NCUIH Endorses Bills Providing Advance Appropriations for IHS

On October 12, 2021, Representatives Betty McCollum (D-MN-04) and Don Young (R-AK-1) introduced a pair of bipartisan bills that would amend the Indian Health Care Improvement Act (IHCIA) to provide advance appropriations to the Indian Health Service (IHS).


The Indian Programs Advance Appropriations Act of 2021 (H.R. 5567), introduced by Rep. McCollum, authorizes advance appropriations authority for certain accounts of the Bureau of Indian Affairs, Bureau of Indian Education, and IHS. The Indian Health Service Advance Appropriations Act (H.R. 5549), introduced by Rep. Young, authorizes advance appropriations authority for IHS.


NCUIH has long advocated for advance appropriations for IHS to insulate Indian health care providers from shutdowns and allow for long-term planning. A companion Senate bill, Indian Programs Advance Appropriations Act of 2021 (S. 2985), was introduced by Senators Ben Ray Luján (D-NM) and Martin Heinrich (D-NM) on October 7.


NCUIH welcomes the Members of Congress’ legislation to provide budget stability for IHS and strengthen the federal government’s commitment to uphold its trust and treaty responsibilities to American Indians and Alaska Natives.

Call to Action: Contact Congress Today to Retain Funds for Indian Country in Build Back Better

Dear Indian Health Advocate,

Yesterday, we sent out a policy alert about threats to remove funding for Indian Country from Build Back Better.

We need your help to contact Congress to uphold its commitment to provide Indian Country with at least $20.5 billion for critical resources.

Please use this toolkit to spread the word.

Please use the following text below as a template to call or email to your Member of Congress. If you can please, call and email your representative. You can find your representative here.

Thank you for your leadership. Your outreach on this is invaluable to providing resources for all American Indians and Alaska Natives.


Letter to Congress

Dear [Representative NAME or Senators NAMES]:

As an Indian health advocate, I ask you to please contact Speaker Pelosi and Leader Schumer to support Indian Country in Build Back Better.

As cuts are being made, it is imperative that the federal government prioritize Indian Country in the upcoming Budget Reconciliation package. We respectfully request you preserve the House Natural Resources Committee’s inclusion of $20.5 billion for Indian Country with $42 million for urban Indian organizations. On September 9, the House Natural Resources Committee approved its piece of the budget reconciliation package. This included $42 million for urban Indian organizations to construct and update their facilities to improve health outcomes for the patients who rely on these services that UIOs have never had access to. This funding would help provide critical upgrades that other facilities have already made during the pandemic, such as an air purification system. These funds are critical to upholding the trust and treaty responsibilities of the federal government to all American Indians and Alaska Natives.

As part of this trust obligation, the federal government funds Indian Health Service (IHS) system, which includes IHS facilities, Tribal Programs, and UIOs who provide high-quality and culturally competent care to the American Indian/Alaska Native population. The budget resolution allocated just $20.5 billion (0.59%) to the Indian Affairs Committee to enact policies for Native health, education, housing, energy, climate, and language programs as well as facilities. This funding alone does not adequately address the needs of Indian Country and should be protected from further budget cuts, especially during the COVID-19 pandemic, which has devastated American Indian/Alaska Native communities.

As Indian Country is already underfunded, we should not be at risk of cuts in the Build Back Better plan. We urge Congress to take this obligation seriously by retaining the $20.5 billion for Indian Country with $42 million for urban Indian organizations.


[Your Name]



Post your support on your Facebook.

  • Example post:
  • I just called Congress to support Indian Country in Build Back Better. Find out how you can too here: [insert link here]
  • [graphic]


From your Twitter account, tweet to your Member of Congress.

  • Find your Member of Congress here.
  • Example tweet:
  • Dear [@ Member’s handle], please #SupportIndianCountry in Build Back Better by keeping the $20.5 billion in the final bill.

