Letter to VA in re: Comments on Continuity of Health Care Access for Veterans

Submitted via: tribalgovernmentconsultation@va.gov

November 4, 2016
Dr. David J. Shulkin Chief Executive
Veterans Health Administration
810 Vermont Avenue, NW,
Washington, DC 20420

RE: Comments on Continuity of Health Care Access for Veterans

Dear Dr. Shulkin:

On behalf of National Council of Urban Indian Health (NCUIH), I write to submit comments in response to the September 12, 2016 Dear Tribal Leader Letter in regards to Consolidating Programs of Departments. NCUIH fully supports the increasing the quality of care in the Veterans Affairs (VA) system and appreciates the VA for allowing Tribal comments, but NCUIH has some concerns regarding the VA-IHS MOU and reimbursement agreements.

The National Council of Urban Indian Health was founded 18 years ago to represent the interests of Urban Indian Health Programs (UIHPs) before Congress and Federal agencies, and to influence policies impacting the health conditions experienced by urban American Indians and Alaska Natives (AI/AN).The National Council of Urban Indian Health is a 501(c)(3), membership-based organization devoted to support the development of quality, accessible, and culturally sensitive health care programs for AI/AN living in urban communities. NCUIH fulfills its mission by serving as a resource center providing advocacy, education, training, and leadership for urban Indian health care providers. NCUIH strives for healthy American Indians and Alaska Natives living in urban settings, which comprise over 70% of the AI/AN population, supported by quality, accessible health care centers and governed by leaders in the Indian community.

NCUIH represents urban Indian Health Programs receiving grants under Title V of IHCIA and the American Indian and Alaska Natives they serve.

NCUIH praises the initiatives VA has taken to improve the quality of healthcare AI/AN Veterans receive. We support Tribal requests that in order to uphold and respect Tribal sovereignty, the agreements cannot be consolidated and the rates should stay the same. We also ask for a more efficient path to finalize agreements that do not take four years.


Creation of a VA, Tribal and Urban Technical Advisory Health Care Committee

One of the VA’s goals is to connect veterans with health care services through raising awareness of available health services and working to remove barriers to care. NCUIH strongly supports the full inclusion of the Indian health system, I/T/U (IHS, Tribal and urban), as key partners in the VA’s community care network.

Pursuant to the Memorandum of Understanding (MOU) between the Department of Veterans Affairs (VA) and Indian Health Service (IHS) from 2010, the VA has a trust responsibility to engage in Tribal consultation and support the government-to- government relationships with federally recognized Tribes as well as a fiduciary responsibility to AI/AN in urban settings.

The MOU recognizes “the importance of a coordinated and cohesive effort on a national scope, while also acknowledging that the implementation of such efforts requires local adaptation to meet the needs of individual tribes, villages, islands, and communities, as well as local VA. IHS, Tribal, and Urban Indian health programs”, thus supporting and recognizing the importance of coordinated and comprehensive efforts to work with the entire I/T/U system. After the initial agreement was signed, and consistent with the law and spirit of the MOU, the now former IHS Principal Deputy Director Roubideaux travelled to UIHPs and encouraged them to take advantage of the new VA IHS agreement.

NCUIH requests that the VA include Urban Indian Health Programs (UIHPs) and build strong relationships with them and Tribal governments in order to increase the number of AI/AN Veterans who access VA programs, benefits, and services. The VA, IHS, and Tribal partners have achieved significant successes through joint workgroups on increasing care coordination, health care services, and reimbursement for training and cultural competency for eligible Veterans. While those partnerships are successful, there are still many urban Indian veterans not being served. NCUIH recommends creating a committee with both Tribal and urban Indian representatives to ensure that the VA is serving all veterans in Indian Country.

This committee would allow to successfully and fully implement mutual goals set forth in the MOU such as the promotion of “patient-centered collaboration” and the facilitation of “communication among VA IHS, American Indian and Alaska Native Veterans, Tribal facilities, and Urban Indian Clinics…” as well as the establishment of “effective partnerships and sharing agreements among VA headquarters and facilities, IHS headquarters and IHS, Tribal, and Urban Indian health programs in support of American Indian and Alaska Native Veterans…” which are applied through meaningful consultation with Tribal and urban communities that have a working knowledgeable of providing care to their AI/AN veteran communities would increase access to medical care.

Additionally, NCUIH urges the VA to recognize that while IHS plays significant role in the funding and support of Tribal Health Programs (THPs) and UIHPs, it cannot be the decisive voice for them. NCUIH strongly urge the VA to establish direct communication with Tribes and UIHPs regarding all aspect of implementation of any agreements and MOUs and provide Tribes and UIHPs with the opportunity to review draft of such agreements before they are submitted to Congress.

Lastly, pursuant to VA-IHS MOU, and in the spirit of full inclusion of Indian health system I/T/U, NCUIH urges that Tribal and UIHP representatives are at the same table with IHS in the negotiations or discussions with VA.

Improve Access to Medical Care

Many AI/AN Veterans experience various challenges in receiving VA health care benefits in remote environments and even in urban settings.

IHS/Tribal/Urban Health Programs provide exceptional culturally competent medical care closer to home. NCUIH supports efforts to promote and expand upon putting AI/AN Veterans in control of how, when, and where they wish to be served quality health care services. NCUIH recommends that the VA work with UIHPs to provide additional outreach and advocacy resources to ensure that AI/AN Veterans are aware of various health care benefits available in their community.

