NCUIH Resource: Tribal Nations Summit Briefing Book on Urban Indian Health Issues

On Novemeber 29, 2022, the National Council of Urban Indian Health (NCUIH) collaborated on the White House Tribal Nations Summit Briefing held by the National Indian Health Board (NIHB) and National Congress of American Indians (NCAI) for Indian Country leaders to prepare for the upcoming White House Tribal Nations Summit. As the organization that advocates for the health and well-being of urban Native Americans, NCUIH prepared a resource that highlights key priorities for urban Indian organizations (UIOs).

One of the main priorities for NCUIH is tribal sovereignty. The organization stands in strong support of consultation and the nation-to-nation relationships between Tribes and the United States government. NCUIH also supports the work of the Tribal Budget Formulation Workgroup, which crafts a budget request for Congress and the Administration each year. NCUIH also advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act. This policy states that it is the responsibility of the US government to ensure the highest possible health status for Indians and urban Indians and to provide the necessary resources to do so.

UIOs and urban Indians face unique challenges when it comes to access to healthcare. There are 41 UIOs that serve Indian Health Service beneficiaries at over 90 locations, but these organizations receive significantly less funding per patient than other healthcare facilities. On average, the health care spending in the US is $11,172 per person, while tribal and Indian Health Service (IHS) facilities receive only $4,078 per patient from the IHS budget. UIOs receive even less, at just $672 per patient.

Despite these challenges, UIOs serve a significant portion of the Native American population. Over 95% of UIO patients are tribal citizens, and over 70% of Native Americans do not live on federally recognized tribal land. NCUIH is advocating for 100% Federal Medical Assistance Percentage for UIOs to help address these disparities in healthcare access.

NCUIH is also advocating for advance appropriations for IHS— a top priority across Indian Country. The Indian healthcare system, including IHS, Tribal facilities, and UIOs, is the only major federal healthcare provider funded through annual appropriations and is not protected from government shutdowns and continuing resolutions. This policy is needed to save Native lives, as lapses in federal funding puts lives at risk. During the 2019 government shutdown, several UIOs had to reduce services or close their doors entirely, forcing them to leave their patients without adequate care which unfortunately led to fatalities. Advance appropriations is critical to provide certainty to the IHS system and ensure unrelated budget disagreements do not risk lives.

The Full Resource:

Urban Indian Health Issues
White House Tribal Nations Summit Briefing Book

National Council of Urban Indian Health (NCUIH)

  • Tribal sovereignty is a top priority for the National Council of Urban Indian Health (NCUIH). We know all too well that the promises made to American Indians and Alaska Natives are often broken. NCUIH stands in strong support of Consultation and the Nation-to-Nation relationships of Tribes and the United States government.
  • NCUIH strongly supports the work of the Tribal Budget Formulation Workgroup to craft a budget request for Congress and the Administration each year. NCUIH follows the guidance and requests of the Workgroup in its recommendations to Congress.
  • NCUIH advocates for the US government to uphold the Declaration of National Indian Health Policy in the Indian Health Care Improvement Act: “Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians—  to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”

Urban Indian Organizations and Urban Indians

  • 41 Urban Indian Organizations serve IHS beneficiaries at over 90 locations
  • The average health care spending in the United States is $11,172 per person, however, Tribal and Indian Health Service (IHS) facilities receive only $4,078 per American Indian/Alaska Native (AI/AN) patient from the IHS budget. Urban Indian Organizations (UIOs) receive just $672 per AI/AN patient from the IHS budget.
  • 95% of Urban Indian Organization patients are Tribal citizens
  • Over 70% of AI/AN citizens do not reside on Federally Recognized Tribal Land.

100% Federal Medical Assistance Percentage for Urban Indian Organizations

Background of 100% Federal Medical Assistance Percentage (FMAP) for UIOs:
  • FMAP is the percentage of Medicaid costs covered by the federal government, through reimbursement to state Medicaid programs. As a baseline, FMAP cannot be less than 50% of the cost of services provided.
  • In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) amended section 1905(b) of the Social Security Act to set the FMAP at 100% for Medicaid services “received through an Indian Health Service (IHS) facility whether operated by the Indian Health Service or by an Indian tribe or tribal organization.”
  • Congress authorized 100% FMAP for IHS facilities so that Medicaid payments could supplement the chronically underfunded IHS annual appropriation and provide IHS with additional financial resources to better fulfill the federal government’s trust responsibility to provide safe and quality healthcare to American Indians/Alaska Natives (AI/ANs).
  • Despite being an integral part of the Indian healthcare system, UIOs were overlooked in the original legislation authorizing 100% FMAP for IHS and Tribal healthcare providers. As a result, the federal government is not paying its fair share for Medicaid-IHS beneficiaries and is skirting the trust responsibility.
What is the issue?
  • In March 2021, Congress authorized 8 fiscal quarters of 100% FMAP coverage for Medicaid services at UIOs for IHS beneficiaries through the American Rescue Plan Act of 2021 (ARPA).
  • Since 2021, the federal government has been covering 100% match for IHS-Medicaid beneficiaries but starting on March, States will have to go back to paying for a portion of services received from IHS-Medicaid beneficiaries at UIOs.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
How Tribes Can Support
  • Create a resolution supporting permanent 100% FMAP for UIOs.
  • Support 100% FMAP in Fiscal Year 2023 Omnibus bill.
  • Contact your Members of Congress before it expires in 4 months to support an extension to the provision in the end-of-year Omnibus.
  • If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org
What Needs to be Done Now?
  • Tell the Administration that the federal government must fulfill its trust responsibility for all IHS beneficiaries by making 100% FMAP permanent.
  • The 100% FMAP provision for UIOs is going to expire in four months and the federal government will no longer be honoring its trust responsibility to IHS-Medicaid beneficiaries who receive care at urban Indian organizations.
  • Congress needs to hear from Tribes that 100% FMAP provision for UIOs needs to be permanently authorized or at least extended to provide adequate care for tribal citizens living in urban areas.
What Tribes Can do to Support

If your Tribe is interested in supporting 100% FMAP for UIOs, please contact policy@ncuih.org

Tribal Support
     Create a resolution supporting permanent 100% FMAP for UIOs.
Congressional Advocacy
     Support 100% FMAP in the Fiscal Year 2023 Omnibus bill.

  • Contact your Members of Congress before it expires in 4 months to support an extension to the ARPA provision in the end-of-year Omnibus.

