Indian Health Legislative Update Presented by: Stacy A. Bohlen, Executive Director Jessica Steinberg, Director of Center for Native American Health Care Policy and Research Devin Delrow, Director of Policy Caitrin Shuy, Director of Congressional Relations

SAVE THE DATES! TPHS Request for proposals open NOW – closing date February 23

FY 2018 Appropriations House and Senate Committees currently negotiating FY 2018 final levels. Current continuing resolution expires on February 8, 2018… then??

FY 2018 President’s Budget Request $4.7B for IHS (-$300 MILLION) 6% decrease PRC (-$14M) Indian Health Professions (-$6.3M) Facilities (-$98M) CDC (-$1.2 BILLION) 17% decrease NIH (-$6 BILLION) The budget calls for cutting funding for all federal departments besides the Departments of Defense, Veterans Affairs, and Homeland Security. It would decrease non-defense spending by $57 billion in FY 2018. This budget is a proposal of what the Administration thinks that funding priorities should be for next fiscal year. The final funding decisions will be made by Congress, and key leaders in Congress have made public statements emphasizing that.

FY 2018 Draft Interior Appropriations FY 2018 House Appropriations Committee Recommended $5.1 billion for the IHS in FY 2018 (+$97 million) and the Senate Committee Recommend $5.04 billion (+$1 million) $3.867 billion for Services in House and $3.759 billion for Services in Senate $551.6 million for Facilities Full funding of Contract Support Costs PRC - House $928 million (equal to FY 2017) / Senate $930.4 million Dental Services – House $185.9 million / Senate $189.8 million (+7.2 million) Mental Health -- $95.4 million (+$1.4 million) / Senate $97.2 million (+3.1 million) Alcohol & Substance Abuse $220.3 million (+$1.9 million) / $219.7 million (+1.3 million) $130 million for the Indian Healthcare Improvement Fund (IHCIF) “to reduce health care disparities across the IHS system” included in the House but not Senate

Special Diabetes Program for Indians SDPI was renewed on December 22 through March 31 SDPI was NOT included in recent continuing resolution on January 22. Most likely action in Budget Caps deal for FY 2018 Appropriations Energy and Commerce Committee Chairman Greg Walden (R-OR) on January 16, 2017: “We hope that the context of the caps discussions that are going on simultaneously that they can take care of community health centers, Special Diabetes Programs for Indian Country, and teaching hosptials extensions...  That’s all being wrapped up in the bigger, broader budget discussions that would deal with the caps issue.”    SDPI Reauthorization of Act of 2017 has been introduced in both Chambers H.R. 2545/S. 747 Reauthorizes until 2024 $150M/year +medical inflation annually

Children Health Insurance Program CHIP was renewed for 6 years in the Continuing Resolution that was passed on January 22 Savings from tax law enabled longer term renewal Did not include “Extenders” as had been promised. Including: SDPI Community Health Centers MIECHV (Maternal, Infant and Early Child Home Visiting Program) National Health Service Corps Teaching Health Centers SDPI has funded hundreds of diabetes treatment and prevention in Indian Country for the past 19 years. The program is currently funded through December 31, 2017. The IHS will likely use this extension to get funds to grantees for the first part of calendar year 2018. Legislation is working through congress that would renew SDPI for 2 years at $150M/year. Longer was hard to do because of “pay fors” which are already running into partisan disagreement in Congress Continuing broad bipartisan support for the program – September 2016 – letter with 356 House Members and 75 Senators supporting SDPI. Other legislation that would renew SDPI for 7 years and base increases on medical inflation has been introduced. Seeking cosponsors. Based on history, that’s about $39,554,906.60 increase over 7 years.

Restoring Accountability at IHS Act S. 1250/ H.R. 2662 Pay flexibility and relocation reimbursements for employees Mandated IHS employee cultural competency training Reforms Hiring and Firing for IHS Employees Additional incentives for hiring medical professionals Measure appt. wait times Requiring HHS to revisit and reform Tribal Consultation policy Regular reports to Congress HHS OIG reports every 2 years on patient harm and denial of care Representatives  Kristi Noem, Rob Bishop (R-UT), Markwayne Mullin (R-OK), Cathy McMorris-Rodgers (R-WA), and Tom Cole (R-OK) in the U.S. House of Representatives and by Senators John Barrasso (R-WY), John Thune (R-SD) and John Hoeven (R-ND) in the U.S. Senate introduced the Restoring Accountability at the IHS Act earlier this year. The Bill would provide incentives to health care professionals to serve in the IHS, including pay flexibility and relocation reimbursements when employees move to high-need areas, as well as a housing voucher program for rental assistance to employees. Require IHS to create standards to measure wait times and for IHS employees to attend cultural training annually Amend processes to make volunteering at IHS facilities easier by providing liability protections for medical professionals who want to volunteer at IHS hospitals or service units and centralizing the agency's medical credentialing system. Require IHS to engage in a negotiated rulemaking process to establish a new tribal consultation policy for IHS.  Many tribes in Great Plains area have said that IHS is not consulting with them on big issues, and need a better definition of what triggers consultation. Put additional requirements on IHS to ensure that reports and plans are provided to Congress in a timely manner The HHS Office of the Inspector General must put together reports every two years on "patient harm events occurring in Service units and deferrals and denials of care of patients of the Service.“ Requires 3rd party revenue to be used on essential medical equipment, purchased/referred care, and staffing only for IHS operated facilities

