1. Legislative and Policy Update July 18, 2018
Brett Weber
Congressional Relations Coordinator, NIHB

2. Behavioral Health Conference SAVE THE DATE!!
Please join us for our 2 upcoming conferences later in the year as well!
Behavioral Health is July 25-27, 2018 in Washington DC (Omni Shoreham).
Check the NIHB website for hotel/agenda information!

3. 35th Annual National Tribal Health Conference SAVE THE DATE!!
Registration for Our 35th Annual NTHC is now open! Our theme for this year’s conference is “Tribal Unity to Advance the Promise Health”
35th Annual National Tribal Health Conference is September in Oklahoma City, Oklahoma (Renaissance Center). Please mark your calendars to join us!!
Details for registration, award nominations, and calls for proposals are on the NIHB website.
Register at

4. Fiscal Year 2018 Omnibus Signed on March 23, 2018.
Government funded through September 30, 2018.
$50 million to Tribes and Tribal Organizations for Opioids
Treatment, reducing unmet need, & reducing overdose related deaths
$5 million to Tribes and Tribal Organizations for Opioids
Medication-Assisted Treatment Programs
NIHB Board of Directors Passed Resolution
Tribes need to be consulted on how these funds are disbursed!
$5.5 billion for IHS which is an increase of just under $500 million (10%) above the FY 2017 enacted level.
$3.9 billion for services
$867 million for facilities
$718 million for Contract Support Costs.
President Trump signed omnibus on March 23, 2018
Omnibus includes an additional $500 million for IHS, and 50 million for Tribes to treat opioids, and another $5 million for MAT programs.
These funds can go directly to programs on the reservations offering treatment, reducing unmet need for addiction services, and decreasing the fatality rate on overdose related deaths.
These will be in the form of grants. NIHB has continued to stress the needs for formula funding for Indian health, but these resources will still make a huge difference.
At the April 2018 meeting of the Board of Directors, NIHB approved a resolution calling for SAMHSA to consult with Tribes to ensure that money reaches the Tribes with the greatest need.
Overall, IHS received $5.5 billion for FY 2018, 10% above FY That is a fairly significant increase, and we’ll see in a little bit that that momentum has continued.

5. FY 2019 Appropriations Testimony
Labor-HHS Subcommittee
Interior-Environment Subcommittee
Has Funding Jurisdiction over HHS
NIHB testified on April 27, 2018
Advocated for Tribal set asides in national public health programs and for increased investment in programs operating successfully in Indian Country, such as Good Health and Wellness in Indian Country
Has Funding Jurisdiction over Interior and Indian Health Service
NIHB Chairman Vinton Hawley testified on May 10, 2018.
Advocated for full funding of IHS pursuant to the recommendations of the Tribal Budget Formulation Workgroup
NIHB follows the Interior and Labor HHS appropriations subcommittees very closely.
Labor-HHS Subcommittee has funding jurisdiction over the Health and Human Services Department and all the agencies under it, such as Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention.
NIHB testified before the House Labor-HHS Appropriations Subcommittee on April 27, 2018.
Our Chief Executive Officer Stacy Bohlen offered this testimony to Chairman Tom Cole and Ranking Member DeLauro. In particular, she highlighted the success of the Good Health and Wellness in Indian Country Program, which would be eliminated in the President’s Budget Request, and asked for full funding of the program at $32 million.
We also work with the House Interior Subcommittee. It has funding jurisdiction over IHS and many other Tribal-specific agencies such as the Bureau of Indian Affairs.
Chairman Vinton Hawley testified before that committee on May 10 and advocated for full funding for IHS. You’ll see on the next slides how our work paid off. Congress is hearing the voice of the Tribes louder than ever and we got some good funding levels in these appropriations bills.

