ihs self-governance advisory committee (tsgac) quarterly ... · marilynn “lynn” malerba, chief,...

IHS SELF-GOVERNANCE

ADVISORY COMMITTEE (TSGAC)

QUARTERLY MEETING

OCTOBER 23-24, 2017

Embassy Suites DC Convention Center

900 10th Street Northwest, Washington, DC 20001

Phone: (202) 739-2001

IHS Tribal Self-Governance Advisory Committee and Technical Workgroup Quarterly Meeting

Tuesday, October 24, 2017 Wednesday, October 25, 2017

Embassy Suites Washington DC - DC Convention Center

900-10th Street NW Washington, DC 20001 Phone: (202) 739-2001

Table of Contents

1. TSGAC Information a. TSGAC Agenda b. 2018 TSGAC Calendar c. TSGAC Membership Matrix

2. Tribal Caucus

a. Joint TSGAC/DSTAC Letter, RE: Unpaid and Underpaid Third Party Benefits from Private Insurers

b. TSGAC Letter Request for Tribal Consultation on the Sanitation Deficiency System Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities (SDS) Guidance

c. TSGAC Letter to Mary Smith, re: Identification of Staff for Developing Level of Need Funded Data

d. TSGAC Letter to Buchanan, re: Update to Level of Need Funded Data and Workgroup Request

e. TSGAC Letter re: Participation in the Office of Tribal Self-Governance Director Interview & Selection Process

3. TSGAC Committee Business a. July Quarterly Meeting Summary b. July Quarterly Meeting Assignment Matrix c. TSGAC Correspondence Matrix d. Strategy Session Notes e. Strategy Session Recap f. Strategy Session Blueprint

4. Joint TSGAC and Direct Service Tribes Advisory Committee Meeting, October 23,

2017 – Update and Next Steps a. Meeting Agenda

5. IHS Strategic Plan

a. IHS Acting Director DTLL b. IHS Strategic Plan Framework and Timeline

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education

P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE AND TECHNICAL WORKGROUP QUARTERLY MEETING Tuesday, October 24, 2017 (8:00 am to 5:00 pm)

Wednesday, October 25, 2017 (8:30 am to 12:45 pm)

Embassy Suites Washington DC - DC Convention Center 900-10th Street NW

Washington, DC 20001 Phone: (202) 739-2001

AGENDA

Tuesday, October 24, 2017 (8:00 am to 5:00 pm)

Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical Workgroup with RADM Michael D. Weahkee, Acting Director, IHS

8:00 am Tribal Caucus Facilitated by: Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC)

Discussion of IHS Strategic Plan Workgroup Lost Collections from Private Insurance -- Pharmacy Benefit Managers

and Medical Services Tribal Consultation on Sanitation Deficiency System Guidance Document Interviews for Director, Office of Tribal Self-Governance, IHS Level of Need Funded Workgroup and Process Metrics and analysis of impact of Medicare-Like Rates Implementation Other

9:00 am Meeting Called to Order Welcome Invocation

Roll Call Introductions – All Participants & Invited Guests 9:15 am TSGAC Opening Remarks

Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Acting Director and Principal Deputy Director, IHS (Invited)

9:40 am TSGAC Committee Business Approval of Meeting Summary (July 2017) Update: 2017 Tribal Strategy Session, September 5-6, 2017

Jennifer McLaughlin, Self-Governance Associate, Jamestown S’Klallam Tribe

10:00 am Office of Tribal Self-Governance Update

IHS TSGAC & Technical Workgroup Quarterly Meeting Page 2 October 24-25, 2017 – AGENDA

Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS Status of TSGAC recommendations regarding Title V implementation

(initial TSGAC letter dated 2/27/27) 10:30 am Break 10:45 am Joint TSGAC and Direct Service Tribes Advisory Committee Meeting,

October 23, 2017 – Update and Next Steps Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS Melanie Fourkiller, Policy Analyst, Choctaw Nation of Oklahoma, and TSGAC

Tribal Technical Workgroup Co-Chair 11:15 am Office of Resource Access and Partnerships Update Terri Schmidt, RN, Acting Director, Office of Resource Access & Partnerships

(Invited) Workgroup to address lack of payment by private insurers for Pharmacy

Benefit Manager (PBM) and certain medical claims 12:00 pm TSGAC Members’ Executive Session with Acting IHS Director 1:30 pm Renewing the National IHS-Veterans Administration Memorandum of

Understanding Honorable Carolyn Clancy, M.D., MACP, Deputy Under Secretary for Health for

Organizational Excellence, Department of Veterans Affairs Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS (Invited)

Veterans Health Administration’s request to alter the payment methodology to IHS and Tribal Health Programs

Coordination of Care Follow up to the Veterans Administration’s Fall 2016 Consultation and

July, 2017 Roundtable 2:30 pm Indian Health Service Budget Update Elizabeth Fowler, Deputy Director for Management Operations, IHS (Invited)

Fiscal Year 2017 Funding Distribution Fiscal Year 2018 Appropriations Fiscal Year 2020 National Budget Formulation

3:00 pm Legislative Update

Caitrin Shuy, Director of Congressional Relations, National Indian Health Board (Invited)

Status of Health Reform Legislation Special Diabetes Program for Indians Restoring Accountability in the IHS of 2017 (S 1250 & HR 2662) Other Updates

3:30 pm Office of Information Technology Update (OIT) CAPT Mark Rives, DSc, Director, Office of Information Technology, IHS (Invited) Randall Hughes, Tribal Liaison, OIT, IHS (Invited)


Stuart Ferguson, PhD, Chief Technology Officer, Alaska Native Tribal Health Consortium, TSGAC Representative to ISAC (invited)

Update from ISAC Meeting, September 19-20, 2017 Veteran Affairs Migration to Cerner and Impact on the Resource and

Patient Management System (RPMS) Updates Future plans for RPMS IT Service Catalog – Tribal Consultation results and next steps

4:00 pm Implementation of the IHS Quality Framework and Associated Initiatives Capt. Michael Toedt, M.D., IHS Chief Medical Officer (Invited)

Jonathan Merrell, RN, BSN, MBA, IHS Acting Deputy Director for Quality Health Care (Invited)

Update on IHS accreditation and credentialing processes Patient wait times/Improving Patient Care (IPC) initiative Workforce development and critical staff vacancies

o Government and Accounting Office (GAO) Visits 4:45 pm Preparation for Discussion with Acting IHS Director

5:00 pm Recess until October 25, 2017


Wednesday, October 25, 2017 (8:30 am – 12:45 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical

Workgroup with RADM Michael D. Weahkee, Acting Director, IHS

8:30 am Welcome and Introductions


8:45 am Contract Support Cost Policy Update

Mickey Peercy, Executive Director of Self-Governance, Choctaw Nation of Oklahoma Roselyn Tso, Acting Director, IHS Office of Direct Service and Contracting Tribes (Invited)

Workgroup Update, August 16, 2017 Meeting Next Steps

9:15 am Patient Protection and Affordable Care Act (ACA) Implementation Update

Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Incorporated Doneg McDonough, Consultant, TSGAC

Outreach and Education Project Update (Tribal Sponsorship Fast Track Tool)

Administration and Congressional ACA Related Actions in 2017 and 2018 9:45 am “Re-Imagine HHS” Initiative, HHS Strategic Plan and IHS Strategic Plan

Development Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Acting Director and Principal Deputy Director, IHS (Invited)

“Re-Imagine HHS” Report due to Office of Management and Budget by September 11, 2017

HHS Strategic Plan Update and Tribal Consultation Process and timeline for IHS Strategic Plan Development

10:30 am Joint TSGAC and Acting IHS Director Discussion 11:15 am Closing Remarks


11:30 am Lunch 12:15 pm TSGAC Technical Workgroup Working Session 12:45 pm Adjourn TSGAC Meeting

2018 Calendar

Date Event Location

January 23‐25, 2018

1st Quarterly Meeting Washington, DC‐Embassy Suites DC Convention Center

March 27‐29, 2018 2nd Quarterly Meeting Washington, DC Embassy Suites DC Convention Center

April 22‐26, 2018 Tribal Self‐Governance Annual Consultation Conference

Albuquerque Convention Center Albuquerque, NM

July 17‐19, 2018 3rd Quarterly Meeting Washington, DC‐Embassy Suites DC Convention Center

September 11‐12, 2018 (Tentative)

Tribal Self‐Governance Strategy Session

Minneapolis, Minnesota‐ TBD

October 1‐4, 2018 4th Quarterly Meeting Washington, DC‐Embassy Suites DC Convention Center

2019 Proposed Calendar

Date Event Location

January 22‐24, 2019

1st Quarterly Meeting Washington, DC‐TBD

March 26‐28, 2019 2nd Quarterly Meeting Washington, DC‐TBD

April 21‐25, 2019 or April 28‐ May 2, 2019

Tribal Self‐Governance Annual Consultation Conference

TBD

July 16‐18, 2019 3rd Quarterly Meeting Washington, DC‐TBD

September 10‐11, 2019 Tribal Self‐Governance Strategy Session

TBD

October 1‐3, 2019 4th Quarterly Meeting Washington, DC‐TBD


P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

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MEMBERSHIP LIST (May 19, 2017)

AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Jaylene Peterson-Nyren, Executive

Director Kenaitze Indian Tribe

Primary 150 N Willow St. Kenai, AK 99611 P: (907) 335-7200 Email: [email protected]

Gerald “Jerry” Moses, Senior Director Intergovernmental Affairs, Alaska Native Tribal Health Consortium

Alternate 4000 Ambassador Drive, LIGA Department Anchorage, AK 99508 P: (907) 729-1900 Email: [email protected]

Albuquerque Ruben A. Romero, Governor Pueblo of Taos

Primary PO Box 1846 Taos, NM 87571 P: 575-758-9593 ~ F: 575-758-4604 Email: [email protected]

Raymond Loretto, DVM, Tribal Council Representative Pueblo of Jemez

Alternate PO BOX 100 Jemez Pueblo, NM 87024 P: 575-834-7359 ~ F: 575-834-7331 Email: [email protected]

Bemidji Jane Rhol, Tribal Council Secretary Grand Traverse Band of Ottawa & Chippewa Indians

Primary 2605 N West Bay Shore Drive Peshawbestown, MI 49682-9275 P: (231) 534-7494 Email: [email protected]

VACANT Alternate

Billings Beau Mitchell, Council Member Chippewa Cree Tribe

Primary PO Box 544 Box Elder, MT 59521 Email: [email protected]

Shelly Fyant, Tribal Council Member The Confederated Salish and Kootenai Tribes of the Flathead Nation

Alternate PO BOX 278 Pablo, MT 59855 P: (406) 275-2700 ~ F: (406) 275-2806 Email:

California

Ryan Jackson, Council Member Hoopa Valley Tribe

Primary PO Box 1348 Hoopa, CA 95546 Email: [email protected]

Robert Smith, Chairman Pala Band of Mission Indians

Alternate 35961 Pala-Temecula Rd. Pala, CA 92059 P: 760-891-3519 ~ F: 760-891-3584 Email: [email protected]

Great Plains VACANT Primary

VACANT Alternate

Nashville Marilynn “Lynn” Malerba, Chief Mohegan Tribe of Connecticut TSGAC Chairwoman

Primary 5 Crow Hill Road Uncasville, CT 06382 P: 860-862-6192 ~ F: Email: [email protected]

TSGAC & Technical Work Group Membership List May 19, 2017

Page 2 of 6

Casey Cooper, Chief Executive Officer Eastern Band of Cherokee Indians Hospital

Alternate 43 John Crowe Hill Rd. PO Box 666 Cherokee, NC 28719 Email: [email protected]

Navajo Jonathan Nez, Vice President Navajo Nation

Primary PO BOX 7440 Window Rock, AZ 86515 P: (928) 871-7000 Email: [email protected]

Nathaniel Brown, Delegate of the 23rd Navajo Nation Council Navajo Nation

Alternate PO BOX 3390 Window Rock, AZ 86515 P: (928) 871-6380 Email: [email protected]

Oklahoma 1 John Barrett, Jr., Chairman Rhonda Butcher, Director Citizen Potawatomi Nation

Primary Proxy

1601 S. Gordon Cooper Dr. Shawnee, OK 74801 P: 405-275-3121 x 1157 F:405-275-4658 Email: [email protected]

Kay Rhoads, Principal Chief Sac and Fox Nation

Alternate 920883 Hwy 99 Stroud, OK 74079 P: (918) 968-3526 x 1004 F: (918) 968-1142 Email: [email protected]

Oklahoma 2 Jefferson Keel, Lt. Governor Chickasaw Nation

Primary PO Box 1548 Ada, OK 74821 P: 580-436-7232 ~ F: 580-436-7209 Email: [email protected]

Gary Batton, Chief Mickey Peercy, Executive Director Choctaw Nation of Oklahoma

Alternate Proxy

PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]

Phoenix VACANT

Primary

VACANT Alternate

Portland W. Ron Allen, Tribal Chairman/CEO Jamestown S’Klallam Tribe TSGAC Vice-Chairman

Primary 1033 Old Blyn Highway Sequim, WA 98382 P: 360-681-4621 ~ F: 360-681-4643 Email: [email protected]

Tyson Johnston, Vice President Quinault Indian Nation

Alternate P.O. Box 189 (1214 Aalis Drive) Taholah, WA 98587 P: 360-276-8211 ~ F: 360-276-4191 Email: [email protected]

Tucson Daniel L.A. Preston, III, Councilman Tohono O’odham Nation

Primary P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]

Anthony J. Francisco, Jr., Councilman Tohono O’odham Nation

Alternate P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]



Page 3 of 6

TSGAC TECHNICAL WORKGROUP AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Brandon Biddle

Alaska Native Tribal Health Consortium

Tech Rep 4000 Ambassador Drive Anchorage, Alaska 99508 P: 907-729-4687 Email: [email protected]

Alberta Unok Deputy Director Alaska Native Health Board

Tech Rep 4000 Ambassador Drive Anchorage, Alaska 99508 P: 907-562-6006 Email: [email protected]

Albuquerque Shawn Duran Taos Pueblo

Tech Rep P.O. Box 1846 Taos, N.M. 87571 P: 575.758.8626 ext. 115 Email: [email protected]

Bemidji John Mojica Mille Lacs Band of Ojibwe

Tech Rep 43408 Oodena Drive Onamia, MN 56359 P: 320-532-7479 ~ F: 320-532-7505 Email: [email protected]

Billings Ed Parisian Chippewa Cree Tribe

Tech Rep PO Box 544 Box Elder, MT 59521 Email: [email protected]

California VACANT

Tech Rep

D.C. (National)

C. Juliet Pittman SENSE Incorporated

Tech Rep Upshaw Place 1130 -20th Street, NW; Suite 220 Washington, DC 20036 P: 202-628-1151 ~ F: 202-638-4502 Email: [email protected]

Cyndi Ferguson SENSE Incorporated

Tech Rep Upshaw Place 1130 -20th Street, NW; Suite 220 Washington, DC 20036 P: (202) 628-1151 ~ F: (603) 754-7625 C: (202) 638-4502 Email: [email protected]

Doneg McDonough

Tech Rep (Health Reform)

Phone: 202-486-3343 (cell) Fax: 202-499-1384 Email: [email protected]

Great Plains VACANT Tech Rep

Nashville Dee Sabattus United South and Eastern Tribes, Inc.

Tech Rep 711 Stewarts Pike Ferry, Suite 100 Nashville, TN 37214 Email: [email protected]

Navajo Patrese Atine Navajo Nation Washington Office

Tech Rep 750 First Street NE, Suite 1010 Washington, DC 20002 P: 202.682.7390 E-mail: [email protected]

Oklahoma Rhonda Farrimond Choctaw Nation

Tech Rep PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]


Page 4 of 6

Melanie Fourkiller Choctaw Nation Tribal Technical Co-Chair

Tech Rep PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 C: 918-453-7338 Email: [email protected]

Karen Ketcher Cherokee Nation

Tech Rep PO Box 948 Tahlequah, OK 74465 P: 918-772-4130 Email: [email protected]

Kasie Nichols Citizen Potawatomi Nation

Tech Rep 1601 S. Gordon Cooper Dr. Shawnee, OK 74801 P: 405.275.3121 ~ F: 405.275.0198 C: 405-474-9126 Email: [email protected]

Phoenix VACANT Tech Rep

Portland Jennifer McLaughlin Jamestown S’Klallam Tribe

Tech Rep 1033 Old Blyn Highway Sequim, WA 98382 P: (360) 681-4612 ~ F: (360) 681-4648 Email: [email protected]

Eugena R Hobucket Quinault Indian Nation

Tech Rep PO BOX 189 Taholah WA 98587 P: (360) 276-8211 ~ F: (360) 276-8201 Email: [email protected]

Tucson Veronica Geronimo Tohono O’odham Nation

Tech Rep P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]



Page 5 of 6

FEDERAL TECHS AREA MEMBER (name/title) STATUS CONTACT INFORMATION HQ Jennifer Cooper

Deputy Director, OTSG (Federal Tech Co-Chair)

OTSG Rep 801 Thompson Ave, Suite 240 Rockville, MD 20852 P: 301-443-7821 ~F: 310-443-1050 [email protected]

Jeremy Marshall Policy Analyst, OTSG

OTSG Rep 801 Thompson Ave, Suite 240 Rockville, MD 20852 P: 301-443-7821 ~F: 310-443-1050 [email protected]

Great Plains Sandy Nelson (POC) Director, Office of Tribal Programs

Area Rep 115 4th Avenue, SE, Suite 309 Aberdeen, SD 57401 P: 605-226-7276 ~F: 605-226-7541 [email protected]

Alaska

Lanie Fox (POC) Director, Office of Tribal Programs

Area Rep

4141 Ambassador Drive, Suite 300 Anchorage, AK 99508-5928 P: 907-729-3677 ~F: 907-729-3678 [email protected]

California Travis Coleman IHS Agency Lead Negotiator

Area Rep 650 Capitol Mall, Ste 7-100 Sacramento, CA 95814 P: 916-930-3927 ~F: 916-930-3952 [email protected]

Nashville Lindsay King IHS Agency Lead Negotiator

Area Rep 711 Stewarts Ferry Pike Nashville, TN 37214-2634 P: 615- 467-1521 ~F: 615-467-1625 [email protected]

Navajo Floyd Thompson Executive Officer IHS Agency Lead Negotiator

Area Rep Hwy 264 (St. Michael, AZ) Window Rock, AZ 86515-9020 P: 928-871-1444 ~F: [email protected]

Alva Tom (POC) Director, Indian Self-Determination

Area Rep Hwy 264 (St. Michael, AZ) Window Rock, AZ 86515-9020 P: 928-871-1444 ~F: 928-871-5819 [email protected]

Oklahoma Max Tahsuda Director, Tribal Self-Determination IHS Agency Lead Negotiator

Area Rep

701 Market Drive Oklahoma City, OK 73114 P: 405-951-3761 ~F: 405-951-3868 [email protected]

Portland Denise Imholt IHS Agency Lead Negotiator

Area Rep 1414 NW Northrup Street, Suite 800 Portland, OR 97209 P: 503-414-7792 ~F:503-414-7791 [email protected]

Tucson Robert L. Price (POC) Public Health Advisor, Office of Tribal Affairs

Area Rep 7900 South J Stock Road Tucson, AZ 85746 P: 520-295-2403 ~F:520-295-2540 [email protected]


Page 6 of 6

OTHER RESOURCES MEMBER (name/title) ORGANIZATION CONTACT INFORMATION Caitrin Shuy Director of Congressional Relations

National Indian Health Board P: 202-507-4085 Email: [email protected]

Devin Delrow Director of Federal Relations

National Indian Health Board P: 202-507-4072 Email: [email protected]

TSGAC Mailing Address: c/o Self-Governance Communication and Education


Delivered electronically to [email protected]

September 14, 2017 RADM Michael Weahkee Acting Director Indian Health Service U.S. Department of Health and Human Services 5600 Fishers Lane Mail Stop: 08E53 Rockville, MD 20857 RE: Unpaid and Underpaid Third Party Benefits from Private Insurers Dear Acting Director Weahkee: We write on behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) and the IHS Direct Service Tribal Advisory Committee (DSTAC) to request that you designate it a high priority to address the inappropriate and illegal action by insurance companies and benefit mangers erroneously under paying Indian health and Tribal facilities on behalf of all of Indian country. As discussed in the January 2017 IHS TSGAC meeting, the payment issue involves insurance plans and pharmacy benefit managers identifying ITU’s as non-network facilities and denying ITU claims, which seems to have become a standard practice in IHS and must be corrected in a timely manner. This has resulted in estimated millions of dollars being underpaid to IHS and Tribal facilities for the care they provide. It is our understanding that the IHS Division of Business Office Enhancement, Office of Resource Access and Partnership (ORAP) is aware of these issues and has formed a workgroup within IHS, including the IHS Office of General Counsel, to resolve these payment issues. Again, during the July 2017 IHS TSGAC meeting, an update on the workgroup’s work was requested and responded to by Carol Chicharello, Acting Director, Division of Business Office Enhancement, ORAP wherein she stated that IHS has reached out to the Caremark plans and had initial discussions. She reported that it appears they want to work with IHS to resolve the payment issues and asked for specific examples, which IHS has provided. It was also stated that there will be some additional need for right of recovery payment, identifying points of contact for Tribes, etc. The IHS workgroup focused primarily on Caremark issues and would like to expand to other pharmacy benefit managers in the future, with acknowledgement that there are denials on the medical claims also. She reported that IHS needs to update their prompt payment notice and work with larger insurers and if necessary reach out to the state department of insurances to enforce the right to recovery. IHS has yet to develop a process to share solutions with Tribes but plans to do so. As we are all aware, the funding streams for Indian health care are very limited and do not meet the needs of Tribal citizens. Therefore, this issue seems to be of the utmost importance as it has the potential to bring millions of [reimbursed] needed dollars back into the Indian health care system. Each day that this goes unresolved means lost resources that should be coming in to supplement woefully insufficient appropriations for Indian health. We respectfully request that IHS make this work a priority and provide monthly reports on the work and path forward so that IHS and Tribes can begin to recoup some of these unpaid and underpaid claims.

