NCUIH Endorses Bipartisan, Bicameral Bill to Improve Public Health Emergency Preparedness for Indian Health Care Providers

On March 31, 2022, Senator Elizabeth Warren (D-Mass.), Representative Ruben Gallego (D-Ariz.), Senator Martin Heinrich (D-N.M.), and Representative Tom Cole (R-Okla.) introduced the Centers for Disease Control and Prevention (CDC) Tribal Public Health Security and Preparedness Act (S. 3968). The bill would allow Tribes  to apply directly to the Centers for Disease Control and Prevention (CDC) for Public Health Emergency Preparedness (PHEP) program funds. Currently, only states and certain local entities may apply for PHEP funds to respond to public health emergencies. The bill  authorizes $750 million for each of fiscal years 2023 through 2025 for the PHEP program 5% tribal set-aside of the total CDC PHEP funds.  Additionally, urban Indian organizations (UIOs) are included in several important consultation provisions in the bill that would ensure they are included in crafting public health plans.

“The National Council of Urban Indian Health (NCUIH) is pleased to endorse Rep. Gallego’s CDC Tribal Public Health Security and Preparedness Act which provides Tribes access to Public Health Emergency Preparedness (PHEP) program funds and includes urban Indian organization input on the development of public health plans. The COVID-19 pandemic has had devastating impacts on Native communities, and this bill’s equitable access to critical preparedness funds will ensure Indian Country will be better prepared to respond to future public health emergencies.” – Francys Crevier (Algonquin), CEO, NCUIH.

The CDC Tribal Public Health Security and Preparedness Act is cosponsored by Senators Tina Smith (D-Minn.), Amy Klobuchar (D-Minn.), Cory Booker (D-N.J.), Tammy Baldwin (D-Wisc.), and Bernie Sanders (I-Vt.). The bill has been endorsed by leading Native American advocacy groups— including the National Congress of American Indians, National Indian Health Board, and NCUIH. It currently awaits consideration.

This bill has been added to the NCUIH legislative tracker and can be found here.

Background

Inequities in access to public health resources has caused the COVID-19 pandemic to have a disproportionate impact on Indian Country. The CDC Tribal Public Health Security and Preparedness Act helps address this issue by:

  • Allowing   to apply directly to the CDC PHEP program;
  • Requiring the CDC to fund at least ten tribes for emergency preparedness and include a
  • Exempting tribes   needing to match funds and waive many of the reporting requirements to minimize the administrative burden on tribal nations; and
  • Requiring grant recipients to include tribes, tribal organizations, and urban Indian organizations in their consultation process in their development of public health plans.

 

Senate Text of Bill

Senator Warren’s Press Release

 

President Biden Continues to Demonstrate Strong Commitment to Urban Indians, Proposes Over 50% Increase for Urban Indian Health for FY 2023

The FY 2023 budget request includes $113 million for urban Indian health, a 53% increase over the FY 2022 enacted amount and mandatory appropriations for IHS.

On April 25, 2022, the Indian Health Service (IHS) published their Fiscal Year (FY) 2023 Congressional Justification with the full details of the President’s Budget, which includes $112.5 million for Urban Indian Health— a 53.2% increase above the FY 2022 enacted amount of $73.4 million. According to the IHS Congressional Justification,This funding increase could support an estimated 1,072,935 health care, outreach, and referral services to Urban Indian users in FY 2023.” The President’s proposal included a total of $127.3 billion in discretionary funding for the Department of Health and Human Services (HHS) and, for the first time ever, $9.3 billion in mandatory funding for IHS for the first year, which includes $9.1 billion in proposed law funding and $147 million in current law funding for the Special Diabetes Program for Indians (SDPI). The budget proposes increased funding for IHS each year over ten years, building to $36.7 billion in FY 2032, to keep pace with population growth, inflation, and healthcare costs.