6. Fiscal Year 2019- Interior Appropriations
FY 2018 Enacted
President's Budget Request
TBFWG Recommendation
House Interior Appropriations
Senate Interior Appropriations
IHS Total
$5.5 billion
$5.4 billion
$6.4 billion
$5.9 billion
IHS, Hospitals and Clinics
$2.0 billion
$2.1 billion
$2.4 billion
$2.2 billion
IHS, PRC
$963 million
$955 million
$1.2 billion
$965 million
$964.8 million
IHS, Mental Health
$99.9 million
$105.2 million
$207.8 million
$106.8 million
$105.3 million
IHS, Alcohol & Substance Abuse
$227.8 million
$235.3 million
$327.8 million
$238.6 million
$245.6 million
IHS, Dental Health
$195 million
$204 million
$252 million
$208 million
$203.8 million
IHS, Facilities
$867.5 million
$505.8 million
$803 million
$883 million
$877.5 million
Contract Support Costs
$718 million
$822 million
$818 million
Urban Indian Health
$49.3 million
$46.4 million
$67.3 million
$60 million
Community Health Reps
$63 million
$92.2 million
Health Education
$19.9 million
$36 million
$20.6 million
SDPI
Mandatory
Discretionary
First, let’s talk about Interior. I realize this is a lot of numbers and I wont go through each line item. This bill funds several agencies, including the Environmental Protection Agency and the Department of the Interior. Importantly, the bill also covers many agencies operating directly in Indian Country, including the Bureau of Indian Affairs and the Indian Health Service (IHS).
The House Appropriations Committee released its Fiscal Year (FY) 2019 Interior and Environment Bill and held a markup on June 26. The bill passed out of committee on a party line vote of
The Senate Interior Appropriations Subcommittee marked up its bill on June 12 and the full committee did so on June 14. In none of these markups were any amendments impacting these funding levels approved. So the numbers you see here are the numbers for the final vote.
The Interior and Environment Appropriations bill would fund IHS at $5.9 billion. This is a $370 million increase over the FY 2018 enacted level and $500 million above the level proposed in the President's Budget Request to Congress. While Tribes are appreciative of this increase, to ensure IHS is able to provide quality care at the level of need, the National Indian Health Board supports the National Tribal Budget Formulation Workgroup's recommendation of $6.4 billion for IHS in FY 2019.
Importantly, no mention is made of reforming the Special Diabetes Program for Indians (SDPI). The President's budget request sought to remove SDPI from mandatory spending and subject it to the appropriations process. Tribes are glad to see this successful program will not be jeopardized. 
Additionally, no language was included in the bill to eliminate the Community Health Representatives program. This irreplaceable program is currently funded at $60 million, but the President's proposed budget would have eliminated the program, taking away funding from staff who help patients navigate the healthcare system and receive care. Tribes are glad to see the proposed elimination will not move forward in either the House or Senate legislation.
Overall, the bill includes cuts to the EPA’s budget, so it is doubtful that Democrats will support the legislation as a whole when it comes up for a floor vote. We will keep you updated on this as it develops through the political process.

7. Fiscal Year 2019- House Labor HHS appropriations
Program
FY 2018 Enacted
President's Budget Request
Tribal Rec
House Labor-H
Senate Labor-H
CDC, Preventive Health and Health Services Block Grant
$144.5 million (not specific to Tribes) $0
5% Tribal Set Aside
CDC, Good Health and Wellness in Indian Country
$16 million
$32 million
Unspecified
CDC, Public Health Emergency Prep
$656 million (not specific to Tribes)
$660 million (not specific to Tribes)
$690 million
$680 million
SAMHSA, State Targeted Response
5% Tribal Set Aside ($50 million)
$1 billion (no Tribal set aside)
10% Tribal Set Aside
$ 1 billion, $50 million for Tribes
$1.5 billion, $50 million for Tribes
SAMHSA, Mental Health Service Block Grant
$562.3 million
$562.6 million
Direct Tribal Funding
$722.5 million
$747.5 million
SAMHSA, Tribal Behavioral Health Grants
$14.9 million
$15 million
$50 million
$40 million
$ 30 million
SAMHSA, Circles of Care
$7.2 million
$8.5 million
SAMHSA, Substance Abuse Block Grant
$1.85 billion (not specific to Tribes
$1.9 billion (not specific to Tribes)
$2.4 billion, no set aside
$1.9 billion, no set aside
HHS, Secretary's Minority AIDS Initiative
$53.9 million
$53.9 million, IHS Set aside
$53.9 million, no set aside
CMS, Exemption from Medicaid Work Requirements
Not Included
Include Legislative Language
HHS, Expansion of Self-Governance
Let’s turn now to Labor-HHS. Again, lots of numbers and I wont go through each item. The Labor-HHS bill funds public health programs, including those working in Indian Country that are critical to Tribal Health. In the House, the Labor-H Appropriations Subcommittee Chair is Tom Cole, with whom NIHB and the Tribes have a fantastic working relationship. It’s clear from these numbers that that relationship has paid off.
The House Labor-HHS Subcommittee released its bill on June 14 and held a mark up on June 15. On July 13, the House Appropriations Committee had their markup, which lasted about 6 hours. There were a number of partisan votes, but the important take away is that the Tribes were able to preserve all of the gains made at the subcommittee level.
On the Senate side, The Labor-HHS Subcommittee held its markup on June 26 and the full committee held its mark up on June 28. Once again, no amendments affecting these programs was approved.
I want to highlight one program, the Good Health and Wellness in Indian Country. The President’s Budget Request would have eliminated this successful program. We asked our allies on the Appropriations Committee to reject this request and instead build on the program’s success with a $32 million investment, doubling the program. The House included our request! We are working on the Senate side to protect this monumental gain!
NIHB will continue to provide updates to Tribes as the Appropriations season continues.

