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IHS

SELF-GOVERNANCE

ADVISORY COMMITTEE

(TSGAC) MEETINGOCTOBER 3-4, 2018

Embassy Suites DC Convention Center

900 10th Street Northwest

Washington, DC 2000

Phone: (202) 739-20011

TABLE OF CONTENTS

IHS Tribal Self-Governance Advisory Committee and Technical Workgroup Meeting

Wednesday, October 3, 2018 Thursday, October 4, 2018

Embassy Suites Washington DC - DC Convention Center 900 10th Street NW

Washington, DC 20001 Phone: (202) 739-2001

Table of Contents

1. TSGAC Informationa. TSGAC Agendab. 2019 SGCE Calendarc. TSGAC Membership Matrixd. Workgroup Assignment Matrixe. Correspondence Matrix

• Letters from TSGAC• Letters from IHS

f. The Stronger Medical Workforce Act – VA Commissioned Personnel

2. Update of IHS Priorities from Self-Governance Strategic Plan3. Veterans Affairs (VA) – Implementing the VA Mission Act of 2018

a. Graduate Medical Education Pilot

4. Medicaid Legislative Priorities5. TSGAC Committee Business

a. Approval of Meeting Summary (July, 2018)b. Nomination of TSGAC Member and Alternate – Phoenix Area

6. Advanced Appropriations for IHS-Government Accountability Office Report

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education

P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE AND TECHNICAL WORKGROUP QUARTERLY MEETING

Wednesday, October 3, 2018 (8:30 am to 5:00 pm) Thursday, October 4, 2018 (8:30 am to 5:00 pm)

Embassy Suites Washington DC - DC Convention Center

900-10th Street NW Washington, DC 20001 Phone: (202) 739-2001

AGENDA

Wednesday, October 3, 2018 (8:30 am to 5:00 pm)

Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) Technical Workgroup (TW)

(Official Tribal/Federal TW members, Self-Governance Coordinators and other Technical Representatives are welcome.)

(This session is to prepare for the TSGAC Meeting.)

8:30 am Meeting of Technical Workgroup Welcome Invocation Introductions 8:50 am Opening Remarks

Melanie Fourkiller, Senior Policy Analyst, Choctaw Nation, and TSGAC Technical Workgroup Tribal Co-Chair Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS, and TSGAC Technical Workgroup Federal Co-Chair

9:10 am Update of IHS Priorities from Self-Governance Strategic Plan

Jay Spaan, Executive Director, Self-Governance Communication and Education (SGCE)

9:30 am Resource Patient Management System (RPMS) Modernization and

Conversion ▪ How will Self-Governance Tribes needs be captured? ▪ How will Self-Governance Tribes be included in funding? ▪ How will Self-Governance Tribes be included in the proposed study?

9:45 am Unpaid Claims from Pharmacy Benefit Managers and Medicaid Managed

Care Organizations Melanie Fourkiller, Senior Policy Analyst, Choctaw Nation, and TSGAC Technical Workgroup Tribal Co-Chair

10:00 am Veterans Affairs (VA) – Implementing the VA Mission Act of 2018

http://www.tribalselfgov.org/

IHS TSGAC & Technical Workgroup Meeting Page 2 October 3-4, 2018 – AGENDA

1st 2019 TSGAC Meeting

• Graduate Medical Education Pilot • Loan Repayment Program • Request for Tribal/VA Workgroup on reimbursing PRC

10:15 am Medicaid Legislative Priorities Doneg McDonough, TSGAC Technical Advisor 10:30 am Indian Health Care Improvement Fund Workgroup (IHCIF) – Phase II

James C. Roberts, Senior Executive Liaison, Intergovernmental Affairs, Alaska Native Tribal Health Consortium, Tribal Co-Chair, IHCIF Workgroup

10:45 am Community Health Aide Program (CHAP) Workgroup

Dr. Glorinda Segay, Executive Director, Navajo Nation Department of Health and Tribal Co-Chair, CHAP Workgroup

11:00 am Section 105(l) Lease Obligations of the IHS 11:15 am Preparation of Talking Points for TSGAC Meeting 12:00 Noon Lunch (provided)

Wednesday, October 3, 2018 (1:00 pm to 5:00 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and

Technical Workgroup with RADM Michael D. Weahkee, Principal Deputy Director, IHS (TSGAC will be joined by the Direct Service Tribes Advisory Committee)

1:00 pm Tribal Caucus

Facilitated by: Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC)

• Review and editing of TSGAC Technical Workgroup Talking Points • CMS Civil Rights Issues – National Strategy • IHS Director Nomination (Acting IHS Director delegation expired on 9/25) • Response to IHS recent response on Sec. 105(l) Leases • Discussion on transfer of IHS budget from Interior to HHS • Other Issues

2:00 pm Meeting Called to Order Welcome Invocation

Roll Call Introductions – All Participants & Invited Guests 2:15 pm TSGAC Opening Remarks

Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Principal Deputy Director, IHS



2:40 pm Direct Service Tribes Advisory Committee (DSTAC) Update and Discussion Nicolas Barton, Cheyenne and Arapaho Tribes, and Chairman, IHS DSTAC

• Joint DSTAC/TSGAC Letter to IHS Requesting Update of IHS Tribal Consultation Policy, August 10, 2018

• Opportunities for Joint Advocacy with DSTAC • Strategic Look at Budget Formulation Process

3:00 pm TSGAC Committee Business

• Approval of Meeting Summary (July, 2018) • Nomination of TSGAC Member and Alternate – Phoenix Area • Review of Self-Governance Professionals Workshop and Strategy

Session, September 10-12, 2018, St Paul, MN • TSGAC Involvement in OTSG Deputy Director Selection Process • 2019 TSGAC and Self-Governance Meeting Schedule

3:20 pm Office of Tribal Self-Governance (OTSG) Update

Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS

• OTSG Staffing

3:40 pm Indian Health Service Budget Update Elizabeth Fowler, Deputy Director for Management Operations, IHS (tentative) Terra Branson, Self-Governance Coordinator, Muscogee (Creek) Nation

• Fiscal Year 2018 Appropriations • Fiscal Year 2019 President’s Budget Request • Fiscal Year 2020 Budget Formulation

• Fiscal Year 2021 Budget Formulation 4:00 pm Tribal Caucus with Trent Morse, HHS White House Liaison (TBD) 5:00 pm Recess until October 4, 2018



Thursday, October 4, 2018 (8:30 am – 5:00 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical

Workgroup with RADM Michael D. Weahkee, Principal Deputy Director, IHS 8:30 am Welcome and Introductions


8:45 am Opioid Litigation Update Geoffrey Strommer, Partner, Hobbs, Strauss, Dean and Walker, LLP

Donald Simon, Partner, Sonosky, Chambers, Sasche, Endreson and Perry, LLP 9:15 am Indian Health Care Improvement Fund (IHCIF) Workgroup Update

James C. Roberts, Senior Executive Liaison, Intergovernmental Affairs, Alaska Native Tribal Health Consortium, Tribal Co-Chair, IHCIF Workgroup Elizabeth Fowler, Deputy Director for Management Operations, IHS, Federal Co-Chair, IHCIF Workgroup (tentative)

9:35 pm Patient Protection and Affordable Care Act (ACA) Implementation Update

Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Inc. Doneg McDonough, Consultant, TSGAC

• Legislative Priorities for Medicaid in Indian Country 10:00 am Office of Information Technology Update (OIT)

Mitchell Thornbrugh, Acting Chief Information Officer and Acting Director, Office of Information Technology, IHS (Tentative)

• Veteran Affairs’ Migration to Cerner and Impact on the Resource and Patient Management System (RPMS) Update

• IHS Health Information Technology Modernization Research Project • Data requests for Tribal advocacy (April 17, 2018 TSGAC letter) • ISAC Workgroup Update and New Charter • Data available to support Tribal Sponsorship Programs (TSGAC Request to

IHS to design an RPMS report) 10:30 am Department of Veteran’s Affairs (VA) – Graduate Medical Education (GME)

Kathleen Klink, MD, FAAFP, Acting Deputy Chief Academic Affiliations Officer, Veterans Health Administration (VHA) Dr. Edward Bope, MD, FAAFP, Director of GME Expansion, Office of Academic Affiliations, VHA

Dr. Douglas Eby, Vice President of Medical Services, Southcentral Foundation • Implementation of Section 403 of the VA Mission Act of 2018 authorizing a

GME pilot with priority for IHS/Tribal facilities 11:00 am Office of Environmental Health and Engineering (OEHE) Gary Hartz, Director, OEHE, IHS

• Tribal Consultation on Sanitation Deficiency System (SDS) Guidance Document – concluded September 14, 2018



11:30 am Advanced Appropriations for IHS – Government Accountability Office Report Jay Spaan, Executive Director, Self-Governance Communication and Education (SGCE)

• Review of the Report • Strategy and Next Steps

12:00 pm Lunch - TSGAC Members’ Executive Session with IHS Principal Deputy

Director 1:00 pm Legislative Update

Stacy Bohlen, Chief Executive Officer, National Indian Health Board

• Appropriations • Restoring Accountability in the IHS of 2017 (S 1250 & HR 2662) • Opioid Legislation • Other Indian Health and Related Updates

1:30 pm Unpaid Claims by Pharmacy Benefit Managers and Medicaid Managed Care

Organizations Terri Schmidt, Acting Director, Office of Resource Access and Partnerships, IHS

• Plan with timeline 1:50 pm Joint TSGAC and Acting IHS Director Discussion

• Contract Support Cost Policy – status of pending decision • Purchased and Referred Care Policy Status – Tribal Consultation and

Workgroup Meeting • IHS Strategic Plan Draft and Consultation – status • Behavioral Health Grants Tribal Consultation • Other Issues

3:45 pm Closing Remarks


4:00 pm TSGAC Technical Workgroup Session • Assignments and Follow-up Items

5:00 pm Adjourn TSGAC Meeting

2019 SGCE Calendar

Date Event Location

January 22-25 (Begins on Tuesday Ends on Friday)

2nd TSGAC/SGAC Meeting Washington, DC Embassy Suites DC Convention Center

March 31-April 4 Tribal Self-Governance Annual Consultation Conference

Traverse City, Michigan Grand Traverse Resort and Spa

July 15-18 3rd TSGAC/SGAC Meeting Washington, DC Embassy Suites DC Convention Center

September 10-12 Tribal Self-Governance Strategy Session

TBD

September 30-October 3 1st TSGAC/SGAC Meeting ‘20 Washington, DC- Embassy Suites DC Convention Center

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P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

MEMBERSHIP LIST (September 25, 2018)

AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Diana Zirul

Tribal Council Member Kenaitze Indian Tribe

Primary 150 N Willow St. Kenai, AK 99611 P: (907) 335-7200 Email: [email protected]

Gerald “Jerry” Moses, Senior Director Intergovernmental Affairs, Alaska Native Tribal Health Consortium

Alternate 4000 Ambassador Drive, LIGA Department Anchorage, AK 99508 P: (907) 729-1900 Email: [email protected]

Albuquerque Ruben A. Romero, Governor Pueblo of Taos

Primary PO Box 1846 Taos, NM 87571 P: 575-758-9593 ~ F: 575-758-4604 Email: [email protected]

Raymond Loretto, DVM, Tribal Council Representative Pueblo of Jemez

Alternate PO BOX 100 Jemez Pueblo, NM 87024 P: 575-834-7359 ~ F: 575-834-7331 Email: [email protected]

Bemidji Jane Rhol, Tribal Council Secretary Grand Traverse Band of Ottawa & Chippewa Indians

Primary 2605 N West Bay Shore Drive Peshawbestown, MI 49682-9275 P: (231) 534-7494 Email: [email protected]

Jennifer Webster Councilwoman Oneida Nation

Alternate PO Box 365 Oneida, WI 54155 P: 920-869-4457 Email: [email protected]

Billings Beau Mitchell, Council Member Chippewa Cree Tribe

Primary PO Box 544 Box Elder, MT 59521 Email: [email protected]

Shelly Fyant, Tribal Council Member The Confederated Salish and Kootenai Tribes of the Flathead Nation

Alternate PO BOX 278 Pablo, MT 59855 P: (406) 275-2700 ~ F: (406) 275-2806 Email:

California Ryan Jackson, Council Member Hoopa Valley Tribe

Primary PO Box 1348 Hoopa, CA 95546 Email: [email protected]

Robert Smith, Chairman Pala Band of Mission Indians

Alternate 35961 Pala-Temecula Rd. Pala, CA 92059 P: 760-891-3519 ~ F: 760-891-3584 Email: [email protected]

Great Plains Kenneth Baker Jr. Spirit Lake Health Center

Primary PO Box 309 Fort Totten, ND 58335 P: 701-766-1672 Email: [email protected]

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Arliss Krulish Spirit Lake Health Center

Alternate 7473 35th St NE Fort Totten, ND 58335 P: 701-766-1600 Email: [email protected]

Nashville Marilynn “Lynn” Malerba, Chief Mohegan Tribe of Connecticut TSGAC Chairwoman

Primary 5 Crow Hill Road Uncasville, CT 06382 P: 860-862-6192 ~ F: Email: [email protected]

Casey Cooper, Chief Executive Officer Eastern Band of Cherokee Indians Hospital

Alternate 43 John Crowe Hill Rd. PO Box 666 Cherokee, NC 28719 Email: [email protected]

Navajo Jonathan Nez, Vice President Navajo Nation

Primary PO BOX 7440 Window Rock, AZ 86515 P: (928) 871-7000 Email: [email protected]

Nathaniel Brown, Delegate of the 23rd

Navajo Nation Council Navajo Nation

Alternate PO BOX 3390 Window Rock, AZ 86515 P: (928) 871-6380 Email: [email protected]

Oklahoma 1 John Barrett, Jr., Chairman Primary 1601 S. Gordon Cooper Dr. Rhonda Butcher, Director Proxy Shawnee, OK 74801 Citizen Potawatomi Nation P: 405-275-3121 x 1157

F:405-275-4658 Email: [email protected]

Kay Rhoads, Principal Chief Alternate 920883 Hwy 99 Sac and Fox Nation Stroud, OK 74079

P: (918) 968-3526 x 1004 F: (918) 968-1142 Email: [email protected]

Oklahoma 2 Jefferson Keel, Lt. Governor Chickasaw Nation

Primary PO Box 1548 Ada, OK 74821 P: 580-436-7232 ~ F: 580-436-7209 Email: [email protected]

Gary Batton, Chief Mickey Peercy, Executive Director Choctaw Nation of Oklahoma

AlternateProxy

PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]

Phoenix VACANT Primary

Delia Carlyle Alternate

Portland W. Ron Allen, Tribal Chairman/CEO Jamestown S’Klallam Tribe TSGAC Vice-Chairman

Primary 1033 Old Blyn Highway Sequim, WA 98382 P: 360-681-4621 ~ F: 360-681-4643 Email: [email protected]

Tyson Johnston, Vice President Quinault Indian Nation

Alternate P.O. Box 189 (1214 Aalis Drive) Taholah, WA 98587 P: 360-276-8211 ~ F: 360-276-4191 Email: [email protected]

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Tucson Daniel L.A. Preston, III, Councilman Tohono O’odham Nation

Primary P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]

Anthony J. Francisco, Jr., Councilman Tohono O’odham Nation

Alternate P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: Anthony.francisco@tonation- nsn.gov

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TSGAC TECHNICAL WORKGROUP AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Brandon Biddle

Alaska Native Tribal Health Consortium Tech Rep 4000 Ambassador Drive

Anchorage, Alaska 99508 P: 907-729-4687 Email: [email protected]

Alberta Unok Deputy Director Alaska Native Health Board

Tech Rep 4000 Ambassador Drive Anchorage, Alaska 99508 P: 907-562-6006 Email: [email protected]

Albuquerque Shawn Duran Taos Pueblo

Tech Rep P.O. Box 1846 Taos, N.M. 87571 P: 575.758.8626 ext. 115 Email: [email protected]

Bemidji John Mojica Mille Lacs Band of Ojibwe

Tech Rep 43408 Oodena Drive Onamia, MN 56359 P: 320-532-7479 ~ F: 320-532-7505 Email: [email protected]

Billings Ed Parisian Chippewa Cree Tribe

Tech Rep PO Box 544 Box Elder, MT 59521 Email: [email protected]

California VACANT Tech Rep

D.C. (National)

C. Juliet Pittman SENSE Incorporated

Tech Rep Upshaw Place 1130 -20th Street, NW; Suite 220 Washington, DC 20036 P: 202-628-1151 ~ F: 202-638-4502 Email: [email protected]

Cyndi Ferguson Tech Rep Upshaw Place SENSE Incorporated 1130 -20th Street, NW; Suite 220

Washington, DC 20036 P: (202) 628-1151 ~ F: (603) 754-7625C: (202) 638-4502 Email: [email protected]

Doneg McDonough Tech Rep (Health Reform)

Phone: 202-486-3343 (cell) Fax: 202-499-1384 Email: [email protected]

Great Plains VACANT Tech Rep

Nashville Dee Sabattus United South and Eastern Tribes, Inc.

Tech Rep 711 Stewarts Pike Ferry, Suite 100 Nashville, TN 37214 Email: [email protected]

Navajo Patrese Atine Navajo Nation Washington Office

Tech Rep 750 First Street NE, Suite 1010 Washington, DC 20002 P: 202.682.7390 E-mail: [email protected]

Oklahoma Rhonda Farrimond Choctaw Nation

Tech Rep PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]

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TSGAC & Technical Work Group Membership ListMay 19, 2017

Melanie Fourkiller Tech Rep PO Box 1210 Choctaw Nation Durant, OK 74702 Tribal Technical Co-Chair P: 580-924-8280 ~ F: 580-920-3138

C: 918-453-7338 Email: [email protected]

Karen Ketcher Cherokee Nation

Tech Rep PO Box 948 Tahlequah, OK 74465 P: 918-772-4130 Email: [email protected]

Kasie Nichols Tech Rep 1601 S. Gordon Cooper Dr. Citizen Potawatomi Nation Shawnee, OK 74801

P: 405.275.3121 ~ F: 405.275.0198C: 405-474-9126 Email: [email protected]

Phoenix VACANT Tech Rep

Portland Jennifer McLaughlin Jamestown S’Klallam Tribe

Tech Rep 1033 Old Blyn Highway Sequim, WA 98382 P: (360) 681-4612 ~ F: (360) 681-4648 Email: [email protected]

Eugena R Hobucket Quinault Indian Nation

Tech Rep PO BOX 189 Taholah WA 98587 P: (360) 276-8211 ~ F: (360) 276-8201 Email: [email protected]

Tucson Veronica Geronimo Tohono O’odham Nation

Tech Rep P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: veronica.geronimo@tonation- nsn.gov

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FEDERAL TECHS AREA MEMBER (name/title) STATUS CONTACT INFORMATION

HQ Jennifer Cooper Director, OTSG (Federal Tech Co-Chair)

OTSG Rep

5600 Fishers Lane, MS: 08E05C Rockville, MD 20853 P: 301-443-7821 E: [email protected]

Jeremy Marshall Policy Analyst, OTSG Tamara Clay Policy Analyst, OTSG

OTSG Rep

5600 Fishers Lane, MS: 08E05C Rockville, MD 20853 P: 301-443-7821 E: [email protected]/[email protected]

Alaska Lanie Fox Director, Office of Tribal Programs

Area Rep

4141 Ambassador Drive, Suite 300 Anchorage, AK 99508-5928 P: 907-729-3677 ~F: 907-729-3678 E: [email protected]

Albuquerque Russel Pederson Director OEHE IHS Agency Lead Negotiator

Area Rep

4101 Indian School Road, NE Albuquerque, NM 87110 P: 505-256-6737 E: [email protected]

Bemidji Chris Poole IHS Agency Lead Negotiator

Area Rep

522 Minnesota Ave NW Bemidji, MN 56601 P: 218-444-0475 E: [email protected]

Billings Bryce Redgrave Executive Officer

Area Rep

29400 4th Avenue, North Billings, MT 59101 P: 406-247-7248 E: [email protected]

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California Travis Coleman Contracting Specialist IHS Agency Lead Negotiator

Area Rep

650 Capitol Mall, Suite 7-100 Sacramento, CA 95814 P: 916-930-3981 x39 E: [email protected]

Great Plains Dan Davis Federal Liaison

Area Rep

115 Fourth Avenue SE, Room 309 Federal Building Aberdeen, SD 57401 P: 605-226-7776 E: [email protected]

Nashville Ashley Metcalf IHS Agency Lead Negotiator

Area Rep

7111 Stewarts Ferry Pike Nashville, TN 37214 P: 615-495-1297 E: [email protected]

Navajo Dee Hutchison Executive Officer

Area Rep

Hwy 264 (St. Michaels, AZ) Window Rock, AZ 86515 P: 928-871-5801 E: [email protected]

Oklahoma Lindsay King Director Office of Tribal Self-Determination IHS Agency Lead Negotiator

Area Rep

701 Market Drive Oklahoma City, OK 73114 P: 405-951-3733 E: [email protected]

Phoenix Randall Morgan Director, Office of Self-Determination

Area Rep

40 N. Central Ave, Suite 608 Phoenix, AZ 85004 P: 602-364-5354 E: [email protected]

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Portland Jason Davis Financial Analyst, ISDA Rena Macy Budget Analyst

Area Rep

1414 NW Northrup Street Portland, OR 97209 P: 503-414-7793/503-414-5540 E: [email protected]/[email protected]

Tucson Mark Bigbey Executive Officer IHS Agency Lead Negotiator

Area Rep

7900 S J Stock RD Tucson, AZ 85743 P: 520-295-2404 E: [email protected]

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OTHER RESOURCES MEMBER (name/title) ORGANIZATION CONTACT INFORMATION Caitrin Shuy Director of Congressional Relations

National Indian Health Board P: 202-507-4085 Email: [email protected]

Devin Delrow Director of Federal Relations

National Indian Health Board P: 202-507-4072 Email: [email protected]

TSGAC Mailing Address: c/o Self-Governance Communication and Education


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Technical Workgroup Assignment Matrix

Updated: October 1, 2018

Technical Workgroup Co-Chairs: Melanie Fourkiller, Tribal Co-Chair Jennifer Cooper, Federal Co-Chair

Assignment Person(s) Responsible

Date Task Originated

Status

1. Develop metrics to evaluateeffectiveness of Medicare LikeRates regulation (non-hospitalbased services) afterimplementation.