“The Indian Health System and urban Indian health have long been severely underfunded: only 1% of the Indian health budget goes to urban Indian health despite more than 70% of American Indians and Alaska Natives residing in urban areas. We are grateful for the President’s inclusion of $113 million for urban Indian health in FY 2023. President Biden has shown a strong commitment to urban Indian communities, and we recognize this Administration’s dedication to improving outcomes for all of Indian Country. As the final amount still falls well short of fully funding the Indian Health Service to properly provide health care services for all Natives in the United States to meet the trust responsibility, we will continue to push Congress to provide all the resources necessary to protect the lives of the entire Native population, regardless of where they live,”

– Francys Crevier (Algonquin), CEO, NCUIH

 

Line Item

FY21
Enacted

FY22 Enacted

FY23 TBFWG Request

FY23
President’s
Budget

Urban Indian Health  $62,684,000 $73,424,000  $949,900,000  $112,514,000
Indian Health Service $6,236,279,000 $6,630,986,000 $49,800,000,000 $9,100,000,000

 

The National Council of Urban Indian Health requested full funding for urban Indian health for FY 2023 at $949.9 million and at least $49.8 billion for IHS in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. The marked increase for FY23 is a result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored. The Congressional Justification states, “IHS recognizes that we must continue to work in consultation with Tribes and confer with Urban Indian Organizations, and with our partners in Congress, to ensure the budget is structured and implemented correctly with the resources identified over the next 10 years.”

Background and Advocacy

On March 28, 2022, President Biden released his budget request for Fiscal Year FY 2023, pending the more detailed IHS budget request released April 25, which includes specifics on the IHS budget request, including the funding recommendations for urban Indian health.

On April 5, 2022, NCUIH President-Elect and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2023 funding for Urban Indian Organizations (UIOs). NCUIH requested $49.8 billion for the Indian Health Service and $949.9 million for Urban Indian Health for FY 2023 as requested by the TBFWG, Advance appropriations for IHS, and support of mandatory funding for IHS including UIOs.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations in support of increasing the urban Indian health line item for FY 2023. The letter has bipartisan support and calls for the highest possible funding for Urban Indian Health up to the TBFWG’s recommendation of $949.9 million and advanced appropriations for IHS until such time that authorizers move IHS to mandatory spending.

Next Steps

The Appropriations Committees will review the President’s Budget for consideration as they craft their bills for FY 2023. NCUIH will continue to work with the Biden Administration and Congress to push for full funding of urban Indian health in FY 2023.

Tribal Veteran Advocate Conference To Be Held May 2-3, 2022

The Department of Veterans Affairs (VA) will be hosting a two-day Tribal Veteran Advocate Conference on May 2 and 3, 2022 from 10 a.m. to 3 p.m. PST (1 p.m. to 6 p.m. EST). This conference will involve training on understanding VA benefits and programs and will provide updates about the latest news affecting American Indian and Alaska Native Veterans. Topics which will be addressed during the training include: specially adapted housing grants, advance care planning, Program of Comprehensive Assistance for Family Caregivers (PCAFC), and Native Veteran spouses and dependency.

To register for the virtual training, click here.

NCUIH Submits Comments to DOJ on Missing and Murdered Indigenous People

On April 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Department of Justice’s (DOJ) Dear Tribal Leader letter seeking stakeholder input on DOJ’s efforts to address the unacceptably high rates of violent crime in American Indian and Alaska Native communities and the missing and murdered Indigenous persons (MMIP) crisis. In its comments, NCUIH thanked the DOJ for its commitment to working with Tribes to develop and support Tribally-driven solutions to violent crime and MMIP, while noting the need for the federal government to also work with Urban Indian Organizations (UIOs) to address these issues.  NCUIH emphasized that working with all AI/AN communities across the United States is required by both Executive Order 14053, Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People (E.O. 14053), and Deputy Attorney General Monaco’s Memorandum establishing the DOJ’s Steering Committee to Address the Crisis of Missing or Murdered Indigenous Persons.  NCUIH further offered to assist DOJ in establishing strong working relationships with UIOs as it works to address these pressing public safety issues.