8. Medicaid Update
On January 17th CMS issued a Dear Tribal Leader Letter stating that CMS could not provide an exemption for AI/ANs because of Civil Rights reasons
Tribal leaders contacted their members of Congress:
Inform HHS and CMS leadership that this decision was incorrect
Direct HHS and CMS to work with Tribes to find a solution that respected the trust responsibility.
On May 7th, CMS updated its position, stating that they would strongly consider state proposed accommodations for AI/AN from work requirements on a state by state basis
On June 29, a federal judge blocked Kentucky’s Medicaid work requirements
So, as you well know, the Administration got into some hot water earlier this year.
CMS issued a letter to tribal leaders in January 2018, stating that CMS could not approve a tribal exemption because it would unfairly favor a group of people based on their race (a civil rights violation)
Tribal leaders were quick to respond. They contacted their members of Congress asking those members to inform the Secretary of HHS and the Administrator for CMS that their decision to classify Tribes as a race-based status was incorrect and to direct the agencies to work with Tribes to find a solution that respected the trust responsibility.
On May 7th, CMS updated its position, stating that they would strongly consider state proposed accommodations for AI/AN from work requirements on a state by state basis. CMS did not reference any “civil rights concerns” at that meeting. Furthermore, CMS has directed states to work with Tribes through the consultation process to propose these accommodations. Secretary Azar then said he considered the matter closed.
Finally, on June 29, a federal judge blocked Kentucky’s Medicaid work requirements from being approved. We expect this issue to reappear in litigation in the near future and in other states as well.

9. Subcommittee Report Language
House Labor-HHS Committee Report included specific language:
“…the Federal government has consistently held Indian Tribes as a unique group when applying Federal law and policy.”
“No discretionary action taken by any Administration can impede the direct relationship between the Federal government and the provision of health care for Indian Tribes."
So, as you well know, the Administration got into some hot water earlier this year.
CMS issued a letter to tribal leaders in January 2018, stating that CMS could not approve a tribal exemption because it would unfairly favor a group of people based on their race (a civil rights violation)
Tribal leaders were quick to respond. They contacted their members of Congress asking those members to inform the Secretary of HHS and the Administrator for CMS that their decision to classify Tribes as a race-based status was incorrect and to direct the agencies to work with Tribes to find a solution that respected the trust responsibility.
On May 7th, CMS updated its position, stating that they would strongly consider state proposed accommodations for AI/AN from work requirements on a state by state basis. CMS did not reference any “civil rights concerns” at that meeting. Furthermore, CMS has directed states to work with Tribes through the consultation process to propose these accommodations. Secretary Azar then said he considered the matter closed.
Well the Labor-HHS report included guiding language that Tribes are a unique political group, not a race-based classification. This is a significant victory and shows that Congress is on the Tribes’ side with this dispute. We know the agencies learned their lesson.

10. IHS Reform Legislation
H.R. 5874, Restoring Accountability in the IHS Act
Congresswoman Kristi Noem (R-SD)
Introduced on May 18, 2018
Approved by House Natural Resources Committee on June 13, 2018.
Stated goals of the legislation:
offer better tools for recruiting the agency's staff and leadership,
improve care standards,
dramatically increase accountability. Specifically the bill would:
Requires all IHS employees and contractors to undergo cultural competency training
Expands the loan repayment program and recruitment tools
Streamlines the volunteer credentialing process
Provides transparency in reports from CMS
Switching gears a little bit, there is currently legislation from Rep. Krist Noem seeking to reform IHS. Ms. Noem is South Dakota’s loan representative, and she is particularly concerned with the quality of care issues that have come up in the Great Plains Area.
Her bill is HR 5874, the Restoring Accountability in the IHS Act, and it was introduced on May 18 and approved b committee on June 13. You may think that is a pretty speedy turnaround, and it is, because this bill is substantially similar to bills introduced in previous Congresses and the Committee had actually had a hearing on a very similar bill last year.
Stated goals of the legislation:
offer better tools for recruiting the agency's staff and leadership,
improve care standards,
dramatically increase accountability. Specifically the bill would:
Requires all IHS employees and contractors to undergo cultural competency training
Expands the loan repayment program and existing recruitment tools
Streamlines the volunteer credentialing process and reducing related paperwork
Provides transparency in reports from CMS

