NCUIH Sends Letter in Support of the IHS Request to Detail Public Health Service Commissioned Officers to Urban Indian Organizations

On May 24, 2022, the National Council of Urban Indian Health (NCUIH) sent a letter to the Chairs of the House and Senate Appropriations Committees, Representative Chellie Pingree (D-ME-1), and Senator Jeff Merkley (D-OR), and to the Ranking Members Representative David Joyce (R-OH-14) and Senator Lisa Murkowski (R-AK), expressing NCUIH’s support for detailing Public Health Service Commission Officers (PHSCOs) to Urban Indian Organizations (UIOs). Detailing officers to UIOs would assist UIO personnel in providing skilled, culturally competent healthcare, help address workforce shortages, and increase collaboration across the federal healthcare system.

Amending the law would provide the Indian Health Service (IHS) with the discretionary authority to detail PHSCOs directly to a UIO to perform work related to the functions of the Service. Such authority would be comparable to the existing authority to detail Officers to Indian Self Determination and Education Assistance Act (ISDEAA) contractors and compactors for the purpose of carrying out the provisions of their ISDEAA contracts (section 7 of the Act of August 5, 1954 (42 U.S.C. § 2004b). The bill would support the 41 UIOs that serve the 70% of American Indians and Alaska Natives that live outside of reservations. Currently, UIOs only get 1% of IHS funding, so to fully staff UIOs, Public Health Service Commissioned Officers need to be deployed.

The Biden Administration and IHS support this deployment of PHSCOs to UIOs by including the provision in their Fiscal Year 2023 budget. NCUIH urges Chair Pingree and Merkley and Ranking Members Joyce and Murkowski to support this provision in the 2023 budget, and if not feasible, to support this provision in the next budget or in a stand-alone bill.

Background

Section 215 of the Public Health Service Act (PHSA) authorizes the Secretary of Health and Human Services (HHS) to detail officers to federal agencies and state health or mental health authorities. While UIOs have requested that officers be detailed to them to fill many roles related to the functions of the Public Health Service, subsection (c) of Section 215 (42 U.S.C. 215(c)) prevents UIOs from receiving detailed officers because they do not fall within the requirement that non-profits eligible for detailing be educational or research non-profits, or non-profits engaged in health activities for special studies and dissemination of information.” UIOs do not qualify under the current statutory language. Changing this language would allow IHS to detail officers to UIOs to perform work related to the functions of the Indian Health Service.

NCUIH Submits Comments to IHS on the Special Diabetes Program for Indians for Fiscal Year 2023

On May 16, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Special Diabetes Program for Indians (SDPI). These comments responded to the Dear Urban Indian Organization Leader correspondence initiating Area Urban Confers on the SDPI, dated April 15, 2022. In the comments, NCUIH emphasized the importance of SDPI and its impact in reducing health disparities related to diabetes for AI/AN populations. NCUIH also proposed recommendations for fiscal year (FY) 2023 including an increase in funding to at least $250 million with built-in automatic annual medical inflationary increases and additional support for UIOs seeking supplemental funding sources for diabetes-related care.

SDPI and Its Importance to Indian Country

As a grant program inclusive of all three components of the IHS/Tribal Health Program/Urban Indian Organization (I/T/U) system, SDPI has been a resounding and demonstrable success in reducing diabetes and diabetes-related illnesses in Indian Country. The National Indian Health Board has called SDPI “the nation’s most strategic, comprehensive and effective effort to combat diabetes and its complications.” SDPI remains a critical program to continue to address disparately high rates of diabetes among AI/ANs.

SDPI has directly enabled UIOs to provide critical services to their AI/AN patients, in turn significantly reducing the incidence of diabetes and diabetes-related illnesses among urban Indian communities. As of 2022, 30 out of the 41 UIOs received SDPI funding. Facilities use these funds to offer a wide range of diabetes treatment and prevention services, including but not limited to exercise programs and physical activity, nutrition services, community gardens, culinary education, physical education, health and wellness fairs, culturally-relevant nutrition assistance, food sovereignty education, group exercise activities, green spaces, and youth and elder-focused activities.