Tribe and Tribal Organization Support for 100% FMAP for UIOs

Advance Appropriations

Advocacy
  • On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs, Tom Udall, in support of IHS advance appropriations legislation.
  • On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the Fiscal Year (FY) 2022 omnibus.
  • On June 16, 2022, NIHB and NCAI requested that the Committee support and include IHS advance appropriations in the current FY 2023 appropriations bill in an action alert.
  • On June 24, NCUIH issued a call to action to reach out to Speaker Pelosi for House support of advance appropriations.
  • On June 24 and July 1, 2022, NCUIH sent a letters to Speaker Pelosi and House Minority Leader McCarthy to support advance appropriations for IHS.
  • On June 29, 2022, NCUIH sent letters to the Senate Interior Appropriations Committee and the Senate Committee on Indian Affairs to support advance appropriations for IHS.
  • On June 30 and July 1, 2022, NCUIH sent letters to Senate Majority Leader Schumer and Senate Minority Leader McConnell to support advance appropriations for IHS.
  • On August 19, NCUIH issued a second call to action to reach out to Speaker Nancy Pelosi for House support of advance appropriations.
  • On August 22, 2022, NCUIH launched a website with educational resources on advance appropriations.
  • On October 26, 2022 NCUIH launched an advance appropriations social media campaign and toolkit with the hashtag #AdvanceIndianHealtht.
  • On October 28, 2022, NCUIH released an advance appropriations advocacy toolkit.
  • In November 2022, NCUIH signed-on to NIHB’s intertribal and inter-organization Congressional and White House letters requesting advance appropriations for the FY 2023.
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Urban Indian Leader, Walter Murillo, Speaks at White House Conference on Hunger, Nutrition, and Health

On September 28, 2022, Walter Murillo, CEO of NATIVE Health and President-Elect of the National Council of Urban Indian Health (NCUIH), headlined a panel titled “Breaking Barriers: Bridging the Gap Between Nutrition and Health” at the White House Conference on Hunger, Nutrition, and Health. Mr. Murillo highlighted high rates of food insecurity in Indian Country, which intersects with other social determinants of health such as limited housing, employment, and lack of trust in health care systems in Native communities. In the Phoenix area, NATIVE Health has engaged with partners to create community gardens, teach traditional seeding and recipes, and deliver food boxes to elders during the height of COVID to support access to healthy and nutritious meals for urban American Indians/Alaska Natives (AI/ANs).

Video of the panel: https://www.youtube.com/watch?v=U1_iLHCOAeY

Background

UIOs provide essential access to nutrition, food, and health resources for the more than 70 percent of AI/ANs living off-reservation. AI/AN people experience the highest rates of diabetes across all racial and ethnic groups (14.5 percent), compared to 7.4 percent of non-Hispanic Whites. According to a 2017 report published in the Journal of Hunger & Environmental Nutrition, “[u]rban AI/ANs were more likely to experience food insecurity than rural AI/ANs.” Moreover, diabetes and heart disease are among the top five leading causes of death for AI/AN people who live in urban areas. Additionally, urban AI/AN people are more than three times more likely to die from diabetes than their White peers and have higher death rates attributable to heart disease than urban White people.

It’s been more than 50 years since the first and only White House Conference on Food, Nutrition, and Health was held in 1969. At the Conference, the Administration announced a National Strategy that identifies steps the government will take and catalyzes the public and private sectors to address the intersections between food, hunger, nutrition, and health. The Administration sought input on the development and implementation of this national strategy and initiated Tribal Consultation on June 28, 2022.  On July 15, 2022, NCUIH submitted comments to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) and recommended that they support urban Indian organizations (UIOs) to promote food security, nutrition, and exercise; include urban AI/AN populations in future research efforts and government projects; and establish consistent Urban Confers regarding nutrition, hunger, and health.

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DAY OF ACTION: Save Native Lives – Show Your Support on November 30!

Contact Congress  Access the Social Media Toolkit  NCUIH Advance Appropriations Website  Advance Appropriations One-Pager

The National Council of Urban Indian Health is hosting a Day of Action in support of Native communities on November 30.

  • Who: National Council of Urban Indian Health and all supporters of stable funding for the Indian Health Service (IHS)
  • What: Day of Action on Social Media
  • When: November 30, 2022 – Native American Heritage Month is quickly drawing to a close and it’s time for the United States government to truly honor Native communities by stabilizing health care funding and ending the budget delays that hinder health services. The White House is also hosting an in-person Tribal Nations Summit on November 30 and December 1. Meanwhile, Congress is hard at work finalizing the end of year legislation and this is a top priority that Native communities have requested for inclusion to help Native communities.
  • Where: Online and on Capitol Hill
  • Why: During the last government shutdown, 5 Indian Health Service patients died as health clinics dealt with the lapse of funding. IHS is the only major federal provider of health care solely funded through regular annual appropriations. IHS is the only major federal provider of health care vulnerable to government shutdowns and temporary, “stopgap” budgets. Congress can change this by providing a FY2024 level-funded advance appropriation for most of the IHS.
  • How: You can get involved by using our social media toolkit and sending letters to Congress to support stable funding for the Indian Health Service this year.
  • Social Media Toolkit

Watch and Share the Explainer Video

DAY OF ACTION PLAN

POST ON SOCIAL MEDIA – Share you support for stable funding for IHS with your followers!

WHEN: Tuesday, November 30, 2022, beginning at 9 am EST.

HOW: Use these graphics and our toolkit to post on social media and call on your Member of Congress to take action!

Access the Social Media Toolkit

  Advance Indian Health

Advance Appropriations

EMAIL YOUR MEMBER OF CONGRESS

STEPS TO CONTACT CONGRESS

  • Step 1: Copy the email below.
  • Step 2: Find your Representative here and your Senator here.
  • Step 3: Paste the email into the form on your Member of Congress’ contact page and send. Please contact Meredith Raimondi (policy@ncuih.org) with questions.

Email to Your Representative and Senators

Dear [Member of Congress],

As an Indian health advocate, I respectfully request you ensure the inclusion of advance appropriations for the Indian Health Service (IHS) in the upcoming Fiscal Year (FY) 2023 final spending package until mandatory funding for the agency can be achieved.

The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations. If IHS were to receive advance appropriations, it would not be subject to government shutdowns, automatic sequestration cuts, and continuing resolutions as its funding for the next year would already be in place. We need this to protect Native lives!

I respectfully ask that you honor the federal trust obligation to American Indians and Alaska Natives by ensuring advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership and your commitment to upholding the United States trust responsibility.

Sincerely,
[contact information]

Background

The National Council of Urban Indian Health is advocating tirelessly to Congress to ensure advance appropriations for the Indian Health Service (IHS).

