HHS to hold Tribal Consultation on Proposed Rule to Strengthen Nondiscrimination in Health Care

On July 25, 2022, the Department of Health and Human Services (HHS) announced a proposed rule to implement Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in certain health programs and activities. The proposed rule strengthens and restores civil rights protections for patients, beneficiaries, and consumers in certain federally funded health programs and other HHS programs.

The rulemaking affirms protections against discrimination on the basis of sex, inclusive of sexual orientation and gender identity, consistent with the US Supreme Court holding in Bostock v Clayton County. The rulemaking also reinforces protections against discrimination in seeking reproductive health care services.

A Tribal Consultation on the proposed rule will be held on August 31 at 2:00 pm EDT. Click here to register in advance. Public comment in response to the proposed rule is due September 23, 60 days after the notice.


Under the Trump Administration, HHS issued final regulations on the implementation of Section 1557 in early June of 2020, which narrowed the scope of the rule by:

  • Eradicating prohibition on discrimination based on gender identity and sex-stereotyping
  • Embracing blanket religious freedom and abortion exemptions for health care providers
  • Removing the provision preventing health insurers from varying benefits that discriminate against certain marginalized groups of individuals
  • Lessening protections for individuals with limited English proficiency
  • Eliminating prohibitions against discrimination based on gender identity and sexual orientation in ten other federal health care regulations.

On June 15, 2020, the US Supreme Court published its decision on Bostock v. Clayton County. Under this ruling, sex discrimination includes discrimination based on sexual orientation and gender identity. While the case is specific to an employment context, it has since been used in support of nondiscrimination efforts that include sexual orientation and gender identity. Given the ruling in this case, a number of federal courts issued nationwide preliminary injunctions to block parts of the 2020 Final rule.

The Section 1557 rule was first issued under the Obama Administration in 2016.

Call to Action

Section 1557 Notice of Proposed Rulemaking (NPRM) seeks to address gaps identified in prior regulations. In order to advance protections under this rule it:

  • Reinstates the scope of Section 1557 to cover HHS’ health programs and activities.
  • Clarifies the application of Section 1557 nondiscrimination requirements to health insurance issuers that receive federal financial assistance.
  • Aligns regulatory requirements with Federal court opinions to prohibit discrimination on the basis of sex including sexual orientation and gender identity.
  • Makes clear that discrimination on the basis of sex includes discrimination on the basis of pregnancy or related conditions, including “pregnancy termination.”
  • Ensures requirements to prevent and combat discrimination are operationalized by entities receiving federal funding by requiring civil rights policies and procedures.
  • Requires entities to give staff training on the provision of language assistance services for individuals with limited English proficiency (LEP), and effective communication and reasonable modifications to policies and procedures for people with disabilities.
  • Requires covered entities to provide a notice of nondiscrimination along with a notice of the availability of language assistance services and auxiliary aids and services.
  • Explicitly prohibits discrimination in the use of clinical algorithms to support decision-making in covered health programs and activities.
  • Clarifies that nondiscrimination requirements applicable to health programs and activities include those services offered via telehealth, which must be accessible to LEP individuals and individuals with disabilities.
  • Interprets Medicare Part B as federal financial assistance.
  • Refines and strengthens the process for raising conscience and religious freedom objections.

American Indians/Alaska Natives (AI/ANs) are historically marginalized and underserved when it comes to healthcare. The Section 1557 notice of proposed rulemaking finds that: AI/ANs under 65 have an uninsured rate of 28 percent, higher than any other racial or ethnic group; AI/ANs received worse care than white individuals in the areas of patient safety, person-centered care, care coordination, the effectiveness of care, healthy living, and affordable care for 40 percent of 108 quality measures; more research is needed to determine the root causes of maternal mortality among AI/AN women, but a recent study suggests that provider-related factors, including implicit bias, must be addressed to reduce AI/AN maternal mortality; and there is uneven representation in minority populations, including AI/ANs, in Alzheimer’s research and clinical trials.

