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.