Funding Limbo Underscores Complexity of Pandemic Health Care in Indian Country

Tribes are moving forward with their own emergency measures while awaiting additional help from federal funding. One source says the Indian Health Services-run network has a critical lack of intensive-care beds and ventilators.

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A $40 million congressional appropriation to help tribes cope with the coronavirus in Indian Country is stuck in administrative limbo at the Centers for Disease Control, awaiting further action by Congress to clear the way for the money to move to tribes.

On Wednesday the Senate passed a second emergency appropriation that includes an additional $64 million for Indian tribes. That funding will go directly to Indian Health Services (IHS), but the legislation does not include a fix for the logjam blocking the initial $40 million from reaching Indian health programs.

The funding bottleneck underscores the inter-agency complexity of providing supplemental healthcare services for tribal nations, which are individually moving forward with their own emergency measures to address the pandemic.

So far, there are several confirmed and presumptive cases identified within tribal communities. Among them, an employee of Oregon’s Confederated Tribes of the Umatilla Indian Reservation’s Wildhorse Casino and the Yankton Sioux Tribe member in South Dakota both tested positive for COVID-19, the latter at the tribal Indian Health Service clinic. 

The Yankton Sioux Tribe approved a tribal declaration of disaster last Friday. Tribal offices and schools will be closed. Meanwhile, the Umatilla Board of Trustees closed down the Wildhorse Casino for two days to sanitize the facility from floor to ceiling. Umatilla schools are closed and elders are on lockdown. The tribe is asking all community members not to travel farther than 75 miles from the reservation, which would limit traffic to more urban areas like Portland where there are higher rates of confirmed cases. 

The Oglala Sioux Tribe in South Dakota announced a state of emergency. Navajo Nation reported its first two confirmed cases as well.

On March 6, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which allocated $8.3 billion in emergency funding. That included a $40 million set-aside for tribal nations through the Centers for Disease Control (CDC). But the CDC, which is taking the lead on the pandemic nationally, has no mechanism to distribute the funds directly to tribes or Indian Health Services, which provides day-to-day healthcare services in Indian Country.

Indian Health Services, which provides treaty-required healthcare to tribal members, falls under the Department of Health and Human Services. The CDC also falls under HHS, but the agencies have different missions and run as separate agencies.

In the March 6 appropriation, Congress put an additional $40 million in the CDC’s Public Health Emergency Preparedness (PHEP) Cooperative to distribute to tribes.. But since tribes are not eligible for that program, the CDC cannot pass the money to tribal programs without additional action from Congress.

New Mexico Senator Tom Udall introduced the CDC Tribal Public Health Security and Preparedness Act on March 11 to make tribal health organizations eligible for the funds.

According to a congressional source who participated in a conference call with the Indian Health Services late last week, the funding impasse is just one of several problems with healthcare emergency measures in Indian Country. The source, who spoke on the condition of anonymity, said IHS is not prepared to handle a COVID-19 outbreak. Other issues include a dramatically insufficient number of ICU beds and ventilators in the IHS-run network. 

The call consisted of a long list of questions about the epidemic that the agency was unable to answer, the source said.

IHS representatives speaking in the telephone briefing admitted there are shortages in basic medical equipment, as well as a lack of solutions for challenging transportation needs on reservations. 

According to the source, an IHS representative said they are testing patients for COVID-19 and sending them home. Many Native households are multigenerational, which creates a heightened risk for transmission of the disease from younger family members to the older, more vulnerable members of the community. The IHS did not respond to the Daily Yonder’s request for additional comment.

On a separate call held by the National Indian Health Board (NIHB) on Tuesday, Julia Hostler of IHS told tribal leaders and health professionals about intermediate sources of healthcare assistance available to tribes while the agency works on releasing the CDC funds.  

Tribes may draw from the Strategic National Stockpile, which provides medical equipment and supplies during emergencies, and the Director’s Emergency Fund, a small pot of money set aside by the agency for unexpected crises, Hostler said. Tribes can reach out to their regional IHS directors to request resources from the stockpile.

Victoria Warren-Mears, the director of the Northwest Tribal Epidemiology Center, says a potential funding fix could come through an inter-agency agreement between IHS and CDC. Warren-Mears contends that the “most logical flow of funds is from the CDC to IHS then from IHS to distribute to tribes and tribal contracts” because IHS already has the infrastructure in place to distribute these funds to every tribe in the country.

Inter-agency agreements like this between the CDC and IHS have been done in the past but not during an emergency. The Northwest Portland Area Indian Health Board and the National Indian Health Board are asking their member tribes to send a letter to HHS Secretary Alex Azar, who oversees both agencies, asking for a similar flow of funds. 

Late Wednesday afternoon, the Senate passed the Families First Coronavirus Response Act. The bill includes $64 million in emergency funds that go directly to the Indian Health Services for coronavirus response, but the bill does not include a legislative fix for the previously appropriated $40 million to the CDC. Among other provisions, the Families First bill eliminates costs for COVID-19 testing at IHS facilities and across the country. 

In a statement to the Daily Yonder, Oregon Senator Ron Wyden (D) said: “It is critical that tribes in Oregon and across the country have the resources they need to effectively and swiftly respond to this pandemic. That starts at the top. This failure by the Trump administration hits Umatilla tribal members especially hard, given devastating February floods, which have exacerbated a stressed health system and the stability of important local businesses.”

A spokesperson for the Confederated Tribes of the Umatilla Indian Reservation in northeast Oregon said the pandemic will affect more than the health of the tribes. “The community [needs] to reevaluate the economic impacts of the virus,” said Jiselle Halfmoon, public information officer for the tribes. “It is more than only a health crisis.” 

The Umatilla tribes established a two-pronged incident command team that is evaluating how to limit both the public health and economic harm in the community. 

The tribe’s accounting department “retrobudgets,” giving the tribe a contingency that keeps them afloat in times of emergency. The tribe has enough saved to pay workers and keep programs operational for over a year. As of March 18, CDC funding has not reached the community, leaving the tribe to foot the bill, Halfmoon said. 

Halfmoon said that emotions are mixed across the Umatilla community. Some people are skeptical that social distancing is necessary, while others are building care packages for tribal elders. 

“We’re doing everything we can,” Halfmoon said.

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