We need your help contacting Congress and posting on social media to support securing advance appropriations and mandatory funding for IHS. The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal health care provider funded through annual appropriations.

If IHS were to receive advance appropriations, it would ensure continuity of care for American Indians and Alaska Natives and complement President Biden’s budget request to honor commitments to Tribal nations and communities. In fact, Native communities have experienced deaths due to government shutdowns in the past and according to a recent study, Native Americans experienced the biggest drop in life expectancy— decreasing by 6.6 years between 2019-2021. The lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

We urge you to post your support for advance appropriations on social media. We also urge you to contact your Member of Congress and request that they support including advance appropriations for IHS in the Fiscal Year (FY) 2023 final spending package. You can use the toolkit below for your advocacy and the text below as a template to call and/or email your Members of Congress.

Thank you for your leadership. Your outreach on this is invaluable to providing greater access to health care for all American Indians and Alaska Natives.

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NCUIH Statement on Letter from IHS on Protecting Native Patients From Funding Delays and Government Shutdowns

FOR IMMEDIATE RELEASE

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

WASHINGTON, D.C. (November 16, 2022) – The National Council of Urban Indian Health (NCUIH) received a letter from the Indian Health Service (IHS) in response to a request to allow urban Indian organizations (UIOs) to receive an exception apportionment, which would protect them from a government shutdown by providing the full-year base funding amounts.

Today, NCUIH Chief Executive Officer, Francys Crevier (Algonquin), released the following statement in response to the IHS letter:

 “During the last government shutdown in 2019, five patients died. These are five relatives— mothers, fathers, grandparents— who are no longer part of our community and unable to pass on our cultural traditions that they hold, all because of federal budget disputes. It is atrocious and tragic that the government expects Indian health providers to continue providing services to the most vulnerable population in the country without an enacted budget. Congress regularly fails to reach a budget agreement in time year after year, and Native people are the ones that suffer. Budget delays hinder healthcare delivery and it’s unacceptable. To truly honor its commitment to Native people, the government must act to end budget delays that cost lives. Indian Country has tirelessly advocated for secure funding through advance appropriations for IHS, which is the only major federal healthcare provider funded through annual appropriations. The federal government continues to prove that the safety of Native lives is not a concern, as the government fails to fund IHS in a timely manner and does not provide exception apportionment to the programs that carry out healthcare services to the over 70% Native population living in urban areas.”

Background

IHS has only once, in 2006, received full-year appropriations by the start of the fiscal year. In the absence of an exception apportionment during these budget disputes that may cause the government to shut down, UIOs are subject to the shut down too. Federal shutdowns require UIOs to lay off staff, reduce hours and services, and even close their doors, ultimately leaving their patients without adequate health care.

IHS received an exception apportionment to provide the full-year Secretarial Amount to Tribal Health Programs with Indian Self-Determination and Education Assistance Act contracts and compacts, but this exception does not apply to IHS-operated health programs or UIOs. IHS states, “IHS-operated health programs continue to provide services in the absence of appropriations, even if the health programs are unable to pay health care professionals and related staff, pay invoices for referred care, and purchase supplies and medicines.”

Take Action

NCUIH has been working with our partners to #AdvanceIndianHealth and has more information on how to get involved here: https://ncuih.org/advance/. We will continue to push for including advance appropriations for IHS in the final Fiscal Year 2023 spending bill to provide funding certainty to the Indian healthcare system.

Full Text of IHS Letter

Dear Ms. Crevier:

I am responding to your September 23, 2022, letter, regarding an exception apportionment for Urban Indian Organizations (UIOs). The Indian Health Service (IHS) is committed to hearing concerns about the effect of the Fiscal Year (FY) 2023 Continuing Resolution on UIOs.

Urban Indian Organizations are a critical component of the Indian health care system. The Indian Health Service’s top priority is to avoid disruptions in operations and to lift the unnecessary administrative burden that comes with Continuing Resolutions (CRs), sequestration, and government shutdowns for the entire Indian health system, including UIOs.

In your letter, you highlight actions that the current and prior Administrations implemented to limit budgetary uncertainty and ensure continuity of operations for IHS and Tribal Health Programs during government shutdowns. You also request that the IHS seek an exception apportionment under the “safety of human life” justification to provide UIOs with funding above the pro-rata amount appropriated under a CR.

An exception apportionment describes a type of account-specific apportionment that can be issued for operations under a CR in lieu of the Office of Management and Budget (OMB) issued automatic apportionment, which provides the pro-rata funding level available under a CR. Exception apportionments must be requested and approved by OMB each year. The IHS has received an exception apportionment for a portion of its funding since FY 2020.

The exception apportionment allows the IHS to provide the full year Secretarial Amount to Tribal Health Programs with Indian Self-Determination and Education Assistance Act (ISDEAA) contracts and compacts with performance periods that start under the period of a given CR, as opposed to the pro-rata funding amount that is otherwise available under a CR. The exception apportionment does not apply to IHS-operated health programs or UIOs. It is important to note that the IHS exception apportionment does not fall under the “safety of human life” exception for apportionments.

The OMB Circular No. A-11: Preparation, Submission, and Execution of the Budget, the basis for a Safety of Human Life and Protection of Federal Property (“life and safety”) establishes that exception apportionments may be granted in extraordinary circumstances where the safety of human life or protection of Federal property is a concern during a government-wide lapse of appropriations.

Instead, the IHS exception apportionment authority is rooted in the unique nature of ISDEAA funding agreements, and the timing of such funding agreements. This is why the exception apportionment only applies to Tribal Health Programs whose ISDEAA agreements have a performance period that begins during the period of the CR. Urban Indian Organizations receive their funding through Federal Acquisition Regulation (FAR) contracts, consistent with Title V of the Indian Health Care Improvement Act, and therefore are not eligible for funding above the pro-rata amount available during a CR under this exception apportionment authority.

Your letter references “excepted programs” under the Antideficiency Act (ADA) during the 2018 – 2019 government shutdown. Indian Health Service operated health care programs are “excepted” during a government shutdown, which means that IHS-operated health programs must continue to provide direct health care services in the absence of an appropriation. The exception under a government shutdown does not provide additional funding during the period of a government shutdown. This exception only applies to Federal functions, and does not apply to Tribal Health Programs. Under this exception, IHS-operated health programs continue to provide services in the absence of appropriations, even if the health programs are unable to pay health care professionals and related staff, pay invoices for referred care, and purchase supplies and medicines.

