NIHB’s Analysis of 2024 Federal Spending Negotiations

Posted on August 24, 2023 by Erisel Cruz

The House and Senate have each released their annual appropriations bills for the Indian Health Service (IHS) and other HHS accounts. The outlook on spending for FY 2024 is a tightening belt, with very low chances of breakout changes, including the addition of more funding for IHS. This fall, the National Indian Health Board (NIHB) will be advocating to oppose IHS rescissions, expand advance appropriations to all IHS accounts, and reclassify CSC and 105(l) mandatory payments as mandatory spending. Outreach to Congressional members back in their district during August recess and maintaining pressure into the fall will be critical to maximizing Tribal program investment.

Overall, the change in party control of the House of Representatives has ushered in less spending on domestic programs, including U.S./Tribal relations, which corelates with lower spending outcomes in both the House and Senate appropriations bills. While each proposal is more in line with projections of past enacted amounts, the House and Senate take fundamentally different paths to achieve FY24 spending. Under detailed scrutiny, most of the annual increase is carried by just a handful of accounts – a systemic and repetitive practice that leaves some IHS programs losing purchasing power year after year, setting back an already chronically underfunded treaty and trust obligation to Tribal nations.

Read NIHB’s full analysis.

Reauthorization of the Special Diabetes Program for Indians

Posted on August 24, 2023 by Erisel Cruz

The Special Diabetes Program for Indians (SDPI) serves 780,000 American Indians and Alaska Natives across 302 programs in 35 states.1 SDPI focuses on community-directed approaches to treat and prevent Type 2 diabetes in Tribal communities that are culturally informed. American Indians and Alaska Natives suffer disproportionately from Type 2 diabetes, but thanks to the success of SDPI, that statistic is improving.

SDPI expires on September 30, 2023 and Congress is currently considering the reauthorization. The Congressional Diabetes Caucus led the effort in circulating a bipartisan sign-on letter requesting support to reauthorize SDP and SDPI. With the help of NIHB and other partners, the letters received 60 Senate signers and 240 House signers. However, these letters do not reauthorize the program.

SDPI has not seen a funding increase in 20 years. Legislation was introduced in the House (H.R. 3561) and Senate (S. 1855) that would reauthorize the SDPI program at $170 million in annual funding for two years. Both of these bills have passed out of their respective committees but are waiting for a floor vote to be scheduled in their respective chambers. SDPI is the most effective effort to combat diabetes and its complication, therefore, reauthorization must be a top priority.

Even though SDPI is widely bipartisan, with federal funding deadlines approaching and a closely divided Congress, SDPI renewal is not guaranteed.

We need your help! Please contact your member of Congress and let them know that SDPI must be renewed by the end of September! You can find SDPI fact sheets and information here.

More background on SDPI below:

Congress established the Special Diabetes Program for Indians (SDPI) in 1997 as a mandatory funding program as part of the Balanced Budget Act to address the growing epidemic of diabetes in American Indian and Alaska Native (AI/AN) communities. The Special Diabetes Program for Type 1 Diabetes (SDP) was established at the same time to address the opportunities in type 1 diabetes research. Together, these programs have become the nation’s most strategic, comprehensive, and effective efforts to combat diabetes and its complications.

At a rate approximately 2 times the national average, AI/ANs have the highest prevalence of diabetes. In some AI/AN communities, over 50% of adults have been diagnosed with type 2 diabetes and AI/ANs are 1.8 times more likely to die from diabetes.

SDPI has become the nation’s most effective federal initiative to combat diabetes. Thanks to SDPI, for the first time, from 2013 to 2017 diabetes incidence in AI/ANs decreased each year. AI/ANs are the only racial/ethnic group that have seen a decrease in prevalence. Fewer cases have coincided with a decrease in diabetes related mortality by 37 percent between 1999 and 2017. SDPI has also resulted in significant savings from Medicare due to reduction in End Stage Renal Disease (ESRD). Between 1996 and 2013, incidence rates of ESRD in AI/AN individuals with diabetes declined by 54 percent. This reduction alone is estimated to have already saved $520 million between 2006-2015.2 Hospitalizations for uncontrolled diabetes among AI/AN people has also dropped by 84 percent, which significantly lowers health care costs.

This success is due to the nature of this grant program which is administered at the federal level but is implemented locally. This design has allowed Tribal communities to design and implement diabetes interventions that address locally identified community priorities. Tribal leaders have identified community adaptability to be a strong element of SDPI’s success. They have shared that the ability of the community to make local level decisions, choose best practices, and adapt the program to be culturally appropriate has been vital to its success. Communities with SDPI-funded programs have seen substantial growth in diabetes prevention resources, including more than doubling the number of on-site nutrition services, and physical activity and weight management specialists for adults, and an exponential increase of sites with physical activity services for youth.

Programs are able to address the most urgent needs in their communities, and this has led to incredible results both locally and nationally. Programs have reported improvements in A1Cs, blood pressure, diabetes-related eye disease outcomes, and foot health of their patients. Because programs are locally led, staff are often able to incorporate both traditional practices and evidence-based prevention. This combined approach has led to significant community buy-in. Kevin Fortuin, the SDPI Program Manager for Tohono O’odham Nation shared “O’odham people have always been traditional runners. The connection between traditional foods, activity, and exercise is tied not only to health, wellness, diabetes prevention, and management, but also in terms of who the O’odham people are. It’s part of the O’odham culture.”

