Senate Committee on Indian Affairs Holds Hearing on Access to Water in Native Communities

On September 27th, The Senate Indian Affairs Committee held a hearing entitled “Water as a Trust Resource: Examining Access in Native Communities.”. The witnesses were Bryan Newland, Assistant Interior Secretary for Indian Affairs; Benjamin Smith, Deputy Director of IHS; Crystalyne Curley, Navajo Nation Council Speaker; Valerie Nurr’araaluk Davidson, Alaska Native Tribal Health Consortium (ANTHC) President; Kali Watson, Department of Hawaiian Homelands Chairman; and Heather Tanana, Universal Access to Clean Water for Tribal Communities project Initiative Lead.  

Committee Chairman, Brian Schatz, called the oversight hearing to order, stating in his opening statement that “native households are 19 times more likely than non-Native households to lack indoor plumbing.” The Senate Indian Affairs Committee, Energy and Natural Resources Committee, and Environment and Public Works Committee coordinated hearing efforts to address the ongoing challenges communities everywhere are facing when it comes to clean water access.  

During COVID-19, the consistent health and safety inadequacies that American Indians and Alaskan Natives (AI/ANs) experience were brought to light. Congress addressed water insecurity in Native communities through the Bipartisan Infrastructure Law and the Inflation Reduction Act. $3.5 billion went to IHS for critical water and sanitation infrastructure while $2.5 billion was used to fund existing water rights settlements and drought mitigation in AI/AN communities. Vice Chair Murkowski acknowledged in her remarks the vast amount of existing grants across several agencies that could be used for AI/AN communities but are not currently. Additionally, the Senator discussed the importance of including every committee related to this broad issue, including but not limited to the Agriculture Committee.  

Ms. Davidson was asked specifically about the data currently available regarding operation and management needs for the Alaska region, and whether AI/AN communities could wait until IHS completes its own study and disburse their findings, which is unlikely to occur until FY 2027. Davidson responded by discussing the extensive data and feedback that ANTHC has already provided IHS but has not seen the light of day. Stating further that “from our perspective, we can either spend our limited time and resources to perfect another study and make that study perfect, or we can invest in what we already know works. And the data that ANTHC has previously provided is not an estimate. These are from real systems that exist in Alaska today. And so, we believe that the best investment would be to use those dollars to be able to fund a pilot project that would be able to extend and provide real information that the IHS could then build upon. And so, really, we have a choice to make. We can either fund another study or we can make an investment…” 

To view a video of the hearing and read witness testimony, visit Senate Committee on Indian Affairs website. The National Indian Health Board is launching a Technical Assistance Center in conjunction with the Environmental Protection Agency’s Thriving Communities Network to connect Tribes with existing resources and opportunities around environmental justice issues, including water sanitation. The Technical Assistance Center will launch at the end of 2023.  


NIHB Hosts Tribal Health Equity Data Symposium

On September 25 and 26, the National Indian Health Board (NIHB) hosted the Tribal Health Equity Data Symposium in Washington, DC. Over the two-day event, speakers, panels, and facilitated sessions covered a range of topics, including measuring health equity with an Indigenous lens, culturally relevant data collection methods, promising practices in improving the collection of race and ethnicity data, and challenges and opportunities in Tribal access to data held by federal and state agencies. These discussions concluded that future directions for health equity work should honor the importance of good stewardship of American Indian/Alaska Native (AI/AN) data, Tribal access to datasets held by federal and state agencies, and furthering Indigenous perspectives in health equity and health research.  

NIHB Chairperson and Alaska Area Representative, Chief William Smith (Valdez Native Tribe), delivered the opening remarks, noting, “Data is a critical component of the path to health equity.” Keynote speakers Abigail Echo-Hawk (Pawnee) and Dr. Myra Parker (Mandan-Hidatsa-Cree) began the discussion on what a culturally driven approach to measuring health equity can look like with their presentations on “Decolonizing Data: Restoring Culture, Building Beauty,” and “Indigenizing Data: Mapping a Path Toward Health Equity,” respectively. Dr. Donald Warne (Oglala Lakota) continued the conversation on day two with his keynote titled, “Measuring Health Equity with a Tribal Lens: Leaning on Strengths, Sovereignty, and Indigenous Identity.” 