IHS TRIBAL SELF-GOVERNANCE ADVISORY

COMMITTEE

mailto:[email protected]

TSGAC Letter Re: Unpaid and Underpaid Third Party Benefits from Private Insurers September 14, 2017 Page 2 of 2

As always, TSGAC and DSTAC appreciate the ongoing efforts to improve the funding streams for Indian health care and look forward to continued collaboration in addressing these very important payment issues. If you have any questions or concerns regarding this letter, please feel free to contact us at Lynn Malerba, [email protected] for TSGAC and Nicolas Barton, [email protected] for DSTAC. Thank you.

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Nicolas Barton, Executive Director Chairwoman, IHS TSGAC Cheyenne & Arapaho Tribes Chairman, IHS DSTAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS Roselyn Tso, Acting Director, Office of Direct Service and Contracting Tribes, IHS




P.O. Box 1734, McAlester, OK 74501

Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

Delivered electronically to: [email protected]

August 31, 2017 RADM Michael Weahkee, Acting Director Indian Health Service Office of the Director 5600 Fishers Lane Mail Stop: 08E53 Rockville, MD 20857

RE: Request for Tribal Consultation on the Sanitation Deficiency System Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities Dear Acting Director Weahkee: On behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC), I write to request that you initiate Tribal Consultation on the 2003 working draft Sanitation Deficiency System (SDS) Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities (“SDS Guidelines”) before any revised guidelines issued by IHS Office of Environmental Health and Engineering (OEHE) are finalized. Over the last year TSGAC has received updates regarding OEHE’s activities. These updates have been critically important and responsive to many of our concerns. During our recent quarterly meeting in July, OEHE shared that they plan to finalize and release the SDS Guidelines. These guidelines have remained as a working draft since May 2003, but have been applied as a policy of the Agency. Use of the guidelines has resulted in some concerning outcomes, including inconsistencies in its application among Area Offices. Our understanding is that, even prior to publication of the working draft of the SDS Guidelines, Tribal Consultation and feedback was not collected, or was not used. These guidelines effect distribution of funding and implementation of the program and, as such, Tribes should have the opportunity to review and provide meaningful input prior to finalization. Additionally, IHS Leadership has consistently heard testimony that access to safe drinking water and adequate waste water and sanitation facilities are critical to the health and welfare of communities across Indian Country. In fact, the Department of Health and Human Services reported that a staggering 47 percent of American Indian/Alaska Native homes were in need of repair and nearly six percent did not have any access to adequate sanitation facilities. Given the need and the President’s stated interest in fortifying the nation’s infrastructure, TSGAC would like to see the IHS actively engage Tribes to review the SDS Guidelines and develop a process to accurately evaluate and report need in Tribal communities. Only through a collaborative, concentrated effort can we secure additional funds to ensure that issues with access to clean and safe water do not persistent.

http://www.tribalselfgov.org/


TSGAC Letter RE: Request for Tribal Consultation on the Sanitation Deficiency System Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities August 31, 2017 Page 2 of 2

Thank you for considering our request. We look forward to working with you and others to updating the SDS Guidelines. If you have any questions or concerns regarding these recommendations, please contact me at [email protected]. Thank you.

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: RADM Kevin Meeks, Acting Deputy Director of Field Operations, IHS

Gary J. Hartz, P.E., Director, Office of Environmental Health & Engineering, IHS Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC and Technical Workgroup


IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE

c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501


Sent electronically: [email protected] December 16, 2016 Mary Smith, Principal Deputy Director Indian Health Service Office of the Director 5600 Fishers Lane Mail Stop: 08E53 Rockville, MD 20857 RE: Identification of Staff for Developing Level of Need Funded Data Dear Principal Deputy Director Smith: During the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) October 2016 Quarterly Meeting, Tribal leaders expressed their increasing concerns with the lack of IHS staff attention and due diligence paid to the Indian Health Care Improvement Fund (IHCIF) and the Level of Need Funded (LNF) calculations as required by statute. On behalf of the TSGAC, this letter captures the broader points of our discussion and outlines next steps. As you are aware, the Indian health system faces significant funding disparities when compared to other Federal health care programs. This disparity continued to grow in 2015, with IHS per capita spending at just $3,136 per person, while the national average per capita spending was $8,517 per person. The Indian Health Care Improvement Act (IHCIA) established the IHCIF to eliminate the deficiencies in health status and health resources and requires a report to Congress to address the current health status and resource deficiency for each IHS Service Unit, Indian Tribe, or Tribal organization. Despite the American Indian and Alaska Native (AI/AN) health disparities and a legislative mechanism to address resource deficiencies, little to no funding has been used to expand services necessary to bring health parity for AI/AN people. The TSGAC previously commented to you in a letter dated September 27, 2016 (enclosed), that the 25 U.S.C. 458aaa-13(a)(2) of the Indian Self-Determination and Education Assistance Act requires the annual report to Congress on the administration of the Tribal Self-Governance Program include a detailed analysis of LNF. This analysis must include the level of need funded for each Tribe, either directly by the Secretary, under Self-Determination Contracts, or under Self-Governance Compacts and Funding Agreements. However, the most recent reports do not include this analysis, leaving Tribes and Congress with less data to support continued funding increases to IHS. As such, TSGAC has a number of requests to help Tribes learn more about IHCIF and LNF, and assist the agency in updating information related to each:



TSGAC Letter RE: Identification of Staff for Developing Level of Need Funded Data December 16, 2016 Page 2 of 2

First, the TSGAC respectfully requests a copy of the required Congressional report on the

current health status and resource deficiency for each IHS Service Unit required by 25 U.S.C. § 1621(f). This report was due to Congress no later than three years after the date of enactment of the IHCIA.

Second, we request that IHS identify statistical/technical staff as point of contact for IHCIF and LNF data. The IHS staff who previously conducted this statistical analysis has retired and a new point of contact is necessary to perform future LNF calculations.

Third, we request a joint Tribal/Federal Workgroup with actuarial and health economist support to update, review and analyze the IHCIF. In the course of its’ work, we hope the Workgroup will re-open the technical evaluation of the Indian Health Care Improvement Fund Methodology completed in 2010 and re-evaluate the recommendations received from Tribes at that time. Then, through Tribal consultation, IHS can explore whether changes to the existing approach are necessary for better articulation of the IHCIF in the future.

Finally, we further request, that the first step simply be an update of the existing data in the LNF analysis.

Thank you for your continued partnership and commitment to improving the health care status of American Indians and Alaska Natives. Tribal advocacy for the funding needs for Indian health are much more compelling when they can be supported by current data and benchmarked against health care spending outside of IHS. We look forward to re-engaging in work on the IHCIF. Should you have questions or require additional information, please do not hesitate to contact me at (860) 862-6192 or via email at [email protected]. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC Members Enclosure: TSGAC Letter dated 9/27/16 - Comments on FY 2015 Report to Congress on Administration of the Tribal Self-Governance Program




Sent Electronically to [email protected]

September 27, 2016

Mary Smith, Principal Deputy Director

Indian Health Service

Mail Stop: 08E86

5600 Fishers Lane

Rockville, MD 20857

Re: Comments on FY 2015 Report to Congress on Administration of the Tribal Self-

Governance Program

Dear Principal Deputy Director Smith:

On behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory

Committee (TSGAC), I write to provide comments on the Fiscal Year 2015 Report to Congress

on the Administration of the Tribal Self-Governance Program. TSGAC appreciates the

opportunity to submit these comments in response to your recent letter to Tribal leaders dated

August 21, 2016.

As you know, this Report is required by law annually under § 514 of the Indian Self-

Determination and Education Assistance Act (ISDEAA), 25 U.S.C. § 458aaa-13. Subsection

514(b)(4) requires that each annual report to Congress, before being submitted to Congress, be

distributed to Tribes for comment. Subsection 514(b)(5) requires that each annual report to

Congress include the separate views and comments of the Tribes and Tribal organizations.

TSGAC previously submitted comments and recommendations, as recently as last year,

to improve the annual report so that it meets the statutory requirements outlined in ISDEAA.

Unfortunately, the FY 2015 Report does not reflect recommendations made in 2015 on the FY

2014 and do not meet the statutory requirements. As such, we find it necessary to spell out the

statutory requirements for this report.

Subsection 514(a)(2) requires that each annual report to Congress include a detailed

analysis of the level of need being presently funded or unfunded for each Tribe, either

directly by the Secretary, under Self-Determination Contracts, or under Self-Governance

Compacts and Funding Agreements.

Subsection 514(b)(2) of the ISDEAA requires, in addition, that each annual report to

Congress identify:

(A) The relative costs and benefits of self-governance;

(B) With particularity, all funds that are specifically or functionally related to the

provision by the Secretary of services and benefits to self-governance Indian

Tribes and their members;



TSGAC Letter to Mary Smith, Principal Deputy Director September 27, 2016

RE: Comments on FY 2015 Report to Congress on Administration of the TSGP Page 2

(C) The funds transferred to each self-governance Indian tribe and the corresponding

reduction in the Federal bureaucracy;

(D) The funding formula for individual Tribal shares of all headquarters funds,

together with the comments of affected Indian Tribes and Tribal organizations,

developed under § 514(c); and

(E) Amounts expended in the preceding fiscal year to carry out inherent Federal

functions, including an identification of those functions by type and location.

Subsection 514(b)(3) further requires that each annual report to Congress also contain a

description of the method or methods (of any revisions thereof) used to determine the

individual Tribal share of funds controlled by all components of IHS (including funds

assessed by any other Federal agency) for inclusion in Self-Governance Compacts or

Funding Agreements.

Given the statutorily requirements, TSGAC provides the following comments to revise

the FY 2015 Report and to improve future Congressional reports that are more responsive to the

statutory reports.

1. Include an analysis of level of need funded and unfunded. The report does not

contain any analysis of the level of need, being presently funded or unfunded for each

Tribe. However, IHS does have data to evaluate the level of need funded and unfunded

for Tribes and Service Units. IHS should work with Tribes to develop a data analysis and

the best method to present the outcomes within the future Tribal Self-Governance

Program reports.

2. Expand on examples of benefits of Self-Governance. There is no analysis of the

relative costs and benefits of Self-Governance as required by § 514(b)(2)(A). This

statutory requirement is reasonably read to require the IHS to conduct a cost/benefit

analysis with examples of how Tribes have successfully redesigned their compacted

programs in a cost effective way to improve program performance for the benefit of their

communities. Instead, the report simply provides a listing of possible actions that Tribes

might undertake and refers to the next section that lists the total amounts that

Headquarters and the Area Offices have expended for Self-Governance. This is not

responsive to the statutory requirement and does not accurately illustrate the tremendous

success the Tribal Self-Governance Program brings to the Indian Health System.

Self-Governance Tribes have reduced Federal administration of health care in Tribal

communities while providing culturally competent care, expanding local services, and

strengthening Tribal economies. This report is an opportunity to let Congress know about

how Tribes participating in Self-Governance have redesigned programs, leveraged other

Federal resources, and created partnerships with the private sector to expand services and

improve care for their communities. It is an opportunity to inform Congress of specific

examples of program successes and the language on page 5 leaves much to be desired.

3. Specify other department funding available to enhance Tribal Self-Governance

Program. The listing of total amounts expended by IHS Headquarters and IHS Area

Offices in Section E does not comply with ISDEAA requirement to provide “with



particularity, all funds that are specifically or functionally related to the provision by the

Secretary (HHS) of services and benefits to Self-Governance Indian Tribes and their

members.” HHS agencies provide funding to Tribes to enhance and complement their

Self-Governance programs. These activities should be included in the report.

4. Provide a corresponding analysis of reduction in Federal bureaucracy. While

Section F of the Report does show funds transferred to each Tribe in Exhibit A, there is

no analysis or illustration of any corresponding reduction in the Federal bureaucracy as

required by ISDEAA. The simplistic statement provided does not provide valuable or

informative data to Congress that Title V is achieving one of its stated goals, “to provide

for a measurable parallel reduction in the Federal bureaucracy as programs, services,

functions, and activities (or portions thereof) are assumed by Indian Tribes.” As

previously recommended, TSGAC suggests a more detailed description and year-to-year

comparison to measure reductions in Federal bureaucracy and further illustrate the Tribal

Self-Governance Program success. The requirement in ISDEAA necessitates measurable

outcomes, not just a vague statement about Federal actions prior to the formal

establishment of Title V.

5. Clarify inherent Federal functions by type and location. ISDEAA requires that IHS

include the “amounts expended in the preceding fiscal year to carry out inherent Federal

functions by type and location.” Despite sharing the residuals total, it is not clear what

functions the IHS continues to provide to Self-Governance Tribes using the IHS

Headquarters residual amount, nor is the report specific about how this amount is

determined annually. This number also does not accurately reflect the amount of funding

IHS Area Offices retain to carry out inherent Federal functions.

There are criteria for identifying inherent Federal functions, which the Report could

reference. The term “inherent Federal functions” is defined in § 501(a)(4) as meaning

“those Federal functions which cannot lawfully be delegated to Indian Tribes.” The

Federal Activities Inventory Reform Act of 1998 (FAIR), P. L. 105-270 (112 Stat. 2382-

2385), codified as a note to 31 U.S.C. § 501, defines an “inherently governmental

function” as meaning “a function that is so intimately related to the public interest as to

require performance by Federal Government employees.”

The FAIR lists certain types of activities, involving the interpretation and execution of

Federal laws, which determine whether a function is inherently governmental. OMB

Circular A-76 also is a source for defining inherently governmental functions by type, as

well as a recent Policy Letter 11-01 dated September 12, 2014 (76 Federal Register

56227). These sources could be used to respond more adequately to the statutory

requirement in § 514(b)(2)(E).

6. Provide additional opportunity for Tribal input. This annual report is a unique

opportunity for IHS to share the success of Self-Governance. However, the Agency has

not made recommended improvements. Prior to development and release of the Report,

TSGAC respectfully requests to work together to implement the changes requested

above.



In closing, TSGAC appreciates the opportunity to submit comments on this Report and

looks forward to working with you on future Reports. Should you have any questions or if I can

provide any additional information, please contact me at [email protected].

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut

Chairwoman, IHS TSGAC

cc: P. Benjamin Smith, Director, Office of Tribal Self-Governance

TSGAC Members and Technical Workgroup


IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE

c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501


Sent electronically: [email protected] May 26, 2017 RADM Chris Buchanan, Acting Director Indian Health Service Office of the Director 5600 Fishers Lane Mail Stop: 08E53 Rockville, MD 20857

Re: Update to Level of Need Funded Data and Workgroup Request Dear RADM Buchanan: During the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) March 2017 Quarterly Meeting, Tribal leaders expressed their increasing concerns with the lack of updated Level of Need Funded (LNF) data. This letter serves as a follow up to the TSGAC letter to Ms. Smith, dated December 16, 2016 (enclosed), requesting additional educational training regarding the Indian Health Care Improvement Fund (IHCIF), LNF calculations and plans to update information related to each. The letter specifically requests IHS to:

1. Share a copy of the Congressional report on the current health status and resource deficiency for each IHS Service Unit required by 25 U.S.C. § 1621(f);

2. Identify statistical/technical staff as point of contact for IHCIF and LNF data;

3. Establish a joint Tribal/Federal Workgroup with actuarial and health economist support to update, review and analyze the IHCIF; and,

4. Update the existing data in the LNF analysis.

As you know, Level of Need Funded (or Federal Disparity Index) data has not been updated since 2010, now a benchmark year for federal health care funding. In this budgetary climate, it is critical that IHS and Tribes accurately benchmark unmet health care needs with reliable data. An updated LNF analysis is imperative to support essential funding requests to Congress.

The TSGAC previously requested that IHS either contract with a health economist or

otherwise obtain staff to prepare an LNF analysis, as well as establish an LNF Workgroup. Once an IHS contractor or staff can update this information and a Workgroup is established to conduct an LNF analysis, updated data will be available to justify unmet health care needs to Congress. Given the urgent need to complete an analysis, TSGAC requests a status update to our requests to contract with a health economist or obtain staff to update the LNF data as well as efforts to convene an LNF workgroup.



TSGAC Letter RE: Update to Level of Need Funded Data and Workgroup Request May 26, 2017 Page 2 of 2

Thank you for your continued partnership and commitment to improving the health care

status of American Indians and Alaska Natives. Tribal advocacy for the funding needs of Indian health are much more compelling when they can be supported by current data and benchmarked against health care spending outside of IHS. We look forward to re-engaging in this work. Should you have questions or require additional information, please do not hesitate to contact me at (860) 862-6192 or via email at [email protected].