The criteria for safety of human life excepted programs under a government shutdown is not always the same as the criteria for receiving a safety of human life exception apportionment. Programs that are excepted for safety of human life reasons under a government shutdown generally do not receive exception apportionments. For example, although IHS-operated health programs are excepted during a government shutdown and must continue providing direct health care services in the absence of appropriations, IHS-operated health programs do not receive an exception apportionment. The safety of human life exception for apportionment purposes is used in very narrow circumstances.

The exception apportionment authority provides a partial solution to the unpredictability of Federal appropriations for the IHS, and is likely the extent of what the Agency can achieve within existing authorities. While an exception apportionment does resolve some of the unpredictability in the IHS budget for some Tribal Health Programs, it is not a full solution to the challenges the IHS faces as a result of continuing resolutions. The exception apportionment also does nothing to prevent the negative consequences of government shutdowns for IHS-operated health programs and UIOs; it only prevents those consequences for Tribal Health Programs in some circumstances. The consequences of a government shutdown directly impact the ability of IHS-operated health programs, Tribal Health Programs, and UIOs to provide high quality health care to the American Indian and Alaska Native communities we serve.

The Biden Administration has taken the historic steps of requesting advance appropriations in FY 2022 and a fully mandatory budget in FY 2023 for the IHS to fundamentally change the way the Agency receives its appropriations and resolve the negative impacts of budget uncertainty. We sincerely appreciate your support as we work toward achieving these goals.

Thank you for your continued support on our shared mission to raise the health status of urban Indians to the highest possible level. If you have additional concerns, please directly contact Ms. Jillian Curtis, Chief Financial Officer, Office of Finance and Accounting, IHS, by telephone at (301) 443-0167, or by e-mail at jillian.curtis@ihs.gov.

Sincerely,
Roselyn Tso
Director

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Urban Indian Organizations Encouraged to Apply for Connecting Kids to Coverage Cooperative Agreement

On October 17, 2022, the Department of Health and Human Service’s Centers for Medicare & Medicaid Services (CMS) released a Notice of Funding Opportunity (NOFO) for the Connecting Kids to Coverage HEALTHY KIDS American Indian/Alaska Native (AI/AN) 2023 Outreach and Enrollment Cooperative Agreements (Healthy Kids 2023). The grant is a competitive grant open exclusively to Indian Health Service Providers, Indian Tribes, tribal consortiums, tribal organizations, and Urban Indian organizations (UIOs). The NOFO makes available up to an additional $6 million (pending availability of funds), with the estimated maximum award amount being $1 million for up to 7 awardees. The award will be issued April 1, 2023, and the period of performance will last from April 1, 2023-March 31, 2026.  An information session will be held on November 17 at 3:00 PM EST. UIOs are encouraged to apply by the deadline on December 20, 2022, at 3pm EST. For more details on the requirements for the application and the cooperative, see here.

About the Cooperative Agreement

The Healthy Kids 2023 program provides funding to reduce the number of AI/AN children who are eligible for but not enrolled in, Medicaid and the Children’s Health Insurance Program (CHIP), and to improve the retention of eligible children enrolled in these programs. Funding will support strategies aimed at:

  • Increasing the enrollment and retention of eligible AI/AN children, parents, and pregnant individuals in Medicaid and CHIP
  • Emphasizing activities tailored to communities where AI/AN children and families reside, and
  • Enlisting tribal and other community leaders and tribal health and social services programs that serve eligible AI/AN children and families

Suggested outreach strategies for grant recipients:

  • Partnering with tribal programs that work with children and families;
  • Engaging schools and other programs serving young people in outreach, enrollment, and retention activities;
  • Establishing and developing application assistance resources to provide high quality, reliable Medicaid/CHIP enrollment and renewal services in local and tribal communities;
  • Using social media to conduct virtual outreach and enrollment assistance; and
  • Using parent mentors and community health workers to assist families with enrolling in Medicaid and CHIP, retaining coverage and finding resources to address social determinants of health.

All awardees will be required to report the following data:

  • Number of AI/AN children for whom an application for health coverage has been submitted
  • Number of AI/AN children verified to be newly enrolled in Medicaid or CHIP
  • Number of AI/AN children denied new enrollment in Medicaid or CHIP
  • Number of AI/AN children for whom the recipient submitted a renewal form for Medicaid or CHIP coverage
  • Number of AI/AN children verified to be renewed in Medicaid or CHIP
  • Number of children denied renewal coverage in Medicaid or CHIP
  • The outreach and enrollment activities completed during the month

Background

The Healthy Kids Act provides $120 million for activities aimed at reducing the number of children who are eligible for, but not enrolled in, Medicaid and CHIP and improving retention of enrolled children. Of the total amount, 10% is reserved for outreach to AI/AN children. Since 2009, enrollment grants and cooperative agreements have been awarded to over 330 community-based organizations, states, and local governments, including 65 tribal organizations. Community-based organization awardees have included health programs operated by urban Indian organizations.

CMS is seeking to engage with Native communities to help overcome reluctance among some Native families to enroll in Medicaid and CHIP because they can receive care directly from the Indian healthcare system. AI/AN children consistently experience the highest uninsured rate of any racial/ethnic group, with uninsured rates that are more than double that of white children, and Medicaid and CHIP are therefore critical sources of coverage for Native children. In addition, the Indian healthcare system as a whole also benefits when eligible AI/AN patients enroll in Medicaid and CHIP. Indian Health Service, Tribal and Urban Indian Organization (I/T/U) facilities can bill Medicaid and CHIP for services provided to AI/AN Medicaid/CHIP beneficiaries, bringing in additional funds to the I/T/U facility to hire more staff, pay for new equipment, increase services, and renovate buildings.

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The Agency for Healthcare Research and Quality Requests Nominations from Populations Underrepresented in Medicine to Serve as Peer Reviewers

On September 21, 2022, the Agency for Healthcare Research and Quality (AHRQ) published a request for nominations. The public should nominate individuals from populations underrepresented in medicine to serve as members to the AHRQ Initial Review Group (IRG). The IRG is responsible for the scientific peer review of AHRQ grant applications and is comprised of study sections, each with a particular research focus. These AHRQ grants support health services research and training. Nominations are also welcomed from minority-serving institutions, academic health centers, community-based organizations, professional societies, or other state and federal agencies.

Interested individuals may nominate themselves, and organizations—including UIOs—and individuals may nominate one or more qualified persons for study section membership. Nominations should be received on or before December 31, 2022. Nominations should be submitted by email to dsr@ahrq.hhs.gov. All nominations must be submitted electronically, and should include:

  1. A copy of the nominee’s current curriculum vitae and contact information, including mailing address, phone number, and email address.
  2. Preferred study section assignment.