E.O. 14053 and Deputy Attorney General Monaco’s Memorandum: Inclusion of Urban AI/AN Communities

AI/AN people are the victims of violence, murder, and rape at rates higher than the national average.  As part of the federal government’s response to these issues, President Biden signed E.O. 14053, on November 15, 2021.  E.O. 14053 directs the federal government to “to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.”  E.O. 14053 committed the federal government’s to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.”  E.O. 14053 specifically directed the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of  American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.”  In addition, E.O. 14053 directed the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”

With respect to DOJ, Section 4 of E.O. 14053, contained the following directives:

  • “The Attorney General, in coordination with the Secretary of the Interior and the Secretary of Health and Human Services (HHS), as appropriate, shall sustain efforts to improve data collection and information-sharing practices, conduct outreach and training, and promote accurate and timely access to information services regarding crimes or threats against Native Americans, including in urban areas.”
  • “The Attorney General, in coordination with the Secretary of the Interior and the Secretary of HHS, shall develop a strategy for ongoing analysis of data collected on violent crime and missing persons involving Native Americans, including in urban Indian communities, to better understand the extent and causes of this crisis.”

In addition, on November 15, 2021 Deputy Attorney General Monaco signed a Memorandum establishing a Steering Committee to Address the Crisis of Missing or Murdered Indigenous Persons.  Deputy Attorney General Monaco ordered the Steering Committee to review the Department’s current guidance, policies, and practices with respect to MMIP, recommend any changes necessary to better facilitate the DOJ’s work on MMIP, and to develop a comprehensive plan to strengthen the Department’s work to address the issues of MMIP.  Deputy Attorney General Monaco also directed the Steering Committee to seek and consider the views of stakeholders including UIOs.

NCUIH’s Comments to DOJ

In its comments, NCUIH requested that DOJ ensure its compliance with E.O. 14053’s requirement to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground,” by engaging in consistent and clear communication with UIOs and providing UIOs with notice of future consultations held pursuant to E.O. 14053.  NCUIH further urged DOJ to provide specificity regarding its plans to incorporate UIOs into the policies, procedures, and projects set forth in E.O. 14053 and in Deputy Attorney General Monaco’s Memorandum.

NCUIH noted collaboration with UIOs is not only required by E.O. 14053 and Deputy Attorney General’s Memorandum, but it is also sound public policy.  AI/AN individuals living in urban areas face many, if not all, of the same violent crime and MMIP issues as AI/ANs living on reservations or trust Iand.  UIOs are active and important partners in combatting crime and promoting violence prevention in urban AI/AN communities.  UIOs are also working together to develop innovative partnerships to provide services for victims of crime across jurisdictions.  As a result, UIOs are an integral partner to eradicating these pandemics of violent crime and MMIP.

NCUIH also requested that DOJ establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs.  An Urban Confer is an established mechanism for dialogue between the federal government and UIOs. Urban Confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that resulted in seventy percent (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.

NCUIH will continue to monitor the DOJ’s work on violent crime in Indian Country and MMIP.  NCUIH will also continue to advocate for the inclusion of UIO’s in DOJ’s efforts to ensure that E.O. 14053’s directive to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” is met.

NCUIH Submits Comments to SAMHSA on SUD Patient Confidentiality Rules, 42 CFR Part 2

On April 6, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Substance Abuse Mental Health Services Administration (SAMHSA)’s Dear Tribal Leader letter regarding the federal requirements for confidentiality of Substance Use Disorder (SUD) patient records found at 42 CFR Part 2 (Part 2). In its comments NCUIH emphasized the importance of including Urban Indian Organizations (UIOs) in discussions on rules and policies, like Part 2, which apply to both UIOs and Tribal healthcare facilities. NCUIH also highlighted that a strong Urban Confer policy and improved communications with UIOs will assist SAMHSA, HHS, NCUIH, and UIOs in collaborating to ensure the highest level of substance abuse treatment and mental health treatment for all American Indian and Alaska Natives (AI/ANs).

