Representative Markwayne Mullin in re NCUIH Priorities

April 25, 2017

The Honorable Markwayne Mullin
1113 Longworth House Office Building
Washington, DC 20515

In re: NCUIH’s legislative priorities over the next year

Dear Representative Mullin:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents urban Indian health care programs (UIHPs) across the nation that provide high-quality, culturally-competent care to urban Indians, I thank you for speaking at our recent Washington Summit and take this opportunity to respond to your request that NCUIH provide you with its legislative priorities for the next year.

NCUIH was founded to represent the interests of UIHPs before Congress and federal agencies, and to address the health conditions experienced by urban AI/AN. NCUIH is 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 education, training, and leadership for UIHPs to Congress and the Administration. NCUIH strives for healthy AI/AN living in urban settings, supported by quality, accessible health care centers and governed by leaders in the AI/AN community. NCUIH represents UIHPs receiving grants under Title V of the Indian Health Care Improvement Act and the AI/AN they serve.

"Urban Indian" refers to any AI/AN person who is not living on a reservation, either permanently or temporarily--often because of the federal government's forced relocation policy or lack of economic opportunity, which now makes up more than 70% of the AI/AN population.

At the outset, please let me emphasize that the retention of IHCIA is paramount for NCUIH. However, given the apparent Congressional understanding that any repeal of the Affordable Care Act (ACA), whether in whole or in part, should not undo the ACA’s permanent authorization of IHCIA, as reflected in the House GOP reform bill (H.R. 1628), thanks in large part to your leadership, we shall first address the funding need and then address NCUIH’s three top legislative priorities that you requested.

Fully fund an Indian Health Service that can address the needs of urban Indians

Despite the efforts of appropriators, the Indian Health Service (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 health care and delay basic health care. NCUIH, as part of the National Tribal Budget Formulation Workgroup, has highlighted both IHS’ inadequate funding and its inevitable consequences. While health care spending per capita across the nation was more than $8,500 in 2015, IHS spending on health care per user was just

Not surprisingly, the life expectancy for AI/AN people is more than four years below the national rate, and AI/AN people die at higher rates than other Americans from diabetes, alcoholism, unintentional injuries, suicide, and homicide; AI/AN people also have higher mortality rates from cervical cancer, pneumonia/influenza, and child-birth.

There are other factors that influence health, but there’s no denying the overarching importance of money. IHS told the Congress in its most
recent Justification of Estimates for the Appropriations Committees that, “the alarmingly inadequate access to health services by AI/AN (is) due to underfunding of IHS.” Thanks to conscientious Congressional appropriators, IHS funding

has grown, but those annual increases have largely been eaten up by health care inflation and an increase in the agency’s patient population.

Despite more than two-thirds of AI/AN people living off reservations, IHS spends only 1% of its budget on the provision of health care to urban Indians. In fact, the increases from FY2012’s enacted amount of $43,053,000 in the following years have not even kept up with inflation, let alone health care inflation. In FY16, the enacted amount was $44,741,000. The decision to allow UIHP funds to be used for grants or contracts for the administration of urban Indian alcohol programs that were originally established under the National Institute on Alcoholism and Alcohol Abuse and transferred to IHS will further constrain the budget for urban Indian health care and the budget should, at the very minimum, adjust accordingly.

Tribes, whether they receive health care directly or indirectly from IHS, are already being short-changed, so the solution is not to take money from the Tribes and use it to address the unmet needs of urban Indians; rather, IHS’ budget needs to be increased in order to allow the agency to, among other things, better serve the vast majority of AI/AN people who live in urban areas.

1. Preserve the Medicaid benefit for AI/AN people and provide UIHPs with 100% FMAP

Medicaid is a program which has served the AI/AN community very well. Between 2013 and 2015, enrollment of AI/AN people in Medicaid increased by 217,000, or 15%. If per capita caps and block grants are used by the federal government to shift Medicaid costs to the states, the program’s benefit must be preserved for AI/AN people. H.R. 1628 would have exempted from the per capita caps to the federal government’s contribution to Medicaid payments to IHS and Tribal facilities, but not UIHPs, an inequitable arrangement that also would have applied to the bill’s proposed block grants. Even if UIHPs were to also be exempted from per capita caps and block grants, Medicaid’s financing would be fundamentally altered in ways which will inevitably impact all AI/AN people. In particular, states are likely to offset lost federal contributions from per capita caps and block grants by making eligibility for Medicaid more difficult. Consistent with the federal government’s Trust Responsibility, all of Indian Country, including urban Indians, should be shielded from the adverse impacts of the inevitable measures states would undertake to slash spending and narrow eligibility.

H.R. 1628 would have ended Medicaid Expansion, under which participating states receive higher federal payments for enrolling poorer Americans. In significant part because of Medicaid Expansion, the uninsured rate of AI/AN people has dropped 30% since 2010, from 24.2% (2010) to 15.7% (2015). If current law is unchanged, it has been estimated that an additional 550,000 uninsured AI/AN people can be made eligible for comprehensive coverage under current and planned ACA Medicaid Expansions. Again, NCUIH urges that an exception be made for Indian Country with respect to ending Medicaid Expansion.