Professionals from across the spectrum of health data joined the symposium as guest speakers. Centers of Disease Control and Prevention (CDC) Senior Health Scientist, Delight Satter (Confederated Tribes of Grand Ronde), and Indian Health Service (IHS) Officer and Director of the Office of Information Technology, Mitchell Thornbrugh (Muscogee Creek Nation), and Meagan Khau, Director, Data Analytics & Research Group within the Centers for Medicare and Medicaid Services’ Office of Minority Health represented federal partners in Tribal data work. Sujata Joshi of the Northwest Portland Area Indian Health Board, and Rachael DeMarce (Little Shell Tribe of Chippewa Indians and Blackfeet Nation) and Ben Han of Alaska Native Tribal Health Consortium represented regional Tribal organizations and their ideas for future work with health equity and data. Other guest speakers included Native researchers and NIHB subject matter experts. 

Concluding sentiments from the symposium conveyed the importance of using data in advocacy efforts. The final presentation of the event, “Putting it into Practice: Story as Data and Data as Story,” ended with a call to widely share stories of Tribal data and its impact on health equity work.  

The Tribal Health Equity Data Symposium contributes to NIHB’s ongoing advocacy for improved data practices to protect Tribal sovereignty and advance health equity, in laws, policies, and private industry standards. NIHB advances Tribal data priorities by providing technical assistance and policy analysis for Tribal leaders as they participate in Tribal consultations and Tribal Advisory Committee meetings with government agencies like the Office of Management and Budget, CDC, National Institutes of Health, IHS, and others. In addition, NIHB is leading several data projects to make improvements in specific areas, like Maternal Mortality Review Committees and Electronic Case Reporting. 

Videos, slides, poster presentations, and other resources from the symposium will be posted on NIHB’s website here. The full report on the event is expected to be published in January 2024. If you would like to learn more about NIHB’s work, you can read NIHB’s Health Equity in Indian Country Report here.   



CMS Takes Action to Make Care for Older Adults & People with Disabilities More Affordable and More Accessible

Last week, the Centers for Medicare and Medicaid Services (CMS) issued its final rule updating Medicaid regulations that aim to make it easier for low-income older adults and people with disabilities to get help with their Medicare costs. The new final rule on “Streamlining Medicare Savings Program Eligibility Determination and Enrollment” simplifies the burdensome processes for applying to, and verifying income and assets for, the Medicare Savings Programs (MSPs) across states.  

The agency notes that only about half of the people eligible for MSPs are currently enrolled, so reducing the paperwork burden and streamlining the enrollment rules will help many older adults get the financial help that MSPs offer. The changes are designed to  help the millions of people who currently have MSPs retain coverage during redeterminations and renewals, especially our Elders who we have seen dropped from coverage. 

Under the final rule, many recipients of supplemental security income (SSI) will now be enrolled automatically into the most comprehensive form of MSP coverage: the Qualified Medicare Beneficiary (QMB) eligibility group, which covers Medicare premiums and cost sharing.  According to CMS, this should ease the burden on MSP applicants and enrollees to provide documentation of income and assets and should ensure QMB enrollment for people with Part A premiums is effective when Medicare entitlement begins.  

Learn more about the new rule in CMS’s press release. 

Centers for Disease Control and Prevention (CDC) Tribal Advisory Committee Meets and Visits Local Tribal Health Center

Centers for Disease Control and Prevention (CDC) Tribal Advisory Committee Meets and Visits Local Tribal Health Center 

The Centers for Disease Control and Prevention (CDC) Tribal Advisory Committee (TAC) meeting was hosted by the Oneida Nation in Green Bay, Wisconsin on September 6-7. The CDC Tribal Advisory Committee advises the CDC and the CDC Director on policy and programmatic efforts that affect American Indian and Alaska Native (AI/AN) health. The TAC works with CDC leadership to exchange information about public health issues, provide guidance, and ensure that AI/ANs and Tribes are included in all public health efforts. National Indian Health Board staff attended the CDC TAC Meeting and provided technical assistance to Tribal leaders.  


Topics covered during the meeting included CDC budget, Indigenous knowledge, improving Tribal access to public health data with electronic case reporting, evaluation, and maternal mortality prevention, among others.  Tribal leaders serving on the TAC emphasized the importance of equitable funding for public health in Indian Country. TAC members also requested that the CDC provide more transparency about which non-Tribal entities have access to Tribal public health data and for which purposes. Another issue raised was the absence of CDC Director Mandy Cohen from the TAC meeting, observing that President Biden has stated that it should be a priority of federal agencies to proactively engage with Tribal leaders and Tribal advisory committees, and that requires participation from top agency leadership. Other discussions included the vital role of Indigenous knowledge and culture in health. As explained by the TAC Chair and Deputy Principal Chief Bryan Warner of the Cherokee Nation, “What we’re finding is that there’s healing in our language.” 