NCUIH’s Recommendations to SAMHSA

On March 10, 2022 NCUIH attended SAMHSA’s Tribal Consultation on federal requirements for confidentiality of SUD patient records found at 42 CFR Part 2.  Following the Tribal Consultation, NCUIH submitted written comments to SAMHSA on behalf the 41 Urban Indian Organizations (UIOs) it represents.  In its written comments, NCUIH noted that almost every UIO provides behavioral health, mental health, or SUD care to American Indians and Alaska Natives living in Urban Areas.  In fact, in 2021, 6 UIOs were awarded grants through the SAMHSA-funded Tribal Behavioral Health Grant Program, which is aimed at increasing the support and delivery of culturally-tailored suicide and substance abuse prevention services to AI/AN youth to the age of 24.  NCUIH also noted that because UIOs operate under contracts with the Indian Health Service, and receive other forms of federal funding, Part 2 rules on SUD patient records apply to UIOs which provide SUD counseling to patients.

Accordingly, NCUIH requested that HHS host an Urban Confer with UIOs regarding changes to Part 2.  Informing UIOs of the Part 2 changes and receiving UIO feedback is especially important given the vital work UIOs do to reduce the impact of substance abuse in AI/AN communities.  As providers of culturally focused health care, UIOs are well placed to address and treat SUD in AI/AN patients.  The work UIOs do to combat substance abuse in urban AI/AN communities is essential, given that rural and urban AI/ANs need SUD treatment at virtually the same rate and almost seventy percent (70%) of the AI/AN population lives in urban areas.

NCUIH further recommended that SAMHSA, and HHS more broadly, establish an Urban Confer policy.  Establishing an Urban Confer policy is consistent with the federal government’s trust responsibility to improve the health of AI/ANs.  Urban Confers are also sound public health policy as they will allow SAMHSA and HHS to gain a greater understanding of the AI/AN patient population and increase collaboration with the entire Indian Health Care system.

NCUIH is looking forward to working more closely with SAMHSA on urban AI/AN health and will continue to keep UIOs updated on SAMHSA’s most recent policies and practices that impact their work and affect AI/AN communities.

NCUIH Submits Comments to IHS on Urban Indian Organization On-Site Review Manual

On April 12, 2022, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations in response to the Indian Health Service’s (IHS) February 11, 2022 notice and request for comment on the information collection titled “Urban Indian Organization On-Site Review,” Office of Management and Budget Control Number 0917-00XX.  NCUIH requested that the on-site review manual be updated regularly, that IHS provide UIOs with a consolidated list of required documents prior to the on-site review, and that IHS enable UIOs to use existing administrative or site visit data in meeting the requirements of the Manual. NCUIH also encouraged the Office of Urban Indian Programs (OUIHP) to host an Urban Confer to personally hear UIO input on and experience with the on-site review process.

IHS On-Site Review Manual

The Indian Health Care Improvement Act (IHCIA) requires the Secretary of Health and Human Services, through the IHS, “to conduct an annual onsite evaluation of each urban Indian organization which has entered into a contract or received a grant under section 1653,” of the IHCIA.   As part of this statutorily mandated process the IHS Office of Urban Indian Health Programs (OUIHP) drafts and publishes the Manual, which is used to accomplish the annual review of UIOs.

In the nine years that the current Manual has been in use, UIOs have experienced significant changes, including adapting to the COVID-19 pandemic, and relevant standards of national healthcare accrediting organizations like the Association for Ambulatory Health Care (AAAHC) have changed.  Accordingly, NCUIH submitted comments, drawn directly from UIOs’ experience with the Manual and the annual review process, to inform the IHS on necessary areas of modification in the Manual.  NCUIH’s comments also included general recommendations concerning the annual review process.