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC and Technical Workgroup Members Enclosure: TSGAC Letter dated 12/16/16 – Identification of Staff for Developing Level of

Need Funded Data





Delivered electronically to: [email protected]

August 31, 2017 RADM Michael Weahkee, Acting Director Indian Health Service Office of the Director 5600 Fishers Lane Mail Stop: 08E53 Rockville, MD 20857 RE: Participation in the Office of Tribal Self-Governance Director Interview & Selection Process Dear Acting Director Weahkee: Thank you for attending the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) Meeting July 18-19, 2017. We appreciate the time and information you shared with us during those two days and look forward to working with you to advance Self-Governance and fully implement Title V of the Indian Self-Determination Education and Assistance Act. As you know, the Office of Tribal Self-Governance (OTSG) plays a critical role in the agency’s activities with Tribal Leadership, coordinating meetings, facilitating policy discussions, and promoting Self-Governance. Perhaps most importantly OTSG provides information and technical assistance to Tribes currently operating and interested in developing Self-Governance activities. Given the unique role this office plays in Self-Governance, it is critical that Tribal Leadership be engaged when the Agency is filling management vacancies. In fact, TSGAC leadership was included in the interview process and provided recommendations prior to the selection of the OTSG Deputy Director. During the July meeting, you shared that the agency plans to begin filling acting and vacant positions within the agency. TSGAC would like the opportunity to similarly engage in permanently filling the OTSG Director role. As such, we ask that Chief Lynn Malerba of the Mohegan Tribe and Chairman W. Ron Allen of the Jamestown S’Klallam Tribe be able to participate when the agency initiates the interview and selection processes. For your convenience, our contact information is as follows: Marilynn “Lynn” Malerba Chief, Mohegan Tribe [email protected] (860) 862-6192

W. Ron Allen Chairman/CEO, Jamestown S’Klallam Tribe [email protected] (206) 369-6699

If you have any questions or concerns regarding the recommendations from above please contact me at [email protected]. Thank you.

Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup






TSGAC Letter Re: Participation in the Office of Tribal Self-Governance Director Interview and Selection Process August 31, 2017 Page 2 of 2



INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE

AND TECHNICAL WORKGROUP QUARTERLY MEETING Tuesday, July 18, 2017 (8:00 am to 5:00 pm)

Wednesday, July 19, 2017 (8:30 am to 12:45 pm)

Embassy Suites Washington DC - DC Convention Center 900-10th Street NW

Washington, DC 20001 Phone: (202) 739-2001

Meeting Summary

Tuesday, July 18, 2017 (8:00 am to 5:00 pm)

Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical Workgroup with RADM Michael D. Weahkee, Acting Director, IHS

Tribal Caucus Facilitated by: Jefferson Keel, Lt. Governor, Chickasaw Nation and Mickey Peercy, Proxy for Gary Batton, Chief, Choctaw Nation Meeting Called to Order Welcome Invocation: Jefferson Keel, Lt. Governor, Chickasaw Nation Roll Call: Alaska: Gerald “Jerry” Moses, Senior Director, Intergovernmental Affairs, Alaska Native

Tribal Health Consortium Albuquerque: Ruben A. Romero, Governor, Taos Pueblo

Raymond Loretto, DVM, Governor, Pueblo of Jemez Bemidji: Jane Rohl, Tribal Council Secretary, Grand Traverse Band of Ottawa &

Chippewa Indians Billings: Beau Mitchell, Council Member, Chippewa Cree Tribe California: Daniel Jordan, Proxy for Ryan Jackson, Chairman, Hoopa Valley Tribe Navajo: Patrese Atine, Proxy for Jonathan Nez, Vice President, Navajo Nation Oklahoma 1: Kasie Nichols, Proxy for John Barrett Jr., Chairman, Citizen Potawatomi Nation Oklahoma 2: Mickey Peercy, Proxy for Gary Batton, Chief, Choctaw Nation Jefferson Keel, Lt. Governor, Chickasaw Nation Portland: W. Ron Allen, Chairman/CEO, Jamestown S’Klallam Tribe Tucson: Daniel L.A. Preston III, Councilman, Tohono O’odham Nation Introductions – All Participants & Invited Guests TSGAC Opening Remarks Jefferson Keel, Lt. Governor, Chickasaw Nation RADM Michael D. Weahkee, Acting Director, IHS

RADM Weahkee thanked the attendees and participants and impressed the importance of continued engagement during this transition.

IHS TSGAC & Technical Workgroup Quarterly Meeting Page 2 July 18-19, 2017 – Meeting Summary

The Acting Director shared information regarding his personal and professional experience including experience as the CEO of the Phoenix Indian Medical Center and various positions at IHS Headquarters

HHS Secretary Price has top three priorities patients, people, and partnership for all agencies and asked for innovation to address serious mental health issues, childhood obesity, and combating the opioid abuse.

IHS has set three priorities to address align with the Secretary’s priorities. o People: 70% of workforce is American Indian and Alaska Native (AI/AN) and their health

and wellbeing is important to IHS. Recruitment continues to be a challenge and top priority. IHS has already adopted global recruitment to streamline application process to allow applicants to be considered for a number of similar openings across the system. IHS has also been given priority access to candidates that have applied to the health service corp.

o Partnerships: These partnerships will be critical to improving IHS outreach and services. IHS recently signed an MOU with Boys & Girls Club to promote healthy behavior among AI/AN youth. MD Anderson Center in Houston to enhance cancer treatment and screening. Tribal consultation remains a top priority for IHS and RADM Weakhee plans to evaluate additional Tribal consultation needs.

o Quality: Rolling out consultation on Emergency Telemedicine, which increases access to Emergency Medicine Providers. They will be expanding this service to other service units outside the Great Plains Area. IHS also need to focus on utilizing improvement sciences to maximize opportunities for the administration of health care and service delivery.

o Resources: This remains a top issue for the agency as it seeks to accomplish its mission and ensure improvement are made to create sustainable change.

TSGAC Committee Business Approval of Meeting Summary (March 2017)

o Choctaw Nation made a motion to approve the meeting summary. o Chippewa Cree Tribe of the Rocky Boy's Reservation seconded the motion. o Motion passed without objection.

Joint TSGAC and Direct Service Tribes Advisory Committee Meeting, October 23, 2017 at the Health and Human Services Building in Washington, D.C.

o Participants were given a draft agenda to consider. o It has been several years since the two committees have met together. o Items to Consider:

Level Need Funded to the budget session. Reimagining initiative and reorganization plan. Discussion to identify additional authority needed to use end of the year funding.

o Do we want to include Urbans and/or Members of the HHS Secretary’s Tribal Advisory Committee? We want to work with Tribal Leaders before we provide feedback.

2017 Tribal Strategy Session Agenda o We are moving in a new direction for setting up this Strategy Session. Instead of

focusing on refining and updating the Strategy document, we would like to focus more on the implementation of the priorities identified. We are also looking to energize the grassroots network and improving our communication plan.

o We are also recruiting additional folks to the planning team.


Office of Tribal Self-Governance Update Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS

Outcomes of the April Agency Lead Negotiator Meeting o This was a good opportunity to really talk about and look at negotiations, transfer of

PSFAs to Tribes, and how things can be improved. o One outcome was the identification that a Federal/Tribal toolkit and checklist to help new

and interested Tribes transition to Self-Governance. o There were discussions about how to strengthen and support those who are designated

to represent the IHS Director during negotiations. There is a great, but perhaps outdated, training curriculum OTSG has and will be working to implement.

o The ALNs plan to meet after this TSGAC meeting to discuss these projects in greater depth.

As you know we are still awaiting new tables to provide to negotiating Tribes. There are currently Tribes in negotiations and OTSG hopes that by the October meeting they

will have new Self-Governance Tribes to announce. They also solicited for the planning and negotiation cooperative agreements in June and should

be able to make announcements about those awards in October. California Area, Office of Tribal Self-Governance, and SGCE hosted training in Southern

California at the end of June. Updating the PSFA manual is still on the radar and OTSG continues to work with Tribes to

update that document. Tribes should look for an announcement regarding the Self-Governance Congressional Report

in the new future. Tribal Questions: When is the best time to have negotiations? Is there a time when Tribes

should not enter negotiations? o Response: This is a Tribally-driven initiative, so it is dependent on the Tribe’s plans.

However, working with the ALN on the schedule is critical to the process as well. Tribal Question: What is the status of the Planning and Negotiated Cooperative Agreement

Grant applications? o Response: They are in objective review. Hope to have a list of the awardees by the end

of July. Tribal Question: Do you have any success stories that you can share?

o Response: Our goal was to have Ho-Chunk in Self-Governance by the Annual Consultation Conference, which did happen. Additionally, we have several Tribes who we expect to be finished with negotiations around late summer/early fall.

Office of Environmental Health and Engineering Chuck Grim, DDS, Chairman, Facilities Appropriations Advisory Board, IHS

FAAB Meeting Update o FAAB is a statutory committee within IHS, who meets at least twice a year. o Conducted a survey to evaluate potential new facilities and additional needs to

accommodate expanded authorities under ICHIA, mental, long-term care, special needs, and dialysis units. The new and expanded authority added on $4.2 billion.

o A workgroup has been assigned to assist in the clarification regarding the budget needs and assessments from FAAB.

o The last FAAB group developed proposals for a new priority system. The current group reviewed the proposal and sent communication to the Director. IHS responded that the new system will be implemented with the other list has been completed.

o FAAB is preparing for a 2021 report. They have developed a timeline and will follow to ensure the report is completed on time.


o The Agency is updating the health systems planning system and others to ensure web-based access is available to Tribes and Federal employees alike.

o Next meeting will be in Seattle in August and Director Hartz can provide information regarding vacancies on the Board.

Gary Hartz, Director, Office of Environmental Health and Engineering, IHS

o OEHE is looking at capital investments in existing facilities and the needs request is moving forward.

o Tribal Comment: Where do inpatient and outpatient behavioral health facilities rank among need for Indian Country. Response: After completion of the backlogged system, behavioral health facilities

would be the first priority facilities to be considered. o Tribal Comment: It’s important that we have honest discussions about what is going on

with Tribal facility needs. The lack of facilities is forcing Tribes to treat a health issue as a detention issue and filling detention centers with those suffering from addiction - further distressing limited public safety funding.

o Tribal Comment: There is concern that the Joint Venture template is restricting Tribal options to provide services that are permitted under the IHCIA expanded authorities. Perhaps a legislative fix to change the process, but there may be opportunity in this administration. Response: We can work things out to expedite the process of getting Tribal

facilities approved and built. Currently, it would be about 2-3 years before the joint venture program opens back up for solicitation.

Sanitation Facilities Construction and Access to Sanitation Tracking and Reporting System (STARS)

o Tribal Comment: you told the Oklahoma caucus that you would discontinue the use of the non-Indian home definition. As such, do you have draft guidance and are you working to update that document? Response: Yes, we will be removing that everywhere it appears and provided

oral instructions to the Areas. Additionally, we will release the requested data in a general form. However, we will not release individual data files.

o Tribal Comment: Where will Tribes have input on how you will develop and implement the draft guidance the impact the deficiency level definition? Response: We will continue to work in the 5-level deficiency model, which

requires a “lack of water and sanitation facilities” but level 4-level deficiency is defined as “lack of water or sanitation facilities.”

o Tribal Comment: There is a large need for facilities for mental health and combating the opioid epidemic. Rocky Boy built a facility for mental health without any assistance from IHS. However, IHS has to assist Tribes with funding and try to provide additional flexibility. Response: IHS has tried to leverage opportunities whenever possible and

enhance funds from other resources; however it seems there is room for additional need.

Tribal Comment: We have to look at things like mental health, facilities, infrastructure, etc., we have to look at it as the whole package and not just individual pieces. You talk about all this funding, but in reality it is not very much by the time it trickles down and we address each piece needed to construct facilities. We need to think about funding these projects as whole package.

o Response: We have been asked this question by Congressional members as well, but the reality is that we have to build infrastructure systems because they do not exist.

Tribal Comment: We would like to have more consultation on the draft guidance before you develop and finalize it.


o Response: The guidance probably will not be packaged until the end of the Fiscal Year and will take that request back to the senior staff team to follow up on this request.

Break Office of Resource Access and Partnerships Update Carol Tisherillo

Pharmacy Benefit Manager Issues o IHS has done outreach to the Caremark and others to determine the issues that Tribes

are having with right of recovery. o Tribal Comment: We have seen that this a major issue, as is causes IHS and Tribes not

to be able to collect multi-millions of dollars. This is something that also affects medical and with the major underfunding, it is critical we address the issue. Our understanding is that there is a workgroup within the IHS. As such, when will Tribes have input or involvement in the workgroup that was developed to address this?

o Tribal Comment: What reimbursement are we talking about? Response: This is reimbursement for private insurance.

o Tribal Comment: Is there a simple answer to resolve this issue? Response: Well it depends on the prescription benefit management (PBM)

company and the declinations range from legal definition of IHS, Tribal and Urban facilities or the PBM’s requirement that patients fill prescriptions at certain businesses.

o Tribal Comment: We would recommend that you leverage Tribal expertise on this issue. IHS Response: We have also had issues with Caremark and have been focusing

mainly on that issue. However, we would like to expand that work to other insurers. We are working with the National Pharmacy Billing Committee to resolve additional issues without other PBM. Defining the reason for denials is the difficult part and we are trying to work through those issues.

o IHS Comment: We are also working on the medical side. We are looking at updating the prompt payer letter, working with state insurance company, and educating PBMs.

o Tribal Question: What is your established process for sharing solutions with Tribes? Response: We are not that far in the discussion yet, but we can work on a plan to

share with Tribes. o Tribal Comment: Does the Veterans Administration (VA) have this problem?

Response: No, the VA does not bill for those services. o Tribal Comment: When you work on developing a letter to send regarding these issues,

you need to specifically include that Tribes have must also be paid. Purchased/Referred Care (PRC) Workgroup Update Melissa Gower, Senior Advisor, Policy Analyst, Chickasaw Nation Jim Roberts, Senior Executive, Intergovernmental Affairs, Alaska Native Tribal Health Consortium

A few years ago the workgroup reevaluated the allocation methodology ago it was determined that revising the methodology is not the best thing to do, because of controversy and ongoing Affordable Care Act implementation and Medicaid expansion.

o There are issues with the access to compare component and alternate resources in the evaluation.

The workgroup also discussed the Government Accountability Office (GAO) PRC report and recommendations.

o The workgroup felt that the GAO took a very limited view of the PRC allocation, excluding other resource allocations based on access to care.

In regard to lowering the CHEF threshold, Director Schmidt explained that IHS would announce a decrease in the threshold from $26,000 to $19,000.


Tribal Question: Have there been any discussions about collecting good information from patients to improve PRC systematic issues?

o Response: Yes, we did discuss that and determined there is a need for best practices. This will be on the agenda for the workgroup moving forward.

TSGAC Members’ Executive Session with Acting IHS Director Joint Discussion on Restoring Accountability in the Indian Health Service Act of 2017 Caitrin Shuy, Director of Congressional Relations, National Indian Health Board

Introduced the staff members from the Hill that have been working to draft and introduce the Restoring Accountability in the Indian Health Service Act of 2017.

This team is receiving comments and feedback to improve and ensure that the final legislation will alter some of the problems at IHS.

Matt Hittle, Legislative Director, Office of Representative Kristi Noem

Many of the provisions Main Provisions:

o Incentives for recruitment, retention, and personnel evaluation o Cultural sensitivity requirements for providers and staff working in the IHS o Several reports to assess the Service practices to modernize practices o Accountability with reporting to improve personnel practices, wait times, etc. o Ensuring employees can be hired and fired

We want input from across the country and are more than willing to meet with Tribal leaders to hear their recommendations.

Jacqueline Bisille, Policy Advisor, Senator John Hoeven, Chairman, U.S. Senate Committee on Indian Affairs

The Senate Committee on Indian Affairs has been pursuing improvements to the IHS since the issues to the Great Plains came to a head nearly two years ago.

They are thankful to be able to work on this with Congressional members in the House. Senator Hoeven wants to hear from Tribal leaders. Starting in August staffers will be traveling

across Indian Country to meet with and gather input. The Committee is looking forward to a mark in September following additional input from Tribes.

Ken Degenfelder, Republican Legislative Staff, Indian, Insular and Alaska Native Affairs Subcommittee, House Natural Resources Committee

Some of the issues within IHS are far-reaching and this bill is a good place to start in addressing those.

The House is hoping to move the legislation prior to November. Kim Moxley, Policy Advisor, Office of the Vice Chairman, U.S. Senate Committee on Indian Affairs

Senator Udall is very aware that all Tribes are different. Senator Udall also wants to ensure that all parts of the IHS system are accounted for, including IHS, Tribes, Urban, and that what is done in one of those does not negatively affect the others.

The Minority agrees an emergency exists and actions are necessary to change the tide at IHS. Democrats have concerns that some of the personnel provisions are controversial and could

have negative outcomes for IHS if some of the incentives and disincentives for hiring and firing do not result in additional litigation for the Service.

Discussion Tribal Question: How will this legislation affect Self-Governance Tribes’ flexibility? This flexibility

is necessary in order for Tribes to provide necessary service to Tribal citizens.


o Response: This legislation was put into place to address the systemic issues in direct service facilities. That does not discount the issues Self-Governance Tribes experience and we would love to have discussions about what issues could be resolved in this legislation or in others. However, there are major issues and tragedies that need to be addressed in the Great Plains and other areas with significant direct service facilities.

Tribal Comment: While we see and understand the issues that are in the Great Plains, it does not reflect how all of the IHS Areas work. It is important to ensure that this legislation does not negatively impact the IHS Areas that are working well. Additionally, it is not enough to just pass legislation that only focuses one method of health care delivery in IHS. If there is not funding added to support the provisions, nothing will actually change.

Tribal Comment: That comment leads to the next logical conclusion, that this bill creates and unfunded mandate. Additional language may need to be included so that Congress has to revisit and amend the language regularly to provide update.

o Response: There is a workgroup in place to improve the IHS in the House to provide additional support or oversight. The Chairman of the workgroup is Markwayne Mullin. The Oklahoma delegation frequently mentions the success of Self-Governance. I think Tribes in the Great Plains are very interested in Self-Governance, but Congress wants to make sure that these Tribes are not inheriting an understaffed and unaccredited facility.

o Response: We agree that regular engagement with Congress to provide feedback regarding the IHS and any outlying issues that need the Committee’s attention. We recognize that many Tribes have taken over the management of Federal facilities without proper funding. We need to ensure that Tribes and IHS receive full funding.

Tribal Question: How do we best engage with the workgroup? o Response: The best contact would be Taylor Hittle, who is work with coordination of the

workgroup. She can be reached at [email protected]. Tribal Comment: The legislation provides authority to the Secretary to remove underperforming

staff through a disciplinary process. Will that authority be delegated down to the local level? Supervisory and accountability should happen at the local level whenever possible, because Area level staff sometimes are not familiar with

Tribal Comment: Since 2010 and additional 238,000 American Indian and Alaska Natives (AI/AN) have been enrolled for Medicaid and private insurance. Elimination of those resources would further exacerbate the issues IHS is experiences. If Medicaid expansion occurs in other States another 250,000 IHS beneficiaries would be eligible for programs. These are critical resources that help Tribes and the IHS to provide needed services.

o Response: We fully understand this and recognize that Medicaid resources are the stop-gap that keep many facilities operating pending full funding. Senator Udall also supports Tribes in this effort and will be bring the message that Medicaid cannot be rolled back without major detriments to AI/AN.

Tribal Comment: There are not many provisions in the legislation that support Self-Governance. For instance, duplicative reporting between Government Performance and Results Act (GPRA) and Uniform Data System data reporting. Access to Resources and Patient Management System (RPMS) data for Tribal Epidemiology Centers. I would also encourage that you look at the definition section of this bill needs to be cleaned up, especially since there are some provisions from which Tribally-operated facilities should be exempted. Additionally, the provision about waiving Indian Preference needs to be addressed so that there are not unintended consequences.

o Response: The intention is that these provisions would be optional and we want to make it clear that Self-Governance Tribes will not be forced into compliance with these mandates.

o Response: We have begun the amendment process and have identified this as provision that needs more work and clarification.


