Letter to Senate Committee on Indian Affairs in re The Tribal Veterans Health Care Enhancement Act (S.304)

May 15, 2017

The Honorable John Hoeven  
Senate Committee on Indian Affairs
838 Hart Senate Office Building           
Washington, DC 20510

The Honorable Tom Udall
Ranking Member
Senate Committee on Indian Affairs
838 Hart Senate Office Building
Washington, DC 

In re: The Tribal Veterans Health Care Enhancement Act (S. 304)


Dear Chairman Hoeven and Ranking Member Udall:

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 your leadership on issues of concern to Indian Country.

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.

I write today about The Tribal Veterans Health Care Enhancement Act (S. 304), which was introduced on February 3 and marked up by your Committee on March 29. The bill would allow the Indian Health Service (IHS) to pay the Department of Veterans Affairs (DVA) for services provided to AI/AN veterans who have been referred by IHS to DVA.

NCUIH appreciates that S. 304 is intended to improve health care for AI/AN veterans, an important goal which we obviously share.

We have four concerns about the approach taken by S. 304. The first two concerns arise because the bill conflicts with the fundamental legal structure on which the provision of health care to AI/AN people is based:

  1. Under the Trust Responsibility, the federal government, which includes both IHS and DVA, is required to provide health care to AI/AN people. Therefore, DVA should not be charging AI/AN veterans for copayments, even if they are ultimately paid by IHS, as the DVA has the same Trust Responsibility asIHS.
  1. Further, IHS is the payer of last resort, with the exceptions allowed only for Tribes and Tribal organizations. This bill could quietly make an additional exception for DVA and set a precedent for additionalexceptions.

NCUIH’s additional two concerns about S. 304 are more practical:

  1. Given DVA’s far superior financial endowment and IHS’ chronically underfunded budget, it makes no sense for IHS to divert its own precious dollars to reimburse DVA for health care services the federal governmentis obligated to provide AI/ANveterans.
  1. The failure of DVA to implement its Memorandum of Understanding (MoU) with IHS with respect to urban Indian health programs (UIHPs) already prevents UIHPs from being reimbursed by DVA for services they provide to AI/ANveterans.

It was believed that with the signing of the MoU DVA and IHS understood the value of AI/AN veterans being treated in the IHS I/T/U system. In 2010, the two agencies signed an MoU to promote inter-agency collaboration which “recognize(d) 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."

DVA and IHS have implemented this MoU for IHS and tribal providers, but not for UIHPs. This dereliction makes no sense. AI/AN people, including veterans, often prefer to use Indian health care providers for reasons related to performance, cultural competency, or availability of non-health care-related services. Consequently, AI/AN veterans are more likely to receive adequate health care when they can determine how, when, and where they are served. DVA sometimes experiences surges in demand which understandably outstrip its ability to serve, and these surges can often be satisfactorily addressed through the use of UIHPs. 

Because of the failure of DVA and IHS to comply with the plain language of the MoU, despite NCUIH’s best efforts, AI/AN veterans cannot freely choose to receive care from Indian providers when they are off reservations, because UIHPs will not be fully reimbursed by DVA.

To the extent there should be money going back and forth between DVA and IHS, NCUIH believes it should instead be going from DVA towards IHS.  In fact, one of the best ways the Committee could promote improved health care for AI/AN veterans would be to direct DVA to finally implement the MoU, rather than advance S. 304. It would also be vital to ensure when Tribes attempt to make agreements with the DVA, that they be processed in a timely fashion and not upwards of 4 years and counting for someTribes.

Thank you for your consideration of our views. NCUIH very much hopes to further discuss S. 304 with you before the legislation receives any additional consideration. Please do not hesitate to contact NCUIH’s Director of Governmental Affairs Francys Crevier (fcrevier@ncuih.org) if you have any questions.




Ashley Tuomi 

National President