SDPI has been so successful that it has been recognized as one of the most successful public health interventions in our nation’s history, after childhood vaccination. SDPI models have been applied to other populations as well. One state Medicaid agency actually contracts with SDPI programs to treat the non-native population in the state because the methods are so effective.

Unfortunately, SDPI has faced significant uncertainty with stagnant funding and short-term reauthorizations. A 2020 NIHB survey found that 43 percent of SDPI programs faced challenges related to cutbacks in services due to funding uncertainty, and 39 percent of programs faced potential delays in purchasing medical equipment.[3] “The uncertainty of funding has resulted in the need to prioritize personnel expenses over other program-related expenses… As such, the participation of SDPI staff in events such as the annual Village Health Fairs was placed in potential jeopardy,” one respondent shared. Another respondent stated their program faced challenges, including, “not being able to hire staff for program activities in a timely manner [and] not being able to maintain staff due to uncertainties.”

NIHB Calls on United Nations and Member States to Implement Indigenous Determinants of Health as Part of the 16th Session of the Expert Mechanism on the Rights of Indigenous Peoples

Posted on July 31, 2023 by Erisel Cruz

NIHB Chairman William Smith testified on July 18 about the importance of culture in healing for Indigenous People at the 16th Session of the Expert Mechanism on the Rights of Indigenous Peoples.

“NIHB’s sole commitment and focus is to the health care and public health for all American Indian and Alaska Native Peoples. That includes the work of healing our Peoples and our Nations,” said Chairman Smith, a citizen of the EYAK Tribe in the Alaska Village of Valdez. “That work cannot succeed without restoration of language and culture, and healing from colonization. Our very concepts of what it is to be healthy are rooted in our cultures, languages and in in our shared and individual histories. Without standing in the full knowledge and understanding of the impact colonization has defined in all indigenous experience, we will not know health. We will not heal.”

In April, NIHB supported the United Nations Permanent Forum on Indigenous Issues’ adoption of the Indigenous Determinants of Health (IDH), an international paper with 17 Indigenous authors including NIHB, designed as a tool to help UN Member States understand the social determinants of health as they relate to Indigenous Peoples. In May, at the 76th World Health Assembly, NIHB supported the World Health Organization’s adoption of the IDH.

Now, NIHB is focused on ensuring these organizations continue to listen to Indigenous Peoples to create further recommendations on health.

Face-to-Face Meetings for the Medicare, Medicaid, and Health Reform Policy Committee (MMPC) and the Tribal Technical Advisory Group (TTAG)

Posted on July 31, 2023 by Erisel Cruz

From July 25 to July 27, the MMPC and TTAG held their first Face-to-Face meetings in over three years. These meetings brought together Tribal health policy advocates, Tribal leaders, and leadership from the Centers for Medicare and Medicaid Services (CMS) to discuss recent developments and current priorities for the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) programs. The MMPC is a committee within NIHB that serves as a forum for Tribes, Tribal organizations, and those that work in Tribal health policy to share information on emerging issues and to identify agenda and action items for the TTAG meeting which follows the next day. The TTAG meeting began on July 26 at the National Museum of the American Indian and was attended by committee members from IHS service areas, as well as representatives from NIHB, the National Council on Urban Indian Health, National Congress of American Indians, and Tribal Self Governance Advisory Committee. Both meeting agendas featured a variety of presentations and discussion points, and three issues resounded throughout.

During this period of “Unwinding ,” Medicaid has resumed checking eligibility and disenrolling as a result of the end of the public health emergency. At present, CMS has not publicly released disenrollment data by state. During a discussion with Daniel Tsai, Deputy Administrator and Director of the Center for Medicaid and CHIP Services, Mr. Tsai announced that general statistics on Medicaid disenrollment will be shared imminently. However, demographic data including racial and ethnic background will likely not be available for several more months. Tribal representatives also shared that there have been difficulties with certain states sharing their disenrollment data with Tribes, which has impeded efforts to combat disenrollments due to procedural missteps rather than ineligibility.

The TTAG also touched base with Mr. Tsai on the recent Four Walls grace period extension through February 2025, which permits IHS and Tribal facilities to receive Medicaid reimbursements for services provided outside of the “four walls” of their facilities. Mr. Tsai shared that this extension was intended to signal CMS’s intention to resolve the Four Walls limitation and to create time to work through the complex regulatory impact of such a change and the statutory barriers that exist.

It was also shared that CMS is considering Arizona’s 1115(a) Demonstration Waiver application to reimburse for traditional healing with the support of Medicaid and expects to have a decision before the end of the 2023 calendar year. There are three other pending waiver applications with traditional healing components: California, New Mexico, and Oregon. Arizona was the first state to submit an application to CMS back in 2016. Should it be approved, the Arizona waiver would lay the foundation for the remaining waivers.