Tribal Comment: The provision in the Better Care Reconciliation Act (BRCA) that allows non-Indian private providers to receive 100% Federal Medical Assistance Percentages (FMAP) for AI/AN is a concern. The 100% FMAP reimbursement was originally implemented to help underfunded IHS, Tribal and Urban (I/T/U) facilities and anything that changes that should have specific and additional Tribal consultation.

o Response: The concern comes from areas like North Dakota where the state is paying a large portion for AI/AN health care. Senator Hoeven believes this is a Federal Trust Responsibility and that AI/AN should have access to those services. The Senator does not believe this will change the behavior of the patients seeking care, but will clarify who is responsible for payment.

o Response: Senator Udall agrees that anything that may change the way Tribes interact with states has to have meaningful Tribal engagement.

Tribal Comment: Self-Governance Tribes submitted testimony that raises a number of issues and concerns. Do we need to clarify any of the issues that we raised?

o Response: We received testimony from a number of Tribes and organizations. We are still working through those in addition to receiving technical assistance from IHS. Rest assured that we will reach out if we need additional clarification.

Tribal Comment: We appreciate your work on this legislation and Lummni Nation will have comments to submit. Additionally, there is a lot of historical knowledge in this room that you and others could leverage in the future.

Office of Information Technology Update (OIT) CAPT Mark Rives, DSc, Director, Office of Information Technology, IHS Randall Hughes, Tribal Liaison, OIT, IHS

Veteran Affairs (VA) Migration to the Military Health System (MHS) Genesis and Impact on the RPMS Updates

o They decided to take an off-the-shelf system which will require VA practices to conform to the MHS Electronic Health Records (EHR) systems.

o The transition to Genesis will take about 10 years to complete, which means that the VA will have to continue supporting the Veterans Information Systems and Technology Architecture (VISTA). This means support for RPMS will continue. We will have to make a decision, but there doesn’t need to be a panic around it.

o Tribal Comment: Tribes have an investment in RPMS and Office of Information Technology (OIT) services, so we want to be part of the process to decide if and when IHS transitions to another system.

o We want to make sure we are accepting comments on this process and how best to proceed. IHS had successful engagement in the first two consultations hosted, but additional calls will be scheduled in early August.

o Any comments can be submitted to [email protected] until August 25, 2017. o OIT plans to develop a Request for Information (RFI) to ask the industry to visualize an

RPMS 2.0. We posed this question to Information Systems Advisory Committee (ISAC) in

June who then tasked a smaller workgroup to continue to focus on this question. Futures plans for RPMS

o Support for RPMS will continue for the immediate future. o Enhancements for data interoperability are needed and will move forward. o We need to make sure that interoperability is maintained so that IHS can continue to

ensure longitudinal data access. o Must continue to address “day-to-day” RPMS updates. o Long-term plan is to watch the VA and see what they are doing for their transition.


Cybersecurity o There were two major attacks in 2017, which did not affect IHS or Tribal facilities. o In response to the attacks IHS developed patches and with the help of HHS, applied

those to 50,000 computer-like devices. o HHS also wanted to reach out to Tribal partners and ensure they were getting the

information needed. Tribal Comment: I do feel as if we are making positive strides forward and we appreciate your

work to date. ISAC is great, but does not replace Tribal Consultation. We want to be at the table as you make these decisions. ISAC made specific recommendations at their last meeting, what is the status of those recommendations with Rear Admiral Weahkee and has there been any progress since the meeting.

o Response: One was the development of the RFI. IHS should pursue a commercial off-the-shelf (COTs) solution and identify

funding sources. Captain Rives recommends that IHS complete the RFI prior to pursuing the

COTs options. ISAC Co-Chair Comment: The initial charge for the ISAC meeting was to look closely at

modernizing the EHR system. ISAC wanted to make sure that we are looking at all EHRs, including RPMS. The committee wanted to be sensitive to the actual and opportunity costs of switching to a “new” system.

Tribal Question: How long will VA actually provide active support to VISTA and RPMS? o Response: We are just making an estimate, but if you consider what the Department of

Defense (DOD) did during their transition we expect six to seven years of full support. Tribal Comment: Muscogee (Creek) Nation has minimal interaction with RPMS, but it has been

a challenge creating interoperability with RPMS, NextGen, and Cerner so we are watching the Agency’s actions and next steps.

Tribal Comment: What’s the status for the solution so that Tribes can share data between off-the-shelf solutions and RPMS?

o Response: That effort is ongoing, but we expect that most sites will be able to initiate reporting in Fiscal Year 2018.

Community Health Aide Program Workgroup Update Dr. Chris Halliday, D.D.S., M.P.H., RADM (ret.), USPHS, Deputy Director, Division of Oral Health, OCPS (DHAT Lead) Georgianna Old Elk, Public Health Advisor, Community Health Representative Lead, OCPS (CHA Lead) Minette Wilson, Public Health Advisor, Division of Behavioral Health, OCPS (BHA Lead)

Ms. Wilson provided background regarding the Community Health Aide Program (CHAP) background including legislative history and activities to expand CHAP to the lower 48.

CHAP Policy consultation began in June 2016, IHS accepted comments and then published a policy on CHAP expansion. A team of program leads was established in April and plan was assembled to further develop the policy.

Expansion Framework includes four phases. o Phase I: Assessment, what does the system currently look like? o Phase II: Design, what will the program look like? o Phase III: Implementation, how do we roll it out? o Phase IV: Evaluation, how well is the program performing? However evaluation will run

parallel with all four phases of the program. There are many differences between Community Health Aides in Alaska and Community Health

Representatives in the lower 48.


Programs Overview: o Behavioral Health Aide (BHA) currently:

Tiered-Practice levels Certification through Tribal Colleges & Universities (TCU’s) Centers for Medicare and Medicaid Services (CMS) Reimbursement Explore Regional Certification vs. National Certification

o Community Health Representative (CHR) Working to adapt existing CHR model to mirror the Alaska CHAP model Paraprofessional services are available to supplement current workforce. Offering training programs for current CHRs to get mental health aide

certification. You can find CHR training at They have a goal to make the program reimbursable in the new future.

o Dental Health Aide (DHA) Tiered-Practice Levels, including DHA I-III and Dental Health Aid Therapy

(DHAT), the latter be the most controversial The Indian Health Care Improvement Act (IHCIA) requires significant state

legislation changes in order to implement the upper level programs. The workgroup will discuss certification to determine which geographic level will

be the most advantageous. As a note dentistry is moving toward a national dental certification for

dentists, etc. Training programs

Kellogg Foundation and few others have developed a national curriculum to train dental therapists.

Commission on Dental Accreditation has developed a process to accredit training programs.

Workgroup Charter is currently in development. The workgroup would include focus on what CHAP would look like and would include representation from all IHS Areas as well as subject matter experts.

o Once the workgroup is established the workgroup will make sure that they reach out in develop a CHAP policy.

Tribal Question: Is the plan to have one national certification process or would it be on an area-by-area basis?

o Response: This is something we would like to determine in the national workgroup. We have heard a lot of comments that we do not need to do something that will affect how other areas operate and as such, it will be one of the first issues we address.

Tribal Comment: What is the timeline of the workgroup development and how will membership be selected?

o Response: We hope to have representation from technical experts by the end of the calendar year and will work to ensure there is representation from existing experts and Tribal representatives.

HHS “Reimagining” Initiative RADM Michael D. Weahkee, Acting Director, IHS RADM Kevin Meeks, Acting Deputy Director of Field Operations, IHS

On March 13, 2017 the Administration signed the Executive Oder 13781 initiating the “Reimaging Initiative.”

The effort includes six principles engagement, empowerment, service, performance, stewardship and sustainability.


A workgroup for this initiative has been established, which includes delegates from IHS. Overall there are 5 workgroups involved and IHS had five representatives participating in the process.

o Health Care Systems – Dr. Ty Reidhead o Public Health - Dr. David Gann o Economic and Social Wellbeing - Beverly Cotton o Scientific Advancement – Dr. Jeffrey McCollum o Management and Stewardship – Captain Mark Rives – almost exclusively focused

Human Resources and Acquisition. The workgroups focused on big picture efficiency and accountability while focused on

Department wide processes. Through the workgroups, IHS delegates emphasized the need for Tribal consultation. Four of the six initiatives that grew out of initiative were to improve delivery and responsiveness

to people. IHS wants Tribal comments regarding this initiative and the Agency want to solicit Tribal input

regarding how IHS can be reimagined to improve quality and care. Tribal Comment: HHS has a responsibility to work directly with Tribes and not just through IHS.

HHS needs to understand that their obligation includes more than just IHS. Additionally, IHS delegates need to include representation from the many IHS areas especially from those areas which do not conform to the “typical” Tribal government, specifically those who do not have reservations.

Tribal Comment: The private sector needs cannot be including in this initiative. Tribal Comment: There needs to be more flexibility when it comes to funding. Additionally,

states should not be a part of getting funded to Tribes. Tribal Comment: Full accountability of all appropriated funding. Tribes recognize what it costs

to provide an inherent federal function and direct services. IHS should be more transparent and provide regular information to Tribes regarding their portion of the agency.

Tribal Question: What happens next regarding the information you submitted to the Office of Management and Budget (OMB)?

o Response: Currently we are unsure. However, the best guess would be that it will be refined and then distributed to the Agency and to Tribes.

Tribal Comment: We need advocacy for full funding and it needs to be on every level of HHS, not just IHS. In reimagining IHS you must ensure that you are being held accountable to Indian people. There are tools a resources available within Self-Governance Tribes that can be leveraged. One of the things that makes Self-Governance successful is that Tribes are accountable to individual citizens. Ask yourself, “Is this the “best” way to provide this service? Are we doing this using the best known information and practices?”

Tribal Comment: This is a very long topic for discussion. There are some IHS and Tribal sites that have come up with innovative ways to adapt health care delivery.

Tribal Comment: It is all about the options. We need to provide best practices and options to Tribes and IHS.

Tribal Comment: Where do you see IHS in this reimagining initiative? o Response: Currently the Agency is trying to replicate best practices from the different

IHS areas. Tribal Comment: Tribal consultation before decisions are made is important. Recently, we have

dealt with instances where Tribes are being talked to as the decisions were already made. Additionally, there is a difference between reimagining and reorganization and we need to be clear that this is a response to the Executive Order regarding reorganization. Tribes are happy to entertain conversations regarding a strategic plan which would truly include a reimagining process.


Tribal Comment: As final recommendations have been slated to be released at the end of September, we recommend that IHS begin Tribal consultation. Coming to these meetings is good, but not a substitute for Tribal consultation

Federal Comment: There is also an initiative to deregulate and streamline regulations within this Administration. If you have ideas for regulations that could be altered or rescinded we would gladly accept those recommendations.

Tribal Comment: We recommend that IHS start the official consultation process to receive responses from Tribes. Has there been an initiative to include or review the recommendations provided by Tribes to the IHS in January regarding the Headquarters reorganization efforts. Did IHS submit written recommendations to the agency as part of the recommendations?

o Response: No IHS did not provide written recommendations. Tribal Comment: Some Tribes have already responded to the question regarding deregulation.

Perhaps the agency should review that during this time and let us know what may be considered.

Tribal Question: Can you repeat the six initiatives identified and do you know how they will play into the draft report?

o Response: We do not know how it will play into the overall plan. The initiatives are: Restoring market forces. Putting people at the center of HHS programs. Leveraging the power of data. Turning HHS into a more innovative and responsive organization. Generating efficiency through streamlined processes. Moving to a 21st century workforce.

Patient Protection and Affordable Care Act (ACA) Implementation Update Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Incorporated Doneg McDonough, Consultant, TSGAC

Outreach and Education Project Update o One of the new deliverables included in this agreement was to develop a toolkit to assist

Tribes considering the Tribal Sponsorship Programs. o The website has been set up to launch this tool today and will be going live later this

week. o The presenters previewed the toolkit and provided an overview of the pieces needed to

complete the analysis online. Tribal Sponsorship Program for Title I Contracting Tribes

o In May of 2015, TSGAC and Direct Service Tribal Advisory Committee (DSTAC) agreed to partner to ensure Title I Contracting Tribes have a right to contract funds and offer Tribal Sponsorship to IHS beneficiaries.

o Earlier this year the first Title I Tribe entered into a contract and initiated a Tribal Sponsorship Program. Additional Tribes are considering this opportunity and it looks as if the work on behalf of both the committees has been a positive for Tribes.

ACA Legislative Update o As of now, the replacement bill proposed by Senator McConnell is dead and several

Senators have voiced that they won’t vote in favor of proposing a complete repeal. As such, the next step would be to just improve the ACA.

o We anticipate that the budget deal will include market stabilization and reinsurance amendments to assist with ACA implementation.

o An attractive alternative may be to block grant tax credits and Medicaid funding to each state, which is included in the Cassidy-Graham bill.

o Speaker Ryan proposed a budget that makes major cuts to mandatory and non-mandatory funding including Medicare, Food Stamps, and other social service programs.


o Debt-limit ceiling deadline has been extended to mid- or late- September. This will be another opportunity to achieve significant savings or cuts to non-defense programs.

Preparation for Discussion with Acting IHS Director

Recess until July 19, 2017

Wednesday, July 19, 2017 (8:30 am – 12:45 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical Workgroup

with RADM Michael D. Weahkee, Acting Director, IHS

Welcome and Introductions Jefferson Keel, Lt. Governor, Chickasaw Nation RADM Michael D. Weahkee, Acting Director and Principal Deputy Director, IHS

Indian Health Service Budget Update Ann Church, Acting Chief Financial Officer, IHS Melanie Fourkiller, Policy Analyst, Choctaw Nation and TSGAC Tribal Technical Workgroup Co-Chair

IHS Fiscal Year (FY) 2017 Funding and Continuing Resolution o The FY17 budget and appropriations finally passed in May. o IHS received an increase of $230 million 4.8% over the 2016 enacted level. o The FY17 appropriations included:

An indefinite appropriation for CSC. Pay costs increases and some inflationary amounts. Staffing for two facilities – Choctaw Nation and Flandreau Santee Sioux Tribe. Approximately $26 million for prescription drug program, Substance Abuse and

Suicide Prevention Program, and behavioral health programs. The majority of this funding will be going out under grant announcements.

Program increases for Urban Indian Programs and Small Ambulatory Program ($5 million), and staffing quarters ($6 million) were also included.

$27 million for accreditation emergencies, which allows the agency to have assert discretion over the use of these funds.

o Tribal Comment: Why was there a delay in publishing a solicitation for the Small Ambulatory Program? Response: We will have to follow up with a response.

o Tribal Comment: How was the decision made to send the behavioral health increases out sent through grants and why? Response: There is a limited amount of funds and the agency wanted to make

sure that these funds go to the areas with the greatest need. o Tribal Comment: Tribes have been fighting for a long time to get funding as reoccurring

line items. As such, where have you been hearing through consultation that Tribal leaders want behavioral health program funding in the form of grants? Response: The rationale is that if you divide up a small amount of funding evenly,

rather than putting it in a grant, you do not get a large amount and therefore cannot make the most of the entire amount of funding appropriated. We will review the decision and report back to TSGAC.

o Tribal Comment: In our experience the Tribes that get grants are not necessarily where the most need is, but rather where the best grant writers are. As such, it would be best to reevaluate the grant making process within IHS, because those Tribes who do not have


the capacity to write good grants, are not getting the funding and resources they really need.

o Tribal Comment: Even if it is a small amount of money that Tribes will receive through reoccurring funding, it will make a major difference. Every bit of funding matters and grant restrictions do not allow Tribes to exercise Self-Governance in regard to that funding.

o Tribal Comment: We call this “Granting Away Self-Governance.” Though you may not be able to evaluate changes based on a small amount of money, but over time a recurring distribution supports long-term plans for Tribes and makes a difference in the long run.

o Tribal Comment: Taos Pueblo is a small Tribe and we do not have a grant writer on staff. There is an administrative cost to IHS to run grant programs. These funds only support the administration.

o Tribal Comment: Tribes would prefer to have the money come down in a small portion so that sustainable programs can continue overtime.

Small Ambulatory Increases o Tribal Comment: Will there be staffing packages to along with small ambulatory grants? o And what is the status of the pay cost increases?

Response: We will have to follow up with Director Hartz and get back to you. The pay costs increases have been distributed.

The President’s FY 2018 Budget Request o The President requested $4.7 billion. You will notice in the FY18 Budget is compared to

the annualized FY17 budget. o Now that we know the FY17 Budget the FY18 Proposal would be a $301 million or 6%

decrease from the FY17 budget. o Highlights from the FY18 Budget Request includes:

Maintains CSC as a separate discretionary appropriation. Assume that SDPI will be reauthorized and included in the budget. This budget prioritizes and focuses on the direct services provided. Facilities and Construction had the majority of decreases, but maintained some

funding for ongoing construction and planning to include the Alamo Health Center, Rapid City Health Center Dilcon Health Center in Arizona.

FY18 Appropriations o The House has marked up the bill and they included $5.1 billion for IHS, which is $398

million over the President’s proposal and $97 million over the FY17 enacted level. Tribal Comment: How much of President’s request is for CSC and is the $131

million in the Indian Health Care Improvement Fund (IHCIF) being used for facilities and not Level of Need Funding (LNF) because the data has not been updated or worked on as Tribes have requested?

Response: It includes an estimate of $718 million for CSC. However, the entire need would be funded as it is an indefinite appropriation item. The funds for the IHCIF would be distributed based on the formula and LNF methodology.

Tribal Comment: We appreciate the increase and thankful that Congress is providing oversight and funding. When do you expect to revisit the LNF formula?

Response: Information from the last consultation is available on the website and we agree that things need to be continually updated.

Tribal Comment: We must update the LNF data. We need Cliff Wiggins to share how the formula was developed and updated.

Response: We are working to download as much information from Mr. Wiggins as possible.


FY 2019 National Budget Formulation Evaluation o Preparing for the budget formulation and consultation process. Instructions for this

should come out in August. o The last formulation process determined that we should stay with a national budget and

do away with the area-specific budgets. This decision was basically because there was confusion about how the area-specific budget would be utilized in the future.

o There were also requests that pre-trainings and technical assistance be provided to those participating the 2020 formulation process.

o It was also requested that a facilitator be included in the 2020 formulation process. IHS is working to make arrangements for a facilitator.

Joint TSGAC and Acting IHS Director Discussion Scheduling CSC Face-to-Face Meeting

o Tribal Comment: The workgroup recommends that a face-to-face meeting be scheduled to follow up and discuss the Annual CSC Calculation (ACC) tool. Additionally, there was a two-day technical workgroup meeting to review the ACC tool and provide recommendations. The summary of that meeting was never shared with the full workgroup. Response: We are supportive of holding a meeting. However, there has been

some challenge with scheduling. We issued a letter that suggested we meet in early September. However, if we were to piggy back on another meeting, we could meet in August.

Tribal Response: TSGAC will share the suggested dates and follow up with the piggy back dates that work best for the Tribal side.

LNF Point of Contact and Follow Up o Tribal Comment: TSGAC has issued letters regarding this issue. We recommended that

a workgroup be developed because we need to update the data for this and review the methodology. Response: We have been successful in entering a contract with Cliff Wiggins to

work on LNF as well as Tribal Shares tables. We will be meeting in the next week to discuss how to best address and approach the issues with regard to the workgroup.

o Tribal Question: Is there any idea about when the workgroup will take place? Response: Currently we are still in the planning phase and will be able to

respond to the TSGAC letter once we get farther along in the process. Tribal Response: When a process is put in place we ask that a briefing call or an

update be provided so that Tribes are aware about what the plans are. o Tribal Comment: CPN has implemented an initiative to show the trends in funding over

time. The two graphs we have included show the per capita funding, both with and without LNF increases over time. This data shows that LNF funding is a major part of the funding we receive and without it funding levels would be much, much lower.

o Tribal Comment: We make light of Senator Tester’s frustration, but he is frustrated. We must pay attention to these issues so that Members that do not represent Tribes need to understand this narrative.