HHS encourages all stakeholders, including patients and their families, health insurance issuers, health care providers, health care professional associations, consumer advocates, and government entities, to submit comments through regulations.gov.

NCUIH will continue to closely monitor the proposed rule and related issues, concerns, and comments.

CDC Endorses Fourth COVID-19 Vaccine for Adults

On Tuesday, July 19, 2022, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, MPH, endorsed the CDC Advisory Committee on Immunization Practices’ recommendation for Novavax’s COVID-19 vaccine as another primary series option for adults 18 and older. Novavax’s vaccine, Adjuvanted, was granted an emergency use authorization on July 13, 2022, by the US Food and Drug Administration.

The Novavax vaccine, Adjuvanted, is another two-dose vaccine that will be available to administer to adults 18 and older in the coming weeks. The Novavax vaccine is administered three weeks apart and uses a more traditional technology for vaccine delivery. In total, there are now four different COVID-19 vaccines for adults 18 and older to choose from; Moderna, Pfizer, Johnson & Johnson, and Novavax.


American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of the pandemic, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized and 2.2 times more likely to due to du COIVD-19.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of July 2022, AI/ANs have the highest vaccination administration rates in the US with 73% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.

Bipartisan Support for Urban Confer at Senate Hearing

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

The Administration and Congress emphasized the importance of urban confer legislation on issues such as COVID-19 vaccine distribution and Medicaid reimbursement in this week’s Senate hearing.

WASHINGTON, D.C. (July 25, 2022) – On July 20, 2022 the National Council of Urban Indian Health (NCUIH) testified before the Senate Committee on Indian Affairs (SCIA) in support of the Urban Indian Health Confer Act (H.R. 5221). Dr. Patrick Rock (Leech Lake Band of Ojibwe), Chief Executive Officer at the Indian Health Board of Minneapolis and NCUIH member, explained how this bipartisan, bicameral legislation would enable Urban Indian Organizations (UIOs) to engage in urban confer with all divisions within the Department of Health and Human Services (HHS) so that American Indians/Alaska Natives (AI/ANs) living in urban areas are made aware of major healthcare policies that affect them. Deputy Director of the Indian Health Service (IHS), Benjamin Smith, also testified on this critical legislation.

Testimony Highlights

Lack of Urban Confer Affects COVID-19 Vaccine Rollout and 100% FMAP Implementation for UIOs

In his testimony, Dr. Rock stressed how the lack of Urban Confer has enabled HHS and agencies outside of IHS to disregard the needs of urban Indians and neglect the federal obligation to provide healthcare to all AI/ANs, “Through the Indian Health Care Improvement Act, the Indian Health Service has a legal obligation to confer with UIOs, which is an essential tool used to ensure access to health services for Native people. Unfortunately, HHS has interpreted it to mean that only IHS has the requirement to confer with UIOs. It is crucial to patient care that HHS and ALL agencies it operates establish a formal confer process.”

To define the severity of this issue, he explained how communication issues between HHS and UIOs surrounding the initial COVID-19 vaccine rollout in December of 2020 created unnecessary hardships, resulting in many clinics experiencing serious delays in vaccine distribution. This had dire consequences, as the pandemic took the lives of AI/ANs at the highest rates of any population. Dr. Rock continued to explain how urban confer would also help with the implementation of the American Rescue Plan Act (ARPA) provision that provides 100% Federal Medical Assistance Percentage (FMAP) for services provided to Medicaid beneficiaries at UIOs for two years. Congress authorized this with the intent to increase financial resources for UIOs, however, UIOs are still not receiving any financial benefit from 100% FMAP and do not have a policy to confer with the Centers for Medicare and Medicaid Services (CMS) on this issue. In response to Senator Tina Smith’s (D-MN) concerns about this ARPA provision that Congress worked hard to get for UIOs and how urban confer may have alleviated this issue, Dr. Rock noted that, “Unfortunately, we have yet to see really any type of activity or actual reimbursement occur, utilizing the 100% FMAP through the federal system, which is extremely, extremely disappointing. We continue to seek out solutions moving forward. I think we’re going to need to help with our state partners as well as our federal partners including CMS. This would be an important point to have access to and conferring with CMS.” He highlighted that “an urban confer policy across HHS agencies, including CMS, would be instrumental in ensuring that obstacles relating to programs and benefits that directly affect UIOs are addressed quickly so UIOs are better equipped to provide healthcare to their patients.