NCUIH’s Recommendations to IHS

In its comments, NCUIH made the following requests, and recommendations based on NCUIH’s consultations with UIOs and NCUIH’s subject matter expertise:

  • Update the Manual regularly and as needed to remain consistent with other relevant accreditation processes
  • Provide greater flexibility in the Manual to accommodate diverse UIO program/facility goals and services
  • IHS to provide a consolidated list of requirement documents to UIOs prior to the on-site review
  • Ensure that UIOs can use existing administrative or site visit data in meeting the requirements of the Manual

In addition to the preceding recommendations regarding the Manual itself, NCUIH also requested that OUIHP host an Urban Confer with UIOs to learn about their experiences with the on-site review process.  NCUIH also submitted the following general recommendations concerning the annual review process for consideration:

  • Provide a timeline for processing information collected in the annual review process
  • Improve overall review by ensuring reviewers are licensed medical providers
  • Improve instructions on the limited annual waiver process

NCUIH looks forward to an updated On-Site Review Manual that will provide valuable information for UIOs and IHS.  NCUIH will continuing to monitor development and revision of the On-Site Review Manual and inform UIOs of pertinent information.

Resource: Comparison of the Veteran Health Administration and IHS Facilities Funding Document Released on NCUIH Website

Social Support for Elders May Help Prevent Cardiovascular Disease and Death

Researchers from the University of Washington Seattle released a report on Valentine’s day that shows that increasing social support could not only improve depressive symptoms, but also prevents cardiovascular disease and even pre-mature death in older American Indian and Alaska Native (AI/AN) people.

Researchers studied AI/AN adults who participated in the Strong Heart Family Study from 12 communities in over 3 regions between 2000-2003 and, “ .” There was a correlation between those who had reported depressive symptoms, lower quality of life, isolation, heart disease, and death.

Participants in the study were middle-aged adults. The depressive symptoms cited were emotions such as anger self-criticism, and cynicism, and were matched with poor quality of life and isolation. However, better social support saw lower cynicism levels, anger, and trauma. Researchers found that depression and a poorer quality of life, along with social isolation created a higher risk for mortality and cardiovascular events. However, social support lowered that risk. Overall, the study suggests that social support leads to better mood and quality of life in AI/AN elders, and may even lower cynicism, stress, and overall disease risk.

Urban Indian Organizations already provide so much programming and support for their elders, not only in the form of social connections, but also health services. It is a priority to connect elders to one another and other resources to help address social determinants of health and close the health inequalities that urban Indian communities face in the United States.

Suicide Statistics in AI/AN Communities on the Rise: Recent Updates from the CDC

During November 2021, the CDC released a report on “Provisional Numbers and Rates of Suicide by Month and Demographic Characteristics: United States, 2020”, which covers initial pandemic-era data on suicide rates nationwide.

One of the most important findings for the AI/AN community that the study found is that, “for males, age-adjusted suicide rates were higher in 2020 than in 2019 for non-Hispanic Black, Non-Hispanic AI/AN, and Hispanic males and lower for non-Hispanic White and non-Hispanic Asian males.” Suicide is a complex multifaceted public health issue, which affects the AI/AN community at disproportionate rates. Although suicide rates decreased for many non-Hispanic White groups within the country, they increased for many other ethnic minority groups including non-Hispanic American Indian or Alaskan Native people. Due to a lack of overall research on issues pertaining to the AI/AN community and the complex issues related to suicide, studies like this are necessary to highlight the impact of mental and behavioral healthcare on AI/AN communities (and the supports that are needed). Without data, organizations and the nation are unable to provide accurate support and solutions.

The COVID-19 pandemic has caused many public health issues to be amplified, such as ongoing issues with mental health, substance abuse, financial difficulties, as well as many other factors. Due to the COVID-19 pandemic, many of the possible risk factors associated with suicidal behavior may have increased, which increases the concern that deaths by suicide in 2020 might have increased as well. This report details the numbers of deaths by suicide by the demographics of sex and race and Hispanic origin, by month for the year 2020. These statistics are then compared with final 2019 rates. Rates are compared year-to-year to monitor changes within key demographics by year.

These provisional estimates are based on 99% of all 2020 death records received and processed by the National Center for Health Statistics, but this likely is still an undercount of AI/AN deaths. Since 1979, over 45% of people who self-identified as AI/AN on a national survey had their race misclassified after death (usually as White).