TSGAC Request to Delay Catastrophic Health Emergency Fund Rule o Tribal Comment: We have requested that this be suspended. Is there a status update on

that request? Response: We have made the request to suspend the action and it will remain

suspended until we see the results of that case. Notice for Meetings with IHS Small Ambulatory Program


o IHS did receive funding for more programs in June and are trying to get the solicitation out by the end of August. However, there is restrictive language that does not allow any of this funding to be for staffing. We will likely only be able to fund three projects with the $5 million.

o Tribal Comment: We are frustrated because we knew the money was coming. A solicitation should have been prepared ahead of time so that it could be sent as soon as the funding was apportioned. Please send the solicitation as soon as you possibly can.

Permanent Staffing in IHS o RADM Weahkee is the first of people to come into IHS on behalf of the new

Administration. As such, he has been given the authority to begin filling those key positions that have “acting” officials, especially the Office of Tribal Self-Governance. We are committed to continue involving Tribes in filling those positions, especially those in areas that directly affect Tribes.

o Regarding Area Directors, we do have two vacancies that we have been unable to fill and we request that Tribes reach out if they know of anyone to fill those positions.

o Tribal Comment: TSGAC requests that when it comes to filling OTSG positions you include the committee in that process.

Closing Remarks RADM Michael D. Weahkee, Acting Director, IHS

I appreciate all the feedback we have received over the last couple of days and even prior to the meeting. I especially appreciate the information regarding the grant process this morning and will follow up to see if this is something we can change moving forward.

Please continue to join the IHS update calls and engage in these discussions. Jefferson Keel, Lt. Governor, Chickasaw Nation Congratulations on joining the executive staff. We appreciate your efforts, courage, and tenacity to keep things moving forward. IHS Special Presentation Recognizing Terra Branson, Self-Governance Communication & Education Director

For her dedication and work in advancing the health of AI/AN across the country, IHS presented Terra Branson with a letter of recognition and IHS medal for all of her efforts.

TSGAC Technical Workgroup Working Session Adjourn TSGAC Meeting

1

Technical Workgroup

Assignment Matrix Updated: October 10, 2017

Technical Workgroup Co-Chairs: Melanie Fourkiller, Tribal Co-Chair Jennifer Cooper, Federal Co-Chair

Assignment Person(s) Responsible

Date Task Originated

Status

1. Develop metrics to evaluate effectiveness of MLR after implementation.

Mickey Peercy (PRC Workgroup) Doneg McDonough

April 13, 2015 9/15/17: Include on October Quarterly TSGAC Meeting, Tribal Caucus.

2. Develop and include in IHS Self-Governance Policy protocols for self-governance negotiations, including but not limited to expectations for information and document sharing and protocol for proper communication with Tribal leadership. Review with TSGAC. (see April 10, 1997 letter to TSGAC from previous IHS Director).

1997 IHS Director Letter

[SG Negotiations issue – whether IHS ALNs should accept provisions (at Tribal option) that have been previously negotiated in other Compacts/FAs, to the extent applicable to that Tribe.]

Jennifer Cooper SGCE Mickey Peercy Rhonda Farrimond Melanie Fourkiller Cyndi Ferguson Terra Branson Shawn Duran Alberta Unok

July 21, 2016 Other issues and recommendations remain regarding Title V implementation. 7/20/17: This group agree to review the ALN Handbook and make recommendations moving forward. 9/15/17: Will be included for update on October, 2017 Quarterly Meeting agenda.

3. Develop TSGAC Comments to the SG Congressional Report.

Melanie Fourkiller Carolyn Crowder SGCE

October 27, 2016

On hold until next report is sent out for Tribal Consultation

4. Outline of the successes of Self-Governance

Melanie Fourkiller Melissa Gower Terra Branson Jim Roberts Cyndi Ferguson

January 25, 2017

On hold, pending outcome of SGCE Fellow Research 9/15/17: Terra will follow up with contractors to report the status of this.

5. Letter from TSGAC to VA reiterating our objection to automatically consolidate IHS/Tribal reimbursement agreements into the CHOICE program (hold current agreements harmless); include objection to S. 304 (Thune’s bill) on IHS paying co-pays to VA; reiterate request that VA make a request to Congress (in the Budget Justification or otherwise) for authority to pay/waive co-pays

Jennifer McLaughlin

March 29, 2017 Drafted. 7/20/17: Should include a request for additional consultation and meetings regarding recent roundtable discussion questions. 9/15/17: Jennifer will add this, and send another draft of the letter for finalization.



Telephone (918) 302‐0252 ~ Facsimile (918) 423‐7639 ~ Website: www.tribalselfgov.org

2

for Native Veterans due to trust relationship; and request the VA head of Intergovernmental Affairs attend the July quarterly meeting.

6. TSGAC letter to Acting Director, IHS on OEHE issues (copy to RADM Meeks, Gary Hartz) (recommendations re: transparency for SDS, consistent use of Deficiency Levels at all Areas/Tribal locations, addressing full implementation of Title V at the next quarterly meeting, specific edits needed/agreed regarding the term “Indian Community” in the draft Guidance on SFC.

Kasie Nichols March 29, 2017 Superceded by item #16 and Completed.

7. Follow up on TSGAC request to IHS to post Vacancy/personnel reports/statistics on the IHS website in an easily accessible place.

Jennifer Cooper March 29, 2017 Jennifer is confirming that this has been completed.

8. Letter from TSGAC to IHS making recommendations on the Loan Repayment Program (designation/expansion of fields of study, assessing growing fields of need within IHS, etc.)

Doneg McDonough

March 29, 2017 Completed.

9. Work with OTSG staff on updating the 2002 Headquarters PSFA Manual.

SGCE Cyndi Ferguson Kasie Nichols Melanie Fourkiller

March 29, 2017 In process. Working Call held October 4, 2017; next working call TBD in November

10. Letter to IHS Acting Director outlining our concerns regarding IHS utilizing grants to distribute funding.

Jennifer McLaughlin

July 20, 2017 In process.

11. Send a joint letter from TSGAC and DSTAC to IHS Acting Director and ORAP Acting Director requesting that IHS make the Pharmacy Benefit Manager issues a top priority to resolve.

Melissa Gower SGCE

July 20, 2017 Completed.

12. Send letter to IHS Acting Director to request that IHS host Tribal Consultation on Sanitation Facilities Construction guidance.

Unassigned-TSGAC will host a call on August 10th at 3:00 EST to discuss this further.


13. Send a request and nomination to Benjamin Smith and Human Resources for a TSGAC appointee to participate in the interview process for the OTSG Director position.

SGCE Terra Branson


14. Follow up on the request for additional information regarding distribution of the Indian Health Care Improvement Fund.

SGCE July 20, 2017 Question re: IHS determining how these funds would be spent – CPN

Updated September 14, 2017

SummaryofIHSTribalSelf‐GovernanceAdvisoryCommittee(TSGAC)CorrespondenceYear:2015‐2017

Updated: September 14, 2017

Ref. #

Date Sent/ Received Addressed To Topic/Issue Action(s) Needed

Response Received

1. 9/14/17 RADM Weahkee, Acting

Director, IHS

Unpaid and Underpaid Third Party Benefits from Private Insurers

Joint TSGAC and DSTAC letter requesting IHS designate it a high priority to address the inappropriate and illegal action by insurance companies and benefit mangers erroneously under paying Indian health and Tribal facilities on behalf of all of Indian country.

2. 8/31/17 RADM Weahkee, Acting Director, IHS

Sanitation Deficiency System Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities

TSGAC Request for Tribal Consultation

3. 8/31/17 RADM Weahkee, Acting Director, IHS

OTSG Director Participation in the Office of Tribal Self-Governance Director Interview and Selection Process

4. 8/1/17 National Indian Health Board

Jake White Crow Award TSGAC Letter of Support for Myra Munson’s Nomination – Jake White Crow Award

5. 7/31/17 RADM Weahkee

Recommendations for the IHS Scholarship and Loan Repayment Programs

TSGAC formal comments and recommendations.

Summary of IHS Tribal Self‐Governance Advisory Committee (TSGAC) Correspondence – 2015‐2017

Page 2 – Updated September 14, 2017

Ref. #


Response Received

6. 7/31/17 Jennifer Cooper

Acting Director, OTSG Request for ACA/IHCIA National Outreach and Education Funding (FY2018)

Request for on-going funding of $300,000 for FY2018.

7. 6/22/17 The Honorable Thomas E. Price Secretary Department of Health and Human Services

Request for Tribal Consultation on HHS Reimagining Initiative and Invitation to the TSGAC Quarterly Meeting July 18-19, 2017

TSGAC invites the Secretary or a representative from the Department to attend the meeting to provide an update of the process and review future opportunities to formally provide our feedback.

8. 6/8/17 Bradley Crutcher Chairman Fort McDermitt Paiute and Shoshone Tribe

Welcome to Self-Governance and Congratulations

Invite to the next TSGAC meeting scheduled for July 18-19, 2017. As a Self-Governance Tribe in an IHS Area with a TSGAC Alternate delegate vacancy, the Fort McDermitt is eligible to submit a letter of nomination for any elected Tribal official or their appointee to serve as an Alternate delegate and select a technical workgroup member to support their work on behalf of the Area.



Ref. #


Response Received

9. 6/8/17 Wilfrid Cleveland

President Ho-Chunk Nation

Welcome to Self-Governance and Congratulations

Invite to the next TSGAC meeting scheduled for July 18-19, 2017. As a Self-Governance Tribe in an IHS Area with a TSGAC Alternate delegate vacancy, the Ho-Chunk Nation is eligible to submit a letter of nomination for any elected Tribal official or their appointee to serve as an Alternate delegate and select a technical workgroup member to support their work on behalf of the Area.

10. 5/26/17

Rear Admiral Chris Buchanan Acting Director, IHS

CHEF Final Rule TSGAC Request to Delay Catastrophic Health Emergency Fund Final Rule

11. 5/26/17

Rear Admiral Chris Buchanan Acting Director, IHS

Update to Level of Need Funded Data and Workgroup Request

TSGAC request for additional educational training regarding the Indian Health Care Improvement Fund (IHCIF), LNF calculations and plans to update information related to each

Letter dated 7/18/17 received from RADM Weahkee which addresses and responses to several TSGAC letters and issues raised during the March 2017 TSGAC Quarterly meeting.

12. 5/24/17 Ms. Seema Verma Administrator Centers for Medicare & Medicaid Services

Medicaid Work Requirements for American Indians and Alaska Natives

TSGAC Comments



Ref. #


Response Received

13. 5/18/17 Rear Admiral Chris

Buchanan Acting Director, IHS RADM Kevin Meeks Acting Deputy Director of Field Operations

Tribal Participation in the Department of Health and Human Services plan to carry out Executive Order 13781

Request to Schedule a Joint TSGAC/DST Call

14. 5/10/17 Rear Admiral Chris Buchanan Acting Director, IHS CAPT Mark T. Rives, USPHS Director and Chief Information Officer Office of Information Technology, IHS

TSGAC Delegate to the Information Systems Advisory Committee (ISAC)

Advancement of A. Stewart Ferguson, PhD, Chief Technology Officer for the Alaska Native Tribal Health Consortium, as the TSGAC delegate for the IHS Information Systems Advisory Committee (ISAC).

15. 5/5/17 Nikki Bratcher Bowman, Acting Director Office of Intergovernmental and External Affairs U.S. Department of Health and Human Services

STAC National At-Large Primary Delegate Nomination

Formal nomination of Jefferson Keel, Lieutenant Governor of the Chickasaw Nation, for the National At-Large Primary Delegate position on the Department of Health and Human Services (HHS) Secretary’s Tribal Advisory Committee (STAC).

16. 5/1/17 Department of Health and Human Services

HHS 19th Annual Tribal Budget Consultation Session on the FY 2019 Budget Request

Written TSGAC Testimony Submitted



Ref. #


Response Received

17. 4/30/17 Jennifer Cooper

Acting Director, OTSG Self-Governance Health Reform National Outreach and Education Semi-Annual Report

Transmittal of 6-month Report

18. 4/11/17 Rear Admiral Chris Buchanan Acting Director

Formation of the Community Health Aid Program (CHAP) Workgroup

TSGAC Recommendations Letter received 6/11/17 from RADM Buchanan which states the IHS is currently addressing administrative details to establish the CHAP Workgroup, including selecting participants, defining key issues and determining meeting timelines.

19. 3/7/17 CMS via regulations.gov Market Stabilization Proposed Rule (CMS-9929-P)

TSGAC Formal Comments

20. 2/27/17 Rear Admiral Chris Buchanan Acting Director Indian Health Service

Self-Governance Negotiations and Create Agency Lead Negotiator Pilot Project

TSGAC Recommendations to Improve Self-Governance Negotiations and Create Agency Lead Negotiator Pilot Project

Letter received 3/24/17 from RADM Buchanan which includes IHS responses to this and several other recent issues raised by TSGAC during the January 2017 meeting.

21. 1/27/17 Norris Cochran Acting Secretary Department of Health and Human Services Rear Admiral Chris Buchanan Acting Director Indian Health Service

Support for Broad Exemption of Indian Health Service from Federal Hiring Freeze

TSGAC support and request for exemption from the hiring freeze for certain staff and contracted positions at the IHS



Ref. #


Response Received

22. 12/16/16 IHS Principal Deputy

Director

Identification of Staff for Developing Level of Need Funded Data

TSGAC provided recommendations regarding analysis of the Indian Health Care Improvement Fund (IHCIF) and the Level of Need Funded (LNF)

23. 12/14/16 IHS Principal Deputy Director OTSG Acting Director

Final Report, “TSGAC Report Network on Adequacy in the Health Insurance Marketplace: Analysis of Two Tribal Sites”

Transmittal of Final Report, “TSGAC Report Network on Adequacy in the Health Insurance Marketplace: Analysis of Two Tribal Sites”

24. 12/5/16 IHS Principal Deputy Director

Updated Contract Support Cost (CSC) Policy

Thank you letter and request that IHS develop a training and outreach plan for Tribal and Federal employees on the new CSC Policy.

25. 11/8/16 Leonard M. Harjo Chief Seminole Nation of Oklahoma

Congratulations and Welcome to Self-Governance

26. 11/8/16 John Berrey Chairperson Quapaw Tribe of Oklahoma

Congratulations and Welcome to Self-Governance

27. 11/8/16 Daniel L.A. Preston, III Anthony J. Francisco, Jr. Representatives Tohono O’odham Nation

TSGAC Tucson Area Representatives Appointment and Participation



Ref. #


Response Received

28. 11/4/16 IHS Director via

consultation.gov IHS Headquarter Re-alignment


29. 11/2/16 Dr. Richard A. Stone Principal Deputy Under Secretary for Health Veterans Administration

Request for the Information about the Veterans Administration’s Co-Payment Policy

TSGAC follow up letter from October meeting and discussion with Dr. Stone

30. 11/2/16 David J. Shulkin Under Secretary for Health Department of Veterans Affairs

Veteran Affairs’ Proposal to Consolidate Community Care Programs


31. 10/31/16 IHS Director via consultation.gov

Catastrophic Health Emergency Fund Proposed Rule (RIN 0905-AC97)


32. 10/31/16 OTSG Acting Director Self-Governance National Indian Health Outreach and Education

Transition of Final Report for 2015-2016

33. 10/28/16 Kitty Marx, CMS Tribal Technical Advisory Group (TTAG) Appointments

TSGAC Re-appointment of TTAG Reps



Ref. #


Response Received

34. 10/28/15 IHS Director via

consultation.gov Purchasing Health Care Coverage (IHS Circular 2016-08)


35. 10/5/16 CMS via regulations.gov HHS Notice of Benefit and Payment Parameters for 2018 (CMS-9934-P)

TSGAC Formal comments


FY 2015 Report to Congress on Administration of the Tribal Self-Governance Program

TSGAC comments and request to work with IHS to implement the suggested Tribal changes.


IHS Quality Framework Draft

TSGAC Comments on IHS Quality Framework Draft

38. 8/23/16 Dr. Baligh Yehia, MD Assistant Deputy Undersecretary for Health for Community Care Veterans Health Administration U.S. Department of Veterans Affairs

Opportunities for Partnerships between Tribal Health Programs and the Veterans Administration

TSGAC comments on the existing Indian Health Services/Tribal Health Programs-Veterans Administration (IHS/THP-VA) Memorandum of Understanding (MOU) and Choice Act Agreements

VA responded on 1/6/17. VA has suggested renewing all existing THP agreements and the VA-IHS National Reimbursement Agreement through December of 2018.

39. 8/16/16 HHS Regulations RIN 0991-AC06: Comments on Proposed Rule; Health and Human Services Grant Regulation: Published on July 13, 2016 (81 Federal

TSGAC formal comments to proposed rule



Ref. #


Response Received

Register 45270, et seq.

40. 7/21/16 Mr. Benjamin Smith, Director, Office of Tribal Self-Governance, IHS

Request for ACA/IHCIA National Outreach and Education Funding (FY2017)

TSGAC formal request for funding

41. 7/14/16 Mr. Michael Fisher Lead Contract Specialist Indian Health Service

Solicitation Number 16-IHS-HQ-SS-0001



Request to Make Self-Governance Resources Available Publicly

TSGAC request to make negotiation documents publicly availability on the OTSG website as resources for Self-Governance Tribes.

43. 6/17/16 Centers for Medicare & Medicaid Services (CMS) Department of Health and Human Services P.O. Box 8011 Baltimore, MD 21244-1850

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2017 Rates, et al. (CMS-1655-P)




Ref. #


Response Received


Director via [email protected]

Proposed IHS Contract Support Costs Policy


45. 5/20/16 Betty Gould, Regulations Officer Indian Health Service, Office of Management Services

Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care Final Rule (RIN 0917-AA12)


46. 5/13/16 Treasury TSGAC Formal Request for Targeted Partial Administrative Relief from Employer Shared Responsibility Provisions

Summary of recommendations from 5/9/16 Tribal/Treasury technical meeting re: potential options for implementing targeted partial administrative relief in order to align the ACA’s Employer Shared Responsibility provisions with the Federal government’s long-standing “special trust responsibilities and legal obligations” to provide health care services to Tribes and Tribal members, most recently re-stated in the reauthorization of the IHCIA.


Catastrophic Health Emergency Fund Proposed Rule (RIN 0905-AC97)

TSGAC formal comments on proposed rule



Ref. #


Response Received


Director

TSGAC Comments on SASP Program Funding Distribution

TSGAC input on the Substance Abuse and Suicide Prevention program in preparation for the funding opportunity announcement planned for early June 2016

49. 5/6/16 Steve Petzinger, OMB Program Examiner

Follow up from March 2016 Tribal Self-Governance Advisory Committee Meeting

Summary of the main issues and actions discussed during TSGAC meeting

50. 5/5/16 CMS CMS-10458, “Consumer Research Supporting Outreach for Health Insurance Marketplace


51. 4/24/16 IHS Principal Deputy Director OTSG Director ORAP Acting Director

SG National Outreach and Education on ACA/IHCIA

Transmittal of 6-month Report

52. 4/18/16 The Honorable Sylvia Burwell, HHS Secretary The Honorable Robert A. McDonald, VA Secretary

Reimbursement Agreement between the Indian Health Service and Veterans Affairs

TSGAC request to include PRC services in reimbursement agreements between the IHS/Tribes and the VA, as soon as possible.

VA responded on 1/6/17. VA has suggested renewing all existing THP agreements and the VA-IHS National Reimbursement Agreement through December of 2018.

53. 4/18/16 Mary Smith, IHS Principal Deputy Director

CHEF Proposed Rule 42 CFR Part 136 - RIN 0905AC97, Catastrophic Health Emergency Fund, File Code 0905AC97

Request to Withdraw Proposed Rule, conduct Tribal Consultation and then reissue the rule.