Dr. Rock emphasized that H.R. 5221 remedies such problems and codifies a proper Urban Confer policy, thus ensuring that AI/AN lives are no longer jeopardized by the lack of adequate communication pathways between HHS agencies and UIOs. To conclude, Dr. Rock stated that H.R. 5221 is an essential parity issue for UIOs that ensures that AI/ANs residing in urban areas continue to have access to high quality, culturally competent health services. He urged SCIA to move forward with this necessary legislation to further improve healthcare delivered to urban Indian patients.

Administration Emphasizes the Importance of Urban Indian Inclusion in Federal Communication

The Administration highlighted that urban AI/AN communities are affected by the absence of an urban confer policy and that UIOs have been persistent in their advocacy to establish a confer process across all of HHS. During the hearing, IHS Deputy Director Benjamin Smith said, “IHS has consistently heard from UIOs through the confer process they would like the opportunity to confer with other HHS operating divisions and staff offices. They have also expressed that the need to confer with other HHS agencies is even more critical due to the pandemic and need for interagency collaboration.” In addition, he said that “the IHS confer process works to ensure that health care priorities for urban Indian populations are being heard and addressed at the local, area, and national levels.”

During questioning, Deputy Director Smith stressed the impact that IHS’ urban confer policy has on UIOs and urban Indians, such as COVID funding decisions, “Throughout the pandemic, Congress provided several supplemental packages that required funding decisions that had a huge impact on urban Indian organizations. We engaged in our policy in invoking our policy to confer with urban Indian organizations to solicit their input prior to making those funding decisions. And we believe that that did have an impact on the manner in which we made those decisions.”

Bipartisan Support from SCIA Members

H.R. 5221 has generated support from Members of Congress on both sides of the aisle. In Senator Smith’s opening remarks and introduction of Dr. Rock, she expressed support for this legislation, which was also introduced by her and Senator James Lankford (R-OK) in the Senate this past May, “This measure is an important step towards parity for urban Native communities and something that I think we should all be able to agree on. I look forward to working with the committee to get this bill across the finish line this year.” Later in her questioning about the urban confer bill, Senator Smith emphasized that “If there had been good consultation across all Department of Health and Human Services, that I think would have been easier to resolve on issues of data sharing, 100% FMAP, I would say also federally qualified health center issues, all of those would be easier to resolve if we had the kind of consultation that our bill would require.”

Senator James Lankford (R-OK) highlighted two UIO leaders from his state on their work towards bettering AI/AN health, “Leaders like Robyn Sunday-Allen and Carmelita Skeeter in Tulsa and in Oklahoma City, they’re the reason that all this works so well. They work incredibly hard and they’re absolutely the gold standard for health care in clinic operations” and went on to express his support for urban confer, “I’m proud to be able to co-sponsor with Senator Smith, the Senate companion Urban Indian Health Confer Act. This simple legislation will ensure that UIOs are brought into important conversations and confer with HHS. We talk a lot about consultation with Tribes. But currently, HHS is not doing consultation with urban Indian clinics and that needs to start.”


An Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. Urban confer policies are a response to decades of deliberate federal efforts (i.e., forced assimilation, termination, relocation) that have resulted in 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 has long advocated for the importance of facilitating confer between numerous federal branches within HHS and UIO stakeholders without any resolve. Currently, only IHS has a legal obligation to confer with UIOs. 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.

