NCUIH President-Elect Statement for the Record for VA Hearing on Veteran Suicide Prevention

On Wednesday, September 22, the House Committee on Veterans’ Affairs (VA) held an oversight hearing entitled, “Veteran Suicide Prevention: Innovative Research and Expanded Public Health Efforts.” The National Council of Urban Indian Health’s (NCUIH) President-Elect, Sonya Tetnowski (Makah Tribe), submitted a written statement for the record for the hearing to address mental health care and suicide prevention for Native Veterans living in urban areas.

Representative Ruben Gallego gave remarks during the hearing, highlighting his bill to end copayments for Native American Veterans that passed as part of the Isakson and Roe Act last Congress and inquired about the VA’s current timeline for full implementation of this provision. Dr. Kameron Matthews, the VA’s Assistant Under Secretary for Health for Clinical Services, said that Gallego’s provision is moving forward, however, there were some nuances about the definition of urban Indian and the VA has been working with the Indian Health Service, the Department of Health and Human Services, and other Tribal organizations to get that language correct.

NCUIH expressed support for Rep. Gallegos bill last year in a letter to Congress that urged for passage of several Tribal Veteran bills.

Watch the full committee hearing here.


House Committee on Veterans Affairs

Chairman Mark Takano and distinguished Committee members, I would like to thank you for inviting me to provide written testimony today regarding care for urban Indian Veterans. My name is Sonya Tetnowski, I am a member of the Makah Tribe, and a Native Veteran of the U.S. Army where I served as a U.S. Paratrooper (Airborne). I am currently the President-Elect of the National Council of Urban Indian Health (NCUIH), which represents the 41 Urban Indian Organizations (UIOs) with 77 facilities. UIOs provide high-quality, culturally competent care to the more than 70% of American Indians and Alaska Natives (AI/ANs) that reside in urban areas. I also service as the President of the California Consortium of Urban Indian Health with 10 members servicing over 100 thousand members.

Additionally, I am the Chief Executive Officer of the Indian Health Center of Santa Clara Valley (IHC) in San Jose, California. IHC provides culturally competent health and wellness services including comprehensive medical care, dental, behavioral health, fitness, nutrition, and family programing to our nearly 23 thousand patients annually, representing over 114 different tribes.

AI/ANs have a long history of distinguished service to this country. Per capita, AI/ANs serve at a higher rate in the Armed Forces than any other group of Americans and have served in all the nation’s wars since the Revolutionary War. In fact, AI/ANs served in several wars before they were even recognized as U.S. citizens. Despite this esteemed service, AI/AN Veterans have lower personal incomes, higher unemployment rates, higher homeless rates and are more likely to lack health insurance than other Veterans.

NCUIH and I as the president elect, have made it a priority to ensure that UIOs are included in the Indian Health Service (IHS) and Department of Veterans Affairs (VA) Memorandum of Understanding (MOU) to help provide health care to AI/AN Veterans. As a Native Veteran myself, I understand the importance of coming home and knowing I have a safe space to receive care. Respectfully, AI/AN Veterans often prefer to use Indian Health Care Providers (IHCPs), including UIOs, for reasons such as cultural competency, community and familial relations, shorter wait times, and shorter distance to travel.

AI/ANs residing in urban areas face significant behavioral health disparities with 15.1% of urban AI/ANs reporting frequent mental distress as compared to 9.9% of the general public, and suicide being the second leading cause of death among AI/ANs. The COVID-19 pandemic had only exacerbated these numbers, as AI/ANs feel the dire impacts of social isolation and the inability to participate in many cultural activities. Adequate reimbursement for behavioral health care and suicide prevention efforts for Native Veterans is critical to fulfil the IHS and VA trust responsibility to urban AI/ANs.

Recommendation: Expeditiously Fully Implement the VA-IHS MOU with UIO inclusion in the Reimbursement Agreement Program (RAP) so UIOs Can Provide Critical Mental Health Care to Native Veterans.

We were grateful for your assistance with the passage of the Health Care Access for Urban Native Veterans Act of 2019 as part of Consolidated Appropriations Act, 2021. Previously, the VA had deemed UIOs as ineligible to be reimbursed for the services they provide to AI/AN Veterans. With this legislative fix, Congress has enabled the VA to reimburse UIOs for services to VA beneficiaries. While the VA has initiated discussions with UIOs, to date, the VA has yet to fully implement the VA IHS-MOU with UIOs. NCUIH requests immediate implementation of the VA-IHS MOU with UIO reimbursement agreements to support care delivery and increase the availability of services to urban AI/AN Veterans.

Additionally, UIOs provide various culturally centered mental health care services to urban Indians and Native Veterans, including operating residential substance use disorder (SUD) programs with inpatient treatment. Clarity around reimbursement for UIO SUD programs must be outlined in the VA-IHS MOU as it is currently unclear on whether UIO residential SUD programs would be reimbursed: 1) based on the prospective payment system Medicare inpatient payments like IHS hospital facilities; 2) the IHS all-inclusive rate (Inpatient Hospital Per Diem Rate) with additional payment available to the extent that physician and practitioner services are provided; or 3) the IHS all-inclusive rate for Medicare Part B Inpatient Ancillary Per Diem Rate.