IHS issued a Dear Tribal Leader Letter on June 1st stating stated that it will engage in additional consultation before moving forward with the rule.



Ref. #


Response Received

54. 4/18/16 Mary Smith, IHS

Principal Deputy Director Recommendations for Health Care Facilities

TSGAC Recommendations 7/23/2016 – Response letter received from IHS. The letter outlines IHS specific responses to each TSGAC recommendation.

55. 4/11/16 Thomas West Kathryn Johnson Treasury Department

Excise Tax on Certain Employer-Sponsored Health Benefits

TSGAC Follow up comments from March 2016 quarterly meeting.

56. 4/5/16 Sylvia Matthews Burwell, Secretary, Andy Slavitt Acting Administrator, Centers for Medicare and Medicaid Services

Oklahoma Section 1115 Waiver Amendment Request


57. 3/29/16 Mary Smith, IHS Principal Deputy Director

Request for Service Unit Data on Health Insurance Status and 2016 Appropriation

TSGAC formal request for two sets of data: 1. Health insurance status of Active Users, by Service Unit (all Service Units) 2. IHS appropriation, by Service Unit (all Service Units)

August 26, 2016. IHS provided the following data sets back to the TSGAC: 1) health insurance status of active Users by Service Unit; and 2) IHS appropriation by Service Unit.

May 17, 2017. Due to HIPPA restrictions, IHS is unable to provide data in smaller cell counts. The information previously provided includes as much detail as legally allowed.

58. 2/29/16 Office of Management and Budget Office of Information and Regulatory Affairs Attn: CMS Desk Officer

CMS–10519, Agency Information Collection Activities: Submission for OMB Review




Ref. #


Response Received

59. 2/19/16 Centers for Medicare &

Medicaid Services

Comments on CMS-9936-N; Waivers for State Innovation


60. 2/2/16 Dr. Debra Houry, MD, MPH Director, National Center for Injury Prevention and Control Centers for Disease Control and Prevention

CDC Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain; Docket CDC-2015-0112

Support for USET Comments on the Proposed Guidelines

3/1/16 - Response received from CDC. Acknowledged the TSGAC comments. CDC expects the final Guideline to help primary care providers offer safer, more effective care for patients with chronic pain and help reduce misuse, abuse and overdoes from opioids.

61. 1/15/16 Center for Consumer Information and Insurance Oversight, CMS, HHS

Comments on Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces

TSGAC Comments on Draft Letter

62. 1/13/16 Mr. Thomas West Tax Legislative Counsel Office of Economic Policy Department of Treasury

Invited to Jan 27-28, 2016 TSGAC Meeting

Continue discussion on Permanent Administrative Relief from Affordable Care Act’s Employer Mandate on Tribes for Tribal Member Employees

Response Received January 14, 2016. Mr. West and others are unavailable, but continue to work on this issue as it is related to Tribes.

63. 1/5/16 Jerry Menikoff, M.D., J.D. Office for Human Research Protections Department of Health and Human Services 1101 Wootton Parkway Suite 200 Rockville, MD 20852

HHS-OPHS-2015-0008 – Proposed Revisions to the Federal Policy for the Protection of Human Subjects

TSGAC Official Comments on Proposed Rule



Ref. #


Response Received

64. 12/21/15 Centers for Medicare &

Medicaid Services

CMS-9937-P, Notice of Benefit and Payment Parameters for 2017

TSGAC Official Comments on Proposed Regulation

65. 11/17/15 Kitty Marx CMS

TSGAC comments Support for 100 Percent FMAP Proposal

66. 11/10/15 Mr. Robert McSwain Principal Deputy Director, IHS

Payment of Settlements to Civil Service Employees

TSGAC requests that IHS provide an accounting to all Tribes of all payments made by IHS into the employee settlement fund by IHS Service Unit location, as well as the number of employees participating in settlement payments at each location.

67. 11/9/15 U.S. Department of Health and Human Services Office for Civil Rights

Nondiscrimination in Health Programs and Activities (RIN 0945-AA02). 80 Fed. Reg. 54172 (Sep. 8, 2015).

TSGAC comments in response to its proposed rule on Nondiscrimination in Health Programs and Activities (RIN 0945-AA02). 80 Fed. Reg. 54172 (Sep. 8, 2015).

68. 11/3/15

Mr. Robert McSwain Ms. Mary Smith IHS

Interpretation of Duplication Provision in 25 U.S.C. § 450j-1(a)(3)

TSGAC respectfully urges IHS to restore its prior position that funding for contract support costs will only be considered duplicative to the extent amounts for those items have been transferred in the Secretarial amount.

Response received from Mr. McSwain on 12/4/15. Due to pending litigation, the IHS letter provides a general response to the issues outlined in the TSGAC original correspondence of 11/3/15.



Ref. #


Response Received

69. 11/3/15

Honorable Sylvia M. Burwell, Secretary Department of Health and Human Services

Final Rule related to expand the Medicare-Like Rate

TSGAC requests that HHS expedite the review and publication of the Final Rule related to expand the Medicare-Like Rate, entitled “Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care,” 79 Fed. Reg. 72160, originally published on December 5, 2014.

70. 10/27/15 Honorable Robert A. McDonald Secretary of Veterans Affairs

Comments on Veterans Access, Choice and Accountability Act of 2014 (Choice Act)

Comments on the Secretary of Veterans Affairs’ (VA) pending report to Congress concerning the consolidation of “all non-Department provider programs” pursuant to the Veterans Access, Choice and Accountability Act of 2014 (Choice Act).

71. 10/26/15 Dr. Elaine Buckberg Deputy Assistant Secretary for Policy Office of Economic Policy Department of Treasury

Request for Permanent Administrative Relief from Affordable Care Act’s Employer Mandate on Tribes for Tribal Member Employees

TSGAC provided a set of preferred options for addressing Tribal concerns pertaining to the imposition of the ACA’s employer coverage and reporting requirements as they pertain to Tribal member employees.


Request for Extension of Transition Relief from the Employer Mandate

TSGAC requested an extension of transition relief in implementation of the employer mandate from January 1, 2015 until at least January 1, 2016 and preferably to January 1, 2017.



Ref. #


Response Received

73. 10/21/15 Dr. Elaine Buckberg

Deputy Assistant Secretary for Policy Office of Economic Policy Department of Treasury

Excise Tax on Certain Employer-Sponsored Health Benefits

Tribal leaders interpret Section 4980I as not applying to Tribal government thereby interpreting this to mean that the excise tax does not apply to Tribal government plans. The legal analysis for this position is provided in TSGAC’s comments to the IRS on Notice 2015-16, submitted on May 15, 2015 (attached) to letter and again in further comments submitted on October 14, 2015 (also attached to letter).

74. 10/16/15 Mr. Robert G. McSwain Mr. Ben Smith Mr. Carl Harper

Transmittal of FINAL Self-Governance National ACA Education and Outreach Report

No action needed. Transmittal of final report for the time period October 1, 2014 through September 30, 2015.

75. 10/14/15 Internal Revenue Service P.O. Box 7604 Ben Franklin Station, Room 5203 Washington, DC 20044

Notice 2015-52 on Section 4980I — Excise Tax on High Cost Employer Sponsored Health Coverage

TSGAC comments and recommendations.

76. 10/13/15 CDR Mark Rives Chief Information Officer and Director Office of Information Technology Indian Health Service The Reyes Building 801 Thompson Avenue Rockville MD, 20852

TSGAC Representative to ISAC

Appointment of Jessica Burger.



Ref. #


Response Received

77. 9/30/15 Mr. Jeff Wu

Deputy Director Center for Consumer Information and Insurance Oversight Centers for Medicare and Medicaid Services

Response to Request for Tribal Consultation on Referrals for Limited Cost-Sharing Variation Plans

TSGAC comments and recommendations.

78. 8/28/15 Mr. Robert G. McSwain, Principal Deputy Director Indian Health Service

Fiscal Year 2014 Report to Congress on the Administration of the Tribal Self-Governance Program

TSGAC input on report in response to IHS request for comments.


Exemption of Tribes from the ACA Employer Mandate

Invitation to October 2015 TSGAC Quarterly meeting to discuss topic.

Confirmed attendance for Oct 7, 2015 at 10:30 am. Pre-briefing scheduled for Oct 2.


Quality Reporting Measures Request that IHS conduct an analysis and comparison of the GPRA and Clinical Quality Management approaches.

Response received from Mr. McSwain on October 5, 2015. Mr. McSwain notified the TSGAC regarding implementation of a major change beginning in FY2016 on GPRA clinical performance measures. The IHS is prepared to implement the Integrated Data Collection System Date Mart (IDCS DM), a new reporting mechanism within the National Data Warehouse.

3/30/16 – Letter received from IHS which includes a comparative analysis of GPRA/GPRAMA Performance Reporting and CMS Clinical Quality Management requirements. This letter and analysis was distributed to the TSGAC and discussed during the 3/30/16



Ref. #


Response Received

TSGAC meeting.

81. 8/4/15 Centers for Medicare and Medicaid Services Department of Health and Human Services Attn: CMS-10561

Comments on CMS-10561, ECP Data Collection to Support Qualified Health Plan (QHP) Certification for PY 2017

TSGAC Official Comments

82. 7/28/15 Geoffrey M. Standing Bear Principal Chief Osage Nation

Welcome to Self-Governance


Multi-Purpose Agreement (MPA) and Joinder Agreement & ISAC Presentation

Address Tribal comments on MPA; and follow up with OIT to host Webinar regarding ISAC.

84. 7/27/15 Centers for Medicare and Medicaid Services

Comments on CMS-2390-P, “Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability: Proposed Rules

TSGAC provided a series of substantive comments (26 pages); along with accompanying attachments. The TSGAC comments mirror the model template developed by a team of health care experts from the MMPC/NIHB.



Ref. #


Response Received

85. 7/10/15 Carolina Manzano

Chief Executive Officer Southern Indian Health Council, Inc.


86. 7/10/15 Vincent Armenta Tribal Chairman Santa Ynez Band of Chumash Indians


87. 7/10/15 Dan Courtney Chairman Cow Creek Band of Umpqua Tribe of Indians


88. 6/29/15 Mr. Robert G. McSwain, Acting Director Indian Health Service

Determination of Contract Support Cost Requirements

TSGAC comments in response to IHS’s position that the amount of contract support costs (CSC) owed under its contracts and compacts with Tribes and Tribal organizations under the Indian Self-Determination Act (ISDA) is determined based on “incurred costs.”



Ref. #


Response Received

89. 6/12/15 Mr. P. Benjamin Smith,

Director, Office of Tribal Self-Governance, Indian Health Service

Tribal Leadership Priorities for “Self-Governance National Indian Health Outreach and Education”

The TSGAC reaffirms the commitment to empower Tribal communities with the knowledge and tools needed to successfully manage and implement the Patient Protection and Affordable Care Act/Indian Health Care Improvement Act (ACA/IHCIA) provisions concerning health care insurance coverage options to improve the quality and access to care for Tribal citizens and Indian communities. TSGAC urges OTSG to amend the Agreement to renew and fund the “Self-Governance National Indian Health Outreach and Education” contract for FY2016


Payment of IHS Employee Settlements.

TSGAC provided comments to the May 22, 2015 IHS Dear Tribal Leader Letter (DTLL) on the Payment of Employee Settlements.

For the current settlement described in the DTLL, and for any future settlements, the TSGAC strongly urges the IHS to reject the flawed plan to cut health care services and consider one or both alternatives proposed.

IHS Deputy Director provided a response back to Tribal Leaders on July 29, 2015. The letter addresses three questions about the settlement that have been raised frequently in various forums since then.



Ref. #


Response Received

91. 5/15/15 Internal Revenue Service

Notice 2015-16 on Section 4980I — Excise Tax on High Cost Employer-Sponsored Health Coverage

TSGAC Comments in Request to Notice from IRS.


Healing our Spirits Worldwide Gathering

Request of IHS support in this effort and the participation of P. Ben Smith, Director, Office of Tribal Self-Governance (OTSG).

IHS Responded on August 29, 2015 to the TSGAC and stated that Mr. Smith is confirmed to attend and participate in the HOSW gathering.

93. 4/23/15

Mr. Robert G. McSwain, Acting Director Indian Health Service

Detail of OTSG Deputy Director

TSGAC request to Director to re-evaluate the detail and assign other staff to OUIHP as soon as practicable.

IHS Responded on August 29, 2015 to the TSGAC and stated that OTSG Deputy Director has officially returned to her position as of 7/27/15.


Special Diabetes Program for Indians (SDPI)

TSGAC comments in response to the DTLL request for comments/consultation on the SDPI programs.

95. 4/20/15 Mr. Robert G. McSwain Mr. Ben Smith Mr. Carl Harper

Transmittal of Self-Governance National ACA Education and Outreach Report

No action needed. Transmittal of 6-month report for the time period October 1, 2014 through March 31, 2015.


Payment of Contract Support Costs for MSPI and DVPI funding

Request that the agency review this issue and that, as committed during 3/24/15 TSGAC meeting, provide a final decision to Tribes on the eligibility of MSPI/DVPI for additional

A Dear Tribal Leader was sent out from IHS Acting Director McSwain on 6/22/15 with an update on how the IHS will move forward with MSPI and DVPI over the next five years. Response received from IHS Acting Director McSwain on 5/18/15. Letter stated the IHS is not required to



Ref. #


Response Received

CSC funds within 30 days. provide additional funds beyond what is included in

the project budgets.


Thank you on Rates of CSC Settlement and Claim Resolutions

Continue timely resolution of outstanding claims and consistent full funding of CSC.

98. 4/3/15 Mr. Gregory E. Demske, Chief Counsel to the Inspector General Ms. Melinda Golub, Senior Counsel Mr. Amitava “Jay” Mazumdar, Senior Counsel Office of Counsel to the Inspector General

Thank you for participating in the Tribal Self-Governance Advisory Committee Quarterly Meeting, March 24, 2015

Further dialogue to occur during the Thursday, April 30th Breakout Session A7, Pursuing and Reinvesting Third Party Revenue, at the upcoming 2015 Annual Tribal Self-Governance Consultation Conference in Reno, NV

99. 2/26/15 The Honorable Derek Kilmer

Self-Governance Tribes 2015 Appropriations Requests for the Bureau of Indian Affairs

Joint letter from TSGAC/SGAC

100. 2/10/15 The Honorable Derek Kilmer

Self-Governance Tribes 2015 Appropriations Requests for Indian Health Service

Joint letter from TSGAC/SGAC



Ref. #


Response Received

101. 2/9/15 Chief Marilynn Malerba,

Chairwoman TSGAC

Agency response to information requested QHPs to IHCPs in specific regions

CMS staff are available to address specific QHP problems and provide further assistance in the process

Response from Marilyn Tavenner, CMMS 2/2/15 to letter dated 12/19/14

102. 1/31/15 Chief Marilynn Malerba, Chairwoman TSGAC

Agency response to the ongoing and unprecedented international Ebola crisis

Response from Dr. Y.Roubideaux, IHS Director, 1/31/15 to letter dated 10-17-14

103. 2/5/15 IHS Director,Dr. Y. Roubideaux

Mandatory Appropriations for Contract Support Coasts

Appreciated partnership and looking forward to working to advance long-term solutions for funding CSC

104. 2/4/15 Betty Gould, Regulations Officer, IHS and Carl Harper, Director ORAP,IHS Submit via regulations.gov

Comments on IHS Proposed Rule entitles “Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated with Non-Hospital-Base Care

Being able to engage in Tribal Consultation on the proposal

105. 1/20/15 Chief Marilynn Malerba, Chairwoman TSGAC

Concerns regarding procedural consistency and information sharing during CSC negotiations on Disputed claims

Response from Dr. Y. Roubideaux, IHS Director, 1/20/15 to letter dated 12-2-14



Ref. #


Response Received

106. 1/14/15 Ms Tracy Parker Warren

Office of Public and Intergovernmental Affairs OTGR(075F)-VA

Comments Submitted Response to Notice of TC: Sec 102 © of the Veterans Access, Choice and Accountability Act of 2014

Urge the Reports enter into agreements for reimbursement also current agreements be used and expanded where possible to speed up implementation to eligible veterans

107. 1/12/15 CCIIO-CMS-DHHS Comments on Draft 2016 Letter to Issuers in the Federally-Facilitated Marketplace

We are available to discuss any of the recommendations contained in the correspondence and attachment on CMS-9944-P

108. 1/8/15 IHS Director, Dr. Y. Roubideaux

2015 TGSAC Quarterly Meetings and Tribal Self-Governance Annual Conference Information

Adjustment to your schedule due to changes for the January Qrtly meetings

Response from Dr. Y.Roubideaux, IHS Director, 1/15/15 re: She will be in attendance Jan 28 also attendance at March Mtg on the 24th

Opening Remarks

Chief Malerba

Partner with other agencies and others that care about social justice Still struggling to have a budget that reflects our needs New England 1600 first immigrants How do we advocate with states that don’t have federally recognized tribes –

how do we adopt those reps and educate them on our topics? ACA reach out to VT, NH and NJ and they said no one has ever talked to us about it before. 13 states don’t have Tribes within their borders

Tribes need to be bi-partisan and there are opportunities with this Administration (tax and infrastructure) – issues cross agency boundaries (infrastructure - indoor sanitation)

Chairman Allen

Refocus on self-governance Keep watchful eye on our President Where are we going – direction and destiny for SG agenda. We have been in

movement for 25 years and have experienced amazing success. If take resources and move them to community we can make dollars work more effective.

Watchful eye on whats going on with congress – last 6 months it has been healthcare but there are many other things we are dealing with – public safety Tribal law and order act, voca, etc. natural resources, education, housing, jobs and economic development

Budget issues – commonly hear $20 billion in federal system that serves Indian country – bottom line is what is the need may be closer to $200 billion or more. Benchmark IHS analysis 10 years ago $30 billion need now take on housing and other issue and number increases

How move agenda forward – the solution is not going to come from the Federal system – we are going to fight for the federal system so we can generate our own strong economies. Mohegan doing amazing; Navajo – doesn’t matter the size

Protect interests and protect sovereignty – bottom line Inouye – sovereignty is the most important – have treaties because sovereign

nations 300 Treaties consummated and 350 plus not consummated. 10-20 years ago we didn’t have a lot of resources but do we have more money if

you calculate in the inflationary value – not sure worth spending energy on Administration has a view that is not positive with respect to domestic spending –

they say give something up to get something funded – discuss it later Hill – have friends and they say have a different idea than the President has

regarding the budget

Strategy Session 2017 Mohegan Tribe Uncasville, CT Page 2

We will not allow the President to name Chiefs – insist he engage with us. Fall this President plans on having a White House meeting with Indian country.

Lot of engagement will take place with the people under the President (Cason, Clarkson, Keel)

Stronger, smarter and more sophisticated – you will not run us over Zinke and Price messages – where will Indian country be in 100 years – we will

tell you. We know what is best for our sovereign nations and we will protect our culture and nations. This is not the new version of termination and it will not happen on our watch.