House Passes Opioid Response Bill that Includes Urban Indian Organizations

On October 20, 2021, the House passed the State Opioid Response Grant Authorization Act of 2021 (H.R. 2379) with a 380-46 vote. This bipartisan bill introduced by Representative David Trone (D-MD-06) would authorize and expand the State Opioid Response grant program for $1.75 billion per year for fiscal years 2022 through 2027. This bill also includes a 5% set aside of the funds for Indian Tribes, Tribal organizations, and urban Indian organizations.


The National Council of Urban Indian Health (NCUIH) worked with Congressional leaders to ensure the inclusion of urban Indians in this important legislative response to the Nation’s opioid crisis and has supported Rep. Trone’s bill since its introduction in early April.


The bill currently awaits action in the Senate.

Vaccines: Preparing for the 2021-2022 Flu Season

New Guidance: Preparing for the 2021-2022 Flu Season

On September 9, 2021 the Centers for Disease Control (CDC) shared recommendations and guidance on co-administration of vaccines with COVID-19 vaccines. The updates provided coverage to the Advisory Committee on Immunization Practices (ACIP) recommendations for the 2021-2022 season, general vaccine guidance during the COVID-19 pandemic, and clinical considerations. During the 2019-2020 season, the CDC estimated that influenza caused 38 million illnesses, 400,000 hospitalizations, and 22,000 associated deaths. Flu vaccination prevents millions of illnesses and deaths each year and is the best way to ensure protection!

Interim Recommendations for the 2021-2022 Season

The Advisory Committee on Immunization Practices (ACIP) released Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. The current guidance states that COVID-19 vaccines should and can be administered without regard to timing of other vaccines. When administering vaccines at the same time a provider should do so at different sites by at least one inch or more. If a COVID-19 vaccine is given with vaccines that may cause a topical reaction, such a pneumonia, it should be done on separate limbs. This guidance can also be found on NCUIH’s Coronavirus Resource Center webpage.

This year’s flu vaccines are all quadrivalent and contain 4 layers of viral protection. Their administration guidance is restricted to age group usage.

Strategies for Vaccination Catch-up

Across all regions, the COVID-19 pandemic impacted general healthcare, including vaccination administration. With reduced vaccine administration, unvaccinated and under vaccinated individuals are at a greater risk to acquiring preventable illnesses and placing communities at risk for outbreak. Strategies should be implemented to promote vaccine schedule adherence and use of recall systems to identify patients who have missed vaccine doses. Immunization systems and electronic health records can support this work. Co-administration considerations can be applied to all patients but are paramount if a patient is behind/at risk of becoming behind on the recommended vaccine schedule or at a greater risk of vaccine-preventable disease.

Clinical Considerations

The CDC maintains a comprehensive surveillance system covering virus surveillance, ambulatory and emergency care, rates of hospitalization, and associated mortality rates.

In preparation for the 2021-2022 season the CDC is expecting for seasonal flu and COVID-19 to co-circulate, along with other respiratory viruses. A report (MMWR) recently released is already showing an uptick in virus spread, like respiratory syncytial virus (RSV).

Co-infection of flu virus strains can occur. There are often overlapping signs, symptoms, and differences with either infection. Community-acquired bacterial co-infection appears more common with influenza than COVID-19 (MRSA, MSSA, pneumococcus, group strep)

  • Incubation period is shorter for influenza (1-3 days) than COVID-19 (2-14 days)
  • Viral shedding of viral RNA detection is generally shorter for influenza
  • Ageusia/dysgeusia are more common with COVID-19 than influenza
  • Onset of disease complications is earlier with influenza
  • High-risk groups for influenza and COVID-19 are similar
  • Testing is needed to distinguish influenza from COVID-19 in addition to observation of clinical clues
  • Antiviral medications for influenza have no effect on COVID-19

No one has time for the flu!

At the urgency stresses that flu, COVID-19, and other illnesses do not discriminate, everyone is at risk. Getting your vaccines for influenza annually is critical as flu viruses are constantly changing and updated protection is the best practice to optimize protection. As COVID-19 vaccination is on the rise, one does not have to delay additional adherence to important lifesaving vaccines!