The Urban Indian Health Confer Act (H.R. 5221/S.4323) will ensure the many branches and divisions within HHS and all agencies under its purview establish a formal confer process to dialogue with UIOs on policies that impact them and their AI/AN patients living in urban centers. This bill was first introduced on September 10, 2021, by Rep. Raúl Grijalva (D-AZ-3), Rep. Betty McCollum (D-MN), Rep. Tom Cole (R-OK), Rep. Karen Bass (D-CA), Rep. Eleanor Holmes Norton (D-DC), and the late Rep. Don Young (R-AK). On October 5, 2021, Walter Murillo (Choctaw Nation of Oklahoma), NCUIH President-elect and Chief Executive Officer of NATIVE HEALTH in Phoenix, Arizona, testified before the House Subcommittee for Indigenous Peoples of the United States in support of H.R. 5221 and on November 2, 2021, this legislation passed in the House by an overwhelming majority of 406 votes. An identical bipartisan bill was also introduced in the Senate on May 26, 2022, by Sen. Tina Smith (D-MN) and Sen. James Lankford (R-OK), S. 4323.

Next Steps

NCUIH will advocate for a swift markup in the Senate on this bill. In addition, NCUIH continues to advocate for an established confer policy between all HHS agencies and UIOs to improve the delivery of health services to all AI/ANs living in urban settings.

Urban Indian Leaders Encouraged to Apply for New Environment Protection Agency Advisory Committee on Children’s Health

On July 7, 2022, the Environment Protection Agency (EPA) announced a  request for applications to fill vacant seats on the Children’s Health Protection Advisory Committee (CHPAC).  Appointed members of the CHPAC serve a three-year term and the expected workload is approximately 10-15 hours per month. The CHPAC provides policy advice and recommendations to EPA on issues associated with regulations, economics, and outreach/communications to address the prevention of adverse health effects to children, as well as critical policy and technical issues relating to children’s health. The CHPAC meets two to three times annually and the EPA reimburses members for travel and other incidental expenses. As both health care providers and non-governmental organizations, leaders from Urban Indian Organizations (UIOs) are eligible to apply for an appointment to the Committee. Nominations should be submitted by August 15, 2022, to EPA_CHPAC@icfi.com and Nguyen.Amelia@epa.gov. For details on what is required in the nomination package, see here. The EPA intends to fill vacancies on CHPAC by March 1, 2023.

CHPAC Objectives and Scope

Chartered under the Federal Advisory Committee Act (FACA), CHPAC was established in 1997 to provide independent advice to the EPA Administrator on a wide range of environmental issues and their impact on children’s health. According to the CHPAC Charter, the CHPAC  is composed of approximately 24-30 members who provide policy advice, information, and recommendations to assist EPA in the development of regulations, guidance, and policies to address children’s environmental health. Committee members generally serve as Representatives of non-Federal interests. The CHPAC  is looking for candidates from industry; Federal, State, local, and Tribal governments; school systems; academia; healthcare providers; and non-governmental organizations. . In considering nominees for the CHPAC, the EPA is looking for background and experience that will contribute to the diversity of perspectives on the committee.

Call to Action

NCUIH encourages interested UIO leaders to submit nomination materials to EPA by August 15, 2022. Because American Indians/Alaska Natives living in urban areas experience the kind of health complications due to environmental issues that the EPA seeks to address, UIO leaders have the experience and expertise to be valuable committee members. The EPA intends to fill vacancies on the CHPAC by March 1, 2023.

Please contact NCUIH policy at policy@ncuih.org if you would like assistance with submission or if you plan to apply.