Background

The AHRQ is one of the twelve operating divisions of the United States Department of Health and Human Services (HHS). The purpose of the “AHRQ [is to] develop[] the knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare professionals, and policymakers make informed health decisions.” Consequently, the AHRQ focuses on investing in healthcare research, creating training materials, and generating measures/data. For the fiscal year of 2022, the AHRQ has an operating budget of $455.4 million.

Scope of the Initial Review Group

The AHRQ IRG conducts scientific and technical review for health services research and training grant applications. AHRQ is specifically encouraging the nomination of individuals from populations underrepresented in medicine to serve on the AHRQ IRG in order to foster a diversity of viewpoints among its members. The IRG is comprised of five subcommittees and nominations for each of the subcommittees should be based on the peer reviewer’s expertise.

  1. Health Care Effectiveness and Outcomes Research: End-stage renal disease; cardiovascular disease; pediatrics; pharmacologist in opioid management; biostatisticians in health services research; health disparities and social determinants of health.
  2. Healthcare Information Technology Research: Biomedical and consumer health informatics; family medicine; health care data analysis; health information technology; health services research in patient-oriented research; electronic health record and data for research; population-based studies in medicine; epidemiology; telehealth/telemedicine; emergency medicine; insurance benefit design; chronic condition care; natural language processing and machine learning; social networking and its determinants of health; health disparities and social determinants of health.
  3. Healthcare Systems and Value Research: Health statistics; health care outcome research; evaluation and survey methods; health system and service research; health care policy research; health economics research; large database analysis; private health insurance/Medicaid and Medicare; learning laboratory development; health disparities and social determinants of health.
  4. Healthcare Systems and Value Research: Health statistics; health care outcome research; evaluation and survey methods; health system and service research; health care policy research; health economics research; large database analysis; private health insurance/Medicaid and Medicare; learning laboratory development; health disparities and social determinants of health.
  5. Healthcare Safety and Quality Improvement Research: Pharmacists with expertise in informatics; infectious diseases specialists; geriatricians; surgeons with a specialty in diagnostic error; health disparities and social determinants of health.
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Native American Health Coalition Sends Letters to Congress Requesting Advance Appropriations for the Indian Health Service

On October 20, 2022, the American Indian/Alaska Native (AI/AN) Health Partners sent letters to House and Senate Interior, Environment, and Related Agencies Subcommittee leadership regarding the fiscal year (FY) 2023 appropriations. In those letters, AI/AN Health Partners urged that the Senate requested advance appropriations amount of $5.577 billion be included in the final FY 2023 IHS appropriation package, among other Indian health provisions.

Letter Highlights

The AI/AN Health Partners stated that since IHS has been chronically underfunded, it often does not have sufficient resources to accomplish its duty of raising the physical, mental, social, and spiritual health of all Native people to the highest standard.

They continue by explaining how the need for advance appropriations was highlighted in a Government Accountability Office (GAO) report from September 2018. In that report, IHS officials and Tribal representatives explained how budget uncertainty resulting from continuing resolutions (CRs) and government shutdowns has a variety of negative effects on the Indian Health system. This includes the lack of access to vital health resources, challenges recruiting and retaining employees (resulting in staffing shortages), and the inability to fund planned pay increases (such as cost-of-living adjustments).

The coalition also noted that the Senate bill provided for advance appropriations, whereas the House bill did not. The letters conclude by requesting the full inclusion of the Senate-provided funding for advance appropriations in the final FY 2023 appropriations package.

Full Letter Text

The full text of the AI/AN Health Partners letter to Senate appropriators can be found below:

Dear Chairman Merkley and Ranking Member Murkowski:

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for American Indians and Alaska Natives (AI/ANs).  AI/ANs face substantial health disparities, and higher mortality and morbidity rates than the general population. The Indian Health Service (IHS) is critical to how they access health care.  However, the IHS must have sufficient resources to meet its mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

A long-standing priority for our organizations has been to increase the professional workforces in facilities run by the IHS and tribal organizations.  As you work to finalize fiscal year 2023 appropriations for the IHS, we urge you to include several significant budget increases that we believe will dramatically improve the delivery of health care to AI/ANs.

The Health Professions account provides loan repayment, the Service’s best recruitment tool, for providers who work in Indian Country.  It also funds scholarships for Native American health care students.  Currently, the IHS lacks sufficient funding to meet its needs.  The Service has over 1,398 vacancies for health care professionals. In fiscal year 2021, a total of 1,658 health care professionals received loan repayment. However, the IHS had 341 requests for loan repayment that could not be fulfilled.  At the same time, the Service had over 500 new scholarship applicants but was only able to fund 255 new awards. For fiscal year 2023, we urge you to support the House Interior Appropriations bill amount of $93,568,000 for the Indian Health Professions account to help the IHS to close its vacancy gap.

Medical and diagnostic equipment

Health care professionals need modern equipment to make accurate clinical diagnoses and prescribe effective medical treatments.  The IHS and tribal health programs manage approximately 90,000 devices consisting of laboratory, medical imaging, patient monitoring, pharmacy, and other biomedical, diagnostic, and patient equipment.  However, many of these facilities are using outdated equipment like analog mammography machines.  In some cases, they are using equipment that is no longer manufactured.  Today’s medical devices/systems have an average life expectancy of approximately six to eight years.  The IHS calculates that to replace the equipment at the end of its six to eight-year life would require approximately $100 million per year.  We urge you to support the fiscal year 2023 House-approved amount of $118,511,000 for health care facilities equipment.

Staff Quarters

Decent staff housing is essential for the IHS and tribes to be able to recruit health care personnel.  Many of the 2,700 staff quarters across the IHS health delivery system are more than 40 years old and in need of major renovation or total replacement.  Additionally, in a number of locations the amount of housing units is insufficient.  Decent staff quarters, especially in remote areas, is essential for attracting and keeping health care providers in Indian Country.    In a March 23, 2021, hearing before the House Natural Resources Subcommittee for Indigenous Peoples of the United States, the Honorable Rodney Cawston, Chairman, Colville Business Council Confederated Tribes of the Colville Reservation Nespelem, WA spoke about how the lack of housing affected tribes’ ability to attract health care workers  “Included in the housing needs on a reservation to recruit working professionals, especially medical professionals to rural communities like Washington state it’s always difficult because we don’t always have the available housing for working professionals.”