 

 

Citations:

Centers for Disease Control and Prevention. (n.d.). Vital Statistics Rapid Release – cdc.gov. CDC.gov. Retrieved January 20, 2022, from https://www.cdc.gov/nchs/data/vsrr/VSRR016.pdf

PRESS RELEASE: NCUIH Testifies at Two Congressional Hearings Regarding Critical Funding for Urban Indian Health

Congressional leaders emphasized the need to increase resources for urban Indian health and provide opioid funding for urban Indian communities.

FOR IMMEDIATE RELEASE

NCUIH Contact: Meredith Raimondi, Vice President of Public Policy, mraimondi@ncuih.org, 202-417-7781

WASHINGTON, D.C. (April 5, 2022) – The National Council of Urban Indian Health (NCUIH) President-Elect and CEO of the Indian Health Center of Santa Clara Valley, Sonya Tetnowski (Makah Tribe), testified before the House Interior Appropriations Subcommittee as part of American Indian and Alaska Native (AI/AN) Public Witness Day hearing regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). Maureen Rosette (Chippewa Cree Nation), NCUIH board member and Chief Operating Officer of NATIVE Project, testified before the House Natural Resources Oversight & Investigations Subcommittee for a hearing entitled, “The Opioid Crisis in Tribal Communities.” In their testimonies, NCUIH leaders highlighted the critical health needs of urban Indians and the needs of the Indian health system.

NCUIH thanks the members of the subcommittees for the opportunity to testify on the needs of urban Indians and encourages Congress to continue to prioritize urban Indian health in FY 2023 and years to come.

House Appropriators Demonstrate Strong Commitment to Indian Health

NCUIH President-Elect Tetnowski testified before the House Appropriations Subcommittee along with Ms. Fawn Sharp for the National Congress of American Indians, Mr. Jason Dropik for the National Indian Education Association, and Mr. William Smith for the National Indian Health Board. The House Appropriations Committee uses testimony provided to inform the FY 2023 Appropriations decisions.

NCUIH requested the following:

  • $49.8 billion for the Indian Health Service (FY22 Enacted: $6.6 billion) and $949.9 million for Urban Indian Health (FY22 Enacted: $73.4 million) for FY 2023 as requested by the Tribal Budget Formulation Workgroup
  • Advance appropriations for the Indian Health Service (IHS)
  • Support of mandatory funding for IHS including UIOs

Full Funding for the Indian Health System a Priority for Congress

Many Members of Congress on both sides of the aisle noted the need to increase resources for Indian health in order to meet the trust responsibility. The federal trust obligation to provide health care to Natives is not optional and must be provided no matter where they reside,” said Ms. Tetnowski in her testimony, “Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

Ranking Member David Joyce (R-OH-14) agreed with Ms. Tetnowski, “There is still much to do to fulfill the trust responsibility.” Representative Mike Simpson (R-ID-02), also emphasized that more must be done so “there’s not disparity between Indian Health Services and other health services delivered by the federal government.”

President Sharp stated, “This subcommittee’s jurisdiction includes some of the most critical funding for Indian Country. As detailed in the 2018 Broken Promises Report, chronically underfunded and inefficiently structured federal programs have left some of the most basic obligations of the United States to tribal nations unmet for centuries. We call on this subcommittee in Congress to get behind the vision of tribal leaders for right these wrongs by providing the full and adequate funding for Indian country.”

The Case for Mandatory and Advance Appropriations for IHS

The Indian health system, including IHS, Tribal facilities and UIOs, is the only major federal provider of health care that is funded through annual appropriations. For example, the Veterans Health Administration at the Department of Veterans Affairs receives most of its funding through advance appropriations. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions (CRs) as its funding for the next year would already be in place. According to the Congressional Research Service, since FY 1997, IHS has once (in FY 2006) received full-year appropriations by the start of the fiscal year.

“During the most recent 35-day government shutdown at the start of FY 2019, the Indian health system was the only federal healthcare entity that shut down. UIOs are so chronically underfunded that several UIOs had to reduce services, lose staff, or close their doors entirely, forcing them to leave their patients without adequate care. Advance appropriations is imperative to provide certainty to the IHS system and ensure unrelated budget disagreements do not put lives at stake,” said Ms. Tetnowski.