Mickey Peercy (PRC Workgroup) Doneg McDonough

April 13, 2015 Update: Terri Schmidt, ORAP, IHS has provided periodic updates on MLR results, which have been very positive. Consider whether to keep this as an active project.

2. Develop and include in IHS Self-Governance Policy protocols forself-governance negotiations,including but not limited toexpectations for information anddocument sharing and protocolfor proper communication withTribal leadership. Review withTSGAC. (see April 10, 1997 letterto TSGAC from previous IHSDirector).

1997 IHS Director Letter

[SG Negotiations issue – whether IHS ALNs should accept provisions (at Tribal option) that have been previously negotiated in other Compacts/FAs, to the extent applicable to that Tribe.]

Jennifer Cooper SGCE

Mickey Peercy Rhonda Farrimond Melanie Fourkiller Cyndi Ferguson Terra Branson Shawn Duran Alberta Unok

July 21, 2016 Other issues and recommendations remain regarding Title V implementation.

7/20/17: This group agree to review the ALN Handbook and make recommendations moving forward.

9/15/17: Will be included for update on October, 2017 Quarterly Meeting agenda.

3. Develop TSGAC Comments tothe SG Congressional Report.

Melanie Fourkiller Carolyn Crowder SGCE

October 27, 2016

Pending next report sent out for Tribal Consultation

4. Outline of the successes of Self-Governance

Melanie Fourkiller Melissa Gower Terra Branson Jim Roberts Cyndi Ferguson

January 25, 2017

On hold, pending outcome of SGCE Fellow Research

9/15/17: SGCE to follow up with contractors to report the status of this.

5. TSGAC letter to IHS ActingDirector on GPTCHB eligibility forSelf-Governance. EncourageOSG to work with Board to findsolutions

Bryan Shade Jay Spaan

July 19, 2018 Completed.

6. TSGAC letter to IHS ActingDirector regarding IHCIF – lengthof meetings extended and

Jim Roberts July 19, 2018


P.O. Box 1734, McAlester, OK 74501

Telephone (918) 302‐0252 ~ Facsimile (918) 423‐7639 ~ Website: www.tribalselfgov.org

2

succession planning for IHCIF expert.

7. Review of revised HISAccountability Act and potentialSGCE letter (HR 5874)

Jay Spaan July 19, 2018

8. Develop TSGAC letter to NIH –support of the Tribal Report on“All of Us”

Unassigned. March 29, 2018 Pending distribution of the Tribal report and opening of Tribal Consultation.

9. Work with OTSG staff onupdating the 2002 HeadquartersPSFA Manual.

Jennifer Cooper SGCE Cyndi Ferguson Kasie Nichols Melanie Fourkiller

March 29, 2017 In process. Working Call held October 4, 2017; next working call TBD in November

10. Letter to VA requesting a meetingto discuss including PRC inreimbursement agreements –a. Include White Paper, based onMelissa Gower’s paper b. Address access to care issuesc. Request small workgroup

Jennifer McLaughlin


11. Letter to IHS Director, re: PRCreimbursement by VA as requiredby the IHCIA.

Terra Branson July 19, 2018

12. White paper, re: CSC on CHEFreimbursements.

Terra Branson March 29. 2018 On hold until CSC Policy matter is decided by IHS.

13. Team to develop BehavioralHealth Consultation Commentsfor TSGAC

Shawn Duran, Terra Branson, Karen Ketcher, Kasie Nichols, Jim Roberts


14. Team to develop SanitationDeficiency System TribalConsultation Comments forTSGAC.

Brian Shade, Jeremy Arnette, Jim Roberts, Jerry Moses


15. TSGAC letter to IHS on using FY2018 Inflationary Increases forSection 105(l) leases.

Geoff Strommer Melanie Fourkiller

July 19, 2018 Completed. (Copied to Appropriations Cmttee)

16. Develop TSGAC letter to GAOregarding AdvancedAppropriations

Unassigned March 29, 2018 Topic is on the October, 2018 TSGAC Agenda to identify next steps.

17. Communication to TSGACMembers, Alternates, FederalPartners, TWG on Meetingfrequency and format changes.

Jay Spaan July 19, 2018 Completed.

18. Joint TSGAC/DSTAC letter withrecommendation of JointTribal/Federal Workgroup tomake recommendations onupdating the Tribal ConsultationPolicy for IHS. (Consultationpolicy and protocol should involvefeedback loop regarding howinput from Tribes is incorporatedinto final product.)

Cyndi Ferguson, Sense Inc.


19. TSGAC letter of support for Corps(WH Reorganization Plan) to:Office of Surgeon General(VADM Jerome Adams), AsstSecy Health (Adm Vince Giroin),Secretary Azar and White House– mention that Indian Countrywould like to see all calls to active duty go to the Indian Health Care system.

Melissa Gower July 19, 2018 Completed.

3

20. TSGAC letter to VA Office ofAcademic Affiliations (OAA)requesting involvement indesigning the GME Pilot programto fund residents in IHS andTribal health facilities. (prior to theregulatory process).

Melanie Fourkiller Jim Roberts

July 19, 2018 Completed. (OAA attending 10/04/18 TSGAC Meeting.)

21. Health Access Standards (VA) –Request for Information -- dueJuly 30th

Jim Roberts Melanie Fourkiller

July 19, 2018 Deadline elapsed.

22. Advocate for reimbursement fortraditional health services, esp.for reintegration.

MMPC Members July 19, 2018 Referred to Medicare and Medicaid Policy Committee.

23. Request a Tribal AdvisoryCommittee for HHS HealthResources and ServicesAdministration. (they have aTribal Consultation Policy but noTAC).

STAC Technical Reps

July 19, 2018 Referred to the HHS Secretary’s Tribal Advisory Committee (STAC) – was included in STAC talking points for September 24-25, 2018 meeting.

Updated September 14, 2018

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence Year: 2018

Updated: September 14, 2018

Ref. #

Date Sent/ Received Addressed To Topic/Issue Action(s) Needed

Response Received

1. 9/14/18 RADM Weahkee, Acting

Director, IHS

Sanitation Deficiency System (SDS) Guide Tribal Consultation

Formal TSGAC comments.

2. 8/20/18 RADM Weahkee, Acting Director, IHS Jennifer Cooper, Director, OTSG

Support of the Great Plains Tribal Chairmen’s Health Board’s (“Board”) Efforts to Assume Management of Sioux San Hospital

Official TSGAC support of Board.

3. 8/20/18 Karen Sanders, MD Acting Chief Academic Affiliations Officer Veterans Health Administration Kathleen Klink, MD, FAAFP Acting Deputy Chief Academic Affiliations Officer Veterans Health Administration

Implementation of Indian Specific Provisions of the VA Mission Act

TSGAC request to engage further on the provision of the Act. Invitation extended to attend the October 2018 meeting.

4. 8/16/18 The Honorable Robert Wilkie, Secretary U.S. Department of Veterans Affairs

Inclusion of Purchased and Referred Care (PRC) in Veterans Affairs and Indian Health Service Reimbursement Agreements

TSGAC official comments and recommendations.

Summary of IHS Tribal Self‐Governance Advisory Committee (TSGAC) Correspondence – 2015‐2018

Page 2 – Updated September 14, 2018

Ref. #

Date Sent/ Received Addressed To Topic/Issue Action(s) Needed Response Received

5. 8/10/18 Mick Mulvaney, Director Office of Management and Budget

Alex M. Azar II, Secretary, HHS

ADM Brett P. Giroir, M.D. Office of the Assistant Secretary for Health

VADM Jerome M. Adams, M.D., M.P.H. Office of the Surgeon General, HHS

Delivering Government Solutions in the 21st Century, Reform Plan and Reorganization Recommendations

TSGAC comments regarding Commission Corps.

6. 8/10/18 RADM Weahkee, Acting Director, IHS

Updates to Indian Health Service (IHS) Tribal Consultation Policy

TSGAC/DSTAC Request to form Joint IHS/Tribal Workgroup

7. 8/1/18 IHS Consultation IHS Behavioral Health Funding

TSGAC formal comments.

8. 7/27/18 IHS Consultation Section 105(l) Lease Funding “Dilemma”

TSGAC formal comments.



Ref. #


Response Received

9. 7/26/18 Jennifer Cooper,

Director, OTSG Request for ACA/IHCIA National Outreach and Education Funding (FY2019)

Request for on-going funding of $300,000 for FY2019.

10. 7/6/18 IHS Consultation Response to the IHS May 18, 2018 Dear Tribal Leader Letter (DTLL) initiating Tribal consultation on changes to the Indian Health Manual; PRC Chapter

TSGAC official comments. Letter received from IHS on July 6th that the comment deadline has been extended until August 6th.

11. 6/22/18 VA Representatives:Jon Rychalski, Assistant Secretary for Management and Chief Financial Officer of the Department of Veterans Affairs (invited)

Kameron Matthews, MD, JD, Acting Assistant Deputy Under Secretary for Health for Community Care, Veterans Health Administration (invited)

Sarah Dean, Associate Legislative Director at Paralyzed Veterans of America (invited)

Letters of Invite Request for presentation at July 2018 TSGAC meeting.

Reps attended the July 2018 meeting.



Ref. #


Response Received

12. 6/22/18 RADM Weahkee, Acting

Director, IHS Office of Environmental Health & Engineering Updates

TSGAC concerns with the recent announcement of the Small Ambulatory Program (SAP) awards.


Unpaid and Underpaid Third Party Benefits from Private Insurers

TSGAC follow up on the matter of the pattern of violation of the Indian Health Care Improvement Act (IHCIA) with regard to payment from some private insurers.


Recommended Revision to the Contract Support Cost (CSC) Policy

TSGAC Formal Comments in response to IHS Dear Tribal Leader Letter dated 4/13/18

15. 4/19/18 Jennifer Cooper, Director, OTSG

Self-Governance National Indian Health Outreach and Education” (2017-2018)

Transmittal of Semi-Annual Report


Follow-up Items from Tribal Self-Governance Advisory Committee Meeting, March 28-29, 2018

Summary of Issues Discussed Letter received from IHS on July 6th with responses to issues raised during the March 2018 TSGAC meeting.


Exemption of Indian Health Service (IHS) Beneficiaries from Medicaid Work and Community Engagement Requirements

Opposition to Medicaid Work requirements and strongly disagree with the interpretation by the Office of Civil Rights



Ref. #



Chairman W. Ron Allen, TTAG Chairman

Recommendations for Improved Communication on Special Rule for Family Policies to AI/AN Marketplace Applicants to Prevent Loss of Comprehensive Indian-Specific Cost-Sharing Protections

Recommendations to TTAG (regarding conveyance to CMS)


Consultation on Recommended Revision to the Contract Support Cost (CSC) Policy

TSGAC Recommendations

20. 4/5/18 CAPT Mark Rives IHS

Information Systems Advisory Committee (ISAC) Charter

TSGAC Comments and Recommendations


TSGAC Representatives to the Community Health Aide Program (CHAP) Workgroup

Official appointment of TSGAC representatives

22. 3/9/18 CMS Regulations Comments on Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment (CMS-10401/OMB control number 0938-1155)

Submission of TSGAC formal comments.



Ref. #


Response Received

23. 3/1/18 W. Ron Allen

TTAG Chair Review of Summary of Benefits and Coverage (SBC) Documents

TSGAC report and recommendations on SBCs to coordinate the efforts of the TSGAC and the TTAG with an aim to secure needed revisions to the preparation and review of SBCs.

24. 2/22/18 HHS Consultation.gov TSGAC Delegate to 20th Annual HHS Budget Consultation Session

Appointment of Melanie Fourkiller


TSGAC Support for IHS Advance Appropriations

TSGAC request to IHS to inquire with GAO and ask them for a progress report on efforts to draft a report on the use of advance appropriations authority for healthcare programs across the Federal government, including problems encountered, any estimates of cost savings, and applications to the IHS.

26. 2/5/18 RADM Weahkee, Acting Director, IHS P. Benjamin Smith Jennifer Cooper Liz Fowler

Concerns about Inconsistencies in the IHS Funding Agreement Negotiation Process

TSGAC concerns about the current disagreement between IHS and a new Self-Governance Tribe regarding the timing and responsibility of the IHS to distribute Title V payments.

March 27, 2018 Letter received from RADM Weahkee addressing issues and concerns raised during the January 2018 TSGAC Quarterly Meeting.

27. 1/8/18 CMS Regulations.gov Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service,

Official TSGAC comments



Ref. #


the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P)

Letters From TSGAC



Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

Sent to: [email protected]

July 26, 2018

Jennifer Cooper, Director Office of Tribal Self-Governance Indian Health Service Mail Stop 08E05C 5600 Fishers Lane, Parklawn Building Rockville, MD 20857

RE: Request for ACA/IHCIA National Outreach and Education Funding (FY2019)

Dear Ms. Cooper:

On behalf of the Tribal Self-Governance Advisory Committee (TSGAC), I want to thank you and the Indian Health Service (IHS) for your on-going support for the Project work conducted by the TSGAC on the Affordable Care Act (ACA)/Indian Health Care Improvement Act (IHCIA) for outreach, education, technical, research and analytical support nationally to Self-Governance Tribes. As you know, the overall objective of this Project is to improve Indian health care by conducting training and technical assistance across Self-Governance communities to ensure that the Indian health care system and all American Indians/Alaska Natives (AI/ANs) are prepared to take advantage of the health insurance coverage options that will improve the quality of and access to health care services, and increase resources for AI/AN health care. All deliverables under the Project are carefully monitored and documented in writing

throughout the year; and included in both the semi-annual and annual report submitted to IHS.

A few select highlights (among others) from the current FY2018 Project year include:

Conducted analysis of all IHS Active Users, insurance status by Area/Service Unit for

FY2016-FY2017

Prepared TSGAC Brief on American Indian and Alaska Native (AI/AN) Marketplace Enrollment and Cost‐Sharing Payments

Participated in in-person trainings conducted by CMS for IHS and Tribal programs on

ACA-related issues, including Tribal Sponsorship

Distributed regular broadcasts to Self-Governance Tribes regarding latest ACA/IHCIA

related issues

Surveyed the Self-Governance Tribes and presented 4 Webinars to date on topics of

interest

Presented on three panels at the 2018 Annual Tribal Self-Governance Consultation

Conference

We continue to have a strong interest by Self-Governance Tribes in this Project. We

regularly receive positive feedback on the resources that have been developed to date.

mailto:[email protected]

TSGAC Request for ACA/IHCIA National Outreach and Education Funding (FY2019) July 26, 2018 Page 2

Therefore, we would like to respectfully and formally request that funding be provided to

continue this effort for the upcoming FY2019. We want to thank the Jamestown S’Klallam Tribe

(JST) for implementing this Project under their existing Indian Health Service Self-Governance

Funding Agreement. Our request would be that a new Amendment for $300,000 to the JST

Funding Agreement be entered into and implemented for the upcoming FY2019.

We anticipate that this funding would be used to continue efforts in the main categories

of: (1) Webinars/Trainings; (2) Technical Assistance; (3) Outreach and Education; and, (4)

Policy Analysis. We would be happy to work directly with you to identify any further deliverables

that OTSG would like to include in the Amendment.

In closing, we hope that you will consider this request so that we may continue to serve

the Self-Governance Tribes on the ACA/IHCIA outreach and education issues. Please do not hesitate to contact me at (860)862-6192; or via email: [email protected]. Thank you. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: RADM Michael Weahkee, Acting Director, IHS P. Benjamin Smith, Director, Office of Intergovernmental Affairs, IHS TSGAC Members and Technical Workgroup





Via email to: [email protected] July 27, 2018 RADM Michael D. Weahkee, Acting Director Indian Health Service 5600 Fishers Lane Mail Stop: 08E86 Rockville, MD 20857 RE: Section 105(l) Lease Funding “Dilemma” Dear RADM Weahkee: On behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC), I am writing in response to your letter dated July 10, 2018, in which you initiated Tribal consultation on how to fund leases under section 105(l) of the Indian Self-Determination and Education Assistance Act (ISDEAA). You propose to fund a $13 million FY 2018 shortfall by reprogramming funding from unallocated inflation increases, which would deny Tribes needed program increases to keep pace with the cost of living. A better solution is to immediately seek a supplemental appropriation from Congress. In the long term, the IHS must do a better job of tracking and projecting section 105(l) lease compensation requirements and obtain a separate appropriation dedicated to these costs. As established in the Maniilaq case,1 section 105(l) requires IHS, upon Tribal request, to enter into a lease for a facility owned or leased by the Tribe or Tribal Organization and used to carry out its ISDEAA agreement. As acknowledged in your letter, IHS must compensate the Tribe or Tribal Organization fully for its reasonable facility expenses. The letter also recognizes that IHS has no separate appropriation or other funding source for 105(l) leases, but that the entire $3.95 billion Services appropriation is legally available to pay these mandatory obligations. However, with most of that money already committed to ISDEAA agreements and other obligations, and with 105(l) leases comprising a significant new (and growing) expense, IHS finds itself, as you say, in “a funding dilemma.” With lease proposals totaling $18 million, and only $5 million identified as available, IHS faces a 105(l) lease funding shortfall of $13 million. While the total cost of 105(l) leases has increased significantly in the last two years, an increase was predictable. We request that IHS track and project lease costs and ensure that the budget process reflects the true need. The Administration actually sought to decrease the supplemental Tribal clinic appropriation that IHS has used to fund 105(l) leases and Alaska’s Village Built Clinics (VBCs) from $11 million to $2 million. Congress retained the FY 2017 funding level of $11 million in FY 2018, but obviously that was not nearly enough to cover the 105(l) leases, let alone provide sufficient increases for the chronically underfunded VBCs.