Access to care for our veterans is an important priority for UIHPs, and while the VA has challenges with long wait times, UIHPs do not. When asked at the National Indian Health Board conference why the VA has not worked with the UIHPs to fulfill the federal government’s trust responsibility, the VA stated that there are VA offices in urban settings and working with UIHPs was not necessary. If the solution to helping AI/AN veterans was only to have a VA office nearby, then the problem would not exist. UIHPs can access AI/AN Veterans in a way that the VA cannot cultural competency and better wait times. These veterans may not go to the VA, but they do go to our UIHPs to receive health services as well as other services and community events. Their friends and families go to UIHPs, and many tribal members prefer UIHPs as well. UIHPs gladly provide veterans with services but are very limited in funding as they have less than 1% of the IHS budget. NCUIH proposes that in order to improve access, the VA must work with UIHPs as well as allow UIHPs to host a tribal office to process VA benefits. NCUIH would be happy to work with the VA to make this a reality and truly serve our Native veterans.

To provide an example of how UIHPs are instrumental in saving both Native and non- Native veterans, the VA in Phoenix is walking distance to Native Health, a UIHP. The Office of the Inspector General released a report recently that stated 215 deceased patients were awaiting specialist consultations on the date of their death. Native Health provides primary care, dental and behavioral services, and could have provided care to Native veterans which would allow the VA to focus on specialty services. Many of these deaths could have been prevented if the VA partnered with UIHPs. NCUIH highly recommends that the VA expedite MOUs with UIHPs in order to provide more efficient care.

Additionally, as required by the Veterans Access, Choice, and Accountability Act of 2014, IHS and the Department of Veterans Affairs (VA) worked jointly to submit a report to Congress on the feasibility and advisability of entering into and expanding certain reimbursement agreements for costs of direct care services provided to eligible Veterans who are not American Indian or Alaska Native. According to the “Report on Enhancement of Collaboration between the Department of Veterans Affairs and the Indian Health Service” a national Reimbursement Agreement for Direct Health Care Services was signed on December 5, 2012 between IHS and the Veterans Health Administration. Under this national agreement, VA reimburses IHS facilities for direct health care services provided to eligible Al/AN Veterans. As of January 2015, the national agreement between IHS and VA covers 108 IHS facilities, and VA has successfully negotiated 81 direct care services reimbursement agreements with Tribal Health Programs (THPs). Total reimbursements since December 5, 2012, exceeded $24 million covering over 5,500 eligible veterans. Despite the VA’s commitment to the entire I/T/U system as per the VA-IHS MOU, UIHPs are currently excluded or do not have reimbursement agreements with VA.

Fully implement National VA-IHS MOU

NCUIH fully supports the Tribal recommendation of full implementation of National VA-IHS MOU.

The VA-IHS MOU provides the least administrative burden for VA, IHS, and Tribal Health Programs (THPs) while maintaining successful facilitation of patient care. However, Section 405(c) of the Indian Health Care Improvement Act (IHCIA) has not been fully implemented. The current national agreement as well as majority of agreements with THPs do not include reimbursement for Purchased/Referred Care (PRC). Pursuant to IHCIA provisions, IHS and THPs are to be reimbursed for care provided to AI/AN Veterans including specialty and referral care provided through IHS and THPs.

Inclusion of eligible Veterans who are not American Indian or Alaska Native

The IHCIA Section 405(c) provides the authority for IHS and THPs to receive reimbursement for non-Native veterans. NCUIH supports Tribes’ strong recommendation to VA and IHS to utilize the National VA-IHS MOU to provide care to non-Native Veterans and utilize agreements for reimbursement of the costs of services provided to eligible Veterans who are not AI/AN.

Under Section 813 of the IHCIA, Tribes and Tribal organizations may elect, but are not required, to provide health care services to non-beneficiaries operated health care program. The 25 U.S.C. § 1680c., evidently states that “IHS may also serve non-AI/ANs with the consent of the Tribes being served by the IHS directly.”

A significant amount of Tribes and Tribal organizations, and Urban Indian Health Programs already serve non- IHS-eligible beneficiaries including vast number of non- Native Veterans. Section 405(c) of the IHCIA, as amended and enacted by the Affordable Care Act (ACA), requires the VA to reimburse the IHS, an Indian Tribe, or a Tribal organization for services provided to beneficiaries eligible for services from either Department. The 25 U.S.C. § 1645(c) reads: The [Indian Health] Service, Indian tribe, or Tribal organization shall be reimbursed by the Department of Veterans Affairs or the Department of Defense (as the case may be) where services are provided through the Service, an Indian tribe, or a Tribal organization to beneficiaries eligible for services from either such Department, notwithstanding any other provision of law."

Additionally, under Section 2901(b) of the ACA, I/T/Us are payers of last resort regardless of whether or not a specific agreement for reimbursement is in place “Health programs operated by the Indian Health Service, Indian Tribes, Tribal organizations, and Urban Indian organizations shall be the payer of last resort for services provided by such Service, Tribes, or organizations to individuals eligible for services through such programs, notwithstanding any Federal, State, or local law to the contrary." 25 U.S.C. § 1623(b). While we understand that the VA has a similar provision, IHCIA was enacted later which requires the I/T/U system to in fact and in law be the payer of last resort.

NCUIH fully supports the Tribes urge to full implementation and compliance with Section 405(c) of the IHCIA and Section 2901(b) of the ACA, as reimbursement is legally required and any agreements should cover the full scope of services including health care provided to for non-Native Veterans.


NCUIH hopes that VA, in the spirit of improving AI/AN veterans access to health care, will work with NCUIH in the near future to get our Native veterans the healthcare they are entitled to. We thank you for this opportunity to provide our comments and recommendations and look forward to further engagement with VA on AI/AN Veterans health care related issues. Please contact Francys Crevier, Policy Analyst and Congressional Relations Liaison at FCrevier@ncuih.org, if there are any additional questions or comments on the issues addressed in these comments.


Ashley Tuomi
National Council of Urban Indian Health