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 UPCOMING EVENTS 

Community Health Aide Program (CHAP) TAG Vacancies
 In February 2018, with the announcement of CHAP expansion to Tribes beyond Alaska, IHS created a CHAP Tribal Advisory Group.

 Information on CHAP and CHAP TAG, including vacant  positions, is available on the CHAP
website .

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Top Story
CARESAct
President Signs CARES Act into Law
On Friday, March 27, 2020 Congress approved and the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act (S. 3548). The $2 trillion relief package is the largest in U.S. history, and will provide emergency cash assistance to individuals and families, financial and credit relief for small businesses, student loan deferment, and billions of dollars for healthcare and public health needs. Under the package, adults making under $75,000 in salary per year will receive a $1,200 payment to include an additional $500 per child. The package also includes $8 billion in economic relief for Tribal governments.

The National Indian Health Board alongside sister organizations has continuously advocated for meaningful and urgent relief funding for Tribal governments and Tribal organizations in each COVID response funding package. Under the first two COVID packages, NIHB successfully advocated for $214 million for Tribal healthcare and public health. $80 of that funding is for Tribal public health under the Centers for Disease Control and Prevention (CDC), while $134 million went to the Indian Health Service (IHS) for IHS and Tribal health systems.

On March 20, 2020, NIHB joined by eight national and regional Native organizations submitted a letter to House and Senate leadership urging immediate action on a wide range of healthcare, public health, education, and nutrition priorities. NIHB included Tribal healthcare and public health priorities informed by NIHB's 2020 Legislative and Policy Agenda, which was voted on and passed by NIHB's Board of Directors earlier this year.

To access the Senate letter,  click here
To access the House letter,  click here

On Wednesday March 25, the U.S. Senate unanimously passed the CARES Act by a final vote of 96-0. The package was then passed by voice vote on Friday March 27 by the House of Representatives, and signed into law by the President later that day. Funding victories for Tribal healthcare and public health under the 3rd COVID package include:

Healthcare
  • $1.032 billion for the Indian Health Service (IHS) Services Account available through September 30, 2021
    • Includes up to $65 million for electronic health record stabilization and support
    • Permits the director to transfer up to $125 million to IHS Facilities
    • At least $450 million shall be distributed immediately to Direct Service Tribes and Self-Governance Tribes
Public Health
  • Minimum $125 million in set-aside funding for Tribes and Tribal organizations under Centers for Disease Control and Prevention (CDC)
    • This is the largest Tribal set-aside in CDC history
    • Funding is for surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities
  • Minimum $15 million in set-aside funding for Tribes and Tribal organizations under Substance Abuse and Mental Health Services Administration (SAMHSA)
    • Funding is for mental and behavioral health services in response to COVID-19
  • Minimum $15 million in set-aside funding for Tribes and Tribal organizations under Health Resources and Services Administration (HRSA)
    • Funding is for health surveillance and other needs under the HRSA Rural Health program
Housing
  • $300 million under the Native American Housing Assistance and Self-Determination Act (NAHASDA)
    • $200 million is for Native American Housing Block Grants
    • $100 million is for Indian Community Development Block Grant
Nutrition :
  • $100 million for the Food Distribution Program for Indians Reservations
    • $50 million is for facility improvements and equipment upgrades
    • $50 million is for additional food purchases
Next Steps
NIHB had been strongly pushing Tribal legislative priorities related to Medicare and Medicaid to maximize healthcare revenue streams for IHS and Tribal health programs. In addition, NIHB pushed for direct Tribal access to new public health funding streams and resources to bolster preparedness efforts in Indian Country. While these provisions did not make it into the final bill enacted on Friday, NIHB will continue to push for their inclusion under subsequent COVID relief packages. These provisions include but are not limited to:
  • Making sure IHS and Tribal health programs are reimbursed 100% by the federal government for all medical services authorized under the Indian Health Care Improvement Act (IHCIA)
    • Right now, states have control over what services are covered under state Medicaid programs, and not all states cover medical services authorized under Medicaid or IHCIA. This provision would help maximize 3rd party revenue for IHS and Tribal health programs which are critically needed to respond to the COVID-19 emergency.
  • Fixing the "four walls" issue for IHS and Tribal clinics
    • Right now, IHS and Tribal health programs are largely limited to only receiving Medicaid reimbursement for services provided within the four walls of a clinic. This makes it very difficult to setup outpatient centers, mobile units, and other services that are critical during this pandemic
  • Exempting American Indians and Alaska Natives (AI/ANs) from cost-sharing under Medicare
    • The federal government has trust obligations to pay for healthcare in Indian Country. While AI/ANs do not have cost-sharing under IHS or Medicaid, there exists cost-sharing under Medicare
  • Ensuring direct IHS and Tribal access to the Strategic National Stockpile
    • IHS and Tribal hospitals and clinics are already out of critical medical countermeasures, personal protective equipment, and many drugs. It is very difficult for Tribes to currently access the Stockpile, and there is no guaranteed access in statute. Guaranteeing access in statute will ensure that Tribal access to the Stockpile is not left to the will of the agencies
  • Providing direct Tribal access including a funding set-aside to the Public Health Emergency Preparedness (PHEP) program
    • Right now, PHEP funding goes to all 50 states and several territorial governments. Tribes do not have direct access, and most states do not share these funds. Many Tribes do not have critical public health infrastructure, placing Tribal communities at increased risk of an outbreak. Direct Tribal access to PHEP honors the trust responsibility and strengthens the government to government relationship with the United States.

