National and Regional Committee Updates The Mill Casino Coquille Tribe April 17, 2018

National and Regional Committees U.S. Department of Health and Human Services (HHS) Indian Health Service (IHS) Substance Abuse Mental Health Services Administration (SAMHSA) Centers for Medicare and Medicaid Services (CMS) Portland Area IHS

HHS Secretary’s Tribal Advisory Committee Primary purpose of HHS Secretary’s Tribal Advisory Committee (STAC) is to seek consensus, exchange views, share information, provide advice and/or recommendations; or facilitate any other interaction related to intergovernmental responsibilities or administration of HHS programs, including those that arise explicitly or implicitly under statute, regulation or Executive Order. Portland Area Representative: Ron Allen, Jamestown S’Klallam Meetings: Last meeting: January 17-18, 2018 in D.C. Next meeting: May 9-10, 2018 in D.C. Last meeting was January 17-18. Next meeting is May 9-10 and will be the first meeting that the STAC has with HHS Secretary Alex Azar. Top issues for STAC: -Continued commitment to consultation and government to government relationship between tribes and the U.S. government -Exemption of IHS beneficiaries from work requirements and community engagement requirements -Assistance in combatting the opioid epidemic in tribal communities -Healthcare Workforce Development -Expansion of ISDEAA Self-Determination Agreements and PL 477 -The Adoption and Foster Care Analysis and Reporting System (AFCARS) Final Rule Support -Dental Health Aide Therapists -Contract Support Costs

IHS Tribal Leader Diabetes Committee The IHS Director established the Tribal Leaders Diabetes Committee (TLDC) in 1998 to assist in developing a successful partnership between IHS and Tribal diabetes programs and in deciding the process for distribution of resources from the Balanced Budget Act of 1997 Special Diabetes Program for Indians (SDPI).   Portland Area Representatives: Cassandra Sellards-Reck, Cowlitz (Primary) Sharon Stanphill, Cow Creek (Alternate) Meetings: Last meeting: April 4, 2018 (virtual) Next meeting: May 21-22, 2018, Mystic Lake Center, Prior Lake, MN Last TLDC meetings were on March 26 and April 4. Focus of both meetings was to discuss topics for tribal consultation on SDPI.

IHS Budget Formulation Workgroup IHS organized the Budget Formulation Workgroup to assist the agency in formulating upcoming fiscal year budgets. Develops program priorities, policies, budget recommendations by ensuring active participation of tribal governments and tribal organizations in the formulation of the IHS budget request and annual performance plan.   Portland Area Representatives: Workgroup Co-Chair, Andy Joseph, Jr., Colville Steve Kutz, Cowlitz Tribe Meetings: Last meeting: February 16, 2018 in D.C. Next meeting April 25, 2018 in Albuquerque, NM (evaluate FY 2020/plan for FY 2021) National Tribal Budget Formulation Workgroup met on February 16 in DC to finalize FY 2020 recommendations. FY 2020 evaluation/FY 2021 meeting is in Albuquerque, La Cienega Room, 8:30am-5:30pm. Final recommendations were presented by Co-Chairs of the Workgroup: Our Chairman, Andy Joseph, Jr. Bruce Pratt, Pawnee Nation Victor Joseph, Tanana Chiefs Conferences. Co-Chairs presented the recommendations for FY 2020 to: IHS Leadership at the HHS Annual Tribal Consultation in D.C. on March 1 HHS Leadership at HHS Budget Council for the Tribal Budget Formulation in D.C. on April 11. The FY 2020 Evaluation FY 2021 Planning Meeting will be on Wednesday April 25th in Albuquerque, New Mexico.