Many Members of Congress were interested in hearing more about the differences between mandatory and advance appropriations. In her opening remarks, Chair Pingree pointed out that the mandatory funding proposal, if implemented, would remove the jurisdiction from the Appropriations Committee to the authorizing committees. Both NCAI President Sharp and NIHB Chair Smith also expressed support for the mandatory funding proposal from President Biden. Mr. Smith testified the President’s proposal is “a bold vision to end chronic underfunding and building a comprehensive Indian health care system. We urge Congress to support the request and work together with administrations and the tribes to see that as passed into law.”

Rep. Simpson sought to clarify whether both Advance Appropriations and Mandatory Appropriations remain priorities for Indian Country. President Sharp explained that “both [advance and mandatory funding] are critically important” in fulfillment of the trust responsibility while noting that basic health should be a mandatory expenditure of the United States government. President-Elect Tetnowski also stated that, “Advance appropriations would ensure that we weren’t shut down during any type of government closure. IHS is currently the only health care [provider] in the Federal government that does not have advanced appropriations.”

Resources

Congressional Leaders Express Support for Expanding Opioid Funding to Urban Indians

“Opioid overdose deaths during the pandemic increased more in Native American communities than in communities for any other racial or ethnic group,” said Representative Katie Porter (D-CA-45), “to address this crisis, we need to provide more resources for tribal governments and urban Indian health organizations to treat the opioid epidemic.” 

Urban Indians Left out of Opioid Grant Funding

Funding to assist AI/AN communities to address the opioid crisis have repeatedly left out urban Indians. UIOs were not eligible for the funding designated to help Native communities in the State Opioid Response (SOR) Grant reauthorization included in the recently passed FY 2022 Omnibus (H.R. 2471) despite inclusion of UIOs in the SOR bill (H.R. 2379) that passed the House on October 20, 2021. The final language in the omnibus (H.R. 2471) did not explicitly include “Urban Indian Organizations” as eligible and did not use the language from H.R. 2379. While this was likely a result of legislative text being copied from previous legislation, this prohibits urban Indian health providers from being able to access the critical funding needed to combat the opioid crisis.

“During the last government shutdown, one UIO suffered 12 opioid overdoses, 10 of which were fatal. This represents 10 relatives who are no longer part of our community,” Ms. Rosette emphasized, “These are mothers, fathers, uncles, and aunties no longer present in the lives of their families. These are tribal relatives unable to pass along the cultural traditions that make us, as Native people, who we are.”

Responding to a question from Rep. Stansbury (D-NM-01) on what the committee can do to help support UIO’s work on the ground to address the opioid crisis in Native communities, Ms. Rosette reiterated, “Funding is always an obstacle for us. Grants, like the state opioid response grant, would allow us to provide culturally appropriate treatment to our community, but we were not included. You have to specifically say “urban” along with “tribal” otherwise we are not allowed to get the funding.”

Opioid Epidemic in AI/AN Communities

Since 1974, AI/AN adolescents have consistently had the highest substance abuse rates than any other racial or ethnic group in the U.S. Urban AI/AN populations are also at a much higher risk for behavioral health issues than the general population. For instance, 15.1% of urban AI/AN persons report frequent mental distress compared to 9.9% of the general public.

Additionally, the opioid crisis and COVID-19 pandemic are intersecting with each other and presenting unprecedented challenges for AI/AN families and communities. On October 7, 2021, the American Academy of Pediatrics published a study on caregiver deaths by race and ethnicity. According to the study, 1 of every 168 AI/AN children experienced orphanhood or death of caregivers due to the pandemic and AI/AN children were 4.5 times more likely than white children to lose a parent or grandparent caregiver. Unfortunately, this has exacerbated mental health and substance use issues among our youth. In the age group of 15-24, AI/AN youth have a suicide rate that is 172% higher than the general population in that age group.

Resources

Next Steps

NCUIH will continue to advocate for full funding of Indian Health Service and urban Indian health at the amounts requested by Tribal leaders as well as for additional resources for the opioid response for Native communities.