1 Maniilaq Ass’n v. Burwell, 170 F. Supp. 3d 243 (D.D.C. 2016).

TSGAC Letter RE: Section 105(l) Lease Funding “Dilemma” July 27, 2018 Page 2

IHS proposes to address the problem by reprogramming unallocated FY 2018 inflation increases. While this would avoid any program cuts, it would also reduce badly needed program increases. Reprogramming is always divisive, creating “winners” and “losers,” as we saw in FY 2014 when IHS had to reprogram funds to cover contract support cost shortfalls. Direct Service Tribes rightly complained that they were being penalized, through no fault of their own, for the agency’s failure to estimate and obtain the needed amounts. Similar tension can be expected if the proposed reprogramming of inflation funding goes forward. There is a better solution: to seek and obtain a supplemental appropriation of $13 million (at least) from Congress. IHS can make the case that an unforeseen (though foreseeable) new cost arose following a recent court decision and IHS needs supplemental funding as a bridge to a permanent, long-term solution starting in FY 2019. We understand that this consultation is focused on FY 2018 and that an additional consultation will be held on “sustainable options” for FY 2019 and beyond. But with the FY 2019 appropriations bills working their ways through Congress with only modest increases for Tribal clinics, we would like to make a few brief points on long-term solutions. First, the Administration should cease proposing appropriations act language that seeks to overturn the Maniilaq decision and essentially nullify section 105(l) by making lease compensation discretionary. This backdoor attempt to revoke a provision of the ISDEAA through an appropriations rider is contrary to Congressional intent in the ISDEAA and the trust responsibility to Tribes. Second, IHS must get a handle on these lease costs and ensure that the appropriations committees are well informed. IHS should submit annually an estimate of its need for 105(l) lease compensation early in the budget cycle—not ¾ of the way through the fiscal year—so that the Committees have solid numbers to take into account as the appropriation process unfolds each year. Third, as you discussed with Senator Murkowski at the recent hearing of the Senate Interior Appropriations Subcommittee, section 105(l) lease costs can be expected to rise in the coming years. There is no way around it: more resources will be needed. We recommend that IHS advocate for a separate funding line for 105(l) leases, as you suggested at the hearing, rather than being lumped in with the VBCs in the “Tribal clinics” appropriation. Given the difficulty in predicting lease costs, ultimately the best solution may be a separate, indefinite appropriation such as Congress created for contract support costs. This would ensure full funding for 105(l) leases without cutting programs and hurting patients. It would also avoid tension and possibly litigation between IHS and Tribes regarding allocation of funding. Thank you for the opportunity to comment on this important funding issue. We stand ready to assist IHS in advocating with Congress for additional resources to address this issue. Please do not hesitate to contact me at (860) 862-6192; or via email: [email protected]. Thank you. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup





Via email to: [email protected] August 1, 2018 RADM Michael Weahkee, Acting Director Indian Health Service 5600 Fishers Lane Mail Stop: 08E86 Rockville, MD 20857 Re: Indian Health Service (IHS) Behavioral Health Funding Dear RADM Weahkee: The IHS Tribal Self-Governance Advisory Committee (TSGAC) consistently advocates for funding sources and mechanisms that provide recurring and stable funding to Tribes. We believe these sources provide an opportunity for Tribes to build Tribally-driven, long-term programs that have the capacity to expand over time. As such, we were pleased that the Fiscal Year (FY) 2018 Explanatory Statement of the Consolidated Appropriations Act encouraged the IHS to transfer the behavioral health initiative funding through Indian Self-Determination and Education Assistance Act (ISDEAA) contracts and compacts rather than through grants. Further, we appreciate the consultative approach the Agency is taking to make changes to the current funding process and procedure. In response to your May 18th Dear Tribal Leader Letter and on behalf of the IHS TSGAC, we are providing the following short- and long-term recommendations for your consideration regarding the funding mechanism to distribute behavioral health initiatives currently funded through grants. We strongly recommend that you consider a phased-in approach to alter the funding mechanism and distribute future increases in behavioral health funds. Short-Term Recommendations for Fiscal Year 2018 - 2020 Hold all current grantees harmless. TSGAC is not supportive of any decreased funding which current grantees receive to redistribute funds. Instead, the Committee recommends that current grantees continue to receive funds they have been awarded with additional options at their disposal. Specifically, current grantees should be provided the option to transfer their funds to a Title I contract or Title V funding agreement. Offering this option to Tribes appropriately provides them the authority to choose the mechanism that best works in their communities and it maintains the funding level they receive for the remaining award period. We also recommend that IHS continue to use the national distribution method currently used to allocate funds to all twelve Areas. This results in several benefits. First, it ensures IHS can get money into funding agreements as soon as possible and avoids making changes that could complicate this process or that might require further Tribal consultation. Second, the national distribution method takes into consideration relevant, quantifiable metrics that include poverty, disease burden, tribal size, and user population. Third, this method is also fair, as it allows all twelve of the IHS Areas to receive funding based on data that is representative of the population they serve.


TSGAC Letter RE: IHS Behavioral Health Funding August 1, 2018 Page 2

Convert Grants to ISDEAA contracts and compacts. Current grantees who exercise their option to transfer funds from a grants to ISDEAA contracts and compacts can be provided through their funding agreements. This change provides several critical benefits. First, it will allow current grantees to receive CSC funding to assist in covering their administrative costs associated with managing these behavioral health programs. This is consistent with Congress’ intent to maximize Tribal resources available for the delivery of health care programs. IHS’s current funding mechanism prevents Tribes from collecting the full costs of administering the program, thereby reducing direct services. Additionally, the dissimilar treatment of recurring funding increases from base funds from the same line would be inappropriate to maintain if Tribes choose to receive their funds through a contract or funding agreement. Finally, this change will obviate the need to continually apply for grants and alleviate burdensome and duplicative reporting requirements by relying instead on accreditation, audit, and other procedures that Tribes and Tribal organizations already have in place. Remove reporting requirements for funds transferred through funding agreements with Title V Tribes. Funding transferred through Title V agreements cannot attach reporting requirements unless there are statutory requirements. Upon transfer of the funds from grants to other Title V agreements, IHS should withdraw any additional requirements other than those provided in ISDEAA or subsequent legislation.

Long-Term Recommendations for Fiscal Year 2021 and Beyond National and Future Distributions. We previously recommended and continue to support the national distribution method currently used to allocate funds to all twelve Areas on a longer term. This helps to ensure a fair distribution of resources across all twelve of the IHS Areas. We further recommend that once funds are allocated to each Area, the Tribes and Tribal organizations should be able to decide the appropriate distribution methodology to further distribute these funds within the Area. This recognizes the uniqueness of each Area in that a distribution method used nationally may be inequitable when applied to another Area. Instead, IHS, Tribes, and Tribal organizations in each Area should be able to collaborate in order to determine the most effective manner to allocate resources within the Area to the individual programs. Thus, a given Area could choose from a variety of distribution methods, including:

Allocating funds as Tribal shares that are added to base funding, or

Using another method developed based on the input of IHS, Tribes, and Tribal organizations in that Area.

Use the Tribal Size Adjustment (TSA) formula for future increases. IHS already uses the TSA formula to distribute funds. This formula provides a base amount for small Tribes, guaranteeing a certain amount of funds, and an adjustment factor for Tribes serving larger populations. IHS should begin utilizing this formula distribution in FY2021 with a notification to Tribes about their expected distribution amount early in FY2020. Utilizing the TSA will allow for smooth transition from grant to formula fund distribution and give Tribes adequate time to plan for any changes. Additionally, if new increases are provided in FY2019 or FY2020, those should be distributed based on the TSA formula, not to increase current grant awards. National Management Funding that is Dedicated to IHS Program Administration, Demonstrating Effectiveness, and Raising National Awareness. TSGAC recommends continuing the funding provided to Tribal Epidemiology Centers (TEC) to assist the Tribes in


their Areas with data reporting, determining national, local, and regional outcomes, and conducting evaluation activities—activities that can demonstrate effectiveness and continue to raise national awareness of these issues. However, the TSGAC recommends that in Areas where Tribes do not support continued funding for such assistance, which is currently provided by TECs, Tribes will instead receive the funding to support their own data analysis and reporting, determine local, regional and national outcomes, evaluate program effectiveness, and continue to raise national awareness of behavioral health issues. To the extent other data or information is needed to demonstrate effectiveness, we believe the TECs can work with individual programs to compile that information and produce reports that address this impact. Additionally, we recommend that set-asides directed to IHS national management, such as IHS Project Officers, Coordinators, Grants Management Specialists, and Consultants, be reallocated to the Areas using the national distribution methodology. The current structure fails to account for key differences between Areas: the need for these services provided by Headquarters and individual Areas varies across the Indian Health system and not all Areas benefit equally. Additionally, removing the burdensome reporting requirements associated with these initiatives will also eliminate the need for personnel and consultants to aid with such reporting. A better course is to address the need for any other services currently provided with these funds at the local and Area levels. Each Area can then undertake an independent assessment on whether to set aside funds for Area-wide staff to assist with implementing behavioral health programs. Therefore, we recommend that IHS reallocate to the Areas the funding associated with the administrative set-asides using the national distribution methodology. Further, with the above-referenced exception of funding provided to (TEC), the TSGAC does NOT support the continuance of the current administrative set-asides provided under contracts and cooperative agreements with national organizations. Like the national management funds described above, these contracts do not benefit all Tribes, so national funds should not be devoted to these contracts. And to the extent that existing procurement contracts have been obligated, we recommend that these agreements not be renewed. Setting aside funds to “raise national awareness” of substance abuse and mental health issues currently has limited value, especially in the midst of a very public nation-wide opioid epidemic. Instead, IHS should direct those funds to direct services where they are needed most. Lastly, we recommend that any additional funding that is made available as a result of discontinuing support for IHS program administration, cooperative agreements and contracts be added to program amounts for IHS, Tribal and Tribal organization service providers. As we are not advocating for major changes in the distribution methodology and our recommendations would only lead to increased funding for service providers, not reductions, we do not believe the current multi-year grant cycles prevent these changes from taking place at once. IHS will undoubtedly have administrative cost savings as behavioral health initiative grants are closed out. Any cost savings from a reduction in grant administrative oversight should be evaluated and made available to contracting and compacting Tribes no later than FY 2022. Evaluate and request additional contract support costs (CSC) to meet changes to the funding mechanism. IHS should request additional CSC funds in the President’s Budget Request for FY2020 and beyond to support fully funding CSC needs related to these recurring funds. It is important to request an accurate amount of funds to support new distribution of


increases long-term. CSC funds support ancillary services necessary to fully support the delivery of care and maximize funds appropriated by Congress. This is consistent with Congress’ intent to maximize tribal resources available for the delivery of health care programs. Given the current grant funding mechanism, Tribes must use part of their awards to fund administrative costs, which causes an average 25% reduction across the board in amounts available for programming. However, this change would reverse that trend and allow Tribes and Tribal organizations to dedicate the full award amount to service delivery. The current grant management and application process remains cumbersome and time consuming and inappropriately limits payments of CSC. Therefore, we suggest the short-term options be implemented during this upcoming grant award cycle (FY2018). Finally, if new funding is appropriated, TSGAC recommends that such funding is distributed through the above-referenced long-term approach. Eliminating the competitive grant process and bureaucratic administrative process will enable I/T/U programs to serve more behavioral health patients and implement long-term strategic plans. Thank you for the opportunity to participate in consultation on this important issue. Please do not hesitate to contact me at (860) 862-6192; or via email: [email protected]. Thank you. Sincerely,



TSGAC Letter RE: Delivering Government Solutions in the 21st Century, Reform Plan and Reorganization Recommendations August 10, 2018 Page 2 (GAO) Report raised questions about the need for Corps officers in positions that did not provide direct health services. The TSGAC understands the questions raised, however, we want to ensure that you understand the Corps officers provide a valuable resource as direct service providers within the Indian healthcare system. Even though Corps officers may be more expensive, there is much more latitude in the assignment of such officers which outweighs the additional cost. Civilian employees cannot be assigned to different rural locations in hard to fill positions as the Corps officers. These officers fulfill an incredible need at IHS and Tribal facilities, with the ability to be quickly assigned to rural and remote health facilities to address critical staffing needs that must be sustained to maintain quality health services. A consistent number of Corps personnel serving as a portion of the Indian health system workforce has a stabilizing effect by balancing the frequent civilian vacancies that occur in remote healthcare facilities. The additional cost of recruiting, hiring and training to fill a civilian vacancy multiple times actually makes the use of the Corps a much more affordable option for certain locales and positions. The proposal as outlined would reduce the Corps force from approximately 6,500 officers to no more than 4,000 officers, and create a Reserve Corps that can provide additional surge capacity during public health emergencies. The TSGAC supports the proposal that would require that Corps officers initially work in a hard-to-fill area and continue to serve there, or deploy as needed in a public health emergency. In fact, the TSGAC recommends that all calls to active duty for the Corps go to the Indian healthcare system to fill vacant direct care positions to the most vulnerable populations. We appreciate your continued support of Corps officers to the Indian healthcare system and consideration of this request. If you have any questions or would like to discuss these comments in further detail, please contact me at [email protected]. Thank you. Sincerely,


Chester Antone, Legislative Council, Tohono O’odham Nation and Chairman, HHS Secretary’s Tribal Advisory Committee (STAC)


Sent electronically to [email protected]

August 10, 2018 RADM Michael D. Weahkee, Acting Director Indian Health Service Mail Stop: 08E37A 5600 Fishers Lane Rockville, MD 20857 RE: Updates to Indian Health Service (IHS) Tribal Consultation Policy Dear RADM Weahkee: On behalf of the IHS Tribal Self-Governance Advisory Committee (TSGAC), I am writing to follow up with you regarding the process to update the IHS Tribal Consultation Policy. As you are well aware, the agency has initiated numerous consultations with Tribal governments over the past year involving development and/or updates to program policies and process, funding mechanisms and strategic planning. Further, the TSGAC Tribal leadership and technical representatives have been active members in the many joint IHS/Tribal Workgroups that have been established by the agency to address these issues; and by which form the basis for recommendations that are broadly distributed by the agency for further Tribal input and comment under the IHS Tribal Consultation policy. The IHS Tribal Consultation Policy was last updated in January 2006. As stated in the current policy, “Tribal Governments and the Indian Health Service (IHS) share the goal of eliminating the health disparities of American Indians and Alaska Natives (AI/AN) and ensuring their access to critical health services is maximized. To achieve this goal, it is essential that Tribal Governments and the IHS engage in open, continuous, and meaningful consultation. True consultation leads to information exchange, mutual understanding, and informed decision-making. The importance of consultation with Tribal Governments was affirmed through 1994 and 2004 Presidential Memoranda and Executive Orders issued in 1998 and 2000.” Given the importance of the IHS Tribal Consultation policy and its resulting impact on the operation of key IHS programs, funding distributions and policies, the TSGAC is appreciative of the IHS’s partnership in ensuring that Tribal governments have a voice and seat at the table during these critical discussions. However, we believe that it would be beneficial for the IHS and Tribes to review the current policy and have an opportunity to develop further recommendations and improvements. For example, an essential part of the consultation process should involve a provision and/or protocol on how feedback from Tribes is incorporated into the final product approved by the agency. Therefore, we would like to recommend the formation of a joint Federal/Tribal Workgroup consisting of representatives from all IHS Areas, including representation of Self-Governance, Title I and Direct Service Tribes to review and develop recommendations to update the IHS Tribal Consultation Policy.


TSGAC & DSTAC Letter to IHS Acting Director RE: Updates to Indian Health Service (IHS) Tribal Consultation Policy August 10, 2018 Page 2

The establishment of this Workgroup would be a positive step and provide a great opportunity to take a fresh look at the policy and develop any needed updates to improve this important government-to-government process. We appreciate your continued commitment and partnership to advance these issues and hope that you will seriously consideration these recommendations. Thank you. Sincerely, Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Nicolas Barton, Executive Director Chairwoman, IHS TSGAC Cheyenne & Arapaho Tribes Chairman, IHS DSTAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS Roselyn Tso, Acting Director, Office of Direct Service and Contracting Tribes, IHS



Sent electronically to: [email protected]

[email protected] [email protected]

[email protected] August 10, 2018 Mick Mulvaney, Director Office of Management and Budget 725 17th St., NW Washington, DC 20503 Alex M. Azar II, Secretary Office of the Secretary, HHS 200 Independence Avenue, SW Washington, DC 20201

ADM Brett P. Giroir, M.D. Office of the Assistant Secretary for Health U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 716G Washington, DC 20201 VADM Jerome M. Adams, M.D., M.P.H. Office of the Surgeon General U.S. Department of Health and Human Services 200 Independence Ave SW Humphrey Bldg. Suite 701H Washington, DC 20201

RE: Delivering Government Solutions in the 21st Century, Reform Plan and Reorganization Recommendations Dear Director Mulvaney, Secretary Azar, ADM Giroir, and VADM Adams: On behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC), I write to inform of our full support for the U.S. Public Health Service Commissioned Corps (Corps) and to bring your attention to the impact of the reduction of the Corps as outlined in the Delivering Government Solutions in the 21st Century, Reform Plan and Reorganization Recommendations on the Indian healthcare delivery system throughout the United States. The TSGAC represents over 360 federally-recognized Tribal governments participating in Self-Governance, and advises the Director of IHS on health policy and other matters affecting Tribes. The Indian healthcare system relies heavily on Corps officers for the delivery of healthcare to American Indian/Alaska Natives (AI/AN) throughout Indian Country. The reform plan states “Transform the U.S. Public Health Service Commissioned Corps into a leaner and more efficient organization that is better prepared to respond to public health emergencies and provide vital health services, including by reducing the size of the Corps and building up a Reserve Corps for response in public health emergencies.” The Fiscal Year 2019 Budget raised questions about the value of having Corps officers in roles that civilians can fill, given they are more expensive than equivalent civilians. Only a small percentage of Corps officers deploy for public health emergencies, and many officers encumber positions that could be filled by civilians. In addition, a 1996 Government Accountability Office








Sent Via Electronic Mail: [email protected]

August 16, 2018 The Honorable Robert Wilkie, Secretary U.S. Department of Veterans Affairs 810 Vermont Avenue, NW Room 1000 Washington, DC 20420 RE: Inclusion of Purchased and Referred Care (PRC) in Veterans Affairs and Indian Health Service Reimbursement Agreements Dear Secretary Wilkie:

I write on behalf of the Indian Health Service (IHS) Tribal Self-Governance Committee

(TSGAC), which is representative of 360 Federally-recognized Tribal governments participating

in Self-Governance. The TSGAC advises the Director of IHS on health policy and other

matters affecting Tribes. Many of these Tribes have reimbursement agreements with Veterans

Affairs (VA) pursuant to Section 405(c) of the Indian Health Care Improvement Act (IHCIA).

American Indians/Alaska Natives (AI/ANs) continue to serve in our country’s armed

forces in greater numbers per capita than any other group. The U.S. Census Bureau’s 2015

American Community Survey (ACS) identified 133, 899 veterans as AI/AN.1 AI/AN veterans are

more likely to lack health insurance than veterans of other races. Upon return from their

dedicated service however, many AI/AN veterans encounter various challenges to receiving VA

benefits and access to quality healthcare services.

Factors, such as, residing in remote rural communities, poverty, mental health

conditions, historical mistrust and a limited number of culturally competent healthcare providers

create barriers to care and lead to AI/AN veterans experiencing greater health disparities

compared to other veterans. In addition, regulatory barriers further exacerbate AI/ANs ability to

access care. Restrictions on specialty care, assessment of co-pays, duplicative processes,

overly-burdensome administrative requirements and lack of coordination of care delay access to

care and have caused irreparable harm to veterans.

It is incumbent upon the Federal Government and its subsidiary agencies, VA and IHS,

to uphold their trust obligations and ensure that Native veterans receive timely and quality

culturally appropriate healthcare.

Coordination of Care Between VA and IHS and Current Reimbursement Agreements

The VA-IHS Memorandum of Agreement (MOU) does not currently provide for

reimbursement of PRC at IHS or Tribal healthcare facilities. Consequently, veterans are forced

to maneuver through a complex healthcare system and an elaborate administrative process

1 American Indian and Alaska Native Veterans: 2015 American Community Survey, August 2017.



TSGAC Letter – The Honorable Robert Wilkie, Secretary, VA August 16, 2018 Re: Inclusion of PRC in Reimbursement Agreements Page 2

usually requiring multiple referrals in order to address their healthcare needs. This overly-

burdensome duplicative referral process is counterproductive and impedes timely and efficient

access to care for Native veterans.

Although the MOUs have demonstrated success in facilitating patient care for veterans,

neither the current national agreement nor the Tribal agreements include reimbursement for

PRC. The legal authority that authorizes this provision of care already exists. Section 405(c) of

the IHCIA, as amended and enacted by the Affordable Care Act (ACA), requires the VA to

reimburse the IHS or Tribal healthcare facilities for services provided to beneficiaries.

Veterans often require additional services that are not available at IHS or Tribal

healthcare facilities. In many instances eligible veterans are also eligible for PRC services. The

PRC program authorizes Indian Healthcare facilities to purchase services from a network of

private providers. IHS and Tribal health programs are the payors of last resort2, which require

that all other sources of obtaining health services must be exhausted prior to receiving care

through the PRC program. These services may include primary or specialty care that is not

available at an IHS and/or Tribal healthcare facility. Many Tribes utilize provider networks to

ensure veteran’s healthcare needs are being met.

The VA, however, will not reimburse Tribes for their referrals but instead insist that the

veteran in need of specialty care return to the VA health system for a VA referral for care. In

certain instances, this level of care may be directly available and provided under the current

reimbursement agreements and reimbursed by the VA; however, because the mix of direct

versus purchased care varies across the Indian health system, some IHS or Tribal health

programs may purchase more care from outside providers, which is currently going

unreimbursed by VA.

This illogical and inconsistent type management of care is inefficient, a waste of

resources (both time and money) and fails to prioritize the healthcare needs of Native veterans.

