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.

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