NCUIH Submits Comments to the Indian Health Service on Improving Urban Indian Health Program Policy, Procedures, and Effectiveness

On June 17, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments and recommendations to the Indian Health Service (IHS) about the Indian Health Program Policy  (the Policy) in the Indian Health Manual (IHM), Chapter 19, “Urban Indian Health Program.” These comments responded to the agency’s Dear Urban Indian Organization Leader letter dated April 14, 2022, initiating an Urban Confer and seeking recommendations for improving the Urban Indian Health Program policy, procedures, and effectiveness. NCUIH outlined recommendations for IHS, including improvements to the Policy’s oversight and management, improvements to the communication procedures, the addition of an appeals process for UIO annual reviews, clarification of reporting requirements, and general assistance to other federal agencies. NCUIH also requested that IHS develop additional sections about Health Information Technology (HIT) systems, data collection, and the use of federal government facilities and sources of supply.


The main purpose of the Policy is to “establish policy, procedures and responsibilities for the Urban Indian Health Program,” as authorized by the Snyder Act. The government and UIOs use guidance from the Policy “to ensure access to high-quality and safe health care services for Urban Indians; to support health promotion and disease prevention programs targeted to urban populations; and to assess program performance to evaluate whether Urban Indian community needs are met.” In its comment, NCUIH noted that IHS has not updated the Policy since 1994. In the intervening 28 years, UIOs have undergone tremendous growth and change, including rapid adjustments in the last two years in response to the COVID-19 pandemic. The recommendations below, which come directly from UIOs’ experience with the Policy, will inform IHS on necessary areas of improvement.

NCUIH supports a collaborative process in which UIOs and IHS engage in open dialogue concerning the Policy to create a comprehensive document. A thorough process will serve UIOs and IHS, and guide all parties in their pursuit to provide high-quality and culturally focused healthcare to AI/ANs living in urban areas.

NCUIH’s Recommendations to IHS

NCUIH recommended the following improvements and additions to the Policy:

  • Improve the Policy’s consistency concerning oversight and management
    • NCUIH shares UIOs’ concerns that the current language in the Policy needs to be strengthened, and the roles and responsibilities of the IHS and UIOs need to be more clearly defined.
    • There is also a general need to improve consistency across all levels of IHS concerning oversight and management, including disbursement of funds, communication, IT support, and more.
    • Over one year after enacting the American Rescue Plan Act, several UIOs still do not have the entirety of the funding, and the discrepancies between areas can vary greatly. Delayed funding due to the bureaucracy of a specific geographic region flies in the face of the federal trust responsibility to provide the highest level of health care to all AI/ANs regardless of residence.
    • NCUIH notes that many UIOs report strong working relationships with their Areas. As such, IHS should work with UIOs to identify best practices and distribute lessons learned across the Areas and Headquarters levels to improve the current inconsistencies UIOs are experiencing.
  • Incorporate improved communication and annual training for Area Offices
    • NCUIH requests that IHS provide language on improved communication between Area Offices and UIOs as well as annual training for Area Offices.
  • Provide more transparent communication regarding supplemental funding
    • NCUIH requests that IHS modify Section 3-19.3 G – H and Section 3-19.4 “Grants Programs” to clarify the processes and procedures for supplemental funding.
    • NCUIH also suggests that OUIHP develop one-pagers associated with each round of funding and its allowability for UIOs to utilize as they create Scopes of Work and update their contracts.
    • For future health emergencies, NCUIH recommends that IHS establish a plan to communicate funding changes to UIOs through webinars and resources to avoid dissemination of conflicting information.
  • Include an appeals process for UIO Annual Reviews
    • NCUIH recommends that IHS include an Appeals Process for UIOs in Section 3-19.3 (F) “Program Evaluation and Review” to give UIOs recourse for program evaluations, opportunities to report UIO noncompliance or satisfactory performance, and a platform to voice their concerns.
  • Clarify and update reporting requirements
    • NCUIH requests that Section 3-19.5 “Reports” be modified to further clarify what requirements are needed for UIOs to report.
  • Provide general assistance to other federal agencies
    • As NCUIH works with other federal agencies to encourage them to implement Urban Confer mechanisms, we request that IHS similarly support these efforts to the maximum extent practicable.

