NCUIH's Letter in re Infrastructure Investment in Urban Indian Health Programs

May 15, 2017

The Honorable John Hoeven
Chair, Senate Committee on Indian Affairs
1337 Longworth House Office Building
Washington, DC 20515

The Honorable Doug LaMalfa
Chair, House Natural Resources
Subcommittee on Indian, Insular, and Alaska Native 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 20510

The Honorable Norma Torres
Ranking Member, House Natural Resources Subcommittee on Indian, Insular and Alaska Native Affairs
1337 Longworth House Office Building
Washington, DC 20515

In re: Infrastructure investment in urban Indian health programs

Dear Chairs and Ranking Members:

On behalf of the National Council of Urban Indian Health (NCUIH), which represents urban Indian health programs (UIHPs) across the nation that serve urban Indians, who constitute more than 70% of all American Indians / Alaska Natives (AI / AN), I convey our appreciation for your leadership on issues of concern to our patients and providers and take this opportunity to tell you of NCUIH’s agenda for infrastructure investment in our own important part of 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.

The President and Congressional lawmakers understand the urgent need to invest in the nation’s infrastructure and have talked about spending as much as
$1 trillion. NCUIH appreciates your determination to ensure that a significant fraction of that amount is devoted to the long-ignored infrastructure needs of the AI/AN community. At the same time, NCUIH asks you to ensure that investment in Indian Country’s health care infrastructure take into account the needs of UIHPs as well as those of the Indian Health Service (IHS) and Tribes.

Although it is difficult to generalize about more than forty different entities from around the nation, the infrastructure needs of UIHPs are not that different. In some cases, the buildings which house our clinics have become so old that the maintenance costs of staying compliant with safety codes are becoming increasingly difficult to manage. In other cases, our buildings have been grandfathered into compliance with the codes. However, in still other cases, when a UIHP focuses on the provision of referral services, the age of the building may almost be irrelevant. It is also important to note that IHS has a facilities priority list that has a wait list of over 10 years long for Tribal and IHS facilities, and urbans do not have the ability to be placed on the list. There is currently no access to funding allocated for UIHP facilities. Some of the IHS and Tribal facilities that have been in danger of shutting down were on that list. There must be a large priority on infrastructure for Indian Country to ensure the Trust responsibility is met and AI/AN have access to quality healthcare in quality facilities for the I/T/U system.

The Indian Health Board of Minneapolis (IHBM), Minnesota, reports that,

The building we are currently housed in is almost 50 years old. The cost of maintaining the building is increasing as more costly repairs are required due to age. We have attempted to keep up with codes by upgrading necessary and mandatory changes in the facility. In some instances, we have been grandfathered in on certain codes. While we have upgraded some building systems in an effort to be more energy efficient, we are aware that newer buildings would see a savings related to HVAC and electricity usage…

“(Our p)rograms are constrained as there is no additional space. There are additional services we wish to offer but cannot due to lack of space. These new services could potentially be revenue positive in a sense that they increase patient utilization of other services…

IHBM is in the process of considering the construction of a new building to attract more patients and expand services. We have acquired land within two miles that is in a more accessible area, including transportation access, as well as nearby Native American housing. We would require significant capital to see this project through.

The Seattle Indian Health Board (SIHB) reports that its physical infrastructure

is over forty years old, and only marginal updates have been possible due to cost constraints and lack of revenue streams to allow for reimbursement…Construction and repair costs in Seattle are outpacing the national average due to the city’s hyper job growth.

The Indian Health Care Resource Center (IHCRC), in Tulsa, Oklahoma, reports that,

With more than 35 health and behavioral health providers and a steadily increasing patient base, the program finds itself needing to redesign the existing building and expand space.

“A portion of the existing building redesign will focus on the `pod configuration’ for care. The pod configuration assists in the implementation of the patient- centered medical home model. The pods involve team work areas and collaboration spaces that promote communication. Some of the many benefits to the pods are much smaller travel distances for the healthcare employees, patients get a more personalized and intimate feeling during their care, the open ‘bull pen’ allows for an efficient work flow, and more flexible exam rooms. The pod configuration will also increase the number of available exam rooms. The cost of this remodel is estimated to be near $500,000.

“Even with the remodel, IHCRC has maximized available space in the existing facility. The IHCRC pharmacy fills almost 900 prescriptions per day. Increased staff to handle the volume also necessitates a pharmacy expansion in the near future. Likewise the dental department needs to double in size at the very least in order to add dentists and extend services beyond the current limitations.
“The success of the wellness programs, especially fitness, has resulted in the need for space dedicated to that type of programming. IHCRC is also experiencing the need for placing certain specialty care providers in-house, including physical therapy, again requiring additional space.
“In 2010 IHCRC acquired the property to the north of its existing facility. IHCRC hopes to build a facility that will eventually house specialty care, health and wellness, and some support staff. Doing so will provide space for the expansion of dentistry, optometry, behavioral health, and pharmacy. The new building is estimated at $8,000,000 to $9,000,000 based on the average cost per square foot of a medical building.
“IHCRC borrowed money to build its current facility. The facility has not yet been paid in full. Updates and equipment upgrades are usually paid through third party billing money. However, as federal money decreases, the need to utilize third party revenues for direct patient services increases. IHCRC will need to successfully launch a capital fundraising campaign if it is to be built.”

Recommendation: Establish a line-item in the budget process for construction projects for UIHPs specifically, which would allow UIHPs to invest more money into patient care.

The age of medical and laboratory equipment is also an important infrastructure issue for UIHPs.

