.

Thanks for your consideration. Please contact NCUIH’s Director of Governmental Affairs Francys Crevier (fcrevier@ncuih.org) if you have any questions about our position on DHS’ waiver request.


Ashley Tuomi
National Council of Urban Indian Health