NCUIH’s Requests to IHS

NCUIH made the following comments and recommendations about the SDPI:

  • SDPI should be permanently reauthorized and funding increasing to $250 million, with built-in automatic annual medical inflationary increases
    • SDPI funding has been stagnant at $150 million since 2004. Due to inflation and increases in health care costs, the level of funding has effectively reduced over the past nearly twenty years. This places the onus on Indian Health Care Providers to make up the funding difference to ensure the continued success of SDPI.
    • The federal government’s trust responsibility to AI/ANs requires that the government provide services and resources to improve the health of AI/AN citizens and the United States has pledged to provide all resources necessary to eradicate the health disparities between AI/ANs and the general population of the United States. Because AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, SDPI falls well within the federal government’s trust responsibility to AI/ANs, and it is the duty of the United States, not Tribes and UIOs, to reconcile funding concerns with programmatic need.
    • In addition, NCUIH urges the federal government to collaborate with other federal agencies to create or identify supplemental funding sources and communicate the availability of these funds to UIOs.
  • NCUIH requests that IHS ensure that SDPI remains inclusive of UIOs, especially if IHS is considering structural changes to SDPI.
    • NCUIH asks that IHS communicate any potential recommendations to UIOs as soon as possible and hold proper and timely Urban Confer sessions, as is required by the federal trust responsibility and the Indian Healthcare Improvement Act, prior to making any formal recommendations to Congress.

NCUIH will continue to closely follow IHS’s progress and policies with SDPI and advocate for future of this vital program.

Government Accountability Office Calls on Agencies to Improve Information on Federal Funds for Native Communities and the Budget Formulation Process

On May 19, 2022, the Government Accountability Office (GAO) published a new report calling for immediate action to improve transparency for federal funding that benefits American Indians and Alaska Natives (AI/ANs), including AI/ANs living in urban areas. GAO found divergent interpretations of the Office of Management and Budget’s (OMB) guidance for identifying and providing information on federal funding related to the Native American crosscut. GAO also found that three of the agencies whose budgets are captured in the crosscut do not have formal processes for incorporating Tribal input into their budget proposals and do not develop budgets that reflects the needs of Tribes.  The report recommends seven key agency actions to improve budget formulation and reporting processes for programs that serve AI/AN communities, including urban Indian organizations (UIOs) and the 70 percent of AI/ANs living in urban areas.

The Native American Crosscut and The Beginning of GAO’s Investigation

GAO is an independent, nonpartisan federal agency tasked by Congress with examining how taxpayer dollars are spent and provides both Congress and federal agencies fact-based recommendations to help the government save money and work more efficiently. GAO reviews federal programs across a broad range of topics and concerns, including health care, education, economic development, environmental protection, justice, and infrastructure. Agency oversight supports federal efforts to uphold the trust responsibility.

The U.S. Commission on Civil Rights published a 2018 report detailing broken promises to AI/ANs, which recommended regular assessment of unmet needs for both urban and rural AI/AN communities. Shortly thereafter, GAO launched an investigation of agency failures to keep accurate, consistent, and comprehensive records of federal programs benefiting AI/ANs, and transparency mechanisms to facilitate monitoring of such funding. This included a review of consultation, data collection, and reporting practices at OMB. OMB serves as a clearinghouse for budget formulation and reporting across federal agencies and publishes the most comprehensive annual report of federal funding that benefits Native peoples across federal agencies, known as the Native American crosscut. GAO also investigated the extent to which pertinent agencies have formal processes for incorporating Tribal input when developing their budget proposals and the extent to which their budget proposals reflects Tribal needs

GAO’s Recommendations Regarding the Native American Crosscut and Budget Formulation

GAO published seven recommendations to improve federal practices related to budget formulation, data sharing, transparency, and oversight:

  1. The Director of OMB should issue clear guidance as part of the annual budget data request for the Native American Crosscut that directs agencies to provide detailed information about how they collected data to report and selected programs to include; and
  2. The Director of OMB should publish in the Native American Crosscut a statement of its purpose and detailed information that it receives from agencies in response to its budget data request; and
  3. The Director of OMB should establish a formal process to regularly solicit and assess feedback about the Native American Crosscut from tribal stakeholders and relevant federal agencies, and to incorporate such feedback into guidance; and
  4. The Secretary of Transportation should ensure that the Deputy Assistant Secretary for Intergovernmental Affairs develops a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests and program reauthorization proposals for programs serving tribes and their members; and
  5. The Secretary of Education should ensure that the department develops a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests for programs serving tribes and their members; and
  6. The Secretary of Agriculture should ensure that the Office of Tribal Relations and the Office of Budget and Program Analysis develop a formal process to ensure meaningful and timely input from tribal officials when formulating budget requests and program reauthorization proposals for programs serving tribes and their members; and
  7. The Director of OMB should update OMB’s annual budget guidance to direct federal agencies to assess, in consultation with tribes, tribal needs for federal programs serving tribes and their members, and submit this information as part of their publicly available budget documents.

Though the report did not provide explicit recommendations for the Department of Health and Human Services (HHS) or the Department of the Interior (DOI), GAO noted the failure to provide public notice in Indian Health Service budget formulation sessions and concerns that inclusion of urban Indian organizations in such processes remains discretionary.

In response to the published recommendations, OMB expressed overall agreement, shared general plans to better capture and report on funding that benefits Native peoples, and is currently considering new consultation recommendations. The Department of Transportation and the Department of Education agreed with the relevant recommendations, while the Department of Agriculture neither agreed nor disagreed.  DOI provided no comments.

NCUIH will continue to monitor ongoing efforts to improve the budget formulation process, and to provide updates to budget formulation and reporting practices across federal agencies.

NCUIH Submits Comments on Fiscal Year 2023 Appropriations Priorities to the Office of Management and Budget

On May 18, 2022, NCUIH submitted written comments and recommendations in response to the Office of Management and Budget (OMB) Dear Tribal Leader letter seeking Tribal consultation on appropriations priorities for programs and services that serve Tribal governments, organizations, and peoples in Fiscal Year (FY) 2023. Though NCUIH noted recent investments in the Indian Health Service (IHS) discretionary budget, the comments highlighted evidence that funding falls far short of documented need and fails to address inflation in the cost of medical care, particularly for the 70 percent of American Indians/Alaska Natives living in urban areas. NCUIH made six key recommendations to fully fund and support health services for Native organizations and communities, including urban Indian organizations (UIOs).

Background

OMB serves as a clearinghouse for budget formulation by developing overarching presidential priorities, coordinating across agencies, and publishing the annual President’s Budget. Last year’s Presidential Memorandum on Tribal Consultation and Strengthening Nation-to-Nation Relationships established an ongoing priority to uphold the federal trust responsibility through tribal engagement and consultation. Consistent with this memorandum, the OMB initiated a Tribal consultation to promote tribal priorities in the FY 2023 President’s Budget on April 25, 2022. Officials sought comment on programs that serve Tribal governments, organizations, and communities. In particular, the agency noted interest in feedback on shifting funding for IHS from discretionary to mandatory and reclassifying 105(l) Lease costs.

Current Action

NCUIH made six recommendations to improve delivery of health services to AI/ANs living in urban areas through the FY 2023 budget, including:

  1. Fully Fund Urban Indian Health at $949.9 million for FY 2023.
    As of FY 2018, the average health care spending is $11,172 per person, however, Tribal and IHS facilities receive $4,078 per IHS-eligible patient. UIOs receive just $672 per AI/AN patient from the IHS budget, significantly below federal per capita spending levels. This forces UIOs to operate on very slim margins, causing significant difficulty during unforeseen events.
  1. NCUIH supports the President’s FY 2023 Budget proposal for mandatory funding for the IHS.
    Since 1997, IHS has only once received full-year appropriations by the start of the fiscal year (FY 2006). This leaves the IHS subject to government shutdowns, automatic sequestration cuts, and continuing resolutions, which negatively impact patient care. For instance, during the 35-day government shutdown at the start of FY 2019, UIOs were forced to lay-off staff, reduce hours, reduce services, and some, unfortunately, had to temporarily close their doors due to the lack of funding. Mandatory funding for IHS is necessary and long overdue to ensure stable and predictable funding for AI/AN healthcare that is exempt from the political process.
  1. NCUIH requests that OMB hold a separate urban confer with UIOs to discuss the budget request for urban Indian health programs.
    IHS is the only federal agency with an Urban Confer Policy—no other agency, including agencies under the Department of Health & Human Services (HHS) that oversee programs for UIOs, has an established mechanism for dialogue with UIOs. Outside of the IHS Urban Confer process, urban AI/ANs have no specific representation with federal agencies regarding health care matters that affect them, leaving them on the margins of critical conversations on AI/AN health care that occurs across the Executive Branch.
  1. Create a Tribal Office and a Tribal Advisory Committee with UIO Representation
    During the recent virtual OMB consultations, Tribal leaders asked for a permanent position within OMB dedicated to AI/AN health care, a liaison between Indian Country and OMB, and/or an Office of Tribal Affairs within OMB. This new position or office would help coordinate communication and facilitate outreach to address budgetary shortfalls. NCUIH supports this request and stresses that UIO consultation and involvement is imperative to fulfill the President’s vision to improve health equity for AI/ANs. NCUIH also supports the request that OMB establish an OMB Tribal Advisory Committee with UIO representation.
  1. NCUIH requests that OMB provide an exception apportionment that is inclusive of the entire I/T/U system.
    In the absence of an exception apportionment, if Congress does not reach a budget agreement in time and the federal government must shut down, UIOs are subject to the shutdown. Federal shutdowns require UIOs to lay off staff, reduce hours and services, and even shut their doors, ultimately leaving their patients without adequate health care. During the 2019 shutdown, multiple patients died while an East Coast UIO was closed.
  1. Improve data accuracy for urban AI/ANs
    OMB’s Office of Information and Regulatory Affairs (OIRA) oversees the implementation of federal government-wide policies in the areas of information policy, privacy, and statistical policy. In this field of practice, the establishment of statistical standard practices is a critical government function. When searching for and comparing health indicators, assessing the health status of entire AI/AN communities, testing academic research using vital statistics, and conducting epidemiological studies in support of public health, it is very common to wrestle with misclassifications of race for AI/AN people. This is due, at least in part, to the fact that tribal membership or descendancy is a political status classification, not a racial category.  .NCUIH requests that OMB consult with NCUIH and UIOs to ensure that OIRA’s statistical standard practices appropriately account for urban AI/ANs. Additionally, NCUIH requests that OMB commit to continuously consulting and working with NCUIH and UIOs to improve OIRA’s data accuracy for urban AI/ANs

NCUIH will continue to monitor the FY 2023 budget formulation process and report developments across federal agencies and in Congress.

NCUIH Endorses Bicameral Bill that Extends Grants to Urban Indian Organizations to Treat Long COVID

On April 7, 2022, Representative Ayanna Pressley (D-MA-07) and Senator Tammy Duckworth (D-IL) introduced the bicameral Targeting Resources for Equitable Access to Treatment for Long COVID (TREAT Long COVID) Act (H.R. 7482/S. 4015) to increase access to medical care and treatment for communities and individuals struggling with Long COVID. Specifically, this legislation would establish a grant program for eligible entities, including urban Indian organizations (UIOs), for the purpose of creating or enhancing capacity to treat patients with Long COVID through a multidisciplinary approach. The bill authorizes up to $2 million in grant funding to eligible entities and the period of a grant shall be up to three years, with an opportunity for renewal.

The TREAT Long COVID Act is co-sponsored by Rep. Donald Beyer (D-VA-8), Rep. Lisa Rochester (D-DE-1), Sen. Tim Kaine (D-VA), and Sen. Edward J. Markey (D-MA). The National Council of Urban Indian Health (NCUIH) endorses this bill that brings critical funding to UIOs to treat the lasting effects of COVID on the American Indian/Alaska Native (AI/AN) community.