Further, this policy does not align with the VA’s mission and creates additional barriers for AI/AN

veterans in need of care. Rather than creating additional obstacles, we need to ensure and

improve access to all types of care for Native veterans. Including purchased and referred care

in the National and Tribal MOU and allowing for reimbursement for these referrals is essential to

ensure that veterans receive quality healthcare. Attached to this correspondence is a brief

paper describing further how reimbursing IHS and Tribes for PRC benefits Native veterans’

access to care and improves care coordination.

Establish A Workgroup or VA Tribal Advisory Committee

The TSGAC urges the VA to establish a formally sanctioned workgroup or Tribal

Advisory Committee comprised of Federal and Tribal officials to provide education, advocacy,

policy guidance and recommendations regarding implementation of the VA-IHS MOU, related

individual Tribal MOUs, and to ensure cooperation and coordination of healthcare programs and

services for veterans. Currently, the VA has a Minority Veterans Committee, however it is not

sufficient for meaningful tribal consultation and deliberation on issues that pertain to the

complex and varying infrastructure of tribal healthcare facilities. Members of the

2 25 U.S.C. § 1623. Special rules relating to Indians; and 42 CFR § 136.61 Payor of last resort.

TSGAC Letter – The Honorable Robert Wilkie, Secretary, VA August 16, 2018 Re: Inclusion of PRC in Reimbursement Agreements Page 3

workgroup/committee will serve as liaisons for Tribes and Veterans within their communities and

regions, as well as, Advisors to agency.

Further, the establishment of a formal workgroup/committee will provide a forum for

Tribes and the agencies to work together as government-to-government partners to address

policy, legislative, budget, program and service issues from a principled standpoint and

formulate recommended actions with the goal of advancing healthcare access and quality of

care for veterans. While the IHS serves an important role in providing funding and technical

support to Tribal healthcare facilities, they do not supplant Tribal governments as key decision-

makers. Tribes must be afforded a seat at the table and there must be a comprehensive and

properly structured process that allows Tribes to participate fully.

We firmly believe that adhering to mutually agreed upon solution-oriented processes will

create policies that promote and support veterans care and respect Tribal sovereignty and self-

determination. This Tribal-Federal partnership remains a work in progress to ensure that the

treaty and trust obligations of the Federal government are upheld and serve as a backdrop

against which all VA policy decisions directly affecting and/or impacting Tribes should be

measured. If you have any questions or would like to discuss these comments, please contact

me at [email protected]. Thank you.

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Stephanie Birdwell, Director, Office of Tribal Government Relations, VA

RADM Michael D. Weahkee, Assistant Surgeon General, USPHS and Acting Director, Indian Health Service Jennifer Cooper, Director, Office of Tribal Self-Governance

TSGAC and Technical Workgroup Members Attachment: Reimbursement for Purchased and Referred Care (PRC)


INDIAN HEALTH SERVICE (IHS)/VETERANS ADMINISTRATION (VA) ISSUE Reimbursement for Purchased and Referred Care (PRC)

August 2018 Background: In addition to providing primary healthcare services, IHS and Tribal Health Programs (THPs) utilize provider networks to provide specialty services (or other services not directly provided by IHS/THPs) to American Indian/Alaska Native (AI/AN) veterans. The networks are critical in providing care to veterans living in rural and remote areas. The VA currently reimburses IHS and THPs for care they directly provide under the IHS/VA Memorandum of Understanding (MOU). Despite the payor of last resort requirements that are included in federal policy1, the VA has not provided reimbursement for PRC specialty and referral care provided through IHS/THPs. Practically, if a veteran receives care directly from IHS and THPs, the VA reimburses. However, if a referral is needed for specialty care (or other services not directly provided by IHS/THPs), the VA only pays for the specialty service if the veteran goes back to the VA health system and gets another referral by a VA provider. The PRC program authorizes Indian health care facilities to purchase services from a network of private providers. The payor of last resort statute and regulations require that all other sources of obtaining health services be exhausted prior to receiving care through the PRC program. These services may include primary or specialty care that is not available at an IHS and/or Tribal healthcare facility. Because the assessment and referral conducted by the IHS/THP provider is not accepted by VA, resulting in having another initial consultation by a VA provider (more time, money for redundant assessments at additional cost to the taxpayer). There are often additional challenges with coordination of care between the VA or VA providers and the initial IHS/THP provider that made the referral. This is a not a good use of federal funding, nor is it navigable for veterans. In certain instances, this level of care may be directly available and provided under the current reimbursement agreements and reimbursed by the VA. However, because the mix of direct versus purchased care varies across the Indian health system, some IHS or Tribal health programs may purchase more care from outside providers, which is currently going unreimbursed by VA. This is illogical and results in inconsistent coordination and quality of care to the Native veteran. It is also expensive, inefficient, and waste of valuable tax payer dollars. As a result, THPs are choosing to, with consent of the veteran, refer out for specialty treatment or other medically necessary health services without VA involvement and eating that cost so veterans can be treated in a complete and timely manner. The impact to veterans that do go back to the VA is delayed treatment and results in a different level/standard of care for AI/AN veterans. The bottom line is that, in the best interest of the veteran, THPs that run their own health programs are often forced to absorb the costs when they refer veterans out for third party care rather than sending them back to the VA for the referral. Since health care systems (IHS, THP, VA) all utilize Medicare Like Rates, and all other resources such as Medicare, Medicaid and private insurance are required to be collected by the contracted provider prior to

1 25 U.S.C. § 1623. Special rules relating to Indians; and 42 CFR § 136.61 Payor of last resort.

IHS/THP payment, the cost would remain approximately the same to VA to reimburse IHS/THPs for PRC services.

Another barrier that is created by forcing Native veterans to return to VA is the assessment of co-payments for certain veterans. Health care provided to Native Americans and Alaska Natives is based upon solemn treaties, other federal law and the government-to-government relationship that has established a federal trust obligation for such services. The IHS is barred from collecting co-payments for health services for AI/AN, as this would be contrary to the federal trust responsibility to provide health care. When veterans are returned for specialty care to VA, co-payments are applied to these AI/AN veterans, which is inappropriate for the aforementioned reasons. However, the VA has determined it is required to collect co-pays from all veterans as applicable under federal statute, including AI/AN veterans. If the IHS/THPs can simply be reimbursed for any purchased care provided through their programs, the problem of the assessment of co-pays to these veterans is significantly lessened.

Full implementation of Section 405 (c) of Indian Health Care Improvement Act: To date, the VA-IHS/THPs MOUs have proven to be successful in facilitating patient care and has been the least administratively burdensome approach for all parties, most of all AI/AN veterans. However, the Indian Health Care Improvement Act (IHCIA Section 405(c) has not been fully implemented. The current national agreement and, by default, nearly all THP agreements do not include reimbursement for Purchased/Referred Care (PRC).

25 U.S. Code § 1645 - Sharing arrangements with Federal agencies (c) Reimbursement - The Service, Indian tribe, or tribal organization shall be reimbursed by the Department of Veterans Affairs or the Department of Defense (as the case may be) where services are provided through the Service, an Indian tribe, or a tribal organization to beneficiaries eligible for services from either such Department, notwithstanding any other provision of law.

PRC consists of purchased health care that is provided through IHS/THPs. Reimbursement for specialty care provided through PRC is essential to ensure that Native veterans receive the best care possible. Nationally, only one in thirteen visits is an inpatient visit, but veterans often need additional services which cannot be provided directly by an IHS Service Unit or THP.

Recommendation: THPs, in particular, work hard to provide a seamless health care experience. Lack of coordination of care for specialty care and other medically necessary care paid by PRC will only create more barriers for our veterans. We recommend that the VA include PRC in the IHS/THP reimbursement agreements so that there is no further rationing of health care provided by IHS and THPs to Native veterans and other eligible AI/ANs in the system. The aim of this initiative is to ensure the IHCIA is fully implemented and ensure the VA fully reimburses for services provided by IHS/THPs as required in Section 405(c) of the IHCIA.



Sent electronically to: [email protected] [email protected]

August 20, 2018 Karen Sanders, MD Acting Chief Academic Affiliations Officer Veterans Health Administration 810 Vermont Ave, NW Room 10A2D Washington, DC 20420

Kathleen Klink, MD, FAAFP Acting Deputy Chief Academic Affiliations Officer Veterans Health Administration 1800 G Street , NW Room 878 Washington, DC 20006

RE: Implementation of Indian Specific Provisions of the VA Mission Act Dear Acting Chief Sanders and Acting Deputy Chief Klink: I write on behalf of the Indian Health Service (IHS) Tribal Self-Governance Committee (TSGAC), which is representative of 360 Federally-recognized Tribal governments participating in Self-Governance. The TSGAC advises the Director of IHS on health policy and other matters affecting Tribes. Tribal governments are particularly interested in beginning a dialogue with you about the new programs created under the recently passed VA Mission Act of 2018, Public Law 115-182. American Indians/Alaska Natives (AI/ANs) continue to serve in our country’s armed forces in greater numbers per capita than any other group. The U.S. Census Bureau’s 2015 American Community Survey (ACS) identified 133,899 veterans as AI/AN. AI/AN veterans are more likely to lack health insurance than veterans of other races. Upon return from their dedicated service however, many AI/AN veterans encounter various challenges to receiving VA benefits and access to quality healthcare services. Factors such as, residing in remote rural communities, poverty, mental health conditions, historical mistrust and a limited number of culturally competent healthcare providers create barriers to care and lead to AI/AN veterans experiencing greater health disparities compared to other veterans. In addition, regulatory and administrative barriers of the VA and IHS further exacerbate AI/ANs ability to access care. As you may be aware, the Indian healthcare system, consisting of facilities and programs operated by the U.S. Health and Human Services (HHS), Indian Health Service (IHS), Tribes, Tribal Organizations and Urban Indian Health Programs, serve a great number of AI/AN veterans, and often extend services to non-Native veterans through partnerships with VA. These Indian health programs have significant workforce challenges due to most facilities being located in rural and/or remote locations. The HHS Health Resources and Services Administration (HRSA) automatically designates IHS, Tribally-operated and Urban Indian Health programs as Health Professionals Shortage Areas (HPSAs) and Medically Underserved Area and Medically Underserved Population (MUA/MUP) for these reasons.




TSGAC RE: Implementation of Indian Specific Provisions of the VA Mission Act August 20, 2018 Page 2

The TSGAC was very encouraged to review the provisions of the recent VA Mission Act, specifically Section 403 which included a “Pilot Program on Graduate Medical Education and Residency.” This new pilot includes facilities operated by Tribes, Tribal Organizations and IHS as “covered facilities” for purposes of the program and requires such facilities have a priority in placement of residents. Representatives from the VHA Office of Community Care and the VA Office of Tribal Government Relations were in attendance at our July, 2018 quarterly meeting in Washington DC to discuss our ongoing partnerships with VA. During that meeting, this section of the VA Mission Act was discussed briefly. The TSGAC would like to engage with you about how the Office of Academic Affiliations (OAA) envisions implementing the pilot, and how IHS and Tribes can be involved early in the planning to ensure that any regulations or policy that may be developed in the future for the pilot work optimally in Indian Country. Toward that end, we cordially extend an invitation to you to attend the next meeting of the TSGAC, which is held jointly with IHS officials. The meeting will be held on October 3-4, 2018 at the Embassy Suites Convention Center, 900 – 10th Street, NW, Washington, DC. We can accommodate times on the agenda between 2:00 pm to 5:00 pm on October 3rd, or any time between 8:30 am to 4:00 pm on October 4th. Please contact Jay Spaan, Executive Director, Self-Governance Communication and Education, at (918) 302-0252 or via email at: [email protected] regarding your availability. The TSGAC appreciates your commitment and service to our veterans, and we are hopeful you can attend the October session to discuss how we can collaborate on our shared mission. If you have any questions or would like to discuss these comments, please contact me at [email protected]. Thank you. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Stephanie Birdwell, Director, Office of Tribal Government Relations, VA

RADM Michael D. Weahkee, Assistant Surgeon General, USPHS and Acting Director, IHS Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS

TSGAC and Technical Workgroup Members






[email protected]

August 20, 2018 RADM Michael D. Weahkee Acting Director Indian Health Service Mail Stop: 08E37A 5600 Fishers Lane Rockville, MD 20857

Ms. Jennifer Cooper, Director Office of Tribal Self-Governance Indian Health Service Mail Stop 08E05C 5600 Fishers Lane, Parklawn Building Rockville, MD 20857

RE: Support of the Great Plains Tribal Chairmen’s Health Board’s (“Board”) Efforts to Assume Management of Sioux San Hospital Dear RADM Weahkee and Ms. Cooper: On behalf of the Tribal Self-Governance Advisory Committee (“TSGAC”), which represents more than 360 Tribal Governments, I am writing you today to voice support of the Great Plains Tribal Chairmen’s Health Board’s (“Board”) efforts to assume management of Sioux San hospital. The TSGAC was briefed on this issue during our recent July 2018 quarterly meeting and had a chance to review the June 7, 2018 letter that was sent to you from the Board.

As you know, the Sioux San hospital has faced significant challenges delivering quality health care in recent years. In July 2017, IHS gave notice to Congress that it intends to permanently close the inpatient and emergency departments of the Sioux San Hospital—a change the Tribes have objected. This history of poor care and concerns about the future of the Sioux San Hospital motivated the Oglala Sioux Tribe, the Cheyenne River Sioux Tribe and the Rosebud Sioux Tribe to come together to consider various options to improve the health care programs that serve their communities. After many months discussing and deliberating options, each of the Tribes passed a resolution stating that their preferred option is for the Board to assume the management of the Sioux San Hospital under Title V of the ISDEAA. The Tribes are confident that significant improvements will result under a self-managed system.

Indian Health Service states on its website that participation in Self-Governance affords

Tribes the most flexibility to manage health care programs and tailor health care services to the needs of their communities. I request that IHS consider the importance of this flexibility as you work with the Board to identify options that will facilitate and not hinder the Board’s efforts to enter into a Title V Compact—the approach determined by these Tribes as the best option for meeting the needs of their communities. Title V specifically calls upon the Secretary to facilitate the inclusion of PSFAs into self-governance and facilitate the achievement of Tribal health goals and objectives.




TSGAC Letter to IHS Acting Director and OTSG Director RE: Support of the Great Plains Tribal Chairmen’s Health Board’s (“Board”) Efforts to Assume Management of Sioux San Hospital August 20, 2018 Page 2

Thank you for supporting and advancing Self-Governance. If you have any questions or would like to discuss these comments, please contact me at [email protected]. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jerilyn Church, MWS, Chief Executive Officer, GPTCHB TSGAC Members and Technical Workgroup





September 14, 2018

RADM Michael D. Weahkee Acting Director Indian Health Service 5600 Fishers Lane, Mail Stop: 08E86 Rockville, MD 20857

RE: Sanitation Deficiency System (SDS) Guide Tribal Consultation

Dear RADM Weahkee:

On behalf of the Tribal Self-Governance Advisory Committee (TSGAC), we thank you for the opportunity to comment on the proposed updates to the Indian Health Service (IHS) Sanitation Deficiency System (SDS) - A Guide for Reporting Sanitation Deficiencies for American Indian and Alaska Native Homes and Communities (commonly known as the “SDS Guide”).

While the TSGAC agrees with several of the key updated SDS Guide elements, we have concerns in several areas and offer the following comments and suggestions:

1. The SDS Guide is based upon the Criteria for Sanitation Facilities Construction Program document. That document was created in 1999 and last updated in 2003. Due to the age of the document it contains no references to Title V. Updating the SDS Guide without first updating the Criteria document may be premature. The Sanitation Facilities Construction Program should put a priority on updating the Criteria document and submit it for Tribal consultation as soon as possible.

2. Deficiencies for Department of Housing and Urban Development Homes. While there is a clear prohibition on serving new homes constructed with grants by the housing programs of the Department of Housing and Urban Development, the SDS guidance adds additional prohibitions for homes constructed under the Section 184 loan guarantee program where the home is not solely titled in the name of the occupant. This seems to be in disagreement with the Office of General Counsel opinion dated 11/20/1961 which states in part: “The terms “Indian homes, communities and lands” are not defined in the statute and their meaning must therefore be reasonably determined by the Service, having in mind the scope and purposes of the statute. As we have previously advised you this Act is to be broadly and liberally construed for the accomplishment of its purposes.”

The opinion goes on to say, “Accordingly it is our view that domestic facilities may be provided for, and transferred to, the occupants of Indian homes even if they do not own the home or the land on which it is constructed” Additionally, the opinion gives two instances where the home may be Indian-occupied but either owned by the Indian Tribe or a nonprofit organization. In both cases the opinion finds that the provision of sanitation facilities is allowable with certain caveats.



Letter to IHS RADM Michael D. Weahkee Page 2 RE: SDS Guide Consultation September 14, 2018

In light of this we believe that homes constructed with Section 184 loan guarantees should be eligible for inclusion in SDS regardless if the title was solely in the name of the occupant, the Tribally Designated Housing Entity or a combination of the two.

3. SDS Eligibility and Reporting. There are several areas in the eligibility section of the SDS guidance that are of concern, which impact certain Areas more than others and in which all Areas may not agree on a proposed solution. For example: the Alaska Area has a major issue with requiring a pro rata contribution for the incidental benefit for buildings that IHS deems ineligible for core sanitation projects in Indian communities. While Alaska agrees with the Communities with Varying Eligibility limitation of eligibility to communities under 10,000, other Areas strongly oppose that requirement, feeling that the Communities with Varying Eligibility section (Section 4(g)) that disallows service to communities with populations over 10,000 and Tribal membership under 50% is unduly restrictive, given that there is no population limit within the public law. In fact, the Indian Health Care Improvement Act (IHCIA) states that "it is in the interest of the United States, and it is the policy of the United States, that all Indian communities and Indian homes, new and existing, be provided with safe and adequate water supply systems and sanitary sewage waste disposal systems as soon as possible.”

The best, and easiest, solution to address these issues is to allow each Area to set its own eligibility criteria, as long as the criteria are in accordance with federal law and regulations. This would allow each Area to address its priority issues and would also be consistent with the tenets of tribal self-governance, which does not require that tribes follow IHS policy, only federal law and regulations. Under this recommendation, the funding for each Area would continue to be distributed according to the national methodology. Areas would implement their respective eligibility criteria after funding was received from that distribution. There is longstanding precedent for this in the Purchased and Referred Care program, in which two IHS Areas have established their own eligibility and funding criteria.

4. Exceptions. Section 4(h) allows the listing of projects which may not be eligible for IHS funding provided the costs are coded as ineligible, yet when there are no eligible costs associated with a project it is excluded by IHS Headquarters from the SDS list. Perhaps some additional clarification could be added to this section on the mechanism to add projects that may be ineligible for IHS funding but can still be funded by other agencies such as EPA.

5. Project Classification - Primary Infrastructure Category. Section 6(h) does not contain a category for water supply infrastructure. Is this an oversight or will it be included in another listed classification?

6. Capital Cost. Section 7(d). GAO recommendation # 3 states: The Director of IHS should reassess the point distribution across the Sanitation Deficiency System scoring factors as part of its program guidelines update, in light of trade-offs between funding projects that address the most severe sanitation deficiencies and projects that meet other needs. If IHS desires to comply with this recommendation then it would be appropriate to assess if the current capital cost scoring mechanism is contributing to lower Deficiency Level and Health Impact projects being funded ahead of those with higher DL and HI scores. A greater emphasis on DL and HI scores and a smaller emphasis on the remaining factors would help to alleviate the situation.


7. Local Tribal Priority. Section 7(e). A clarification should be made regarding whether or

not all federally recognized tribes are eligible to submit projects and attach priority points to those projects, even though the tribe may be located within the jurisdiction of another tribe.

8. Total Score/Tiebreakers. We recommend involving the Area’s Tribal Advisory Committee in the decision making process on how to break projects with tied scores and not leave the decision solely to the Area SFC Director.

9. Ready-to-Fund. Since the December 2017 draft of the SDS Guidance, the language for Ready-to-Fund (RTF) projects has changed to require “completed design” rather than “preliminary design”. The Preliminary Engineering Report (PER) is currently in use for SDS projects and was designed with achieving RTF status in mind. Because the phrase “completed design” could be construed as a term-of-art and potentially exclude use of a PER, we recommend updating this section to simply require a PER and using neither completed nor preliminary design terminology.

10. Appendix B. In Appendix B, a reservation of authority for the SFC Director appears: “The indices and methodology used to develop the total allowable cost figures may be modified at the discretion of Director of the Division of Sanitation Facilities Construction.” We are concerned that this could result in changes to allowable unit costs that do not follow the SDS guide standards. When changes in indices or methodology need to occur, SFC should consult with tribes prior to making alterations, rather than exercising unilateral authority.

