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WASHINGTON -- More needs to be done to serve the needs of Native American tribes battling COVID-19, speakers told a House committee on Thursday.

"Native Americans continue to experience disproportionately high rates of disease such as diabetes, coronary heart disease, and respiratory infections that CDC has identified will result in a higher risk of poor outcomes from COVID-19," Francys Crevier, executive director of the National Council of Urban Indian Health, said at a . "The enhanced risk our patients face compounds on the historic underfunding of urban Indian health.... It's essential for Congress to provide adequate resources to help the entire Indian Health System (IHS) for the current pandemic and the resurgence as well."

Crevier added that even though the federal government is required by law to work with Native Americans, "many agencies are operating as if there is no legal requirement to engage in dialogue with urban Indian organizations," she said. "With no seat at the table, we've been unable to effectively communicate the significant needs on the ground. We request that the IHS work with HHS [the Department of Health and Human Services] to create an HHS-wide confer policy so they're not leaving behind urban Indians, which are 70% of the population." She requested that Congress allot $80 million to urban Indian organizations to help them renovate aging buildings and to put in COVID-19 accommodations such as air purification systems.

'Dirty Indians'

Stacey Bohlen, CEO of the National Indian Health Board, said, "We hear baseless stories from many quadrants of the nation about how 'dirty Indians' are causing the outbreaks or how private hospitals are refusing to accept referrals to treat our people. These same echoes came across all previous disease outbreaks that plagued our people from smallpox to HIV to H1N1, and it begs the question and the statement: It's time for change." The board applauds the money Congress has allocated for IHS to combat COVID-19 under the CARES Act and would spend under the stalled HEROES Act, "but despite important investments, there remains plenty of opportunity to do more," she said.

As of June 8, IHS reported 13,487 COVID-19 cases; however, these are likely underestimates, Bohlen said. Last month, the Navajo Nation surpassed New York City for the highest COVID-19 infection rate, and in New Mexico, Native Americans are 10% of the population but 55% of the state's COVID-19 cases, she said. In addition, a University of California Los Angeles study found if tribes were states, "the top five infection rates nationwide would be tribal nations."

Subcommittee chairman Betty McCollum (D-Minn.) was sympathetic to the need to do more. "Tribal communities in particular are disproportionately feeling the effects of this pandemic," she said. "The United States government has a trust and treaty responsibility to tribes, and signed treaties promising to provide healthcare and other services, and hundreds of years later, the failure to meet these treaty and trust obligations continues ... Today we see the dire effects of the failure to meet those needs. The federal government has failed to provide clean water and sanitation services. Without clean water, our Native American brothers and sisters are unable to fully protect themselves with frequent handwashing to prevent the spread of the virus." Likewise, the federal government hasn't provided enough housing, forcing Native Americans to live in overcrowded homes that don't allow for social distancing, she said.

In fact, "the nation's failure to provide basic services is so acute that the international aid organization Doctors Without Borders is assisting Native Americans in the Southwest," McCollum said. "I'd like to believe organizations focused on helping Third World countries would not have to be in Indian Country, but they are here, helping us, and we are grateful." In 2017, IHS per-capita spending for Native Americans was $4,078, compared to $8,109 for Medicaid, $10,692 for healthcare at the Department of Veterans Affairs, and $13,185 for Medicare beneficiaries, she noted.

A Struggling Healthcare System

Committee Republicans also agreed with the need for more funding. Rep. David Joyce (R-Ohio), the subcommittee's ranking member, said the IHS has been ill-equipped to deal with COVID-19, "struggling to recruit providers, procure supplies and equipment, and provide enough bed space." The work of the IHS "has been commendable under the circumstances, but ultimately all these challenges boil down to funding," responsibility for which "falls squarely on the Congress."

McCollum did have a pointed question for Indian Health Service director Rear Adm. Michael Weahkee. Under several COVID-19 relief bills, "this subcommittee has provided IHS with almost $1.1 billion for COVID-19 relief; to date, the IHS has obligated 614 million of those dollars. Could you please tell the committee why IHS has not obligated the remaining $482 million?"

Part of the reason is paperwork, Weahkee responded. "[For] some of the funds we received, notably most recently through the Paycheck Protection Program and the Healthcare Enhancement Act, there were requirements that testing plans be provided by each tribe," he said. "Those added requirements require that we use a bilateral amendment process which requires the agency and the tribe to discuss and both sign bilaterally these agreements; that additional process has taken some time."

Drop in Third-Party Payments

Another problem is that government funds are often available only through competitive grants, Weahkee said. "I've heard so many times from tribal leaders, it's very difficult to utilize competitive grant processes.... Larger tribes may have that capacity, while small tribes may have somebody with six different hats trying to write a grant on the side. During a pandemic when you need that funding right away... going through the extra burden of writing a grant is extremely difficult." Alternatives could include appropriating the money directly to the IHS, authorizing the agency to put the money directly into existing contracts, or enabling directly transfers from the CDC or the National Institutes of Health, he said.

Rep. Derek Kilmer (D-Wash.) asked how much money IHS facilities were losing from a drop in payments by third-party payers due to the pandemic; Kilmer noted that in fiscal year 2019, IHS collected $1.14 billion in third-party reimbursements. "With 3 months of anecdotal data, we have a good understanding of what the picture looks like," said Weahkee. "By and large we've got between 30% to 80% loss compared to this time last year; that varies across the country and by size of facility, but there's definitely significant losses in third-party revenues which will be hard to make up; it will take likely several years to make up for the loss of third-party revenues." Some IHS sites in Alaska say "it's a significant concern just being able to make payroll in the out months should this drag on much longer," he added.

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