CDC officials provided updates to the TAC from different divisions. CDC Behavioral Scientist and Evaluator Stacey Ann Willocks shared that their Indigenous Evaluation Toolkit is in the process of being adapted for use across all types of public health programs. CDC Chief Evaluation Officer of the Office of Policy, Performance, and Evaluation, Daniel Kidder, also shared that the CDC is working on a refresh of the CDC framework for evaluation that includes cultural competency considerations and health equity.  


The TAC meeting included a site visit to the Oneida Community Health Center. Oneida Community Health Center is part of the Oneida Nation’s Comprehensive Health Division and strives to provide “the highest level of quality, culturally sensitive, holistic, and preventive health care” to Oneida citizens. Hosts of the health center visit shared the importance of patient-centered, culturally-informed design, noting that the health center building incorporates elements of traditional longhouse design and many Oneida design motifs. 


The CDC TAC noted the many open seats on the committee and the need for more Tribal representatives and alternates. The CDC TAC consists of 17 representatives: 1 delegate (and 1 alternate) from a federally recognized Tribe from each of the 12 Indian Health Service Areas, and 1 delegate (and 1 alternate) from 5 National At-Large Tribal Member (NALM) positions. If you are interested in joining the TAC and helping to ensure the federal government upholds its trust responsibility and honors the government-to-government relationship, NIHB can offer support. If you have questions on the process or want assistance in the nomination process, please contact Garrett Lankford, NIHB Federal Relations Analyst, at [email protected] or 202-996-4302.  

Tribal Leaders Diabetes Committee Meets as Special Diabetes Program for Indians Requires Reauthorization

From September 19 to September 20, the Tribal Leaders Diabetes Committee (TLDC) held its quarterly meeting in Washington DC. The TLDC is a Tribal advisory committee that provides input to the Indian Health Service (IHS) on policies related to diabetes and the Special Diabetes Program for Indians (SDPI). This meeting was especially important, given that SDPI will expire on September 30, 2023. SDPI reauthorization is necessary to continue SDPI after the end of 2023.  

National Indian Health Board (NIHB) Congressional Relations Coordinator, Taylor Barrett, shared a legislative update at the meeting capturing the rapidly evolving congressional environment. The week of the TLDC meeting, a government shutdown and SDPI reauthorization by December both appeared likely. 

IHS Director, Roselyn Tso, joined the TLDC to provide updates on current IHS projects and to discuss details on the process for SDPI’s distribution. During this time, TLDC members raised their interest in allowing SDPI programs to receive funds through 638 contracts and compacts and the various budget impacts and data sharing logistics of this proposed change.  

Other topics of discussion and presentations included the Federal Advisory Committee Act and Unfunded Mandates Reform Act, the IHS Produce Prescription Pilot Program, and the National Diabetes Prevention Program. Alaska, Albuquerque, and Bemidji areas shared area reports detailing the successes and challenges of select SDPI programs. IHS also shared at the meeting that it has a plan to announce additional SDPI funding soon.  

Following the TLDC meeting, committee members, acting in their capacity of as Tribal leaders, had multiple meetings with Congress to provide education on the SDPI program and its successes. NIHB facilitated meetings with five Senate and four House Offices, including a meeting directly with Congressman Salud Carbajal (CA-24).  

For more information on how to take action and advocate for the reauthorization of SDPI, you can access a sample letter to send to Congress on SDPI renewal here and view sample talking points here.  Despite widespread support, legislation to renew SDPI has not passed either the House of Representatives or the Senate. It will expire on September 30, 2023 unless Congress acts.  


STAC and DTAC Host Their Fourth Quarter Meetings in Rapid City, South Dakota

Last month, Tribal leaders and federal partners met in Rapid City, SD, to attend the Direct Service Tribal Advisory Committee (DSTAC) and Health and Human Services Secretary’s Tribal Advisory Committee (HHS STAC) 4th quarter meetings. Tribal leaders on STAC and DSTAC from all 12 IHS areas met with Health and Human Services (HHS) Secretary Xavier Becerra, IHS Director Roselyn Tso, and the principal leadership of HHS operating divisions to discuss Tribal priorities for HHS.

