Indianz.Com > COVID-19 > Rep. Raul Ruiz (D-Arizona)
Posted: May 8, 2020

Rep. Raul Ruiz. Photo by Indianz.Com (CC BY-NC-SA 4.0)


May 7, 2020

Dr. Ruiz, Sen. Harris Lead Fight for Tribal Health Funding in Next COVID-19 Relief Legislation

Ruiz Spearheads Bicameral, Bipartisan Push for Emergency Funding

Washington, DC – Congressman Raul Ruiz, M.D. led a letter signed by 47 bipartisan members of the House calling for Speaker Nancy Pelosi (D-CA) and Minority Leader Kevin McCarthy (R-CA) to include dedicated funding for Indian Health Service, Tribal health programs, and Urban Indian Health Organizations (I/T/U) to recover from significant COVID-19 related losses in revenue in the next stimulus legislation.

“Tribal health facilities are the primary source of health care for millions of native American individuals, and many are struggling to keep their doors open during this crisis,” said Dr. Ruiz. “Native communities often have greater health disparities than other populations, and it is essential that Congress provides a significant emergency relief fund to support tribal health programs.”

“The National Indian Health Board urges lawmakers to include direct financial relief for Indian Health Service and Tribal health facilities in the next congressional response package to help replenish shortfalls in third party reimbursement dollars due to the COVID-19 pandemic. Third party reimbursements from payers like Medicare, Medicaid, and private insurance are integral to the fiscal stability of the Indian health system. Similar to federal, state and private healthcare systems, Tribes are utilizing every resource to protect their citizens from COVID-19 including issuing stay-at-home orders, cancelling non-emergency medical procedures, and reducing in-person health clinic visits. Unfortunately, those precautions are resulting in millions of lost third-party revenue that pay for essential health services from elder care to dental care to diabetes treatment. NIHB commends Congressmen Ruiz and Congressman Mullin for urging their colleagues to support third party reimbursement relief funding for the Indian health system,” said NIHB Chairperson Victoria Kitcheyan and Tribal Councilmember for the Winnebago Tribe of Nebraska.

“Third-party reimbursements are vital to Urban Indian Organizations (UIOs) and to the Indian health system as a whole. This is a matter of keeping facilities open for the patients and families who need them during this pandemic. Unfortunately, the COVID-19 pandemic is upending this system. UIOs are experiencing millions in lost third-party reimbursement as a result of impacts from COVID-19. We are grateful for this bipartisan bill to help the Indian Health Care Providers who are operating on the front lines of this pandemic,” said Francys Crevier, NCUIH, Executive Director.

Dr. Ruiz’s letter advocates for a dedicated emergency appropriation to help tribal health facilities recover from lost revenue as a result of the COVID-19 pandemic. Because most non-essential and elective procedures have been cancelled in order to comply with public health measures, tribal health facilities are not collecting revenue from third-party reimbursements for provided care.

Third party reimbursements can account for more than 50% of the operating budgets for tribal health programs. In 2019 alone, federally operated IHS facilities collected over $1 billion in third party reimbursements. 

You can read the letter below and on Rep. Ruiz’s website.


The Riverside-San Bernardino Indian Health Organization is a consortium made up of nine local tribes and provides services for tribal members in the region. Several of their facilities are operating with reduced schedules during COVID-19. 

Partner tribes include the Agua Caliente Band of Cahuilla Indians, the Pechanga Band of Luiseno Mission Indians, the Ramona Band of Cahuilla Indians, the Cahuilla Band of Indians, the Soboba Band of Luiseno Indians, the Morongo Band of Mission Indians, the Santa Rose Band of Cahuilla Indians, the San Manuel Band of Mission Indians, and the Torres-Martinez Desert Cahuilla Indians,

H.R. 748, the CARES Act, allocated $100 billion to support hospitals that are struggling from losses in revenue, but did not include a set-aside specifically for the tribal health care system. On April 22nd, the Department of Health and Human Services announced they would allocate $400 million from this fund to the Indian Health Service. While this is important, it will not be sufficient to cover the losses. The National Indian Health Board estimated that tribal health facilities will require as much as $1.7 billion to make up for lost revenue since mid-March.

The letter was signed by the Co-Chairs of the Native American Caucus, Deb Haaland & Tom Cole, as well as the Chairs of the two Congressional Subcommittees who oversee the Indian Health Service, Anna Eshoo (Energy and Commerce Health Subcommittee) and Betty McCollum (Appropriations Interior and Environment Subcommittee).

Letter Text:

Dear Speaker Pelosi and Minority Leader McCarthy,

As you continue to work on legislation to provide economic support and relief to Americans across the country, we urge you to include a significant coronavirus relief appropriation dedicated to Indian Health Service (IHS), Tribal Health Programs and Urban Indian Organizations (I/T/U) to recover from significant COVID-19 related losses in revenue.

One issue that has continued to strain IHS resources during the COVID-19 pandemic is the lack of a specific emergency coronavirus relief fund to replace third-party reimbursement revenue for the I/T/U system. Third-party billing receipts are integral to the financial stability of the I/T/U system because the funding that Congress appropriates each year for the Indian Health Service is insufficient to cover the cost of all of the health care needs for American Indian and Alaska Native individuals. Third-party reimbursements from private insurance as well as Medicare, Medicaid and the Veterans Health Administration make up a significant portion of funding for tribal health care facilities.

In 2019, federally-operated IHS facilities alone reported $1.14 billion in third-party collections, equaling roughly a fifth of the entire IHS budget for that year. For Tribal health programs, third-party dollars can equate to over half of their operating budgets for healthcare. Third-party reimbursements for Urban Indian Organizations (UIOs) now total more than the entire urban Indian health annual appropriation.

During the course of the COVID-19 pandemic, many I/T/U facilities have stopped conducting elective procedures and limited most non-COVID-19 related care. As a result, these facilities have experienced a drastic reduction in third-party reimbursements. These reimbursements are essential to allow programs to make payroll, expand services, and provide quality care to patients.

Without an emergency coronavirus relief fund to help I/T/U sites, tribal health care facilities may be in danger of closing, and the health disparities that already exist in Indian Country will become further exacerbated. For example, American Indian and Alaska Native communities suffer disproportionately from many health issues that make them highly susceptible to COVID-19, including hypertension, asthma, cancer, and heart and cardiovascular disease . Failure to secure the necessary funds and resources to provide COVID-19 related care is putting these communities at risk.

In order to ensure the sustainability and operational health of I/T/U sites around the country, we urge you to include a significant coronavirus relief appropriation specifically dedicated to supporting I/T/U health care facilities. This will ensure that funding is provided in a way that more closely meets the needs of all IHS assisted facilities.

The CARES Act allocated $100 billion for hospitals and providers of which the Department of Health and Human Services provided $400 million to IHS. According to analysis by the National Indian Health Board and the National Council of Urban Indian Health, this funding will be insufficient to address the need in Indian Country and we urge you to explicitly provide direct coronavirus relief funding to help I/T/U facilities replenish lost revenue.

Thank you for your consideration of this request to include a specific coronavirus relief fund to help I/T/U facilities replace lost third-party reimbursement revenue. We look forward to continuing to work with you to fulfill the trust and treaty responsibilities of the United States Government to provide for the health and well-being of American Indians and Alaska Natives.


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