Advocacy strategies for Urban Indian health Programs

1. Training Materials Prepared by the National Council of Urban Indian Health Advocacy strategies for Urban Indian health Programs

2. Framework for Legislative Advocacy • Identify both the problem and the solution • Ask: what is the problem I’m facing? What is the solution to this problem? • Identify the individuals able to help you • Ask: Which individuals will be able to assist me? • How can I make it easier for this person to help me? • Ask: exactly what steps are required to help me? • How can I convince an unwilling person to help me? • Ask: what facts can help me overcome this resistance?

3. Step 1 - Identify Both the Problem and the Solution • Identify the problem – then determine what actions would be necessary to eliminate it. • Problem – my UIHP sees a great deal of Medicaid patients, but my state is cutting back on covered Medicaid services. As a result these services are unaffordable for many AI/AN patients, reducing third party revenue coming into my program. • Solution – if these services for AI/AN patients were reimbursed by the federal government at 100% (FMAP), my state would have no incentive to cut services. • Therefore, I’m asking that Medicaid services provided by my clinic be reimbursed at 100% FMAP.

4. Step 2 - Identify the Individuals Able to Help • This is often a very complex question, but extremely important. • You don’t want to waste your time (or others’) asking for help from someone who can’t assist! • NCUIH is happy to help identify the individual Members and Committees of Congress who have the authority to solve your problem. • E.g. – in order to achieve 100% FMAP for UIHPs, this would require additional expenditure of federal funds for AI/AN health care purposes. Therefore, speak with: • Senate Indian Affairs • Senate Finance • House Natural Resources • Senate Health, Education, Labor, and Pensions

5. Step 3 – How Can I Make it Easier for This Person to Help Me? • Members of Congress (and their staff) are extremely busy, and do not have the time or resources to research possible solutions to your problem. • Present the solution to your problem to the member of Congress so that it’s easier for them to help you! • NCUIH is able to identify the statutory changes necessary to help solve your problem – as always, feel free to call on us.

6. Make It Easy For Congress to Help! • By providing members of Congress or their staff with the precise statutory language required to solve your problem, you increase the likelihood that the statutory solution will be included in subsequent legislation. • This also demonstrates good will, dedication and commitment to achieving a solution, and political savvy and sophistication which will lead to a more cooperative and constructive relationship with Congressional staff.

7. What Steps are Required to Solve My problem? • “Congressman/Congresswoman, my state is pursuing drastic cuts to Medicaid covered services. But if services for AI/AN people were reimbursed by the federal government at 100%, states could then make an exemption for AI/AN patients. • In order to provide urban Indian health programs with 100% FMAP, the following minor change would need to be made to Social Security Act Sec. 1905 (42 U.S.C. 1396d): • ‘The Federal medical assistance percentage shall be 100 per centum with respect to amounts expended as medical assistance for services which are received through an Indian Health Service facility whether operated by the Indian Health Service, by an Indian tribe or tribal organization, or by an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act), whether directly, by referral, or under contract or other arrangement between such urban Indian organization and another health care provider.’”

8. Step 4 – How Can I Convince an Unwilling Person to Help Me? • Unfortunately, not all members of Congress consider AI/AN health care a priority. • Possible objections to 100% FMAP proposal • How much is this going to cost? We’re currently running huge deficits. • Can’t AI/AN people just receive these services at IHS? • Obamacare is supposed to cover everyone – why can’t they just purchase an exchange product?

9. Anticipate These Objections and Have Answers Ready! • How much is this going to cost? We’re currently running huge deficits. • Latest data from CMS show that total UIHP Medicaid billing is only $16.3 million, with the state share expected to be signifcantly less than half that. This figure represents less than 0.0006% (6 ten thousandths of 1 percent) of the budget deficit for FY2012. • Can’t AI/AN people just receive these services at IHS? • Urban Indians are individuals and their descendants who were removed (often forcibly) from their homes and communities during the shameful period of Relocation and Termination. Congress and the Supreme Court have repeatedly reaffirmed the obligion of the United States to provide health care to AI/AN people wherever they reside. Urban Indians often live far from tribal lands and IHS facilities. • Obamacare is supposed to cover everyone – why can’t they just purchase an exchange product? • Congress has long acknowledged that AI/AN people paid up front for health care by the federal confiscation of their land and resources. The Affordable Care Act was not intended to substitute for the provision of health care services to AI/AN people through the I/T/U (IHS, Tribal, Urban) health delivery system. UIHPs provide cultural-competent care in fulfillment of Trust Responsibility.

10. Broad Themes for UIHP Advocacy • Most members of Congress are not familiar with the challenges faced by Urban Indians, and fewer still understand the complexities of the I/T/U health delivery system. • Remind Congressional staff that Urban Indian communities are the direct result of forcible relocation policies undertaken in the 1950’s and 1960’s which attempted to eliminate Native communities and culture through forced assimilation. • Remind Congressional staff that Trust Responsibility requires that the federal government assume the cost and provision of health care for Native people.