“NCUIH is pleased to endorse Rep. Ayanna Pressley and Sen. Tammy Duckworth’s Targeting Resources for Equitable Access to Treatment for Long COVID Act. The COVID-19 pandemic has disproportionately impacted Native communities and we are left to deal with the devastating lasting impacts of this disease. We are grateful for the inclusion of urban Indian organizations to be eligible for these critical grants to address Long COVID conditions,” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

The bill was referred to the House Energy and Commerce and Senate Health, Education, Labor, and Pensions Committees. It currently awaits consideration. This bill has been added to the NCUIH legislative tracker and can be found here.

Background

Native communities face some of the harshest disparities in health outcomes of any population in the U.S. and are disproportionately impacted by the COVID-19 pandemic. American Indians and Alaska Natives have infection rates over 3.5 times higher than non-Hispanic whites, are over 3.2 times more likely to be hospitalized as a result of COVID-19 and have higher rates of mortality at younger ages than non-Hispanic whites.

The impact of COVID-19 on American Indian and Alaska Native health will continue beyond the pandemic. Lasting illness such as Long COVID need to be addressed.

NCUIH Resource: American Indian/Alaska Native Data on COVID-19

The TREAT Long COVID Act would expand treatment for Long COVID nationwide by:

  • Authorizing the Department of Health and Human Services to award grants up to $2,000,000 to health care providers, including community health centers;
  • Granting funding for the creation and expansion of multidisciplinary Long COVID clinics to address the physical and mental health needs of patients;
  • Prioritizing funding for health providers that plan to engage medically underserved populations and populations disproportionately impacted by COVID-19;
  • Ensuring that treatment is not denied based on insurance coverage, date or method of diagnosis, or previous hospitalization;
  • Encouraging ongoing medical training for physicians in Long COVID Clinics and other health care workers serving patients; and
  • Requiring grantees to submit an annual report on its activities that includes evaluations from patients.

Full Text of the House Bill

Full Text of the Senate Bill

Bipartisan Urban Indian Health Confer Act Introduced by Senators Smith and Lankford

On May 26, 2022, Senators Tina Smith (D-MN) and James Lankford (R-OK) introduced the Urban Indian Health Confer Act (S. 4323). This legislation would require the Department of Health and Human Services (HHS) to confer with urban Indian organizations (UIOs) on policies and initiatives regarding health care for the over 70% American Indians and Alaska Natives (AI/ANs) living off of reservations.

The National Council of Urban Indian Health (NCUIH) worked closely with Senators Smith and Lankford on the introduction of this Senate companion bill to H.R. 5221. Representatives Raúl Grijalva (D-AZ-3), Betty McCollum (D-MN), Tom Cole (R-OK), Karen Bass (D-CA), Eleanor Holmes Norton (D-DC), and the late Don Young (R-AK) were original cosponsors of the House legislation. On November 2, 2021, the Urban Indian Health Confer Act (H.R. 5221) passed the House of Representatives by 406 to 17.

NCUIH has long advocated for the importance of facilitating confer between numerous federal branches within HHS to ensure access to high-quality health services for all Native people. At a hearing on October 5, 2021, HHS explained that rollouts of COVID-19 vaccines were delayed to urban Indians due to lack of an urban confer policy.

The National Congress of American Indians (NCAI) has also passed a resolution to “Call for the U.S. Department of Health and Human Services (HHS) Secretary to Implement an Urban Confer Policy Across the Department and its Divisions” showing broad support among stakeholders in Indian Country. 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.

“Proper urban confer policies across all HHS agencies has been long overdue and exacerbated amid the current public health crisis ravaging Indian Country. We welcome the federal government’s effort to further fulfill their trust and treaty obligation for all American Indians and Alaska Natives, including those residing in urban areas,” said Walter Murillo (Choctaw Nation of Oklahoma), Chief Executive Officer of NATIVE HEALTH and NCUIH Board Member.