Patient Protection and Affordable Care Act- Updated Payment Parameters and Improving Health Insurance Markets for 2022 & Beyond

Final Rule: Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond.


On September 27, the Department of the Treasury, collectively with HHS (the Departments), issued a final rule revising the 2022 user fee rates for issuers offering qualified health plans (QHPs) through federally-facilitated Exchanges and State-based Exchanges. This rule finalizes policies designed to promote greater access to comprehensive health insurance coverage, consistent with applicable law and with the administration’s policy priorities detained in recent Presidential executive orders (EO 14009 and EO 13985).


NCUIH submitted comments regarding the proposed regulations, the equity goals proposed by the Administration, and how these goals should permeate each policy consideration by HHS and other agencies. These comments included how CMS should provide specific guidance and examples of how agencies and state officials can assess and address systemic barriers within their healthcare systems. Additionally, NCUIH commented on section 1332 waiver regulations and was pleased to that the new waiver regulations aim to explicitly analyzes and prioritize health equity by encouraging states to evaluate their proposed section 1332 waivers in line with E.O. 13985. Urban Indian organizations are severely impacted by social determinants of health and experience significant health disparities compared to other racial groups.[1] Because of these disparities, NCIUH hoped to see explicit analysis of how proposed state waivers will improve the healthcare access of AI/AN people. In response to NCUIH’s comments, the Departments responded that, while the comment was outside the scope of the rule, HHS is actively seeking ways to engage with stakeholders to advance health equity- and address the social determinants of health that disparately impact communities of color.


This rule also finalizes modifications to Section 1332 Waivers for State Innovation of the ACA. Through section 1332 waivers, the Departments aim to assist states with developing health insurance markets that expand coverage, lower costs, and make high-quality health care accessible for every American. The Departments also encourage states to develop their own waiver proposals that reduce barriers for individuals to access benefits. For example, states may propose waiver programs that increase plan options for comprehensive coverage, reduce premiums, improve affordability, and address social determinants of health.


By rescinding the policies and interpretations outlined in the  ) and repealing the previous codification of its guardrail interpretations in part 1 of the 2022 Payment Notice final rule; the Departments believe that these new policies and interpretations will align with the Administration’s goals to strengthen the ACA. Thusly, increasing enrollment opportunity in comprehensive, affordable health coverage among the remaining underinsured and uninsured. Moreover, these policies will further advance this Administration’s goal of increasing access to coverage by empowering states to develop innovated health coverage options for their residents through section 1332 waivers that best fit the states’ individual Notably, section 1332 provides the Secretary of HHS and the Secretary of the Treasury the discretion to approve or deny waivers when appropriate even if an application meets the four statutory guardrails.


The Departments received 262 comments on the section 1332 waiver proposals from a mix of stakeholders, including general advocacy organizations, disease advocacy organizations, states, issuers, providers, individuals, and other entitles. The overwhelming majority of stakeholders supported the section 1332 waiver proposals and encouraged the Departments to finalize the policies as proposed.


In order to encourage states to develop innovative waivers, the Departments are finalizing the policies, interpretations and regulatory amendments as proposed.  This final rule is effective on November 26, 2021.


[1] Monique Adakai et al., Health Disparities Among American Indians/Alaska Natives – Arizona, 2017, 67 Morbidity and Mortality Weekly Report 1314 (2018).

NCUIH Endorsed Indigenous Peoples’ Day Act Introduced in House and Senate

On September 30th, a group of Members of Congress introduced bipartisan, bicameral legislation to replace the term Columbus Day with Indigenous Peoples’ Day across all federal law and regulations. This legislation would also establish Indigenous Peoples’ Day as a public holiday. The NCUIH endorsed bill would allow the federal government to follow in the footsteps of at least 13 states and over 100 cities across the nation.

The Indigenous Peoples’ Day Act (H.R. 5473) was introduced by Representatives Torres, DelBene, Bonamici, and Davids within the House and currently has 64 total co-sponsors. The Senate partner bill (S. 2919) was introduced by Senators Lujan and Heinrich and currently has 7 total co-sponsors.