11. Veterans Legislation IHS-VA MOU extended until 2022
$50 million in IHS savings from
GAO currently studying effectiveness of MOUs
Legislation Creating VA Tribal Advisory Committee
Turning now to veterans health legislation, IHS and the VA renewed their Memorandum of Understanding through the year 2022.
The original MOU allowed for reimbursement agreements for the VA to fund IHS care for Native American Veterans. We expect those agreements to be extended as well.
Between 2012 and 2017 the VA reimbursed $50 million to IHS and Tribal facilities, serving over 5,000 eligible veterans nationwide. This is just a fraction of one percent of the VA’s annual budget.
The Government Accountability Office is currently studying the effectiveness of MOUs between the IHS, Tribes, and the VA, and we expect the results of that study in the near future.
NIHB has also been working with Senators on legislation to create a Tribal Advisory Committee at the VA. This would be one of the only TACs actually congressionally mandated, which has a lot of advantages. We expect this bill to drop in the summer this year.
I’ve also included a picture here of the new design for the Native American Veterans Memorial on the National Mall. As you may have heard, the artist, Harvey Pratt, designed the memorial to be a place for reflection and healing for Native American Veterans and their families. It is expected to be completed in 2020.

12. Opioids—NIHB on Capitol Hill
Senate Committee on Indian Affairs
Hearing on March 14, 2018
Sam Moose Testified for NIHB
Tribal Programs in Great Lakes
Special Behavioral Health Program for Indians
Written Testimony
Senate Committee on Health, Education, Labor, and Pensions
House Energy and Commerce Committee (has jurisdiction over health issues in House)
Senate Finance Committee (has jurisdiction over Medicare/Medicaid in the Senate)
NIHB Board of Directors Member and Bemidji Area Representative Sam Moose testified at a Senate Committee on Indian Affairs hearing devoted to the opioids crisis on March 14, 2018.
He spoke on the Tribes in his area and how they are responding to the opioids crisis and what support Congress needs to give them.
Mr. Moose also encouraged the Committee to create a Special Behavioral Health Program for Indians, which would be modeled off of SDPI.
We have also submitted written testimony for the record on issues such as data sovereignty, Health IT needs, and treatment funding and flexibility to multiple Tribal committees.

13. Opioids—Ongoing Work in Senate
Senate Health, Education, Labor, and Pensions (HELP) Committee Opioid Crisis Response Act (S. 2680)
Most likely to be Senate’s opioids package
5% Set Aside for Tribes in State Targeted Response
3% Set Aside for Tribes for Infant Programs
Working to include Special Behavioral Health Program for Indians ($150 million/year)
The Senate Finance Committee HEAL Act
Package of 22 bills to address Medicare, Medicaid, and telehealth
Some of the bills include AI/AN, but no direct funding
Committee Markup occurred on Tuesday, June 12th
Lots is going on right now on opioids. Basically every committee with jurisdiction has either already held a hearing, is holding a hearing, or both.
There are lots of different bills floating around, some better for Tribes than others.
The House is still developing its opioids package, and the Senate is a little further along in that process.
The Senate Health, Education, Labor and Pensions Committee passed the bill out of committee on April 28. It is fairly good for Tribes.
It includes 5% of State Targeted Response funds going directly to Tribes—this is a long standing Tribal priority
3% set aside to Tribes to fund programs treating new borns and infants affected by opioids
Our number 1 priority for further inclusion is to add SBHPI into the bill. This would fund behavioral health programs in Indian Country similar to how SDPI operates. We have been leaning especially on HELP Committee Republicans such as Chairman Lamar Alexander, Lisa Murkowski, and Susan Collins.

14. Opioids—Outlook Moving Forward
Opioid Crisis Response Act (S. 2680) likely to be Senate’s opioids package
NIHB working to include priorities in amendments as the bill comes to the floor
Votes likely pushed back until after Supreme Court nominee is confirmed
House has passed ~60 bills related to opioids
Most do not have direct Tribal impact
SUPPORT for Patients and Communities Act (H.R. 6)
Unclear at this point if the House will take further action without the Senate’s input
The outlook for opioids legislation looks a lot less certain than it did a few months ago.
We have heard that Leader McConnell will not prioritize anything ahead of the Supreme Court nomination, so legislation such as OCRA and the Farm Bill may be pushed into August or even into the lame duck session after the election.
OCRA is likely to be the basis for the Senate’s comprehensive opioids package. Pieces from other bills may be included in the manager’s amendment, which is an amendment submitted by the author of the bill, in this case Chairman Lamar Alexander and Ranking Member Patty Murray.
NIHB is trying to get our priorities into the manager’s amendment. Again, we are not certain of a timeline.
The House on the other hand has been very active. They have passed about 60 bills, most of which do not directly impact Tribes. For example, HR 6 includes regulatory fixes to Medicare, Medicaid and the Children's Health Insurance Program (CHIP) to expand the use of non-opioid therapies for pain management, expand telehealth and e-prescribing services, allow for more flexibility in prescribing medication-assisted treatments, and improve Medicare and Medicaid surveillance of opioid prescribing practices.
We do not expect the House to pass additional opioids legislation before the Senate does.