As IHBM explains:

Most equipment is replaced every five to seven years as it wears out. There have been times in our history where funding has not been available for replacing equipment when necessary. We usually pay for this expense by negotiating best deals, as well as paying out of direct patient revenue, when available.

IHCRC reports that it

consistently works to maintain up-to-date, state-of-the-art equipment. However, as technology improves and the cost of care rises, maintaining up-to- date equipment places a significant burden on the organizational budget. Recent expenditures include new dental equipment, a new dental sterilization unit, and new pharmacy software. And these updates are only the beginning.”

SIHB reports that the

condition of all medical and lab equipment is extremely poor and nearly as old as its (40 year-old) building.”

Electronic record-keeping is another important infrastructure issue. IHBM reports that,

(Its) system is slow and takes more time than necessary for providers to navigate. The reporting features are deficient in reporting population health statistics.”

SIHB reports that its electronic record-keeping

is adequate with a planned $200,000 investment to our technology program”.

Recommendation: In consultation with UIHPs, a standard data collection package should be developed through RPMS to address the appropriate functional service capacity of UIHPs based on their various levels of support, so that they can provide adequate reporting of program and population outcomes. Also, the funding of RPMS to full capacity to bring it up to a level to address this need. The General Services Administration (GSA) should be directed to help UIHPs to reduce the costs of information technology as well as medical and laboratory equipment by leveraging their combined purchasing power, which will ultimately allow UIHPs to invest more money in patient care.

Access to UIHPs is obviously crucially important—from parking to public transportation. The more inaccessible a UIHP is, the more difficult it is for the local Indian community to obtain regular health care.

Recommendation: Require any state or municipality that receives federal transportation infrastructure funding to ensure that at least some of it is used to increase access to any existing UIHP.

Recommendation: Provide subsidies for UIHPs to fund their own shuttle services to transport elderly and physically disadvantaged patients.

As you know, UIHPs do not use federal employees and manage to provide high-quality, culturally competent health care to urban Indians despite consuming a tiny fraction of the IHS budget of just over 1%--because they must raise substantial sums of money from non-federal sources, ranging from state and local governments to philanthropic organizations. MIHB, for example, pays for its infrastructure improvements through special grants and / or accumulated surpluses. In fact, UIHPs are an exemplary public-private health care partnership (P3s) which merit greater federal support.

Recommendation: A fraction of the infrastructure investment designated for Indian Country should be used to establish a fund by which the federal government matches, dollar-for-dollar, the non-federal funds raised by UIHPs to address their infrastructure needs. Such matching federal contributions will help to offset the infrastructure deficit faced by UIHPs while still encouraging UIHPs to continue to be entrepreneurial in raising capital from non-federal sources. In an era of budget constraints, the P3 approach UIHPs have pioneered in Indian Country best promotes high-quality, cost-effective health care, and this approach should be encouraged.

Mr. Del Nutter, the chief executive officer of Denver Indian Health and Family Services (DIHFS), reminds us that the federal government itself—without spending any additional money—can contribute significantly to offset the infrastructure deficit facing UIHPs. His own program provides the urban Indian community, in Denver, Colorado, with primary care, behavioral services, diabetes treatment, as well as dental care, and it also helps to enroll eligible urban Indian patients in Medicaid.

Mr. Nutter’s clinic leases its current space, which includes 7,800 square feet, and it will soon move into a slightly larger rental facility consisting of 9,000 square feet, costing over $1.5 million in rent for 10 years and $1 million in renovations. Mr. Nutter must move because his leaser wants to change course with the property, leaving Mr. Nutter with no other choice but to lease another property that will take away much needed funding from the services he currently provides to his patients. With some notoriety, the Department of Veterans Affairs (DVA) has recently built a new medical center in Denver, which will leave vacant several DVA buildings, and it plans to eventually leave itsa 30 year-old nursing home. Mr. Nutter has urged the IHS and DVA to use the authority in the Indian Health Care Improvement Act “to acquire excess or surplus personal or real property of the federal government for donation to an urban Indian organization.” DVA’s old nursing home includes 23,000 square feet of space. If donated to DIHFS, Mr. Nutter’s program could significantly expand its services and offer space to other Indian health care providers in Denver, making the program a convenient one-stop-shop for the city's entire Indian community, not to mention saving him over $2.5 million in leasing fees and renovations. Even better, the money Mr. Nutter saves from owning rather than leasing the clinic’s infrastructure can be plowed back into patient care.

Unfortunately, there is no requirement that DVA donate its old, surplus building to DIHFS. DVA could sell the property to anyone or discard it, instead of being used by Mr. Nutter’s patients and improve the lives of AI/ANs in his area.

Recommendation: The donation provision in IHCIA should be strengthened, consistent with the federal government’s Trust Responsibility to provide health care for AI/AN, in order to establish a strong preference for donation to a UIHP when that UIHP has formally declared its interest in excess or surplus federal personal or real property which is located in an urban setting.

Recommendation: the GSA should be tasked with determining which federal real property is now or could be in the next five years determined excess or surplus which is within 25 miles of any existing UIHP and submit a report with its findings to the Congress as well as IHS.

Recommendation: Fund all IHS and Tribal projects on the 10 year wait list in order to truly provide access to quality health facilities that will not be in danger of shutting down in the future, potentially saving thousands of lives as well as millions in lawsuits, investigations and reports.

Recommendation: Host field hearings near different UIHPs as well as Tribal facilities to understand the immediate needs for infrastructure in the Indian health community.

Thanks for your consideration of our views and recommendations. NCUIH anticipates offering additional recommendations as the Congress gives further consideration to infrastructure investment. If you have any questions, please contact NCUIH Director of Governmental Affairs Francys Crevier (


Ashley Tuomi National