IHS PRC Workgroup The charge of the IHS Director’s Workgroup is to provide recommendations to the Director on strategies to improve the agency’s PRC programs. Reviews input received to improve PRC program, evaluates the existing formula for distributing PRC funds, and recommends improvements in the way PRC operations are conducted within the IHS and Indian Health System.   Portland Area Representatives: Andy Joseph, Jr., Colville (Primary) John Stephens, Swinomish (Alternate) Meetings: Last meeting: March 8-9, 2018 in Albuquerque, NM PRC meeting was March 8-9, 2018 in Albuquerque, NM. The meeting was chaired by Jim Roberts (Tribal Co-Chair) and Liz Fowler (Federal Co-Chair). IHS Office of Resource and Partnership (ORAP), where it was announced that $344 million had been saved from the implementation of the Medicare-Like Rates regulation in 2016. In addition, IHS announced that for FY 2017, for the first time ever, all submitted Catastrophic Health Emergency Fund (CHEF) claims had been successfully reimbursed. Last year, IHS also implemented payment methodology for non-hospital services for PRC. Currently the PRC spending rate has slightly decreased and is lower than the funding rate. It is likely lower because more people were eligible for alternate resources made available through the Medicaid expansion. In addition, ORAP announced they are doing a number of studies on the assessment and impact of certain policies on PRC, including Medicaid Expansion, the Impact of ACA Marketplace Enrollment, and potential Medicaid Work Requirements. They are partnering with the Agency for Healthcare Research and Quality (AHRQ) to conduct the studies. The highlight of the meeting was the Workgroup’s discussion with the Government Accountability Office (GAO). In June, 2012 the GAO released a report entitled “IHS Action Needed to Ensure Equitable Allocation of Resources for the Contract Health Services Program.” In the report, the GAO recommended that Congress consider requiring IHS to develop a new PRC formula based on the following criteria:

IHS CSC Workgroup The CSC Workgroup meets to further the federal government’s administration of CSC within the IHS. The agency is in active participation with Tribes, has developed a comprehensive CSC policy to implement the statutory provisions of ISDA. Portland Area Representative: Tribal Co-Chair, Andy Joseph, Jr., Colville Meetings: Last meeting: March 6-7, 2018 in Albuquerque, NM Next meeting: April 23, 2018 12:00pm-1:30pm in Albuquerque, NM Contract Support Costs Workgroup Meeting was March 6-7, 2018 in Albuquerque. There was disagreement between tribal representatives and IHS as to next steps following the last meeting.   Tribal position: On March 7th the IHS Contract Support Cost Work Group agreed unanimously on a proposed change to section 6-3.2E(3) of the IHS Manual.  The change would address one of the agency’s concerns involving the computation of Service Unit duplication amounts.  It was agreed in that meeting that the next step would be a Dear Tribal Leader Letter putting the proposed change out for a 30-day tribal comment period.  In addition, it was agreed that IHS would organize a smaller agency-tribal technical workgroup to explore issues raised in connection with section  6-3.2E(2) of the Manual.  The issue  here concerns the determination of indirect-type costs for tribes and tribal organizations that do not have applicable indirect cost rates, and the interplay between that process and the duplication offset process laid out in subsection (3).  It was agreed that this work would be completed reasonably quickly so that the full CSC Work Group could reconvene and discuss this matter within 45 to 60 days.      IHS position- per Ben Smith at TSGAC meeting: No commitments were made at the meeting. IHS only agreed on two motions: (1) future consultation on the proposed amended language of the 97-3 offset policy; (2) to reconvene the workgroup within 45 days to discuss the amended language further. Next step: A 1.5 hour meeting will be held at TSGAC on Monday, April 23 during lunch.

IHS TSGAC At the recommendation of self-governance tribes, representatives from the self-governance tribes and Indian Health Service staff developing guidelines for establishment of the Tribal Self-Governance Advisory Committee (TSGAC). Provides information, education, advocacy, and policy guidance for implementation of self-governance for implementation of self-governance within the Indian Health Service. Portland Area Representatives: Ron Allen, Jamestown S’Klallam (Primary) Tyson Johnston, Quinault (Alternate) Meetings: Last meeting: March 28-29, 2018 in D.C. Annual conference: April 22-26, 2018 in Albuquerque, NM TSGAC Quarterly meeting was on March 28-29 in D.C. Chairman Allen was in attendance. TSGAC Annual Conference is the week of April 22 in Albuquerque, NM. Admiral Weahkee didn’t attend the meeting, Ben Smith attended in his stead. Tribes voiced their dissatisfaction that Admiral Weahkee didn’t attend. It was a pretty light agenda: IHS provided an update on activities and workgroups (CSC, IHCIF, CHAP, etc.) Appropriations for FY 2018 to FY 2020 Replacement of RPMS- IHS received over 40 proposals in response to RFP.