For fiscal year 2023, the House Appropriations Committee set aside $40,000,000 in the Health Care Facilities line item specifically for staff quarters at existing facilities.   We strongly urge you to support this directive.   The Senate Interior Subcommittee included report language seeking a report on the situation, but that will delay needed funding for at least two years.

Electronic Health Record

Being able to have a modern electronic health record (EHR) system, is essential to enable the IHS and tribal health professionals to provide accurate and vital health care for patients.  The IHS uses its EHR for all aspects of patient care, including maintaining patient records, prescriptions, care referrals, and billing insurance providers that reimburse the Service for over $1 billion annually.  A new EHR system will allow the IHS and tribes to communicate with other entities that AI/AN patients seek care from like the Veterans Affairs, Department of Defense, and tribal and urban Indian health programs.  We urge you to support a fiscal year 2023 appropriation of $284,500,000 for an electronic health record system.   This is the same amount that the House approved, and the Administration requested.

Advanced appropriations

Our organizations were pleased that for fiscal year 2023, the Senate Interior Subcommittee provided $5,577,077,000 for advanced appropriations for the Indian Health Service.  The need for the advanced appropriations was addressed in a September 2018 GAO report, “INDIAN HEALTH SERVICE Considerations Related to Providing Advance Appropriation Authority.”  IHS officials, tribal representatives, and other stakeholders told the GAO how budget uncertainty resulting from continuing resolutions (CRs) and government shutdowns can have a variety of effects on the provision of IHS funded health care services for AI/ANs.    Regarding recruitment and retention of health care providers, GAO reported that IHS officials and tribal representatives said that funding uncertainties can exacerbate challenges to staffing health care facilities:

“…when recruiting health care providers, IHS officials said CRs and potential government shutdowns create doubt about the stability of employment at IHS amongst potential candidates, which may result in reduced numbers of candidates or withdrawals from candidates during the pre-employment process.  IHS officials said that many providers in rural and remote locations are the sole source of income for their families, and the potential for delays in pay resulting from a government shutdown can serve as a disincentive for employees considering public service in critical shortage areas that do not offer adequate spo

usal employment opportunities. Tribal representatives said CRs create challenges for tribes in funding planned pay increases— such as cost-of-living adjustments— for health care staff at their facilities, and they may, as a result, defer increases.”

The House Appropriations Committee did not include funding for advanced appropriations in its fiscal year 2023 bill for the Indian Health Service.  We urge you to maintain the Senate advanced appropriations amount of $5,577,077,000  in the final Fiscal year 2023 IHS appropriation.

Thank you for considering our requests.  We look forward to working with you to improve health care for American Indians and Alaska Natives.

About the AI/AN Health Partners

The AI/AN Health Partners is a coalition of health organizations dedicated to improving health care for AI/ANs. Members of this coalition, all of whom signed the letters to the House and Senate appropriators, include:

  • The Academy of Nutrition and Dietetics
  • The American Academy of Dermatology Association
  • The American Academy of Pediatrics
  • The American Association of Colleges of Nursing
  • The American Association of Colleges of Osteopathic Medicine
  • The American College of Obstetricians and Gynecologists
  • The American Dental Association
  • The American Dental Education Association
  • The American Psychological Association
  • The Association of American Medical Colleges
  • The Commissioned Officers Association of the USPHS
  • The National Kidney Foundation

Background and NCUIH Advocacy

AI/ANs face substantial health disparities compared to the general population. In the Fiscal Year (FY) 2023 Performance Budget Submission to Congress, the Indian Health Service (IHS) highlights these disparities, noting that the “Indian health system is chronically underfunded compared to other healthcare systems in the United States”.

The National Council of Urban Indian Health’s (NCUIH) analysis revealed 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. This low per-patient spending makes it difficult for UIOs to address growing patient needs.

NCUIH has been a staunch advocate for adequate funding of IHS, especially advance appropriations. NCUIH’s 2022 Policy Priorities includes securing advance appropriations as a top policy priority to improve AI/AN health and improve funding certainty for IHS. Advance appropriations has been a priority for Indian Country for years and has broad support from Native health advocates. Over the past 10 years, there have been six resolutions in support of advance appropriations from NCUIH, the United South and Eastern Tribes (USET), the Inter-Tribal Council of the Five Civilized Tribes (ITC), the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), and the American Bar Association.

On January 17, 2019, NCUIH sent a letter to the Vice Chairman of the Senate Committee on Indian Affairs (SCIA), Tom Udall, in support of IHS advance appropriations legislation. On March 9, 2022, NCUIH joined NIHB and over 70 Tribal nations and national Indian organizations in sending a series of joint letters to Congress requesting advance appropriations for IHS in the FY 2022 omnibus. NCUIH also sent letters to Speaker Pelosi, House Minority Leader McCarthy, Senate Majority Leader Schumer, Senate Minority Leader McConnell, the Senate Interior Appropriations Committee, and the Senate Committee on Indian Affairs in support advance appropriations for IHS. Most recently, NCUIH also passed a resolution on August 22, 2022 in support of advance appropriations.

NCUIH Additional Resources on Advance Appropriations

NCUIH has a variety of additional resources including:

Next Steps

NCUIH continues to advocate for the inclusion of advance appropriations for IHS in the final appropriations package. NCUIH will also provide updates on the status of advance appropriations in Congress during final negotiations.

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Congressional Support for Advance Appropriations for the Indian Health Service

The following is a list of Members of Congress who have ever expressed support for Advance Appropriations for IHS whether through a letter, cosponsorship, testimony, statement.[1]

