“For months, we watched this virus from afar,“ said Cherokee Nation Principal Chief Chuck Hoskin Jr. “We hope people understand this has now hit home and is a very real pandemic that can affect anyone of us.”

But a widespread shortage of tests has largely prevented tribes from monitoring for the virus, which they worry could spread rapidly through their tight-knit communities. And most American Indians and Alaska Natives now live in urban areas, where American Indian health organizations are already running low on medical supplies and funding.

In hard-hit Seattle, for example, one health center anticipates losing $734,000 a month during the response effort — assuming it doesn't first run out of supplies and be forced to close. Other frontline urban American Indian facilities reported receiving fewer than a dozen coronavirus tests.

The initial $8.3 billion coronavirus response package President Donald Trump signed into law March 6 allocated $40 million to help support American Indian care providers. Administration officials have since touted to tribal leaders the cash infusion as extraordinary for its inclusion of urban American Indian organizations and indicative of how serious Washington is approaching the outbreak.

Yet the money remains hung up as officials at IHS and the CDC debate how to solve an obscure appropriations hurdle. Congress initially allocated the aid as grants through the CDC, despite warnings from tribal organizations and some House staffers that it could invite bureaucratic snafus, two people with knowledge of the process said.

Congressional appropriators say they inserted specific language to avoid issues and ensure tribes were eligible for the funding.

“We checked with CDC when we were finalizing the language,” said Evan Hollander, a spokesperson for the House Appropriations Committee.

But the CDC has since told tribal organizations that it can’t distribute the funds because it doesn’t have the necessary funding relationship with the IHS hospitals, tribal-run health facilities and urban American Indian organizations that are supposed to receive it.

Tribal leaders said the CDC has also balked at their idea to set up an inter-agency transfer that would deliver the money to IHS directly, questioning whether it has the authority for such a transfer

A CDC spokesperson did not respond to specific questions about the funding, saying only that the agency is working across the administration and with tribal organizations to “finalize a plan to allocate these funds and maximize public health impact and reach to tribal populations.”

The IHS has also said there's another problem. Even if it received a direct funding transfer from the CDC, it could not simply hand over the money to tribes and urban American Indian organizations because the legislation structured the funds as grants, which requires a more complex process.

Federal officials haven’t yet offered other alternatives for freeing up the money, and have remained vague about the funding’s status in conversations with tribes.

“Health providers across Indian Country are risking their lives on the front lines of this crisis,” said Meredith Raimondi, a spokesperson for the National Council of Urban Indian Health, which supports health services for American Indians living in urban areas. “We don’t know what the delay is.”

The delay comes as the Trump administration races to pour resources into the broader national response, promising a “whole-of-government” effort aimed at reinforcing frontline hospitals and ramping up production of ventilators and face masks.

On a conference call last Friday, IHS officials, led by chief medical officer Michael Toedt, told House and Senate staffers that the agency’s health system had 625 hospital beds available nationwide, including just six ICU beds and 10 ventilators, according to three people with direct knowledge of the discussion. There are another 772 beds available across tribal-run health programs, he said, according to one person on the call.

Tribes rely heavily on IHS facilities, which provide many health care services to American Indians and Alaska Natives at no cost under the federal government’s long-held trust responsibility. Over a quarter of the tribal population in the U.S. is uninsured, more than double the national rate.

Toedt days later reportedly revised IHS’ capacity figures on a press call for media outlets that cover Native issues. But IHS also warned at least one Hill office that the agency doesn’t have accurate information readily available because reporting is optional for tribal programs, and IHS was still collecting data from its regional offices, according to a person briefed on the call.

IHS has since told POLITICO that as of Thursday, the agency had 37 ICU beds and 1,257 hospital beds across both IHS facilities and ones run by tribal organizations themselves, as well as 81 ventilators.

Pressed further on IHS’ readiness, one IHS official characterized the agency as a “shoestring operation.” At another point, Toedt downplayed the threat by telling staffers that “IHS believes this virus will be slower to reach Indian country,” according to a person on the call.

“It was quite scary, to be very frank,” said the person, who left the discussion shaken.

Another person on the call blamed chronic underfunding of the IHS for the agency’s dire assessment. “They’re working out of a hole that is so deep it’s really kind of unfathomable,” that person said.

An IHS spokesperson noted that the agency’s annual budget is less than one-sixth what tribal leaders estimate is needed to fully fund the American Indian health system. When asked about Toedt’s comments on the virus’ spread, the spokesperson emphasized that IHS has “always been clear that this is a rapidly evolving situation.”

The IHS has also made few promises to organizations running low on critical protective equipment and medical needs, just as the rest of the health care industry struggles to stock up ahead of an expected wave of patients.

Unlike states, American Indian organizations cannot easily draw on the federal Strategic National Stockpile designed specifically to aid the response to a public health emergency. Instead, the IHS told tribal organizations in recent weeks that its National Supply Service Center, created in 1981 to aid tribal needs, will release two models of respirators to help bridge the gap. However, it warned, the respirators are already expired.

IHS confirmed those details, telling POLITICO that the broader health department is “inundated” with supply requests from all over the country.

“To address ongoing nationwide shortages IHS has offered, at no cost, N95 respirators that have exceeded their manufacturer-designated shelf life, in accordance with CDC guidelines,” the IHS spokesperson said. The CDC has said expired N95 respirators may offer more protection than surgical masks.

In a survey published Tuesday by the National Indian Health Board, just 16 percent of its tribal leaders, providers and partners reported receiving federal resources of any form to aid the response. Even fewer — 4 percent — had received basic protective equipment.

“We don't know what this really looks like,” Bohlen said of the virus’ impact on Indian country. “Because we don’t have the tools necessary — like the rest of America — to figure out what is going on here.”