11. Appendix E. There are several issues that we have with the Deficiency Level (DL) descriptions in Appendix E. Public Law 94-437 defines a Deficiency Level 4 as: an Indian tribe or community with a sanitation system which lacks either a safe water supply system or a sewage disposal system. We strongly believe that the wording in this section is critically important. IHS’s longstanding interpretation of this section is that homes with water or sewer systems which were considered unsafe are DL4. This would include homes that did not comply with the primary drinking water standards of the Safe Drinking Water Act. We agree with that longstanding interpretation.

The new interpretation is that these homes are DL3, because the home does not comply with applicable water supply and pollution control laws. There are many instances where a home’s water supply may not comply with water supply laws, yet the water is safe to drink. For example, a water system that lacks adequate pressure or does not meet current design standards. However, when water does not comply with the primary standards of the Safe Drinking Water Act, it should be categorized as a DL4. Also in Appendix E, homes with water sources that produce less than 5 gallons per capita per day are listed as DL4. Homes with water sources that produce less than 30 gallons per capita per day are listed as DL3. Homes with water sources that produce as little as 31 gallons per capita per day are not found to have a deficiency. These are figures from the World Health Organization and give minimum water supply guidelines for undeveloped countries. The average home in the United States uses around 300 gallons per day, and IHS should endeavor to see that Tribal homes are served at the same levels as the rest of the United States. Another example from Appendix E, homes with surfacing septic tank effluent are categorized as DL3. Even though IHS defines this as “partially treated” sewage, the high amount of pathogens in septic tank effluent should cause concern and be a priority by categorizing these projects as DL4. The primary removal of pathogens occurs in the soil and not the septic tank.


Finally, the TSGAC requests that the IHS quantify the entire need for water and sanitation deficiencies in Indian country and request the needed appropriations to eradicate all such deficiencies within the next 5 years.

In closing, we thank you for the opportunity to participate in the consultation process. We look forward to working with you on this critical issue as we all endeavor to raise physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. If you have any questions or would like to discuss these comments, please contact me at [email protected]. Sincerely,



Letters from IHS

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service Rockville MD 20857

SEP 15 2018

Dear Tribal Leader and Urban Indian Organization Leader:

I am writing to update you on the progress of efforts to clarify Indian Health Service (IHS) and Tribal pharmacy claim rejections with Pharmacy Benefit Manager (PBM) CVS/Caremark (CVSC). I am pleased to announce new information regarding this issue.

Last year, the IHS worked with CVSC to establish two pilot sites, one IHS pharmacy (Phoenix Indian Medical Center) and one Tribal pharmacy (Chickasaw Nation), to test a process by which previously rejected claims would be reviewed by CVSC. In April 2018, CVSC set up an e-mail address for IHS, Tribal, and Urban Indian Organization (I/T/U) pharmacy staff to transmit rejected claims, so that CVSC experts could troubleshoot and identify system issues that were causing these claims to be rejected. As a result of pilot site participation and e-mail submissions received, CVSC was able to determine a work-around to allow I/T/U claims to be paid.

Reprocessing of the claims identified to date is currently underway in the CVSC test system. This testing will remain in effect for 3 to 4 more weeks. CVSC is also working on amending the logic underlying I/T/U claims payment and changes that will classify I/T/U National Provider Identifiers as “specialty pharmacy” providers, which will also help prevent improper denials of I/T/U pharmacy claims in the future. We anticipate that this process will be complete by the end of September 2018.

Thank you for support and partnership in addressing this important issue. We will provide additional updates as new information becomes available.

Sincerely,

/Michael D. Weahkee/

RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Acting Director

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service Rockville MD 20857

SEP 14 2018

Dear Tribal Leader and Urban Indian Organization Leader:

I am writing to provide you with my decision on the Indian Health Service (IHS) proposal to reprogram a portion of the fiscal year (FY) 2018 funding increase appropriated for inflation to fund lease cost agreements with Tribes or Tribal Organizations authorized under section 105(l) of the Indian Self-Determination and Education Assistance Act (ISDEAA).

The IHS announced this Tribal Consultation and Urban Confer on July 10 and received a total of 48 written comments. I appreciate the input provided through these written responses. A summary of the comments is provided as an enclosure to this letter, which includes general expressions of disapproval of the proposal.

I understand the concerns raised in the comments about redirecting additional funds appropriated for the purpose of addressing inflation. However, as I indicated in the July 10 letter announcing Consultation and Confer on this matter, if the IHS did not use the inflation funds for funding these 105(l) lease cost agreements, the Agency would need to reprogram base budget funding from Federal Service Units, Area Offices, and Headquarters, disproportionally impacting parts of our IHS, Tribal, and Urban health system. Other resources, for example, supplemental appropriations, are not feasible, and the IHS must use existing appropriations within the FY 2018 Services account to meet the payment requirement of section 105(l) of the ISDEAA.

Therefore, for FY 2018 only, I decided to reprogram $25 million from the $70.4 million inflation increase received in the IHS’s FY 2018 Services appropriation to address the 105(l) lease cost agreements. The IHS completed the required formal congressional notification process and reprogrammed funds from each of the Services budget line items that received a portion of the inflation funding increase, with the exception of Purchased/Referred Care, which is funded at an earmarked amount in appropriations language. The remaining $45.4 million of the $70.4 million total inflation funding increase has been allotted to Area Offices for further distribution to Service Units and/or payment to Tribes, Tribal Organizations, and Urban Indian organizations through their ISDEAA compact/contract or Indian Health Care Improvement Act contract.

The IHS will continue to consult with Tribal Leaders and Confer with Urban Indian Organization Leaders, as well as Congress, as we work together to identify and discuss long-term solutions. Thank you for your continued support and partnership with the IHS.

Sincerely,

/Michael D. Weahkee/

RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, US Public Health Service Acting Director

Enclosure

The Stronger Medical Workforce Act

At the Secretary’s Tribal Advisory Committee (STAC) last week, RADM Weahkee referenced The Stronger Medical Workforce Act as a concern for PHS Commission Corp at IHS facilities. The proposed legislation, introduced earlier this year by Senator Tester, requires the VA to identify impediments and challenges to filling vacancies and craft a plan to fill them. Under Tester's bill, the VA and the Surgeon General will work together to assign at least 500 commissioned Public Health Service Officers to VA facilities. It also designates VA facilities as underserved areas.

S.2356: https://www.congress.gov/bill/115th-congress/senate-bill/2356/text

SEC. 5. ASSIGNMENT TO DEPARTMENT OF VETERANS AFFAIRS OF COMMISSIONED OFFICERS OF THE REGULAR CORPS OF THE PUBLIC HEALTH SERVICE.

(a) Assignment.-- (1) In general.--Not later than 180 days after the date of

the enactment of this Act, the Secretary of Veterans Affairs and the Surgeon General shall enter into a memorandum of understanding for the assignment of not fewer than 500 commissioned officers of the Regular Corps of the Public Health Service to the Department of Veterans Affairs.

(2) Manner of assignment.--Assignments under paragraph (1) shall be made in the same manner in which assignments are made to other Federal agencies.

(b) Reimbursement.--The Secretary shall reimburse the Surgeon General for such expenses as the Surgeon General may incur in assigning commissioned officers pursuant to a memorandum of understanding entered into under subsection (a).

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.congress.gov_bill_115th-2Dcongress_senate-2Dbill_2356_text&d=DwMFAg&c=euGZstcaTDllvimEN8b7jXrwqOf-v5A_CdpgnVfiiMM&r=LJ8SdZXf0jt8xCPXI_2QHdnHWz_-yPgYp51mGZfET80&m=VUGpGrsLOKMAZcv9ofqcADkZhKVDV4wxaALoeetGUxc&s=3qL0N06MJMYuMBNfaG1OvgRRKrvgrcXJvSq4u3FhSgg&e=

“No right is more sacred to a nation, to a people, than the right to freely determine its social, economic, political and cultural future without external interference.

The fullest expression of this right occurs when a nation freely governs itself. We call the exercise of this right Self-determination.

The practice of this right is Self-government.”

– Joe De La Cruz

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Contents Vision & Mission Guiding Principles Development of the Strategic Plan Success of Tribal Self-Governance Future of Tribal Self-Governance Role of SGAC, TSGAC, and SGCE Goals, Objectives, Strategies, and Measures Role of Partners

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021

Vision & Mission

Vision: Preserve, protect, and advance Tribal and Indigenous sovereignty, culture, history, treaty, and right to self-governance.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Guiding PrinciplesTribes are sovereign nations. As such, all relations between the United States and Tribal Nations are of a formal government‐to‐government nature.

As sovereign nations, Tribal governments have the inherent authority and control over their territories, Treaty rights, natural resources, and the welfare of their citizens. Further, Tribal governments have the authority to set internal priorities (without federal interference) and, under Self‐Governance, may redesign programs and reassign federal funds to more efficiently and effectively meet their local needs.

Tribal governments are accountable to their citizens, which is intrinsic in any accountability model on the utilization of federal funds.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Development of the Strategic PlanEach year, Self-Governance Tribes conduct a strategic planning session to chart the course for the future of Tribal Self-Governance.

To identify goals, objectives, strategies, and measures, we are taking the following actions:

• Analyzing the results of the strategic planning session• Evaluating prior strategic plan• Feedback and input from SGAC, TSGAC, and SGCE Board. • Feedback and input from Tribal leaders and officials• Feedback from community members • Review of existing literature and information, including the Native Truth report.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Success of Tribal Self-Governance

The success of Tribal self-governance is undeniable. Tribal nations of all sizes, location, and governance structure have demonstrated that Tribes are more effective and efficient implementing federal programs and providing services to their citizens and communities than Federal agencies and bureaucracies that are not held accountable by the citizens they serve.

This section will include several “case studies” that exemplify the success of Self-Governance.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Future of Self-Governance

Tribal nations have continuously sought to build upon the success of Self-Governance by expanding self-governance opportunities to additional agencies and departments in the federal government. Tribal nations envision a future in which every Federal Agency that has a program serving Indian Country will participate in Self-Governance.

All Tribal Nations will have the opportunity to exercise their inherently sovereign powers of tribal self-government.

All federal funds to administer programs will be disbursed through a single contract and funding agreement.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Role of SGAC, TSGAC, and SGCE

This section will include organizational charts, relationship charts, and descriptions.

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Goal Areas, Objectives, Strategies, and Measures

Goal areas will be categorized, potentially into the following categories:

Cross-cutting Tribal Self-Government Goals

Enhancing Self-Governance at DOI

Enhancing Self-Governance at HHS

Effectiveness and Long-Term Viability of SGCE

Objectives will be classified as:

MonitoringObjectives that need to be monitored but no direct action has been identified.

GrowingObjectives where action is ongoing, needs to continue, and additional actions may be added.

BuildingObjectives where no current action is taking place but action is needed.

Examples of potential goals, objectives, and strategies:

Goal Area 1: Ensure All Tribal Nations Have the Opportunity to Pursue Their Right to Tribal Self-Government

Every Tribe has the right to pursue Self-Government. And yet, a number of barriers hold back many Tribes across the country from developing and administering culturally appropriate programs that serve their communities.

Objective 1: Identify barriers that hinder Tribal nations from pursuing Self-Governance.

Strategies: To identify barriers, SGCE will take the following actions: (1) conduct a survey of Tribal nations, (2) hold roundtable discussions with direct service tribes; (3) interview Tribal leaders.

Goal Area 3: Enhance the effectiveness of SGCE and ensure the long-term viability of the organization.

Objective 1: To enhance SGCE’s capacity to serve as the key organization for Self-Governance.

Strategies: SGCE will take the following actions: (1) workforce planning, (2) align budget and resources with Strategic Plan, (3) increase opportunities to foster knowledge transfer, (4) enhance SGCE’s research and policy capacity, (5) seek additional funding sources needed to implement new initiatives, (6) enhance technical support and educational resources for SGAC, TSGAC, Self-Governance Tribes, and future Self-Governance Tribes, and (7) enhance outreach and collaboration with all Tribal nations, tribal communities, and federal agencies.

Measuring Performance

Who will accomplish the activity?

When will it be completed?

How will we evaluate effectiveness of the activity?

TRIBAL SELF-GOVERNANCE STRATEGIC PLAN, 2019 – 2021Role of Partners

Indian Health Service

Department of the Interior

Inter-Tribal Organizations

Edward T. Bope MD, FAAFPDirector of GME Expansion

Office of Academic AffiliationsVeterans Health Administration

VA Education MissionNIHB Conference

VETERANS HEALTH ADMINISTRATION

What is the VHA Mission?

Honor America’s Veterans by providing exceptional health care that improves their health and well-being.


Education is one of VA’s 4 Statutory Missions (38 USC 7302)

(a) … in order to assist in providing an adequate supply of health personnel to the Nation, the Secretary— to the extent feasible without interfering with the medical care and treatment of veterans, shall develop and carry out a program of education and training of health personnel;


“To Educate for VA and the Nation”

• Largest provider of health care training inthe Nation – 120,000 annually

• Second largest federal funder of GME

• Office of Academic Affiliations GME directsupport ~ $950,000,000 annually


Medical Education Scope

• OAA GME support:• 11,000 positions•Over 43,000 individual residents

• 24,000 medical students receiveclinical training in VA each year

• Almost all programs sponsoredoutside of VA through AffiliationAgreements (3 exceptions)


Scope of Affiliations (AY2016-17)

• 144 of 149 allopathic medical schools

• 34 of 34 osteopathic medical schools

• 40+ health professions

• 1,800+ colleges and universities

• 7,200+ program agreements


VA NY Harbor Healthcare


Catskill and Bainbridge CBOCs

Bainbridge

Catskill


Veterans Access, Choice, & Accountability Act (VACAA)

• PL 113‐146: Enacted by Congress & signed bythe President on August 7, 2014 – Section301(b)

oProvision to expand VA GME by “up to 1,500 positions” over 5 years beginning 1 year after signing. Now extended to 10 years

oFunding priorities defined in law

o1055 Positions now awarded


Funding Priorities in VACAA

Facility Characteristics

• A shortage of physicians

• No prior GME

• Areas with a “high concentration of Veterans”

• Health Professional Shortage Areas (HPSAs) as defined by HRSA

Program Characteristics

• Primary Care

• Mental Health

• Other specialties “the Secretary deems appropriate” (interpreted as those specialties having excessive wait times for care)


MISSION Act 2018 - Public Law 115-182

• Four sections of this comprehensive bill will have a direct impact on VA’s clinical education mission (Sections 301, 303, 304, and 403).

• Other sections concerning community care referral and payment authorities are anticipated to have secondary effects on VA’s health professions education effort.


SECTION 301 - Designated Scholarships for Physicians and Dentists Under the VA Health Professions Scholarship Program

• Directs the development of adesignated component withinHPSP for medical and dentalstudents.

• 50 scholarships annually tomedical and dental students.


Section 301

• Scholarships are for a period of 2‐4 years.

• Awardees are obligated to serve as full time employees in the Veterans Health Administration for a period of 18 months for each school year or portion of a year that they receive HPSP benefits.

• VA is permitted to give preference to Veterans

This Photo by Unknown Author is licensed under CC BY‐NC‐SA


SECTION 303 - VA Specialty Education Loan Repayment Program

• Establishes the Specialty Education Loan Repayment Program (SELRP) which is intended to help VA attract physicians in medical specialties that the Secretary determines are difficult to recruit for or retain personnel in.

• Participants must have outstanding loan balances that were used to pay for the education that qualified them for specialty training (i.e. tuition, books, fees, reasonable living expenses).


Section 303• VA may give preference to

applicants who are Veterans or will participate in residency programs in health care facilities that are: 1) located in rural areas; 2) operated by Indian tribes, tribal organizations, or the Indian Health Service; or 3) affiliated with underserved VA health care facilities. This Photo by Unknown Author is licensed under CC BY‐SA


Section 303

• No more than $40,000 per year maybe disbursed to awardees for a totalof 4 years ($160,000).

• Following specialty training, SELRPparticipants are required to serve asfull-time VA clinical practiceemployees for 12 months for every$40,000 in benefits received.


SECTION 304 Veterans Healing Veterans Medical Access and Scholarship Program -VMAS

• VA will fund the medical education of 18 eligible Veterans at the following covered institutions:

• 1) Texas A&M University; 2) East Tennessee State University; 3) Wright State University; 4) Marshall University; 5) University of South Carolina; 6) Charles R. Drew University of Medicine and Science; 7) Howard University; 8) Meharry Medical College and 9) Morehouse School of Medicine.


Section 304

• Each participating VMAS medical student will get: 1) tuition for four years; 2) books, fees, and technical equipment; 3) fees associated with the National Residency Match Program; 4) two away rotations in fourth year of medical school to VA health care facilities; and 5) a monthly stipend during their four years enrolled in medical school in an amount determined by VA.


Section 304 – Each participant must

• have acceptable academic standing;• complete post-graduate training that

leads to eligibility for board certificationin a medical specialty applicable to VA;

• secure a state license to practicemedicine;

• agree to serve for four years as a full-time VA clinical practice employee


SECTION 403 - Pilot Program on Graduate Medical Education

• Establish physician residency positions authorized under Public Law 113-146 (i.e. the Choice Act) at the following “covered facilities” through August 7, 2024:

• 1) VA health care facilities; • 2) Health care facilities operated by a tribal organization;• 3) Indian Health Service (IHS) facilities;• 4) Federally qualified health centers; • 5) Department of Defense health care facilities; • 6) Other health care facilities deemed appropriate by the

Secretary.


Section 403• Directs VA to consider

physician specialty andgeographic locationshortages whendetermining the coveredfacilities where residentsare placed.

• VA will determine clinicalneed by using the six factorsidentified in the statute.


Section 403

• Place at least 100 residents in the followingsubcategories of covered facilities: 1) IHSfacilities; 2) health care facilities run by anIndian tribe or tribal organization; or 3) thoselocated in communities that VA designates asunderserved using the criteria established inSection 401 of The MISSION Act.

• Allows VA to pay for the stipends and benefits ofphysician residents in the pilot programregardless of whether they provide care in a VAor non-VA “covered” setting.


Section 403• If new residencies are established in the pilot VA will

reimburse the institution for the following costs: • 1) curriculum development; • 2) faculty recruitment and retention; • 3) ACGME accreditation expenses; • 4) the portion of faculty salaries attributable to the

pilot; • 5) the expenses related to educating physician

residents in the pilot. • An extensive Congressional reporting requirement is

mandated for the pilot


Office of Academic Affiliations

• http://www.va.gov/OAA/index.asp•


Link to VA Handbooks/Policies

• http://www.va.gov/oaa/handbooks.asp


Contact Information

• Edward Bope, MD, [email protected]

FOR INTERNAL TRIBAL USE ONLY; NOT FOR WIDER DISTRIBUTION

2018-10-01 TSGAC Legislative Priorities under Medicaid Page 1 of 1

“MEDICAID INDIAN AMENDMENTS ACT” OVERVIEW OF LEGISLATIVE PROPOSAL

As of October 1, 2018

In order to more fully meet the federal trust responsibility to American Indians and Alaska Natives1 (AI/ANs) and Indian Tribes, Tribal leaders have proposed a set of legislative initiatives. Titled the

“Medicaid Indian Amendments Act”, upon enactment, these initiatives would improve access to quality health care services for low- and moderate-income AI/ANs across all states.

Current federal regulations define Indian Health Care Providers (IHCPs)—which consist of Indian Health Service (IHS), Tribal, and urban Indian programs2—and provide 100% federal funding for Medicaid services furnished to AI/ANs by (and through) IHS and Tribal, but not urban Indian, providers.

The Medicaid Indian Amendments Act aims to build on the existing IHCP status and federal funding mechanism to ensure access to a uniform set of health care services for low- and moderate-income AI/ANs across all states. The main provisions of the Medicaid Indian Amendments Act are:

1. Authorize IHCPs in all states to receive Medicaid reimbursement for a uniform set of health careservices—referred to as Qualified Indian Provider Services—delivered to AI/ANs.

2. Create authority for states to extend Medicaid eligibility to all AI/ANs with an income up to138% of the federal poverty level (FPL).

3. Extend full federal funding (through 100% FMAP) to Medicaid services furnished by urban Indianproviders to AI/ANs, in addition to services furnished by IHS/Tribal providers to AI/ANs.

In addition, the following items would be included in the Medicaid Indian Amendments Act:

4. Clarify in federal law and regulations that state Medicaid programs are—

o Permitted to implement policies limited to AI/ANs and/or IHCPs (through waivers or

State Plan Amendments), including without concern of violating (a) “comparability”

or (b) “statewideness” standards.