Please contact your Members of Congress and ask them to co-sponsor the Indigenous Peoples’ Day Act.


The Senate bill includes a $30 million increase above the FY21 enacted level for urban Indian health.

On October 11, 2021, the Senate Appropriations Committee released its fiscal year (FY) 2022 Interior, Environment, and Related Agencies bill, with $92.7 million for urban Indian health. The bill would authorize $7.61 billion for the Indian Health Service (IHS) for FY22, an increase of $1.38 billion above the FY21 enacted level and $593 million below the President’s request. Other key provisions include an additional $6.58 billion in advance appropriations to IHS for FY23 and a facilities fix to allow Urban Indian Organizations (UIOs) to use existing IHS funding for facilities improvement and renovations.

“After decades of being ignored and forgotten, we applaud the Senate Appropriations Committee for the robust legislation proposed to improve outcomes for Indian Country. We are especially encouraged to see the commitment to ensure equitable consideration for all Native communities. We are grateful for all Members of Congress who supported the request for full funding for Indian health, including urban Indian health, especially Senators Schatz, Feinstein, Murkowski, Tester, Moran, Merkley, Hoeven, Van Hollen, Heinrich, and Murray,” said NCUIH CEO Francys Crevier.  


The National Council of Urban Indian Health (NCUIH) and the Tribal Budget Formulation Workgroup (TBFWG) requested $12.759 billion for the Indian Health Service (IHS) with an urban Indian health line item of $200.5 million for FY 2022. Additionally, 28 Congressional leaders requested $200.5 million for urban Indian health in FY 2022 from the House Appropriations Committee.  

House Appropriations Status 

The House bill (HR 4372) included $200.5 million for urban Indian health and was advanced by subcommittee June 28, and $8.1 billion for the Indian Health Service. The measure was part of a seven-bill package the House passed on July 29.  

Senate Bill Highlights 

Appropriations Chairman Patrick Leahy stated in the bill summary, “The bill makes an unprecedented investment to fulfill the federal government’s treaty and trust responsibilities to Native Americans by providing $18.1 billion for tribal programs and – for the first time – securing advanced appropriations for the Indian Health Service (IHS). The advance appropriation for IHS for fiscal year 2023 will enable IHS to continue to provide health services without interruption or uncertainty, improving the quality of care and providing peace of mind for patients and medical providers.”  

Indian Health Service 

  • $7,616,250,000 for IHS for fiscal year 2022, an increase of $1,379,971,000 to the enacted level and a decrease of $593,029,000 to the request 

Urban Indian Health 

  • $92,684,000 for the Urban Indian Health program, $30,000,000 above the enacted level and $7,316,000 below the budget request. 

Facilities Fix for Urban Indian Health 

  • “SEC. 435. The Secretary of Health and Human Services may authorize an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603) that is awarded a grant or contract under title V of that Act (25 U.S.C. 1651 et seq.) to use funds provided in such grant or contract for minor renovations to facilities or construction or expansion of facilities, including leased facilities, to assist the urban Indian organization in meeting or maintaining standards issued by Federal or State governments or by accreditation organizations.” 

Advance Appropriations for IHS 

  • $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022
  • “The Committee recommendation also provides, for the first time, advanced appropriations for Indian Health Services and Indian Health Facilities. The bill includes $6,586,250,000 in advance appropriations for fiscal year 2023, equal to the fiscal year 2022 Committee recommendation in accordance with the Concurrent Resolution on the Budget for Fiscal Year 2022. The Committee recognizes that budget uncertainty due to temporary lapses of appropriations and continuing resolutions have an effect on the orderly operations of critical healthcare programs for Native American communities. Existing challenges related to recruitment and retention of healthcare providers, administrative burden and costs, and financial effects on Tribes were identified areas of concern in a Government Accountability Office [GAO] study (GAO–18–652).” 

Contract Support Costs and 105(l) Leases 

  • “The Committee strongly supports revising the budgetary classification for Contract Support Costs and Payments for Tribal Leases with the goal of including the language needed to codify such a change in the final appropriations Act for fiscal year 2022.” 