IHS DSTAC IHS Director established the Direct Service Tribes Advisory Committee (DSTAC) to address health service delivery issues and concerns important to direct service tribes. The work of the Committee is specifically aimed at the areas of trust, data and budget. Portland Area Representatives: Greg Abrahamson, Spokane (Primary) Janice Clements, Warm Springs (Alternate) Meetings: Last meeting: March 13-14, 2018 in Arlington, VA Next meeting: April 30-May, 2018 in Albuquerque, NM IHS provided an update on: IHS Budget, Strategic Plan, Office of Information Technology, CSC, CHAP, Annual meeting, and Rapid Opioid Alert Response. We were initially concerned about the CHAP update. The presentation that was shared stated that CHAP would be at the national level, not regional, and that HIS was only looking at expanding DHATs and BHAs, not CHAs. After our 1:1 meeting with Admiral Weahkee and his staff on February 28, we were relieved to learn that lHS was not set in stone with information that was presented on CHAP.

IHS FAAB Facilities Advisory Appropriation Board (FAAB) is charged with evaluating existing facilities’ policies, procedures, and guidelines for recommending changes, if necessary. Participates in the development and evaluation of any proposed new policies, procedures, and guidelines of facilities construction priorities. Portland Area Representatives: Tim Ballew, Lummi (Primary) Andy Joseph, Jr., Colville (Alternate) At the National Budget Formulation Meeting in February, FAAB presented information for FY 2020. This information in delegates folder. I wanted to highlight that FAAB reported on new health care facilities construction: “At the current rate of HCFC appropriations (100m/year), a new facility in 2018 would not be replaced for 300 to 400 years. To replace HIS facilities every 60 years (twice a 30 year design life), would need HCFC appropriations of 700m annually…. Without a sufficient, consistent, re-occurring HCFC appropriation the entire IHS system is unsustainable.” 2016 Indian Health Service and Tribal Health Care Facilities’ Needs Assessment Report to Congress total estimated cost for new and replacement facilities is over $14.5 billion. Next meeting: We heard it’s during self-governance conference but we haven’t seen any announcements about it.

IHS IHCIF Workgroup Indian Health Care Improvement Fund (IHCIF) Workgroup was established in anticipation of a FY 2018 IHCIF appropriation to assess the impact of past allocations to address inequities, effects of the current health care environment, and make recommendations that will be sent out for tribal consultation. Portland Area Representatives: Gail Hatcher, Klamath (Primary) Steve Kutz, Cowlitz (Alternate) Meetings: Last meeting: April 12-13, 2018 in Denver, CO Next meeting: May 17-18, 2018 in Denver, CO The IHCIF formula was established to determine the overall level of need funded for health care. IHS established a new IHS/Tribal IHCIF workgroup to review the existing IHCIF formula and recommend changes for future use. A review of the IHCIF formula at this time acknowledges the considerable changes in the health care environment since the 2010 Tribal Consultation on IHCIF. The IHS is currently updating the data used in the existing IHCIF formula by collecting and analyzing the FY 2016 user population numbers, recurring base budgets at IHS and Tribal sites, geographic cost differentials, and health status data. IHS anticipates having this data update completed in January 2018 and then they will share the findings in a report to the IHS/Tribal IHCIF workgroup. Last disbursement was in 2012. A lot has changed since 2010 so House appropriations committee asked IHS to review/update the IHCIF formula. Workgroups on user population vs. service population, benchmark measures, access to care, and alternate resources. Last meeting was April 12-13 in Denver; last meeting is May 17-18. End of May, workgroup submits recommendations to IHS Area Director. In June, IHS will initiate 30-day Tribal consultation. End of July, IHS Acting Director issues final decision. In August, FY 2018 IHCIF allocations issued.