Action Alert: Save Native Lives – Contact Congress Today to Take Action

Title Last Name First Name State District Party
Sen. Murkowski Lisa AK R
Rep. Peltola Mary AK At-large D
Rep. Sewell Terri AL 7 D
Rep. O’Halleran Tom AZ 1 D
Rep. Kirkpatrick Ann AZ 2 D
Rep. Grijalva Raul AZ 3 D
Rep. Schweikert David AZ 6 R
Rep. Gallego Ruben AZ 7 D
Rep. Stanton Greg AZ 9 D
Sen. Feinstein Dianne CA D
Sen. Padilla Alex CA D
Rep. LaMalfa Doug CA 1 R
Rep. Huffman Jared CA 2 D
Rep. Garamendi John CA 3 D
Rep. Roybal-Allard Lucille CA 4 D
Rep. Thompson Mike CA 5 D
Rep. Matsui Doris Matsui CA 6 D
Rep. Obernolte Jay CA 8 R
Rep. McNerney Jerry CA 9 D
Rep. Khanna Ro CA 17 D
Rep. Lofgren Zoe CA 19 D
Rep. Lieu Ted CA 22 D
Rep. Carbajal Salud CA 24 D
Rep. Chu Judy CA 27 D
Rep. Cardenas Tony CA 29 D
Rep./Dr. Ruiz Raul CA 36 D
Rep. Bass Karen CA 37 D
Rep. Calvert Ken CA 42 R
Rep. Barragan Nanette CA 44 D
Rep. Levin Mike CA 49 D
Rep. Vargas Juan CA 51 D
Rep. Jacobs Sara CA 53 D
Rep. DeGette Diana CO 1 D
Rep. Neguse Joe CO 2 D
Rep. Courtney Joe CT 2 D
Del. Holmes Norton Eleanor DC At-Large D
Rep. Soto Darren FL 9 D
Rep. Wasserman Shultz Debbie FL 23 D
Rep. Williams Nikema GA 5 D
Sen. Schatz Brian HI D
Rep. Kahele Kaiali’i HI 2 D
Rep. Axne Cindy IA 3 D
Rep. Simpson Mike ID 2 R
Rep. Garcia Jesus “Chuy” IL 4 D
Rep. Schakowsky Jan IL 9 D
Rep. LaTurner Jake KS 2 R
Rep. Davids Sharice KS 3 D
Sen. Warren Elizabeth MA D
Rep. Kennedy III Joe MA 4 D
Rep. Keating Bill MA 9 D
Sen. Van Hollen Chris MD D
Sen. Peters Gary MI D
Sen. Stabenow Debbie MI D
Rep. Kildee Dan T. MI 4 D
Rep. Moolenaar John MI 4 R
Rep. Stevens Haley MI 11 D
Rep. Dingell Debbie MI 12 D
Rep. Tlaib Rashida MI 13 D
Rep. Lawrence Brenda MI 14 D
Sen. Klobuchar Amy MN D
Sen. Smith Tina MN D
Rep. Craig Angie MN 2 D
Rep. McCollum Betty MN 4 D
Sen. Tester Jon MT D
Rep. Armstrong Kelly ND At-Large R
Rep. Bacon Don NE 2 R
Rep. Gottheimer Josh NJ 5 D
Rep. Pallone Jr. Frank NJ 6 D
Rep. Watson Coleman Bonnie NJ 12 D
Sen. Heinrich Martin NM D
Sen. Lujan Ben NM D
Rep. Stansbury Melanie Ann NM 1 D
Rep. Leger Fernandez Teresa NM 3 D
Sen. Cortez Masto Catherine NV D
Sen. Rosen Jacky NV D
Rep. Titus Dina NV 1 D
Rep. Horsford Steven NV 4 D
Rep. Stefanik Elise NY 21 R
Rep. Brown Shontel OH 11 D
Rep. Joyce David OH 14 R
Rep. Mullin Markwayne OK 2 R
Rep. Cole Tom OK 4 R
Rep. Bice Stephanie OK 5 R
Sen. Merkley Jeff OR D
Sen. Wyden Ron OR D
Rep. Blumenauer Earl OR 3 D
Rep. DeFazio Peter OR 4 D
Rep. Fitzpatrick Brian PA 1 R
Rep. Cartwright Matt PA 8 D
Rep. Johnson Dusty SD At-Large R
Rep. Cohen Steve TN 9 D
Rep. Garcia Sylvia TX 29 D
Rep. McEachin A. Donald VA 4 D
Sen. Sanders Bernard VT D
Sen. Cantwell Maria WA D
Rep. Larsen Rick WA 2 D
Rep. McMorris Rodgers Cathy WA 5 R
Rep. Kilmer Derek WA 6 D
Rep. Jayapal Pramila WA 7 D
Rep. Schrier Kim WA 8 D
Rep. Smith Adam WA 9 D
Rep. Strickland Marilyn WA 10 D
Sen. Baldwin Tammy WI D
Rep. Kind Ron WI 3 D
Rep. Moore Gwen WI 4 D
Rep. Gallagher Mike WI 8 R
Rep. Cheney Liz WY At-Large R

 

[1] NCUIH Research as of November 7, 2022. Available here: https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:ff22249f-2dfa-3ef5-8184-99a628541d3b

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NCUIH Presents at DePaul Law School’s Diversity Week to Discuss Challenges to the Indian Child Welfare Act

On November 2, 2022, the National Council of Urban Indian Health’s (NCUIH) Federal Relations Manager, Alexandra Payan, presented at Chicago’s DePaul Law School Student Bar Association’s Diversity Week to discuss the Indian Child Welfare Act (ICWA) and the upcoming Supreme Court case, Haaland v. Brackeen. Alexandra presented alongside Ryann Unabia (Turtle Mountain Band of Chippewa), an Indian Child Welfare Specialist at the Illinois Department of Children and Family Services. In her presentation, Alexandra highlighted the critical importance of ICWA in preserving Tribal Sovereignty, Tribal Identity, and improving the overall health of American Indian/Alaska Native (AI/AN) children. She also provided an analysis of Haaland v. Brackeen and the possible implications if the Supreme Court were to hold ICWA unconstitutional. Oral arguments at the Supreme Court are scheduled for November 9, 2022. NCUIH has and will continue to voice support for ICWA.

Background and Advocacy

ICWA and its Importance to AI/ANs

ICWA represents the gold standard in child welfare proceedings, strengthening and preserving 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 ensures that the previously forced removal of AI/AN children from their homes and their placement into white families will not be repeated.

Today, Native children continue to be overrepresented in state foster care systems at a rate 2.7 times higher than their non-Native peers. This means that while AI/AN children represent 0.9% of all children in the United States, they are 2.1% of all children who are placed in foster care. Because more than 70% of AI/AN people live in urban settings, this overrepresentation undoubtedly includes AI/AN children living in urban areas. 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. NCUIH is hosting a Supreme Court Listening Event for the oral argument on November 9, 2022 to support the National Indigenous Women’s Resource Center’s (NIWRC) event gathering in front of the Supreme Court in support of ICWA.

Legal Proceedings and Opposition to ICWA

In Brackeen, the states of Texas, Indiana, Louisiana, and individual plaintiffs sued the federal government, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment. The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the Administrative Procedures Act (APA).

The initial 2018 ruling by Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas, held that ICWA (including its implementing regulations) is unconstitutional, and the regulations violate the APA. Specifically, Judge O’Connor held that ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  Judge O’Connor further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving tribes the authority to change adoption placement preferences and make states abide by them.