₋ Mandate [or permit] exemption of AI/ANs from work requirements.

o Prohibited from over-riding (through waivers, etc.) Indian-specific provisions in

federal Medicaid law.

5. Address the “four walls” limitations on IHCP “clinic” services.

Implementing these provisions—and thereby strengthening the Medicaid program infrastructure for AI/ANs and IHCPs under federal law across all states—will expand access to a broader set of quality health care services for low- and moderate-income AI/ANs nationally by (a) creating greater uniformity in program eligibility, (b) enabling greater consistency in the breadth of services for which IHCPs are authorized to receive reimbursement, (c) providing consistency in 100% federal funding across all IHCPs for services provided to AI/ANs, and (d) ensuring that demonstration / waiver authorities are available to address challenges—and not eliminate current law protections—specific to AI/ANs and IHCPs.

1 AI/ANs are defined here as persons eligible for services from the Indian Health Service. 2 Pursuant to 42 CFR 447.51, “Indian health care provider” is defined as “a health care program operated by the

Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise

known as an I/T/U) as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C.

1603).”

TSGAC Committee Meeting

July 18-19, 2018

• Chief Malerba, Chair for the TSGAC, opened the meeting and expressedappreciation for all in attendance.

• Melanie Fourkiller, Co-Chair for the Technical Workgroup, conducted a roll calland reported a quorum for TSGAC members.

• Ms. Fourkiller noted that Phoenix has vacancies on the TSGAC and suggestedsending a letter to encourage the Phoenix area to submit a nomination letter to fillthe vacancy.

• Councilmember Carlyle from Ak-Chin Indian Community announced they arestarting the Self-Governance process with IHS.

• Rear Admiral Weahkee announced that on July 10, Tribal consultation wasinitiated on 2018 inflation increases. The consultation ends on Friday July 27.

• On July 12, final decision for 2019 funding distribution for Special Diabetes forAmerican Indians. The funding will remain the same as prior years.

• HIS Strategic Plan for 2018-2022 is now complete and there is a public commentperiod for 30 days. A Tribal Leader call will be held to discuss the plan andreceive input.

Opioid Litigation Update

Geoffrey Strommer, Partner, Hobbs, Strauss, Dean and Walker, LLC

Lloyd Miller, Partner, Sonosky, Chambers, Sasche, Endreson and Perry, LLP

Date: July 18, 2018

Time: 2:30 pm

Key Points

• The opioid crisis is serious and has resulted in 33,000 deaths—115 people dieevery day because of opioid abuse. In Oklahoma alone, there are 1,000 deaths ayear from opioids.

• Most of the litigation has been focused on the manufacturers of opioids. Tribeshave recently become aware of the litigation and worked with the CherokeeNation to bring the first case against industry in a Tribal court. It was determined

that a Tribe may not enforce law against a pharmaceutical company in tribal court, it must be brought in State or Federal court.

• Today, there are 840 court cases against the pharmaceutical industry. Mr. Miller noted that all federal cases have been consolidated to a single court.

• Mr. Miller walked through updates for several of the cases involving Tribal nations and materials were distributed covering the case brought against the pharmaceutical industry by the Muscogee (Creek) Nation.

• Mr. Strommer noted that while all federal cases have been consolidated to a court in Ohio, there are still numerous cases in states.

• In regards of damages to Tribes, Tribes should start to think about the costs to deal with the damages—such as new programs or increased programs to deal with the impact of opioids.

• The Swinomish Tribe opened up an opioid facility that is a state-of-the-art facility to combat opioid abuse.

• Chief Malerba stated that TSGAC would like to keep this update as a standing agenda item as it is very quick moving.

Questions and Responses (Q1) Is there any recourse for specific families or does it all go to governmental entities? (A1) Many of the cases being brought in court are from individual families rather than a government entity bringing a case on behalf of individual families. (Q2) What about the prescribers? Are they being held responsible? (A2) Very few cases are naming physicians but there are a few cases in which the DEA went after physicians.

Committee Business

• Chief Malerba introduced the proposal to discuss changing the structure of the meetings.

o Overview of the proposal: The co-chairs of the Technical Workgroups for

SGAC and TSGAC presented to the SGCE Board, the SGAC, and the TSGAC a proposal to change the number of advisory meetings from four to three and to extend the amount of time dedicated to each Committee. The purpose of making changes to the structure of the meetings is to improve the efficiency, productivity, and effectiveness of the events. Specific changes as a result of the revised structure include:

1. Instead of quarterly advisory committee meetings (4 each year), SGAC and TSGAC will hold 3 advisory committee meetings per year. Each of the 3 meetings will have additional time incorporated so that we are still meeting the same number of days overall (on an annual basis). But, the revised schedule will be more efficient and make better use of your time. To do this, the advisory committee meeting typically held in Match will be eliminated. The March meeting was selected as the one to eliminate because the Annual Conference comes right on the heels of the March meetings.

2.The format of the SGAC/TSGAC meeting week will change so that each Committee (DOI/IHS) would get 1 ½ day of formal meeting time, preceded by a technical work group meeting for ½ day. See below for a description of the daily schedule.

As October will be the first time to try the new structure, the workgroups will evaluate the effectiveness of this structure and propose changes as needed.

Mickey Peercy made a motion to approve and the Quinault Nation seconded the motion. The motion passed unanimously.

Conclusion: The SGCE Board, the SGAC, and the TSGAC, along with our federal partners at DOI and IHS agreed that the proposed changes are a good idea and decided to implement the proposal starting with the October 2018 advisory meetings.

• An IHS representative stated that the Direct Services Tribal Advisory Committee expressed an interest in having a joint meeting with TSGAC and would like to look at October as an option.

• SGCE report on 2018 conference. Tami Snow reported that we had 900 participants

at the conference—the largest conference held to date. The Department of Education did a consultation session. Overall, the sessions were all full and we might need to consider additional sessions for future conferences to meet the needs associated with increased participation.

• The meeting minutes for the March meeting were approved.

Office of Tribal Self-Governance, Indian Health Service, Update Jennifer Cooper, Director, Office of Tribal Self-Governance (OTSG), IHS

Date: June 18, 2018 Time: 3:15 pm

Key Points

• Ms. Cooper provide an update on OTSG staff. Ms. Cooper stated the office is in the process of recruiting for a Deputy Director position. In addition, the office is recruiting for a Senior Financial Analyst position. Ms. Cooper noted that this position is critical to make sure OTSG can move funds in a timely manner to tribes. Ms. Cooper noted there are still two vacancies in the office that need to be filled and the recruiting for those positions will start after the Deputy Director and the Senior Financial Analyst position are filled.

• Ms. Cooper announced that three new Tribes have entered into a Self-Governance

agreement with IHS. The addition of those Tribes brings the total to 101 compacts and 125 funding agreements with over 370 Tribes involved in those agreements.

• Ms. Cooper announced that IHS provides self-governance planning cooperative

agreements when funds are available and the agency is currently reviewing proposals. Ms. Cooper anticipates the agency will make funding announcements in about 2 weeks. These agreements are usually seen as ways for Tribes to expand Self-Governance or enter into new agreements.

• Ms. Cooper stated that efforts to update PSFA handbook are still ongoing but have

been paused. Ms. Cooper anticipates that once the office gets back to full staffing they would like to start back that effort, though it will need to be after negotiations season, and will be conducted in cooperation with a TSGAC workgroup.

Budget Topic Update

Elizabeth Fowler, Deputy Director for Management Operations, IHS Terra Branson, Self-Governance Director, Muscogee (Creek) Nation

Date: June 18, 2018 Time: 3:35 pm Key Points

• Ms. Fowler discussed the FY 2018 budget, including the following: o IHS received 5.5 Billion- a $498 M increase over FY 2017 o Funding for pay costs has already been distributed o Regarding the inflation increase, we have a current active consultation

open to address the inflation funds. Until a decision is finalized the inflation funds have not been disbursed. As soon as a decision is made, IHS will distribute those funds.

o IHS received $66 million to address new staffing requirements at 5 new constructed projects. There are 3 joint venture projects and are currently receiving their funds. The other 2 facilities have already received funds.

o $72 M was for Indian Healthcare Improvement Fund. An update on the Fund will be provided tomorrow morning.

o $58 M ($29M from prior year and $29 M for this year) to address accreditation issues- some funds expended.

o $1M increase for direct operations and oversight activities- in the process of standing up an office of quality.

o Facilities appropriation included the largest increase we have ever seen and those funds have been distributed by formula. Seven facilities from the priority list will be funded for construction.

o $10 M was provided for the small ambulatory program. o IHS received $5M for staff quarters- the first time it has been addressed in

a long time and are going to the areas with greatest need for quarters—Great Plains, Navajo, Alaska.

• Ms. Fowler also discussed the FY 2019 budget, including the following: o Budget submitted to Congress several months ago, requested $5.4 B and

also included some proposed reductions, moving Special Diabetes for American Indians from mandatory to discretionary. Both House and Senate have had some actions, House it has passed full committee at $5.9 B ($370 M increase for new staffing, pay cost, new tribe, Indian healthcare improvement fund, urban facilities, scholarships, contract support costs)

o Senate passed full Committee at $5.8 B ($230 M for new staffing, new tribes, tribal clinic leases, village-built clinics, opioid grants, contract support costs).

o Both House and Senate bills restore funding for programs cut by the President’s budget and both bills keep Special Diabetes funds in mandatory.

o We expect to have a CR for the first part of the year and then an omnibus.

• For FY 2020, we completed the Tribal process in the Spring and the Tribal workgroup presented recommendations on April 11. The details are all pre-decisional at this point but IHS is following the same process as in the past—including meetings with the Secretary’s budget committee. The next steps include HHS submitting a budget request to OMB.

• For FY 2021, we had the initial meeting with Tribes in April. We have some changes planned for the 2021 process, such as additional training and better documentation. The area meetings are expected to occur October through December.

• The House bill includes a statement affirming Tribal sovereignty and prioritizesloan repayment programs and funding for substance abuse disorder counselors.

Questions and Responses(Q1) For FY 18, there was a recent meeting about the Maintenance and Improvementfund and how that would be distributed. What is the status?(A1) The funds have been distributed from HQ to the Areas and there may be someAreas still disbursing funds.(Q2) When will you open the joint venture program again?(A2) We don’t have a specific date or timeline at this point. The solicitation is based onprojects already in the pipeline.(Q3) How many Tribes are on the waiting list for joint venture?(A3) From the last solicitation, there were 6 or 7 identified to move forward.

Contract Support Costs Workgroup UpdateElizabeth Fowler, Deputy Director for Management Operations, IHS

Mickey Peercy, Executive Director of Self-Governance, Choctaw Nation

Date: July 18, 2018Time: 3:55 pm

Key Points• Mr. Peercy stated that we are not moving forward and currently at an impasse.

We thought we had an agreement with IHS, but it got shot down.

• We came back to the table as a joint workgroup and I expected we would meetagain to go over the data but we never got a response on when the workgroupwould even convene.

• Not sure who is running the CSC program now. Still waiting on a response fromIHS. We need to come up with a consensus. We thought we had the consensusbut found out we did not. Nobody was willing to move.

• Ms. Fowler stated that Rosalyn is still the Director over CSC. The CSC 97-3policy provision was suspended last December. HIS met with the workgroup inApril on that provision. The workgroup develop da recommendation and it waspresented to HIS. HIS engaged in broader Tribal consultation on thoserecommendations. The comment period ended and we are sorting through the

comments. We are working to evaluate all comments. We anticipate to issue afinal decision soon and communicate that decision with the workgroup.

Legislative UpdateBrett Weber, Congressional Relations Coordinator, National Indian Health Board


Key Points• President Trump signed omnibus on March 23, 2018

• Omnibus includes an additional $500 million for IHS, and 50 million for Tribes totreat 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 onoverdose related deaths.

• These will be in the form of grants. NIHB has continued to stress the needs forformula funding for Indian health, but these resources will still make a hugedifference.

• At the April 2018 meeting of the Board of Directors, NIHB approved a resolutioncalling for SAMHSA to consult with Tribes to ensure that money reaches theTribes with the greatest need.

• Overall, IHS received $5.5 billion for FY 2018, 10% above FY 2017. That is afairly significant increase, and we’ll see in a little bit that that momentum hascontinued.

• A detailed PowerPoint presentation with notes can be found on theTribalSelfgov.org website. The presentation covers a Medicaid update, the FarmBill, IHS Reform legislation, Veterans legislation, and other legislative priorities.

Questions and Reponses(Q1) The VA Mission Act was passed that include Tribal provisions. Can you letpeople know about those provisions?(A1) NIHB will take a look into the VA Mission Act.

Patient Protection and Affordable Care Act (ACA) Implementation UpdateCyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE, Inc.

Doneg McDonough, Consultant, TSGAC


Key Points• The funding for the ACA Healthcare Project is provided through the Office of

Tribal Self-Governance. The project focuses on webinars and training. Mostrecently, the project had a subject matter expert come in to give a great overviewof the employer mandate.

• Mr. McDonough provided an update related to legislative priorities for Medicaid.Mr. McDonough states that the aim of this initiative is to fix gaps in access toneeded health care services under Medicaid for low- and moderate-incomeAmerican Indians and Alaska Natives (AI/ANs) across all states. He provided aPowerPoint with more information that can be found on the TribalSelfGov.orgwebsite.

Questions and ResponsesComment: The State of Wyoming submitted a waiver for uncompensated care. CMSissued a letter saying they cannot approve at 100 percent for non-Medicaid eligiblepatients. The State of Oklahoma submitted a waiver for “sponsors choice” and it has been at CMS for more than 2 years. We have tried to get CMS to approve the waiver.The State told us that they were told by CMS that a letter would be issued similar to oneissued in Wyoming. This might be something for the ACA Initiative to look into.

Indian Health Care Improvement Fund (IHCIF) Workgroup Update andDiscussion

James C. Roberts, Senior Executive Liaison, Intergovernmental Affairs, AlaskaNative Tribal Health Consortium, Tribal Co-Chair, IHCIF Workgroup (invited)

Elizabeth Fowler, Deputy Director for Management Operations, Federal CoChair,IHCIF Workgroup

Date: July 19, 2018Time: 8:45 am

Key Points • The workgroup completed phase I in May and submitted recommendations in June.

Information on the recommendations can be found on the HIS Website and the agency started consultation. The comment period ended July 13.

• We did a series of in person sessions and a webinar. We received several comments and questions. We turned it into a FAQ document. 65 questions in total. We are currently sorting through all of the comments. We are on a tight timeframe because we have to obligate them by September 30, meaning that HQ needs to get them out to service areas in August.

• On July 30, RADM Weahkee has a call scheduled with the workgroup to discuss the recommendations.

• The recommendations were summarized in a PowerPoint presentation that can be

found on the TribalSelfGov.org website.

Comments: • For many of us, once we settle on the model factors we will want to do a crosswalk

with the original formula. We don’t want to see this as a redistribution.

• The good news is that this is funding that is going to our base budget.

• Kudos to the workgroup for all the great work on this issue and we really appreciate that it was a very deliberative process.

Office of Information Technology Update (OIT) CAPT Mark Rives, DSc, Director, Office of Information Technology, HIS

Date: July 19, 2018 Time: 9:10 am

Key Points • CAPT Rives noted that everyone wants to know what work are we doing to replace

RPMS. He mentioned that IHS is working with several offices to bring in needed resources to accomplish this. Specifically, they are seeking to identify what does RPMS do well, what does it not do well, and what do we need it to do?

• CAPT Rivas stated that DOD and VA went onto a new system and focused oninteroperability, which is helpful for IHS as we can also share information with them.

• In regards to funding for the project, IHS needs $3 billion over 10 years. Officials arestarting to work through some of the budget cycle now to make sure our voice isheard. Officials have also looked at getting a line item for health IT, which would helpbring attention to the need as the budget for health IT is currently under hospitalsand clinics. CAPT Rivas noted that they do not need all $3 billion all up-front. Theamount needed to start the project is much smaller and primarily needed to bring inproject managers and folks to pull together information.

• RADM Weahkee noted that the $3 billion covers maintaining the current RPMS,archiving the data, and moving to the new system. IHS has benefitted from theexperiences at VA and DOD and getting great support from HHS and the ChiefTechnology Office. IHS doesn’t currently have money in the budget formodernization but RADM Weahkee hopes HHS will find some money to help withthe evaluation and moving forward with a more formal budget ask. CAPT Rivas istransitioning to a new position and the person to fill Mark’s shoes will be MitchThornbrugh.

• Mr. Rives provided a PowerPoint presentation that covers the topics discussedduring this session and it is posted on the TribalSelfGov.org website.

Questions and Responses(Q1) Have the 4-6 RPMS sites been selected and will one be a Tribal site?(A1) We would like a good representation and that one would include a Tribal site.(Q2) Why are you not outsourcing this activity?(A2) There are some portions that might be outsourced.(Q3) Can you explain more about the HIMSS analytic for a metric?(A3) It helps to measure patient care. I can provide more information on the details ifyou like.

Department of Veteran’s Affairs (VA)

Sarah Dean, Associate Legislative Director at Paralyzed Veterans of AmericaStephanie Birdwell, Director, Office of Tribal Government Relations, Veterans Affairs

Kristin Cunnningham, Executive Officer to the Deputy Under Secretary for Health,Veterans Affairs

Date: July 19, 2018

Time: 9:30 amKey Points

• VA signed the extension of the reimbursement agreement with IHS and Ms.Cunningham looks forward to extending the same agreement with tribalgovernments. The goal is to extend it for 3 more years and it has been a priorityfor last few months as continuing these partnerships is a priority.

• Ms. Cunningham noted that the VA Mission Act demonstrated Congressionalsupport for these agreements in the VA Mission Act. The VA Mission Act alsosets the expectation that when the VA interacts with veterans they will let themknow how they can use Indian Health Service, so it includes an education piece.In addition, the Act calls allows for residency programs at four tribal facilities andexpands care giver opportunities.

• Ms. Cunningham stated that she knows there is a lot of interest in creating anelectronic process for submitting pharmacy claims. She is happy to report thatefforts are underway to create the system for submitting electronically andintends for this to be fully functional by January 2019.

• In response to comments during the meeting, Ms. Cunningham noted that theyare looking into whether agreements can be extended for a longer-term period inorder to reduce the need for frequent renewals.

Questions and Responses(Q1) Reimbursement for Purchased and Referred Care is not in our agreement. Howdo we address it? The distance issue makes this problematic.(A1) We need to place more on the coordination and the Mission Act requires weuse a different network – need to look at better care coordination.(Q2) We are in remote areas and have to compete with Seattle to get doctors to ourfacility. The reimbursement rate costs are higher for us more to provide quality care.The agreements are focused on our ability to serve Native Veterans but we have lotsof Veterans in our rural areas that are non-Indian. We would love to serve them butneed these agreements to allow us to serve the non-Indian veterans.(A2) Access standards comment period closes this week, so please submit thosecommentsComment: Indian Country is part of the solution to help serve our Veterans. VAneeds to recognize that fact. Also, we need to consider how to get reimbursed formore traditional healing services. Finally, we need to have a workgroup focused onthe reimbursement issues.

INDIAN HEALTH SERVICE

Considerations Related to Providing Advance Appropriation Authority

Report to Congressional Committees

September 2018

GAO-18-652

United States Government Accountability Office

United States Government Accountability Office

Highlights of GAO-18-652, a report to congressional committees

September 2018

INDIAN HEALTH SERVICE Considerations Related to Providing Advance Appropriation Authority

What GAO Found The Indian Health Service (IHS), like most federal agencies, must use appropriations in the year for which they are enacted. However, there has been interest in providing IHS with advance appropriation authority, which would give the agency authority to spend a specific amount 1 or more fiscal years after the fiscal year for which the appropriation providing it is enacted. Currently, the Department of Veterans Affairs (VA) is the only federal provider of health care services to have such authority.

Stakeholders interviewed by GAO, including IHS officials and tribal representatives, identified effects of budget uncertainty on the provision of IHS-funded health care as considerations for providing IHS with advance appropriation authority. Budget uncertainty arises during continuing resolutions (CR)—temporary funding periods during which the federal government has not passed a budget—and during government shutdowns. Officials said that advance appropriation authority could mitigate the effects of this uncertainty. IHS officials and tribal representatives specifically described several effects of budget uncertainty on their health care programs and operations, including the following:

• Provider recruitment and retention. Existing challenges related to the recruitment and retention of health care providers—such as difficulty recruiting providers in rural locations—are exacerbated by funding uncertainty. For example, CRs and government shutdowns can disrupt recruitment activities like application reviews and interviews.