Congress is expected to work on and introduce a fourth supplemental package in coming weeks. In addition to the items listed above, NIHB will continue to strongly advocate for direct funding for IHS and Tribal health programs to ensure Indian Country has the needed resources to protect and preserve health.
CAPITOL HILL UPDATES
On Friday, March 27 Congress approved and the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act (S. 3548). The $2 trillion relief package is the largest in U.S. history, and will provide emergency cash assistance to individuals and families, financial and credit relief for small businesses, student loan deferment, billions of dollars for healthcare and public health needs. Under the package, adults making under $75,000 in salary per year will receive a $1,200 payment to include an additional $500 per child.

The National Indian Health Board alongside sister organizations has continuously advocated for meaningful and urgent relief funding for Tribal governments and Tribal organizations in each COVID response funding package. Under the first two COVID packages, NIHB successfully advocated for $214 million for Tribal healthcare and public health. $80 of that funding is for Tribal public health under the Centers for Disease Control and Prevention, while $134 million is to the Indian Health Service (IHS) for IHS and Tribal health systems.

On March 20, 2020, NIHB joined by eight national and regional Native organizations submitted a letter to House and Senate leadership urging immediate action on a wide range of healthcare, public health, education, and nutrition priorities. NIHB included Tribal healthcare and public health priorities informed by NIHB's 2020 Legislative and Policy Agenda, which was voted on and passed by NIHB's Board of Directors.

To access the Senate letter,  click here
To access the House letter,  click here

Healthcare
  • $1.032 billion for the Indian Health Service (IHS) Services Account
    • Includes up to $65 million for electronic health record stabilization and support
    • Includes up to $125 million for IHS Facilities
    • At least $450 million shall be distributed immediately to Direct Service Tribes and Self-Governance Tribes
Public Health
  • Minimum $125 million in set-aside funding for Tribes and Tribal organizations under Centers for Disease Control and Prevention (CDC)
    • Funding is for surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities
  • Minimum $15 million in set-aside funding for Tribes and Tribal organizations under Substance Abuse and Mental Health Services Administration (SAMHSA)
    • Funding is for mental and behavioral health services in response to COVID-19
  • Minimum $15 million in set-aside funding for Tribes and Tribal organizations under Health Resources and Services Administration (HRSA)
    • Funding is for health surveillance and other needs under the HRSA Rural Health program
Housing
  • $300 million under the Native American Housing Assistance and Self-Determination Act (NAHASDA)
    • $200 million is for Native American Housing Block Grants
    • $100 million is for Indian Community Development Block Grant
Nutrition :
  • $100 million for the Food Distribution Program for Indians Reservations
    • $50 million is for facility improvements and equipment upgrades
    • $50 million is for additional food purchases
 