In addition to the preceding recommendations regarding the current Policy, NCUIH also requested that IHS develop additional sections, including:

  • Health Information Technology (HIT) Systems
    • NCUIH requests the updated Policy also include a section on Health Information Technology (HIT) systems and the IHS modernization process.
  • Data Collection
    • UIOs have noted that the current Policy does not address data collection and request that this be included as a stand-alone section. Additionally, NCUIH asks that any section on data clearly outline how IHS will use the data and if there would be additional reporting requirements from UIOs.
  • Use of Federal Government Facilities and Sources of Supply
    • The Policy should clarify how provisions related to utilization and acquisition of government facilities are carried out, the proper process for UIOs to request these resources, and IHS’ role in transferring any requested property.

NCUIH will continue to closely follow updates to the Policy and assess program performance to evaluate whether urban Indian community needs are met.

Challenge to Indian Child Welfare Act Advances at Supreme Court

The Supreme Court is preparing to hear a constitutional challenge to the Indian Child Welfare Act (ICWA) that consolidates four petitions to review the Fifth Circuit’s April 2021 en banc decision in Brackeen v. Haaland. In this decision, the United States Court of Appeals for the Fifth Circuit upheld the overall constitutionality of ICWA. However, it overturned certain ICWA processes and provisions that concern placement preferences of Native children in Indian homes. On May 26, 2022, the Court received amicus briefs from supporters of the ICWA challengers. The challengers and their amici argue that ICWA violates several constitutional provisions including equal protection, anticommandeering, and nondelegation. The next round of amicus briefs in support of ICWA and Tribal intervenors are due by August 12, 2022, and oral arguments are expected to begin after the Supreme Court term starts in October.


ICWA represents the gold standard in child welfare proceedings, strengthening and preserving American Indian and Alaska Native (AI/AN) family structure and culture. When it was established in 1978, studies showed that between 25% and 35% of all Native children were removed from their homes by state child welfare and private adoption agencies. Of those, 85% were placed with non-Native families, even when fit and willing relatives were available. ICWA re-established tribal authority to safeguard against such practices by requiring that Native children be placed with extended family members, other tribal members, or other Native families prior to placement in non-Indian homes.

Today, Native children continue to be overrepresented in state foster care systems at a rate 2.7 times higher than their non-Native peers. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly has an impact in urban AI/AN communities. According to the Indian Health Service (IHS), Native youth living off-reservation often face a higher risk of health problems, including mental health and substance abuse, suicide, gang activity, teen pregnancy, abuse, and neglect. Additionally, IHS found that urban Indian populations experience the same health problems as the general Indian population, but these problems are exacerbated by a lack of access to family and traditional cultural environments.  Challenges to ICWA threaten to place urban Native youth at even greater risk if they enter foster or adoption systems that do not offer protections to keep them from being further removed from their communities and culture.

NCUIH previously provided an in-depth analysis on the impact of ICWA. We will continue to monitor ongoing developments as Brackeen v. Haaland proceeds to oral argument, and to provide updates on how the case impacts urban Indian communities.

House Appropriations Committee Approves Labor-HHS Bill with Funding Increases for Indian Country

On June 30, 2022, the House Appropriations Committee approved its fiscal year (FY) 2023 Labor, Health and Human Services, Education, and Related Agencies funding bill by a 32-24 vote. The bill authorizes $124.2 billion for the Department of Health and Human Services (HHS)— an increase of $15.6 billion above the FY 2022 enacted level and $298 million below the President’s budget request. Other key provisions include a set-aside at the same FY 2022 funding levels of $15.6 million for IHS facilities/Tribally-Operated Health Programs/Urban Indian Health Programs under the National Health Service Corps (NHSC) Loan Repayment Program, increased funding for the Good Health and Wellness in Indian Country (GHWIC) program, increased funding for the Native Connections grant for behavioral health, and increased American Indian/Alaska Native (AI/AN) set-aside funding for Zero Suicide grants. A more detailed analysis follows below.