The next MMPC Face-to-Face Meeting is tentatively scheduled for October 17, 2023, ahead of the TTAG Face-to-Face Meeting on October 18-19, 2023.

Data on Medicaid Disenrollment – July 25, 2023 Update

Posted on July 31, 2023 by Erisel Cruz

The Kaiser Family Foundation has created a tracker for the most recent data on the unwinding of Medicaid. The data is not specific to American Indians/Alaska Natives.

Rates of disenrollment differ widely across states, ranging from 10% in Michigan to 82% in Texas. On average, 73% of Medicaid participants had their coverage terminated for procedural reasons, rather than being determined ineligible. In states where the data is available publicly, Medicaid procedural disenrollment rates range from 30% in Iowa to 96% in New Mexico. Procedural disenrollments can happen when a state has outdated contact information or when enrollees are unaware of timelines for renewal, for example. American Indians and Alaska Natives are at higher risk of procedural disenrollments.

Note: Since March 2020, the Medicaid continuous enrollment provision placed a hold on all Medicaid disenrollments through the duration of the COVID-19 Public Health Emergency. As of March 31, 2023, the provision is no longer in effect and states have begun to redetermine eligibility of their Medicaid enrollees.

NIHB has created a website with background information and materials about the unwinding process.

Councilman Spoonhunter Testimony

Posted on July 31, 2023 by Erisel Cruz

Councilman Lee Spoonhunter, NIHB Board Member representing the Billings Area, testified to the House Committee on Natural Resources Subcommittee on Indian and Insular Affairs Thursday, July 27, 2023. The legislative hearing discussed the draft legislation: Restoring Accountability in the Indian Health Service (IHS) Act of 2023.

According to the Committee, this hearing was held, in part, to address the Indian Health Service’s history of “substandard medical care, high staff vacancy rates, aging facilities and equipment, and unqualified or predatory healthcare staff.”

“There is no amount of red tape that can patch an underfunded system,” said Spoonhunter. “Imagine having only one day’s worth of food for a week: for generations. The funding of IHS at 1/7th the estimate of the Tribal Budget Formulation Workgroup sets us up for failure.”

Spoonhunter testified that NIHB is supportive of the intent of this bill to address policy concerns at the IHS. However, more work is needed before any amendments are made to the Indian Health Care Improvement Act. The draft bill has many well-intended provisions that seek to address past misconduct and a lack of accountability at the IHS, but these good intentions could have the potential to impact Tribally operated health facilities.

To view the hearing and view additional information on the draft legislation, click here .

Congress Adjourns for August Recess – FY 2024 Funding, SDPI reauthorization, and Other Items still on the “to-do” list

Posted on July 31, 2023 by Erisel Cruz

Last week, Congress adjourned for their 5-week August recess, without resolving many of the key legislative deadlines set to expire on September 30, 2023 – including but not limited to the FY 2024 Discretionary appropriations and the renewal of the Special Diabetes Program for Indians (SDPI).

SDPI: SDPI expires on September 30, 2023. Committees in both the House and Senate have passed legislation (H.R. 3561 and S. 1855, respectively) to renew SDPI for 2 years at a funding level of $170 million per year. SDPI has been funded at $150 million since FY 2004, so this funding increase is an important step towards getting more money for this lifesaving program. On Thursday, July 27, Navajo Nation President, and NIHB Board Member Buu Nygren testified before the Joint Economic Committee discussing the economic impacts of diabetes. NIHB provided support for his testimony through our Tribal Assistance Program – you can view his written testimony here. President Nygren urged the Committee members to support SDPI renewal.

FY 2024 Appropriations: Last week, the Senate Appropriations Committee released and passed its FY 2024 Interior, Environment and Related Agencies Appropriations bill. This bill would fund the Indian Health Service (IHS) at about $7.2 billion, which is a small increase of $218.6 million over FY 2023. However, the Senate’s bill also included a “rescission” of $350 million from IHS from American Rescue Plan Act funds, sending IHS funds back to Treasury. Earlier this summer, the House Appropriations Committee released a bill that would fund IHS at roughly $7.1 billion. The Senate and House Bills both continue IHS advance appropriations. Unfortunately, neither the House nor Senate bill included reclassification of Contract Support Costs and 105(l) leases as mandatory spending, which is a long-time request of Tribal nations. NIHB will be sharing more information about FY 2024 appropriations later this week and what we can expect going into final negotiations and newly established spending caps set by Congress. Stay tuned to your inboxes!

Farm Bill: The Farm Bill is also up for renewal by September 30, 2023, which contains many critical nutrition programs important to Tribal communities. The Senate Committee on Indian Affairs held a hearing on Native priorities for the 2023 Farm Bill Reauthorization. Witness testimony included support for the expansion of Tribal Self-governance in nutrition programs and pilot programs to improve healthy foods in Native communities. NIHB supports the work of the Native Farm Bill Coalition to improve these programs. You can read more about their legislative asks here. The full video of the hearing is available here.

August is a great time to reach out to your Congressional delegation! If you need assistance with talking points or issue briefs for Congress please reach out to Taylor Barrett, NIHB’s Congressional Relations Coordinator at [email protected].