Next Steps

The bill was referred to the Senate Committee on Indian Affairs. It currently awaits consideration. Please get in touch with your Senator to ask them to request that the Senate Committee on Indian Affairs to move forward on this legislation.

Resources

Background

Urban Confer policies are a response to decades of deliberate federal efforts (i.e. forced assimilation, termination, relocation) that have resulted in over 70% of AI/AN people living outside of Tribal jurisdictions, thus making Urban Confer integral to addressing the care needs of most AI/AN persons. Currently, only the Indian Health Service (IHS) has a legal obligation to confer with UIOs.  According to the Congressional Research Services, HHS would have to confer with urban Indian organizations on “provisions of law relating to health care for American Indians and Alaska Natives.”

Missed opportunities for awareness and information provided to UIOs regarding AI/AN healthcare can be avoided through a confer process. For instance, key information regarding vaccine distribution for the initial COVID-19 vaccine rollout was poorly communicated to UIOs and created unnecessary hardship. HHS addressed initial communications only to Tribes and did not direct it to the UIO component of the IHS system. When HHS was asked about whether UIOs needed to similarly decide between an IHS or state vaccine allocation, it was unclear for weeks as to whether they were expected to make such a decision. Eventually, HHS asked UIOs to decide between receiving their vaccine distribution from either their state jurisdiction or IHS the same day as the initial deadline (which thankfully HHS subsequently extended for several days). Some UIOs were informed of the deadline by their Area office with no formal national communication. As a result, many of our clinics experienced delays in vaccine rollout.

“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).

The disregard by some agencies 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 USC § 1660d) (IHCIA).

Senator Cantwell Requests IHS Director Nominee to Prioritize Parity for Urban Indian Health

On May 25, 2022, during the Senate Committee on Indian Affairs (SCIA) nomination hearing to consider Roselyn Tso to be Director of the Indian Health Service (IHS), Senator Maria Cantwell (D-WA) inquired about the status of Federal Medical Assistance Percentage (FMAP) for Urban Indian Organizations (UIOs) during questioning. Senator Cantwell asked if Tso would commit to securing 100% FMAP for UIOs should she become the IHS Director and advocated for the federal government to pay its fair share to IHS Medicaid beneficiaries in urban areas, “I wanted to ask you about 100% FMAP funding for urban Indian health…urban Indian organizations are not treated the same […] It is a big inequity in the delivery of care.” She also advocated for an end to the disparate treatment of UIOs regarding reimbursement for IHS Medicaid Beneficiaries and emphasized that paying a lower FMAP simply because of where someone lives is unjust and unequal. This question helped to promote the interests of urban UIOs to ensure that they are not forgotten when it comes to reimbursement for services to Medicaid beneficiaries, as Tso made no mention of urban Indians or 100% FMAP for UIOs in her remarks.

Senator Cantwell is a fierce advocate for the rights of urban AI/ANs and the National Council of Urban Indian Health (NCUIH) deeply appreciates her efforts to bring the FMAP issue to the Committee.

Background

FMAP is the percentage reimbursed to the states for health care provided by Medicaid. Typically states and the federal government split the cost of providing funding to Medicaid beneficiaries. However, IHS care for Medicaid beneficiaries is entirely covered by the federal government. Many urban AI/ANs rely on Medicaid for their health care and 100% FMAP would ensure that the services provided to urban AI/ANs were paid for. It also saves states millions of dollars.

Including UIOs in 100% FMAP would ensure that AI/ANs are treated equally when it comes to the fulfillment of the trust responsibility. The federal government has a trust responsibility to all AI/ANs, regardless of where they live. Living off the reservation should not mean that your health care provider receives less in Medicaid funds. Implementing parity would rectify the disparities experienced by urban AI/ANs and would allow UIOs to provide more services to urban AI/ANs. It would fulfill the intent behind Congress’ assertion that the provision of health care for AI/ANs “does not stop at the borders of the Indian reservation.”

Once again, we thank Senator Cantwell for her support of urban AI/ANs and look forward to collaborating with her office in the future on this important issue.