The Fifth Circuit Court of Appeals overturned the District Court’s decision in most respects. The Court found that Congress had the authority to enact the law. The majority opinion also held that ICWA’s application to all children eligible for tribal citizenship is not a race-based classification and therefore ICWA does not violate equal protection. This reaffirms that the status of “Indian child” is not an unconstitutional racial classification. However, the court was equally divided as to whether references to “other Indian families” and “Indian foster home” are an unconstitutional racial classification. Because the Court was equally divided on this holding the District Court’s ruling was upheld, but it was without precedential authority. Further, the Court affirmed the District Court’s conclusion that several of the “active efforts” required under ICWA violated the Tenth Amendment, which prohibits the federal government from imposing duties on state officials. The Court was again equally divided on whether ICWA’s placement preferences violate the Tenth Amendment. This narrow but lengthy decision, which was over 300 pages and decided by a divided 16-judge court, creates a confusing precedent for those trying to navigate the law and makes the case ripe for review by the Supreme Court.  The Fifth Circuit also addressed APA challenges to the Bureau of Indian Affairs rules implementing ICWA.

On February 28, 2022 the U.S. Supreme Court agreed to review the Fifth Circuit’s decision in Brackeen v. Haaland. The challengers and their amici argue that American Indian/Alaska Native is a racial classification rather than a political classification, making ICWA constitutionally suspect under the Equal Protection Clause. The challengers and their amici further argue that ICWA violates several constitutional provisions including anti-commandeering and nondelegation.

On May 26, 2022, the Court received amicus briefs from supporters of the ICWA challengers highlighting their arguments. On August 19, 2022, the next round of amicus briefs in support of ICWA and Tribal intervenors were due, which was submitted by NIWRC and signed on by NCUIH, and argues that ICWA constitutes a critical safeguard that protects Indian women and children from abuse and declaring Indian to be a racial classification subject to strict scrutiny would impede Congress’ trust duty and responsibility to address violence against Native women and children. Oral argument is scheduled for November 9, 2022 and the Supreme Court will release its decision by June 30, 2023.

ICWA as a Vehicle to Challenge Federal Indian Law

It is also important to recognize that this case, as well as other on-going challenges to ICWA are part of a broader effort to attack the foundations of Federal Indian Law. The recognition that the AI/AN classification is political classification rather than racial is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment. This political classification goes back to the 19th Century and has been upheld by Courts at multiple levels. Acknowledging the importance of tribal citizenship, AI/ANs are classified by this citizenship, not by their race. However, publications from the organizations supporting this lawsuit and others, including the Cato Institute and the Goldwater Institute, make clear that they view Native identity as being a matter of race, not political identity and citizenship. If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities. A successful attack on ICWA would have far-reaching implications on all areas of Federal Indian Law and policy.

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Senate Amendment Includes Major Report on Indian Boarding Schools

On October 11, 2022, the Senate filed an amendment to the National Defense Authorization Act (NDAA) for Fiscal Year 2023 (H.R. 7900). This amendment includes a major report from the Department of Defense (DoD) on Indian boarding schools and institutions under the control of the DoD.

Amendment Highlights

Section 5302 of the Senate-filed amendment includes a report from the DoD on “former Indian boarding schools and institutions under their jurisdiction or control.” In general, the Secretary of Defense would be required to submit a report to the appropriations committees of Congress providing the following information:

  • An account of all schools or institutions that were located on land that was under the control of the DoD (currently or at the time of operation of a school or institution).
  • Provide a description of the role and actions the Department took in facilitating these schools, including complete accountings, engagements, and actions, the identification of marked and unmarked burial grounds, and the repatriation of the remains of Native students who died while attending a school.

This amendment would also require the Secretary of Defense to consult and engage with Indian Tribes and Native Hawaiian organizations so that a comprehensive report is created in less than one year. Finally, the Secretary would ultimately brief the Congressional appropriations committees on the report’s findings.

Background

The National Council of Urban Indian Health (NCUIH) has continuously advocated for substantial efforts to address the historical trauma and public health impact that boarding schools had on urban American Indian and Alaskan Natives (AI/ANs) and to better understand how this intergenerational trauma has impacted urban AI/AN communities.

In December of 2021, NCUIH submitted comments to the Department of the Interior (DOI) regarding the agency’s Federal Boarding School Initiative, led by Secretary Deb Haaland, the first Native American cabinet holder of DOI. Through that initiative, the DOI would begin to identify boarding school sites, locations of known and possible student burial sites located at or near school facilities, and identify the children and their tribal affiliations to bring them home to their families. NCUIH reiterated its ongoing support for the Administration’s efforts to address the impact of boarding school programs and emphasized the importance of studying not only the impact of boarding school programs for survivors but also the lasting impact of the intergenerational trauma caused by boarding schools within urban AI/AN communities.

In June of 2021, Francys Crevier (Algonquin), NCUIH CEO, issued a statement in response to the discovery of unmarked graves at Kamloops Indian Residential School in Canada. She noted that “Indian Country’s social determinants of health demonstrate the connection to the historical trauma inflicted by these governments that caused tremendous health consequences for our people – most recently with the COVID-19 pandemic taking the lives of many of our relatives.”  NCUIH applauded Secretary Haaland for the administration’s efforts, noting the necessity of the United States and Canada to take responsibility for these horrific actions so the healing process may begin.

Finally, on June 15, 2022, the House Committee on Natural Resources held a markup to consider a series of bills, including the Truth and Healing Commission on Indian Boarding School Policies in the United States Act (H.R. 5444/S.2907). NCUIH worked closely with Senator Elizabeth Warren (D-MA) on this landmark legislation to begin the healing process and ensure the inclusion of UIOs in the creation of a Truth and Healing Commission on Indian Boarding School Policies.  In May of 2022, NCUIH also submitted written testimony to the House Subcommittee for Indigenous Peoples of the United States in support of H.R. 5444. During the hearing, several Members of Congress, such as Senator Cortez Masto (D-NV) and Representative McCollum (D-MN-04), expressed concerns and grievances about the horrific occurrences within boarding schools. Members from both parties agreed there was a need for an established commission, and four amendments were introduced on subpoena power (the compensation of commission members, the wording around funds, and the possibility for reparations). However, the only amendment to be accepted was the amendment editing, “such sums as may be necessary”. The bill passed the committee and now awaits a full hearing on the House floor.

Next Steps

NCUIH continues to advocate for legislation that addresses and rectifies the centuries of historical oppression against Native people and begins the healing process. NCUIH will continue to monitor this amendment and provide any updates on its movement.

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