In addition to SUD programs, UIOs provide traditional healing services to address mental health in urban Indian patients. Traditional healing activities are imperative in addressing mental health challenges in the AI/AN community and should be fully reimbursed by the VA to Native Veterans who receive these services at UIOs.

Recommendation: Ensure Clear and Official Communication from VA to UIOs and Establish an Urban Confer Policy

NCUIH has long advocated for parity for health services for urban Indians, including the establishment of an urban confer policy between the VA and UIOs. Currently, only IHS has a legal obligation to confer with UIOs. As the VA continues to work more closely with UIOs to increase access to health care services for AI/AN Veterans, it is imperative that a formal confer process is established for the VA – a mechanism for regular dialogue with UIOs on policies that impact them and AI/AN Veterans. The absence of Urban Confer with the VA is inconsistent with the government’s responsibility and allows for unclear expectations and missed opportunity for important feedback from AI/AN stakeholders.

Most recently, NCUIH and UIOs had the opportunity to provide input to the VA on the Reimbursement Agreement Program (RAP) template and other issues affecting Native Veterans, however, the mechanism of soliciting stakeholder feedback can be a lesson learned. A letter in July requesting this feedback from UIOs included no information that would alert UIOs of a deadline or anticipated timeline for providing input on the template and this critical information was also not shared during the later listening session. Without clear official communication, VA and IHS cannot ensure that UIOs have a consistent understanding of the agencies’ expectations. This lack of communication can be avoided with the establishment of a confer policy. This confer policy would enable the agency to regularly and directly obtain input from UIOs and would foster a strong working relationship. Going forward we request written guidance containing this important information and deadlines would go a long way to achieving clear communication.

Clear communication practices between the VA and UIOs will allow UIOs to provide feedback on various issues around Native Veteran health, including mental health care, and help ensure that Native Veterans residing in urban areas have access to the critical care they are owed.


The United States must honor its commitments to AI/AN Veterans by providing quality healthcare to urban Indian Veterans, which includes mental health care and suicide prevention efforts. It is no secret that Native Veterans disproportionately suffer from behavioral health disparities, and the recommendations contained in my testimony are necessary to address this burden and close the gap in health services to our Veterans.

We appreciate your continued efforts to ensure tribal members in urban areas are included in public health efforts. Thank you for allowing us to provide testimony and for your tireless efforts ensuring that the voices of tribal members living in urban areas are heard and acted upon. Losing even one Veteran to suicide is too much; help us reach these Veteran’s with our culturally appropriate care.

Bipartisan Urban Indian Health Confer Act Introduced by Grijalva, McCollum and Cole

This bipartisan legislation will improve access to health care for urban Indians.

On September 10, 2021 the Urban Indian Health Confer Act was introduced by Chairman Raúl M. Grijalva (D-AZ), Rep. Betty McCollum (D-MN), Rep. Tom Cole (R-OK), Rep. Don Young (R-AK), Rep. Karen Bass (D-CA), and Del. Eleanor Holmes Norton (D-DC). As an ongoing effort to rectify longstanding parity issues within the Indian health system, this legislation would require agencies and offices within the U.S. Department of Health and Human Services (HHS) to confer with Urban Indian Organizations (UIOs) on policies and initiatives related to healthcare for urban American Indians and Alaska Natives (AI/AN).


The National Council of Urban Indian Health (NCUIH) has long advocated for the importance of facilitating confer between numerous federal branches within HHS and UIO-stakeholders without any resolve. Currently, only the Indian Health Service (IHS) has a legal obligation to confer with UIOs. It is important to note that Urban Confer policies do not supplant or otherwise impact tribal consultation and the government-to-government relationship between tribes and federal agencies.


“Agencies have been operating as if only IHS has a trust obligation to AI/ANs, and that causes an undue burden to IHS to be in all conversations regarding Indian Country in order to talk with agencies. It is imperative that UIOs have avenues for direct communication with agencies charged with overseeing the health of their AI/AN patients, especially during the present health crisis,” said NCUIH CEO, Francys Crevier (Algonquin).


“HHS’ failure to communicate with UIOs about healthcare policies that impact urban Indian communities is inconsistent with the federal trust responsibility and contrary to sound public health policy. The Urban Indian Health Confer Act will establish direct communication for UIOs across the entire department and ensure that urban Indian communities are aware of healthcare policy changes,” said Chairman Raúl M. Grijalva (D-AZ).


Support for confer with UIOs is strong among stakeholders in Indian Country. Recently, the National Congress of American Indians (NCAI) passed a resolution to “Call for the U.S. Department of Health and Human Services Secretary to Implement an Urban Confer Policy Across the Department and its Divisions.” NCUIH is grateful for the support of NCAI and Indian Country and commends Chairman Raúl M. Grijalva (D-AZ), Rep. Betty McCollum (D-MN), Rep. Tom Cole (R-OK), Rep. Don Young (R-AK), Rep. Karen Bass (D-CA), and Del. Eleanor Holmes Norton (D-DC) on taking bold action to resolve this parity issue for UIOs in the I/T/U system.