Despite advocacy by the National Council of Urban Indian Health and Congressional support, urban Indian organizations (UIOs) were not included in the Substance Abuse and Mental Health Services Administration (SAMHSA) State Opioid Response (SOR) grant, which is increased by $250 million above the FY 2022 enacted level in the Committee’s funding bill for FY 2023. The tribal set-aside for this grant was increased by $15 million above the FY 2022 enacted level. The opioid epidemic impacts all AI/ANs regardless of residence and NCUIH will continue to advocate for UIO inclusion in these critical opioid grants.

Bill Highlights

Centers for Disease Control and Prevention (CDC)

  • Bill Report: “The Committee recommendation for the Centers for Disease Control and Prevention (CDC) program level includes $9,540,696,000 in discretionary budget authority, $55,358,000 in mandatory funds under the terms of the Energy Employees Occupational Illness Compensation Program Act, and $903,300,000 in transfers from the Prevention and Public Health (PPH) Fund.” The bill funds the CDC at $10.5 billion, an increase of $2 billion above the FY 2022 enacted level and $231 million below the President’s budget request.
  • Bill Report: “The Committee’s recommended level includes an increase of $4,000,000 for Good Health and Wellness in Indian Country.”

National Institute of Health (NIH)

  • Bill Report: “The Committee recommendation for the National Institutes of Health (NIH) program level includes $46,038,300,000 in discretionary appropriations and $1,420,700,000 in Public Health Service Act (PHS Act) section 241 evaluation set-aside transfers.” The bill provides a total of $47.5 billion for NIH, an increase of $2.5 billion above the FY 2022 enacted level.
Improve Native American Cancer Outcomes
  • Bill Report: “The Committee continues to be concerned that Native Americans experience overall cancer incidence and mortality rates that are strikingly higher than non-Native populations and encourages NCI to expand research efforts to reduce American Indian cancer disparities and improve outcomes. The Committee notes NCI’s successful efforts through the Cancer Moonshot’s Accelerating Colorectal Cancer Screening and Follow-Up through Implementation Science (ACCSIS) program, and parallel efforts by NCI Designated Cancer Centers collaborating with American Indian communities, that are improving colorectal cancer screening, follow-up, and referral for care among populations that have low colorectal cancer screening rates. The Committee encourages NCI to continue efforts such as the ACCSIS initiative to develop durable capacity for tribally-engaged cancer disparities research through an integrated program of research, education, outreach, and clinical access.”


  • Bill Report: “The Committee recommendation for the Substance Use And Mental Health Services Administration (SAMHSA) program level includes $9,024,713,000 in discretionary budget authority, $133,667,000 in Public Health Service (PHS) Act section 241 evaluation set-aside transfers, and $12,000,000 in transfers from the Prevention and Public Health Fund (PPHF).” The bill funds SAMHSA at $9.2 billion – an increase of $2.6 billion above the FY 2022 enacted level.
State Opioid Response Grants:
  • Bill Report: “The Committee includes $1,775,000,000 for State Opioid Response (SOR) grants, an increase of $250,000,000. The Committee further directs SAMHSA to ensure that these resources continue to be managed by State alcohol and drug agencies defined as the agency that manages the Substance Use Prevention and Treatment Block Grant under part B of title X of the PHS Act. This approach will ensure continuity of funding, effective coordination of efforts, and decrease fragmentation within each State system. The Committee supports efforts from SAMHSA through SOR grants to expand access to SUD treatments in rural and underserved communities, including through funding and technical assistance. The Committee encourages SAMHSA to continue to focus on expanding access to evidence-based MOUD in counties that lack providers who are actively dispensing or prescribing MOUD.” The bill provides $1.8 billion for State Opioid Response Grants, an increase of $250 million above the FY 2022 enacted level, and $65 million for Tribes, an increase of $15 million above the FY 2022 enacted level.
    • Does not apply to UIOs
Zero Suicide Grants
  • Bill Report: “The Committee includes an increase of $5,000,000 for the implementation of the National Strategy for Suicide Prevention, including raising suicide awareness, establishing emergency room referral processes, and improving clinical care practice standards. In addition, funding will further support the Zero Suicide model, a comprehensive, multi-setting approach to suicide prevention in health care systems. The Committee also includes an increase of $1,000,000 for the American Indian/Alaska Native (AI/AN) Suicide Prevention Initiative.” The bill funds the Zero Suicide AI/AN set-aside at $3.4 million.
Medication Assisted Treatment
  • Bill Report: “The Committee includes an increase of $35,500,000 for Medication Assisted Treatment (MAT) for Prescription Drug and Opioid Addiction; an increase of $4,500,000, for grants to Indian Tribes, tribal organizations, or consortia; and an increase of $224,000 for general Targeted Capacity Expansion activities.”
Tribal Behavioral Grants (Native Connections)
  • Bill Report: “The Committee includes an increase of $4,250,000 to expand efforts to address the high incidence of substance misuse and suicide among AI/AN populations.” The bill provides a total of $25 million for Native Connection grants.

