NCUIH Submits Comments to IHS on Newly Allocated American Rescue Plan Act Funding and Proposed Build Back Better Act Funding

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On January 21, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) regarding funding opportunities in the American Rescue Plan Act (ARPA) and the Build Back Better Act (BBBA).  The comments were submitted in response to a November 22, 2021 (updated on December 20), IHS Dear Urban Indian Organization Leader letter (DULL) that outlined an additional $210 million allocated for Public Health Workforce Activities from the ARPA.  The DULL also outlined $2.35 billion in proposed funding in the BBBA.

ARPA and BBBA’s IHS Program Impact

In response to the COVID-19 pandemic, President Biden signed the ARPA into law in March 2021.  This COVID-19 relief bill included $84 million for urban Indian health and two years of 100% Federal Medical Assistance Coverage for urban Indian Organizations (UIOs). In November 2021, the Administration announced additional directed funding to support COVID-19 response and recovery efforts in the hardest-hit and high-risk communities and populations, including additional funding of $210 million allocated to the IHS.  The newly allocated funding includes $92 million to provide nurses in Bureau of Indian Educations schools; $67 million to enhance public health capacity for IHS and Tribal Nations; $45 million for additional IHS loan repayment awards; and $6 million for core surveillance and epidemiology work for American Indian and Alaska Native populations.

The BBBA proposes $1.75 trillion in government spending with an emphasis on social and climate goals. While the BBBA is currently stalled in Congress, the proposed funding includes $2.35 billion in additional resources for several IHS programs. The $2.35 billion includes $1 billion to address the 1993 Health Care Facilities Construction Priority List; $945 million for Maintenance and Improvement projects; $124 million for behavioral health services, including necessary facilities improvements; $113 million for Facilities and Environmental Health Support activities; $100 million for Urban Indian Organization construction; $40 million for the Small Ambulatory Program; and $25 million for Tribal Epidemiology Centers.

NCUIH’s Role

On December 15, 2021, NCUIH held a prep call with UIOs to discuss the additional ARPA and BBBA funding. This call allowed UIOs to share concerns, recommendations, and specific requests for the upcoming Urban Confer with IHS.  NCUIH and UIOs then attended the IHS Urban Confer to voice support for and stress the importance of the additional funding.

In its submitted comments, NCUIH applauded the allocation of a further $210 million to support pandemic recovery in AI/AN communities.  The additional ARPA funding will be used to protect children in BIE schools, recruit and retain highly skilled health care professionals, enhance public health capacity, and support epidemiology work for AI/AN populations.  NCUIH noted that at both the December 9, 2021 All Tribal and Urban Indian Organization Leaders meeting and the subsequent December 15, 2021 Urban Confer that the IHS committing to making $47 million of the $67 million allocated to enhance public health capacity and build emergency preparedness available to Tribes, Tribal organizations, and UIOs.  NCUIH reiterated to IHS that it must follow through on this plan and make this funding available to UIOs in addition to Tribes and Tribal organizations, as the funding is crucial to ensuring that all AI/AN communities can continue to battle the on-going COVID-19 pandemic and also build capacity to prepare for future emergencies.

NCUIH also requested that in addition to allocating the additional ARPA funds, IHS promptly disburse previously allocated ARPA funds which many UIOs have still not received.  To date, many UIOs have yet to receive all previously allocated ARPA assistance funds — funds critical to addressing adequate COVID-19 response and recovery.  As new funds are prepared for distribution, IHS must not lose sight of already allocated ARPA funds that are delayed and have yet to be received by all UIOs.

NCUIH also supported and applauded the historic levels of funding for AI/AN health in the BBBA.  However, it urged IHS to take notice of the fact that the level of funding for Indian Country currently proposed in the BBBA is significantly below the $20.5 billion announced in the original reconciliation instruction and the fact that the $2.35 billion in additional funding for several IHS programs does not come close to the $48 billion needed to fully fund IHS.

NCUIH noted with concern that UIOs continue to be excluded from the vast majority of federal funding allocated for AI/AN health.  Of the $2.35 billion in proposed funding, UIOs are ineligible for almost $2.1 billion. Full and inclusive funding of IHS is imperative to ensure Tribes and UIOs have the resources required to serve our communities.

NCUIH expressed its strong support for the $100 million proposed in the BBBA for UIO facilities. This funding will assist UIOs in addressing critical needs that they face in their mission to improve health outcomes for AI/ANs. NCUIH estimates that ninety percent (90%) of UIOs need facility upgrades to improve health care services. Current estimates place the total cost of these needed upgrades at $200 million.  This includes $172 million in shovel ready projects at UIOs.  The allocation of $100 million for UIO facilities in BBBA is historic and long overdue to uphold the trust and treaty responsibilities of the federal government to all AI/ANs.  NCUIH requested that if the BBBA is passed, IHS identify out of the $100 million what it intends to use for administrative functions, so that NCUIH and UIOs can fully assess the total amount of funding available.