Bureau of Indian Affairs – Missing and Murdered Indigenous Women 

  • Missing and Murdered Indigenous Women: $24.9 million  
  • “The Committee is concerned about the crisis of missing, trafficked, and murdered indigenous women that has plagued Native communities. Native American women face high rates of violence and the lack of data on the number of women and girls who go missing or murdered further complicates the Nation’s ability to address this crisis. The Committee recommendation includes both funding and directives under the Bureau of Indian Affairs and the Indian Health Service in order to improve the Federal response to this epidemic.”
  • Note: It is unclear at this time if UIOs would be eligible for the funding resources provided to IHS under this provision. 

Bureau of Indian Education – Native Boarding School Initiative 

  • Native Boarding School Initiative: $7 million 

“In June 2021, the Department announced an investigation into the Federal government’s past oversight of Native boarding schools. The past policies of forcing children into these schools tore families apart and led to a loss of culture and identity for generations of Native American youth. The Committee applauds the efforts of the Department to reexamine this era and looks forward to the findings. The bill provides $7,000,000 for these efforts.” 


Next Steps 

Congress is likely to pass another continuing resolution before the current spending expires on December 3, 2021. If Democrats quickly begin “top-line” budget negotiations, it’s possible they could pass an omnibus funding package in the Senate.  

NCUIH President-Elect Appointed To VA Advisory Committee


Media Contact:
National Council of Urban Indian Health
Meredith Raimondi, Director of Congressional Relations

NCUIH nominated Ms. Tetnowski to represent urban Native Veterans.


WASHINGTON, D.C. (October 15, 2021) – National Council of Urban Indian Health (NCUIH) President Elect and CEO of Indian Health Center of Santa Clara Valley, Sonya Tetnowski, a member of the Makah Tribe, was appointed to the Department of Veterans Affairs (VA) first-ever Advisory Committee on Tribal and Indian Affairs. The Committee will advise the Veterans Affairs Secretary based on personal experience on all matters relating to Indian Tribes, Tribal organizations, Urban Indian Organizations (UIOs), Native Hawaiian organizations, and Native American Veterans. NCUIH advocated for the bill that established the advisory committee and nominated Ms. Tetnowski for the role. In the past many advisory committees that relate to Indian health, including urban Indian health, have excluded urban Indian leaders from positions and conversations, which makes this appointment especially historic.

“NCUIH is proud of Sonya Tetnowski’s representation of urban Indian organizations on the Department of Veterans Affairs new Advisory Committee on Tribal and Indian Affairs. As a Veteran and urban Indian leader Sonya is uniquely qualified to serve on this committee. Sonya will be a strong voice for American Indian and Alaska Native Veterans who reside in urban areas,” said NCUIH President Walter Murillo (Choctaw Nation of Oklahoma).

Ms. Tetnowski was deployed multiple times during her service in the Army and has tirelessly advocated on behalf of health equity for American Indians, including Native Veterans, through Congressional testimony and leadership at NCUIH. In 2019, Ms. Tetnowski testified on bill H.R. 4153, the Health Care Access for Urban Native Veterans Act, which allows Urban Indian Organizations (UIOs) to be reimbursed for providing culturally competent care to American Indian and Alaska Native (AI/AN) Veterans residing in urban areas. Most recently, Ms. Tetnowski appeared before the House Committee on Natural Resources in July 2021. She submitted testimony on Native Veterans Suicide Prevention on behalf of NCUIH in September. Also in October, the Indian Health Center of Santa Clara Valley was recognized with the National Indian Health Board’s 2021 Outstanding Service Award.

“It is an honor to be a part of the first-ever VA Committee on Tribal and Indian Affairs. With approximately 160,000 Native Veterans around the country, it is vital to have a representative on the committee that can ensure that the healthcare needs for our Native Veterans is always a part of the broader discussion to ensure we are removing barriers to care while providing culturally competent care. I appreciate the VA’s foresight and vision to address these challenges” said Sonya Tetnowski (Makah), NCUIH President Elect and CEO of the Indian Health Center of Santa Clara Valley.