• Administrative burden and costs. Both IHS and tribes incur additional administrative burden and costs as IHS staff calculate proportional allocations for each tribally operated health care program and modify hundreds of tribal contracts each time a new CR is enacted by Congress to conform to limits on available funding.

• Financial effects on tribes. Funding uncertainty resulting from recurring CRs and from government shutdowns has led to adverse financial effects on tribes and their health care programs. For instance, one tribe incurred higher interest on loans when the uncertainty of the availability of federal funds led to a downgraded credit rating, as it was financing construction of a health care facility.

GAO identified various considerations for policymakers to take into account for any proposal to change the availability of the appropriations that IHS receives. These considerations include operational considerations, such as what proportion of the agency’s budget would be provided in the advance appropriation and under what conditions changes to the funding provided through advance appropriations would be permitted in the following year. Additionally, congressional flexibility considerations arise because advance appropriation authority reduces what is left for the overall budget for the rest of the government. Another consideration is agency capacity and leadership, including whether IHS has the processes in place to develop and manage an advance appropriation. GAO has reported that proposals to change the availability of appropriations deserve careful scrutiny, an issue underscored by concerns raised when GAO added IHS to its High-Risk List in 2017.

View GAO-18-652. For more information, contact Jessica Farb at (202) 512-7114 or [email protected].

Why GAO Did This Study IHS, an agency within the Department of Health and Human Services (HHS), receives an annual appropriation from Congress to provide health care services to over 2 million American Indians and Alaska Natives (AI/AN) who are members of 573 tribes. IHS generally provides services through direct care at facilities such as hospitals and health centers. Some tribes receive IHS funding to operate their own health care facilities. Tribal representatives have sought legislative approval to provide IHS advance appropriation authority stating that it would facilitate planning and more efficient spending. Experts have reported that agencies can use the authority to prevent funding gaps, and avoid uncertainties associated with receiving funds through CRs.

House Report 114-632 included a provision for GAO to review the use of advance appropriations authority and applications to IHS. Among other things, this report (1) describes advance appropriation authority considerations identified by stakeholders for providing IHS-funded health care services, and (2) identifies other considerations for policymakers related to providing the authority to IHS. GAO reviewed its prior reports related to IHS, VA, government shutdowns, and CRs, and interviewed officials from IHS, several tribes and other organizations representing AI/AN interests, the Office of Management and Budget, VA and other experts.

GAO provided a draft of this report to HHS, which had no comments; to VA, which provided general comments; and to tribal representatives, which provided technical comments that were incorporated as appropriate.

https://www.gao.gov/products/GAO-18-652



Page i GAO-18-652 Advance Appropriation Authority Considerations for IHS

Letter 1

Background 4 VA’s Advance Appropriation Authority for Health Care 11 Budget Uncertainty Effects on the Provision of IHS-Funded Health

Care That Were Cited by Stakeholders 13 Considerations for Policymakers Related to Providing Advance

Appropriation Authority to IHS 19 Agency Comments and Third-Party Views 21

Appendix I Comments from the Department of Veterans Affairs 23

Appendix II GAO Contact and Staff Acknowledgments 25

Table

Table 1: Numbers of Federally Operated and Tribally Operated Indian Health Service (IHS) Facilities, as of October 2017 5

Figure

Figure 1: Transfer of Funds from Indian Health Service (IHS) to Tribes and Tribal Organizations, Fiscal Year 2017 8

Abbreviations AI/AN American Indian and Alaska Native CR continuing resolution HHS Department of Health and Human Services IHS Indian Health Service OMB Office of Management and Budget VA Department of Veterans Affairs VHA Veterans Health Administration VISN Veterans Integrated Service Network

Contents

This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

GAO-18-652 Advance Appropriation Authority Considerations for IHS

441 G St. N.W. Washington, DC 20548

September 13, 2018

The Honorable Lisa Murkowski Chairman The Honorable Tom Udall Ranking Member Subcommittee on Interior, Environment, and Related Agencies Committee on Appropriations United States Senate

The Honorable Ken Calvert Chairman The Honorable Betty McCollum Ranking Member Subcommittee on Interior, Environment, and Related Agencies Committee on Appropriations House of Representatives

The Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), receives an annual appropriation from Congress to provide certain health care services to over 2 million American Indians and Alaska Natives (AI/AN) who are members of federally recognized tribes.1 IHS services are generally provided through direct care at IHS facilities such as hospitals and health centers, and when services are unavailable at these facilities, the facilities may pay for patients to obtain services, including specialty care, from external providers. In addition to federally operated IHS facilities, some federally recognized tribes choose to operate their own health care facilities, for which they receive at least partial support through IHS funding.

IHS, like most federal agencies, receives appropriations through annual appropriations acts and the appropriations become available upon enactment, not at some future date. However, there has been interest in providing IHS with advance appropriation authority—an appropriation of

1Federally recognized tribes have a government-to-government relationship with the United States and are eligible to receive certain protections, services, and benefits by virtue of their status as Indian tribes. The Secretary of the Interior publishes annually in the Federal Register a list of all tribal entities that the Secretary recognizes as Indian tribes. See, e.g., 83 Fed. Reg. 4235 (Jan. 30, 2018). There are currently 573 federally recognized tribes.

Letter


new budget authority that becomes available one or more fiscal years after the fiscal year for which the appropriation providing it is enacted.2 Organizations representing AI/AN people have advocated for Congress to provide IHS with advance appropriation authority, stating that advance appropriations would allow for greater planning, more efficient spending, and higher quality of care for AI/AN individuals. Although not commonly provided for federal programs, experts have reported that advance appropriations have implications for agencies’ ability to manage during periods of budget uncertainty, in terms of preventing funding gaps, and avoiding issues associated with receiving short-term funds through continuing resolutions (CR).3 The Department of Veterans Affairs (VA) is the only federal agency that currently receives advance appropriations for its health care program, which is administered by its Veterans Health Administration (VHA).

House Report 114-632 included a provision for us to report on the use of advance appropriation authority for health care programs across the federal government, and applications to IHS.4 This report

1. describes the advance appropriation authority that VA has for its health care program;

2. describes the advance appropriation authority considerations identified by stakeholders for providing IHS-funded health care services; and

3. identifies other considerations for policymakers related to providing advance appropriation authority to IHS.

To describe the advance appropriation authority that VA has for its health care program, we reviewed statutes related to VA’s specific advance appropriation authority and interviewed VHA officials, including headquarters officials from the Office of Finance and the Office of Rural Health. In addition, we interviewed officials from the Office of Management and Budget (OMB) who work with VA in planning for

2Legislation has been introduced in the House to provide IHS with such authority. See Indian Health Service Advance Appropriations Act of 2017, H.R. 235, 115th Cong. (2017). 3CRs provide temporary funding to allow agencies or programs to continue to obligate funds at a particular rate—such as the rate of operations for the previous fiscal year—for a specific period of time, which may range from a single day to an entire fiscal year. 4See Pub. L. No. 115-31, § 4, 131 Stat. 135, 137 (2017); 163 Cong. Rec. H3874 (daily ed. May 3, 2017); H.R. Rep. No. 114-632, at 89 (2016).


advance appropriations. We also reviewed our prior reports examining VHA budget processes and experience with advance appropriations.

To describe the advance appropriation authority considerations identified by stakeholders for providing IHS-funded health care services, we reviewed our prior reports that examined the effects of CRs and government shutdowns on federal agencies, and interviewed IHS officials and tribal representatives. Specifically, we interviewed IHS officials and tribal representatives about their perceptions of the potential advantages or disadvantages of advance appropriations for IHS, including their perceptions of the effects of budget uncertainty on the provision of IHS-funded health care. IHS officials we interviewed included individuals from the Office of the Director, the Office of Finance and Accounting, the Office of Direct Service and Contracting Tribes, the Office of Tribal-Self Governance, and the Division of Acquisition Policy, among others.

Additionally, we interviewed tribal officials, including those who currently serve as co-chairs for IHS’s National Tribal Budget Formulation Workgroup (who collectively represent multiple individual tribes and groups of tribes).5 We selected tribal officials to interview to help ensure a range of experiences and different types of funding agreements with IHS. We also obtained information from representatives of several additional tribes and tribal organizations.6 Our interviews and other information obtained from representatives of these tribes and tribal organizations are not generalizable to all federally recognized tribes. We also interviewed officials from associations representing tribal and AI/AN interests, including the National Indian Health Board and the National Council of Urban Indian Health.7 For context, we also spoke with VA officials from two regional networks—Veterans Integrated Service Networks (VISN)—about their experience with advance appropriations; VA officials indicated

5The National Tribal Budget Formulation Workgroup, which is a formal participant in IHS’s budget formulation process and consists of two tribal representatives selected from each of the 12 IHS areas, meets annually and prepares the final set of tribal budget recommendations and presents these to the IHS Director and HHS senior officials. 6We supplemented our interviews with written materials submitted by tribal representatives in response to our request for input. 7In this report, we use the term “tribal representatives” to include tribal officials as well as officials from associations representing tribal and AI/AN interests.


that these VISNs have extensive experience in serving rural populations, including AI/AN veterans.8

To identify other considerations for Congress and agency officials related to providing advance appropriation authority to IHS, we reviewed materials documenting past efforts to obtain advance appropriation authority for IHS—including proposed legislation and documents from advocacy groups such as the National Indian Health Board, as well as our prior work related to the consideration of advance appropriations for VA. For context, we also reviewed our past reports and those from the Congressional Research Service on various aspects of IHS—including budgeting processes. We interviewed IHS officials regarding their processes for budget planning and VA officials regarding their experiences planning for advance appropriations. In addition, we interviewed officials from OMB, the Congressional Research Service, and the Congressional Budget Office.

We conducted this performance audit from August 2017 to September 2018 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

IHS was established within the Public Health Service in 1955 to provide certain health services to members of federally recognized AI/AN tribes, primarily in rural areas on or near reservations. IHS provides services directly through a network of hospitals, clinics, and health stations

8VISN offices provide management and oversight to the medical centers and clinics within their assigned geographic areas. Each VISN office is responsible for allocating funds to facilities, clinics, and programs within its region and coordinating the delivery of health care to veterans.

Background

IHS Health Care System and Tribal Health Care


operated by IHS, and also funds services provided at tribally operated facilities.9

As of October 2017, IHS, tribes, and tribal organizations operated 168 service units, 48 hospitals, and 560 ambulatory care centers—including health centers, school health centers, health stations, and Alaska village clinics.10 See table 1.

Table 1: Numbers of Federally Operated and Tribally Operated Indian Health Service (IHS) Facilities, as of October 2017

Type of facility Federally operated Tribally operated Total Service unitsa 54 114 168 Hospitals 26 22 48 Ambulatory care centers 78 482 560

Source: IHS | GAO-18-652. aIHS service units are administrative entities within a defined geographical area through which services are directly or indirectly provided to eligible Indians. A service unit may contain one or more health care facilities and may cover a number of small reservations, or, conversely, some large reservations may be covered by several service units.

9When services are not available at federally operated or tribally operated facilities, IHS may pay for services provided through external providers through its Purchased/Referred Care program. IHS also provides funding to nonprofit, urban Native American organizations through the Urban Indian Health program to provide health care services to AI/AN people living in urban areas. See 25 U.S.C. § 1653.

Based on the needs of their communities, tribes and tribal organizations can choose to receive health care administered and operated by IHS, or assume responsibility for providing all or some health care services formerly administered and operated by IHS. Under the Indian Self-Determination and Education Assistance Act (ISDEAA), as amended, federally recognized Indian tribes can enter into self-determination contracts or self-governance compacts with the Secretary of HHS to take over administration of IHS programs for Indians previously administered by IHS on their behalf. Specifically, through self-determination contracts, Indian tribes can assume responsibility for administration of programs for the benefit of Indians because of their status as Indians that would otherwise be managed by IHS. Through self-governance compacts, Indian tribes can assume responsibility for administration of IHS programs that are otherwise available for tribes and Indians and also consolidate those programs. Pub. L. No. 93-638, 88 Stat. 2203 (1975) (codified as amended at 25 U.S.C. §§ 5301-5423). The provisions governing self-determination contracts are found in title I (25 U.S.C. §§ 5321-5332). The provisions governing self-governance compacts with IHS are in title V (25 U.S.C. §§ 5381-5399). 10IHS service units are administrative entities within a defined geographical area through which services are directly or indirectly provided to eligible Indians. A service unit may contain one or more health care facilities and may cover a number of small reservations, or, conversely, some large reservations may be covered by several service units.


According to IHS officials, the agency provides services almost exclusively in locations designated as Health Professional Shortage Areas, with most locations identified as extreme shortage areas.11 In addition, IHS data indicate that about 35 percent of certain IHS facilities, including four hospitals, were identified as isolated hardship posts in 2016.12

IHS oversees its health care facilities through a decentralized system of 12 area offices, which are led by area directors; 10 of these 12 IHS areas have federally operated IHS facilities. IHS’s headquarters office is responsible for setting health care policy, helping to ensure the delivery of quality comprehensive health services, and advocating for the health needs and concerns of AI/AN people. The IHS area offices are responsible for distributing funds to the facilities in their areas, monitoring their operation, and providing guidance and technical assistance.

IHS’s estimated budget authority for fiscal year 2018 is over $5.6 billion, an increase of almost $580 million from its enacted budget authority of just over $5 billion in fiscal year 2017.13 IHS has agreements with tribes and tribal organizations by which it transfers a substantial portion of its 11HHS’s Health Resources and Services Administration designates areas identified as having a shortage of primary care physicians as primary care Health Professional Shortage Areas. Primary care is defined as the specialties of family medicine, internal medicine, pediatrics, and obstetrics and gynecology. The agency also designates Health Professional Shortage Areas in dental health and mental health. 12Isolated hardship posts are described as ‘‘unusually difficult, which may present moderate to severe physical hardships for individuals assigned to that geographic location.’’ According to IHS, physical hardships may include crime or violence, pollution, isolation, a harsh climate, scarcity of goods on the local market, and other problems.

In 2016, we reported that residents of tribal lands often lack basic infrastructure, such as water and sewer systems, and telecommunications services. See GAO, Telecommunications: Additional Coordination and Performance Measurement Needed for High-Speed Internet Access Programs on Tribal Lands, GAO-16-222. (Washington, D.C: Jan. 29, 2016.) 13The $5.6 billion estimate for fiscal year 2018 includes the amounts enacted for Indian Health Services and Indian Health Facilities by the Consolidated Appropriations Act, 2018, plus an estimate for Contract Support Costs from the President’s fiscal year 2019 budget justification, for which IHS receives an annual indefinite appropriation of “such sums as may be necessary.” See Pub. L. No. 115-141, div. G, tit. III, 132 Stat. 348, 677-679 (2018). “Budget authority” refers to authority provided by federal law to enter into contracts or other financial obligations that will result in immediate or future expenditures (or outlays) involving federal government funds. Most appropriations are a form of budget authority that also provides the legal authority to make the subsequent payments from the Treasury.



budget authority to tribes and tribal organizations. For example, in 2017, the agency transferred approximately 54 percent of its total budget authority to tribes and tribal organizations to operate part or all of their own health care programs through self-determination contracts and self-governance compacts.

• Self-determination contracts: IHS had 373 self-determination contracts in place with 220 tribes in 2017.

• Self-governance compacts: IHS had 98 self-governance compacts in place—including 124 funding agreements—with 360 tribes in 2017.14 See figure 1 for the percentage of IHS’s total budget authority transferred to tribes in fiscal year 2017.

According to IHS officials, over the last few years an increasing number of tribes have sought to enter into contracts and compacts with IHS to assume responsibility for some or all of their health care programs, and thereby receive funding from IHS.

14A funding agreement is an annual or multi-year agreement that generally identifies the programs and services to be assumed by the tribe, describes the financial terms of the agreement, and sets out the responsibilities of the HHS Secretary.


Figure 1: Transfer of Funds from Indian Health Service (IHS) to Tribes and Tribal Organizations, Fiscal Year 2017

Unless otherwise specified in law, funding included in annual appropriation acts is available for obligation during a single fiscal year, after which it expires. For this reason, the continuation of normal government operations depends upon the enactment each fiscal year of a new appropriations act. Any lapse in appropriations—a funding gap—causes most government functions to shut down.15 To avert a government shutdown, Congress may enact one or more CRs. CRs are spending bills that provide funds to allow agencies to operate during a specified period of time while Congress works to pass an annual appropriations act. Relevant aspects of the federal budget environment include the following.

15There are certain exceptions to this requirement, such as a determination by the head of the agency that continued action is necessary because of an emergency involving the safety of human life or the protection of property.

Federal Budget Environment


Frequency of CRs and shutdowns. In all but 4 of the last 40 fiscal years—including fiscal year 2018—Congress has enacted CRs.16 Since fiscal year 1999, CRs have varied greatly in their number and duration—the number of CRs enacted in each year ranged from 2 to 21, and the duration of CRs has ranged from 1 to 187 days. Regarding lapses in appropriations that resulted in government shutdowns, in January 2018 the government partially shut down for 3 calendar days after the CR in place expired. Other shutdowns have lasted longer—16 calendar days in October 2013 and 21 calendar days in December 1995 through January 1996. We have previously reported on the effects of CRs and shutdowns for federal agencies.17

Budget authority during a CR. CRs provide “such amounts as may be necessary” to maintain operations consistent with the prior fiscal year’s appropriations and authorities. To control spending in this manner, CRs generally prohibit agencies from initiating new activities and projects for which appropriations, funds, or other authorities were not available in the prior fiscal year. They also require agencies to take the most limited funding actions necessary to maintain operations at the prior fiscal year’s level.

Budget authority during a funding gap. Certain federal health care programs have various budget authorities that can allow for continued operations during a funding gap. For example, VA’s advance appropriations authority for its health care programs allows operations to continue after one appropriation expires, using the previously enacted budget for the next year. Although IHS does not have this authority, Congress has enacted longer periods of availability for certain IHS appropriations that would allow the activities they support to continue during a funding gap, assuming the appropriation has not run out. For example, IHS’s appropriation for Indian health facilities remains available

16CRs vary from year to year in their application to federal agencies and activities. We did not determine the number of years in which IHS received funding through CRs during this period. 17See, for example, GAO, Budget Issues: Continuing Resolutions and Other Budget Uncertainties Present Management Challenges, GAO-18-368T (Washington, D.C.: Feb. 6, 2018); GAO, 2013 Government Shutdown: Three Departments Reported Varying Degrees of Impacts on Operations, Grants, and Contracts, GAO-15-86 (Washington, D.C.: Oct. 15, 2014); and GAO, Continuing Resolutions: Uncertainty Limited Management Options and Increased Workload in Selected Agencies, GAO-09-879 (Washington, D.C.: Sept. 24, 2009).

https://www.gao.gov/products/GAO-18-368T




until expended, in contrast to its appropriation for Indian health services, which is generally available for a single fiscal year.18

In this regard, funds for Indian health services that IHS transfers to tribes and tribal organizations during the 1-year period of availability are deemed to be obligated at the time of the award and thereafter remain available to the tribes to operate their own health care programs without fiscal year limitation.19 Thus, to the extent sufficient funding remained available from federal or other sources during a lapse in appropriations, a tribe could continue to operate its own health care programs during a shutdown. To operate IHS’s health care system on an emergency basis during a funding gap, IHS would need to determine what programs and activities qualified for an emergency exception under the law.20

Contingency planning for government shutdowns. Federal agencies must determine what activities and programs they are permitted or required to continue prior to a potential shutdown. This includes designating certain employees as “excepted” employees who would be expected to continue to work during the shutdown and who would be paid upon the enactment of an appropriation.21 Employees who are not “excepted” would be subject to furlough.

Citing funding uncertainty associated with continued use of CRs, AI/AN advocacy groups such as the National Indian Health Board have requested that Congress grant IHS advance appropriation authority; legislation to provide IHS this authority has been introduced more than once. The most recent such legislation, H.R. 235, introduced in January 2017 (not enacted), would have provided IHS with 2-year fiscal budget authority for its Indian health services and Indian health facilities accounts, similar to the authority that VA currently has for its health care

18See, e.g., Pub. L. No. 115-141, 132 Stat. 679. 19See, e.g., Pub. L. No. 115-141, 132 Stat. 677. Because AI/AN tribes and tribal organizations are sovereign entities, they are not subject to government shutdowns, though they could be adversely affected by the resulting funding gaps. 20To invoke this exception, the emergency must involve the safety of human life or protection of property. See 31 U.S.C. 1342. 21Historically, Congress has also permitted the retroactive payment of employees who did not work during a shutdown. See, e.g., Pub. L. No. 115-120, § 2001, 132 Stat. 28, 29 (2018).