Finally, H.R. 1628 would have allowed states to impose work requirements for Medicaid, even though many AI/AN people live in isolated areas with often staggering levels of unemployment and few opportunities for job retraining and placement services. If denied eligibility for Medicaid because of unrealistic work requirements, those AI/AN people will be forced to secure health care from an IHS which is already severely rationing services. If work requirements are imposed on Medicaid enrollees, again, there should be an exception for AI/AN people.

As you know, NCUIH has a specific concern about Medicaid’s Federal Medical Assistance Percentage (FMAP), which is 100% only for IHS services provided to tribes, directly or indirectly, but not to UIHPs. In other words, an AI/AN person can receive 100% Medicaid FMAP coverage for services received on her reservation, but that same AI/AN person can be covered for significantly less when she is provided with those same services by a UIHP.

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.” NCUIH would greatly appreciate the opportunity to work with you to introduce a stand-alone bill to fix FMAP for UIHPs, generate support for that legislation, and then try to attach it to must-pass legislation.

2. Reauthorize the Special Diabetes Program for Indians

It is imperative that the Special Diabetes Program for Indians (SDPI) be reauthorized before its expiration on September 30. Grants to health care providers in Indian Country made pursuant to SDPI have been instrumental in the marked reduction in the incidence rate of diabetes—and the related savings to Medicare, IHS, and third party providers. The failure to reauthorize this program would severely undermine the promising progress UIHPs have made against diabetes. Quite simply, SDPI must be reauthorized if Indian Country is to educate against, treat, and prevent the terrible scourge that is diabetes.

The Congress is very familiar with the grim statistics of the toll that diabetes inflicts on Indian Country. AI/AN adults are 2.3 times more likely to have diabetes compared with non-Hispanic whites and the death rate due to diabetes for AI/AN is 1.6 times higher than the general U.S. population. And the costs in dollars are also extraordinary—in 2012 alone 11% of AI/AN people with diabetes accounted for 37% of all IHS adult treatment costs.
However, the Congress also knows that SDPI achieves outstanding results and that the program saves significant money in the long run. For instance, End-Stage Renal Disease (ESRD) is the largest driver of Medicare costs, and in 2000-2011, ESRD in AI/AN people with diabetes declined 43%, a greater decline than any other racial or ethnic group. SDPI essentially pays for itself as well as saves the government and I/T/U facilities money. SDPI supports over 330 diabetes treatment and prevention programs in 35 states, which have led to significant advances in diabetes education, prevention, and treatment.

3. Include UIHPs in the coverage of the Federal Tort Claims Act

Under the Federal Tort Claims Act (FTCA), federally-supported health care centers can obtain medical malpractice liability protection with the federal government acting as their primary insurer. Under such protection, a health center, its employees, volunteers and eligible contractors are considered federal employees and are immune from lawsuits for medical malpractice. A patient who alleges acts of medical malpractice by a covered health center must instead sue the federal government, which assumes responsibility for costs related to a claim resulting from the performance of a medical, surgical, dental, or related function. There is no cost to a covered health center or its providers.

IHS and Tribal providers, as well as other comparable federal health care centers, are covered by the FTCA. Arbitrarily denied FTCA coverage, UIHPs must buy their own expensive malpractice insurance. Furthermore, to cover volunteers but not cover UIHP providers is nonsensical. Volunteers were given FTCA coverage in part to attract volunteers to urban and rural areas.
Not covering UIHP providers who are committed to Indian health is against the spirit of the law.

Given that IHS spent just $44.7 million on urban health care in FY2015, malpractice insurance is a significant hit on UIHPs’ budgets. Extending FTCA coverage to UIHPs would allow them to devote more resources to caring for their patients.


As you know, NCUIH’s agenda comprises other issues as well, including directing the Department of Health and Human Services to establish a confer policy for UIHPs, so that they, like Tribes (as well as UIHPs with respect to IHS specifically), have seats at the table when discussions are held about the impacts on communities of policy changes; including UIHPs in the implementation of the Memorandum of Understanding between the Department of Veterans Affairs and IHS, as is already the case with IHS and Tribal providers, so that AI/AN veterans in urban settings can receive the same level of health care; and correcting the inaccurate and incomplete definitions of “Indian” in the ACA which force the I/T/U system to deny health care to eligible AI/AN people, regardless of what is eventually done to the existing health care process.

Thank you again for speaking at our Washington Summit and challenging NCUIH to provide you with our legislative priorities over the next year.
Please contact NCUIH Director of Governmental Affairs Francys Crevier ( if you have any questions. NCUIH very much looks forward to working with you to advance the health care-related interests of urban Indians.


Ashley Tuomi National