At the meeting, after two years of collaboration and consultation with Tribes, Secretary Becerra signed the updated HHS Tribal consultation policy. During the meetings, NIHB staff also had the opportunity to visit the Pine Ridge Reservation, home of the Ogalala Sioux Tribe. Attendees visited the Thunder Valley Community Development Complex and the Wounded Knee School district and learned about local initiatives funded by HHS operating divisions that advance health equity and well-being for Lakota people. Attendees also visited the Wounded Knee Massacre Memorial and toured the Pine Ridge Hospital, a 45-bed facility serving a Lakota Indian population of more than 17,000 and the largest hospital in the Great Plains Area. Site visits like these share valuable experiences and stories that inform the NIHB Government Relations team’s work with partner organizations, technical assistance to Tribal leaders, and advocacy for Indian Country.

Tribal Advisory Committees (TACs), like STAC and DSTAC, are advisory bodies consisting of members of American Indian and Alaska Native (AI/AN) Tribes. TACs provide advice, recommendations, and input on policy and program issues with implications for AI/AN healthcare providers and patients across various operating divisions within HHS. TACs are powerful tools to help the federal government collaborate with Tribes and Tribal communities throughout the US and serve as a vehicle at the beginning of the policy formulation process.

NIHB provides support and policy expertise to TACs, and the organization also helps to nominate and place Tribal leaders on TACs. If you are interested in joining and serving on a TAC, you can email Garrett Lankford at [email protected] for more information. You can also click this link for additional information on TACs.

CMCS Informational Bulletin on Four Walls: Grace Period Extended through February 2025

On September 8, Deputy Administrator and Director of the Center for Medicaid and CHIP Services (CMCS), Dan Tsai, published a CMCS informational bulletin (CIB) announcing the further extension of the “four walls” grace period to February 2025. CMS’s current interpretation of the clinic benefit regulations provided in 42 C.F.R. § 440.90 prohibits Medicaid reimbursement for “clinic services” provided outside of the four walls of a facility. Without this grace period, the current interpretation prevents access to care, including home visits, telehealth, and other necessary outpatient services. The bulletin clarifies that this grace period extension applies to Tribal, IHS-operated, and state facilities.    

The CIB notes the period of unwinding after the COVID-19 public health emergency has increased workloads and potentially complicated a Tribe’s decision about the Federally Qualified Health Center (FQHC) option presented by CMCS in a CIB published on January 15, 2021. CMCS suggested pursuing FQHC status for facilities as a potential solution because the CMS clinic benefit regulations which create the “four walls” rule do not apply to FQHCs. The bulletin also echoed what Mr. Tsai shared at the last TTAG Face-to-Face meeting in July: this extension is meant to signal the agency’s intention to resolve the four walls issue and to give CMS time to work through the complex regulatory impact of such a change and the statutory barriers that exist. 

“The Indian Health Service is Here to Stay” – IHS Tribal Self-Governance Advisory Committee Convenes Fall Meeting

On August 30th and August 31st, the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) held an in-person meeting in Washington, DC. The TSGAC provides an opportunity for Tribal leaders and federal officials to engage on IHS programs, services, and issues with particular focus on strengthening Tribal self-governance. This most recent meeting featured updates and discussions about Fiscal Year 2024 appropriations, IHS’s unobligated funds, and IHS’s standing on the Government Accountability Office’s High Risk List   

National Indian Health Board (NIHB) Director of Budget and Appropriations, Tyler Scribner, presented an analysis of the 2024 Fiscal Year Appropriations legislative outlook. Mr. Scribner discussed the significance of Continuing Resolutions given that the FY 2023 will end on September 30th. Passing a Continuing Resolution would keep the government funded beyond September 30. Fortunately, most of the IHS budget has IHS advance appropriations, so even if a government shutdown were to occur, these functions of IHS would continue.  

IHS Director of Office of Finance and Accounting, Jillian Curtis, IHS’ unobligated funds. IHS shared that the Purchased/Referred Care (PRC) Program makes up 16% of prior year unobligated balances. Ms. Curtis shared that part of the root cause for these unobligated balances is the suspension of services during the COVID-19 public health emergency, which lessened referral activity. Congress is concerned about this issue as well, especially as they look to make funding decisions for FY 2024. To manage these unobligated funds, IHS has developed a Status of Funds Dashboard which displays funding balances in real time. IHS is also currently both leading an agency-wide effort to identify causes and solutions for unobligated funds and reviewing unobligated funds by location to update plans for their management. IHS Deputy Director Benjamin Smith also shared that IHS will soon announce Tribal consultation to revise the medical priorities list, which impacts PRC eligibility, to strengthen IHS’ focus on prevention services.  