A fourth supplemental funding package is expected to be introduced by Congress in coming week. NIHB will continue to strongly advocate for direct funding for IHS and Tribal health programs to ensure Indian Country has the needed resources to protect and preserve health.
FEDERAL ADMINISTRATION AND STATE GOVERNMENT UPDATES
HHSbudget
HHS Tribal Budget Consultation to be Held Virtually on April 8, 2020
On Monday March 23, the Department of Health and Human Services issued a a Dear Tribal Leader Letter (DTTL) informing Tribes that the 22nd U.S. Department of Health and Human Services (HHS) Annual Tribal Budget Consultation Session will NOT be taking place in person given the COVID-19 national emergency. HHS Budget Consultation was originally scheduled to take place in-person in Washington DC on April 8 and 9.

Instead, HHS will be holding a virtual technical assistance session on the afternoon of Wednesday, April 8, from 1:00 PM Eastern to 4:00 PM Eastern. The virtual session will be led by the Assistance Secretary for Financial Resources (ASFR). ASFR officials will provide an in-depth presentation on the HHS budget process. 

The deadline to submit written testimony on Tribal healthcare and public health priorities for the Fiscal Year (FY) 2022 budget is now  Friday, May 1, 2020 . Testimony can be emailed to consultation@hhs.gov.

For more information and to participate in the virtual session, visit the link here.
To access a copy of the full letter, click here
IHSSSSS
On Friday March 27, the Indian Health Service (IHS) issued a Dear Tribal Leader Letter (DTTL) outlining the funding distribution of the $134 million in total secured for IHS under the second COVID-19 package. IHS held a national call with Tribal leaders on Monday, March 23 to request guidance and recommendations from Tribes on how IHS should distribute the funding.

In addition to the $64 million appropriated to IHS under the Families First Coronavirus Response Act, IHS was able to secure an additional $70 million from the Department of Health and Human Services (HHS) Public Health and Social Services Emergency Fund to bring total funding to $134 million. The additional $70 million from HHS is money that the Department received under the first COVID supplement, the Coronavirus Preparedness and Response Supplemental Appropriations Act.

To access the DTTL,  click here

As outlined in the letter, the distribution method is as follows:
  • $70 million to support a wide variety of preparedness and response activities such as cost for medical supplies, personal protective equipment (PPE), staffing costs. This funding was transferred to IHS from the Public Health and Social Services Emergency Fund, appropriated in the  Coronavirus Preparedness and Response Supplemental Appropriations Act under H.R. 6074, enacted on March 6, 2020.
    • Of the $70 million transferred to IHS, the agency will distribute $30 million to IHS federal health programs in support of COVID-19 response activities.
      • Distribution of the $30 million to Direct Service sites will use the same allocation methodology used in determining Federal Hospitals and Health Clinics base funding levels.
    • Of the $70 million, IHS will use $40 million to purchase personal protective equipment (PPE) and medical supplies through the IHS National Supply Service Center.
  • $64 million for COVID-19 testing in Indian Country included in the  Families First Coronavirus Response Actunder H.R. 6201, enacted on March 18, 2020.
    • IHS will allocate $61 million to be distributed among the IHS Federal health programs and Tribal health systems.
      • The methodology for distributing the $61 million will use the same methodology for program increases in Hospitals and Health Clinics funding.
    • Of the $64 million in new resources, $3 million will support urban programs.
Prevalence
Is there data on the number of AI/ANs with confirmed cases of covid-19 and deaths from the virus?   No, there is not and there will not be for the foreseeable future.   Some Tribes will be able to report this data, both Tribes who operate their health programs and those who are IHS Direct Service Tribes, but we are not likely to get reports on documented cases from the usual sources of county and state health departments.

Eventually, using data match methodologies we may be able to calculate the rate of death by estimating the number who had the covid-19, the denominator, and the numerator, the number of deaths. A data match is feasible where the AI/AN has been seen in an IHS, Tribal or Urban health program, although not without a high level of epidemiological expertise and substantial funding to conduct the research.
Does any helpful data exist that Tribes can rely on to gauge the prevalence for their tribe and their region of the country? Yes, state reports are very accurate and reported in every state, but this level of analysis is too high to be helpful for a Tribe who population is vastly smaller than the state population. County level data will be more helpful and since this unit of government has public health responsibilities it is a likely source of data.