“Native Americans serve in the military at a higher rate than any other population, and over 70 percent of Native Americans live in urban areas. Urban Indian organizations, like the Indian Health Center of Santa Clara Valley (IHC) fill a crucial gap in the health care system for Native Americans that do not have access to more remote facilities run by the Indian Health Service. I congratulate Sonya Tetnowski (Makah), CEO of the IHC on her appointment to the inaugural Tribal Veterans Affairs Advisory Committee to represent our Native Veterans,” said Rep. Ro Khanna (D-CA-15).

“A wide range of VA activities impact urban Indian organizations and the communities they serve. Sonya‘s appointment as the Committee representative for urban Indians provides an added layer of accountability for VA to uphold its trust responsibility to Native Veterans living outside of reservation boundaries,” said Sunny Stevenson (Walker River Paiute Tribe), NCUIH Director of Federal Relations.


Testimonies by Ms. Tetnowski 



With the start of the 2021-22 school year around the corner and some schools starting this week, the entire country is again facing thousands of local decisions about under what conditions schools will reopen, in view of the major upheaval caused by the delta variant of coronavirus.  This strain is highly contagious, on the same level as measles and chickenpox, therefore public health officials are urging strict enforcement for mask wearing, physical distancing and vaccination.  To increase support for vaccines we must double down on containment and mitigation measures, including extensive testing, isolation, use of masks and social distancing of 3 feet at school campuses, under CDC guidelines.  To quote Dr. Rachel Levine, Assistant Secretary for Health at HHS, “We must cocoon a child surrounded by vaccinated adults.” This means that all teachers must be vaccinated, and children must wear masks while in school.  We all play a role and what the pandemic has taught us is that we are all interconnected.

Other Vulnerable Groups

Amidst these decisions weighing heavily on the minds of elected officials and public health officers, one piece of good news is that Pfizer will be seeking another Emergency Order Authorization in the fall for its new COVID-19 vaccine for children ages 5 to 11 years old.  (Younger than 5-yrs-old groups will take longer, because of the size of clinical trials and the cautious approach to de-escalate dosage when treating toddlers and infants).

Dr. Anne Edwards with the American Academy of Pediatrics reported on a national call with HHS and the CDC that pediatricians are seeing a lot of respiratory illness in medical offices, the ICU and regular hospital beds.  She and all medical staff strongly encourage everyone in the 12-and-older age group who are eligible to get vaccinated.  Studies show that no one is more trusted than Pediatricians, therefore the physician should take the time during medical visits to clear up any questions for the family.  We all need your help as trusted leaders in your community.  Dr. Amy Mullins, from the American Academy of Family Physicians, added that when confronting vaccine hesitancy, data shows that there is no single public message that will always overcome.

In addition, evidence about the safety of COVID-19 vaccination during pregnancy has been growing, including in the early months of pregnancy.  There is a trove of surveillance data, according to Dr. Peter Marks from the Federal Drug Administration (FDA).  Pregnant and recently pregnant women are more likely to get severely ill compared with non-pregnant people.  These data strongly point to the conclusion that the benefits of receiving a COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy.  During the week of August 11, the Centers for Disease Control advanced this information and posted recommendations on their website.  Learn More.

Vaccine Boost

The FDA recently authorized a third dose or boost of the MRNI-type vaccine for those people who are immune-compromised, ages 15 and over.  Further, the evidence and rationale for taking this next step tells us that if a patient is only taking two medications for the underlying health condition, there is very little risk when taking a third dose.  The Advisory Committee on Immunization Practices (ACIP) will have to issue final guidance on this matter.

When administering immunizations, providers may wish to separate the administration of shots, especially when dealing with live viral vaccines and fever is present).  Soon the CDC will disclose real world evidence.

We ALL need your Help and the enlistment of public and private employers to take extra steps, such as time off from work to get vaccinated and providing free rides to vaccination sites.