Interest in Advance Appropriation Authority for IHS


appropriation accounts. HHS, on behalf of IHS, has not requested that IHS be granted advance appropriation authority during its annual budget submissions to Congress.

VA, through the VHA, operates one of the nation’s largest health care systems, with 171 VA medical centers, more than 1,000 outpatient facilities, and total health care budget authority of about $69 billion in fiscal year 2017. VA provided health care services to about 6.8 million veterans in fiscal year 2017, and the agency forecasts that demand for its services is expected to grow in the coming years.

VA was granted advance appropriation authority for specified medical care accounts in the Veterans Health Administration in 2009.22 Currently, VA’s annual appropriations for health care include advance appropriations that become available in the fiscal year after the fiscal year for which the appropriations act was enacted. Under this authority, VA receives advance appropriations for VHA’s Medical Services, Medical Support and Compliance, Medical Facilities, and Medical Community Care appropriations accounts and is required to provide Congress with detailed estimates of funds needed to provide its health care services for the fiscal year for which advance appropriations are to be provided. According to VA officials, veterans service organizations were the primary advocates who sought advance appropriation authority for VA’s health care program.

In its health care budget proposal each year, VA submits a request for the upcoming fiscal year, as well as an advance appropriation request for the following year. In early 2018, for example, VA submitted a request for fiscal year 2019, as well as a fiscal year 2020 advance appropriation request. According to VA, more than 90 percent of its budget request is developed using an actuarial model that is based in part on VA’s actual health care utilization data from prior years; for example, the 2020

22Pub. L. No. 111-81, 123 Stat. 2137 (2009) (codified as amended at 31 U.S.C. § 1105(a)(37) and 38 U.S.C. § 117). This authority took effect with the budget submissions for fiscal year 2011.

VA’s Advance Appropriation Authority for Health Care


advance appropriation request used fiscal year 2016 data.23 VHA officials said that the agency calculates its advance appropriation request to fund needed care as estimated by its actuarial model, with less funding requested for other expenses (such as non-recurring maintenance) and officials told us this is consistent with direction provided by OMB. OMB officials told us that the amount provided in the advance appropriation is intended to provide VA with some assurances that it will be able to continue health care operations seamlessly across fiscal years.

In the subsequent year (the year during which the advance appropriation can be used), VA may request an adjustment to the amount previously provided through advance appropriations—referred to by agency officials as a “second bite”—an arrangement that is intended by design to help respond to more recent policy changes or significant events. For example, VA requested a “second bite” increase of $2.65 billion for fiscal year 2018, to the $66.4 billion initially provided to its VHA accounts through its advance appropriation. Both OMB and VHA officials said this “second bite” provides an opportunity to make an adjustment to VA’s advance appropriation using updated utilization data. VHA officials told us that changes in policy (such as determining which veterans or what health benefits can be covered) sometimes drive changes from the initial budget request. For example, policy changes can include adding an additional presumptive condition—such as health conditions associated with Agent Orange exposure—resulting in a new health benefit, or a costly new drug treatment, as in the case of the addition to the drug formulary of a new Hepatitis C drug treatment.24

Despite having advance appropriation authority, VA has faced challenges in budget formulation, in addition to the general management and

23We have previously reported on this model—the Enrollee Health Care Projection Model—and other aspects of VA’s health care budget estimation process. See, for example, GAO, Veterans’ Health Care: VA Uses a Projection Model to Develop Most of Its Health Care Budget Estimate to Inform the President’s Budget Request, GAO-11-205 (Washington, D.C.: Jan. 31, 2011); GAO, Veterans’ Health Care Budget: Transparency and Reliability of Some Estimates Supporting President’s Request Could Be Improved, GAO-12-689 (Washington, D.C.: June 11, 2012); GAO, Veterans’ Health Care Budget: Improvements Made, but Additional Actions Needed to Address Problems Related to Estimates Supporting President’s Request, GAO-13-715 (Washington, D.C.: Aug. 8, 2013); and GAO, VA’s Health Care Budget: In Response to a Projected Funding Gap in Fiscal Year 2015, VA Has Made Efforts to Better Manage Future Budgets, GAO-16-584 (Washington, D.C.: June 3, 2016). 24See GAO-16-584.









oversight challenges we cited in adding VA to our High-Risk List in 2015.25 Specifically, we reported in our 2017 update to the High-Risk List that VA faces challenges regarding the reliability, transparency, and consistency of its budget estimates for medical services, as well as weaknesses in tracking obligations for medical services and estimating budgetary needs for future years.26 These challenges were evident in June 2015, when VA requested authority from Congress to move funds from another appropriation account because agency officials projected a fiscal year 2015 funding gap of about $3 billion in its medical services appropriation account.27

IHS officials, tribal representatives, and other stakeholders we spoke with described how budget uncertainty resulting from CRs and government shutdowns can have a variety of effects on the provision of IHS-funded health care services for AI/ANs.28 The following summarizes these effects, along with the views of IHS officials, tribal representatives, and other stakeholders on how advance appropriation authority could mitigate them, and VA’s related experiences:

Provision of health care services. IHS officials said that, in general, most health care services would be expected to continue at IHS-operated facilities during a shutdown, as health care providers would be deemed “excepted” personnel under the agency’s contingency plan.29 However, officials noted some health care procedures could be delayed, as determined on a case-by-case basis at the local level. IHS officials also acknowledged that tribal health care programs may not have access to

25See GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015). 26See GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017). 27In our report examining that instance, we noted that that the majority of the projected funding gap was the result of higher-than-expected obligations for VHA’s program providing care in the community through non-VA providers. See GAO-16-584. 28For this report, leaders from individual AI/AN tribes as well as officials from advocacy organizations that work on behalf of tribes and AI/AN people are referred to, collectively, as tribal representatives. 29According to IHS, staff involved in the safety of human life and protection of property would continue to report for work and provide services under the agency’s contingency plan, consistent with actual occurrences in the past.

Budget Uncertainty Effects on the Provision of IHS-Funded Health Care That Were Cited by Stakeholders






furloughed IHS staff who do not work during a shutdown, such as support staff at local IHS area offices, who may carry out administrative duties on their behalf. For example, tribal representatives told us that during a previous government shutdown, finance employees from the local IHS area offices were furloughed (and thus not permitted to work), which created challenges for tribal health care operations that depended on these IHS employees to process payments and agreements.

IHS officials stated they believe advance appropriations could help ensure continuity of health care services through certainty of funding. IHS officials also said that while lapses in appropriations do not halt patient care, they do create complications—such as the determination of excepted personnel as described above—that could be eliminated by funding provided through advance appropriations. Tribal representatives said the certainty of funding that would come with IHS having advance appropriations would create a sense of stability in tribal health care programs as well.

VA VISN officials we spoke to said having advance appropriations has improved their ability to manage resources for continuity of services and allowed them to avoid the substantial additional planning that occurs before a potential government shutdown when agencies are determining which providers and staff would be deemed excepted. According to the VISN officials, knowing that funding is coming—as opposed to having less certainty—would allow an agency to plan and prioritize its services more efficiently.

Health care program planning. Tribal representatives said operating health care programs with short-term funding provided through a series of CRs—and facing potential government shutdowns—rather than a full year’s apportionment hinders their ability to plan for new programs and for improvements that need to be carried out across budget years or that require large up-front investments, such as an electronic medical records system or other significant information technology purchases. Tribal representatives said there are often plans that they have to set aside because they don’t have enough funds to start a project during a CR, and—if there are multiple CRs—there is not enough time left in the budget year to start bigger projects once an annual appropriation is passed. Tribal representatives also told us that they believe that advance appropriations would help tribal health care programs plan for current and future needs. For example, one tribal official told us advance appropriations would allow tribes to plan for long-term health initiatives. The official’s specific tribe has a gestational diabetes program in


conjunction with a local university that the tribe could plan to take full responsibility for if they had more funding stability.30

VA VISN officials we interviewed provided several examples of how they believe advance appropriations facilitate their planning. For example, VISN officials told us advance appropriations allow them to plan strategically for equipment purchases: if they need to buy a CT scanner, they would plan to do site preparation in one year—for example, reconfiguring the space for the new equipment by moving walls, electrical rewiring, etc.—and buy the scanner in the next year. With advance appropriations, they know they are going to have funds for an expensive equipment purchase available the next year; without an advance appropriation, they would not be sure, and could spend funds on preparation and then ultimately not have the funds to make the equipment purchase. These officials also said having advance appropriations gave them confidence in making current plans to provide the new shingles vaccine for their over-50 population in 2019, including the ability to secure an adequate supply of the vaccine from the manufacturer.

Provider recruitment and retention. IHS officials and tribal representatives said existing challenges related to their recruitment and retention of health care providers—many of which are related to the rural and remote locations of many of IHS’s facilities—are exacerbated by funding uncertainty resulting from CRs or potential government shutdowns.31 IHS officials said CRs and government shutdowns can disrupt recruitment activities such as IHS marketing efforts, job advertisements, application review, interviews, and candidate site visits. Additionally, when recruiting health care providers, IHS officials said CRs and potential government shutdowns create doubt about the stability of employment at IHS amongst potential candidates, which may result in reduced numbers of candidates or withdrawals from candidates during the pre-employment process. IHS officials said that many providers in rural and remote locations are the sole source of income for their families, and the potential for delays in pay resulting from a government shutdown

30According to the Centers for Disease Control and Prevention, gestational diabetes is a type of diabetes that is first seen in a pregnant woman who did not have diabetes before she was pregnant. 31We have reported on challenges IHS faces in recruiting and retaining clinical staff, including the rural location of many IHS facilities and insufficient housing for providers. See GAO, Indian Health Service: Agency Faces Ongoing Challenges Filling Provider Vacancies, GAO-18-580 (Washington, D.C.: Aug. 15, 2018).



can serve as a disincentive for employees considering public service in critical shortage areas that do not offer adequate spousal employment opportunities. Tribal representatives said CRs create challenges for tribes in funding planned pay increases—such as cost-of-living adjustments—for health care staff at their facilities, and they may, as a result, defer increases.

IHS officials and tribal representatives stated they believe advance appropriations could mitigate these challenges. For example, IHS officials said that with advance appropriations, recruitment and outreach activities could continue without disruption, and selected candidates could be brought on board as scheduled. One tribal representative stated that advance appropriations could help with recruitment by providing perceived job stability that is similar to VA or the private sector.

According to VA VISN officials, the agency’s experience with advance appropriation authority suggests that advance appropriations can facilitate physician recruitment, including hiring. If, for example, they were far along in the hiring process at the end of a fiscal year, but could not finalize the hire before the end of the year, having advance appropriations for the next fiscal year provides the certainty that they will be able to make the hire in the new fiscal year.

Commercial contracts and vendor negotiations. IHS officials and tribal representatives said budget uncertainty can lead to vendor reluctance to provide services to IHS and tribally operated facilities. IHS officials said they have heard from vendors—who are typically Indian- or veteran-owned small businesses in the communities being served by IHS—that they lose trust in IHS and federally-funded tribal health care programs when they are affected by budget uncertainty. One tribal organization told us delays in receiving full funding because of CRs has inhibited its ability to pay invoices for pharmaceuticals in a timely manner, which has harmed its relationship with its vendors.

VISN officials told us that advance appropriations can provide an element of stability to agency funding that may serve to reassure potential vendors.32 According to VISN officials, vendors can be hard to find in

32We previously reported that agencies have delayed executing contracts while under a CR, which could increase costs. See GAO, Budget Issues: Continuing Resolutions and Other Budget Uncertainties Present Management Challenges, GAO-18-368T (Washington, D.C.: Feb. 6, 2018).




remote and rural areas, and their perception of funding certainty can play a role in encouraging their participation as government contractors. As contracting with the federal government can be burdensome, particularly for smaller vendors, VISN officials said, any measures—such as advance appropriations—that could enhance the stability of agency contracting could make these vendors more likely to participate in government contracting.

Administrative burden and costs. IHS officials and tribal representatives said the agency and tribes incur additional administrative burden and costs when the government is funded through multiple CRs, due to the high proportion of IHS funding that is transferred to tribes through contracts and compacts.33 Specifically, IHS officials said there is an additional administrative burden generated by each CR that results in the distribution of funds to tribes.34 For each CR period, IHS headquarters staff generate proportional funding allotments, which they provide to individual area offices, which then also conduct processing activities to generate payments from these allotments to the tribes in their areas.35 As part of this process, IHS officials said they modify hundreds of tribal contracts and make amendments to funding agreements associated with tribal compacts, and those efforts represent a significant administrative burden for IHS staff. Tribal representatives also described administrative burden associated with CRs. As one representative of a group representing several tribes told us, each CR requires the same processing and manpower for each partial payment as for a full apportionment, and moreover, CRs require tracking and reconciliation that is not necessary for a single, full apportionment. IHS officials and tribal representatives noted that time and money spent on these

33We previously reported that agency officials said that managing within the constraints of a CR had created additional work, which potentially reduced productivity. In particular, shorter and more numerous CRs can lead to more repetitive work, including entering into shorter-term contracts or grants multiple times to reflect the duration of the CR. See GAO-18-386T. 34Contracting tribes receive payments from IHS on a mutually-determined schedule that may vary (e.g., lump sum annual payment, quarterly payments, etc.), and compacting tribes generally receive annual lump sum payments. If tribal payments are due during a CR, then IHS makes payments in proportion to the term of the CR. 35IHS officials told us that it is not administratively feasible to distribute funds through the same process when Congress passes very short-term CRs (such as those lasting for a period of only 1 to 3 days). In such instances, IHS would generally not distribute the funds for such a brief period, but instead combine them with the next apportionment, assuming the next apportionment is for a longer CR or a full budget.



additional administrative activities detract from other priorities, including patient care.

IHS officials said that advance appropriations would reduce this administrative burden, and added that having advance appropriations would allow for more efficiency in processing payments to tribes. IHS officials suggested that the agency would have to do less administrative work overall, because currently, under a single year appropriation (with recurrent CRs), they may modify or amend agreements 7 or 8 times within a fiscal year. Although acknowledging that advance appropriation authority would entail the additional burden of preparing budget requests for more than one fiscal year, they expect this administrative burden to be less than those under repeated CRs.

Financial effects on tribes. According to tribal representatives we spoke with, funding uncertainty from recurring CRs and from government shutdowns has led to particular adverse financial effects on tribes that operate their own health care programs with funding from IHS. For example, according to tribal representatives,

• Funding uncertainty surrounding a CR results in more expensive commercial loans (with higher interest rates) to finance construction of new health care facilities. Specifically, a tribal representative said the uncertainty of the availability of funds due to a CR resulted in a downgrading of the tribe’s credit rating, and hence higher interest rates, as it was planning a clinic expansion.

• During a government shutdown, some tribes must redistribute funds from other budget categories to replace health care funding from IHS in order to continue providing health care services. Some tribes have economic development activities that provide additional funding and facilitate this redistribution, but others do not. For example, one tribal organization said that during the 2013 government shutdown, it had to take out loans and maintain a line of credit in order to pay for services and make payroll. Subsequently, that tribal organization had to pay interest on those loans, causing greater financial hardship.

• Tribes attempt to mitigate the challenge of not knowing their final annual payment from IHS under recurrent CRs by keeping extra funds in reserve for emergencies, which limits the remaining funds available for providing health care services.

• Short-term funding under CRs or delayed funding after a lapse in appropriations can limit the ability of tribes and tribal organizations to


invest funds from IHS and generate interest that can be reinvested in tribal health care programs.

• CRs have affected the ability of tribes to reduce costs by planning for bulk purchases at favorable rates. For example, some tribes in Alaska prefer to make bulk purchases of heating oil during “barge season’’—when waterways are still navigable and not frozen. If they do not have enough money for a bulk purchase because of a CR’s limited funding, they must purchase fuel in smaller quantities, which is ultimately significantly more expensive. Tribal representatives told us one beneficial financial effect of advance appropriations for tribes could be providing opportunities for longer term contracts with vendors, which could result in cost savings that could be used for tribal health care programs.

We identified three types of considerations for policymakers related to providing advanced appropriation authority to IHS—operational, congressional flexibility, and agency capacity and leadership considerations. We identified these considerations based on a review of our 2009 testimony that examined considerations for granting VA advance appropriation authority, in which we identified key questions that would be applicable to any agency being granted such authority, and our interviews with VA, IHS, and other officials.36 In our 2009 testimony, we noted that proposals to change the availability of the appropriations for VA deserved careful scrutiny, given the challenges the agency faces in formulating its health care budget and the changing nature of health care.37 Similar consideration would apply to IHS.

Operational considerations. If Congress were to grant IHS advance appropriation authority, it would need to make operational decisions regarding what amount of IHS funding would be provided in advance appropriations, with input from OMB and IHS as appropriate. Specifically, Congress could consider the following questions:

(1) What proportion of IHS’s estimated budget would be provided in the advance appropriation—the full amount, or less (as is the case for

36See GAO, VA Health Care: Challenges in Budget Formulation and Issues Surrounding the Proposal for Advance Appropriations, GAO-09-664T (Washington, D.C.: Apr. 29, 2009). 37See GAO-09-664T.

Considerations for Policymakers Related to Providing Advance Appropriation Authority to IHS




VA)? Which appropriations accounts would be included? Further, would funds intended for transfer to tribes be handled differently?

(2) Under what conditions, if any, would there be changes to funding provided through advance appropriations during the next budget cycle? For example, would Congress expect to adjust the advance appropriation amount through a “second bite,” as is the case with VA?

Congressional flexibility considerations. We reported in 2009 that consideration of any proposal to change the availability of the appropriations VA receives for health care should take into account the impact of any change on congressional flexibility and oversight. These same considerations hold merit regarding potential changes to the appropriation status of any federal agency, including IHS. Specifically, advance appropriation authority reduces flexibility for congressional appropriators, because it reduces what is left for the overall budget for the rest of the government—meaning the total available for appropriations for a budget year is reduced by the amount of advance appropriations for that year, when budgets have caps.

Agency capacity and leadership considerations. IHS officials told us they believe the agency’s current budget planning processes would be adequate for estimating advance appropriation budget requests, because IHS begins planning for its budget request 3 years in advance. Officials added that IHS plans its budget so far in advance to have sufficient time to work with tribes in formulating recommendations for its budget request. IHS officials said that a downside to planning so far in advance is that they do not necessarily have the most current information while formulating the budget request. In addition, we noted prior to VA receiving advance appropriation authority that advance appropriation authority could potentially exacerbate existing challenges when developing or managing a budget, generally, due in part to the higher risk of uncertainty when developing estimates that are an additional 12 months out from the actual budget year (e.g., 30 months out instead of 18 months).38

We raised certain capacity and leadership concerns based on our previous work when we added IHS to our High-Risk List in 2017.39 Further, in June 2018, we found that while IHS had taken some actions to 38See GAO-09-664T. 39See GAO-17-317. In addition to IHS, we added other federal programs servicing tribes and their members to our High-Risk List, including education and energy programs run by the Department of the Interior.




partially address these concerns, additional progress was needed to fully address these management weaknesses.40 For example, IHS still does not have permanent leadership—including a Director of IHS—which is necessary for the agency to demonstrate its commitment to improvement. Additionally, while the agency has made some progress in demonstrating it has the capacity and resources necessary to address the program risks we identified in our reports, there are still vacancies in several key positions, including in the Office of Finance and Accounting. While not directly related to consideration of advance appropriations, IHS’s high-risk designation and continuing challenges in mitigating the deficiencies in its program point to questions about the agency’s capacity to implement such a change to its budget formulation process.

We provided a draft of this report to HHS and VA for review and comment. HHS did not have any comments. We received general comments from VA that are reprinted in appendix I.

We also provided relevant draft portions of this report to NIHB, which represents tribal and AI/AN interests. NIHB provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretaries of the Department of Health and Human Services and the Department of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or [email protected]. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page

40See GAO, High Risk: Agencies Need to Continue Efforts to Address Management Weaknesses of Federal Programs Serving Indian Tribes, GAO-18-616T (Washington, D.C.: June 13, 2018).

Agency Comments and Third-Party Views

http://www.gao.gov/




of this report. GAO staff who made key contributions to this report are listed in appendix II.

Jessica Farb Director, Health Care

Appendix I: Comments from the Department of Veterans Affairs

Page 23 GAO-18-652 Advance Appropriation Authority Considerations for IHS


Appendix II: GAO Contact and Staff Acknowledgments


Jessica Farb, (202) 512-7114 or [email protected]

In addition to the contact named above, Kathleen M. King (Director), Karen Doran (Assistant Director), Julie T. Stewart (Analyst-in-Charge), Kristen J. Anderson, and Leonard S. Brown made key contributions to this report. Also contributing were Sam Amrhein, George Bogart, Christine Davis, and Vikki Porter.

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

(102264)


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