At the end of the day we are a team – we have a mission and a game plan “SG works”

What is the new message – tax reform is about sovereignty and your jurisdiction and authority

We are going to survive and move our agenda forward Budget Discussion Bureau of Indian Affairs (BIA)

Sequestration/Rescissions Protect Base Budgets – as opposed to one time grants FY2020 Budget Formulation Guidance Greenbook – Tribes need to weigh in Indian Trader Act – listening sessions regulations

Indian Health Service (IHS)

Process is similar to the BIA Budget Formulation Process - Tribal priorities; Area Regional Meetings; National Roll up

Budget delays – need for advanced appropriations Tell your story – need to go beyond it Support urban health centers because they provide services to members and

hope they get a seat at the budget formulation table How can national committees work together to advance their priorities Create transparency in the formulas and formula methodology – agency not

forthcoming; OMB attend meetings and understand TSGAC needs; line item for SG (push SG up to the front)

Appropriations for IHS 2017 – several increases but IHS is considering pushing the money out in the form of grants

Execution of the budget is just as important as appropriations FY2018 – President’s skinny budget pushed out; House passed Interior Bill and

several increases to IHS in that bill but zero increase to PRC which is one of top priorities. Interesting provisions – IHS study on unfunded priorities in Indian Health Care Improvement Act and IHS has to respond within 90 days of passage. Provision on reimbursement – directs IHS to report on trends in population being served and how population is being served (Medicare, Medicaid, 3rd party, compacted and contracted programs) Maximize 3rd party


reimbursements and we need to have a discussion about it. Some of it requires a comparison among areas (may stem from the issues with the Great Plains)

CSC reduction but IHS overstated need in 2017 – any cuts to CSC will go straight to the Tribes not the agency.

What will be budget vehicle? CR but how will hurricanes and fires impact the final budget?

Legislative Update

477 - Successful program but resistance from IHS with flexibility and accountability. Past couple of years effort to develop legislation to revamp the program and limit agency discretion. Last Congress close to enacting – passed in Senate and then House with few changes went back to the Senate and there was agreement but clock ran out and the Senate was not able to pass the bill. Current congress – momentum carried forward into this Congress – House passed Bill on February 22 voice vote and pending in the Senate – same bill waiting for Senate to act. Wait for UC calendar to be put on the floor of the Senate. First window of opportunity this bill will pass the Senate.

Reauthorization of NAHASDA – Expired in October of 2013. In 2014 House passed reauthorization bill but held up on Senate side (Senator Lee Utah – Native Hawaiian portion is raced based and stopped bill from being enacted) This Congress dynamic different – fiscal conservatives raised their own issues and hasn’t passed House side over funding and on Senate side Hoeven introduced a scaled down version of the Act and removes Native Hawaiians. Tribal advocates are luke warm about it. It is not clear what the prospects are right now.

Repeal and Replace Affordable Care Act (ACA) – Defeat of the “skinny bill” but doesn’t mean repeal and replace is off the table. There have been efforts (bipartisan) to fix some of the provisions and hearings on insurance issues. President still urging replace and repeal. Big issues sucking up the oxygen not sure how much time to focus on ACA. Good news Indian country – House version would protect IHCIA and Indian provisions but bad news gutted Medicaid. Watch it as it develops over next weeks and months.

Restore Accountability in Indian Health Service Act of 2017 – Introduced May 2017 goal is to institute structural changes in the IHS. Focus on the unintended consequences on SG principles – there is language to try and prevent it but it may not be sufficient.

Reauthorization of the Special Diabetes Program for Indians - Program will expire at the end of September. There has been effort to reauthorize it. There was an effort to reauthorize in the Doc fix but there is no Doc fix this time so have to identify another legislative vehicle. CHIP program – hearing later this week and hope is to attach SDPI funds to that bill. $150 million dollars and if not reauthorized it will be a significant blow to the programs that have developed. Funding needed for disasters – how will it impact CR.

Title IV – Fifteen (15) year initiative and a draft bill was prepared by Tribal advocates and efforts every Congress to enact this legislation and multiple hearings held. Administration was fully behind it – passed Senate then went to the House side. Association of American Federation of Wildlife Agencies raised


alarm with the bill. Spent a year to work with the organization to come up with language and we were able to address it in a package of amendments. After reached Agreement – House staffer raised two issues BOR – killed the bill. Need to work on the House side and find the right champion to advance the bill.

Expand SG Program within HHS – Title IV directed HHS to conduct a feasibility study and concluded it was feasible for 11 programs. Tribes drafted legislation and Tribal witness showed up and no one from HHS showed up. Resistance at HHS to expand SG. Obama Administration set up a Committee but the effort died out. Institutional resistance has proven to be a difficult nut to crack.

Policy BIA

Tax Authority and Indian Trader Act – last Administration tried to update it and there were differences of opinion between Acting Assistant Secretary and Solicitor so could not get it done. Listening Sessions are currently being held.

Executive Order 13781 Comprehensive Reorganization of the Executive Branch – instructed to review operations and propose to OMB better way to run the shop with less staff. We need to be mindful of plans and their proposal and how it would impact the agencies that serve us.

DOI Secretary Zinke – notion of leadership is best if leadership move around similar to the military. Regional Directors and SES are being moved all over the country. Concern – RD get assigned to an area and they learn about the area and the complexities of the area Tribes is this the best way to serve Tribes. What is our opinion of this? Are they trying to push them out?

Policy IHS

We need to think about health in a broad perspective. We need IHS and they are a big employer in rural areas. Indian health is inequitably – doesn’t increase with demographics, technology, because on discretionary and we are subject to sequestration.

Need to look at Social determinants – food, early childhood, education, access to healthcare

Contract Health and Purchase and Referred Care – need for services Better coordinate with VA on Tribal priorities IT systems – as VA changes their health system need to be vocal Reorganization of Government Services – any changes proposed need to go to

the Tribes through consultation. Haven’t seen documents even though requested it.

Look at level of need funding with a health economist. If provide for level of need provided how does it prevent the costs from escalating in the future?

Expansion of Medicaid – some of the states are recommending people with access to Medicaid are working and how do you do that in Indian country with no job opportunities?


Communication and Education Blueprint Government Relations – Ascertain federal and state priorities for CN Organize events Oversee tribal/federal/state nominations Manages voter registration Attend At-Large meetings Political giving for Federal/State races Ascertain Priorities – what is the plan? Annual meetings develop and execute strategies (list of things you want to advance – try to figure out possible to move based on current political climate) Federal – legislative, regulatory and judicial – have to be proactive testify, write letters State – Protect Tribal/State compact structure, Indian Arts and Crafts Bill What is your role in the process? Pre-introduction know the issue – idea/proposed bill language After the introduction – letter of support/letter expressing concerns/collaboration Legislative Hearing – witness, testimony/statement for the record, questions at hearing/for legislative record Mark-up – amendments Engage the Administration because Congress will ask the agency for technical assistance and their views Develop a legislative record – important to memorialize statements and positions by interested parties Sending letters is critical Who should you meet with? Cherokee Nation footprint in every state and abroad and use citizens in every state to their advantage. Know Committees of jurisdiction and other relevant committees Seek meetings with leadership Prior to meeting – choose proper targets; work both sides of the aisle Crystalize your ask – what do you want them to do? Is it politically feasible? Does it line up with their policies? Meeting – Brief 15-20 minutes – handouts brief and state clearly your position Building Alliances – National organizations, regional organizations, lawyer/lobbyists Questions Agencies don’t feel like they can advocate so we request they let us know and we can thread the questions to be asked to Congress.

Integrity and trust is important and relationships are important Identify the stumbling block and frame your question that way

One of the alliances is the Native American Caucus in the House. We need our congressional delegates to join it. Share the value of it.

Kildee formed the Native American Caucus because there was a time when legislation attacking Tribes was developing in the House. So formed Native American Caucus to serve as a bi-partisan body to educate both sides of the aisle to prevent proposals from coming forward. Made sure briefing sessions –


where is there agreement? Where do we not agree? So we agreed up front what we would work on. Defeated negative proposals had champions on the House side and outreached to members on both sides of the aisle and make sure Native American issues was part of the briefing book.

To be effective in DC – It is about developing relationships with individuals who make decisions. Be succinct and clear – when write a letter tell them upfront what you want. These people are swamped and overworked. Ask them to have lunch with you because they remember you. Attend fundraisers – make contributions. In terms of lobbying – remember you have a team and that team is important. Have to have integrity to identify pitfalls and troubleshoot pitfalls. Need to work the national and local level simultaneously. Use real life examples – biologist bear thermometer. Overview of Education and Communication Plan and SG Report Cards – documents helpful for legislative associates – there is a lot of turnover in these positions on the hill. Questions Consider hosting the Strategy Session in DC. Brief Tribal Leaders prior to meetings in DC Self-Governance

1988 SG Demonstration Project P.L.100-472 Title III No permanent legislation and regulations Initial 10 Tribes met with DOI and BIA Advance the government-to-government process a new partnership Tribal leaders, finance and technical staff worked together and negotiated

collectively SG Coordinators met regularly to share documents 1989 SGCE Office was formed – central office to coordinate SG efforts, share

resources, provide trainings, develop SG Guidebooks, plan and coordinate Annual Conferences and Strategic Sessions

261 SG Tribes in DOI and 363 in IHS SG Coordinators contact other coordinators in the region, attend SG quarterly

meetings, utilize resources on the SGCE website, participate in SG annual conferences and strategy sessions, share success stories and best practices, find a mentor/be a mentor

Questions/Comments

Make sure communicate issues that new Tribes may have to share experiences and connect with one another

Certain regions push back and do not support SG – continue to push forward Salt River – finished negotiation to take over land, titles and records function.

The NW Region allows Confederated Salish and Kootenai handle it; San Francisco does same but Western doesn’t. It took 19 years for Salt River to get it through –obstructions Tribal, agency and central office level. Had to go back to


the formula. In region have Navajo and Tohono O’odham – formula use land base – fought to use land transactions instead. It was going to take 3 years to do a gifting with one land owner. Own lease payouts, turn around pay outs within 3 work days.

Old Guard blazed trail and defended the sovereignty of the Tribe – it was about authority, jurisdiction and control over your affairs. Navajo consider SG – ripped Tribes up and down but now Navajo is in. Great Plains issue is treaty rights but this does not absolve treaties. Are we there? No there are new obstacles emerging the system has the propensity to protect itself because they do not like the idea and will look for ways to undermine us. We are showing success but we have a long way to go. When do we feel we have won the war? We have changed the tide. Inherent Federal Function is still not well defined yet – they need to show us what federal statute says that we cannot take it over.

What is sovereignty? Sovereignty is whatever you do with your powers that you have – however far you take them. It is up to the Tribe to determine what they want to do for their people.

Joe DelaCruz – quit acting like fort Indians waiting for the blankets and food and take control of our affairs

Midwest BIA employee (new) made comment why should I help you? You are self-governance. 20 years ago when Red lake was negotiating we interviewed all the offices said if took share it will hurt other Tribes so we left it. There were times when they hid the shares and didn’t include SG Tribes in funding increases. Everyone has to be watchful for this type of thing.

Ysleta del Sur – also there is a fallacy on the Tribal side that once compact out of the region but that is not true. Stay involved and put accountability back on the regional director.

Within the system you still have senior staff or anyone underneath them that may or may not know a lot about SG so we have to continue to educate them and educate new players. If there are programs A through Z no one is taking everything. There are always a handful of programs you left and inherent federal functions that are their job. They need to identify our proprieties and our budget.

Strategy – challenge the leadership in their region to establish regular orientation or updating of the SG agenda.

We had to educate community members and council when we decided to go SG and every year when we negotiate we remind them of what those are.

What are the rebuttals to the regional folks? Inherent federal functions are not contracted duties so there are some things we need to forge through.

Common questions – develop a list that we hear or common perceptions we hear and what are the responses?

We need to remind OSG and OTSG that they should be strongly advocating on our behalf and educating their own colleagues. SG Tribes need to get behind the Tribe and support them. Sometimes we do not get that support from them.

It has to be about service and not money because often the programs are underfunded. Dental services we get $20 a year so we need to subsidize it.


ICWA funding if we just relied on federal funds what kind of service would we be providing our people?

When Tribes take money we are really helping the federal government do their job.

A lot of us look around and ask how did you do it and make it work – this is of value. It provides confidence take what you can get and run.

Salt River – won’t sign funding agreement unless you satisfy these conditions and now went to 5 year funding agreement.

Tribe exercising sovereignty and set up infrastructure to take that function over under their jurisdiction

Two sets of work – one among ourselves sharing amongst Tribes – documents how to negotiate and implement programs – consolidating programs The practices we use to have fallen away and we could educate ourselves and new Tribes coming in.

Why not instead of how to –sharing of how we do certain things and run certain programs or have a clearinghouse of examples.

Success breeds new kinds of problems and you don’t always share. Executive Orders Self-Determination and Self-Governance is a product of Republican Administrations. Josh Petri is the new senior policy analyst at NCAI and will be the key contact for SG.

Executive Order on Executive Branch Reorganization – actions are already occurring staffing issues and staffing changes at DOI. Continue to ask for consultation. Hope a lot of things will be pulled back once consultation is held. Reform plans were supposed to be submitted to the President soon. Acting AS-IA stated he would only have Tribal input first then the draft plan would be released after that. DOI has not submitted a plan yet. We won’t see a draft plan. All indications at DOI are that they do not have a plan to submit. Subcommittee holding the hearing led by two members of the SCIA.

Sounds as though the Departments are being encouraged to circumvent the consultation process.

Sometimes we have to re-emphasize the government to government relationship and there is such a lack of confirmations that the folks that would keep things running are not in place. 124 confirmed positions throughout the entire government – impacting Tribes. In some agencies there is an effort to get around the normal ways of doing things and a lot of constituencies are complaining but the difference for us is our political status.

Inquiries and interactions with the hill have almost doubled. Congress realizes it is filling in the gaps.

Bishop is going to attend Tribal Impact Days – Self-Governance is important right now because we show that things are

working. White House is governing by EO and Congress is filling in gaps – EOs are

limited. John Tesuda started yesterday as Principle Deputy


Impact Days next week congressional briefing Tuesday 8:30-1:00pm House and Senate Members from key committees – healthcare, tax, etc.

NCAI Annual Meeting Milwaukee and have space for Tribal consultations – Indian Trader Regulations, Land into Trust and Executive Branch Reorganization.

What Works – What Message do we shape out?

Themes – “Grow Self-Governance – our promise our legacy” “30 Years Strong – Tribal Self-Governance in Action” “30 years strong – sovereignty in action” “Tribal control – Tribal authority” “30 years strong – working to fulfill the promise” “Tribal Self-Governance - 30 years strong making America Great in Indian country” “Self Governance is an evolution” “Tribal Self-Governance expanding SG reducing the bureaucracy” “Self-Governance Ancient Ways Translated in a New Day” “TSG Experience and Evolving” “TSG Making America Ours Again” “First Nations First Resisting the Federal Government since Time Immemorial” “Determining our own destiny”

Common phrases to use with the Administration Come up with a new theme – a lot of these things can become talking points and

messages Develop and Mobilize Teams

Team A, B and C Tribal leadership and co-chairs on the teams Identification of the types of work that needs to be done – track who takes the

lead and spread the workload out amongst everyone Education on the issues – position papers We have a roster – have a second person to list as tech rep SGCE Director can help facilitate SGCE develop issues to share with the Tribes Provide options on how to move forward Need more hands on deck Topics – how will the topics come down – this Administration we will be reacting

to something we didn’t know was happening Proactive work is also in the plan SGCE Newsletter – useful tool Wendy Helgemo Appointed Director of Center for Indigenous Politics and Policy

at George Washington University (former senior advisor on Indian Affairs to Senator Harry Reid)

Staff development – professional development offer small fee Homework item -


Strategy Session Day II

Meeting Preparation – “the how and what to do” Pick your topic, know your topic and develop white paper/issue paper/issue

brief/one pager” Find out what your issue is and state it clearly (example SDPI for Indians –

expire in 30 days) Facts, history, background and other information about the issue – highlight why

it needs to be done by September 30th Reiterate your ask at the bottom – short and sweet “request, ask,

recommendation” Have a packet of information if you plan on visiting a number of offices – four

components (Who we are; (add graphs/pictures); issue/position paper; personal stories; include business card or follow-up document

Packet – (see handout) Folder on one side issue paper and the other side information about Tribal government with pictures of Executive and Legislative branch how the government is set up and how they are held accountable to Tribal citizens

Communicate message and helps staff/congress/Admin learn about the Tribe and leaves impression that professionals and take matter seriously. Want them to care about our cause.

Hearings – Representative Cole held up the per capita graph of how IHS is funded compared to the national average – IHS is underfunded.

Visuals are a good tool to use – anticipate questions and jot down notes on your paper to help guide your discussion

Follow-up after the meeting to check in and see if they need clarification or have questions so you can provide additional details

Questions Slade Gorton trying to cut budget and slash Tribal sovereignty – Tribes united to fight against Gorton – Tribes got together and identified big ticket items – had 500 Tribes visiting with Congress. Proven technique – one page bulleted items – united message. Blueprint Session – create additional structure to the team –“grouping of tasks” that can be bucketed together A - Research portion of the work develop documents that can be leveraged (tech team) B – External communication – SGCE or law/lobbyists C – Strategy and Coordination – Team familiar with legislation and players to advance those issues

Key words – prosperity, sovereignty, 30 years success How do we put buckets of work into action? What are the issues we want to

target? Want to hear from new folks – what can we do to help develop learning process? How do we use these tools on a regular basis?


Look to identify the top priorities we would like to see? Instead of being too reactionary how do we move forward into the proactive area?

Have information packets on how to do things – how we may handle process with a team approach?

Facilitated Session – “Blueprint” Couple components to the Blueprint – this is a “National Communication Plan”

Start with a folder – have theme and logo on front of folder Basic material about Self-Governance (update Report Cards) including frequently

asked questions and misperceptions What is the “Ask” – top issues develop one pager Develop team around task to form the one pager Develop issue papers as needed Form multiple team A depending on “subject matter” - Blueprint is good and like

you can customize it and provide an introduction to SG – Tribes assisting Federal Government in upholding treaty and trust obligations

Narrow down three top priorities: Executive Orders Appropriations/Budget

People need to know who is meeting with who – know what the conversation was about and what the response was include “confidential” section on website that Tribal leaders and representatives can access. Tribes need to know what the latest is on a specific issue – who are the sponsors now so you can ask your rep to sponsor it or sign on as a co-signer.

Purpose of Communication and Education Blueprint is to develop stronger messages, empower group and how to get it done with the Administration and Congress

Strengthen networking Actions – Develop educational materials; Tribal examples – success stories, best

practices and photos; basic facts (frequently asked questions and updating report cards)

Volunteers (Update Report Cards – two work groups DOI/IHS and two areas language and graphics) DOI Report Card: Gerry Hope, Linda Austin, Jennifer McLaughlin IHS Report Card: Beau Mitchell, Melanie, Rhonda Farrimond, Cyndi

Ferguson, Councilwoman Carlyle Brochure – Frequently Asked Questions – updated on the website;

content may need to be updated in the brochure. (SGCE Office) In what forums do we use it? In the materials we are packaging. Training information can be included in the brochure. (maybe defer to new ED to market SGCE Office)

How do we partner with Universities and Graduate Students? Partnered with Harvard – best practices for internal research committees. George WA University


Workgroups on issues – whatever workgroup or team identify two co-chairs to lead the team – small workgroup calls, report back the results of the call to leadership and technical workgroup

Utilize social media and virtual tools – Director SGCE Reporting Forms – collect reports (identify members who serve on the

Committees) – Here are the issues and here is the information we need back. SGCE has a consultant that does PR and graphic design. Branding and

marketing – budget for a PR Firm – fundraising outreach for it and form relationships with mainstream media; identify individuals with experience in this area; convene a press conference.