Finally, NCUIH backed the allocation of $124 million to behavioral health services and necessary facilities in the BBBA.  NCUIH noted that pursuant to the reported text of the BBBA, UIOs are fully eligible to receive funds from this allocation, as there are no restrictions on entities to whom the IHS may disburse this money.  NCUIH urged IHS to maintain this broad eligibility in any implementing regulations if the BBBA is passed.  NCUIH has long advocated before Congress to fund and preserve behavioral health initiatives for UIOs under the Indian health care system, as AI/AN populations are at a much higher risk for behavioral health issues than the general population.  NCUIH is especially encouraged by the ability to use this funding for facility renovation, construction, or expansion. This funding will enhance opportunities for UIO residential programs who have had to reduce the number of patients they admit due to COVID-19 guidelines, in a pandemic that has exacerbated behavioral health needs.

NCUIH will continue to closely monitor the status of the additional allocated ARPA funds.  NCUIH also continues to track the progress of the BBBA and advocate against any further cuts to Indian Country’s allocation in the bill.

NCUIH Submits Comments to IHS on the OUIHP 5-Year Strategic Plan

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On January 28, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Office of Urban Indian Health Program (OUIHP) and the Indian Health Service (IHS) regarding the upcoming 5-Year Strategic Plan (Plan). These comments were submitted in response to a December 3, 2021, Dear Urban Leader letter seeking input for recommendations and in consultation with UIOs to address needs and areas for improvement in the new Plan.

Background

In 2017, the IHS developed an OUIHP Strategic Plan 2017-2021, pursuant to the Consolidated Appropriations Act, which described what the Agency hoped to achieve over the next 5 years.  The 2017-2021 Plan was based on the participation and feedback received from UIO Leaders, IHS staff, and other stakeholders. In fiscal year (FY) 2022, IHS expects to evaluate the existing OUIHP Strategic Plan and to develop a new Plan. According to the OUIHP, the new Plan will include goals, objectives, strategies, and performance measures, based on input from UIO Leaders, partners, and external stakeholders.

NCUIH’s Role

NCUIH provided several comments and recommendations for the Plan. These comments were based on NCUIH’s consultations with UIOs, the IHS Urban Confer held on December 16, 2021, and NCUIH’s subject matter expertise.

In its comments, NCUIH applauded OUIHP for its efforts to meet the goals and objectives of the 2017-2021 Plan, including Objective 2.2 which it successfully accomplished.  However, NCUIH noted that there remains significant unmet goals and objectives from the 2017-2021 Plan which need continued attention and action in the upcoming Plan.  NCUIH supports keeping the 2017-2021 Plan’s goals and objectives in the Plan, except for Objective 2.2. which was completed.  Those goals and objectives are listed below. NCUIH also urged OUIHP to continue to build on and update the 2017-2021 Plan’s goals and objectives in the Plan to further meet the Plan’s stated mission and vision.

  • Goal 1: Support Currently IHS-Funded UIOs’ Efforts to Address the Key Challenges they Identified for Improving and Expanding Access to Care for Urban Indians.
    • Objective 1.1: Support UIOs’ efforts to diversify funding and increase third-party reimbursements to ensure UIO sustainability
    • Objective 1.2: Support UIOs’ efforts to attract and retain skilled, culturally competent health service providers
    • Objective 1.3: Increase awareness and actively seek support for health care needs of Urban Indians
    • Objective 1.4: Strengthen the capacity of UIOs to work as a community to improve knowledge sharing
  • Goal 2: Increase OUIHP’s Administrative Capacity
    • Objective 2.1: Build capacity for OUIHP to transfer administration of the former NIAAA awards
    • Objective 2.2: Lay the groundwork for performance-based oversight, both within the IHS and for the IHS-funded UIOs
    • Objective 2.3: Leverage OUIHP staff capacity by maximizing partnerships and resources. Ensure the IHS has available staff to perform the roles of OUIHP and support the IHS mission regarding Urban Indian health

Additionally, NCUIH recommended the following items be incorporated into the goals and objectives of the Plan:

  • Improved data accuracy
  • Modernizing Health information Technology
  • Establishment of specific metrics by which to measure OUIHP’s progress towards fulfilling the Plan
  • Improved Area Office consistency
  • Increased support for behavioral health services, including for health providers
  • Support for Community Health Representatives (CHRs) at UIOs as authorized in the Indian Health Care Improvement Act
  • Establishment of goals and objectives to support efforts to extend the Community Health Aide Program to UIOs
  • Inclusion of traditional healing practices as an allowable billing expense
  • Development of a fair and equitable UIO All-Inclusive Rate or extension of the existing IHS All-Inclusive Rate to UIOs
  • Incorporation of Title V Contract improvement suggestions from UIOs
  • Improved budget planning with respect to UIOs
  • Modified targets and adaptive planning for unforeseen events such as the COVID-19 pandemic

NCUIH further recommended that the OUIHP and IHS schedule an annual performance plan report.  NCUIH advised OUIHP to incorporate meaningful metrics into the Plan which will permit it to report useful quantitative analysis of its progress towards accomplishing the goals and objectives included in the Plan.  NCUIH believes that any performance plan report should be made publicly available.