The importance of creating a path off the Government Accountability Office’s (GAO) High Risk List was another topic of discussion at the latest TSGAC meeting. The High Risk Report is compiled by the GAO at the start of every Congress to address shortcomings from agencies that “provide critical services.” The GAO first included IHS in its High Risk Report in 2017.  Executive Director of Self-Governance Communication and Education Tribal Consortium (SGCETC), Jay Spaan, shared updates from the GAO Tribal and Indigenous Advisory Committee (TIAC) on the High Risk List. Spaan shared that removing IHS from the List is a priority for the TIAC, and it will also be the focus of multiple upcoming meetings for the committee. The TSGAC highlighted that the GAO understanding Tribal sovereignty is essential as TIAC efforts continue.  

The meeting closed with reflections from Smith that the close of this fiscal year is going to be “extremely busy” and communicated the IHS leadership’s willingness and enthusiasm to work towards “meaningful results because we know the Indian Health Service is here to stay.” 

Congressional Items Left to Do This Week

As of last week, the House and Senate are both back on Capitol Hill. Speaker Kevin McCarthy planned for House lawmakers to pass the defense funding bill, but the votes were not there. Now, the plan is to pass a continuing resolution instead. On September 12th, the Speaker announced an impeachment inquiry into President Joe Biden. The inquiry will be conducted by the House Judiciary Committee, Ways and Means Committee, and Oversight Committee. The Senate was making progress on the minibus, but the unanimous consent request to package the three bills together was blocked, meaning the bills may be considered individually rather than together. Both chambers left last week without accomplishing much, let’s hope this week is different. 

New PRC Area Designations in Washington State and the Mid-Atlantic Region

In August, the Indian Health Service (IHS) released three notices proposing to expand the Purchased/Referred Care Delivery Areas (PRCDAs) for seven Mid-Atlantic Tribes,  the Confederated Tribes of Grand Ronde, and the Spokane Tribe of Indians. Each of these Delivery Area expansions increases the number of Tribal members who are eligible for PRC payment of services but does not increase the funding for these PRC programs.  

The Purchased/Referred Care (PRC) Program can pay for medical or dental services delivered outside of IHS and Tribal health facilities if a Tribal member can meet requirements relating to residency, notification, medical priority, and alternate resources. PRC is an impactful program because it can help fill gaps when Tribal members have difficulty accessing direct care from IHS and Tribal facilities that are far away, unable to offer necessary emergency or specialty care, or are over their capacity. 

Generally, to be eligible for PRC, a Tribal member must live in a county that contains or shares a border with a reservation—though there are exceptions. After consultation, the Secretary of Health and Human Services can modify the boundaries of PRCDAs. New PRCDA designations must take into account factors, including how many Tribal members would be newly included or excluded and impacts on funding.  

In the Mid-Atlantic region proposal, the seven separate PRCDAs for the Pamunkey Indian Tribe, Chickahominy Indian Tribe, Chickahominy Indian Tribe—Eastern Division, Upper Mattaponi Tribe, Rappahannock Tribe, Inc., Monacan Indian Nation, and Nansemond Indian Tribe would combine to create one collective PRCDA. IHS estimates that this redesignation will make a further 1006 Tribal members eligible for PRC. The proposal for the Confederated Tribes of Grande Ronde would expand the PRCDA to now include Clackamas County, which is estimated to grant eligibility to 179 more Tribal members. For the Spokane Tribe of Indians, the revised PRCDA would add Spokane County and Whitman County, making approximately 480 Tribal members newly eligible for PRC.  

It is important to note that while these redesignations make more people eligible, none of these changes come with an increase in funding for the PRC programs. There are limits on the capacities of PRC in part because IHS is chronically underfunded and already serves as the payor of last resort to help make up for this shortage of funding. To this end, PRC requires people to seek funding from alternative resources such as Medicare, Medicaid, or other insurance options to be eligible for payment of services. 

Comments on these PRCDA expansions are open until August 31 for the Mid-Atlantic Tribes, September 6 for the Confederated Tribes of Grande Ronde, and September 8 for the Spokane Tribe of Indians. Commenting on these notices from IHS is an opportunity to exercise Tribal sovereignty and engage in the management of health systems in Tribal communities. See the Federal Register notices linked above for more information on how to comment.