15. Farm Bill— Tribal Priorities
Create pathway for Tribes to administer their own food assistance programs.
Senator Smith introduced a bill on June 11th to give Tribes authority over the operations of all federally funded supplemental nutrition assistance programs (S.3046)
Tribal exemptions from work requirements and time limits for Supplemental Nutrition Assistance Program (SNAP).
Expand Food Distribution Program on Indian Reservations (FDPIR).
Provide Tribes with base funding to develop or expand traditional foods programs.
Require a Congressional inquiry into the impact of drastic cuts or elimination of food assistance programs on the overall food security of Tribes.
One of the largest pieces of legislation coming up this year that will have significant implications for the overall health and nutrition of Tribal communities is the Farm Bill.
On March 1st NIHB joined the Native Farm Bill Coalition along with over 160 Tribes and 12 intertribal and native organizations. Tribes have often been excluded from the planning, development and implementation of national food and agriculture policy and this coalition is meant to be a unified Tribal voice in these discussion.
On January 18th I was also able to testify in front if the Senate Committee on Indian Affairs on Tribal policy recommendation for the Farm Bill. NIHB has been meeting with Senate and House staff as the Farm Bill has moved forward.
The top priorities for NIHB and the Native Farm Bill Coalition include the creation of a pathway for Tribes to administer their own food assistance programs if they choose.
Senator Tina Smith introduced the Tribal Food Sovereignty Act (S.3046) on June 11th which gives Tribes authority over the operations of all federally funded supplemental nutrition assistance programs
This is a big step for Tribes to help restore tribal food sovereignty, and provide better food assistance to more Indian households in need.
Modeled off of PL to allow Tribes to choose food delivery method that works for them and administer food distribution using local knowledge.
Other Legislative Priorities for NIHB include:
Exempt Tribes and Tribal members from work requirements and corresponding time limits for receiving SNAP benefits (more commonly called food stamps)
Expand the Food Distribution Program on Indian Reservations (FDPIR) through increased funding for purchasing of traditional foods, infrastructure development, and nutrition education.
Provide Tribes with base funding to develop or expand traditional foods programs
Require a Congressional Budget Office (CBO) or Congressional Research Service (CRS) inquiry into the impact of drastic cuts or elimination of food assistance programs on the overall food security of Tribes.
The right to healthcare is the right to healthy food.

16. Farm Bill Timeline The Senate Farm Bill passed on June 28th
On a revote the House Farm Bill passed on June 22nd
The current Farm Bill set to expire September 30th
On June 8th the Senate Agriculture Committee release their Bi-partisan version of the Farm.
The bill then passed the Senate on a vote on June 28th.
The Senate Version of the Farm bill included many positive provisions for Tribes including: 
Adjusting the match requirements and funding limitations for the Food Distribution Program on Indian Reservations (FDPIR) so that economically disadvantaged tribes may reach more households in need of assistance;
Authorizing a new $5 million demonstration project to allow some tribes to purchase some FDPIR food under self-determination ("638") contracts;
Creating a Tribal Advisory Committee at the Department of Agriculture, similar to the Secretary's Tribal Advisory Committee at the Department of Health and Human Services
The House Farm Bill included controversial new work requirements on the Supplemental Nutrition Assistance Program (SNAP) and was originally voted down due to the Republican Freedom Caucus and their frustrations with not having a vote on immigration related issues.
After the farm bill failed, Speaker of the House Paul Ryan—In order to win over support of the Freedom Caucus—passed a resolution to address immigration as well as reconsider the farm bill before June 22nd. They were able to get the vote on immigration and passed the house version of the farm bill on June 22nd.
The differences in the two bills will lead to a conference committee to reconcile both the House and the Senate versions of the bill. During this time NIHB will continue to meet with members of Congress to make sure Tribes will not be left out of the Final version of the bill.

17. Thank you! For more information please contact: Brett Weber Bweber@nihb.org