NCUIH also expressed its appreciation to OUIHP for initiating a new Plan proactively by using savings from salaries and for fulfilling its trust responsibility and statutory mandate to confer with UIOs by proactively seeking to collaborate with UIOs on the development of the Plan.  NCUIH stressed that input from UIOs is vital for the IHS and its operating divisions to effectively gather comprehensive feedback, share critical information, and build mutual trust, in addition to being required by the Indian Health Care Improvement Act (IHCIA).

NCUIH strongly believes that the Plan is an important vehicle to articulate leadership priorities, provide direction for program management functions, engage external partners and entities, and measure OUIHP’s progress towards meeting the goals and objectives contained in the Plan.  NCUIH will continue to participate in the development of the Plan and inform UIOs of upcoming opportunities to provide comments and participate in Urban Confers.  NCUIH encourages UIOs submit any comments at future opportunities which they believe will be helpful in the development of the Plan.

NCUIH Submits Comments to HUD on Strategic Plan Focus Areas Urging Support for All Native Communities

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NCUIH urges incorporation of urban AI/ANs and UIOs into focus areas and eventually the FY22-26 Strategic Plan

 

On January 28, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments to the Department of Housing and Urban Development (HUD) in response to its invitation for feedback on its draft FY22-26 Strategic Plan focus areas.  NCUIH stated its strong support for the proposed focus areas: support underserved communities, ensure access to and increase the production of affordable housing, promote homeownership, and advance sustainable communities. NCUIH also affirmed that is heartened by HUD’s attention to the housing needs of American Indian and Alaska Native (AI/AN) communities through the inclusion of Tribal governments in the “support for underserved communities” focus area.  However, NCUIH also urged HUD to more completely fulfill its trust responsibility to improve the housing conditions and socioeconomic status of tribal members by also incorporating urban AI/ANs and UIOs into its focus areas and, eventually, the FY22-26 Strategic Plan.

 

The United States has a general trust responsibility to support AI/AN governments and AI/AN people.  This includes a specific responsibility to “work[] with tribes and their members to improve their housing conditions and socioeconomic status.”  There is no exception to this trust responsibility for tribal members who no longer live on a reservation or reside in an urban area.  Among the efforts the United States will take to make available affordable homes in safe and healthy environments in AI/AN communities is the provision of housing assistance.  In its comments, NCUIH noted that despite its trust responsibility the United States does little to provide AI/AN-specific housing services to urban AI/ANs.

 

NCUIH noted that AI/ANs living in urban areas are disproportionately disadvantaged economically and face numerous barriers to accessing services and achieving a measure of housing security and stability.  NCUIH also observed that urban AI/AN households have higher rates of cost burden, are more likely to live in housing lacking complete plumbing and kitchen facilities, and are more likely to live in overcrowded housing.  Further, the AI/AN population is disproportionately represented in the homeless population nationwide and experience poverty at a higher rate than the overall population.

 

NCUIH urged HUD to consider the needs of AI/ANs living in urban areas in its Strategic Plan focus areas and ultimately in the Strategic Plan. By failing to extend its AI/AN-specific services to urban AI/ANs, HUD fails to fulfill its trust responsibility to the seventy (70) percent of AI/ANs who live in urban areas.  UIOs are uniquely positioned to assist HUD in supporting underserved communities, ensuring access to and increasing the production of affordable housing, promoting homeownership, and advancing sustainable communities among AI/AN people.  UIOs provide numerous other social and community services to urban AI/ANs.  Providing housing services aligns with UIOs’ mission to provide quality, accessible, and culturally competent health and public health services for AI/ANs living in urban settings because housing is a key social determinant of health. HUD has also previously acknowledged the need to coordinate health, housing, and social welfare services.  UIOs have the cultural competency and community connections necessary to further support HUD’s mission and assist HUD in fulfilling it trust responsibility to urban AI/ANs.

 

NCUIH will continue to monitor the development of HUD’s FY22-26 Strategic Plan.  NCUIH will advocate for HUD to incorporating urban AI/ANs and UIOs in the Strategic Plan itself throughout the development process and in future comment opportunities.