IHS CHAP TAG The Community Health Aide Program (CHAP) Tribal Advisory Group (TAG) will provide subject matter expertise, program information, innovative solutions, and advice to the Indian Health Service (IHS) to establish a national CHAP. Portland Area Representatives: John Stephens, Swinomish (Primary) Andy Joseph, Jr., Colville (Alternate) Meetings: Last meeting: March 21-22, 2018 in Phoenix, AZ Next meeting: Fall, 2018 in Portland (tentative) Portland Area CHAP Activities Update— NPAIHB secured funding from private foundations for the last three years to build the policy and legal infrastructure to license, train, and deploy DHATs in the Portland Area. NPAIHB has secured funding through 2021 for DHAT expansion. Washington Tribes through AIHC have elected to fund the exploration and planning phase of creating a Portland Area CHAP Certification Board (modeled after the Alaska CHAP CB) using funds from the Washington State Medicaid Transformation Demonstration. A Behavioral Health Organization in Washington has funded the exploration and planning phase of creating a BHA training program in Washington. IHS formed CHAP TAG -- includes representatives from every Area, DSTAC and TSGAC. First meeting of CHAP TAG March 21-22, 2018 in Phoenix, AZ At request of CHAP TAG, Alaska and Portland Area developed a draft version of an interim policy for area level implementation and shared this with the CHAP TAG and IHS. There will be a virtual meeting at the end of April to gather input and buy in from other Area representatives. IHS will issue a DTLL announcing that an interim policy is in development and will announce a 30-day tribal consultation in May. Next in-person CHAP TAG meeting is tentatively scheduled for the Fall in Portland Area.

CDC TAC CDC Tribal Advisory Committee (TAC) advises CDC/ATSDR on policy issues and broad strategies that may significantly affect AI/AN communities. Assists CDC/ATSDR in fulfilling its mission to promote health and quality of life by preventing and controlling disease, injury, and disability through established and ongoing relationships and consultation sessions. Portland Area Representatives: Travis Brockie, Lummi (Primary) Steve Kutz, Cowlitz (Alternate) and Cassandra Sellard-Recks, Cowlitz (Alternate) Last meeting: March 13-14 TAC cancelled; instead, Tribal Public Health Workgroup had a collaborative work session with CDC. Last TAC was cancelled due to resignation of CDC Director, Dr. Brenda Fitzgerald. Topics of discussion included: Good Health and Wellness in Indian Country- lesson learned. Tribal Public Health Summit Unintentional Injury prevention Violence prevention Data and surveillance

SAMHSA TTAC SAMHSA formed the Tribal Technical Advisory Group (TTAC) in recognition of 2008 Presidential Executive Orders and Memorandum of Tribal Consultation to enhance the government-to-government relationship to honor the federal trust responsibility and obligations to tribes and AI/AN. Portland Area Representative: Jeremiah Julius, Lummi (primary) Nickolaus Lewis, Lummi (alternate) At-Large Member: Andy Joseph, Jr., Colville Meetings: Last meeting: February 13-14, 2018 in D.C. Next meeting: July 23, 2018 in D.C. Last SAMHSA TTAC was February 13 and 14 in DC. Next meeting is July 23, 2018 in DC followed by an AI/AN Behavioral Health Conference. There were presentations on TTAC priorities: Priority 1- Improve Tribal Access to and Eligibility for SAMHSA Grant Funding Priority 2- Improve Access to and Availability of Tribal Data Priority 3- Improve Communications and Partnerships Assistant Secretary for Mental Health and Substance Abuse, Elinore F. McCance-Katz, addressed the TTAC.