Urban Confer policies are a response to decades of deliberate federal efforts (i.e. forced assimilation, termination, relocation) that have resulted in 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to address the care needs of most AI/AN persons.


The Urban Indian Health Confer Act will ensure the many branches and divisions within HHS and all agencies under its purview establish a formal confer process to dialogue with UIOs on policies that impact them and their AI/AN patients living in urban centers.  In fact, absent a confer policy, several agencies within HHS continue to reject repeated attempts to convene with UIOs and agencies to discuss critical urban Indian health issues. Such blatant disregard to communicate with UIOs is not only a failure to urban Indians and is inconsistent with the government’s responsibility, but it is contrary to sound public health policy. The bill would codify the intent of the Federal Trust Responsibility to ensure equitable health care access to AI/AN by amending legislative text in Section 514, Subsection (b) of the Indian Health Care Improvement Act (25 U.S.C. § 1660d) (IHCIA).


The mark up is the Committee’s portion of the Build Back Better Act


Washington, D.C. -The Energy and Commerce Committee, led  by Chairman Frank Pallone, Jr. (NJ-06), met on September 13 -14 to mark up their portion of the Build Back America Act. Bills for committee markup included issues tackling the affordability of healthcare and prescription drug costs, closing the Medicaid gap, expansion of services for seniors and those with disabilities and critical in investments in public health and preparedness following the breakdowns during the COVID-19 pandemic.


“The Build Back Better Act is transformational legislation that invests in the American people, responds to the challenges of our time, and builds back a better future for generations to come” said Chairman Frank Pallone, Jr. (NJ-06).

Committee Mark Up Highlights


Key Components

  • $50,000,000 for funding to grow and diversify the doula: Workforce grants to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, urban Indian organizations, or other appropriate public or private nonprofit 7 entities (or consortia of entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the doula workforce
  • $75,000,000 for grants to health professions schools, academic health centers, State or local governments, territories, Indian Tribes and Tribal organizations, urban Indian organizations, or other appropriate public or private nonprofit 14 entities (or consortia of entities, including entities promoting multidisciplinary approaches), to establish or expand programs to grow and diversify the maternal mental health and substance use disorder treatment workforce.
  • $2,500,000,000 for community violence and trauma interventions. Competitive grants or contracts to local governmental entities, States, territories, Indian Tribes and Tribal organizations, urban Indian organizations, hospitals and community health centers, nonprofit community-based organizations, culturally specific organizations, victim services providers, or other entities as determined by the Secretary (or consortia of such
  • entities) to support evidence-based, culturally competent, and developmentally appropriate strategies to reduce community violence, including outreach and conflict mediation, 19 hospital-based violence intervention, violence interruption, and services for victims and individuals and 21 communities at risk for experiencing violence, such 22 as trauma-informed mental health care and counseling, school-based mental health services.
  • Includes $15 billion in new investments for pandemic preparedness and $3 billion to establish the Advanced Research Projects Agency for Health (ARPA-H).

Bill Mark Up Summary


Comprehensive Plan for Addressing High Drug Prices: A Report in Response to the    Executive Order on Competition in the American Economy” -released by Health and Human Services Secretary  Xavier Becerra

Key  Components

  • Makes drug prices more affordable and equitable for all consumers and throughout the health care system-support drug price negotiation with manufacturers and stop unreasonable price increases to ensure access to drugs that can improve health for all Americans
  • Improves and promotes competition throughout the prescription drug industry – Support market changes that strengthen supply chains, promote biosimilars and generics, and increase transparency
  • Fosters scientific innovation to promote better health care and improve health – Support public and private research and make sure that market incentives promote discovery of valuable and accessible new treatments, not market gaming


Key Component:

  • Ensures affordability of coverage for certain low-income populations by expanding the Affordable Care Act (ACA) premium tax credits to below 100% of the federal poverty level in 2022 through 2024 and reduce cost sharing for these individuals as well.


Key Component:

  • Establishes a federal Medicaid program by 2025 in states that have not yet expanded their programs under the ACA.


Key Component:

  • Permanently extends the Children’s Health Insurance Program (CHIP); require continuous twelve-month coverage for children in Medicaid and CHIP; and make permanent one full year of postpartum Medicaid coverage for pregnant women.


Key Components:

  • Energy and Commerce text includes provisions analogous to the House Ways and Means Committee with addition of dental, hearing and vision benefits to Medicare.
  • $190 billion proposal for investment in home and community-based services (HCBS).

Next Steps

Markups are scheduled to be completed next week. Members will then begin to package them into one bill for consideration in the House. Timing of that vote is uncertain, but the target is to complete this by the September 27 agreed upon date to consider it in tandem with the bipartisan infrastructure package.[1]

[1] Updates on Budget Reconciliation; HHS Drug Pricing Proposal (