Tax Reform Impact on Indian Health Repealed the Individual Mandate in the Patient Protection and Affordable Care Act (ACA). Goes into Effect in 2019 Indians are already Exempt from the Mandate Congressional Budget Office predicts that 13 million fewer people will have insurance coverage by 2027, and premiums will go up by 10% most years

Medicaid Work Requirements On January 11, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a Dear State Medicaid Director (SMD: 18-002) letter, entitled RE: Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries. new policy supports states mandating work requirements through Section 1115 waivers as conditions of eligibility for the Medicaid program However does encourage states to consider Tribal Work programs as meeting the requirements Requires States to consult with Tribes prior to the submission of a waiver The new guidance was created without Tribal consultation despite repeated requests from Tribes Tribes have been universally opposed to the imposition of Medicaid work requirements Administrator Verma indicated that she directed CMS to give AI/AN exemptions to the work requirements but the Division of Civil Rights stopped it

Restoring Accountability at IHS Act NIHB Board Member Victoria Kitcheyan Testified before the Senate Committee on S. 1250 before Senate Committee on Indian Affairs on June 13 and on June 21 at the House Natural Resources Committee Stressed the need for full-time permanent staff, innovative care models like DHAT Need for more Tribal consultation on the bill and provisions in the bill More reporting on quality of care for referral services Better language on self-governance exemptions needed More flexibility for 3rd party revenues Additional Tribal consultation on reporting Current Status: Committees are working on amended language in a bicameral process. Markup delayed due to procedural issues with referrals in the House, but hopefully forthcoming. NIHB submitted suggested language to clarify that Self-governance Tribes would not be subject to the requirements

Mitigating METH Act – S. 2270 Senator Steve Daines (R-MT) introduced legislation that would add Tribes as eligible grantees under the “State Response to the Opioid Abuse Crisis” grants. Would also allow treatment for methamphetamine Funding was put out under this program in the fall, but Tribes did not get the money, and states do not have to use the money to help Tribes. Could be attached to an upcoming national legislation on opioid treatment/ prevention House legislation forthcoming

Veterans’ Health Legislation October 24, 2018 – NIHB submitted testimony for the record on draft legislation for the House Veterans’ Affairs Committee. Testimony requested that the legislation: Reaffirm and maintain the current agreements between VA, IHS and Tribal health programs (as outlined in section 405 of the Indian Healthcare Improvement Act) Clarify that agreements authorized under Section 405 be reimbursed at cost-based rates that IHS annually publishes in the federal register Include Tribes and Urban Indian Health Organizations as “network providers” if they choose to participate in the VA CHOICE program. Explicitly exempt I/T/U system from value-based reimbursement Add reimbursement for Purchased/referred care Exempt AI/AN Veterans from co-pays and deductibles

Veterans’ Health Legislation H.R. 4242 - VA Care in the Community Act introduced on November 3, passed Committee on December 19. Contains exemption for Tribal and federal providers on rates to negotiate higher rates rather than value-based or Medicare rates Allows IHS as an in-network provider and “Any health care provider not otherwise covered under any of subparagraphs (A) 5 through (F) that meets criteria established by the Secretary for purposes of such section.” S. 2193 – Caring for our Veterans Act introduced and passed out of committee on December 5. Similar provisions to house on Tribal and federal “in network” providers Does not include exempt from value-based reimbursement, or Medicare rates Explicitly supports MOUs with Tribes and IHS Increases number of GME spots, allows IHS and Tribes to participate Includes a provision to establish or affiliate with graduate medical residency programs at facilities operated by Indian Tribes, Tribal organizations, and the IHS in rural areas GAO also conducting a study on impacts of IHS/Tribal/VA MOUs. Looking for more Tribal participants in the study! S2193: the Secretary of Veterans Affairs shall continue all contracts, memorandums of understanding, memorandums of agreements, and other arrangements that were in effect on the day before the date of the enactment of this Act between the Department of Veterans Affairs and the American Indian and Alaska Native health care systems as established under the terms of the Department of Veterans Affairs and Indian Health Service Memorandum of Understanding, signed October 1, 2010, 5 the National Reimbursement Agreement, signed December 5, 2012, and agreements entered into under sections 102 and 103 of the Veterans Access, 8 Choice, and Accountability Act of 2014 (Public Law 9 113–146).

Tribal Health Priorities in the Farm Bill January 18, 2018 – NIHB Executive Director Stacy A. Bohlen participated in a roundtable with the Senate Committee on Indian Affairs titled “Advancing Native Food Traditions in Indian Country.”  Tribal policy recommends for the upcoming reauthorization of the Farm Bill.  Stressed the need for federal policy to support traditional food practices, Tribal sovereignty, and self-determination.  Emphasized the link between access to traditional food and health outcomes.  Recommendations: Federal Policies that promote traditional food programming and food sovereignty Self-governance for federal food programs like the Supplemental Nutrition Assistance Program (SNAP)

Contacts More info: www.nihb.org Stacy Bohlen, Executive Director: sbohlen@nihb.org Jessica Steinberg, Director of Center for Native American Health Care Policy and Research, jsteinberg@nihb.org Devin Delrow, Director of Policy, ddelrow@nihb.org Caitrin Shuy, Director of Congressional Relations: cshuy@nihb.org Twitter @NIHB1 Facebook, too!