11. Framework for Appropriations Advocacy • Appropriations advocacy is somewhat simpler for a few reasons • The arguments are more straightforward and intuitive, while objections are easier to anticipate • The individuals who can assist are fewer, they are more familiar with AI/AN issues • Supporting data is more readily available • AI/AN advocates have several important key allies on appropriations committees

12. Appropriations Advocacy for UIHPs • The House Appropriations Subcommittee on Interior, Environment, and Related Agencies • Chair – Mike Simpson, (R-ID) • Key Staffer – Darren Benjamin • Ranking Member – Jim Moran, (D-VA) • Key Staffer – Tim Aiken • Points to stress: • New census data shows that 64% of American Indians and Alaska Natives live in urban areas, but funding for UIHPs is less than 1% of the IHS budget • Between FY2010 and FY2012, the overall IHS budget has been increased by $254 million, an increase of 5.8%. During that time, funding for Urban Indian Health Programs has been decreased in two consecutive years, reducing funding by $155,000. • The Urban Indian Health Programs also absorbed an additional $800,000 in cuts of as a result of the elimination of the Small Grants Programs. • The President's FY2013 request would increase IHS funding by $116 million, while increasing Urban Indian Health funding by only $4,000.

13. Appropriations Strategy • UIHPs always advocate for full funding of the entire Indian Health Service. IHS is currently funded at approximately ¼ of total need. • UIHPs must note that despite important and overdue increases to IHS in recent years, UIHPs have seen two straight years of funding decreases during that time. • UIHPs must stress that our programs provide high quality, culturally competent health care in fulfillment of federal trust responsibility. UIHPs are skillful at leveraging base Title V funding for additional resources, but our base funding is far below what is needed to adequately fulfill our mission. • State budget cuts and limited grant funding have made our Title V funding even more important during these difficult fiscal times.

14. IHS/UIHP Funding, 2006-2013

15. IHS/UIHP Funding 2006-2013 in constant 2010 dollars

16. UIHP Funding as a percentage of the Total IHS Budget

17. Let Us Set Up Your Hill Visit! • NCUIH staff have helped many UIHP directors and employees meet with Congressional staff in the past, and we are honored to be able to provide this service for you again. • NCUIH specifically scheduled our annual conference for a week when Congress was in session, so that you have the opportunity to meet with your member of Congress. • Please let us know if you are interested in scheduling a Hill visit, and what issues you would like to see addressed during that meeting. • We can also provide you with position papers on various issues if you need to conduct these meetings on your own.

18. State Medicaid Advocacyfor UIHPs – ARRA 5006(e) • States are required to establish a consultation process with UIHPs, to regularly seek advice and input from UIHPs, and to solicit advice prior to submission of a SPA, waiver, or demonstration project proposal that is likely to have a direct effect on Indians, Indian health programs, or urban Indian organizations. • CMS is required to disapprove SPAs/Waivers if UIHPs are not offered a provided notice. • Simple notice is not sufficient – must also include a statement of impact on UIHPs or their patients.

19. State Medicaid Advocacy – ARRA 5006(d) • Protections for AI/AN under Medicaid Managed Care • Choice of Provider - AI/AN participating in a non-Indian Medicaid Managed Care entity has right to choose I/T/U provider as for primary care if I/T/U provider is in-network • Network Adequacy - Medicaid managed care entity must show it has sufficient number of I/T/U providers to meet needs of AI/AN population served

20. State Medicaid Advocacy – ARRA 5006(d) • Reimbursement • Medicaid Managed Care entities must reimburse out of network I/T/U providers for services furnished to AI/AN enrollees at a rate not less than that paid to in-network providers for the same services  • Medicaid Managed Care entities must reimburse out of network I/T/U providers that are FQHCs for services furnished to AI/AN enrollees at a rate not less than than paid to FQHC providers for the same services that are in-network • The state plan must pay non-FQHC I/T/U providers any difference if amount paid by managed care entities to non-FQHC I/T/Us for services provided to enrolled AI/ANs is less than that which is offered to providers under the state plan

21. State Exchange Consultation • ACA Section 1311(d)(6) and 42 CFR § 155.130(f) require states to carry out consultation with federally recognized tribes • Narrative language from the interim final rule indicates that CMS encourages, but does not require, state exchanges to consult with UIHPs. • Therefore it is essential that UIHPs establish relationships with tribal stakeholders and state officials

22. Example – State Exchange Advocacy with UIHPs • CMS did not require state exchanges to employ an ARRA 5006(e)-like consultation policy with AI/AN stakeholders • However, Oregon is implementing exactly this time of consultation policy • Develop a process • Exchange in an ongoing exchange of information • Notice and analysis of impact if direct effect on AI/AN stakeholders

23. Oregon State Exchange Consultation Policy • Exchange consultation policy applies to nine federally-recognized tribes, AND NARA of the Northwest • Applies whenever there is decision having a “direct effect” on AI/AN stakeholders • Federally or statutorily mandated proposals or changes in which ORHIX has flexibility in implementation • Proposals or changes impacting services or access to services provided to or contracted for, by Tribal entities or urban Indian Programs

24. Consultation Structure • Ongoing consultation will take place within the context of a Tribal Technical Work Group (just like CMS TTAG!) • Also like CMS TTAG, UIHP is entitled to a seat on this tribal technical work group • Meetings to be held no less than six times per year • Formal consultation will take place when issues cannot be resolved through TTWG

25. Points for Advocacy with State Exchanges • Network Adequacy – UIHPs must be included in State Health Insurance Exchanges • IHCIA Section 206 gives UIHPs a right of recovery for customary or higher billed charges • So if exchanges exclude your UIHP, you can still recover from them for services provided to an enrolled patient • Network adequacy must include a determination of AI/AN need • Offer to be a source of data to help states acertain this need! • AI/AN protections – dedicated staff, model notices

26. We’re here to help! NCUIH staff are here to help you with any questions you may have about advocacy for UIHPs! Feel free to contact us with any questions – (202) 544-0344