Engage in the agenda development when issues arise – list of who groups are and who the reps are and include them in the agenda development

Written reports may be helpful in the future to brief people at the Annual – Hot topics for agenda

Outline what happens – develop testimony – language – messaging for formulation

Issues – Appropriations/Budget - everyone wants more money – SG important

thing is how we improve the system so it is accountable in terms of ensuring SG Tribes receive their fair share; protection of base budgets and use of budget graphics; new money will be coming in at DOJ and Tribes need to be engaged about how the new money will be distributed and what the formula will be; are there things we can do legislatively to authorize transfers from one agency to another; help with re-visualize DOI budget; Expansion of SG across the federal government – getting authority for other departments to send money to DOI

Expansion of SG Agency Wide Inverted Triangle – Administration heavy and funding for the Tribe –

identify inefficiencies and work with Tribal task force to go through the organizational chart

Closing Remarks New chapter for SG – we have lots of reasons for optimism and hope and a better day for our communities in exercising sovereignty and SG and taking back control over our destiny. Success breeds higher expectations. Stronger, more effective, more savvy, and more engaged. It is about our cultural and identity. We have to follow-up and refine materials and conversations with congressional and administrative leadership and make sure we are treated fairly. In old days we had two meetings – then we decided we need to meet amongst ourselves which is where the Strategy Session arose. Busy people always get busier. Sharing – It takes all of us to get this work done. Use everything that you share with me when develop position papers and thoughts. All of the work we do is appreciated. Love how everyone shares their experiences so we can advocate for all of Indian country. We need to continue to work on the fact that Tribes are holistic but the Federal government


wants us to silo everything and force us to conform to their needs. SG is the opposite of this. You honor us by joining us here. It is about putting one foot in front of the agenda. Closing Blessing -

Strategy Session Recap

Take Away Messages

Partnerships – aligning with other agencies that support social justice Advocate in states that don’t have Federally Recognized Tribes (13 states) Bi-partisan opportunities – look for opportunities within the Administration and

Congress “Self-Governance” and local control – game plan is that SG works show Tribal

success from last 30 years Sovereignty, Jurisdiction and Authority - Protect Tribal interests – we are

stronger, smarter and more sophisticated and Tribes will define what sovereignty means to them not the Federal or State Governments

Consultation and Engagement with Tribes – will not allow the President to name “Chiefs” insist they engage with us

Budget

Protect Tribal Base Budgets and funding mechanisms such as contracts and compacts as opposed to grant funding

Hold Tribes Harmless from Budgetary reductions and rescissions Budget Formulation – important to engage in the process and continue to push

for improvements Green book – Tribes need to weigh in with recommended changes Advanced Appropriations – execution of budget is as important as Appropriations

Policies

Indian Trader Regulations Reorganization of the Executive Branch Tribal Consultation Equitable funding for Tribal programs (IHS, Law Enforcement, etc.) Better coordination amongst the agencies (social determinants of healthcare)

and between the agencies and Tribes (VA) IT systems in healthcare Economists to study Trends

Legislation

Legislation – ACA- Repeal and Replace; Medicare/Medicaid and 3rd party collections; Restore Accountability in Indian Health Service Act of 2017; Special Diabetes Program for Indians;

Strategy Session Recap September 6, 2017 Page 2

Tax Reform; 477 Reauthorization of NAHASDA Title IV Expansion of SG

Communication and Education Blueprint

Ascertain federal and state priorities – What is the plan? Develop and Execute Strategies

Be proactive at Federal and State levels of government – testify, write letters, call, visit

What is your role? – Know the issue and crystalize your ask – what do you want? Tell them up front what you want. Is it politically feasible? Does it line up with their policies;, know the committees of jurisdiction and other relevant committees, seek meetings with leadership, work both sides of the aisle

Meetings – Be Brief – keep handouts brief and state your position clearly; identify pitfalls and troubleshoot them; use real life examples (Biologist and Bear)

Build political alliances/form relationships Native American Caucus – plays key role Organize events – attend fundraisers – make political contributions Oversee Federal/state/tribal nominations and manage voter registration

Self-Governance

Overview of the history of SG and role of Tribal leaders, finance and technical staff

Importance of coordination and sharing of documents and resources, including success stories and best practices

Develop a list of common perceptions and our responses Participate in quarterly meetings, strategy session and annual meeting Trainings Challenge leadership in region to establish regular orientation and update the SG

agenda OSG and OTSG need to be stronger advocates and educate their colleagues Focus is on services (money is not sufficient) we are helping the federal

government do their job Develop a Tribal clearinghouse for best practices and sharing of resources

Executive Orders

Continue to push for Tribal consultation

Strategy Session Recap September 6, 2017 Page 3

Re-emphasize the government-to-government relationship NCAI – Impact Days and Annual Conference

Themes

Ideas generated for new theme and talking points and messages Brainstorming ideas – list of suggested themes – couple additional

“30 years of Self-Governance – catalyst to Native prosperity” Wilma Mankiller – opening pages issue in OK state was cracking down on the Tribes “If we work together we will all prosper” Work together we can create jobs and all of us will prosper. SG Tribes are to be commended for exercising sovereignty and energy and making their communities prosperous. Human energy makes America great.

“SG 30 years strong - Sovereignty, Responsibility and Prosperity”

Develop and Mobilize Teams

Mechanics of how we get this work done Keep group cohesive and make progress to get things done Groups may be standing groups or center on issues but we want a more

formalized way to follow-up on work Recruit more folks to help with work Have a more deliberate and organized process to get the work done Identify the type of work that needs to be accomplished; identify leaders of

groups/issues and spread out the workload Need to educate on the issues and develop position papers Professional development is needed – invest in people by training/mentoring We need to be both reactive to what comes down the pipe and proactive in

advancing our plan

SELF-GOVERNANCE COMMUNICATION &

EDUCATION “BLUEPRINT” UPDATED: SEPTEMBER 22, 2017

The purpose of the Self-Governance Communication and Education “BluePrint” is to provide Self-Governance Tribes with the tools needed to launch a major “Tribal Self-Governance Communication and Education Campaign” that will:

1. Develop stronger and better messages about Self-Governance; 2. Empower Self-Governance Leaders and technical staff to speak about the Self-

Governance mission, vision and priorities; and, 3. Focus on how to “get it done” on Capitol Hill and within the Administration.

By forming Teams to lead this effort and improving coordination and communication among Self-Governance Tribes, the BluePrint actions/strategies identified below will be tracked and shared regularly with Self-Governance Tribal leaders, technical staff and the Self-Governance Communication and Education (SGCE) office to assist in the advancement of Self-Governance policy, legislative and budget issues within the Administration and the Congress.

OBJECTIVES AND ACTION ITEMS:

Initiative I - Tribal Networking and Educational Campaign Objective: Develop a coordinated and consistent Self-Governance educational campaign to provide information to Congress, the Administration, non-Self-Governance Tribes and other interested parties regarding Self-Governance. Facilitate and support the active participation of Self-Governance Tribal leaders and representatives in a collective effort to strengthen communication and outreach of Tribal issues and positions on key policy, legislative, budget and administrative proposals. Actions: Develop educational materials that will include: (1) History and description of Self-

Governance; (2) Tribal examples (success stories, photos, best practices) of Self-Governance implementation to include highlights of the creative and positive developments and impacts on Tribal communities; and, (3) Basic facts that everyone should know about Self-Governance (e.g. Update DOI and IHS Self-Governance Report Cards).

Develop an updated Self-Governance Communication & Education Office (SGCE) brochure that outlines the Self-Governance objectives and services provided, including Self-Governance materials, workshops and training sessions;

Identify Teams who will take the lead on respective key priorities included in the 2017-2109 National Tribal Self-Governance Strategic Plan. Each team will identify two Co-chairs who will be responsible for leading the Team, organizing teleconferences, and reporting back regularly to SGCE and at the quarterly DOI SGAC and IHS TSGAC meetings;

Review list of Self-Governance Representatives in other outside Committees/Workgroups and include those individuals in TSGAC/SGAC agenda development as warranted.

Utilize social media and virtual tools to share updates and messages; and, Coordinate and strengthen advocacy efforts with other national and regional Tribal

organizations.

SELF-GOVERNANCE COMMUNICATION & EDUCATION BLUEPRINT DRAFT DATED: SEPTEMBER 22, 2017 PAGE 2

Initiative II - Proactive Legislative & Administrative Initiatives Objective: Develop and build upon existing relationships with Congressional members, the Administration and their staff to advance a proactive agenda for Self-Governance priority policies, budget issues, legislation and Executive Orders. Actions: Track Tribal visits to Capitol Hill: Streamline and update the SGCE website to allow for

updates on Hill visits and to track allies and adversaries; sharing of white papers and strategy discussions among SG Tribes on a secured password protected format. Develop and include a database to track Congressional allies and adversaries on Self-Governance legislation;

Include links to Congressional Committees that have primary jurisdiction for Tribal authorization and appropriations legislation. Include expanded capability to link other Congressional Committees as needed to assist Self-Governance Tribes with advocacy and outreach on legislative issues;

Conduct ongoing educational Training Sessions & Workshops for new Congressional

Members and staff, Administration and other interested Tribes and Tribal organizations; Disseminate regular broadcasts to all Self-Governance Tribes on urgent issues; submit

Congressional testimony and letters for the record, and include “sample” letters for Self-Governance Tribes to utilize.

Coordinate legislative advocacy, including but not limited to: (1) Develop listing of Congressional and Administrative targets to contact and distribute to Self-Governance Tribes; (2) Identify Teams from the TSGAC and SGAC to track and monitor issue(s), track actions and report out to Self-Governance Tribes status of effort and next steps; and (3) Develop advocacy materials and coordinate meetings with Congress and the Administration on Self-Governance legislative and policy issues.

Build political alliances and form relationships. Organize events, attend fundraisers and make political contributions.

Get involved in Federal/State/Tribal nominations and manage voter registration.

Initiative III - Self-Governance Strategic Media and Public Relations Campaign1

Objective: Develop a Press Package that is distribution-ready and insert “topics” as needed for media. Actions: Partner with other national and regional Tribal organizations during major events, (e.g. NCAI

Tribal Unity Impact Days) to advance Self-Governance materials and messaging;

Cultivate relationships with major news bureaus in Washington, D.C. area (Washington Post, USA Today, PoliticoPro, Roll Call, The Hill, etc.);

Identify individuals with expertise in media and public relations to assist Tribes in outreach and

1 A recommendation was made for SGCETC to specifically fund-raise for this campaign and identify an individual/firm with specialized public relations and media expertise.

SELF-GOVERNANCE COMMUNICATION & EDUCATION BLUEPRINT DRAFT DATED: SEPTEMBER 22, 2017 PAGE 3

messaging and utilize local Tribal expertise that have had successful media campaigns;2

Convene regular national and regional press conferences including advertisements, radio, television, and other educational spots;

Audiences to be targeted include non-Self-Governance Tribes, Executive Branch, Legislative

Branch, Judicial Branch, general public, federal agencies, foundations, educational institutions, state governments, business industry, advocacy alliances, international organizations and other media organizations; and,

Self-Governance Tribes can repackage information for local media campaigns and messaging.

2 It was suggested to reach out to Self-Governance Tribes to inquire if they have internal PR/Media staff that may be able to contribute their efforts to advance this Initiative.

INDIAN HEALTH SERVICE JOINT DIRECT SERVICE TRIBES ADVISORY COMMITTEE (DSTAC) &

TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE (TSGAC) MEETING

U.S. Department of Health & Human Services Hubert Humphrey Building – Room 705A

200 Independence Avenue, S.W. Washington, DC 20201

Date: Monday, October 23, 2017 9:00 - 9:05 AM TRIBAL OPENING 9:05 - 9:15 AM TRIBAL OPENING REMARKS

The Tribal Leadership of each Committee will review the shared purpose of the meeting. In addition, they will review the format for the joint meeting, which includes a brief Agency update followed by discussion. The discussion will identify shared priorities and recommendations that the DSTAC and TSGAC can jointly work on.

Marilyn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC Nicolas Barton, Executive Director of Health, Cheyenne & Arapaho Tribes, and Chairperson, IHS DSTAC

9:15 - 9:20 AM INDIAN HEALTH SERVICE (IHS) OPENING REMARKS

RADM Michael D. Weahkee, Acting Director, IHS 9:20 - 9:30 AM INTRODUCTIONS

Morning Moderator: DSTAC Chairperson and TSGAC Chairperson/Vice Chairperson 9:30 - 10:30 AM INDIAN HEALTH SERVICE BUDGET

Purpose: The IHS Office of Finance and Accounting (OFA) will provide a brief update on the IHS Budget including the distribution of new funding. The committees will identify shared concerns and budget priorities. 9:30 - 9:45 AM: Ann Church, Acting Director, OFA, IHS 9:45 - 10:30 AM: Discussion

10:30 – 10:45 AM B R E A K 10:45 – 12:00 PM REIMAGINE HHS AND HHS/IHS STRATEGIC PLAN DEVELOPMENT

Purpose: The IHS will provide an update on the latest Agency efforts on the ReImagine HHS, HHS Strategic Plan, and IHS Strategic Plan. This session will also provide an opportunity for IHS and Tribal representatives to engage in a discussion on these activities, including discussing recommendations for the formation of the IHS Strategic Plan federal-tribal workgroup. 10:45 - 11:00 AM: Indian Health Service 11:00 AM - 12:00 PM: Discussion

12:00 – 1:30 PM LUNCH

INDIAN HEALTH SERVICE JOINT DIRECT SERVICE TRIBES ADVISORY COMMITTEE (DSTAC) &

TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE (TSGAC) MEETING

Afternoon Moderator: DSTAC Chairperson and TSGAC Chairperson/Vice Chairperson

1:30 – 2:45 PM INFORMATION TECHNOLOGY - RESOURCE AND PATIENT

MANAGEMENT SYSTEM Purpose: The IHS Office of Information Technology (OIT) will provide an update on the Resource and Patient Management System (RPMS) Electronic Health Record (EHR). The discussion will focus on IT priorities that affect public health programs as well as how Direct Service and Self-Governance Tribes may improve efforts to address IT issues, including RPMS and other IT related topics. 1:30 - 1:45 PM: CAPT Mark Rives, Chief Information Officer and Director, OIT, IHS 2:00 - 2:45 PM: Discussion

2:45 – 3:00 PM B R E A K 3:00 – 3:45 PM VETERANS ADMINISTRATION (VA) AND IHS MEMORANDUM OF

UNDERSTANDING Purpose: The discussion will focus on the current VA and IHS MOUs and the status of the reimbursement agreements between IHS and Tribes with VA. 3:00 - 3:10 PM: Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS 3:10 - 3:45 PM: Discussion

3:45 – 4:30 PM BEHAVIORAL HEALTH PRIORITIES AND STRATEGIES

Purpose: Tribal representatives and IHS Leadership will discuss the Opioid Epidemic and other behavioral health initiatives and tribal budgeting and funding priorities that affect Behavioral Health Programs. 3:45 - 3:55 PM: Dr. Beverly Cotton, Director, Division of Behavioral Health, IHS 3:55 - 4:30 PM: Discussion

4:30 – 4:55 PM RECAP & NEXT STEPS

Purpose: Tribal representatives will recap and discuss next steps on the development of recommendations that both committees will work together on.

4:55 - 5:00 PM TRIBAL CLOSING

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service Rockville MD 20852

Dear Tribal and Urban Indian Organization Leader: On September 15, the Indian Health Service (IHS) initiated a Tribal Consultation and Urban Confer on the IHS Strategic Plan 2018-2022. I am writing to provide information on ways to submit written and in-person comments and update you on the formation and role of the IHS Strategic Planning Workgroup. There is also an opportunity to provide feedback to the Department of Health and Human Services (HHS) on the HHS Strategic Plan 2018-2022. The IHS seeks your comments and recommendations on the initial IHS Strategic Plan framework (see enclosure). Specifically we are asking the question on the initial framework:

Do the IHS Mission, Vision, Goals, and Objectives reflect the direction and priorities you feel the IHS should pursue over the next 5 years?

On Monday, September 25, the Agency will convene the first in-person Tribal Consultation and Urban Confer session during the National Indian Health Board’s 2017 National Tribal Health Conference at the Hyatt Regency in Bellevue, Washington. The session will take place from 10:00 a.m. to 12 noon (Pacific) in the Evergreen E-F Room. The IHS will also host conference calls, for Tribal Leaders and Urban Indian Organization Leaders, to provide comments. Call in information will be posted on the IHS Calendar Web site at https://www.ihs.gov/ihscalendar.

Tribal Consultation and Urban Confer Conference Calls • Tribal Leaders - Wednesday, October 18, 2017, from 3:00 – 4:00 p.m. (Eastern) • Urban Indian Leaders - Wednesday, October 11, 2017, from 3:00 – 4:00 p.m. (Eastern)

Written comments will be accepted throughout the duration of the Tribal Consultation and Urban Confer period. The deadline to provide your comments is October 31, 2017. Please provide your written comments and recommendations by e-mail at [email protected] or [email protected] with the “IHS Strategic Plan 2018-2022” as the subject line. You may also provide comments by postal mail to the address indicated below. RADM Michael D. Weahkee Acting Director ATTN: IHS Strategic Plan 2018-2022 Indian Health Service 5600 Fishers Lane, Mailstop: 08E86 Rockville, MD 20857

SEP 22 2017

https://www.ihs.gov/ihscalendar



Tribal and Urban Indian Organization Leader

Following the comment period, the IHS will form a short-term IHS Strategic Planning Workgroup, comprised of a small group of Tribal Leaders and IHS employees, to review all comments and draft a list of final Goals and Objectives for IHS leadership review and approval. The IHS will work with the Direct Service Tribes Advisory Committee and the Tribal Self Governance Advisory Committee to determine Tribal participants on the IHS Strategic Planning Workgroup. Once IHS leadership has approved the Goals and Objectives, the IHS Strategic Planning Workgroup will develop Strategies and Measures to achieve the objectives. Input by Tribal and Urban Indian Organization Leaders will again be requested during a 30-day comment period on the draft IHS Strategic Plan including the Strategies and Measures. As I mentioned in the September 15 letter, HHS is also developing an HHS Strategic Plan for 2018-2022. Please be aware within the next few weeks, HHS will request your review and comment on the HHS Strategic Plan. This HHS request is separate from the IHS Strategic Plan Tribal Consultation and Urban Confer process. If you have any questions, please contact CAPT Francis Frazier, Director, Office of Public Health Support, IHS, by telephone at (301) 443-0222 or by e-mail at [email protected]. Thank you for your support and partnership. I look forward to your views and comments.

Sincerely, /Michael D. Weahkee/ RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Acting Director

Enclosure IHS Strategic Plan 2018-2022 Tribal Consultation and Urban Confer Timeline and Draft Framework for IHS Mission, Vision, Goals, and Objectives


DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service Rockville MD 20852

Dear Tribal and Urban Indian Organization Leader: I am writing to initiate a Tribal Consultation and Urban Confer on the Indian Health Service (IHS) Strategic Plan. The IHS is beginning a process for the development of a 5-year IHS Strategic Plan (2018-2022). This will coincide with the development of a Department of Health and Human Services Strategic Plan for 2018-2022. I have enclosed an initial draft framework of the IHS Strategic Plan. This includes the Mission, Vision, Goals, and Objectives that will form the structure for development of implementation strategies and ways to measure success. Through October 31, 2017, I am seeking your comments and recommendations on this initial framework: Do the IHS Mission, Vision, Goals, and Objectives reflect the direction and priorities you feel IHS should pursue over the next 5 years? In conjunction with the Consultation and Confer, the IHS will seek your input on the draft goals and objectives via in-person sessions and conference calls. These meetings will be posted on the IHS Calendar Web site at http://www.ihs.gov/ihscalendar. Additional information will be provided next week about the process for providing comments and on the formation of a short-term IHS Strategic Planning Workgroup and their role in the Strategic Planning process. Thank you for your support and partnership. I look forward to your views and comments.

Sincerely, /Michael D. Weahkee/

RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Acting Director

Enclosure IHS Strategic Plan 2018-2022 Tribal Consultation and Urban Confer Timeline and Draft Framework for IHS Mission, Vision, Goals, and Objectives

SEP 15 2017

http://www.ihs.gov/ihscalendar

ihs self-governance advisory committee (tsgac) quarterly ... · marilynn “lynn” malerba, chief,...

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