CMS TTAG The CMS Tribal Technical Advisory Group (TTAG) serves as an advisory body to CMS. Provides expertise on policies, guidelines, and programmatic issues affecting the delivery of health care for AI/AN served by Titles XVIII, XIX, and XXI of the Social Security Act or any other health care program funded (in whole or in part) by CMS. Portland Area Representatives: John Stephens, Swinomish (Primary) Nickolaus Lewis, Lummi (Alternate) Meetings: Last meeting: February 21-22, 2018 in D.C. Next meeting: July 25-26, 2018 in D.C. Meeting was February 21 and 22 in DC; both John and Nick were present. Next meeting is July 25-26. Hot topics with CMS Leadership were: Medicaid work and community engagement requirements as part of Medicaid eligibility. -Calder Lynch- Senior Advisor to CMS Administrator Office of Civil Rights did not grant an exemption to AI/AN from work requirements because not race based. Tribal position is that tribes/AI are political group and should not be lumped into other race based groups. Tribes requested a call with OCR. Medicaid 1115 Waivers and Opioid Epidemic -Kristen Beronio, Senior Behavioral Health Advisory, Disabled and Elderly Health Programs Group, CMCS talked about CMS guidance on these waivers and IMD exception.

MMPC The Medicare, Medicaid and Health Reform Policy Committee (MMPC) is a standing committee of the National Indian Health Board. The committee is chaired by a member of the NIHB Board of Directors. The primary purpose of the MMPC is to provide technical support to the CMS TTAG. Membership in MMPC is open to individuals authorized to represent a tribe, tribal organization, urban Indian program, or IHS. Meetings: Last meeting: February 20 in D.C. Strategy session: June 12-13 in Tulsa, OK Last meeting was February 20 in DC; strategy meeting is June 12-13 in Tulsa, OK. Next MMPC is July 24 in DC.

NIH TAC The National Institutes of Health (NIH) Tribal Advisory Committee (TAC) is advisory to the NIH, and provides a forum for meetings between elected Tribal officials (or their designated representatives) and NIH officials to exchange views, share information, and seek advice concerning intergovernmental responsibilities related to the implementation and administration of NIH programs. Portland Area Representatives: Robyn Sigo, Suquamish (Primary) Jeromy Sylvan, Port Gamble S’Klallam (Alternate) Meetings Last meeting: March 13-14, 2018. Andrew Shoegren is the TA to Robyn and will provide an update.

Other Updates? IHS Information Systems Advisory Committee (ISAC) IHS Strategic Plan Workgroup IHS Catastrophic Health Emergency Fund (CHEF) Workgroup IHS Health Promotion/Disease Prevention Policy Advisory Committee (HP/DP) IHS Health Research Advisory Council (HRAC) IHS National Tribal Advisory Committee (NTAC) Portland Area Fund Distribution Workgroup (FDWG) Portland Area Facilities Advisory Committee (PAFAC) – presentation on Wednesday, April 18 ISAC Last meeting was March 14-15 in Phoenix; next meeting in September in Alaska. Recommendations: The ISAC recommended the IHS 2018-2022 Strategic Plan specifically include in the next IHS Strategic Plan: Ensure inclusion of information technology (IT) staffing in the IHS Strategic Plan, Goal 1, Objective 1, and Goal 3, Objective 3, to modernize appropriate IT and clinical informatics staffing models. Additionally, the ISAC recommended that the Office of Information Technology (OIT), IHS Headquarters, lead the planning effort for modernization of IT and clinical informatics staffing through the development of a multi-year strategic staffing plan The ISAC recommended the IHS Chief Information Officer (CIO) provide a briefing to them on the Request for Information for IHS Health IT Modernization by March 29, 2018. The ISAC recommended the IT Service Catalog approval and implementation timelines be established no later than April 15, 2018. Actions: The ISAC requested that the OIT Tribal Liaison provide training to ISAC on the revised IT Service Catalog. ISAC Charter Update The ISAC will create a listserv for ISAC announcements and information sharing with interested parties outside of ISAC. ISAC IT Priorities--The ISAC will add Health IT Modernization as the ISAC’s number one priority. The ISAC proposed the next semi-annual meeting in September. Interim teleconference to be scheduled.

Questions…?