Tribes need to stay in touch and build a good relationship with their local county and state public health authorities even as they turn most of their attention to the federal government for a response to the pandemic. However, data about the spread of the virus and outcomes is more accessible at the local and state level. Fortunately, county level data is being collected by various organizations that are developing and updating covid-19 datasets.

The National Indian Health Board is utilizing the county level data of USAFACTS and its daily update of confirmed covid-19 cases and deaths to create data visualizations.   NIHB's daily covid-19 Digital Data Brief is updated on the same schedule as the USAFACTS covid-19 data set and permission has been obtained for NIHB to do so.


What is the value of knowing the prevalence of covid-19 if everyone should be taking the same measures no matter the current status of their county?
These visualizations allow Tribal leaders to see both what is happening in their state, their county, but also view the situation across the nation in the 3,240 other counties. Over time the lessons learned across the nation will be shared and tracking the experience of counties with large Indian populations is essential if we are to draw lessons that apply to Tribes and their citizens. In some cases, this may prevent deaths if disturbing trends are observed in counties with large AI/AN populations. In addition to the covid-19 data, the NIHB public Tableau website has AI/AN population information for every county in the nation including data on age, income and health insurance status. This information will be helpful for emergency planning and the health response to the pandemic.
FraudWarningCOVID-19 Rumor and Fraud Warnings from Federal Agencies
Medicaid and CHIP's Disaster Preparedness Toolkit for State Medicaid Agencies contains guidance on what healthcare providers can do in response to a public health crisis, such as COVID-19. Only after the president has declared a disaster or emergency as well as the HHS Secretary, certain Medicare, Medicaid and Children's Health Insurance Program requirements can be waived to ensure that sufficient health care items and services are accessible to individuals enrolled in Social Security Act programs during the emergency. Specifically, certain guidance allows facilities to provide services in alternative settings such as a temporary shelter, when a provider's facility is inaccessible. More on this can be found on the 1135 Waiver form.

UPCOMING EVENTS, CALLS, AND WEBINARS
IHSAllTribesCall
IHS COVID-19 All Tribes CAll
Please see below for call information to the 
IHS' All Tribes Call on Thursday, April 2nd at 3:30 PM Eastern . This call is intended to update Tribes on the Coronavirus Disease 2019 (COVID-19). Tribal Leaders will have an opportunity to provide comments and ask questions to federal officials. IHS has also scheduled a COVID-19 call for the following week at the same time-call info is the same for both calls.

Date:   Thursday, April 2nd
Time:   3:30 PM - 5:00 PM (Eastern)
Conference Call:   800-857-5577 | Participant Passcode:  6703929
Webinar Adobe Connect:   https://ihs.cosocloud.com/r4k6jib09mj/ | Participant Password:  ihs123
GRANTS & RESOURCES
TemplateResolutionCOVID-19 Template Resolution for Tribes and Tribal Organizations

The National Indian Health Board has created a template resolution for Tribes regarding the 2019 novel coronavirus (COVID-19).  This template may be shared, modified or edited to reflect the unique needs of a Tribal community.
 
Additional resources and links on Tribal Declarations of Emergency:
RuralResponse
Rural Communities Opioid Response Program Notice of Funding Opportunity
Application Deadline: April 24, 2020
HRSA recently released the Rural Communities Opioid Response Program (RCORP) notice of funding opportunity (HRSA-20-031). HRSA plans to award approximately 89 grants to rural communities as part of this funding opportunity. Applications are due by Friday, April 24, in Grants.gov .
Successful RCORP-Implementation award recipients will receive $1 million for a three-year period of performance to enhance and expand substance use disorder (SUD), including opioid use disorder (OUD), service delivery in high-risk rural communities. They will implement a set of core SUD/OUD prevention, treatment, and recovery activities that align with HHS' Five-Point Strategy to Combat the Opioid Crisis.
TitleVI
The Administration on Aging (AOA) and Administration for Community Living (ACL) just released a Title VI (Older Americans Act) Transportation Quick Guide. The Guide contains resources on Part A/B funding that can be used for transportation services and related expenses. To view the Guide, click here .
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