Health Resources and Services Administration (HRSA)

  • Bill report: “The Committee recommendation for HRSA includes $9,295,951,000 in discretionary budget authority, $256,370,000 in mandatory funding and $15,200,000 in trust fund appropriations for the Vaccine Injury Compensation Program Trust Fund, and $7,000,000 for the Countermeasures Injury Compensation Program.” The bill includes $9.6 billion for HRSA, an increase of $683 million above the FY 2022 enacted level and $792 million above the President’s budget request.
Health Centers Program
  • Bill Report: “The Committee recommends $1,945,772,000 for the Health Centers program, $198,000,000 above the fiscal year 2022 enacted level and $107,750,000 above the fiscal year 2023 budget request. Health Centers deliver affordable, accessible, quality, and cost-effective primary health care to millions of people across the country regardless of their ability to pay. Programs supported by this funding include community health centers, migrant health centers, health care for the homeless, and public housing health service grants.”
  • Bill Report: “The Committee includes $155,600,000, an increase of $34,000,000 above the fiscal year 2022 enacted level, for NHSC to support competitive awards to health care providers dedicated to working in underserved communities in urban, rural, and tribal areas. Within this total, the Committee includes an increase of $10,000,000 for loan repayment for mental and behavioral health providers, including peer support specialists, that serve in crisis centers, as described in the fiscal year 2023 budget request. The Committee also includes $15,600,000, the same as the fiscal year 2022 enacted level, within the total to support NHSC awards to participating individuals that provide health services in IHS facilities, Tribally-Operated Health Programs, and Urban Indian Health Programs.”

Resource: America’s Disproportionate Investment in Healthcare for American Indians and Alaska Natives

The National Council of Urban Indian Health recently published a one-pager showcasing the disproportionate gaps in national healthcare investment for American Indians and Alaska Natives (AI/ANs). The Indian Health Service (IHS) and Urban Indian Health budgets have long been underfunded. In the agency’s Fiscal Year (FY) 2023 Performance Budget Submission to Congress, IHS highlighted these disparities, noting that the “Indian health system is chronically underfunded compared to other healthcare systems in the U.S.” NCUIH’s analysis of FY 2018 appropriations shows that the US spends $11,172 in healthcare costs per person. In contrast, Tribal and IHS facilities receive $4,078 per IHS eligible patient, while Urban Indian Organizations (UIOs), which support the over 70% of AI/ANs living off-reservation, receive just $672 per AI/AN patient from the IHS budget. NCUIH data further shows that the gap between tribal budgetary needs submitted via requests to Congress and eventual appropriations has continued to skyrocket over recent years, thereby increasing discrepancies in per-person healthcare spending at UIOs.

Link to resource.

Chart showing America’s Disproportionate Investment in Healthcare for American Indians and Alaska Natives